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

Abstract

In the past years, professional musicians of participatory music practices in healthcare contexts have increasingly worked as artistic allies for care. The musicians shaping these practices have developed ways of engaging with patients and their families, collaborating with healthcare professionals, and potentially also guiding novice musicians. Working with people in a vulnerable situation, care professionals and less-experienced “newcomers” in the interprofessional community of practice, healthcare musicians fulfil various new responsibilities beyond conventional music professionalism. Particularly when coming from a tradition of performance, they are confronted with dilemmas of an ethical nature that require a situated response, especially as they operate in improvised situations with vulnerable patients. Yet, little is known about the nature and types of “ethics work” and how musicians go about solving them. This article explores some typical ethical dilemmas encountered by healthcare musicians in their engagements with people on site, drawing from research underpinning an existing music-in-hospitals practice. Building upon the works of Goldbard and Matarasso, the point of departure is that artists working in any social context will undoubtedly encounter ethical dilemmas but often lack preparedness to deal with them. “Thick” descriptions are analyzed through the framework of care ethics in music-making, and the ethics of participatory arts and community music. The findings present seven intertwined ethical dimensions of musicians working in participatory music practices in hospitals, suggesting that, although the applied situational ethics of their work are partially safeguarded by collaborative means with healthcare professionals, musicians need structural support for building practical skills and awareness of the multidimensional ethics of musical care, also for their own wellbeing.

Over the past two decades, professional musicians have increasingly engaged in participatory music practices within healthcare settings, contributing to meaningful encounters and promoting health and wellbeing (Fancourt & Finn, 2019; Koivisto & Tähti, 2020). These so-called healthcare musicians have developed recognized professional skills sets, marked by contextual adaptability, collaborative skills, and musical sensitivity (Koivisto & Tähti, 2020; Smilde et al., 2014, 2019). Their work supports patients and caregivers alike, often navigating complex interpersonal dynamics, and emotionally charged and unpredictable settings, while under strict institutional protocols such as privacy and safety procedures (De Wit, 2021; Dons, 2019; Koivisto & Tähti, 2020). Musicians’ growing engagement in healthcare aligns with broader movements in healthcare, such as value-based and person-centered care, which emphasize compassion, contact, collaboration, and holistic recovery (Kitwood, 1997; Van der Wal-Huisman, 2024). In this evolving landscape, healthcare musicians are no longer seen merely as performers but as co-creators of responsive health environments. They are also not a homogenic group, but music professionals with varied artistic, community music, and music pedagogical backgrounds (Koivisto & Tähti, 2020). Their expanding professionalism (Westerlund & Gaunt, 2021) now encompasses musical facilitation skills and interprofessional collaboration skills, as well as musical, co-creative processual skills, and contextual adaptive skills (De Wit & Sevindik, 2024; Koivisto & Tähti, 2020). Westerlund & Gaunt (2021) argue that music professionalism—which encompasses “the conduct, aims, values, responsibilities, and ongoing development of a practising professional in the field” (p. xiv)—is a dynamic concept, which “is concerned both with competencies and with the enacting of working practices in occupations that are inherently ethical in nature” (p. xiv). Healthcare musicians’ multifaceted expanding professionalism generates dynamic human encounters that demand rapid, context-sensitive, hence, situational care ethical decision-making (see Tronto, 2015). Their actions impact not only patient wellbeing (Dons & Gaunt, 2021) and collaboration with care professionals (De Wit, 2021) but also the wellbeing of the musicians themselves (Koivisto & Tähti, 2020; Shaughnessy et al., 2023).

