The impact of COVID-19 on music therapy provision in Dutch care homes

ABSTRACT

Introduction

Since the COVID-19 pandemic started in Europe early 2020, day-to-day practice in care homes has changed considerably. Common elements of music therapy – singing, physical contact, proximity – have become questionable. This study explores the impact of the COVID-19 pandemic on music therapy provision and continuation in Dutch care homes.

Method

In December 2020 and January 2021 Dutch music therapists (n = 49) working in elderly care filled out an online survey on their experiences with the COVID-19 pandemic during the first and second wave.  

Results

Twenty different measures were deployed to adapt and continue music therapy throughout the pandemic. Music therapists were required to deploy social distancing, disinfect hands and instruments, and wear a face mask. Residents from different units were frequently unable to participate in music therapy together. Prevalent adaptations were to provide sessions in a common room (79.6%), in smaller groups (67.4%), for more (individual) residents than usual (65.3%) and to use pre-recorded playlists (65.3%). Music therapists experienced low stress and moderate to high hope, despite the substantial impact of the pandemic on professional and personal musical activities.

Discussion

Music therapy provision in care homes has repeatedly been subject to restrictions throughout the pandemic. By the end of the second wave, music therapy had been resumed in care homes, albeit with a range of preventive measures implemented in daily work routines. The pandemic shed light on adaptability of music therapy as a treatment and demonstrates that employer support is essential to enable music therapy provision.

KEYWORDS:

• COVID-19
• pandemic
• music therapy
• music-based interventions
• care home
• elderly care

Introduction

Care for the elderly has been severely affected by the high rate of mortality from COVID-19 in this population (Schols et al., 2020; Van der Roest et al., 2020). By 28 May 2021, approximately 720,358 COVID-19 deaths had been reported in Europe (European Centre for Disease Prevention and Control, 2020). Up to 60% of these deaths occurred in care home settings (Adlhoch et al., 2020; European Centre for Disease Prevention and Control, 2020). From the first confirmed case of COVID-19 in the Netherlands on 27 February 2020 to 27 May 2021, the Netherlands had 1,637,466 confirmed infections and up to 17,592 confirmed COVID-19 deaths (Coronadashboard RIVM, 2021).

The measures taken to prevent the spread of the virus (e.g. face masks, social distance) vary per country, per region and even per care home location (Verbeek et al., 2020). The presence of COVID-19 introduced a range of preventive measures in elderly care organizations. Frequent changes in rigor of those measures caused frustration, uncertainty and stress for elderly people, informal caregivers, and healthcare professionals (Szczerbińska, 2020; Van Tilburg et al., 2021). Music therapy was no exception owing to widely divergent measures, even between different departments of the same organization (Comas-Herrera et al., 2020; Verbeek et al., 2020). Common activities in care homes suddenly became questionable, such as singing, physical contact, and proximity. In psychosocial interventions, and specifically in music therapy, these elements can be seen as crucial to treatment. The impact of the COVID-19 pandemic on music therapists working in the USA was thoroughly assessed during the first wave (Gaddy et al., 2020). Changes in employment status and service delivery methods were prevalent. Respondents to the survey worried about financial instability and decreased client contact hours, explored opportunities for telehealth and working individually rather than with groups. However, while more than 85% of respondents (n = 1,054) remained hopeful both generally and with regards to the music therapy profession specifically, perceived stress was moderate (Gaddy et al., 2020). Recent studies showed that music interventions in general, and specifically music therapy, can be offered in adapted ways (Anglia Ruskin University, 2020; Ashley, 2020; Gaddy et al., 2020), but little is known about how restrictions impacted music therapy provision in elderly care and its impact on music therapists in the Netherlands.

Study purpose

The aim of this study was to gain insight into the impact of the COVID-19 pandemic on music therapy provision in care homes in the Netherlands from the start of the pandemic until the moment of filling out the survey (December 2020–January 2021). To this end, the national and regional COVID-19 measures, the impact on the provision of music therapy, and the professional and personal experiences of music therapists working in elderly care were assessed.

Method

Design

In this cross-sectional study, music therapists working in care homes in the Netherlands were asked to fill out an online survey to explore the impact of COVID-19 on music therapy in care homes and on music therapists themselves.

Participants

Music therapists were approached via an existing network of music therapists working in elderly care (Werkveldgroep Muziektherapie in de Verpleging en Verzorging, VV-MT) in the Netherlands (NVVMT, 2022). This network is part of the Nederlandse Vereniging voor Muziektherapie (Dutch Music Therapy Association; NVVMT, 2022).

