A Kaleidoscope of Musical (Dis-)Engagement: Healthcare Musicians’ Situated Ethical Professionalism as Artistic Alliance for Value-Based Care

Applied Ethics and Ethics of Care

Ethical decision-making involves navigating moral questions and principles that guide actions toward what is considered good or right. It requires choices based on values such as honesty, fairness, and respect for others, rather than personal gain. Ethical behavior reflects concern for the common good and attentiveness to diverse perspectives, often involving dilemmas where competing values or interests must be weighed (Markkula Center for Applied Ethics, 2021; Thompson, 2023).

Given the complexity of ethical frameworks and the authors’ non-specialist background in ethics, this article draws on applied ethics and the ethics of care. Applied ethics focuses on the practical application of moral principles in real-world contexts, offering tools to address nuanced dilemmas. In healthcare and social work, this includes “ethics work”—the ongoing effort to recognize ethically significant aspects of situations, develop responsible professional identities, and justify actions (Banks, 2016; Groot & Abma, 2022). In healthcare, ethics work ensures that care is not only effective but also morally sound, upholding dignity and individual rights.

Participatory health musicking in healthcare presents a distinct area of applied ethics. When musicians work in medical settings, ethical concerns arise around patient vulnerability, consent, and the appropriateness of musical interventions (Matarasso, 2019). Musicians must be equipped with ethical knowledge, including trauma-informed care, cultural safety, and boundary management (Forbes et al., 2025). Their responsibilities extend to respecting privacy and cultural preferences while fostering meaningful, compassionate experiences. These layered considerations suggest the need for a holistic, context-sensitive ethical approach to care. Although caring is traditionally recognized as constituting dyadic relationships, artists practicing care ethics may extend beyond them, fostering broader networks of care and potentially catalyzing cultural change within healthcare settings (Dons & Gaunt, 2021; Thompson, 2023).

Therefore, this article builds its analysis upon a care ethical positioning, which centers around searching for ways of caring well for relationships, needs, and ways of living well for all (Tronto, 2015). It places compassion into ethical reasoning and emphasizes humane values, emotional wellbeing, and the importance of kindness in (health)care (De Wit, 2020; van der Wal-Huisman, 2024). Tronto (2015) points out that “[c]are is about meeting needs, and it is always relational” and that “[t]he trick is to determine the best ways of caring in a particular time and situation” (pp. 4–5). Therefore, ethical care decision-making is also relational and situational (Tronto, 2015). Care ethics recognizes that individuals mutually rely on each other to flourish and that ethical decisions should be responsive to specific circumstances (Kwan, 2023; Leget et al., 2019). Tronto (2015) distinguishes between “caring about” (what makes us attentive), “caring for” (what makes us responsible), “caregiving” (what makes us competent), “care-receiving” (what makes us responsive), and “caring with” (caring democratically and equally) (pp. 5–8, 14), emphasizing different processes and meaning of care.

These ethical care concepts offer a robust framework for examining the ethical dimensions of healthcare musicianship. They support the development of responsible, compassionate practices that honor both artistic integrity and the complex realities of care.

Hospitality and Ethical Competences: Perspectives from Community Music

Artists working in societal contexts inevitably encounter ethical dilemmas, yet many remain unprepared to navigate them (Matarasso, 2019). In the absence of formal ethical guidelines for healthcare musicians, this article draws on adjacent fields—participatory arts, community music, and hospital music—to explore ethical professionalism. Drawing mainly from Goldbard and Matarasso (2021), Lines (2018), Daykin (2012), and music education research (Regelski, 2009; 2022), we conceptualize participatory healthcare musicians’ ethical professionalism as the dynamic interplay of situational needs, principles, acts of caring, relationships, and context-responsive musicking.

A foundational concern in participatory music is that all engagement must be voluntary, equal, and democratic (Matarasso, 2019; Trienekens, 2020; Dons, 2021). In participatory musicking (Small, 1998), where the boundary between artist and audience is downplayed, the emphasis shifts from product to process. The quality of the experience of participatory musicking is judged by how participants feel during the activity (Turino, 2008). Musicians must therefore prioritize participants’ experiences over (Turino, 2008) or in addition to (Dons, 2019) their own artistic agendas. Inclusion of people with diverse abilities is central, and the ethical stance of the musician is one of radical hospitality (Higgins, 2012; Lines, 2018), an ethical orientation that invites presence and participation without imposing meaning. Also, ethical community music practice, under which health musicking can be seen to belong (Koivisto & Tähti, 2020), is built on the relational fabric of the community, not the isolated actions of individuals. This aligns with care ethics, which calls for caring well relationally (Tronto, 2015), rather than viewing individuals as the primary unit of concern. This relational sensitivity requires a particular feeling for ethical timing (Lines, 2018) or ethical attunement (Laukkanen et al., 2021) amidst the unfolding musical interactions. This seems especially vital in healthcare settings, where patients may be vulnerable and emotionally exposed.

