ORIGINAL ARTICLE

What carers and family said about music therapy on behaviours of older
people with dementia in residential aged care
Anthony G. Tuckett
Nursing & Midwifery, The University of Queensland, Brisbane, Qld, Australia

Brent Hodgkinson
Blue Care Central Support, Brisbane, Qld, Australia

Lisa Rouillon
Blue Care Eastside Allied Health, Brisbane, Qld, Australia

Tania Balil-Lozoya
Blue Care Carbrook, Brisbane, Qld, Australia

Deborah Parker
The University of Queensland/Blue Care Research & Practice Development Centre, Brisbane, Qld, Australia

Submitted for publication: 21 January 2014

Accepted for publication: 22 August 2014

Correspondence: TUCKETT A.G., HODGKINSON B., ROUILLON L., BALIL-LOZOYA T., PARKER D. (2015) What carers
Anthony G. Tuckett and family said about music therapy on behaviours of older people with dementia in
Faculty of Health and Behavioral Sciences
residential aged care. International Journal of Older People Nursing 10, 146–157.
Herston
doi: 10.1111/opn.12071
Queensland
4029
Australia Aim. This study sought to evaluate the effectiveness of group music therapy (MT)
Telephone: +61 7 3346 5107 intervention on behaviours of older people with dementia.
E-mail: a.tuckett@uq.edu.au Method. Reported here are qualitative data from five, semi-structured focus groups;
two comprising a total of seven family members and three comprising a total of 23
staff members.
Results. A number of core themes emerged: temporality, effect and policy with a
number of subthemes. The MT effect is tempered by the temporality of (i) the older
person’s dementia state, (ii) the session and (iii) the psychosomatic effect on the
older person. Music therapy is perceived to (i) evoke memories and facilitate
reminiscence, (ii) act as a diversion (has an instrumental value) and it is contentious
to discount the (iii) dichotomy between music and therapist in terms of the overall
effect. Finally, policymakers need to know that MT is (i) highly prized and more,
not less, MT is recommended.
Conclusion. Findings from this study illustrate that the timing of the MT session has
consequences for the workflow in the residential aged care facility; MT has a
psychosomatic effect and participants here evaluate this as temporal. Care providers
and family members acknowledge the instrumental value of MT and its helping with
cognition and exercise. They have mixed views about the effects of the music and the
effect on the older person by the therapist but most definitely want policymakers to
ensure more, not less, planned and better funded MT is part of ongoing care in the
residential aged care context. Areas for future research and policy are also highlighted.

