1.1 Context and rationale

In recent years, music has gained increasing relevance in healthcare, both as a tool for improving care and as a subject of research. Musicians are more frequently involved in healthcare settings, and innovative musical practices are being explored in transdisciplinary collaborations [1–4]. In the Netherlands, notable examples include Rotterdam Erasmus Medical Center’s Music as Medicine program, the project Meaningful Music in Healthcare (MiMiC) by Prins Claus Conservatoire in collaboration with Academic Medical Center Groningen, Amsterdam Academic Medical Center’s Arts in Health initiative, and the project Creating Cultures of Care of HKU University of the Arts. Although some programs, such as MiMiC, also examine the effects of music on healthcare professionals, most research focuses on its direct impact on patients or other health related target groups, for example through compassionate care [5,6].

The sustainability of healthcare systems is increasingly at risk, requiring structural adaptation. The WHO identifies rising healthcare demands, workforce shortages, and financial pressures as universal challenges [7]. These global trends are evident in the Dutch context, where the Dutch Scientific Council for Government Policy (WRR) warns that rising care demands will outpace economic and demographic growth, threatening the sustainability of the healthcare system [8]. In response, the Dutch government has launched programs to promote labor-saving care models, improve employment practices, and support innovation [9,10]. However, progress remains slow. The Council for Public Health and Society (RVS) advocates shifting focus from technical to social innovation and therefore proposes new forms of collaboration and organization [11]. This perspective is supported by the Ministry of Education, Culture and Science, which stresses the societal value of culture and the need to strengthen the role of creative professionals through cross-sector partnerships [12].

International findings, such as WHO’s scoping review on arts in health [13], demonstrate a substantial evidence base for the health benefits of the arts, but limited policy impact. Therefore, Fancourt and Finn emphasize the need for broader, cross-sector implementation and structural adaptation, including preparing students for collaborative, transdisciplinary work. According to Lewis et al. [14], the potential of the arts to contribute to the quality of care indirectly—for example, by improving healthcare working conditions, enhancing organizational processes, and contributing to the sustainability of the healthcare system—remains underexplored.

Fancourt and Finn [13] identify important indirect forms of impact of the arts on quality of care, such as strengthening caregivers’ clinical skills, mental health and well-being, and understanding of health. Proposing a national agenda Arts in Health in the Netherlands, Lewis et al. [14] argue that the arts can strengthen a culture of care by reconnecting professionals with the relational aspects of their work, building resilience, and improving communication with patients. Additionally, Smilde et al. [15] explore how participatory live music can support learning pathways for nurses, moving from professional distance to emotional inclusion and interprofessional reflection. Finally, Van den Berg et al. [5,6] demonstrate that musical encounters enhance compassionate care, by strengthening nurses’ compassion, empathy, and well-being, positively influencing both care delivery and workplace atmosphere [5], as well as nurses’ mood, work pleasure, and team dynamics [6].

1.2 View on human beings: Inherently musical and caring

This study is grounded in the view that all human beings are inherently musical, a perspective compellingly argued by Spitzer in The Musical Human [16]. Musicality, according to Spitzer, is embedded in deep cognitive structures and manifests through various innate abilities—such as rhythm, pitch recognition, melodic memory, and polyphonic listening. These capacities suggest that everyone has a natural predisposition to engage with and be affected by music. However, the way this musicality is expressed varies across cultures and individuals. While infants are highly receptive to diverse musical expressions, preferences and skills tend to solidify early in life.

Spitzer identifies several qualities that make music particularly valuable in healthcare. Its semantic openness and emotional immediacy allow music to evoke deep feelings. Through mimesis, the biological tendency to imitate, music reflects the world and fosters imaginative thinking, enabling individuals to envision possibilities beyond their current reality. Besides, even just listening to music is inherently relational and participatory: the listener mentally imitates the performer, who imitates the composer, who in turn imitates the world, by transforming it into music. Moreover, the human body’s upright posture facilitates shared musical expressions like clapping, singing, and dancing, fostering emotional and social harmony [16].

Concurrently, this study adopts the care ethics framework of Tronto [17], which suggests that all people—including, for example, musicians—are inherently caring. Tronto challenges the notion that care is reserved for professionals or those deemed naturally nurturing. Instead, she emphasizes that everyone is both a caregiver and care receiver throughout life, and that dependency is a fundamental, not deficient, aspect of being human. Care is thus a reciprocal and relational practice [17]. Tronto outlines five phases of care: caring about (awareness), caring for (responsibility), caregiving (action), care receiving (responsiveness), and caring with (political awareness). These phases are also applicable to musicians’ roles in healthcare, highlighting their potential contributions to care processes.