While research into healthcare musicians’ professionalism in care settings is growing (De Wit, 2021; Dons, 2019; Koivisto, 2022), ethical considerations surrounding their professionalism remain underexplored. Unlike music therapists, whose work is grounded in clinical goals and regulated therapeutic frameworks, healthcare musicians operate as artistic practitioners whose focus lies in creating responsive musical encounters rather than delivering therapy. Despite growing trust in healthcare musicians’ expanding professionalism (Ruud, 2012; Smilde et al., 2019), concerns have been raised about the boundaries between healthcare musicians and music therapists engaging in the diversifying field of participatory health musicking, meaning any form of musical engagement providing health and wellbeing affordances (Ansdell & DeNora, 2012; Bonde, 2011; Spiro & Sanfilippo, 2022). Bonde (2011) argues that “health music(k)ing cannot be monopolized by ‘music therapists’, ‘community musicians’ or ‘music and health workers.’ It is an interdisciplinary field, including […] professionals with many different backgrounds and qualifications […]” (p. 136). Thus, the blurring of professional boundaries may provide grounds for further exploration of interprofessionality in musical care practices (Spiro & Sanfilippo, 2022).

The need for increased ethical awareness and responsibility as core competencies exists for all participatory artists, yet remains underexplored (Forbes et al., 2025; Laukkanen et al., 2021; Matarasso, 2019). With regards to professional training, Koivisto & Tähti (2020) point out that as the professionalism of healthcare musicians expands “beyond more conventional positional music making and musicianship” (p. 419), “the influence of musicians’ educational background is also becoming more significant” (p. 430). To ensure safe and effective practice, training addressing ethics is increasingly seen as essential (Matarasso, 2019). Education can help standardize ethical aspects, reassuring healthcare institutions of the value and reliability of arts-in-health work. This includes deepening ethical understanding of health musicking as a collaborative professional practice. In the Netherlands, where this article is based, arts-in-health training programs are developing across conservatoires and arts colleges (Gaillard et al., 2025). However, the field remains fragmented, with varied terminology and approaches that complicate its definition and implementation (Lewis et al., 2024).

In music education research, the discourse around ethical responsibilities and practices of music education professionals can inform health musicking. For example, Regelski (2009; 2022) calls out for viewing music education as a helping profession along with doctors, nurses, and caregivers, who share ethical responsibilities for contributing to people's experiences of a good life (Regelski, 2022). In his framework, Regelski (2022) points out the inevitable situationality of musicking as a social praxis, which aligns with the situational and relational nature of participatory health musicking. Participatory artists working in healthcare settings as helping professionals also face dilemmas that can significantly impact those they engage with. As Matarasso (2019) notes, while they are not clinicians, their influence carries ethical weight. Moreover, artistic practices in societal contexts introduce unique ethical challenges, as artists are accountable for the meanings they create and the effects of their work (Matarasso, 2019).

The transformative and unpredictable nature of artistic engagement in healthcare complicates ethical professionalism. Ethical professionalism in this context is understood as aligned with Regelski's (2022) call for ethical competency in music professionalism: “[A]ny music praxis—indeed, any social praxis, from therapy to nursing to teaching (etc.)—comes with an expectation of ethical competence on the part of the practitioner. Thus, a musical praxis must competently serve the needs of particular (socio-musical) situations” (p. 20). What is more, this complexity can be exactly one of the reasons artists are invited into non-artistic contexts (Coumans, 2023). Smilde and colleagues (2019) introduced the concept of situational excellence to describe healthcare musicians’ adaptive capacity to respond to contextual and situational needs, which aligns with Regelski's (2022) definition of musicians’ ethical competency. However, this concept does not fully articulate how ethical reasoning is embedded in such decision-making.

With the aims of contributing to this research gap and adding to overlooked ethical aspects of healthcare musicians’ professional practice in hospital settings, this article investigates ethical encounters, decision-making, and dilemmas of musicians of the existing participatory music practice of Meaningful Music in Healthcare (MiMiC) in two Dutch hospitals. Building upon previously conducted research, the aim of the article is to identify, deepen understanding of, and provide practical suggestions for the ethical dimensions in musicians’ work in participatory music practices in hospitals and potentially other healthcare settings. Central questions of this article are: What ethical dimensions confront musicians in the interprofessional encounters, decisions, and dilemmas of hospital ward settings, and what do these reveal about how musicians expand their professionalism through participatory health musicking? What are the implications for practice and education?

