Beyond Silence: Music as Environmental Design
By Susan Mazer & Dallas Smith

Posted with permission from The Center for Health Design. The Journal of Healthcare Design, Volumes I-X are available on CD-ROM from The Center at www.healthdesign.org/jour_hc_des.htm

Note from the Presenters: In considering the experience of healthcare consumers as they utilize the facilities in which healthcare is delivered, the questions that need to be addressed are ones pertaining directly to the reality of the experience, in contrast to the intentions or objectives stated by the institutions. The waiting areas (patient and family holding areas, including patient rooms) represent the place where accumulated tension and anxiety define patient care. Thus, this presentation was set up to introduce this issue by allowing the participants to have an analogous experience. This was done through a performance of 180 seconds of anticipatory silence without prior notice. Other portions of this presentation that were experiential and do not translate easily into this transcript have been replaced with an overview of their intention.

Smith: (after 180 seconds of silence) The first piece we performed was titled "Healthcare Waiting Areas: 1993." How did the silence make you feel? In nature, there is no such thing as a pure vacuum. In healthcare facility waiting areas, as well, there is no such thing as pure silence. During those 180 seconds of "silence," there were still sounds in this room: the door in the back opening and closing, waiters rattling dishes, the noise of the ventilation system, and the sound of people breathing. You were wondering, perhaps, what was going on? Did I do something wrong? When are they going to tell me what to do? Do they know what they are doing?

This is how most people may experience time spent waiting in a healthcare facility. However, in this case, there were only 180 seconds – three minutes – of uncertainty. How much longer must one wait for information or an explanation in a medical crisis? What kind of environment must a waiting area be to be comforting? This discomfort – uncertain silence – often continues as healthcare services are delivered. With the addition of beepers, buzzers, overhead-paging, computer printers; the sounds of suffering, laughing, crying, inappropriate conversation; and the 24-hour rock station on the radio at the nurse station, the sounds of the environment are often much worse.

There are any number of elements in the sound environment that can violate the best physical design. In this presentation, we are going to continue the conversation about creating healing environments. Our focus is the aural environment. All of us have just experienced silence for 180 seconds. It was a rather innocent silence, because we are not here because we are in pain, suffering any trauma, or under the influence of medication -- all of which can distort time and make minutes seem like hours. We see the environment functioning as the context for the delivery of healthcare services. All too often, that environment runs counter to the purpose of healthcare; counter to the intention of the services that are being delivered by various specialists and highly trained individuals. Whose environment is it? Who is accountable for the quality of this space? If the environment is not healing, what is it? Once the building is built and the people are there, the responsibility for the quality, both visible and non-visible, may easily be put on the designer. Too often, we have heard the comment, "Well, that is just how hospitals sound. There is nothing that can be done."

It may be true that nothing can be done about some elements required in the hospital. However, there is much that can be done to impact the totality of the environment. The total healing environment cannot be realized by isolated individuals. There must be an institution-wide shift of consciousness, so that the people who are in the facilities every day keep the healing environment in place.

Mazer: When we present workshops on music as environmental design, questions concerning the economic justification for this program do arise. What is clear is that the sound environment is a fact; it exists whether or not we deal with it intentionally. Thus, a price is being paid in the form of increased stress, pain, and exaggerated impact. Institutionally generated symptoms are seldom addressed. However, we know that human beings experience stress, fear, anxiety, especially in situations where they have limited control. The increased stress can impact the recovery process. Silence in an institution is an illusion; it is relative to various other sounds; and it is not neutral or absolute. Silence has its own quality and can be shifted. In the middle of the night when the lights are out and patients are alone, the aural design of the institution is still working. Our goal is to address the sound environment from the human experience of being a caregiver and also a patient.

More Than Just Opinion
The auditory reflex gives us information about when a sound occurs, what that sound is, and where it is located. Once we recognize the sound, we then bring meaning to it. In fact, a neurological synthesis occurs in which the brain puts together what we see with what we hear. When we are only hearing, without the sense of sight, our hearing ability is intensified. Thus, the impact of the sound and our efforts to bring meaning to it are mutually increased.

Music – organized sound – has meaning beyond itself. We, as individuals, connect who we are, what has happened to us, what is currently happening to us, and how we feel with music that is playing. Music is cultural, historical, and personal. It has been a major indicator of social and political mores for as long as it has been recorded. Thus, opinions about music are opinions about who we are in relationship to our past and present.