Ethical considerations

The Medical Ethics Review Board of the University Medical Center Groningen declared the Medical Research Involving Human Subjects Act (Wet medisch-wetenschappelijk onderzoek met mensen, WMO) does not apply to this study (202000721). At the start of the survey, the aim and content of the study were described and digital informed consent was requested.

Data collection

The survey was developed because members of the music therapy in elderly care network (VV-MT) expressed the wish to gain more insight into restrictions and provision of music therapy in other elderly care organizations. The survey that had been conducted in the USA (Gaddy et al., 2020) was adapted to be suitable for the cultural context and the population of music therapists in the Netherlands. The survey was adapted and developed by two researchers and one researcher-music therapist, and subsequently pilot-tested by one music therapist from the board of the music therapy in elderly care network. As this board member is an experienced music therapist (with over ten years of experience in elderly care settings) and the survey was based on a previously distributed survey, the researchers deemed a pilot test by one professional sufficient. The research team selected the questions that were deemed relevant for the Dutch situation. Next, relevant questions were translated by NR. The translations were then discussed within the research team and adjusted if deemed necessary in three steps. First, questions about work setting and target group were adapted, as the focus was specifically on music therapists working in elderly care. Second, questions about music therapy funding, current pay situation, and contact hour impact for other professionals were removed. Third, we adapted the question asking participants to select their three main concerns. Instead, two statements rated on a 5-point Likert scale (1 = never to 5 = always) were asked: “I worry that it will take a long time before I can resume my normal daily life” and “I am currently worried about losing my job or income”. The statement “I feel hopeful about the music therapy profession” was changed into “I am satisfied with my job as a music therapist”. Survey pilot testing demonstrated that it was too long. Questions about personal musical activities were suggested to be removed, as the focus of the survey was music therapy provision. Hence, only four multiple-choice questions about impact of the pandemic (section 6) remained and an open question about the impact on personal musical activities, not related to the music therapy profession, was removed.

The link to the full survey (in Dutch) (available as online supplemental material) was distributed via e-mail by the board to approximately 130 music therapists working in elderly care. While 65 respondents filled in the questionnaire, many were largely incomplete (25% of the surveys were <50% completed). After removal of incomplete surveys and those without informed consent, 49 surveys remained and were included for data analysis, resulting in a response rate of 38%. The survey link was sent on 14 December 2020 and the survey was open until 22 January 2021. An e-mail with a reminder to fill out the survey was sent on 7 January 2021.

Survey

The survey consisted of six sections, with a total of 90 items. Respondents were asked about: demographics (section 1); changes at work throughout the pandemic (section 2); preventive measures and restrictions, and adaptations to the design of music sessions during different waves (section 3); perceived stress (section 4); feelings of hope (section 5); and the impact of the ongoing pandemic (section 6) (supplemental material). In the survey different time points were given: the first wave of the pandemic (March – June 2020), the second wave (July – January 2021), and prior to the pandemic (before February 2020; RIVM, 2021). All waves or periods to which a statement applied could be selected.

To assess stress (section 4), respondents filled out the Dutch version of the Perceived Stress Scale (PSS-10; Cohen et al., 1983). The PSS-10 consists of 10 statements of an individual’s feelings and thoughts in the past month (Cohen et al., 1983). Statements were rated on a 5-point Likert scale (0 = never to 4 = very often), resulting in a single score between 0 (no perceived stress) to 40 (high perceived stress). The scores can be categorized as low (0–13), moderate (14–26), or high perceived stress (27–40; Cohen et al., 1983; Cohen & Williamson, 1988). The PSS-10 has previously been used in a comparable music therapy study (Gaddy et al., 2020). Gaddy et al. (2020) found a good internal consistency of the PSS-10, with a Cronbach’s alpha of 0.89. In the current survey, we added a question following the PSS-10 to indicate to what extent the provided answers had been affected by the ongoing pandemic as well as two questions about worries. Respondents were asked to indicate how frequently they worry about losing their job and how long it would take until normal life would resume.

To assess feelings of hope throughout the pandemic (section 5), the standardized Adult Hope Scale (Snyder et al., 1991) was filled out by respondents. This was consistent with the study by Gaddy et al. (2020). This scale consists of 12 statements that can be rated on an 8-point Likert scale. Four items are fillers; the other eight items are divided in two subscales that represent agency and pathways thinking (Snyder et al., 1991). Agency thinking refers to the determination or mental energy to achieve a certain goal, whereas pathways thinking refers to planning to attain that goal (Hellman et al., 2013; Snyder et al., 1991). Total hope can be calculated from the eight items, which results in a score between 8 (low hope) and 64 (high hope). Gaddy et al. (2020) found a good internal consistency of the Adult Hope Scale, with a Cronbach’s alpha of 0.86. The statement “I am satisfied with my job as a music therapist”, was added to the survey right following the Adult Hope Scale items. This statement was also rated on an 8-point Likert scale to capture respondents’ level of job satisfaction.