1.3 Ethical and aesthetic perspectives on healthcare

Ethically, this study conceptualizes the allocation of care responsibilities not as a set of fixed roles but as evolving moral practices [17,18]. While Walker [18] politicizes ethics more broadly, Tronto [17] specifically politicizes care ethics, particularly in relation to how care responsibilities are allocated within society. From this perspective, musicians’ involvement in healthcare can be seen as introducing new voices into these negotiations, potentially reshaping the distribution of care responsibilities and contributing to a more sustainable system.

Aesthetically, this study values musical encounters not only for their sensory impact. The care process itself can be regarded as having aesthetic properties as well [19,20], as can organizational processes [21]. Furthermore, this study values musical encounters for their transformative potential. Recognizing this potential can enhance the quality of care and job satisfaction in healthcare, and reveal deeper insights—such as questions of justice—within care settings and society [19,20]. Drawing on Schiuma [21], this study assumes that leveraging the aesthetic dimension of organizations can foster institutional adaptability. Artistic practices, including musical ones, offer emotional knowledge that complements technical expertise, reinforcing the human-centered nature of, for example, healthcare institutions and legitimizing partnerships with artists such as musicians [21].

1.4 Research question

This study investigates the following question: In what way do musical encounters in healthcare enhance experiences of connection focusing on the perspectives of care professionals and musicians?

2.1 Case selection and participant recruitment

Three cases were selected through convenience sampling, leveraging the researcher’s network of musicians in healthcare settings (Table 1). The first case involved Bedside Music, a collective of cellists dedicated to person-centered performances in healthcare environments. The researcher, already familiar with its artistic leader, was introduced to a general hospital that had recently partnered with the collective. The second case emerged from a collaboration, initiated by the researcher, between a music therapist at an academic medical center and a postdoctoral researcher at a local conservatory. The third case featured a joint music initiative between a residential care center and a local arts and culture institution, which was looking for a researcher via an online platform for social arts projects. Although not exhaustive, the varied nature of these cases offers a broad perspective on musical encounters in healthcare and social domain. The individual participants (such as project leaders, care professionals and musicians) were recruited by the respective facilitators, provided with information about the study, and invited to participate voluntarily.

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Table 1. Overview cases: Description of musical encounters.

https://doi.org/10.1371/journal.pone.0359306.t001

2.2 Data collection

Data were collected over a two year period, solely by the researcher and mainly through open observations and interviews, supplemented by an elicitation technique (Table 2). Key participants included musicians, care staff and project leaders/facilitators across the three cases. Observations were conducted during musical events such as performances, choir sessions, and meetings. The researcher participated modestly in activities (e.g., by singing along or assisting participants in turning pages) or observed unobtrusively to preserve the authenticity of the encounters. Notes were taken when possible, or voice recordings were made post-event. In cases where COVID-19 restrictions prevented observation, participating musicians, welfare and care professionals submitted reflection reports. Open interviews were conducted with key figures from each project. To deepen emotional insight, the researcher used an “Emotional process form”, adapted from Nonviolent Communication principles [30]. This form, which was pilot tested during a project team meeting, prompted participants to list five sequential emotional keywords reflecting their recent experiences, which then served as a basis for the conversation. The form encouraged self-empathy and reflection, enhancing the depth of the interviews.

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Table 2. Database: Cases and Data.

https://doi.org/10.1371/journal.pone.0359306.t002

Interviews lasted 30–60 minutes and were mostly conducted online due to pandemic constraints. Within each case, data collection continued until no substantive new themes emerged in several of the observations and interviews, or until institutional access restrictions due to the COVID-19-pandemic made further fieldwork impossible.

2.3 Data analysis

The data were compiled into a single database and qualitatively analyzed using Atlas.ti. The analysis followed an inductive process of constant comparison [29]: open coding identified meaningful occurrences and participant interpretations, followed by axial coding, using the group code function in Atlas.ti. This process yielded 19 subthemes, which were organized into a theme matrix, comprising two major themes (columns)—threshold experiences and connective experiences—across three levels (rows): within the musical encounters, among involved professionals, and within the broader organization. The researcher conducted the coding and discussed interpretations with two supervisors. The process was thoroughly documented to ensure transparency and traceability. All data—including interviews, observations, reports, and forms—as well as all analysis steps were securely stored in SURF Research Drive. Metadata were published on the repository platform DataverseNL (https://dataverse.nl/dataset.xhtml?persistentId=doi:10.34894/FBHF2Z). In accordance with the platform’s decision tree (https://zenodo.org/records/18390982), the data were assessed and deemed ineligible for publication, therefore only the metadata were published. The COREQ checklist [31] was used to assess reporting quality and the generative AI tool Microsoft 365 Copilot (bizchat.20251016.51.2) was used to check the manuscript for English grammar.