When people talk about music, the conversations that usually result are centered around opinions. People say, "I like country and western music." Or, "This is the song we played on our first date." Or they say, "This is the song I remember my mother playing for me." Music produces strong opinions that are based on past experiences. It creates boundaries and defines generations. Music is a statement of cultural identity and represents both the parts of our history that we would like to access and the parts we would like to forget. What can be done in healthcare facilities to access those opinions and histories to create another type of experience? As Dallas mentioned, we found that when we first approached healthcare facilities about improving their environmental sounds, we heard the words, "But, this is what a hospital sounds like." Administrators told us, "Your music could be too loud. How could you perform live music, especially with the amount of equipment you require?" So we decided we had to do an intervention in the institution. If we were going to transform the healthcare environment, we had to get the staff to believe and know that it could be different; to move from a stand of "impossibility" to one of "possibility."

We developed a "Music in Residence" program for Washoe Medical Center in Reno, Nevada, to serve as an environmental intervention. We organized it so that we were positioned on a particular unit for up to eight hours. It was the most difficult engagement that we ever booked ourselves into – long hours, with insufficient lighting and staging. We did not know what was going to happen. We had to convince the nursing staff through this "experiment" that the environment could be different due to music.

In oncology, we had logistical problems in locating an appropriate place to perform due to the physical equipment and the sound level. The nurses, wanting this to work, made many voluntary concessions regarding the volume and placement. I was very concerned that when we started to play, the music would be an unwelcome distraction. The nurses not only did not complain, but they made whatever adjustments they needed to in order for our "experiment" to work in this unit.

After we had played for about four hours, the nurses reported that patients who had been on morphine every hour and a half had not asked for medication in more than three hours. They also noticed that some of the patients who were having chemotherapy treatments had requested to be hooked up to the IVs and wheeled out to the hall to listen to the music. At about 7 p.m., after we had been there for six hours, Dallas gave, on request, one of the most astonishing renditions of "Misty" I have ever heard him play.

The nurse manager said that she noticed her staff was far less stressed than usual. Staff members then started talking among themselves and realized that the environment could be different. Thus, in order to bring music into a healthcare facility, environmental design has to be redefined for staff members so they realize they need something different, and know it to be possible. In addition to the oncology unit, this program was offered in rehab, dialysis, admitting, neurology, med-surg, and emergency. In all situations, the staff and patients experienced a significant change in how they and their unit functioned.

The workshop we have developed, "Music: A Life-Altering Decision," is an eight-hour CEU-accredited program for nurses and CME-accredited program for physicians as an experiential workshop. It includes empirical information about the research that has been done in music and medicine. Our goal is to give the staff an opportunity to identify environmental components that are changeable; the impact those elements have on both staff stress and patient outcomes; and the possible strategies for the ongoing creation of a healing environment. Although our main focus is the aural component, we address all variables. The workshop deals with opinion and personal history, because all participants have opinions that function strongly in how they relate to where they are and what is happening to them.

We have learned that if the staff and administration do not understand the issue of aural space and its impact on patient care, the use of music is very limited and the negative impact of the existing sound environment is ignored. We have also found that, in terms of the elements of design, the sound environment is a living, organic, dynamic component. It is changing from moment to moment.

I am sure that if we went back and looked at how each of you processed the three minutes of silence with which we began this presentation, we would see some interesting things. During the "performance" we did specific things, such as getting ready to play our instruments and then not playing, fussing with music, etc. Such silence, without explanation, is occurring when the patient has few felt rights to ask questions, and at a time when he or she has intensified anxiety by virtue of his or her reason for being in a hospital. Such a silence is not neutral. The confusion, tension, frustration, and any other feelings that you felt are similar to the feelings experienced by patients and families when they enter waiting areas or the emergency room. They are greeted by a receptionist, and they wait, and wait, and receive little information.

We emphasize to hospitals that waiting time needs to be a pro-active time for caregivers and patients. They are either going to be better or worse off for having to wait. They will seldom be the same after four hours of waiting, compared with when they first came in.

Smith: If there is a visual environment that is displeasing, one can close one's eyes. However, it is very difficult to shut out the sound environment. In fact, closing one's eyes can make one even more sensitive to the sound environment.

Mazer: One of the issues we deal with in terms of healthcare design is time management, but not in terms of administrative productivity, and all that has been associated with it. We speak now of all the minutes and hours during which a patient lies in the hospital while the protocol is working. More hours pass with the patient being un-attended than attended. The experience of time is negotiable. It is perceived and experienced differently, depending on who we are, what type of environment we are in, and the types of relationships that are exhibited around us. Given the opportunity and capacity to alter time as experienced by the inpatient, we become responsible for that part of patient care.