Finally, the impact of the ongoing pandemic was assessed (section 6). Respondents indicated on a 5-point Likert scale the level of agreement to four different statements, such as: “The (temporary) stop of musical activities/interventions at work impacted me a lot” and “Changes in being able and allowed to use my (singing) voice at work impacted me a lot.” These statements were followed by an open question: respondents could elaborate on the impact COVID-19 had on their daily work activities. At the end of the survey, respondents could freely describe their experiences with COVID-19 from a professional, musical, or personal perspective. Respondents could choose to leave questions blank.

Data analysis

Quantitative data were analyzed using IBM SPSS 26 Statistics Software. Descriptive statistics were used to analyze answers evaluating demographics, work situation, adaptations to music sessions and impact. Frequencies, median scores, interquartile ranges, and percentages were calculated for the different sections. For all statistical tests a p-value lower than 0.05 was considered statistically significant. For the PSS-10 and the Adult Hope Scale, Cronbach’s alpha was computed to estimate internal consistency of these standardized instruments within this study (Ursachi et al., 2015). In general, a Cronbach’s alpha of 0.70 or higher was considered acceptable (Taber, 2018). For the Adult Hope Scale, the median scores and interquartile ranges of the total scale, the pathways subscale, and the agency subscale were calculated. Spearman’s correlations were conducted to assess the strength of the relationship between hope (Adult Hope Scale) and stress (PSS-10). Between subgroups (based on sex, contract type, education level), differences in hope, stress, job satisfaction, and satisfaction with employer support were assessed using Chi square tests.

The survey included three open-ended questions. In section 3 the respondents were asked “How are you being supported during the COVID-19 pandemic by your employer?”. In section 6 respondents could elaborate on the impact of COVID-19 on their daily work activities. Finally, participants were asked: “Would you like to tell us something about your experiences with COVID-19, from a professional, musical or personal perspective?”. These open-ended questions were analyzed using qualitative content analysis (Vaismoradi et al., 2013). All comments were extracted into an Excel 2016 spreadsheet for analysis. Open coding of the data was applied by two researchers separately, assigning a code to every comment and assigning all codes to overarching categories or themes and subthemes. In the organizing phase, consensus coding was performed by the two coders, discussing their analyses. In case of disagreement, the two coders discussed the issue until consensus was reached. Preliminary results were discussed with a third researcher. In the Results section for each open question quotes have been added to illustrate the content of identified themes.

Results

The survey consisted of six sections, and results will be presented per section: (a) demographics, (b) changes at work throughout the pandemic, (c) preventive measures and restrictions, and adaptations to the design of music sessions during different waves, (d) perceived stress and (e) feelings of hope, (f) the impact of the ongoing pandemic.

Section 1: Demographics

Forty-nine music therapists working in elderly care filled out the online survey. Forty-two respondents were female (85.7%; Table 1). Thirty-eight respondents worked as a part-time employee in a care home organization (77.6%). Most respondents knew a colleague (83.7%) or care home resident (79.6%) who had tested positive for COVID-19, whereas eight respondents (16.3%) had been tested positive for COVID-19 themselves. Demographics of incomplete surveys (25% of the surveys were <50% completed) were not analyzed.

Table 1. Demographics.

Demographics (n = 49)	n (%)
Age (median (IQR) [min-max])	39 (31–54) [23–68]
Gender, female	42 (85.7)
Work experience (years) (median (IQR) [min-max])	7 (2–15) [1–30]
Type of employment
Full time NH music therapy employee	7 (14.3)
Part time NH music therapy employee	38 (77.6)
Independently established music therapist	6 (12.2)
Employed in a non-music therapy function/Other	4 (8.2)
Education level
Bachelor	34 (69.4)
Master	15 (30.6)
COVID-19 experiences
Not been quarantined	31 (63.3)
Tested for COVID-19 at some point	38 (77.6)
Tested positive for COVID-19 at some point	8 (16.3)
Knows at least one colleague who tested positive for COVID-19	41 (83.7)
Knows at least one care home resident who tested positive	39 (79.6)