146 © 2014 John Wiley & Sons Ltd


Implications for practice. These views on group MT in residential aged care can
initiate critical reflection on current practices and systems. Research is needed
exploring the timing and scheduling of MT sessions at different times in the day for
older person with dementia exhibiting negative behaviours.
Key words: carer, dementia, family, music therapy, qualitative research, residential
aged care
What does this research add to existing
knowledge in gerontology?
•
The timing and duration of music therapy for persons
with dementia in residential aged care is a vexatious
issue.
•
Music therapy has an instrumental value whereby it is
viewed as an activity, a social gathering, helps with
cognition and promotes exercise.
•
Amongst care providers and family members copar-
ticipating in music therapy for people with dementia,
there is mixed opinion about the role of the music,
therapist and music therapist.
What are the implications of this new
knowledge for nursing care with older
people?
• Care providers’ views and those of family ought to be
examined in order to understand how best to deliver and
provide music therapy services in residential aged care.
• Care providers and family must be more fully included
in music therapy sessions as a mechanism for them to
experience the therapeutic effect as well as to become
more completely educated about music therapy.
How could findings be used to influence policy
or practice or research or education?
• Care providers and family members evaluating music
therapy for people with dementia want policymakers
to know that it is highly prized.
• Care providers and family members want more music
therapy, planned and adequately funded as part of
ongoing care for persons with dementia.
Introduction
Music therapy (MT) plays a vital role in addressing not only the
physical and physiological aspects of ageing, but also the
psychological manifestations and social influences of ageing
© 2014 John Wiley & Sons Ltd
What carers and family said about music therapy
such as loneliness and isolation (Wigram et al., 2002). Music
therapists in the aged care setting often work with older people
who have a variety of behavioural problems which accompany
dementia, such as agitation, anxiety, restlessness, wandering,
aggression, depression and sleep disturbances (Cohen-Mans-
field et al., 1990). The purpose of this present study was to
evaluate the effectiveness of group MT intervention on
behaviours of older people with dementia. Reported here are
qualitative data from semi-structured focus groups comprising
family members and staff in residential aged care in Australia.
Background
Several Cochrane Reviews into MT have reported mixed
outcomes. Two reviews have reported a positive effect, namely
MT might be firstly, an acceptable intervention for persons
with depression and secondly importantly, that MT had a
positive effect in reducing depressive symptoms (Maratos
et al., 2008); and MT may have a positive effect on the
communicative skills of children with autistic spectrum disor-
der (Gold et al., 2006). In contrast, a third review found no
overall conclusion could be made from the evaluation of the
effect of MT for people with dementia due to studies having
insufficient sample size and analyses (Vink et al., 2004).
Set against this context, various studies have examined
active MT methods and the use of familiar individualised
music as important factors for consideration with this
population (Brotons & Marti, 2003; Takahashi & Matsush-
ita, 2006). Active MT methods include those strategies
employed by the music therapist that engage the older person
to interact and actively participate in the music intervention.
An essential component of active MT techniques clearly
implies the presence of the music therapist in delivering the
intervention with the older person live.
The effects of institutionalisation and specifically the
residential aged care facility can manifest with older adults
withdrawing or becoming depressed and isolating themselves
by sitting alone with their head down, giving minimal eye
contact and not initiating speech (Nugent, 2002). Music in the
environment may encourage an older person to lift their head
and engage with their surroundings (Nugent, 2002). The group
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setting in MT is ideal for facilitating socialisation and
interpersonal interactions (Millard & Smith, 1989). In sup-
porting this notion, Millard and Smith (1989) found that
therapeutic group singing resulted in higher vocal and verbal
participation, increased physical and social behaviours and
significant influences on the frequency of sitting and walking
towards persons with Alzheimer’s disease. Similarly, Pollack
and Namazi (1992) also found that participation in group
music singing significantly increased social interaction between
participant and increased social behaviours such as talking,
touching, smiling, humming, singing and whistling (Gregory,
2002; Cevasco, 2010). Furthermore, a case–control study
concluded MT to be a safe and effective method in treating
agitation and anxiety in persons with moderately severe and
severe Alzheimer’s disease (Svansdottir & Snaedal, 2006).
Enacting music therapy
The delivery of MT programs during the sundowning period
is well documented in the literature. Sundowning is a term
used to describe symptoms of increased arousal or impair-
ment during the late afternoon and evening hours that occur
in people with dementia. Symptoms specifically linked to this
phenomenon include increased disorientation and confusion,
wandering, hyperactivity, restlessness, aggressive behaviour
and anxiety. Music therapy sessions are typically imple-
mented at this time to alleviate and address these targeted
behaviours. Lesta and Petocz (2006) explored the efficacy of
familiar group singing as an intervention to address adverse
mood and social behaviours in older people with dementia
experiencing sundowning. Results indicated that familiar
group singing positively addressed various aspects of sund-
owning and helped to promote social interaction and well-
being. Tomaino (2002) reported that the playing of live
familiar music in the afternoon before sundowning acted as a
diverting tool for agitated behaviours, and furthermore,
Whitcomb (1994) described the use of therapeutic group
singing as an intervention to alleviate the effects of sund-
owning in the afternoon and to encourage positive social
interaction and well-being amongst older people.
However, the enactment of MT sessions must also be
considered in the light of the workplace and workflow and
the subsequent impact it may have on care providers and
older people in residential aged care. In residential aged care
facilities, the timing of MT sessions may conflict with
standardised nursing and medical care tasks for a variety of
reasons. Aged care sector challenges for care providers
include caring for severely ill older people and dealing with
behaviours associated with dementia (Aitken et al., 2002).
The nature of the work and workplace specifically in
148
residential aged care has variously been described as task-
orientated, time-starved and short-staffed (Tuckett, 2005b);
process driven (paper-work) with an ageing workforce that is
dissatisfied (Tuckett et al., 2009a); and a workforce that is
stressed and burnt out (Tuckett et al., 2009b).
Characteristics of the music therapist
Music therapy is intrinsically underpinned by the supportive
and interactive presence of the therapist, the music and the
resident/caregivers (Magill, 2010; Shoemark & Grocke, 2010).
For example, in Cevasco’s study (2010), the MT’s non-verbal
behaviours significantly impacted the effect and participation
of older adults with Alzheimer’s disease and other related
dementia. Specifically, when the MT relied on both affect
(facial affect and eye contact) and proximity (leaning and
moving in), the older persons evidenced a greater positive effect
compared to other treatment combinations (Cevasco, 2010).
Additionally, the therapist is deemed to embody as ‘funda-
mental..essential competencies..’ attributes such as kindness,
compassion and empathy (Magill, 2010: p. 57). In a study
evaluating family caregivers’ perceptions of the role of the
therapist, participants’ data revealed personal and professional
qualities such as ‘gentle voice,..very calming’; ‘smiles. . .see the
love in her eyes’; ‘versatile..I like your flexibility’; and an ability
to ‘..make a connection’ as well as being person centred
(Magill, 2010: p. 59–60).
Method
Participants
A total of 23 care staff participated in three focus group
interviews and seven family members participated in two;
representing three residential aged care facilities (RACF).
Amongst the care staff, 91% (21 of 23) were female; the
majority reported as Personal Care Assistants (PCA) 43% (10
of 23) or Diversional Therapists 22% (5 of 23) with one
participant describing herself as both. Participant registered
nursing staff included 13% (3 of 23) Clinical Nurses/Clinical
Nurse Manager and an Endorsed Enrolled Nurse (EEN).
Three care staff failed to identify their carer status. Finally,
43% (10 of 23) worked regularly in the dementia-specific
unit (DSU) where the researched MT sessions took place. In
the family group, 57% (4 of 7) were female; 43% (3 of 7) of
these were visiting their mother and the fourth attended to
her husband. Amongst the remaining family members, two of
the men were visiting their wives and one his mother. Lastly,
57% (4 of 7) of the residents’ relatives had actively
participated in MT sessions.
© 2014 John Wiley & Sons Ltd

