Design
A qualitative study was performed using open interview techniques. An open interview technique is considered an appropriate and valuable research methodology in palliative care settings, as it allows for the inclusion of patients who would otherwise be unable to participate in other study designs, e.g. filling out questionnaires in quantitative studies [12, 13].
Data collection and analyses were based on the methodological concept of grounded theory [14, 15]. The study was approved by the ethics committee of the Charité - Universitätsmedizin Berlin (EA 1/191/10, 01.09.2010).
Patients
The pre-screening of patients for the study was carried out by the caregiving nurses in a stationary hospice in Berlin with 16 beds.
Patients and their relatives were invited to participate in an interview study on music therapy with the Body Tambura. If they were interested, the music therapists would inform them about the intervention and the procedures of the study.
Inclusion criteria were: receiving palliative care in the hospice, age ≥ 18 years and ability to speak fluent German. Dying patients were excluded as were patients unable to participate due to severe clinical symptoms, unable to talk, or those under legal guardianship.
After providing written informed consent, patients were enrolled in the study and the music therapy started immediately.
If family members or caregivers participated in the music therapy session they were interviewed as well.
Intervention
The Body Tambura was designed as a therapeutical instrument to be placed on the human body (Figure 1). The initial motivation for this new development sprang from a music therapist’s request for an easy-to-handle body instrument for receptive music therapy work with bedridden patients (coma patients). The instrument consists of a very lightweight rectangular corpus (measuring 70 × 33 × 8 cm; L × W × H) equipped with an ergonomically contoured base and a sounding board fitted with 28 (i.e. 7 × 4) strings tuned in the same note pattern as the Indian Tanpura (A – d – d – D). The sound of the Body Tambura is characterized by playing the 28 strings of the instrument evenly to produce fine vibrations and create a softly enveloping monochromatic acoustic space for the listener, which is supposed to induce a state of trance and relaxation [7].
The recommended playing technique is a very even, confluent touching of the strings with the fingertips of both hands alternating. While playing, percussive sounds, background noise (fingernails) and mechanical vibrations/shocks caused by playing too hard should be avoided. In cross section the radius of its curvature is chosen such that it fits the contours of the human body without being constrictive. The contact surface is thus enlarged and can be placed over the patient like a cover. If the instrument is placed at the centre of an adult’s body, the length of the corpus creates contact points between the shoulders and the pelvic region. The corpus is made from fine-pored tonewood which guarantees good stability and optimal vibrational properties, both as a “listening” and as a “feeling” instrument. The instrument weighs roughly 2,200 g. Its construction – in terms of material thickness and quality - is such that the resonating chamber is fabricated to be as light as possible. However, a certain weight is required for good vibration transference and distribution over the entire upper body, which can provoke a pleasant experience.
The intervention was facilitated by two experienced music therapists, both having more than 10 years of professional experience. The Body Tambura was either placed directly onto the body of the patient while he or she was lying down or was played a short distance away from the patient. The duration of treatment was determined by the requirements of the patients. The intervention could be repeated in weekly sessions with up to five sessions for each patient. Each session began with a greeting followed by a short introduction and a request for feedback on the previous session. At the end of each session, the patients had the opportunity to give feedback and share their experiences.
Interview guide and data collection
A semi-structured interview guide was developed by the researchers and music therapists based on former practical experiences and the study aims. Patients were asked:
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How did you experience the music therapy with the Body Tambura?
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What exactly has changed?
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What did you find enjoyable?
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Have you experienced any unpleasant feelings or emotions?
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Have your complaints changed? If so, can you specify which complaints and how they have changed?
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Would you recommend treating other people in your situation with this music therapy?
The main diagnoses and actual complaints of each patient were documented, in addition to basic sociodemographic information such as age, gender and educational background. The interviews were conducted in person in the hospice at the patients bedside by an independent researcher (medical doctor) a few hours after the sessions or on the following day. The aim was to conduct at least one interview with each patient and, should their health allow it, to conduct further interviews to explore their longitudinal experiences,. All participants gave their informed consent. Interviews were digitally recorded and the interviewer wrote up a short interview memo after each interview.
Data analyses
All interviews were transcribed verbatim. Analyses followed a grounded theory approach assisted by the software MAXQDA® [16]. After the first four interviews were transcribed and analyzed, the next four interviews were conducted with taking into account new findings and questions developed from the first round of results. Data collection, coding and theory generation alternated, the analysis process occurred in a triadic and circular constant comparative manner [14, 15]. Written memos during the coding and analysis process supported the analyses and results. The initial data analysis was performed by an experienced qualitative researcher and was critically reviewed by a peer researcher. Generated theories included in the results required the approval of both researchers.