Oncology Staff Reflections about a 52-Year-Old Staff Christmas Choir: Constructivist Research

Introduction

Caring for patients with cancer can be exciting yet stressful as staff deal with patients' symptoms, prognostic uncertainty, and psychosocial adjustments.^1,2 While the 5-year-survival rate from cancer is above 56%, in the United States and Australia many patients still die, ³ including in cancer settings (approximately 150 inpatients die at the Peter MacCallum Cancer Centre each year). Regular exposure to loss can elicit staff members' previous losses, existential questioning,^4,5 and natural grief.^1,6 Compassion fatigue, secondary traumatic stress, ⁷ and burnout^2,6,8,9 may result, adversely affecting emotional well-being and empathy. ⁷ Busy workloads, lack of support, role ambiguity, and interpersonal conflict can also increase vulnerability.^2,8,9

Helpful oncology staff support modalities include overhearing/witnessing ward-based music therapy, ¹⁰ a “participator action approach” intervention focused on helping staff cope, ² and subsidized complementary therapies, although access can be problematic. ¹¹ Public music performances are common in hospitals ¹² yet no research on their effects was found. This is surprising given music's connection with health throughout the ages^13–15 and the neural correlates of music and mood alteration. ¹⁶ Examination of resilience building components of oncology work environments is vital for optimizing staff well-being and retention. This includes the effects of a staff choir.

Peter MacCallum Cancer Centre's staff Christmas choir has performed annually since 1956. Our study examined the choir's effect on patients, visitors, staff choir members, and staff bystanders in 2008. Findings from 111 patient and visitor respondents were published elsewhere, ¹⁷ with 93.7% indicating positive emotional and reminiscent responses. Several described transformative reactions, affirmation of the Christmas message and peaceful or “enlivened” social atmospheres. ¹⁷ This article reports the staff findings: What is the effect of the staff Christmas choir on staff choir members and staff bystanders?

Method

Peter MacCallum comprises 94 inpatient beds and outpatient clinics. Any staff member can join the choir and weekly rehearsals commence around October (see Table 1 for 2008 program). Membership invitations are through staff e-mails, hospital newsletters, and posters.

In 2008, the choir's seven performances were in inpatient wards, outpatient areas, and the staff cafeteria. Performances lasted 40 minutes and averaged 20 singers and 6 instrumentalists; 30 performed throughout the season.

The research approach was constructivist (qualitative) ¹⁸ and informed by grounded theory. Constructivism acknowledges that people's interpretations can differ according to their backgrounds. Knowledge emerges through systematically condensing interpretive data. ¹⁸ Grounded theory methodology promotes explanation of phenomena through purposive (theoretical) sampling,^18–20 and inductive, comparative and cyclic data analysis.^19,20 A grounded theory is generated upon data saturation; when not saturated the methodology can enable thematic representations of findings. ²¹

Convenience and limited purposive sampling were used. A researcher invited choir staff to participate at rehearsals and staff bystanders at performances. Staff who mentioned negative or neutral thoughts were especially urged to participate to maximize data variation. Respondents completed an anonymous, semi-structured questionnaire (Table 2). The conductor was interviewed and a researcher noted reactions to choir performances. The conductor, staff choir, and bystander responses were analyzed with software support. Qualitative interrater reliability ²² was performed. Local ethics approval was obtained.

Results

There were 65 responses including the conductor's interview (see Table 3 for demographic features). Fifteen choir members responded. During performances most bystanders continued working in wards and outpatients, occasionally stopping and listening. Many welcomed the choir; some looked bemused or disinterested. Approximately 60 staff members attended the cafeteria performance. The conductor of 29 years, a classically trained musician and radiation therapist, aims to maximize staff performance and enjoyment through altering the repertoire according to staff abilities and using banter. Emergent themes, with examples of responses informing each theme follow.

Staff Choir Members

Staff Bystanders

Discussion

This qualitative study examined responses from oncology staff Christmas choir members and staff bystanders who heard their performances, were aware of a questionnaire, and motivated to participate. Responder bias of unknown direction was possible. Nonetheless, in a cancer context described by staff as sometimes “overwhelming” and “stressful,” the choir was positive for virtually all respondents.

Many described how the choir helped them to feel closer to patients and other staff. Cohesion is arguably maintained through social, cultural, and symbolic elements contained within music's sonic components throughout time. ²³ Music's capacity to unexpectedly unify was elucidated by Mount ^{24 (p35)} when “in temple with” 15,000 people at an Elton John concert “bursting with happiness, with presence to the moment,” despite acrimonious lyrics. The power of musical communication arises from its “multiplicity of possible messages and interpretations,” ^{25 (p91)} explaining the widely varied findings. Furthermore, lyrics that offend one person may comfort another, such as, “He died for our sins.”

Witnessing positive emotions in patients and visitors aroused joy in some respondents, possibly explained by mirror neurons: witnessing others' emotions may activate one's comparable neural areas. ²⁶ Only two were concerned about the choir's possibly intrusive effects: a Christian and another respondent with unstated religious background. Some staff, however, may have not described further negative reactions fearing they would offend.

A limitation was the small proportion of evidently non-Christian respondents. Purposive sampling of staff with varied ethnic backgrounds is recommended in future research. Palliative care research indicates that staff are willing to disclose religious backgrounds,^27,28 however, 34% did not provide any information here. While some may have felt uncomfortable, the questionnaire statement that this information was “optional” (Table 2) likely discouraged responses.

The findings were comparable with music therapy's supportive effects on staff bystanders.^10,29,30 Oncology managers may promote staff resilience through musically enhancing hospital environments, including through ward-based music therapy, and performances by musically accomplished staff and community members which include Christian and non-Christian celebrations. Continuing research on hospital music performances is necessary: different performances/contexts may produce different findings.

In summary, the staff Christmas choir was a positive experience for almost all oncology staff respondents and comparable choirs should be encouraged for supporting staff in similar contexts.