‘The people in the purple shirts’: Froebelian insights to a Singing Medicine project in a children’s hospital

Froebel’s Mother Songs

Froebel placed emphasis on singing as a pedagogical tool and emotional conduit (Powell et al., 2013). In 1843, he published his book of songs and instructions for mothers of babies and very young children, ‘Mutter und Koselieder’ (Mother Songs) (Froebel, 1843). The songs are accompanied by play games in the form of hand or finger exercises. Froebel argued that the act of singing to babies was a means to convey motherly feelings of love and care; that singing (his) songs could stir latent emotions, which he believed women were biologically predisposed to feel; and that the content of his songs helped both women and babies to understand their place, role and purpose in the world and connectedness to their surroundings and their (divine) creator. In addition to aiding bonding and connectedness between mothers and infants, the actions involved in the games and exercises were designed to encourage infants to use their sense, limbs and whole body. This in turn he argued would strengthen the limbs, body and senses, leading to a more purposeful use of them, an awareness of things as they are and consideration of them. These sensori-motor activities provide the bases for mental activity (including perceptual judgement, logical thinking and abstract thinking; Liebschner, 1992).

Froebel suggested that children must be taught the form and shape of artefects and symbols since once these are known their own imagination, rather than adult direction could and should drive learning through play emphasising children’s agency and control over their own learning (Manning, 2005). The role of education was to excite and empower children and the expectation was that children would demonstrate and exhibit this excitement and empowerment in other areas/contexts of their life. Excitement and empowerment are arguably most effectively achieved through play (Bruce, 2011). Vitality and excitement, Froebel suggested are inextricably linked to play which has a transformative potential uniting human beings, god and nature in a way that is both mystical and spiritual (Lilley, 1967; Whitbread, 1972). Froebel (1974 [1826]) argued that

Play is the highest phase of child development – of human development at this period. Play is the purest, most spiritual activity of man at this stage, and, at the same time, typical of human life as a whole – of the inner hidden natural life in man and all things. It gives, therefore, joy, freedom, contentment, inner and outer rest, peace with the world. It holds the sources of all that is good. (pp. 54–55)

In contemporary early years practice, singing has been found to provide a medium for intimacy and connectedness between practitioners and infants in the manner suggested by Froebel (Powell et al., 2013). For children with long-term chronic ill-health requiring hospitalisation and medical intervention, the possibilities for access to play and creativity may be limited, highlighting potential inequities in social determinants of health (APPGAHW, 2017b) which include access to creative and cultural activities. These inequities can be mitigated through involvement in participatory arts in health projects such as the SM project (APPGAHW, 2017a: 30):

The arts provide a route to better health and wellbeing while health provides a route to the arts that can help to overcome persistent inequalities of access.

APPGAHW (2017b) and Fancourt (2017) suggest a wide range of socio-medical, education and psychological benefits for children from participation in arts in health projects not least providing a medium through which they can exercise control and agency over their life in an environment where acute care focuses on survival, recovery and rehabilitation rather than personal choice.

Consent

Central to the issue of consent is the concept of informed consent, which relies on potential participants being fully informed of all the relevant issues relating to a study prior to providing formal consent. Diener and Crandall (1978) define informed consent as,

The procedures in which individuals choose whether to participate in an investigation after being informed of facts that would be likely to influence their decisions. (p. 57)

The fundamental importance of consent, freely given, to research participation reinforces the view that the researcher should always explain fully the purpose, process and intended outcomes of research and seek consent on that basis (Mason, 2004). Furthermore, participants should be competent to make decisions relating to participating in research, make such decisions voluntarily, without pressure from researchers or research funding bodies, and fully comprehend the nature of the study and the implications of its outcomes to them personally (Cohen et al., 2007). It could be argued that in the absence of such comprehensive and thorough informed consent, participants are more accurately described as ‘research subjects’ than ‘research participants’ (Smyth and Williamson, 2004).

In this study, adult participants were provided with full information relating to the nature of the study, how it would be conducted, how data would be stored and their right to refuse consent and withdraw from the study at any point. The implications of the outcomes of the study for them, including how the study would be disseminated, their right to confidentiality and anonymity during and after the study, and details of the sponsors of the study (The Froebel Trust) were discussed. Information relating to the study was provided in advance of seeking consent, in order that participants had sufficient time to consider the implications and information prior to giving consent. Children’s and adults’ identities have been protected with the use of pseudonyms in all documents and dissemination material. Data were stored securely and password-guarded.