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.

Methods

This article draws from previous research into Meaningful Music in Healthcare (MiMiC), which is a participatory artistic music practice developed in The Netherlands as a collaborative effort between the research group Lifelong Learning in Music (now Music in Context) of Hanze University of Applied Sciences and the surgical department of the University Medical Centre Groningen since 2015. The practice of MiMiC has since been carried out by Foundation Mimic Music in The Netherlands, and spread to conservatoires, musicians and hospitals in Vienna, Graz, and London. MiMiC sessions involve teams of three musicians—sometimes including a student intern—supported by a mediator, performing live music for adult hospital patients, their families, and care professionals during week-long residencies (De Wit & Sevindik, 2024). Using primarily string and woodwind instruments, the musicians adopt a person-centered approach, preparing diverse musical selections and creating improvisations based on patients’ ideas and preferences (De Wit, 2020, 2021; Dons, 2019). Musical encounters occur only when patients invite the musicians into their rooms, ensuring consent and comfort (Smilde et al., 2019). The practice goes beyond entertainment, serving as a catalyst for emotional expression, connection, and wellbeing. Though not its primary aim, MiMiC has been shown to alleviate pain, reduce stress, and improve mood, occasionally leading to decreased reliance on medical interventions such as pain medication (Van der Wal-Huisman, 2024).

This article is the result of a cumulative research approach (Wiseman, 1987) involving the same researchers engaged in a series of projects tied to the development of MiMiC (2015–2019), later ProMiMiC (2019–2023). As an accumulation of knowledge, the topic of ethical professionalism builds upon the already published research data, that is, “thick” descriptions (Geertz, 1973) based on the triangulation of ethnographic fieldnotes, expert interviews, and group discussions with musicians and healthcare professionals, and reflective journals of musicians (De Wit, 2020; De Wit & Sevindik, 2024; Dons, 2019; Smilde et al., 2019). Following once more an ethnographically informed approach (Hammersley & Atkinson, 2007), at the center of the research approach was researcher triangulation and reflexivity with regards to decision-making of which thick descriptions to re-analyze (Flick, 2014). The investigation had an autoethnographic thread (Chang, 2008; Ellis et al., 2014) as all researchers are closely familiar with the practice through many different tasks: musicians, trainers of novice musicians, collaborators with healthcare professionals, participant observers, and mediators. This autoethnographic positioning facilitated a more proximal cultural understanding of the MiMiC practice from within, including first-person experiences.

The current study reports on a qualitative analysis with a hermeneutic cyclical nature (George, 2021), constantly reflecting on the relationship with the data processing and reporting and the MiMiC practice. The research process started with (1) a first consensus of all three authors on defining the research problem based on multiple possible framings, followed by (2) a first consensus by authors 1 and 2 of plausible ethical dimensions in which ethical dilemmas occur, based on the MiMiC musicians’ already established aspects of expanding professionalism: musical facilitators, collaborators, artists, mediator-researchers, and educators/trainers. This consensus guided the process of selecting representative material from the open access published body of work, consisting of over 25 thick descriptions of triangulated ethnographic data (see de Wit, 2021; Dons, 2019; Dons et al., 2023a, 2023b; Smilde et al., 2019). Afterwards, (3) through the selection of 14 contrasting episodes from the already produced thick descriptions, a definite consensus of 7 ethical dimensions was made. Subsequently, (4) a deepened analysis of these dimensions, facilitated by the concepts of care ethics and ethics of participatory and community arts, finally led to the reporting of the findings accord by the three authors.