Thus, what ethical professionalism then enables ethics work? Goldbard and Matarasso (2021) introduce the concept of ethical self-knowledge as central to ethical professionalism. For healthcare musicians, this means cultivating critical awareness of their values, intentions, and accountabilities. Who are they serving—patients, staff, institutions, or the art form itself—and how do these commitments align or conflict? In emotionally charged environments such as palliative care, this self-awareness becomes essential. Ethical self-knowledge requires ongoing reflection and transparency, especially in interdisciplinary collaborations. Closely linked is the development of ethical capacity—the ability to anticipate ethical tensions before they escalate (Goldbard & Matarasso, 2021). Healthcare musicians must remain attuned to hospital culture, patient autonomy, and the emotional impact of music (Koivisto, 2022), often complex, contradictory realities. For example, a musical intervention that comforts one patient may distress another (Smilde et al., 2019). Navigating such ambiguity demands more than good intentions; it requires competence and a willingness to embrace uncertainty. Building on this, ethical skills equip musicians to transform challenges into opportunities and resolutions. Importantly, resolution does not imply consensus but rather a shared sense of dignity and relational closure (Goldbard & Matarasso, 2021). Daykin (2012) stresses the importance of safe practices and collaboration with healthcare professionals to manage risks and define boundaries. While artists are not therapists, they must be able to sense the impact of their work and mitigate potential harm (Daykin, 2012). However, this collaboration can place additional demands on healthcare staff, raising ethical concerns about workload and the need for clear negotiation of responsibilities.

Musicians’ Incentive and Fulfilment

MiMiC musicians are driven by a strong ethical incentive to do good and care well, which manifests as a deep resonance with patients’ emotional and physical experiences. Their commitment to finding the right music for each individual reflects a person-centered approach rooted in empathy and responsiveness. This ethical engagement is not one-sided; musicians often describe a reciprocal joy when witnessing the positive impact of their music. As one musician shared, “You get a sense of satisfaction when you see, like, the music is doing something to them, that they are enjoying it.” A poignant example is the “Opening the Curtain” episode (Smilde et al., 2019), where two men sharing a hospital room connect through a joint improvisation after the curtain between them is drawn back. Their mutual recognition—through eye contact and smiles—transforms the space, offering the musicians a moment of profound emotional reward: “It fills my heart with joy.”

At the same time, following the artistic nature of the practice, musicians find it important to create music that also meets their satisfaction. This raises the ethical question: How much artistic freedom is possible or permissible within the structure of collaborative and ethical care? Some musicians reflect critically on this tension, pointing out that artistic quality and expressive freedom are essential not only for the integrity of the work but for its value for the patients. Yet these artistic impulses can come into conflict with the unpredictable emotional terrain of hospital settings, where musical choices—genre, lyrics, tone, improvisational direction—carry subjective and sometimes unforeseen emotional weight.

Improvisation, while powerful, can also lead to ethical dilemmas when patients’ emotional responses are unpredictable. This becomes particularly pronounced when musicians feel reduced to “living jukeboxes,” expected to fulfil any musical request at any moment, or conversely, when they are perceived as limited to a single genre because of the classical instruments they carry (see De Wit & Sevindik, 2024). This can increase a sense of pressure to fulfil all musical needs and even to overstep one's boundaries as a musician.

Here we recognize that musicians demonstrate ethical attunement (Laukkanen et al., 2021): They are attentive, receptive, and emotionally responsive in the moment of caring musicking. In Tronto's (1998, 2015) terms, they clearly care about and care for the people they encounter. However, what remains underdeveloped is their capacity to integrate this ethical sensitivity with their own artistic agenda. As Dons (2019) suggests, musicians often lack the tools to navigate the intersection between artistic intention and care-ethical responsibility. This gap represents a vulnerable area within their expanding professionalism—one where ethical awareness is present, but the practical means to balance artistic identity with care-oriented decision-making are still emerging.