A Sampling of Research
For some of our work, we have had to review the research on music and medicine. At one point, we thought about putting our music aside and doing research ourselves. But it would have been research that told people what they already intuitively know. We did not believe this was our mission. Then we had the good fortune to speak with Dr. Clifford Madsen, a noted music therapist at Florida State University in Tallahassee, Florida. It became clear that the Center for Music Research, and other similar organizations and individuals are doing substantial research in the field of music and medicine. The issue of implementation, however, remains the challenge.

Through Dr. Madsen, we were able to access a Meta-Analysis, prepared by Dr. Jayne Standley, also of Florida State University. She reviewed the major research on music and medicine and compiled a summation of 30 relevant studies, selected from 80 documented studies. Studies were reviewed and eliminated for the Meta-Analysis based on criteria, including the credibility of the clinical setting. Studies utilizing artificially induced pain or anxiety were not included.

The research implied several conclusions: 1) women respond to music with somewhat greater effect than men; 2) it was also noted that the Effect Size was greater (Since a great deal of research has been done in labor and delivery, this obviously influenced this conclusion. Because childbirth is limited to women, that statistic will probably remain out of proportion. As mentioned, the number of female participants in the study definitely impacted the results of that study.); 3) music has greater measurable effect when there is some pain present; 4) music has been shown to enhance the impact of an analgesic, and is also better than just the analgesic or anxiolytic by itself. Obviously, greater or lesser degrees of wellness are harder to measure than moving from conditions of pain and anxiety to a neutral state. The use of music as a protocol, as opposed to entertainment, is measured in the same way as any other protocol, i.e., when a change in the condition is evidenced or reported; and 5) the most conservative measure of music's effect is the patient self-report, followed by physiological measures and observational measures.

I know few patients who will say that they feel worse than they actually do, but many will not say how bad they feel. This is especially true when the method of dealing with pain involves more pain, or when pain can indicate the procedure that most frightens the patient. A dramatic measure of music's effect was obtained in a study of nor-adrenaline levels, secreted when anxiety is experienced, as measured in pre- and post-tests. Results were more dramatic when live music was presented by a trained music therapist. I do not know what kind of recorded music was listened to, and I do not know who the music therapist was. The study indicated that live music has more impact than recorded music. That may be debated and depends on the quality of either. Fortunately, modern technology has finally allowed recorded music to be bigger than life.

The delivery systems used in these experiments are not adequately described in any of the research. The reports say that researchers used a cassette player or headphones. There is no indication of when records (LPs) were used and no indication of the quality of the performances or who performed the music. So, when we look at the research, it is clinically heavy and musically light. The music is not dealt with in enough detail. In terms of physiological measures, music has been found to affect the respiratory rate, amount of medication for pain, and anxiety levels. Length of labor and childbirth was shown to be dramatically impacted by music. In fact, one study over 24 hours of 50 women in labor showed that John Philip Sousa marches definitely had a positive effect.

In terms of research to be generated and programs to be offered, the results must be manifested in healthcare objectives, in improved rate of recovery, decreased length of stay, and reduced stress as exhibited by staff and families. What healthcare designers hold themselves accountable for must be transferred into therapeutic objectives.

Smith: These statistics were compiled over many years of studies. In fact, the discipline of music therapy has been in existence for 50 years or so. Uniformly, the results indicate that the use of music in conjunction with other treatments yields better results than the absence of music. Despite the weaknesses on the music side of the studies, we are amazed that the results of these studies have not been applied. They have not permeated the medical industry at large. In fact, staff music therapists are relatively rare. When they are present, they are often looked down upon, equated with pet therapists, physical therapists, etc., all of whom rank below doctors, nurses, and nurse's aides.

Defining Music Therapy
I would like to distinguish our work from traditional music therapy. The therapy model offers a one-to-one patient/therapist relationship. In the case music therapy, music is used as an administered protocol for a measured amount of time. We do not treat patients. We treat the space in which patients are placed. Our approach is to use environmental design that will affect the institution at large, which holds the patients, staff, administrators, families, visitors, etc. If that design is incorporated in the overall plan, our work should create positions for music therapists to help keep that environment in place.

