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Soundscapes in Hospitals – Music Therapy Perspectives

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 Soundscapes in Hospitals - Music Therapy Perspectives1

Eckhard Weymann
Dept. of Music Therapy, Hamburg University of Music and Theater, Germany

Introduction and Background

In hospitals, the environmental qualities to which people are exposed can decisively influence
their well-being, their recovery from diseases and their ability to function. This is true for pa-
tients as well as for employees. The concept of the "healing environment” (Stichler, 2001)
focuses not only on the architecture of the rooms, but also on other factors of the sensory
environment in hospitals such as light, nature, colors, acoustics, sound, etc., and even organ-
isational and communication cultures. Especially audibly perceived qualities (like noise,
sounds, music) are highly influential - regardless of whether they have been deliberately de-
signed or not, whether they are consciously perceived or remain unnoticed. They can be ex-
perienced as either conducive or stressful. A Cochrane Review “Sensory environment on
health-related outcomes of hospital patients” (Drahota et al., 2012) reports that in 85 of 102
relevant studies in hospitals music was used as an intervention. The review sums up: “…music
may help improve patient-reported outcomes such as anxiety” (Drahota et al., 2012, p. 2).
According to ISO (International Organization for Standardization, retrieved from
https://www.iso.org/obp/ui/#iso:std:iso:12913:-1:ed-1:v1:en), Soundscape is defined as the
“acoustic environment as perceived or experienced and/or understood by a person or
people, in context”.
The introduction to the definition comments: “There are similarities between the concepts of
'landscape' and 'soundscape'; both are based on perception by people. For the purpose of this
International Standard, soundscape will be understood as a perceptual construct, related to a
physical phenomenon. The standard distinguishes the perceptual construct (soundscape)
from the physical phenomenon (acoustic environment), and clarifies that soundscape exists
through human perception of the acoustic environment.”
The perception of the soundscape in a hospital waiting room is constructed by the acoustic
environment in the room and the subjective connotations of the listener. This is relevant for
healthcare environments, where high levels of anxiety and stress can be expected, when pa-
tients are worried about their health and suffering from acute illness. The acoustic conditions
of the soundscape may amplify or moderate these feelings – and vice versa: the individual’s
emotional conditions may alter the perception of the situation.
The influence of noise pollution in health care areas has been widely discussed and studied.
The WHO-“Guidelines on community noise” (Berglund, Lindvall, & Schwela, 1999) outlined
the health effects of noise exposure, also in hospitals. The environmental qualities to which

1
Conference paper, presented at the 13th International Workshop on Computer Music and Audio Technology
(WOCMAT), HsinChu City, Taiwan, 7th December 2017
people are exposed can decisively influence their well-being and their ability to function and
to recover. We find many studies on noise pollution in emergency departments, in post an-
aesthesia care units (PACU) and in operating theatres (e.g. Ortiga et al., 2013; Short, Ahern,
Holdgate, Morris, & Sidhu, 2010). Often noise levels are reported exceeding the international
recommendations. „For 90% of the time, the noise is above 50 dB(A) which exceeds the hos-
pital recommendations by at least 5 dB(A) for the Australian Standard and 10dB for the WHO
guidelines” (Ortiga et al., 2013, p. 48).
De Ruiter (2015) points out another way of how sounds can influence the patients:
For patients in bedrooms, hearing is a very important sense. A large part of patient life
can be regarded as a “radio play”: the daily activities are announced by their specific
sounds. Footsteps of nurses, conversations of doctors and nurses, rattling trolleys,
clanging of dust bins, etc. Other sounds accompany them: alarms, respirators, paging
calls, ice machines, paper towel dispensers etc. (p. 2439)
Similarly, patients in the waiting area of an ED are in an unfamiliar and highly complex envi-
ronment, trying to find some orientation by listening to footsteps, conversations between
doctors and nurses. And waiting anxiously for the announcement of their names for their ap-
pointment.
The patients are in an unusual and unintended situation, their autonomy and privacy are lim-
ited. This is often accompanied by pain and concerns about health issues. The external condi-
tions should therefore contribute as much as possible to recovery.