Section 2: Changes at work throughout the pandemic

For five (10.2%) respondents, no changes in their work situation occurred throughout the pandemic, and seven (14.3%) had prior experience with working from home (Supplemental Table A). During the first wave, 32 respondents (65.3%) were allowed to provide music therapy, which increased to 45 (91.8%) during the second wave. The number of music therapists allowed to provide music therapy sessions in person at the care home almost doubled. It increased from 18 (36.7%) during the first wave to 32 (65.3%) during the second wave. In December 2020 and January 2021, at the end of the second wave, 35 (71.4%) respondents had the same number of contact hours as before the pandemic started (Supplemental Table A). Twenty respondents (40.8%) believed care home residents’ demand for music therapy had increased throughout the pandemic, but these music therapists observed no changes in the type of indication (symptoms) for music therapy. To illustrate, one music therapist indicated, “When therapies were offered again, the requests concerning depression, negative moods increased more and more” (respondent 36). Another music therapist described “[…] I noticed that fear, mood and sense of purpose problems are much more intense [now] and present in larger numbers” (respondent 13). Comments made by these respondents suggest that the medical indication for music therapy remained the same, but the prevalence and severity of symptoms increased among residents. A third music therapist commented that increase in client demand might have been caused by visitation restrictions in care homes.

Five music therapists elaborated on changes in responsibilities or tasks. Three music therapists described how they supported care staff with care tasks whenever needed. One music therapist described how music was part of the psychosocial team to offer support to employees during a COVID-outbreak within the organization. Another music therapist wrote that music therapy had stopped for vulnerable residents to decrease the number of contacts. In December 2020—January 2021, almost three-quarters of the respondents (71.4%) returned to the number of hours they worked before the start of the pandemic. Contact hours for eleven respondents (22.4%) were still less, in contrast to three respondents (6.1%) for whom contact hours increased compared to before the start of the pandemic.

On a 5-point Likert scale, more than half of the respondents (n= 27, 55.1%) were satisfied with the support of their employer (median 4, IQR 3–4; Table 2). Sixteen respondents (32.7%) were neither satisfied nor unsatisfied. Six respondents (12.2%) were unsatisfied. Forty-three respondents (87.8%) described how they were supported by their employer, for which six different themes were identified during qualitative content analysis (Table 2). Most comments related to theme 1, personal/mental support offered by the employer (17 respondents, 32.1% of the comments). For example, one music therapist described: “Psychological help can be offered. I can also contact my employer with questions” (respondent 17). Ten different respondents (18.9%) commented on theme 2: measures and protective equipment. Experiences were both positive and negative: “Support is well, when it comes to testing or not. Taking care of yourself. Less well, when it comes to obtaining protective measures and guidelines when you work in different locations, as they are not always clear” (respondent 29). Eight respondents (15.1%) commented on theme 3: flexibility to adapt: “There is a lot of understanding and consideration is given to other interpretations. I experience a lot of support and trust from my employer” (respondent 38). Seven respondents (13.2%) commented on theme 4, facilities and communication: “We get almost daily updates regarding the measures, messages from the board of directors, there are more meetings and all departments stay alert” (respondent 36). Another seven respondents (13.2%) commented on the provided support. Five of these respondents (9.4%) described support as absent or minimal. Four respondents (7.5%) stressed the importance of appreciation and recognition by their employer.

Table 2. Themes and quotes describing support of employers throughout the pandemic.

Satisfaction with employer support		n (%)
Unsatisfied		6 (12.2)
Not unsatisfied/not satisfied		16 (32.7)
Satisfied		27 (55.1)
Theme	n (%)	Examples of quotes (43 unique quotes)
Personal/mental support	17 (32.1)	“Short lines with team & management, extra support possible from psychology & spiritual care departments.” (respondent 7)
Measures and protective equipment	10 (18.9)	“I think it’s done optimal: the guidelines within the one location where I work are clear. Not nice, but clear.” (respondent 19)
Flexibility to adapt	8 (15.1)	“I am given space, people are thinking along, they do not work against you.” (respondent 16)
Facilities and communication	7 (13.2)	“We receive almost daily updates regarding the guidelines, messages from the board, there are more meetings and all disciplines keep an eye on each other.” (respondent 36)
Evaluation of provided support	7 (13.2)	“Not, only antagonized.” (respondent 24)
Recognition and appreciation by employer	4 (7.5)	“There is a support line, a psychosocial support team at the location and employees regularly receive encouraging emails and/or presents.” (respondent 33)
Total	53 (100%)