However, as I said earlier, one person alone cannot make this change. The responsibility for the healing environment cannot be put solely on the shoulders of the designer, music therapist, or any other specialist, because every individual staff member is responsible for keeping that environment in place 24 hours a day. Churches have done a great job of creating environments. When people walk into a church, even if no one is there, they know what is appropriate and what is not. We would like to see that same respect generated upon entering healthcare institutions. Unfortunately, often when music is added, it is done in such a way that the waiting room feels like a shopping mall, an elevator, or "happy hour" at the bar. There are places for these types of music in our lives, but such music is not appropriate for healthcare environments, because of the denial implied and, thus, the negative environmental impact.

A suggested listening list that identifies music that "heals" (implying that music not listed does not heal) has been requested by many individuals and institutions. Unfortunately, it is not that simple. Just as doctors are expected to deliver a "magic pill," musicians, regardless of their intention, cannot deliver the "magic song" that will heal everyone all the time. We seek to empower the healthcare professional to be sensitive to all levels of musical impact, which include ethnic, cultural, personal, and spiritual elements; and to become astute at encouraging the ongoing re-design of a space that may seem static. What will work for an 85-year-old Alzheimer's patient may not work for a 17-year-old paraplegic. On the other hand, we have seen a demonstration of a sound environment that is appropriate for both these individuals.

We take the position that a healing environment has to be based on the interaction of a knowledgeable staff with the patients and visitors. The ideal sound environment may vary from patient to patient, from one time of day to another, and from one unit to another.

Mazer: In terms of how to create a healing sound environment, at this point, we could probably document more of what does not work that what does. However, all of our experiences and the evidence coming from research indicate that some things certainly help more than others.

Healing Healthcare Systems is the newest addition to our healthcare projects. It is 24-hour audio/video programming for in-room patient television. We have found, both in live performance and in the results of offering this programming, that when a tool is offered to assist in those issues that medication cannot address, it is easily accepted and used. We have found, as musicians, that if we are appropriate to and honoring of our audience; if we know what we are delivering; and if we do it with great intention, the audience will become open to the music as a positive experience. Thus, it is possible to move beyond conflicting personal tastes. We consider the needs of the patient to be primary; our objective being to facilitate the recovery process. If adding music and visual images to the space inspires a patient to request his or her own music, we consider that to be a positive step in the patient's participation in his or her own recovery. When patients start asking their families to bring in something else, this request generates a conversation that is positive and pro-active in designing the environment in ways that personalize the room.

A study done by Dr. Standley was conducted in a neonatal intensive care unit. The music therapist measured the decibel level of the respirators and the incubators in the intensive care unit. It was about 75 decibels, which is louder than a freight train and not quite as loud as a boiler room. A lullaby tape with a woman's voice, ethnically matched to each child, was recorded and played at 80 decibels, so as to mask the sound of the respirator. Researchers found that the experimental group that had the tapes and lullabies left intensive care seven to 10 days earlier than the control group of infants who had not received the music therapy.

When we discuss this experiment with doctors, we ask them why, if the research is credible and answers all the questions that medicine needs to know about what works, has it not penetrated the medical community? Cassette tapes, at most, are $10 each. Considering the economics of healthcare, why is it that something so cost-effective has not penetrated the medical community? At the same time, we look to designers to be in partnership with us to use this information to convince clients to intentionally design the aural space.

Smith: I might add that all of these statistics from the annals of music therapy came into existence prior to the birth of psychoneuroimmunology, which, in brief, recognizes the impact of the patient's attitude and emotional state on his or her immune system. This is something that we, as musicians, having practiced our art all of our lives, know instinctively. It has taken both time and persistence to get the statistical documentation from enough double-blind studies of medication plus counseling, versus medication alone, to prove that the psychological component can indeed go beyond the limits of medicine alone.

Trust
During this workshop, the participants did an exercise that demonstrated the impact of sound in shifting them from fear into trust in a brief amount of time. The exercise involved partners walking each other around the room, in silence with one partner blindfolded. While the environment was contained, in one space, with a group of individuals known to each other, the addition of music shifted the quality of the space. This exercise was designed to demonstrate the power of the aural environment as it impacts patients when other factors exist that deprive them of control over their own environment. Blindfolded, the issues of color and light are moot. There is, however, an exaggerated sense of hearing as one tries to gain and maintain a sense of the space. Thus, the sounds in the room, the approximate location of physical objects and other people, and the loss of orientation, together, cause a dramatic increase in stress. Participants in the two workshops reported an elevated heartbeat and other physical manifestations of fear.