Atmosphere
We all know, that audibly perceived stimuli, like noise, sounds, music, are atmospherically
highly influential, they can alter our mood and our feelings of wellbeing. In our project “Heal-
ing Soundscape”, we did some exploration of the sound qualities in hospital waiting areas.
Coming from music therapy, multimedia composition and systematic musicology our ques-
tions were – and will be:
1. how are the atmospheric and acoustic conditions for patients and staff in three dif-
ferent waiting areas of the university hospital in Hamburg?
2. Could we modify these conditions using a sound installation? (Hajdu et al., 2017)

Atmosphere is a key concept in the New Phenomenology movement around German philoso-
phers like Hermann Schmitz and Gernot Böhme. It refers to a relational in-between phenom-
enon (Böhme, 2013) connecting the physical and the psychological conditions in their envi-
ronment. For instance, the perceived atmosphere in a waiting room results from a combina-
tion of environmental qualities (object pole) and – at the same time – the emotional condition
of the person in this context (subject pole). We assume, that an atmosphere can be modified
by changing, for instance, sonic qualities of the environment.

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The diagram of fig. 1 shows the circular dynamic of the factors involved in the modification of
an atmosphere by a sound intervention within a healthcare setting (Hajdu, Carey, Lazarevic,
& Weymann, 2017).
Our basic assumption is: sound installations alter the sonic environment. This can contribute
to the improvement of atmosphere in the room and thus modify the emotional state and well-
being of patients and employees in a clinical setting.

Music Therapy – Music Interventions

What is the music therapy perspective on auditory milieus in hospital rooms? Music Therapy
is defined as “…a reflexive process, wherein the therapist helps the client to optimize the cli-
ent‘s health, using various facets of music experience and the relationships formed through
them as the impetus for change” (Bruscia 2014). Music therapy is applied as active or recep-
tive interventions – listening to music or making music actively –, in individual or group set-
tings. Music Therapy interventions always contain a qualified music therapist and a therapeu-
tic relationship.
So, obviously, soundscape interventions differ from music therapy, as there might be no ther-
apist, no designed clients. On the other hand Even Ruud (2010, p. 100) points out: “Music
therapists should take the responsibility for the total sound environment of the wards or in-
stitutions they work in, not only the musical environment but also the soundscape of the in-
stitution”.
According to Thorgaard (2014, p. 97) „Music intervention can be described as a supportive
therapeutic tool using recorded music in creating a sound environment to initiate and main-
tain relaxation, well-being and comfort, as well as a self-management technique to reduce or
control distress“.
We get some orientation in the field of music in hospitals from an article by Foster (2016),
where the author describes several applications (s. Table 1).

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Under the header of “Music Care” Foster differentiates several domains. We will focus here
on two of these:
• Music Therapy (= providing treatment using music within a therapeutic relationship)
• Sound Environment (= bringing intentionality to sounds made in the care environ-
ment).

Fig. 2: Subject, Environment, Music

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Within the polarity of subject and environment, we find inscribed the formats of music ther-
apy (= dealing with the individual as a subject) as well as musical soundscape interventions
(MSI) (= influencing the environment and secondarily the subject).
Mediating music therapy and soundscape interventions we encounter a variety called Envi-
ronmental Music Therapy – EMT, which is defined as:
The use of live music to construct a soundscape which can modulate the perception of
an existing environment. The soundscape is constructed in such a way as to reduce
noise or incorporate ambient sounds (…). Focus is placed on the conversion of dispar-
ate noxious stimuli often present in fragile environments into less threatening
presences.” (Kirkland, 2013, p. 42)
Example
A study on EMT from Kyoto, Japan, presented at the World Conference of Music Therapy in
Tsukuba, Japan (Kitawaki & Adachi, 2017) deals with “The Effectiveness of Environmental Mu-
sic Therapy on Acute Care Unit Staff”. The Japanese government has obligated all companies
that own over 50 employees to have the employees take a stress check-up every year for
maintaining their mental health. This research was to investigate the effectiveness of Environ-
mental Music Therapy (EMT) on reducing the stress level of medical staff working in acute
care units.
• Objective: Reducing stress levels and fostering the ability to handle daily stress
• Methods: For this study music therapists played improvised music with guitar
and/or flute, for 30 minutes, three days a week for a month, 12 times total.
• Participants (n=99), medical staff working in the acute care units completed ques-
tionnaires of the Perceived Stress Scale (PSS, 10 items) before and after the series of
EMT interventions. Also, they gave free comments on the music.
• The investigation showed that the effectiveness of EMT related to the number of
received interventions (dosage/effect relation). The more the staff had the oppor-
tunity to attend EMT, the more increased the possibility for them to handle daily stress.
• Qualitative data from the comments by the participants also supported the effec-
tiveness of live improvised music.
(Kitawaki & Adachi, 2017)