Setting and procedure
The MT sessions and focus group interviews took place in
three residential aged care facilities: RACF-A comprised 84
beds with a 12 bed DSU; RACF-B comprised 76 beds with a
16 bed DSU and RACF-C comprised 42 beds including a 15
bed DSU. Interviews were recorded in late May 2012.1
Details about the MT sessions and participating residents are
given in Box 1.
The five focus group interviews with staff and family
members occurred at the completion of the 12 week MT
intervention period with residents. Separate staff and family
group interviews were conducted, but focus groups were
otherwise heterogeneous in their make-up. Group sizes
ranged from three to nine participants. The study was
approved by the Uniting Care Queensland Human Research
Ethical Review Committee (UCQ HRERC).
Data collection
Data were collected by semi-structured focus group interviews.
The focus groups were conducted by AT, an experienced
interviewer and qualitative researcher. Relying on techniques
for qualitative rigour reported elsewhere (Tuckett, 2005a), AT
kept a ‘thematic log’ in his field journal during the group
discussion(s) to immediately record ideas and key terms and to
operationalise his summary of interview(s) at the end of each
session. In addition to the ‘thematic log’ as a data source, AT
recorded ‘theoretical notes’(Tuckett, 2003/4) immediately
after each interview as these have proven to be a useful
resource for the later discussion section. Interviews lasted
between 20 and 44 minutes, were digitally recorded and later
transcribed as a complementary data source for analysis.
Data analysis
The approach described here has been successfully used
elsewhere (Tuckett et al., 2009a). Our qualitative content
analysis (QCA) ‘falls somewhere between the numerical
orientation of quantitative content analysis and the interpre-
tive orientation of grounded theory’ (Morgan, 1993: p. 119).
In QCA, codes are sorted into categories premised on how
different codes are interrelated, with a view to generating
these categories into meaningful clusters (themes).
1
Post the conduct of this evaluation research, the care organisation
implemented its person-centred, cultural change service model Tailor
Made. This new service model aims to create and deliver especially
designed and fitted solutions that respond to individual and commu-
nity aspirations.
© 2014 John Wiley & Sons Ltd
What carers and family said about music therapy
In the preliminary analysis, initial codes were developed by
AT and BH then independently assimilated ‘data chunks’
under the developing codes for a subset of participants’
statements. As data were read again under assigned codes and
codes were clustered and some merged, the final core
categories (themes and subthemes) were identified. Partici-
pants’ data were then presented to form a narrative that
represented the collective storey grounded within the data set.
Reliability of study
Credibility (validity) was established through peer debriefing
(Hsieh & Shannon, 2005) and the support from previous
relevant research around the final categories (Downe-Wam-
boldt, 1992). Reproducibility (reliability) in the form of
intercoder reliability was measured at the level of coding and
pattern (or core category) identification. Reportedly, studies
have demonstrated agreement between coders in the order of
63% (Curtis et al., 2001) and 80–85% (Cavanagh, 1997)
with the recommendation that a minimum level of intercoder
reliability be set at 75% agreement of coders (Nandy &
Sarvela, 1997). Here, a 76% agreement was measured
between two researchers (AT, BH).
A further measure of rigour is that the researchers AT and
BH arrived at a perfect fit of patterns or core categories
(latent content). That is, the strong intersubjective conver-
gence should ‘give the reader the sense that the patterns in the
latent content must be fairly robust’ (Potter & Levine-
Donnerstein, 1999: p. 266).
Results
Temporality
Temporality describes notonly the older person’s position along
their dementia-illness continuum, but also the perceptions the
carers and family have about the duration of the MT effect and
the practicalities of planning the session within the day.
It depends on the day
The operation and more importantly, the subsequent effect of
MT must be considered in the context of the older person’s
dementia continuum. That is, ‘(they)..don’t necessarily remem-
ber an hour later, two hours later, that they’ve actually had
music therapy. . .’ (RACF-B-Carers). The variability of the
dementia and its effect on the individual can mean:
You will see every day, everybody’s different. The one that loved the
music the week before, (and had) a dance, (is now) just sitting there
Mmm
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Box 1 Details about the Music Therapy sessions

Design A ‘Hello’ Song (newly composed by both therapists; the same presented at the beginning of each session at both facilities).
The Hello song included participants’ names, an opportunity for social interaction with MT/other participants

 Singing familiar old songs from memory (medley) as a warm-up.