Mazer: We are obliged to take heed of the reality of the patient experience when specific sensory deprivation exaggerates the impact of those senses still in operation. In the previous exercise, you played both patient and caregiver. The role vacillates between having control and having no control, having more information and having less information. This is the nonverbal, physically invisible component of healthcare that needs to be addressed. When we look at these things that happen to patients in the best, most brilliantly designed gurneys, wheeled by the most highly trained individuals, how do we deal with the fear that dramatically impacts patient outcomes?

Can we, as healthcare and design professionals, hold ourselves accountable for the quality of the space in which we place patients? It is possible to intentionally deal with medical crises in ways that minimize fear. Some of that fear is healthy and normal. It is part of being alive. How do we cut through the silence that is so oppressive and shift it to a safe space? Some of you – no matter who was around you during this exercise – did not feel safe when your eyes were closed. As human beings, we loathe being out of control.

How can we build trust into the design of healthcare facilities? Can we do it in a very intentional way? We have done this exercise for many different groups and it has never generated a different result. When the music starts, people report that the tension goes out of the person they are leading around. It can be noted that the music is unfamiliar, new, and that it is different each time we do this particular exercise.

When you leave this presentation and think about using music as environmental design, it is important that you know that what you have experienced in this session is real. Yet, you are healthy and safe, and you have chosen to be here in this room. In a hospital, people are not healthy, they seldom feel safe, and their very presence there is by limited choice.

What Is Appropriate?
Are we to assume that if we provide music for patients in therapeutic situations, they will be receptive to it? Our answer is that in medicine, patients are not asked what kind of a needle to use or when to administer an IV. We should talk about what music is appropriate for the recovery process, as opposed to the kind of music that may be preferred under a different setting. Patients do trust healthcare professionals to deliver what is appropriate and will best serve their recovery. Yet, in this particular modality, regarding music, what is needed is a specific kind of relationship between the staff, the patient, and the music. It is a different kind of intimacy and trust. When music is appropriately introduced to a patient, our experience has been that the patient becomes willing to try it.

For example, there was a woman who had been in an accident and was in traction in which she was face down, suspended at a 40-degree angle. Patients using this particular apparatus are not able to sleep. It is a very painful position and in addition to the pain generated by the injury, they cannot move. Thus, the medical need for rest is countered by a physical inability to get enough rest. A nurse who had taken our workshop went to this young woman and proposed that she try listening to a specific tape of music on a Sony Walkman for 10 minutes. The young woman was understandably irritable and resistant. But upon listening to the music, for the first time in days, she slept for three hours.

There is a point at which we have to trust that it is the relationship that will create the opening. A relationship has to be built, which is why the beginning of this work is the educational process.

Smith: We have had the experience of music crossing generational barriers and ethnic barriers. Certainly, if it is instrumental music, as opposed to vocal music, the music is more likely to have a universal appeal. The minute there is a song with lyrics, it triggers a certain limited, specific meaning. Whereas, if I play an Indian flute, one does not have to think of India in order to have a positive experience with the type of music that I might be playing. Instrumental music is more universally accessible. Also, we attempt to avoid musical clichÌ

Mazer: Our work in music and healthcare is about using music as environmental design. We are committed to excellence. We are committed to a certain esthetic that is appropriate to the recovery process; to the human process. We hope to create a place for music to be experienced in a more powerful way than it may have ever been experienced. We would also like those who may be afraid of listening to music they have never heard before to validate our position that music does not have to be familiar to work in a healthcare environment.

Smith: I would like to make a few comments in conclusion before we play one last number. We compared the design of music to the design of the diet: that food can be made as healthy as possible. Perhaps food can be made so healthy that it becomes unappetizing.

Music is the same way, in that some people seek to contrive healing music. As they remove elements that might not be healing, they end up with a bland style of music that is not appetizing intellectually or esthetically. We think that variety in music is healthy.

The most important message we would like to leave is to empower you as individuals to use music in the design of your lives and carry it into your professional lives. It is amazing how people will tolerate bad design institutionally that they would never put up with privately at home, in terms of lighting, color, and sound. We know how to make our personal living spaces comfortable for us, and we feel empowered to do so. It is unfortunate that we can go into public places everyday that we would certainly never want to live in, nor spend any time in, much less try to recover and heal in. We control the environment that, in turn, controls us. So, let us feel empowered, as individuals and groups, to bring all the elements together to create a total healing environment.