Healing Soundscape – Musical Soundscape Interventions

Musical Soundscape Intervention (MSI) is defined as
a carefully designed interactive music/sound treatment which aims to contribute to
the improvement of the atmosphere in a room and thus the well-being of all those
present.
The Project
In the ongoing interdisciplinary teaching- and research-project Healing Soundscape 2(2017-
2019) we focus on the sonic environment in a hospital setting and on the atmosphere being
perceived by patients, visitors and employees. It brings together composers, musicologists

2
„Healing Soundscape“ is funded by Claussen-Simon Stiftung, Hamburg, Germany

5
and music therapists from two Hamburg Universities, composing and constructing sound in-
terventions and explore as well as evaluate how they contribute to the improvement of the
well-being of patients and employees.
In our groups, the goal is to explore the auditory atmospheres in three specific waiting rooms
of the Hamburg University Hospital:
• A small waiting room for private patients of the cardiac clinic (PRIV)
• The waiting area of the emergency department (NOT)
• The PACU-Area (post anaesthesia care unit) (PACU)
Methods: The core of this project is theoretical reflections, artistic productions, technical de-
velopments and empirical research within a framework of disciplinary as well as interdiscipli-
nary seminars, workshops and exercises. The results of these courses are to be applied in
practice and empirically evaluated.
Amongst others, we use the following methods:
1. Environmental assessments of waiting rooms
2. Composition: Development of interactive, generative sound compositions and their
technical requirements
3. Interdisciplinary discussions
4. Installation of sound interventions
5. Evaluations of different effects of the sound interventions on patients and employees
In this paper I will focus on 1., environmental assessment, and touch briefly on 2., composi-
tion.
1. Environmental assessment:
Atmospheric Assessment
Our practical research in the waiting rooms began with a phenomenological approach. With
the qualitative method of “Atmospheric Assessment of Rooms” we confronted ourselves with
the actual impressions the rooms made on us. The task, while sitting quietly in one room for
some time, was to observe feelings, bodily sensations, associations etc. In another step the
researcher had to focus on the room and its qualities. Finally, a short description had to be
written in a questionnaire. Later, the texts were analysed, compared and synthesised into
some „essential“ notions. The assessment of the specific atmosphere of a room was devel-
oped to find a basic orientation for the soundscape intervention.

Two examples:
• I feel like a foreign object in space, in an interim, unreal, like suspended in time
• Very strange feeling, cold,surrounded by robots
• I can hardly breathe, fear rises
• Nobody there, am I alone?
Example: Notions from PACU

• Woozy from the dull background noise I feel caught in a bubble.

• Slight tenseness, I cannot find rest. Yet, I am vigilant, on what?
Example: Notions from NOT (emergency department)

6
Imagine a soundscape!
Instruction:
Sit down between the patients. Empathize with the situation of people sitting here. Imagine
yourself being in their position. Ask yourself the following questions and make notes. After 15
minutes leave the place and deliberately get past the situation of a patient.
1. If I were a patient here: what would be good for me now?
- The certainty that I will not get lost. Contact. Direct approach. Liveliness.
2. Which sounds would suit me now?
- Colorful sounds. Varied sounds. Single sounds. Natural noises. Sounds of plucked instru-
ments. No relaxation music. No strings. No percussion.
3. How should the room sound? Like a... (Find a metaphor!)
- Like a green forest clearing.
4. I would like to find a soundscape, in which I feel... (Find some words!)
- Activate. Alive. Not provoked. Happy. Humorous. Light.
Example: Questions and Answers from PRIV (private waiting room)