 Songs to promote music of different body parts including a Balloon game.
 Musical quizzes (fill in the gap, guess the name of the song, guess the lyrics).
 Reality orientation.
 Instrument playing.
 ‘Good bye’ Song (also newly composed for the program, and used the same for both facilities).
The Good bye song included participants’ names and something meaningful from the session.
Residents Residents who participated had been diagnosed with dementia and resided at a dementia specific unit at one of the three
residential aged care facilities (RACF).
Each resident to be eligible for the study had at least one behaviour measured by the CMAI at least once throughout the day
of the baseline rating, was able to understand verbal and/or non-verbal communication and minimally able to engage
with their surroundings (eye contact, facial expressions, seeking source of sound)
Type Group therapy sessions
Frequency Two sessions per week; 91 morning and 91 afternoon; 45–60 minutes
Facilitation Researchers were independent of the treatment; qualified music therapists delivered the intervention
CMAI, Cohen-Mansfield Agitation Inventory; MT, music therapy.

It depends on. . . What do you observe when they’re responding? What behaviour do
The day. (RACF-B-Carers) you see?
Oh, she smiles more (RACF-C-Family)
This effect of the dementia was equally described by family
(S)he falls asleep in the session, but her feet will actually be tapping to
members whereby ‘She’s completely away with the fairies..’
the music
(RACF-B-Family). Perhaps most poignantly of all, the music
Mmm. (RACF-C-Family)
therapy operates in a context of ‘..decline..’:
Furthermore, MT is described as ‘..very settling for
Like the first time we came in she said ‘they’re a load of zombies in
them’(RACF-B-Carers) and ‘Its soothing’ (RACF-A-Carers).
here’. She did. Yeah
Carers at RACF-A and RAFC-B described these effects as
She’s actually become one of them herself now. She doesn’t speak
follows:
now. (RACF-C-Family)
There’s one lady that will cry, she will sit and cry. Whereas I’ve
Their faces just light up..in the moment noticed that when that’s (music therapy) on she doesn’t? Am I right?
Music therapy has a psychosomatic effect on the older person
Yeah, oh absolutely. (RACF-A)
and this effect is temporal. The MT effect is observed through
(W)e have had a lady that repetitively chanted: ‘Nurse nurse nurse’ all
facial expression and mostly positive mood/behaviours, but
the time
the effect is not long lasting. Rather, it is an effect very much
Mmm
in the moment.
When music’s on she’s not doing that
The carers unanimously observe amongst the older persons
Mmm
in MT ‘..enjoyment and happiness there with it’ (RACF-A,
RACF-B-Carers). This manifests as ‘..they smile. . . you can And you can see that she looks a little calmer. (RACF-B)
see them tapping their toes. They nod their head. . .’(RACF-A-
Carers). This particular emotional effect is summed up with: However, while MT ‘does make a difference’, it does not
necessarily make a positive difference ‘(to) all of them’
And it just lights, it just lights, their faces just light up.
(itallics added, RACF-B-Carers). The effect can be variable
(RACF-C-Carers; RACF-B-Carers)
depending on the individual older person. Hence, amongst
The family said it likewise: carers in RACF-C, ‘..certain residents, on certain days will