Consent with children

Consent is a key issue in research with children which raises hard, often unresolved, questions (Alderson, 2004). For example, there is no simple answer to the question of when children are old enough to give consent. Within the United Kingdom, the term ‘child’ means anyone below the age of 18 years. The 1948 United Nations Convention on Human Rights and the 1989 Convention on the Rights of the Child (United Nations, 1989) granted rights to children between the ages of birth to 18 to have their wishes known, listened to and respected. The dilemma for researchers is that the perceived ability of a child to give consent will depend not just on an individual child’s chronological age, but also on their level of understanding. Requiring high levels of understanding for a valid consent, however, could operate to exclude research with children (particularly those who might be described as vulnerable) unless an adult has consented on their behalf (Mason, 2004). This poses an ethical dilemma for researchers, which required reflection.

While on the one hand researchers need to develop ways of engaging children in a wide range of different circumstances, on the other hand in order to obtain high-quality information, they must also ensure that children’s rights are safeguarded (Mason, 2004). In this respect, young children in hospital settings are surrounded by adults who have a legal responsibility to act as ‘gatekeepers’, safeguarding them from outside influences, such as researchers, and arguably, guarding their free choice of whether or not to participate in research (Mason, 2004). Children of all ages are subject to the control of those who have parental responsibility for their welfare and safeguarding. Legally, researchers who wish to include young children who are not considered mature enough (chronologically or developmentally) to make their own decision about participation must obtain the agreement of a least one person who has parental responsibility for the child (Mason, 2004).

Thus, gaining access to children in a hospital setting for the purposes of investigating an issue relevant to them entailed a multi-staged process involving negotiation with a number of adults. In this study, consent was sought first from the professionals responsible for individual wards and the parents and carers of children who consented to participate in the study. Fine and Sandstrom (1988) urged that researchers nevertheless provide such children with an explanation of their involvement as,

. . . children should be told as much as possible . . . their age should not diminish rights, although their level of understanding must be taken into account in the explanations that are shared with them. (p. 46)

Consequently, in this study, simple explanations were provided to children that an adult would be watching the SM sessions because she was interested in how they supported children and families. For child participants (for non-participant researcher observations), children and their parents were informed when the researcher was on-site and asked by health professionals whether they were happy for any session they participated in to be observed. Only those sessions/children and parents who consented were observed.

In addition, the notion of assent was considered appropriate in addition to the adult safeguarding described earlier. It must be stressed that none of the children observed were either non-verbal or un/semi-conscious.

Assent

Young children can be quite demonstrative in expressing their views, even if they do not verbally reject a researcher’s presence or questions. They can, for example, move away from a person they do not wish to be near (Aubrey et al., 2000), refuse to answer questions, change the topic of conversation or in extreme cases be physically aggressive if they feel particularly unhappy about situations. The decision to adopt an ongoing process of assent whereby the child’s acceptance of the researcher within the hospital spaces was taken as assent to participate in the research was considered appropriate. Health professionals and parents were considered competent, as caregivers, to make ongoing judgements regarding any unwillingness on the part of children to participate or distress exhibited by children in relation to the researcher’s presence, and to allow withdrawal from observations when deemed necessary. Assent is not a term which sits comfortably with all researchers, some of whom argue that it may be used where children are simply too afraid, confused or ignored to refuse (see Alderson and Morrow, 2011). This indirect approach for assent/dissent has been successfully used within other studies involving children with developmental delays/disorders (Beresford, 1997; Brooks, 2010; Konaka, 2007). As a practitioner and sensitive professional, the researcher was mindful of her duty to be respectful of children’s rights, views and well-being in the planning and conduct of this study.

Additional concerns related to participants who may be emotionally and psychologically vulnerable due emotional and physical stress due to providing long-term care. To reduce the power relations between the researcher and the participants in this study, participants were not approached initially directly by the researcher in order to avoid placing undue pressure on professionals, parents and children. Rather invitations to participate were issued by the vocal tutors (for professionals) and by health professionals (for parents and children). An information leaflet and consent form was provided to professionals and parents prior to any visits from the researcher. Only those parents and professionals who had indicated an interest in participation were contacted by the research to follow up. The researcher was mindful of the effect of her presence on hospital activity and sensitive to being as non-intrusive as possible.