Section 3: Restrictions and adaptations to music sessions

Twenty different measures were deployed to continue music therapy as much as possible throughout the pandemic (Supplemental Table B). Some measures were already part of day-to-day practice prior to the pandemic, including group sessions of limited size. The median number of restrictions in the first wave was 7 (IQR 5–8.5). Restrictions including no physical contact with clients, no use of music instruments, no group sessions, and the music therapist wearing gloves were deployed more during the first wave than during the second. During the second wave, almost all music therapists had to deploy social distancing, disinfect hands and instruments, and wear a face mask (median restrictions 8, IQR 6.5–9). In most organizations, residents from different care home units (CHUs) were not able to participate together in groups. The most prevalent adaptation to music sessions was to provide sessions in a common room (79.6%), in smaller groups (67.4%), for more (individual) residents than usual. That is, more sessions were provided on an individual basis rather than in a group, which temporarily led to more residents being referred for individual music therapy than before the pandemic) (65.3%) and to more frequent use of pre-recorded playlists (65.3%). Since the start of the pandemic, respondents mainly spent more time on developing new skills (50.0%) and attending online training/education (42.5%), which might be the result of reduced client contact hours.

Section 4 and 5: Perceived stress and feelings of hope

The second part of the survey investigated the impact of the pandemic on the music therapists. Forty-six respondents completed the PSS-10 questions concerning stress. The median score was 13.5 (IQR 10–18), with a range from 1 to 33, indicating low perceived stress. Cronbach’s alpha showed good internal consistency of the PSS-10 (α = .88). The subscales of the Adult Hope Scale, Agency thinking (n = 46) and Pathways thinking (n = 47), had median scores of 25 (IQR 23–27) and 26 (IQR 24–28), respectively. The sum of the subscales results in a total hope score. In this sample, the minimum total hope score was 41 and the maximum score 64, with a median of 51 (IQR 48–55), indicating moderate to moderately high hope. All respondents agreed to some extent with the statement “I am satisfied with my job as a music therapist” (8-point Likert scale, with 1 = definitely untrue, 8 = definitely true), median 7 (IQR 6–8). When added to the hope scale, internal consistency increased slightly (α = .82). There was a medium to strong positive correlation (r = .54, p < .01) between job satisfaction and total hope score.

Correlational analyses between sum scores of the Adult Hope Scale and the PSS-10 indicated a significant negative correlation, r(44) = −.39, p < 0.01. The subscales Agency and Pathways both indicated a significant negative correlation, r(44) = −.37,  p < .05 and r(44) = −.33, p < .05, respectively. Pearson’s Chi Square test showed relationships existed between the stress category (low or moderate) and hope category (X² (2, N = 45) = 6.52, p < .05), job satisfaction (X² (3, N = 46) = 11.11, p < .05), and employer support satisfaction (X² (1, N = 31) = 6.98, p < 0.01). Job satisfaction was related to the hope category (X² (6, N = 46) = 23.58, p < 0.01) and to employer support satisfaction (X² (3, N = 32) = 11.26, p < 0.01). No significant differences in perceived hope, stress, job satisfaction, and satisfaction with employer support were found between subgroups based on sex, contract type, and education level.

Section 6: The impact of the ongoing pandemic

The results of the questions about the impact of the pandemic and restrictions in music making and singing both as a professional and as a personal leisure activity are shown in Supplemental Table C. Especially the impact of not being allowed to freely use one’s (singing) voice (65.2%) and stopping of music activities on the job (67.4%) impacted a lot of music therapists. Interestingly, opinions about (unexpected) positive professional consequences largely varied (disagree 37.0%, neutral 37.0%, agree 26.1%). To illustrate, one music therapist had mixed feelings: “One day I was the ‘expert’, and the next day it was as if that was not important in times of crisis” (respondent 32). First, positive consequences were discovered for individual music therapists. For example, one music therapist mentioned: “My creative abilities and flexibility as a music therapist have grown enormously” (respondent 34). Another therapist mentioned: “Personally, the measure working from home for administration and planning comes in handy. It brings peace and space and traffic congestion can be avoided. Working from home does not benefit communication, so that is a disadvantage. This led to more support for working online” (respondent 1). Second, positive consequences for the care home were experienced: “I found that music (therapy) has given a lot of support for both clients and staff on the cohort [isolation]” respondent 13). Third, digital possibilities were mentioned as a positive consequence by one music therapist: “Within music therapy, it has also shown at work that a lot is possible digitally. New developments in that field have come about in an accelerated form, which I have also experienced as pleasant” (respondent 42).

There was significant overlap in responses to questions concerning impact on daily work activities and the question to elaborate on experiences from a professional, musical or personal perspective. Results of the open-response questions to elaborate on the impact on daily work activities and the impact of the pandemic so far in personal, professional, or musical experiences are presented in Table 3. Thirty-five respondents (61.2%) provided answers on the open-ended questions. Qualitative content analysis of these comments resulted in five themes and nine subthemes (Table 3).

Table 3. Impact of the pandemic from personal, professional and musical perspectives.