Navigating Care Ethics Large and Small

The intimate musical exchanges of MiMiC offer a powerful counterbalance to the clinical routines of hospital life—routines often marked by pain, vulnerability, and emotional strain. For nurses, whose roles may involve administering treatments that cause discomfort, these musical moments provide a rare and meaningful reprieve. When patients visibly respond with joy, calm, or connection, the emotional impact resonates beyond the bedside: Nurses, too, feel affirmed and uplifted (De Wit, 2020).

This shared experience underscores that the benefits of music in healthcare are not confined to patients alone. For musicians, this highlights an important aspect of their expanding professionalism: Ethical attentiveness cannot be limited to the patient alone. While musicians rightly center their attention on the patient, it is ethically vital that they remain attuned to the broader relational field—especially the healthcare professionals who inhabit it. In this way, ethical engagement becomes multidirectional, extending care and attentiveness across the entire ecosystem of the hospital ward.

For healthcare musicians, responding authentically to situational needs is central to their professional practice (Smilde et al., 2019). However, the mentioned broad nature of the relational field as well as the unpredictability of hospital environments can lead musicians to seek comfort in familiar structures. This creates a tension: Relying on pre-formed “gimmicks” or replicating past meaningful moments may offer stability, but it can also undermine spontaneity and responsiveness—qualities essential to ethical, person-centered, participatory musicking. From a care-ethical perspective, each interaction requires renewed attentiveness to what caring well demands in that specific moment (Tronto, 2015). Sustaining this situational sensitivity calls for ongoing reflection, ensuring that musicians remain open, responsive, and ethically attuned rather than defaulting to formulaic habits. Balancing these dynamics remains a delicate and ongoing challenge in their expanding professionalism.

Additionally, whilst operating on a broad, multidirectional level, MiMiC musicians tend to also maximize their attention to the little signals and details. The musical approach of person-centered musicking is known to potentially acknowledge even the littlest non-verbal signs into the music-making; hence musicians are employing their so-called “360 degrees antennae” (Smilde et al., 2019). For example, this may lead the musicians to express concern about ethical judgements of timing (see Lines, 2018), for example, how much time and silence to allow for the person(s) to process their musical experiences after a piece of music, and how soon to support them verbally as musical facilitators? Is the piece of music too long, is brought upon too suddenly, or does the selection of the best piece to match the patient's wishes take too long? A violinist reflects (Dons et al., 2023a, p. 35):

I really felt that we were rushing the situation and we were not letting the room “breathe”

Prominent doubt stands out in the fragment. Musicians may have differing judgements on questions of appropriate timing, which may be connected to their personal qualities of extroversion or introversion, preparedness to handle silent moments, and the sensitiveness of their social antennae to pick up small social clues in the moment. The need to ensure continuity of care through the nurses’ engagement appears to be a significant part of the violinist's care-ethical professionalism. Indeed, the MiMiC musicians seem highly ethically attuned to the concerns of the patients, feeling responsible for how the musical moment is received by the patient, and whether the music resonates: “We do not intend to force music on anyone” (a cellist in Dons et al., 2023a). One could comment that these aspects of ethical timing (Lines, 2018) and the cultivation of individual qualities of caring engagement are clearly emerging within healthcare musicians’ expanding professionalism, yet they are not firmly embedded in current education. This raises the question of whether training such situational, relational capacities may require a more interdisciplinary approach.

Professional Place and Power Relations

At times, patients express the wish not to hear the music offered. In such cases, the musicians seem to experience a feeling of rejection. Although firmly standing behind the principle of having the music being offered to the patients on their terms, their professional confidence in being able to provide valuable musical interactions is challenged. Also, the rejections of musical visits show the musicians’ inexperience and vulnerability in having their audience decline their musical offerings, which rarely happens in a concert setting. Perhaps for this reason, there seems to be a kind of emotional dependence on having the music being accepted by patients, of which the musicians do not appear to be aware. Such projection of artistic needs for acceptance or appreciation on the patients seems ethically feeble and aligns with Goldbard and Matarasso's (2021), as well as Lines’ (2018), perspectives of the need for artists’ ethical self-knowledge.

From a care-ethical perspective, this also points to musicians’ developing an understanding of Tronto's (2015) notion of care-receiving: After acting caringly, the work is not yet complete; one must “look again at the situation” to see whether the care has been received and whether something is missing, and then “try another way” (p. 9). MiMiC musicians often withdraw immediately after a rejection, yet a care-ethical stance might invite them to explore alternative forms of engagement rather than interpreting refusal as a personal or artistic dismissal. Similarly, musicians reflect on situations of playing for the nurses on “their territory”:

I sometimes feel a little uncomfortable in the coffee rooms. […] Sometimes it kind of feels like we are telling (the nurses) that they have to be there, whether they want it or not. It is much nicer if you have the feeling that people want to be there, they chose to be there. […] You do not want to impose, that is not a good feeling.