The researcher familiarised herself with Hospital safeguarding procedures and a Research Passport was obtained from the Hospital before data collection commenced which offered an additional layer of ethical and safeguarding protection. In addition, the researcher joined the vocal tutors in the surgical scrub, gown and glove procedure before entering and after leaving any hospital spaces (cubicles, wards and playrooms) to reduce any infection risk in line with hospital and SM policy.

Ethical approval was given by the Faculty of Health, Education and Life Sciences Academic Ethics Committee and North of Scotland Research Ethics Service.

Interviews

In total, 13 participants were involved in semi-structured interviews as shown in Table 1.

OPEN IN VIEWER

Table 1.

Details of participants.

Participant number	Job title	Age	Length of time working at BCH	Description of children working with
Interview 1	Play facilitator role involves normalising play	26	10 months	Aged 0–7 but mostly aged 0–5 – specialised medicine – anything from gastro problems to bronchiolitis, failure to thrive, neuro problems
Interview 2	Research nurse co-ordinator, intensive care	40	15 years	Birth to 16 with cardiac defects, having cardiac surgery or just under the cardiology team
Interview 3	Family liaison nurse	27	4.5 years	Wide range of children from cardiac, trauma, respiratory, children who are ventilated, intubated and experience short-term and long-term stays
Interview 4	Clinical lead nurse (PICU)	50	6 years	Birth to 16 (sometimes 18), caring for the sickest children in the hospital/country – in the largest PICU in Europe
Interview 5	Sister haemodialysis unit	55	20 years	Birth to 18 – Children are categorised by weight because renal failure limits growth – so 4–70 kg
Interview 6	Chaplain	53	11 years	All children, families and staff in the hospital
Interview 7	Physiotherapist	26	12 months	Children aged birth to 18 across a range of wards
Interview 8	Senior chaplain	57	15 years	All children, families and staff in the hospital
Interview 9	Play worker	25	18 months	Children aged 7–16 years (occasionally up to 18 years)
Interview 10	Consultant paediatrician interventionist	39	7 years	Specialist children’s intensive care for children aged birth to 18
Interview 11	Play worker/family support worker	37	5 years	Children aged birth to 18 on the intensive care unit
Interview 12	Consultant paediatric liver specialist	49	13 years	Children aged birth to 18 who are treated on the liver unit
Interview 13	Teaching assistant	50	9 years	Works in the school on-site on the oncology unit on a one-to-one basis with children aged 4–11 years who have cancer or leukaemia

BCH: Birmingham Children’s Hospital.

The participants were aged from 27–56 years old and held varied professional roles within the Hospital. They had worked in the hospital for varying lengths of time from a few months to two decades and worked with children from birth to early adulthood. The majority of participants were female with only the senior chaplain, the consultant paediatric liver specialist and the consultant paediatrician interventionist being male. Findings from interviews will be reported under the thematic headings of the following:

People in purple shirts: characteristics of the Singing Medicine project

Children’s learning and development

Families’ experiences

There were a number of comments made in relation to the way that the SM project influenced the experience that children and families had at BCH in a positive way. For example,

Some of the children have unpleasant, intrusive and painful medical interventions for example haemodialysis – the Singing Medicine project is something they choose rather than something they have to do or have to have done to them. (Participant 5)

The project appears to bring a sense of normality for children and a wider variety of faces for the children to see, it ‘something nice’ for the children to look forward to in the midst of unpleasant experience of medical interventions, something children can choose rather than something that is done unto them. One participant discussed the way in which the project helps children to connect previous musical experiences with their hospital experience as it provides ‘familiarity with previous music experiences in a familiar environment’. Most profoundly a couple of participants commented on the possibility for the project to help children and families build positive experiences of their hospital stay and to help them to forget why they are visiting the hospital:

Enables children to take a positive memory away from hospital, rather than remembering only that they had blood samples taken, they might also remember the pleasant experience from the SM people. (Participant 7)

Comments related to families were varied and included those that mentioned the way in which the SM project helped with family relationships and those that helped families to cope with difficult and challenging situations

It was also noted as something that helps parents see their child enjoying something and being happy:

So for me the benefit is for the child but also for the family as well, because they might not have seen their child have anything positive for weeks and then this comes along and it’s just that little glimmer of light for them really. (Participant 5)

In this respect, the project was described as encouraging family participation and giving parents something to do with their child in the hospital environment by contrast to other activities which parents can only observe.