Theme/substheme, n (%)		Quotes (45 unique quotes)
Burden 19 (29.7%)
Emotional strain (10)		“[…] experiencing of the sick residents and the capriciousness of and unfamiliarity with the virus brings up many emotions.” (respondent 27)
Burden/workload (3)		“[…] I went on and on, as it were. I noticed that I myself was often more irritated in the evenings because all day long all the stress, sadness and anger of both care workers and clients was projected onto me.” (respondent 36)
Impact on job satisfaction (6)		“[…] singing with people, working in groups and being close to people, are all not possible. Because of this, I’m not in my power, and that has had an effect on my job satisfaction and the feeling that I can be of significance.” (respondent 32)
COVID-19 measures 15 (23.4%)
General measures (8)		“I really hope […] that I can really be near people again without thinking, without keeping 1.5 m distance and without having to wear a face mask.” (respondent 41)
Singing during COVID (7)		“It is particularly difficult for me not to be allowed to sing and to have to wear a face mask all the time, and to keep my distance.” (respondent 11)
Contact and connection with clients 14 (21.9%)
Contact with others (4)		“What I miss the most is the contact with colleagues.” (respondent 38)
Continuity (10)		“ […] you are no longer allowed to do your own work (all treatments have been stopped), being deployed in other work, not knowing what is expected of you, etc.” (respondent 25)
Positive aspects of the COVID-19 pandemic 12 (18.8%)
Developments and creative solutions (3)		“[…] a lot is still possible digitally. New developments in that area have come about in an accelerated form[…]” (respondent 42)
Positive perspective (9)		“[…] my creative ability and flexibility as a music therapist have grown enormously. […]” (respondent 34)
The impact of music 4 (6.3%)
		“Experiencing that music (therapy) gave a lot of support for both clients and staff at the cohort. ” (respondent 13)
Total: 64

Burden

The first and most prevalent theme concerned burden (19 unique comments by 15 respondents, 29.7%), divided in the subthemes emotional strain (“A lot of working from home behind a laptop, little or no contact with colleagues, not having lunch together, frequently canceled sessions because the department was infected, a lot of grief about death and sick residents. In the first period I was a bit in shock”, respondent 15), burden/workload (“It was a busy and tiring time in which there was a lot of extra pressure at work.”, respondent 22), and impact on job satisfaction (“I miss the group activities: singing and moving together. I notice I cannot offer the quality I would like.”, respondent 49).

COVID-19 measures

Next, 12 respondents (15 comments, 23.4%) commented on the COVID-19 measures taken by the nursing home organizations, subdivided in general measures (“Good solutions are not thought of, it’s just blindly following rules that lead nowhere and have a major impact on the well-being of residents”, respondent 43) and singing during COVID (“There’s still a lot of ambiguity about the use of the voice and singing. Having to stop choral singing was difficult. Always pay attention to everything at work and singing with a face mask is also difficult”, respondent 6).

Contact and connection with clients

The third theme, continuity, entails 14 comments (21.9%) of 12 different respondents, subdivided into contact with others (“Not being able to see many colleagues because we are working from home a lot often makes me gloomy and sad. Contact is so important, both professionally and on a personal level.”, respondent 8) and continuity (“Working in your own practice has many advantages. The downside in this pandemic is that people who are already vulnerable are now quickly withdrawing from treatment and developing problems that are more serious. After the first wave, I came back to people who had bigger problems than before the pandemic.”, respondent 28).

Positive aspects of the COVID pandemic

The fourth theme, addressed by 11 respondents, concerned positivity (12 comments, 18.8%), subdivided in developments and creative solutions (“Covid has made me aware of the fact that the entire society can suddenly look very different. Everything is upside down. The advantage is that you can sometimes come up with very creative solutions but, in general, they are no improvements.”, respondent 8) and positive perspective (“At the beginning of June I gave a concert as a saxophonist, accompanied by a pianist, in a large church hall. This was just after the first lockdown and the public was allowed to join, but they were still precautious. Yet everywhere I looked there was someone sitting, like small islands scattered across the church hall. I thought that was special to experience and yet, despite everything, an optimistic image”, respondent 11).

The impact of music

Finally, four respondents (6.3%) stress the impact of music during these times: “Music connects and offers comfort to others also to staff!” (respondent 14) and “ … I am also very grateful that you can mean so much to people in this time” (respondent 22).