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‘act out’ (exhibit negative behaviours) after the music
therapy, it does sometimes have a negative effect on the
behaviours of the residents’.
When the carers were asked to reflect on the duration of
the effects of MT on the older person, their views ranged
across points of view that included: ‘There’s no residual effect
on their behaviour’ (RACF-A-Carers) to ‘it’s in the moment
to be honest. . .’ (RACF-A-Carers); and even ‘maybe a couple
of hours’ (RACF-C-Carers):
One of our resident’s he’s quite a wanderer, umm, when we can get
him to sit down in music therapy, he’ll sit down for a while, but then
he’ll still get up and wander, so it’s not changing his behaviour or
anything. But he will sit there a good 20 minutes before he gets up
again, so it does stop him for a while, so it does have some effect on
him. (RACF-A-Carers)
Family were unsure of the MT effect. Simply put, they
stated: ‘But I don’t know if there is any benefit, I’d like to
think that there is (RACF-B-Family). Even so, they would
‘..hate to see it (music therapy) stop’ (RACF-B-Family).
Earlier is better (but) 3 o’clock is a nice time
Operationally, the timing of the MT session has conse-
quences for the workflow in the aged care facility and impacts
the care providers and the older person. The timing of the
session amongst the carers is contentious.
Opinion is split amongst the care providers about the
scheduling of the MT session as it relates to their work
practices. At RACF-C, there is support for the session to be
earlier in the day:
Earlier is better
They need their toileting regime, so by her finishing at five to five, it’s
a mad rush for the carers and they’re so wound up because they
haven’t been able to do their duty of care
(L)ike one or one thirty might be better than late in the afternoon. . .
Because they do need their afternoon naps for their own health
reasons. (RACF-C-Carers)
Here, the timing interferes with the care providers work
routine. They also expressed a view that later in the afternoon
as a consequence of the phenomenon called ‘sundowning’ the
..residents can become physically aggressive. Or verbally aggressive.
Or get anxious sometimes. (RACF-C-Carers)
In contrast, RACF-B-Carers supported the MT session ‘at
three o’clock in the afternoon. It’s a nice time’ because
..in the morning.. you’ve just got everyone up, you’ve just had
breakfast, you’ve got your breaks to get done, you’ve got toileting,
© 2014 John Wiley & Sons Ltd
What carers and family said about music therapy
and then you’ve got lunch. Like it’s a busier time of the day in the
morning (RACF-B-Carers)
For the carers at RACF-C, the afternoon MT invokes
powerful opposition on the grounds that it interferes with
staff morale:
..not good for staff morale, it’s not good for anyone.
. . .we’re tired. . .they’re tired.
What is apparent through the data is that the timing of the
MT session can be linked not only to workload (in terms of a
task orientation to care) but also how workload is distributed
and prioritised according to staffing levels. At RACF-B, the
afternoon MT is described as the cause of ‘.. a wonderful
evening..’ where the older person is ‘..on top of the world..’
facilitated by the availability and involvement of two
personal carers:
..so I think it’s the time of the day, for us as carers’ it makes it easier
for us to help [name of music therapist]. And I think [name of music
therapist] would probably say that too because she’s said before it’s a
good session for her.
Because [name of carer] and I will both join in (RACF-B-Carers).
Effect
Effect describes the perceived therapeutic outcomes and its
instrumental value – described as providing older people a
diversion from their day-to-day lives. Also here, carers and
family describe the influence of the therapist and/or the music
as impacting the overall MT effect.
Spark those memories
Music therapy operates by evoking memories and facilitating
reminiscence for the older person in residential aged care.
That spark those memories of the residents involved. Like someone
might have been an Elvis person..(or).. Burt Bacharach, or Johnny
Cash, so she’s got to have that. . .
(L)ike there has to be particulars that entice them into having that,
reminiscing, or that good time. (RACF-B-Carers)
.. It jogs their memories, it brings back beautiful memories, and I
think it’s amazing for them. (RACF-A-Carers)
The powerful effect of the MT is such that it ‘..goes into
their hearts and their soul’ (RACF-C-Carers) so that it is
‘taking them back to a pleasant place in their life..to a time
where they could dance and they could go out partying all
night..’ (RACF-B-Carers).
Family concurred. For them, whatever the music therapy
effect, memory is essential:
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What do you think’s going on with music therapy?
I think its feelings..I think it just makes you feel good and there is (sic)
memories with certain things, you know.
It does trigger memories. . .
You listen to certain songs and it brings back memories (RACF-B-
Family)
It’s like a diversion
Music therapy was further evaluated as having instrumental
value. The session provides an activity and a social gathering
both of which are beneficial. In addition, music therapy helps
with cognition and promotes exercise.
Music therapy quite simply is perceived to ‘give them
something to do, because otherwise they’re wandering
around. . . and then they get confused and upset’ (RACF-C-
Carers). MT ‘..bridges a big gap of activity for them..’:
It’s like a diversion.
Yes, it’s a very pleasant diversion for them. They thoroughly enjoy
it. . . (RACF-A-Carers)
As a diversion, it’s a great diversion, you know (RACF-B-Family)
An additional benefit resides in the session’s capacity in
bringing a group of people together:
.. the music therapy has (had) a positive impact on all the residents..as
a social aspect as well as giving them an activity which brings them
joy (RACF-B-Carers)
Right. So for you, there’s no net change, there’s no effect?
The only thing of benefit that I can see is having her there with
company (RACF-C-Family)
Finally, it was felt that MT exercises the older person’s
mind [‘She tends to make their brain work a bit..’ (RACF-C-
Family] such that the music therapist’s techniques and