2.4 Fieldwork

The study coincided with the COVID-19 pandemic, which demanded the full attention of healthcare institutions and made them highly reluctant to grant access to musicians and, even more, to researchers. Consequently, the researcher’s access for data collection was largely limited to musicians, project leaders/facilitators and directly involved staff members, rather than to patients/residents, care staff and managers.

As a result, the dataset does not include the direct voices of patients/residents and healthcare professionals who were not directly involved, or board members. However, the musicians, project leaders/facilitators, and care professionals who participated directly proved both willing and able to represent the perspectives of patients/residents, colleagues, and managers. It can be concluded that this has limited the ability to answer the research question with the desired comprehensiveness. Nevertheless, these specific circumstances provided particularly rich insights into the dynamics at the professional level, as well as at the other levels.

Being a former nurse and project manager in healthcare, as well as an amateur musician herself, the researcher is acquainted with the worlds of experience of respondents and capable of getting access, in-depth observation and interviewing, analyzing, and interpreting. As an experienced qualitative researcher, she continuously reflected on which attitude would best preserve the naturalness of the situation, and remained aware that, despite these efforts, her presence may have influenced the participants’ behaviour.

2.5 Ethical considerations

The research was conducted in accordance with the European General Data Protection Regulation (GDPR) and the Netherlands Code of Conduct for Research Integrity of the Royal Netherlands Academy of Arts and Sciences [32]. Rotterdam University of Applied Sciences (RUAS) and its researchers are committed to this code of integrity, having signed it.

Although RUAS aims for research data to be publicly available wherever possible, according to the prevailing data protection and confidentiality requirements, researchers of the university are not permitted to publicly share full transcripts or field notes, because of its contextual richness which makes full de-identification impossible without severely compromising the scientific value of the dataset and the participants’ consent.

The musical encounters were initiated as innovative activities by the participating care institutions, rather than as a study intervention. Consequently, the researcher did not intervene in the natural setting, which is consistent with the ethnographic research design. As no data were collected directly from patients or residents, and no personal or health-related data were gathered at all, the study did not require medical-ethical approval. At the time the research design was reviewed (2019), RUAS did not yet have a Research Ethics Committee. The secretary of the current committee can be approached with requests for data access (e-mail: eco@hr.nl).

The project leaders/facilitators of the participating institutions informed the participants—both orally and in writing—about the researcher’s involvement in the music project. They also introduced the researcher to the participants, giving them the opportunity to receive more context-specific information and to refrain from participating. At the beginning of all interviews, the researcher checked if the participant recollected the information. Next, she asked the respondent to provide verbal consent to the use the interview recording research purposes, ensuring the participant all information would be anonymized and safely stored. All verbally informed consents were captured in the recordings of the interviews, that in most cases were conducted online due to COVID-19-measures. Finally, for ethical and validating purposes, the facilitators in each case were given the opportunity to provide feedback on the findings and on a draft version of the manuscript. After their minimal feedback was processed, they all provided permission for publication.

3.1 Experiences within musical encounters

Musical encounters in healthcare settings appear to lead to various connective experiences among individuals involved. However, these experiences are often preceded by threshold experiences that must be navigated before connective experiences can occur (Table 3).

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Table 3. Threshold and connective experiences within musical encounters.

https://doi.org/10.1371/journal.pone.0359306.t003

3.2 Experiences among involved professionals

Musical encounters foster professional connections as well. Also these connections are often preceded by threshold experiences (Table 4).

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Table 4. Threshold and connective experiences among involved professionals (in care and music).

https://doi.org/10.1371/journal.pone.0359306.t004

3.3 Experiences within the broader organization

From an organizational perspective, the journey from initial idea to the realization of musical encounters and structural collaboration between care and the arts, is marked by both threshold and connective experiences (Table 5).

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Table 5. Threshold and connective experiences within the broader organization.

https://doi.org/10.1371/journal.pone.0359306.t005

3.4 Overarching construct: precariousness

By abstracting the theme matrices (Tables 3–5), the overarching construct of precariousness emerged [33]. The term encompasses two dimensions: to be handled with care (delicate) and threatened by exclusion (at risk). These dual connotations reflect the core dynamics of musical encounters in healthcare that emerged from the analysis. The first, more positive, aligns with the delicate nature of musical connection, in which threshold experiences are inherent to the artistic process. The second, more negative connotation, relates to professional and organizational fragility, where thresholds often prove too difficult to overcome (Fig 1).