In addition, the project was noted to help with building memories with family for the future if a child passes away. It was also noted as a reminder of the past (before illness) and something about which parents could communicate with their child both in the hospital and at home afterwards.

Normalising medical care

In terms of medical aspects/value of the project, comments were made by participants in relation to children’s neuro-development, heart rate, experiences, mood and benefits for staff as well. One participant mentioned that the project ‘enables us to think about experiences as well as medical care and also think about neuro-development from emotional experiences’.

Some participants mentioned that the project had positive effects for staff for example that it was encouraging for staff to see children enjoying themselves, that it had a ‘positive effect on nurses’, in that ‘it reminds nurses that they are looking after a person first and a patient second’ and that it positively influences the acoustic ecology of restricted spaces which is beneficial for children’s well-being. A couple of participants suggested that the project regulates children’s heart rate and also helps with ventilation:

Almost all children in intensive care have continuous heart rate and oxygen saturation monitoring. There are children who are on a ventilator who have a life support delivered who are having monitoring for those things, blood pressure and heart rates that you would see normalising numbers from a distressed set of numbers to a more calm set of numbers over the time of the Singing Medicine session. (Participant 10)

Some people mentioned that the project can positively impact a patient’s condition by making patients more relaxed (it changes their mood); while another said that it changes the tone of the bed space environment.

One participant felt that the positive experiences provided by participating in the project helps with healing, while another mentioned that it improves a child’s experience of intensive care where,

They may at times be semi-conscious to might not communicate verbally for a while, however, even though they can’t speak, they can still hear music and experience something immensely positive. (Participant 3)

It was also reported to ‘take away pain’ from illness or medical procedures.

Observations

Unstructured narrative observations were undertaken on three occasions. Children were asked individually if they were happy for the researcher to be present and their ongoing verbal and non-verbal signs and signals constantly monitored for any signs of discomfort or distress. Table 2 below describes the context and details of the three observations.

OPEN IN VIEWER

Table 2.

Details of observations.

Room	Number of adults	Number of children	Activities undertaken
Activity room, Ward 15	Three vocal tutors, three parents	Three	Singing and playing instruments to several verses of ‘This is How I Bungalow’, ‘Going on a Picnic’ and ‘Wheels on a Bus’. The children took turns to choose how to Bungalow, what to take on the picnic and actions for each of the songs. Parents joined in with choices, singing and playing instruments.
Ward 15, Oncology (child in isolation room)	Two vocal tutors, one grandparent	One	Singing and playing instruments to ‘Walking in the Jungle’ with several verses. The child was given a choice for each verse as to which animal appeared next. This was followed briefly by another action song before the child shows signs of fatigue and the tutors ended the session accordingly.
Ward 1, Renal ward	Two vocal tutors, two parents	Seven children were present in the ward, but only two were well-enough/wanted to participate on that day	Singing and playing instruments to verses of ‘Going on a Picnic’ and ‘Wheels on the Bus’. Children were given choices about which songs to sing, which instruments to play and which verses and actions were included.

Themes that arose from analysis of observation are discussed below.

Limitations of the study

This study included a small sample which limits the potential to generalise the findings. However, the sample was as varied as possible and the findings are relevant to the hospital setting in which the study was undertaken. Further studies with a larger sample and an evaluative aspect would provide a stronger evidence base. The ethical concerns of a study involving vulnerable participants in a hospital need time to address sufficiently well for an NHS ethics application. It would have been preferable to involve children’s voices had funding and time allowed, and this is an area for further research.

Participants and themes

In total, 13 participants were involved in semi-structured interviews. Themes that arose from interviews included the significance of characteristics of the SM project; contribution to children’s development and learning; families’ experiences; normalising medical care. From observations, there was evidence of choices for children; following children’s lead; facilitating medical care; building memorable moments for families and focussing on children’s holistic development.