The data, that is, the selected episodes combining fieldnotes, reflections, and narrative accounts, were analyzed collaboratively, using first- and second-cycle coding (Charmaz, 2006). The first-cycle coding was flexible for emerging themes, while the second-cycle coding was focused on coding into themes, supported by the literature framework. To follow ethical research protocol (ALLEA, 2023; European Commission, 2013), the previously published thick descriptions are pseudonymized and represented truthfully.

While the authors are confident about the chosen methodological approach and satisfied about being able to identify seven ethical dimensions, they acknowledge that the article may not fully represent the MiMiC practice. A majority of the work and research data, much of which did not end up in this article, suggests that the music sessions run like a well-oiled machine (as described by a musician in Smilde et al., 2019), where the nurses and musicians make significant efforts to work together toward high-quality person-centered care for patients. Therefore, instead of framing the practice as ethically compromised, this article hopes to bring about new awareness and learning of likely ethical struggles encountered by musicians in healthcare settings.

Findings and Discussion

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”

enough. The woman was moved by the music, but she also seemed to have sadness

in her eyes. I would have liked to take some more time to help her to overcome the

emotion a bit more, so that we could have left the room with a lighter mood. […]

Was it ok to leave then? […] I am happy that there were nurses in the room and one of

them stayed behind. So, I feel the woman was left in good hands after all.

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.

The ethical question arising here is how much engagement musicians can expect from the healthcare partners during MiMiC projects, particularly knowing how much occupational pressure the hospital workforce is under? On the one hand, the quality of the musicians’ work is largely dependent on a close collaboration and communication with the care professionals to ensure the safest and most suitable approaches to each patient (Smilde et al., 2019), and furthermore, the cultural development toward value-based care also asks for flourishing, mutually respectful interprofessional teamwork (De Waal, 2018). On the other hand, care professionals are also fully self-governing in choosing whether to engage in the musical encounters. Navigating between a neediness for the nurses’ acceptance and collaboration, while respecting their autonomous choices to (dis-)engage, seems an ongoing dilemma for the musicians. A lack of mutual hospitality (see Higgins, 2012; Lines, 2018) does impact the musicians’ sense of being wanted and belonging: “[…] that is the moment when you feel ‘oh, actually I’m a visitor, I’m an outsider’” (from Dons et al., 2023a, p. 34).

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.

The ethical reflection on the nurse's positioning toward the patient and assumptions of them as a person, by saying “We often approach it like: ‘It is probably a characteristic’,” shows an insightful admission of an ethical dilemma, which, in this case was helped to be solved by the music-making: seeing the person behind the patient.

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).

A musician reflects on the sense of guilt about the musical choice, which may have led to the woman's discomfort, as well as a great sense of worry and care towards a student musician in the team with her (from Smilde et al., 2019, pp. 32–35):

[A fellow musician] said that he would have preferred to play an improvisation and wondered if the situation would have turned out differently if [the patient] would not have been as moved by that music as she was by Elvis. […] Suddenly, I felt this feeling of panic and guilt having had made that call and somehow having been responsible for her terrible suffering in the moment. Still, when I think about it myself, I think that Elvis was a very lovely choice for the moment. […] An improvisation might have been irritating for the older woman who did not want the music to begin with. […] [The student musician] also said that it was especially shocking for him to see what happened to [the woman], as he was playing the melody. He seems to have a feeling of responsibility for her sudden suffering […].

In this reflection, the musician is concerned about the care ethics toward the patient and the student. It also shows the ethical responsibilities of healthcare musicians who are working with student interns. The care goes beyond the ethics of the immediate participatory artistic processes, but also poses the ethical question: By what kinds of learning experiences are novice musicians confronted in the practice? And what are the best ways for caring for them in such situations? To overcome the shock of practice in this episode, reflection about the ethical decisions being made in the musical approaches, as well as later a collective expression of their concerns about the situation to the nurses, seemed crucial for a resolution (Goldbard & Matarasso, 2021).

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.