Discussion

In this study, we explored the impact of the pandemic on music therapy in elderly care in the Netherlands, up to the end of the second wave in January 2021. Twenty different measures were deployed to adapt and continue music therapy throughout the pandemic. During the second wave, almost all music therapists had to apply social distancing, disinfect hands/instruments, and wear a face mask. In most cases, group sessions with residents from different CHUs were not allowed. Prevalent adaptations were to provide music sessions in a common room (79.6%), in smaller groups (67.4%), for more (individual) residents than usual (65.3%), and to use pre-recorded playlists (65.3%). Music therapists in this sample experienced low stress and were hopeful, despite the substantial impact of the pandemic on their personal and professional musical activities. Fortunately, almost all respondents (91.8%) were allowed to facilitate music therapy sessions – albeit adapted to restrictions – during the second wave, as opposed to only 65.3% during the first wave.

As a result of the restrictions and measures, creativity was expected from intervention providers to still offer therapy. An adaptation often heard in other healthcare settings worldwide was to transfer sessions from face-to-face to an online setting, despite numerous limitations (Agres et al., 2021; Kantorová et al., 2021). In the sample of Gaddy et al. (2020) telehealth was often used (55%) as an alternative service. In the current sample, providing music therapy online was not prevalent: only eight music therapists (16.3%) offered music therapy online during the first wave, and only one provided sessions online during the second wave (2.0%). Online music therapy might be hampered by several barriers. To illustrate, Philip et al. (2020) identified multiple barriers for transferring choir rehearsals for people with COPD from face-to-face to an online setting. Challenges can relate to digital access and digital literacy, and it can be more challenging to establish relationships, achieve group motivation and cohesion in an online setting (Philip et al., 2020). Challenges identified in transferring music therapy for home-dwelling people with dementia to an online setting concern sharing instruments, singing together, engaging online, and adapting non-verbal communication (Molyneux et al., 2020). These aspects may be even more challenging when working with older people with dementia living in a care home.

While online music therapy did not expand, the demand for in-person music therapy did increase according to many respondents (n = 20). One therapist mentioned visitation restrictions as a possible cause, which is confirmed by Van Tilburg et al. (2021), who noted an increase in loneliness amongst elderly people in the first wave. Other studies reported that staff noticed an increase in severity of neuropsychiatric symptoms (NPS; Simonetti et al., 2020; Van der Roest et al., 2020), which is often a reason for referral to music therapy treatment. However, changes in NPS may vary per care home, as McArthur et al. (2021) found no significant impact of lockdown on NPS.

This sample of music therapists reported low stress during the second wave of the COVID-19 pandemic. Stress scores in the current sample seem lower than in the US sample (median score of 13.5 versus mean score of 20.1) reported by Gaddy et al. (2020), although this probably has to do with the timing of the survey (first versus second wave). To illustrate, a comparable moderate perceived stressed score (19.2) was reported during the first wave in a sample of frontline nurses (n = 176; Pasay-an, 2020). Respondents in the current study reported feeling moderately to very hopeful, as did respondents in the USA in the first wave (Gaddy et al., 2020). Two decades ago, Snyder et al. (1991) found that people with higher hope scores remained more hopeful in stressful situations compared to people with lower hope scores. A possible explanation for hopefulness in the current sample might be the relatively low risk to lose one’s job in a contracted position. In addition, we take into account that personal issues from daily life exerted an influence on respondents’ answers. The personal impact of the COVID-19 pandemic may be comparable for music therapists across the world. However, since the work situation for music therapists in the Netherlands as well as in the United States might have differed before the start of COVID-19, it is difficult to compare practical changes between Dutch music therapists and their American counterparts with regards to the current pandemic (Gaddy et al., 2020). However, a difference worth mentioning is that in the Netherlands, music therapists are often contracted employees at care homes, making the threat of losing their job or income less prominent.

When Dutch music therapists were asked about their satisfaction with their job and employer support throughout the pandemic, more than half of the respondents were satisfied. Along with low perceived stress, these are beneficial conditions for music therapists’ mental health (Maben & Bridges, 2020). The majority of respondents felt supported by their employer during the pandemic (Table 2). Feeling supported and recognized by the healthcare team is a protective factor for mental health (De Kock et al., 2021). Other protective factors identified in this review concerned: experience with prior outbreaks, availability of adequate protective equipment and good guidance by superiors. Possible risk factors concern the point in the pandemic curve, increased working time, and risk of frontline exposure. The combination of mild presence of risk factors and strong presence of protective factors as described by De Kock et al. (2021) can explain the low stress, high hopes, job satisfaction and satisfaction with employer support found in the current study. Similarly, Newman et al. (2021) found that frustration and distress were lower in care staff that felt supported by their employer. Elderly care professionals’ experiences during the pandemic show similar themes around the world. For example, similar themes have previously been identified in nurses from Italy, Mexico, Peru, and Spain during the first wave (Sarabia-Cobo et al., 2020). These restrictions may even lead to professionals experiencing vocal tiredness or impairment and avoiding use of voice (Ribeiro et al., 2020). Respondents experienced feelings of fear, uncertainty, emotional exhaustion, commitment, and sense of duty. Not being allowed to use their singing voice and wearing a face mask at work had a major impact on many respondents: “I really hope that the vaccinations will make the situation controllable again. So that I can really be near people again without thinking, without keeping 1.5 m distance and without having to wear a face mask.” (respondent 41) and “Singing daily with a face mask is very tiring. Not being able to show your emotions through the face mask to people with dementia is intense. […] The work has become emotionally much more difficult” (respondent 18).