activities make the session ‘..almost like a quiz for them as
well’ (RACF-C-Carers). Not only does the session exercise
their mind it acts as a medium through which physical
exercise is achieved:
When you’ve got the music therapy that some of them [residents] that
don’t go to exercises will get up and dance.
Right
Oh, for sure, yeah.
So they are getting an exercise session within the music therapy.
(RACF-B-Carers).
I think it’s the therapy, I think it’s the music. . .She’s both
Perceptions prevail about the separate/mutually inclusive
effects of the music and the effect on the older person by the
therapist. Complicating this were the views that an enter-
152
tainer (musician) is just as good as a musical therapist. The
interpersonal effect of the therapist is agreed, and specific
personal characteristics were described.
Care providers’ experiences with music as song in which
the song acts as an intervention is inextricably linked with the
therapist:
I was singing to one of the residents the other day, she was yelling out
and she went quiet.
And I think it’s just all from [name of music therapist].. that’s sort of,
carried on between, with everyone.
OK. So, it gives you another. . ..
Avenue.
Another avenue to helping, especially with dementia. (RACF-C-
Carers)
This music/therapist binary can be so influential that those
that ‘.. might have lost their speech. . .or don’t speak..’ but
when ‘.. you put on music, or if [name of music therapist]
there, they will start singing’ (RACF-A-Carers). In essence,
the notion of therapist as musician is captured below:
So is it. . .?
Music.
Therapy, or is it music?
I just think it’s therapy.
I just think its music therapy.
She’s both (RACF-C-Carers)
The therapist effect was described as ‘they know her, they
know why she’s there..she gets a chair..and they’re all
gravitating towards (her)’ (RACF-A-Carers). For some at
RACF-A, ‘it’s most likely the guitar that’s the trigger’. In
contrast, the music effect alone was stated: ‘Honestly, I think
it’s the music that connects them’ (RACF-A-Carers) and
elaborated thus:
One particular resident you’d have trouble toileting him, and it will
be ‘No, no, no’..but then as soon as you actually started singing one
of the songs that they knew, that behaviour then, sort of, eased a little
bit, you managed to be able to get that done.
It’s part of the songs that they listen to in therapy (RACF-B-Carers)
Further probing about the music effect alone (Would you
see the same effect by turning on a CD?), for carers at RACF-
C and RAFC-B, the response was ‘No. Because there’s more
personalised involvement (with MT)’ (RACF-C-Carers).
This engagement as personal contact by the therapist was
described variously as ‘they see someone’s face (music
therapist’s) and they associate it with something that is
pleasurable’ (RACF-A-Carers); ‘she (music therapist) sings
her goodbye song..she mentions their names..It’s a real
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personal (sic), it really makes them feel great. . .a bit special’
(RACF-C-Carers). As such, carers at RACF-A pondered
whether a different therapist or even an entertainer (musi-
cian) would do the same job as well? Carers at RACF-C
concurred with colleagues at RACF-A that ‘I think it depends
on the actual therapist..I think you would get a different
reaction..’. However, this did not necessarily translate into a
negative reaction, rather:
I’m sure if somebody new does comes along, that once a routine has
been built up, a rapport, that they’ll probably get the same reaction.
(RACF-A-Carers)
Furthermore, a ‘good entertainer’ able to ‘..(be) involved in
what’s happening..’ was thought to be as effective as a music
therapist:
They need to connect with the person.
But there are entertainers that could do that as well.
Absolutely (RACF-A-Carers)
Not all carer groups were convinced. RACF-B carers had
some reservations about substituting the music therapist
with an entertainer (‘We get other entertainers that come in
and they’ll listen to it, but they don’t get involved as much’).
For them, the music therapist has qualities that set her
apart:
[Name of music therapist] actually putting sparks into them to bring
things out of them. Like, she’s giving them something that they can
relate to, whereas a musician comes and plays what is his repertoire,
he may ask for requests, some people don’t like what he’s playing
whereas [name of therapist] is making a conscious effort to make
them ‘all inclusive’. She’s got a calming effect in the way she talks to
them (RACF-B-Carers)
These personal characteristics were further described and
validated across the three RACFs. The music therapist is
‘..passionate about what they do’ (RACF-C-Carers) with a
very strong person-centred focus. This latter quality was
borne out in the focus group data through carers articulating
that the music therapist does what she does as ‘..she connects
individually..’ with residents (RACF-B); by ‘..understanding
the individual..’ (RACF-C); as ‘..she gets them involved..’
(RACF-C) through ‘Bringing their personal bits into it
(RACF-C).
Bodily movement revealed itself to explain how both music
therapists in this study establish and keep the individualised
connection with each older person in the session:
That’s right, she works the room, she skates around on the wheels.
And she’ll be on one side and then she’s on the other side, and then
she’ll be encouraging someone to get up. . . (RACF-B-Carers)
© 2014 John Wiley & Sons Ltd
What carers and family said about music therapy
.., are there qualities of the music therapist that are important?
She will look at that person and she looks them straight in the eye
when she’s playing the music and she looks and smiles at them
Yeah, she’s like a snake charmer really isn’t she.
I think she’s well suited to the job she is doing. (RACF-C-Family)
Finally, a range of more specific qualities were described.
These included a ‘nice soft voice. She has got a calming effect’
(RACF-A-Carers); a ‘..lovely smile that she brings in’ (RACF-
C-Family); an ‘..ability to interrelate with everyone. . .the
ability to be flexible..’ (RACF-C-Carers).
In the context of these personal qualities carers used to
describe the music therapist, and consistent with the previ-