Relational aspects

The characteristics of the project were emphasised including the identity and personal attributes of the vocal tutors. They appear to hold attributes noted by Hoskins and Smedley (2017) of understanding the imperative of play and enabling environments in developing children’s participatory competencies. They ‘begin where the learner is’ (Bruce, 2011: 30). The singing games appeared to provide a medium for connectedness and some degree of intimacy between children and parents as suggested by Froebel (1843) and Powell et al. (2013).

Medical and contextual aspects

Medical benefits of participation in the SM project were reported in terms of normalising hospital experiences and medical care. Furthermore, there was discussion of reducing children’s heart rates and assisting ventilation. Further to this, the benefits for staff well-being that result from observing children experiencing something pleasurable and uplifting were noted. Improvement in the tone of the ‘bed space’ and calming children/reducing pain were additional benefits as well as providing a means for children with sensory impairments to engage and respond where they might not have otherwise been able.

Contextual aspects of the SM project included the appropriateness of its use for end of life situations, particular benefits for children with mental health problems, children who have not responded to other stimuli, younger/developmentally younger children, post-transplant patients, children placed in isolation and not receiving many visitors (where it can provide distraction) and children who need rehabilitation. The challenge for the vocal tutors is to support children and families in a way that does not disrupt or distract from the important work of health professionals in the hospital (e.g. in end of life situations).

Professionals value the contribution that the SM project makes to children’s emotional state during their treatment at the Hospital. This can include helping to calm children, improve their mood or stimulate them where necessary. It can also serve as a distraction which helps to reduce anxiety, pain and stress in relation to medical treatments as noted by Preti and Welch (2004). Children have a choice whether and how to participate in the singing games and this was perceived as important for and to contribute to their happiness. Furthermore, SM is beneficial for members of staff at BCH and while this is not the primary aim of the project, it is an important secondary outcome.

Children and families alike were perceived to have an improved experience of their care at BCH if they participated in the SM project. This is because the project brings a sense of normality and offers choices and pleasant experiences in the midst of often unpleasant, intrusive and painful treatments. SM brings structure to the children’s week and offers a way to connect past experiences from home, family and other social settings to their experience in hospital.

Educational and development aspects

The SM project offers the opportunities for educators to observe children and align observed progress with relevant curricula such as the EYFS (Department for Education (DfE), 2018). In addition, the vocal tutors collaborate with educators to facilitate children’s educational targets. Further to this, children’s participation in the SM project was perceived as beneficial to children’s holistic development and was thought to contribute to a number of areas of formal curriculum and development domains. An important aspect of this was the way in which the vocal tutors take the time to familiarise themselves with each child’s interests and competencies as noted by Bruce (2011) is crucial to liberating children’s own ideas (Liebschner, 1991).

An important contribution to children’s spiritual and cultural experiences during their stay at BCH is highlighted from this study. The manner in which the SM project facilitates connectedness between people from diverse socio–cultural-economic backgrounds and the sense of achievement and participative empowerment that was enabled by the project were thought to have positive influences on spiritual and cultural well-being. These ideas bring Froebel’s (1885) notions of play bringing ‘joy, freedom, contentment, inner and outer rest, peace with the world and play providing a source of something that is unquestionably good’ into contemporary arts in health contexts.

Family aspects

The benefits of children’s participation in the SM project for families and family practices were predominantly related to the benefits for family relationships and joint participation in an enjoyable activity. This was because participation from all family members is encouraged and families can continue to participate in new songs learned through the project together at home. Therefore, the project helps to re-build or strengthen family bonds and enables the development of ‘happy’, ‘positive’ memories which can be shared together when the child leaves hospital or enjoyed by parents and other family members in the event that children do not recover from their illness. It can also bring happy memories for families of events before their child was ill and provide time and opportunity for parents to have respite during their visit to the hospital should they not wish to participate with their child. These benefits extend beyond Froebel’s idea of the child benefitting from learning through play to the concept of family learning through play in accord with Froebel’s Mother Songs. Similarly, the singing games were thought by professionals to facilitate holistic child development as the games and activities were foundational for physiological benefits (such as heart regulation) as well as motor and mental benefits such as co-ordination and colour/shape recognition and language development.