Power dynamics between musicians and healthcare professionals can complicate collaboration in hospital settings. Tronto (2015) argues that “[e]veryday life is political because all caring, every response to a need, involves power relationships. Especially when we are thinking about the care that we can’t provide for ourselves, caregivers are in a position of relative power” (p. 9). In the MiMiC practice, musicians often have limited influence over nurses’ involvement, even when working with the nurses’ own patients (De Wit, 2020). While a nurse's absence may signal trust in the musicians’ professionalism, it can also leave them unsupported in emotionally complex situations—such as when patients struggle to communicate or react strongly to the music. Musicians describe nurses as “the mirror of the situation” (Dons et al., 2023a), using their responses to gauge the appropriateness and impact of musical interventions. At times, however, musicians perceive a certain lack of hospitality or openness from nurses, which can subtly hinder the relational flow of the encounter and reinforce the asymmetry of power.

To encourage nurse participation, musicians have developed strategies such as tailoring repertoire or inviting nurses into improvisational processes. These efforts, though potentially seen as manipulative, are ethically motivated and aim to enhance patient wellbeing. By fostering nurse engagement, musicians strengthen the relational fabric of care, making music sessions more responsive, supported, and ethically grounded (see De Wit, 2020, 2021).

In other examples, the MiMiC sessions seem capable of easing power relations between nurses and patients, particularly when the care relationship is not functioning well. In the narrative data, nurses reflect being able to relate better to their patients through witnessing their interactions and responses to the musicians in the music sessions. In one example, the musicians’ added value to the care made a change in the way a nurse viewed a patient as a person (from Smilde et al., 2019, pp. 50–51):

[I now know to ask the patient:] Well, yes, what is the reason you are so grumpy? is there something wrong? You continue to ask more about it. There is always a reason behind it. That is what I have learnt. We often approach it like: “It is probably a characteristic.” But that is not always it. If you have experienced something terrible, or you are really homesick, then you can also react quite differently. Then, you are different from who you usually are. I also notice it within myself. I am always very open, but if I experience something terrible, I can also retreat into my shell.

While MiMiC musicians are aware of power dynamics with nurses, they often overlook their own influence over patients (Dons & Gaunt, 2021). This is evident in how they interpret patients’ wishes, pre-select music, and rely on assumptions from previous projects. Musicians frequently speak of “giving back control” through music-making (Smilde et al., 2019; Dons, 2019), yet this framing reflects their own interpretation of events rather than patients’ lived experiences. Their reflections reveal limited ethical self-awareness regarding the authority they hold—entering hospital rooms as able-bodied, educated professionals with unnegotiated positions as facilitators. In one episode, for example, musicians invited a patient to co-create and conduct a piece. Initially, the patient expressed discomfort at having “three complete strangers” at his bedside. Later, a musician interpreted the moment as empowering: “It was just very nice to give that a musical-allegorical touch by giving him a baton” (Smilde et al., 2019, p. 46). While well-intentioned, such interpretations risk overlooking the patient's vulnerability. This highlights a blind spot in ethical reflection and supports Goldbard and Matarasso's (2021) concept of ethical capacity—the ability to anticipate tensions before they become dilemmas.

Ultimately, as a practice embedded in societal conventions, the musical interactions are also influenced by the power dynamics of society at large. The professional status of nurses in hospital contexts is deemed higher than the status of musicians, for example, making musicians have to work for their status, and perhaps having to compromise. To illustrate, commonly musicians are filmed during sessions by nurses, patients, or their families. Even though filming is prohibited in hospitals by standard protocols, cameras are these days a normal part of everyday life, and filming is often framed as a compliment. Yet, musicians typically have no control over where those recordings might be shared. In almost all cases, musicians consent without resistance. Yet, this consent is rarely informed or critically discussed. The ethical question emerges here: Who supports musicians in navigating boundaries, such as filming, especially when refusing to be filmed may feel at odds with the ethos of care or hospitality?

Ways of Dealing with Highly Emotional Situations

While MiMiC musicians are prepared to engage in person-centered, responsive musical interactions, they are typically not trained to handle the emotional intensity that such encounters may evoke. Unlike nurses or music therapists, whose education explicitly includes emotional care and boundaries, musicians are often left to navigate these complexities without professional tools or guidance.