ously cited RACF-B carers who had some reservations about
substituting the music therapist with an entertainer, this
group made this salient point:
It’s, obvious she wants to know the residents, she becomes part of
their lives.
She’s keen to be involved, she knows everyone’s name,
So not everyone can be a music therapist, and not every musician can
be a music therapist. And I know they do a very long course, but
music therapists can be musicians.
Mmm.
There’s a differing, there is a professional strand in them, they’ve got
to have the respect for the people they’re dealing with, you can see
that it’s not just a job, it’s their being.. (RACF-B-Carers)
Policy
As a final core theme, care providers want the policymakers
to know that music therapy is highly prized and worthwhile
in dementia care and in residential aged care generally where
palliative care is increasingly the norm rather than the
exception.
We honestly think it’s a good thing (but)
Concurring with family, they want policymakers aware that
more not less music therapy, planned and adequately funded
as part of ongoing care is required. At the level of the RACF,
thought needs to be given to the timing and duration of the
session. Music therapy after all, should be for everyone:
I think lots more. I think if [name of music therapist] was able to do it
every day of the week I’d be really happy, because I can see a change,
. . .I think the music from [name of music therapist] really lifts them.
(RACF-C-Family)
Across the three carer focus groups representing three
different RACF, the consensus was that the MT sessions are
‘a good thing’:
153
A.G. Tuckett et al.
We honestly think that it is a good thing.
It is definitely a good thing for the residents (RACF-C-Carers).
They are really worthwhile, honestly, they really are (RACF-A-
Carers)
I’d hate to see it stop (RACF-B-Family)
Given what has been said about the timing of the MT
session, the caveat is ‘It’s a good thing, but the time needs to
be looked at. And the length of time they give the session’
(RACF-C-Carers).
A way forward on this timing issue can be found by
increasing the frequency of sessions:
I think more sessions.
Yeah, but group sessions not one-on-ones. (RACF-A-Carers)
Needs more time of it, like an extra session (rather) than less.
So you think more sessions rather than. . .?
I think so, yeah, if you could have a couple of afternoons a week..
(RACF-B-Carers)
Finally, complementing their request for policymakers to
consider the scheduling (timing), duration and frequency of
the music therapy sessions, carers also spoke about the
‘continuity’ of them:
..you couldn’t have a casual person coming here one day, you need
continuity.
You need continuity so that there’s that element of trust and recall.
That’s why she’s good because she does come in on a regular basis.
(RACF-B-Carers)
In addition, in response to the interviewer (AT) asking
carers in RACF-A ‘What’s the take home message to policy
makers?’, they responded:
When they’re palliative (at) the end of life.
Yeah.
It’s very good. (To involve) the human touch is quite good at the end.
Yeah. It can be soothing.
I’ve just heard it’s [music therapy] been good towards the end and
they seem to peacefully go after it, for some reason. I don’t know
why, but I have heard of it happening.
Furthermore, the sentiment that ‘Everyone’s got the right
to music therapy, it’s something that shouldn’t just be cut
off. That would be the only thing (policymakers should
know)’ (RACF-B-Carers) was couched in arguably, frus-
trated commentary about funding allocated to music
therapy.
For me the take home message is (for) Government’s running funding
. . . but because it’s [music therapy] not actually a therapy that is
directly linked to a medical problem, we don’t get the funding for
it.
154
Mmm.
And if the people sitting in that tower could just look down and see
the benefits because not only are they just having music, they’re
getting the exercise of dancing.
It works in dementia. (RACF-B-Carers)
Discussion
The purpose of this study was to evaluate the effectiveness of
MT intervention on behaviours of older people with
dementia. Reported here are qualitative data from five,
semi-structured focus groups comprising RACF staff mem-
bers and family members. From the onset, we again note
that several Cochrane Reviews into MT have reported mixed
outcomes whereby two reviews reported a positive MT
effect while a third, specifically evaluating the effect of MT
for people with dementia, could make no definitive conclu-
sions (Maratos et al., 2008; Gold et al., 2006; Vink et al.,
2004).
The scheduling (timing) of the MT session has conse-
quences for the workflow and impacts the care providers and
older person. Differing opinion related to the timing of the
MT session emerged. In this specific context, MT as a
preferred afternoon activity was set alongside the fact that
care staff were able to integrate and interact during the
afternoon because of manpower levels that equally facilitate
attending to care tasks. In contrast, RACF-C staff held to a
consensus not to have MT late in the afternoon and to reduce
its duration. A similar rationale was proposed – in the
afternoon the older persons were left agitated, with a
heightened sundown effect. Consequently, staff working
patterns suffer and compounds staffs’ fatigue in the after-
noon. In the interests of the older people in residential aged
care, however, research suggests that the sundowning effect
can be ameliorated by MT (Tomaino, 1994; Whitcomb,
1994); MT has a protective effect mid-afternoon (Bruer et al.,
2007) and specifically to reduce agitation, music listening
approximately 30 minutes before the agitation peak is
recommended (Gerdner, 1999).
Unsurprisingly, care providers would describe the MT
effect as evoking memories and facilitating reminiscence for
the older person. Older persons in residential aged care are
thought to thoroughly enjoy it as a therapeutic intervention
(Brotons & Marti, 2003). The positive impact on the older
person is described as providing joy, enjoyment and a social/
socialising activity (Cevasco, 2010).
The temporal effect of MT (Daveson & O’callaghan,
2011) is perceived to be very much in the moment. This in
situ effect calms and induces happiness at the time of the
© 2014 John Wiley & Sons Ltd