Conclusions and Recommendations

The findings suggest that while participatory music-making in healthcare settings is often framed by a strong ethos of care, this care is neither straightforward nor equally supported across all participants. We identified seven interconnected ethical dimensions, each pointing to specific tensions, needs, and opportunities for improving safe and ethical practice for musicians working in healthcare: musicians’ incentive and fulfilment, navigating care ethics large and small, professional place and power relations, ways of dealing with highly emotional situations, the shock of practice, safe practice for all, and struggles of research-informed practice and ambiguity.

The MiMiC musicians consistently demonstrated care-based incentives, striving to connect with patients through emotionally attuned, person-centered music-making. However, emotionally charged or unpredictable situations revealed challenges in ethical responsiveness. Musicians sometimes questioned and showed doubt about whether their actions truly aligned with patient needs, especially when lacking time or support to reflect. This highlights that ethical care in music-making depends not only on intention but also on structures that enable real-time responsiveness (Goldbard and Matarasso, 2021; Thompson, 2023). Power dynamics emerged across multiple relationships—between musicians and patients, newcomers and experienced peers, and musicians and healthcare staff. Unlike nurses, they lacked structured training for managing grief, illness, or emotional reactions, often improvising care through artistic presence. Integrating these elements into music education—ideally through interdisciplinary approaches—would strengthen both practitioner wellbeing and the ethical quality of care. Finally, while musicians respected institutional norms around patient safety, their own safety was often overlooked.

In all, what stands out in the findings is the multidirectionality of the ethical dimensions: Musicians’ ethics work is demanded situationally and dynamically on diverse aspects and multiple levels simultaneously. The ethical decision-making situations they face are kaleidoscopically ever changing and can be both experienced and interpreted in various ways. This asks for both ethical self-awareness and excellent teamwork. The authors feel that the care ethical framework (Kwan, 2023; Thompson, 2023; Tronto, 2015) is a fitting lens through which the ethical aspects of the musical processes could be analyzed, as the identified dimensions mostly related to the quality of interactions, inter-relational decision-making, and abilities to recognize the needs of others. These stand at the core of care ethics. The findings underline Matarasso's (2019) and Goldbard and Matarasso's (2021) pleas for increasing artists’ ethical self-awareness.

The findings support several recommendations for education and practice:

Acknowledge “ethics work” (Groot & Abma, 2022) within the professionalism paradigm of healthcare musicians as a multidirectional, situational, and layered practice.

Recognition of safe practice including musicians, with attention to their own emotional and ethical safety.

Since ethics of care in participatory music practices require structural support, attention to power dynamics, role clarity, emotional preparedness, and aftercare are needed. Creating clearer role definitions at the beginning of any music-in-healthcare practice development, with particular attention to separating mediation, research, and musicianship to reduce ambiguity. Also developing ethical support mechanisms for music-in-healthcare practices, such as neutral facilitators or ombudspersons, to address dilemmas and team tensions as sensitively as possible.

Reimagining healthcare musicians’ training with more focus on building emotional resilience, power awareness, and caring protocols for newcomer musicians.

Nurturing interprofessional learning communities to create spaces for addressing and learning to solve dilemmas in ethically sensitive, person-centered work. In the case of music-in-hospitals practices, this could include various healthcare professionals in combination with musicians, researchers, and mediators.

Practical solutions could include the launching of “ethics cafés” in conservatoires, care organizations, and music-in-care practices to provide reflective spaces for rehearsing ethical decision-making and to normalize ethical questioning as a part of professionalization in higher music education.

Ultimately, the integration of musicians into healthcare settings represents a complex and evolving practice. It requires both artistic sensitivity and ethical depth, grounded in relational awareness and interdisciplinary cooperation. The work presented here indicates that healthcare musicians operate within a kaleidoscopic framework where clinical, emotional, and social dimensions continuously interact, which should be dealt with in a responsive, reflective practice shaped by care, context, and collaboration.