Strengths and limitations

A methodological strength of this study was the combination of quantitative and qualitative data of the questionnaires. Open comment sections offered complementary insight into experiences of music therapists in the first and second wave of the COVID-19 pandemic. This study offered insight into measures and restrictions applied over time to adapt music (therapy) sessions during a pandemic. This can offer valuable insights into decisions concerning adaptations to clinical music (therapy) trials that took/take place during the pandemic (Papatzikis et al., 2020). A limitation during the development of the survey is that it was only pilot-tested by one music therapist. Other limitations of this study were the small sample size and the low response rate, which may have resulted in a skewed representation of the situation for the provision of music therapy in elderly care in the Netherlands. Previous studies found that online questionnaires may result in a lower response rate (Draugalis & Plaza, 2009; Fincham, 2008), although there may be other causes, for example, the questionnaire was sent out just before the Christmas holidays and non-respondents may have been pre-occupied with COVID-19. The survey of Gaddy et al. (2020) yielded a 15% response rate, although the sample in the current study concerned a much smaller and very specific subgroup of music therapists. A response rate of 30% was expected to be sufficient to make reliable statements about the opinions and experiences of music therapists (Lindemann, 2019; Nulty, 2008). There may also be recall bias, as respondents were asked about experiences with the first wave during the second wave. It should be noted that the exact number of music therapists connected to the network at the time the survey link was sent was not known. Due to privacy regulations, the research team did not have access to the data (the mailing list), entailing the exact number of members included in the mailing list, nor to the exact number of music therapists. Upon inquiry, it turned out that the board also did not know the exact number of music therapists included in the mailing list. Hence, the response rate may even be lower than 38%. Another limitation was the high number (25%) of incomplete surveys (of 65 only 49 were completed). The survey was quite extensive as it consisted of 6 sections and 90 items. The length of the survey and the sensitivity of the subject may have deterred some respondents. The framing of statements in section 6 of the survey may have affected responses, as three out of four statements were negatively formulated (Supplemental Material).

Conclusion

This study shows that music therapy has largely resumed in care homes by the end of the second wave, albeit with a range of preventive measures implemented in the daily work routine. Quantitative findings from this study demonstrated that the COVID-19 pandemic did not lead to high stress and low hope in the current sample of Dutch music therapists, while the qualitative themes gave an impression of tough and stressful experiences during the first year of the COVID-19 pandemic. The pandemic shed light on the adaptability of music therapy as a treatment during stressful times. It demonstrates that music therapists are resilient professionals, for which employer support and availability of resources may be an important requirement. Future research may aim to create an overview of the preventive measures, restrictions, and subsequent adaptations to the provision of music sessions taken in different countries. Future research could further investigate the role of singing in music-based interventions, the impact of singing with a face mask on singing quality, and verbal, non-verbal, and musical communication. In addition, barriers and facilitators to the use of online music therapy sessions in people with dementia should be further investigated. Finally, it would be valuable to assess the impact of music therapy during the pandemic on care home residents themselves.

Acknowledgments

We thank the music therapists who participated in our study for their valuable insights and for sharing their experiences.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/08098131.2022.2084637

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

No funding was received for this study.

Notes on contributors

Naomi Larissa Rasing

Naomi Larissa Rasing has been trained as a music therapist and psychologist and works as a PhD researcher at the department of General Practice and Elderly Care Medicine at the University Medical Centre in Groningen, the Netherlands.

Sarah Janus

Sarah Janus has been trained as a psychologist and health scientist and works as a researcher at the department of General Practice and Elderly Care Medicine at the University Medical Centre in Groningen, the Netherlands.

Annemieke Vink

Annemieke Vink has been trained as a psychologist and works as a music therapy researcher and teacher at the Department of Music Therapy, ArtEZ University of the Arts, Academy of Music, Enschede, the Netherlands.

Sytse Zuidema

Sytse Zuidema is a professor on Elderly Care Medicine and Dementia at the Department of General Practice and Elderly Care Medicine at the University Medical Center Groningen.