session with little residual influence. However, some felt that
the MT session(s) had a sundown effect whereby the MT
effect carried across and improved behaviours of the resident
(s) during the afternoon (Tomaino, 1994; Whitcomb, 1994;
Lesta & Petocz, 2006). This sundown effect was supple-
mented by two male carers (one present in the focus group)
who were allocated time to further interact with the resident
(s). This effect across time finds some support in Brotons and
Marti’s pilot study (2003); more firmly in the study by Bruer
et al. (2007) who found improved cognition lasting into the
next day; and over a 2-year period, MT had the long-term
physiological effect of decreasing systolic blood pressure
(Takahashi & Matsushita, 2006).
Music therapy helps with cognition and promotes an older
person’s exercise (Cevasco, 2010). A value of the MT session
is that it is a diversional activity (Daveson & O’callaghan,
2011) that makes the older person think. Studies support the
MT effect on cognition. Whether music alone amongst
professional computer information systems developers (Les-
iuk, 2010), or as MT amongst elderly persons with dementia,
cognitive performance improves. Likewise, MT incorporating
playing a musical instrument is exercise and MT elicits a
physical response (Takahashi & Matsushita, 2006). The
cumulative MT effect herein is that older adults who exercise
have previously demonstrated improved cognition involving
reasoning, memory and reaction time (Clarkson-Smith &
Hartley, 1989).
The present findings suggest a misunderstanding between
the music and therapist effect. The carer groups perceived
sometime separate, sometime mutually inclusive effect of the
music and the effect on the therapist on the resident.
Through the habit of regular sessions and the attendant
calming-happiness effect, older persons respond positively
on seeing the therapist arrive. For RACF-A, the MT effect is
about the music, not the therapist. Sentiment was expressed
that a good musical entertainer can engage and can have a
comparable effect. Whether the MT experience is dyadic
(Shoemark & Grocke, 2010) or premised on a triadic
foundation (Magill, 2010), the music/therapist relationship
is symbiotic and thus inseparable. Unequivocally, the pres-
ence and the personality of the music therapist play an
important and influential role in music therapy (Cevasco &
Grant, 2003; Magill, 2010). With the same degree of
certainty, in an RCT study seeking to measure cognitive
changes as a consequence of MT, the researchers make it
very clear that ‘results are not intended to infer general
efficacy for therapeutic interventions involving music by
persons outside the music therapy profession. . .’ (Bruer
et al., 2007: p. 324). In other words, a musical entertainer
will not suffice.
© 2014 John Wiley & Sons Ltd
What carers and family said about music therapy
Specific music therapist (personal) characteristics were
described. The MT needs to be able to individualise the
music and most importantly operate on a very personal and
personable level. The ability of the music therapist (or
entertainer) to engage is very important. That is, there is a
very strong interpersonal influence that cannot be discounted
as contributing to the effect of the music therapy session
(Magill, 2010; Shoemark & Grocke, 2010). The therapist
consciously makes an effort to include every person, interacts
and knows to ‘play their songs’. The interpersonal qualities
and the actions of the music therapist were described –
singing to the person, referring to them by name, moving in
close and engaging through eye contact (Cevasco, 2010;
Magill, 2010).
Limitations and recommendations for further research
The analysis of the data reported here is limited by the
number of focus group interviews (5) and by the content of
those interviews. Although, the utilised research strategies
and operational techniques (Tuckett, 2005a) coupled with
findings confirmed in other studies (e.g. Magill, 2010;
Shoemark & Grocke, 2010; Cevasco, 2010), suggest trans-
ferability and thus overall trustworthiness (Tuckett, 2005a).
Further investigation of care providers’ views must be
examined in order to understand how to best deliver and
provide MT services in residential aged care. For example,
future research should explore the timing and scheduling of
MT sessions at different times in the day for older people
with dementia (Bruer et al., 2007).
Conclusion
The purpose of this study was to evaluate the effectiveness of
MT intervention on behaviours of older people with demen-
tia. Reported here are qualitative data from five, semi-
structured focus groups; three comprising RACF staff mem-
bers and two comprising family members. Operationally, the
timing of the MT session has consequences for the workflow
in the aged care facility and impacts the care providers and
the older person in residential aged care. Music therapy has a
psychosomatic effect on the person with dementia and
participants here evaluate this as temporal. Furthermore,
MT has an instrumental value observed as an activity, a
social gathering and as helping with cognition and exercise.
Mixed views exist about the effects of the music and the
effect on the older person by the therapist. Finally, research
participants want policymakers to ensure more, not less,
planned and better funded MT is part of ongoing care in the
residential aged care context.
155
A.G. Tuckett et al.
Implications for practice
 Care providers and family members want the policy-
makers to know that music therapy is highly valued
(Brotons & Marti, 2003) and beneficial in dementia
care and in residential aged care generally, even if the
effect is temporal. In a context where palliative care is
increasingly the norm rather than the exception, MT
has its place (Magill, 2010). They want policymakers
aware that more not less music therapy planned across
the day is required. MT should be for everyone; carers
especially want the session(s) to be universal – beyond
the DSU and spread out into the facility more broadly.
Consequently, MT funding needs re-thinking. Find-
ings suggest the MT effect is enhanced through the
‘continuity of the therapist’ and to this end a program
of MT is recommended (Cevasco, 2010).
 Data reveal that care providers and family do not fully
comprehend the theoretical and practical underpin-
nings of the work of music therapy, including the role
of the therapist. We recommend that care providers
and family be fully included in MT sessions as a
mechanism for them to experience the therapeutic
effect, as well as to become more completely educated
about MT.
Contributions
Study design: AT, BH, LR, TB-L, DP; data collection: AT,
LR, TB-L; data analysis: AT, BH and manuscript prepara-
tion: AT, BH, LR, TB-L, DP.
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