Music acts as an emotional catalyst in healthcare contexts, surfacing personal memories, grief, joy, or fear for patients and families (MacDonald et al., 2012), and equally for musicians. These moments can be deeply moving—and, at times, overwhelming. Yet, musicians are not always equipped to deal with the aftermath of these emotional responses. This ambiguity creates both ethical and professional uncertainty, and raises the question: Should offering emotional “after-care” be considered as a part of healthcare musicians’ responsibilities, or should this responsibility remain with clinical staff such as nurses? —and if the former, who is responsible for equipping them with the necessary skills?

Musicians also report uncertainty in navigating moments when patients “overshare” deeply personal or traumatic stories. Without training in therapeutic boundaries, or emotional containment, musicians are left to make ad hoc decisions in emotionally vulnerable moments, balancing between remaining hospitable (Lines, 2018) and protective of necessary boundaries. This touches upon the ethical decision-making on safeguarding the wellbeing of the patient and protecting the emotional safety of the musicians simultaneously. In a situation where a patient was moved by a musical interaction (Dons et al., 2023a, p. 36), a musician experienced doubt about whether it was appropriate to end the session when the patient was still emotional. She recounts how the professional opinion of a coordinating nurse—who stayed behind to comfort the patient—offered her reassurance, which her fellow musicians could not:

I did not somehow trust the opinions of the other musician colleagues […] I felt that her professional opinion weighed somehow more than ours, which is kind of interesting, as we are also experienced already in handling emotions.

This example reveals a vulnerable point in the ethical professionalism of musicians in healthcare: They are expected and willing to operate sensitively, yet lack formal training in emotional care to trust their decision-making capacity. The reliance on nursing staff for emotional validation points to a structural gap, which could call for adequate training for emotional after-care in the healthcare musicians’ training.

The Shock of Practice

A central dilemma has to do with how many occurrences, that is, kaleidoscopically fast-changing or acute care situations; unexpected emotional responses; witnessing of blood, bruises, amputations or people in great pain, can be mentally anticipated and prepared for in the educational settings at a conservatoire. There is an inherent unpredictability—what might be termed the “shock of practice”—that confronts novice musicians, particularly music students, in healthcare settings. While training can offer frameworks, skills training, and simulations, it cannot fully prepare students for the immediacy and gravity of real-world situations. This also increases the sense of responsibility for their wellbeing by experienced musicians working with them in care contexts.

In the episode “Disconnection within Participation” (Smilde et al., 2019, pp. 32–34), musicians are confronted with an ethical decision-making scenario: two patients—a young and an older woman—share a room, each with different needs. The older woman is resting and wants to be left out of the musical exchange, while the younger one does want to engage. This situation challenges musicians to navigate between the opposite wishes of the patients, and try to adapt their communication, choices of music, and contact accordingly. The musicians opt for a calm piece by Elvis Presley, which would minimally disturb the older woman. Suddenly, the younger woman gets emotional from the piece, which results in an unexpected physical discomfort on her abdomen. The musicians end the piece short, and a nurse steps in to help the woman. Smilde and colleagues (2019) write:

[It was a] challenging situation which was full of a sense of uncertainty and apprehension; the musicians clearly did not know what to do and how to act, and also initially they did not get any support or guidance from the nurses (p. 34).

Finally, the dynamics within the team of musicians reveal further ethical tensions, particularly regarding experience and power imbalances. If one of them is a newcomer, or a non-native Dutch speaker, while others are more experienced, a dependency may emerge leading to unequal distribution of decision-making and interaction. This leads to questions such as: How is the decision-making within a musician team negotiated under such conditions? What weight does experience carry in fostering inclusive and supportive collaborative spaces, while simultaneously co-creating a safe music session for all involved?

Safe Practice for All

The concept of safe practice (Daykin, 2012) in healthcare music-making cannot be confined to physical safety protocols alone. As suggested, it extends to emotional, ethical, and artistic dimensions—for patients, musicians, and nurses. As musicians work in increasingly regulated clinical environments such as hospitals, where care protocols are clearly defined and patient vulnerability is foregrounded, musicians often face a dual demand: to maintain artistic integrity and freedom while ensuring that their work remains sensitive, ethical, and safe (Dons, 2019). This raises again the question about artistic freedom and what is permissible within the given situation.