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Fig 1. The precarious nature of musical encounters.

https://doi.org/10.1371/journal.pone.0359306.g001

4.1 Theory

The findings align with the scoping review of WHO-Europe, which highlights the health benefits of music, but notes challenges in translating evidence-based knowledge into practice [13]. Consistent with Clift [34], who identifies an attention deficit for wider issues and circumstances in the WHO-report, our study modestly suggests that (organizational) contexts play a critical role in enabling or obstructing musical encounters. Thresholds at the organizational level, such as short-term policymaking and limited managerial involvement and commitment, contrast with organizational opportunities like strategic positioning or employee retention, as well as with the potential for connective experiences of patients, residents and professionals. This hierarchy may suggest that sustainable implementation of musical encounters in healthcare requires attention to organizational culture and leadership.

The findings also may connect musical encounters to broader healthcare challenges. For instance, shared musical enjoyment and inspiration may support quality of care, job satisfaction and staff retention, while improved employee-employer relationships could inform more efficient and effective care structures. These remain hypothetical implications rather than outcomes demonstrated in the present study. However, recognizing the potential contribution of musical encounters to future institutional challenges may enable managers and board members to lead innovations more effectively. Furthermore, inter-organizational collaboration, if not hindered by unclear responsibilities and limited commitment, could further advance the role of arts in healthcare, as advocated by WHO Europe [13].

The theoretical view on human beings as inherently musical and caring [16,17] and the ethical and aesthetic perspective on healthcare [17,19,20] provide lenses through which the findings can be interpreted and reflected upon. Spitzer’s anthropological perspective on music making [16], and Tronto’s ethical-political perspective on the distribution of care responsibilities [17] are central to deepening the understanding of the observed dynamics. As participants’ aesthetic experiences were not explored in depth, the aesthetic perspectives of Thompson [19], De Kock [20] and Schiuma [21] on healthcare and its institutions, play a more supportive role, enriching and deepening the findings.

From an anthropological perspective, the findings affirm Spitzer’s view in The Musical Human that music resonates deeply with people, offering a wide range of connective experiences that are especially valuable in care contexts [16]. The artistry of professional musicians—through sensitivity and flexibility—enhances these experiences, supporting Spitzer’s claims about music’s capacity to evoke sensemaking, harmony, and inspiration. However, while participants conceptually acknowledge the potential of musical encounters to stimulate innovation, this was not demonstrated in practice in the study.

The experiences within the musical encounters also reflect Tronto’s conception of the caring human, which views care as inherently relational, recognizing that all individuals are both in need and capable of providing care [17]. This opens possibilities for musicians to be acknowledged as (artistic) caregivers. Yet, the study also highlights ethical and political dimensions of care, showing that hierarchy and voice may influence who is able to participate in, and shape, musical encounters as a form of care. For example, managers and board members often remained indifferent, while involved professionals and project leaders lacked authority.

Finally, the study may reinforce aesthetic perspectives on healthcare. Echoing Thompson [19] and De Kock et al. [20], the findings may indicate that musicians can enhance the quality of both care and care work, through evoking aesthetic sensations. These findings also may resonate with Schiuma’s [21] ideas about the value of aesthetic sensations in organization development, suggesting that similar principles could help care and cultural institutions navigate transitions. Despite participants acknowledging this potential, assumptions that musical encounters would benefit the organization or the wider healthcare system remained largely cognitive and aspirational in this study, rather than empirically realized.

As the literature suggests [35,36] musical encounters also have the potential to cause harm, as identified Music Induced Harm model [36]. In this study, minor incidents include a choir member fainting, a patient reacting with distress, and a care professional becoming nervous while preparing for a concert. Musicians faced risks such as exposure to illness, emotional rejection, and challenges to artistic freedom.

4.2 Methodology

This study faced several methodological limitations that shaped its scope and findings. First, in all three cases, some musical performances were cancelled or could not be observed due to COVID-19 measures. In addition, these restrictions prevented the researcher from interviewing patients/residents and care professionals who were not directly involved in the musical encounters. Secondly, care professionals, often working under time constraints, were generally less inclined to engage in the musical encounters, focusing instead on clinical responsibilities. Managers and board members were even more detached. As a result, their perspectives are underrepresented, limiting the completeness and depth of the findings.

It can be concluded that the exploratory nature of the study, the limited number of cases, and restricted access to events and participants due to the COVICD-19 measures, the transferability and broader implications of the findings are limited. However, the methodology’s strength lies in its contextual richness, revealing the importance of the organizational context surrounding the traditional tripartite relationship between patient, professional, and musician in musical encounters in healthcare. Moreover, the researcher’s familiarity with music, healthcare, and diverse perspectives enabled nuanced observation, interviewing, and interpretation.