2. Composition.
The given notions can give valuable hints as to how to compose music for a particular waiting
room.
With the music our aim is
• to create a soundscape which has little performativity and draws little attention
• which has an implicit effect in modifying the atmosphere.
This intention is rooted for instance in the work of Eric Satie (“music d’ameublement”) and
Brian Eno’s Ambient Music. But also Morton Feldman and György Ligeti are famous progeni-
tors for our musical approach (Hajdu et al., 2017). Brian Eno’s (1978) notion “it must be as
ignorable as it is interesting” is a valuable guideline for soundscape compositions.
In order to create unobtrusive or neutral music we used textures characterized by the follow-
ing qualities (Hajdu et al., 2017):
• Disjunction (harmonic, melodic, timbral and/r spatial)
• Aperiodicity
• Sonic richness of individual sounds
• Slow to medium tempo
• Low to medium dynamics
For the sound generation we use a music engine called DJster based on the work of composer
and music theorist Clarence Barlow. It relies on the use of algorithms and enables the com-
poser to produce generative music algorithmically. The DJster program
features a flexible 17-dimensional parameter space in which some of its parameters
are linked in clever ways to create a sense of tonality and metricity, or its opposites,

7
 atonality and ametricity. In addition, a virtually unlimited number of scales (…) and
meters (…) can be chosen as the material basis on which the probabilistic event gener-
ator operates on. (Hajdu, Carey, Lazarevic, & Weymann, 2017)

Conclusion
Our observations and reflections about the waiting rooms led us to some principles for suita-
ble sound interventions in public spaces of hospitals. Under the premises of atmosphere, neu-
tral music and others, we collected and discussed sounds, completed the first compositions,
installed technical equipment in one of the waiting rooms which we designated as a Listening
Room, where people can listen to the compositions in the afternoons and on weekends.
A control module has been developed, which provides the visitors with active controls over
the sound output and different settings of the compositions. The control module will also
serve as an evaluation tool.
In a laboratory, students will test effects of the soundscape compositions on subjects, e.g.
with an oxymetry test. We will develop other means of evaluation from this.
We experienced it as a big challenge to bring together people from different professional
fields – which also means: different cultures of thinking, styles of talking, perspectives. Inter-
disciplinary projects are not easy to realise, but we think, they are always worthwhile and
gratifying.

References:
Berglund, B., Lindvall, T., & Schwela, D. (1999). Guidelines for Community Noise. a68672.
from World Health Organization, Geneva, Switzerland
http://whqlibdoc.who.int/hq/1999/a68672.pdf
De Ruiter, E. (2015). Healing soundscape: hospital acoustics 2.0. Proceedings of EuroNoise
2015, 2439-2444.
Drahota, A., Ward, D., Mackenzie, H., Stores, R., Higgens, B., Gal, D., & Dean, T. (2012).
Sensory environment on health-related outcomes of hospital patients. Cochrane
Database of Systematic Reviews, 3.
Eno, B. (1978). Liner Notes. On Music for Airports/Ambient 1.
Hajdu, G., Carey, B., Lazarevic, G., & Weymann, E. (2017). From Atmosphere to Intervention:
The circular dynamic of installations in hospital waiting areas. Paper presented at the
International Conference on New Interfaces for Musical Expression Conference,
NIME, Copenhagen, Denmark.
Kirkland, K. H. (Ed.) (2013). International dictionary of music therapy. London: Routledge.
Kitawaki, A., & Adachi, S. (2017). The Effectiveness of Environmental Music Therapy on Acute
Care Unit Staff. Paper presented at the World Conference of Music Therapy Tsukuba,
Japan.

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 Ortiga, J., Kanapathipillai, S., Daly, B., Hilbers, J., Varndell, W., & Short, A. (2013). The sound
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Ruud, E. (2010). Music therapy: A perspective from the humanities: Barcelona Publishers.
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