From a care ethics perspective, safety of a musical encounter seems to depend on how much the musicians are informed about the patient. Musicians need sufficient contextual information to base their ethical decision-making on. Yet, they also aim to encounter the patients without assumptions and pre-suppositions about them. While some musicians prefer minimal information to maintain openness and avoid labeling or stereotyping, others express discomfort when entering complex situations without preparatory information. This ambivalence reflects an ethical tension at the heart of relational care, which has to do with the fragile balance of hospitality and pre-preparedness. Over-knowledge could lead to a bias or over-cautiousness, while under-knowledge may result in unintended emotional distress.

Ultimately, safe practice must also include self-care. Musicians need space to process difficult moments, reflect on ethical challenges, and develop self-compassion. This means building support systems that go beyond short debriefs and accepting that taking care of oneself is part of the ethics work in this context. The data suggest that the musicians’ emotional labor of the work is frequently underestimated, and despite their central position in triggering and navigating emotional dynamics, they often lack access to formal support mechanisms. This echoes Shaughnessy, Hall and Perkins’ (2023) concern that musicians in health settings experience emotional impacts that remain largely unacknowledged in their training and professional development.

Taken together, the findings suggest that “safe practice” is co-constructed, as Thompson (2023) suggests in relation to his concept of networks of care, which are shaped through interactions, institutional norms and culture, and ethical negotiation. Musicians appear highly attuned to the risks their work may pose to others, but less supported in identifying or managing the risks they themselves face. Their strategies for negotiating safety—adapting their performance, seeking validation from clinical staff, or suppressing discomfort—speak to the complexity in healthcare environments. What emerges is not a call for more control but for clearer articulation of boundaries, responsibilities, and support systems that can sustain both ethical care and creative integrity.

Struggles of Research-Informed Practice and Ambiguity

Finally, as explained, MiMiC was developed in a research-informed way. This meant that data-collection took place throughout and that musicians also took part in collecting and generating data, as well as mediating between the different stakeholders on the ward. Participant observation (see De Wit, 2020; Dons, 2019; Smilde et al., 2019) being the main mode of data collection, some musicians complained about feeling watched and that this either made them feel evaluated or under pressure to perform. The struggles of observation were also connected to role blending, particularly among those occupying overlapping responsibilities, for example, mediator-researchers or researcher-musicians. Initially conceptualized as a logistical support task, the mediator was intended to coordinate access, assist with session planning, and facilitate basic communication between musicians, nurses, and patients. However, in practice, this role expanded beyond its original scope.

As sessions unfolded, mediators often found themselves drawn into emotional dynamics—consoling patients after intense musical encounters, interpreting unspoken cues from staff, and sometimes stepping in to resolve interpersonal tensions among musicians. This development introduced new ethical and practical dilemmas. On one hand, the mediator became central to creating a sense of continuity and safety within the care environment. On the other, mediators, especially when also acting as researchers or musicians, struggled to manage boundaries and expectations associated with their multiple affiliations.

The data suggest that mediators who were simultaneously researchers or musicians faced particular challenges in maintaining professional distance. Several participants noted that when the mediator was also a fellow musician, it was harder to discuss conflicts or discomfort openly, as hierarchies or previous relationships could inhibit transparency. Conversely, when mediators had no musical background, musicians sometimes questioned their ability to understand the nuances of the unfolding musical processes.

Compounding these issues was the frequent blending of the researcher and musician responsibilities. Researcher-musicians often found themselves navigating dual identities: observing while simultaneously being perceived by nurses or patients as part of the musical team. In some cases, they (un)intentionally influenced musical choices or processes through their presence, familiarity, or position. This ambiguity raised concerns about the invisible influence of researcher-participants, particularly in moments where their authority or musical background affected the direction or flow of a session. Musicians described instances where a researcher with musical knowledge intervened in performance decisions, sometimes subtly, other times more overtly. These moments had to be actively negotiated among teams, revealing the fine line between observation and participation.

Additionally, the project revealed ethical challenges tied to research partnerships, particularly in how musicians were invited as research participants to reflect on their own values and experiences. While this reflexivity deepened the ethical grounding of the work, it also introduced a form of vulnerability. Being observed, and sometimes critiqued, by colleagues who were also researchers required a level of trust that was not always easy to sustain. Establishing clearer guidelines around transparency, boundaries, and communication, especially in contexts where roles shift fluidly between research, mediation, and musicianship, may be essential for supporting the quality of the practice, the integrity of the research, and the emotional safety of those involved.