Transforming undergraduate student perceptions of dementia through music and filmmaking

Abstract

Background

With nearly 6 million people living with dementia (PWD) in the U.S., there is a critical need to build an interprofessional dementia workforce. Among the novel approaches to expanding new workforce, music and the arts show promise for engaging students and trainees. In order to understand how and why the arts affect attitudes about and engagement with PWD, we examined a service-learning general education undergraduate course centering on music, filmmaking and dementia.

Methods

The undergraduate course curriculum brought students to meet with PWD in dementia care settings, build personalized music playlists, co-produce short films about PWD, and write reflective essays. Two researchers independently completed inductive thematic analysis of the films, essays and course evaluations. Differences were reconciled by consensus.

Results

52 students from three classes completed the course. 24 (46%) were health sciences majors. Three key themes emerged: 1) Music helps undergraduate students connect with people with dementia in meaningful ways; 2) Filmmaking offers students the opportunity to share unique, individualized stories about dementia and music; 3) Reflective writing integrated into the course enabled students to process their experiences. Unexpectedly, 29 students (56%) reported continued engagement with PWD in their careers, families and communities after course completion.

Conclusions

This study identifies reproducible ways in which undergraduate arts courses thematically focused on dementia not only transform student perceptions about dementia, but change the ways in which those students choose to engage with PWD following course completion. Arts and Music Departments may represent an untapped resource for building geriatrics workforce.

INTRODUCTION

The current geriatric workforce is inadequately prepared to care for the 5.7 million people living with dementia in the US.^1,2 The Institute of Medicine has called 1) to enhance in educational curricula and training programs and 2) to expand and improve competence of the entire geriatric workforce to build capacity among healthcare professionals family members, and community care partners.² Despite ongoing educational efforts, the shortage of geriatricians makes it difficult to meet these urgent educational needs.³ In this paper we address how creative and multidisciplinary solutions can offer valuable and underutilized opportunities for addressing these issues.

One strategy to building a larger geriatric workforce involves expanding curricular models to embrace resources found outside the realm of geriatrics and health sciences education. The arts and humanities have the potential to humanize dementia for potential members of a workforce pipeline. Creative approaches to enhancing educational curricula and training that pair geriatric curriculum content with music and arts interventions have shown promise.^4,5 Among clinical trainees, visual and performing arts approaches have been shown to improve attitudes about dementia.⁶ Studies involving arts and music have been conducted in nursing programs^7–9 and medical schools.^10,11 The majority of studies focus on using arts and music to change perceptions about dementia among health sciences professional trainees,^12–16 but trainees comprise a small and already differentiated population. If we are to build workforce, educators need to move upstream.

Arts and music departments offer educational allies with whom to develop person-centered interdisciplinary courses about geriatrics and dementia and to build sustainable partnerships with community organizations. Implementing arts and music courses about dementia at the undergraduate level offers one pathway to engage and recruit needed geriatric workforce, as well as to enhance current curricula through creative and person-centered educational approaches. To date, little research has been conducted about the potential for arts and music courses at the undergraduate level in to change perceptions about dementia and involvement in the care of older adults. Beyond their curricular value, these kinds of courses have the potential to support community-based dementia organizations as well as spread education about existing arts intervention programs for people living with dementia (PWD).

This paper presents the results and outcomes of an undergraduate service-learning course that used music and filmmaking to teach person-centered approaches to dementia. It was carried out in collaboration with facilities certified in the Music and Memory program, a non-profit organization dedicated to bringing personalized music playlists to people living with dementia or other serious medical illness.^17,18 The study was motivated by the following research question: How do undergraduate arts and music courses at the undergraduate level transform attitudes about dementia and impact engagement in dementia care?

METHODS

Study Design

We completed a qualitative analysis of an undergraduate service-learning course, designed and taught by the first author (JG) over three semesters at a public university. The course included music, filmmaking and reflective writing components, and focused on service at local dementia care settings.

Course curriculum

The 3-credit undergraduate service-learning course was developed and taught by a music professor (JG) over three consecutive semesters with 16–18 students each term. The students worked in pairs at one of two dementia care settings. Students received initial classroom training on dementia, ethnomusicology (music anthropology) ethnographic methods, filmmaking basics, and creative aging. A gerontologist taught guest lectures each semester to train students in the basics of dementia care and communication. Students also attended an initial orientation visit to their field site before filming. Over 5–8 weeks, students completed 6–7 three-hour visits to the dementia care settings, either assisted living facilities (AL) or adult day health centers (ADHC). During visits, students worked with people with dementia (PWD), who had consented by proxy to participate, to compile personalized music playlists of their favorite songs. At the end of the semester, these playlists were loaded onto iPods and given to PWD to use with the help of staff and family members. Students took turns interacting with PWD and filming the process. Throughout the course, students wrote multiple reflective essays, workshopped their films and discussed their experiences as a group. At the end of the course, students shared their films with the PWD and their families, the dementia care settings and the local community through public and private screenings. If given permission by families, student films were also shared online. As their final assignment each wrote a reflective essay about the film and their experiences in the course.

Service-learning settings

8 months prior to course initiation, the ethnomusicology professor [JG] established community partnerships with two assisted living facilities and one adult day health center. Each facility agreed to become certified with the Music and Memory program, and to obtain necessary equipment (computer, iTunes gift cards, CDs, Mp3 players, headphones, and splitter cables). A point-person was also designated from each facility to help coordinate and facilitate student-engagement.

Participants

Participants in this community-engaged service-learning course included: students, community partners and administrators, people living with mild to moderate dementia, caregivers and family members. Participating PWD were selected by on-site coordinators if it was thought they would benefit from engaging with students. Specific inclusion/exclusion criteria for PWD were not provided for participation in the course.

Throughout the course and its preparation, the PWD and community partners acted as co-collaborators in teaching about dementia and dementia care principles. Written consent to participate in the course and to be interviewed and filmed was obtained for all participants, and obtained by surrogate decision makers for participants with dementia. Consent for the circulation of student-made films through educational or public channels was requested, but not mandatory. All participants were given the opportunity to remain anonymous or to wave anonymity. Student participation in this study was optional. Consent was obtained for all participants. This study focuses only on the students.

Data Analysis

Data for this study included the students’ reflective essays, short films and course evaluations. Reflective essays ranged from 500–1200 words. Two researchers independently completed inductive thematic analysis of the films, essays and course evaluations [JG and TA], and discussed with the third author [AKS].¹⁹ Differences were reconciled by discussion until a point of thematic saturation was reached across and within the three courses. Themes were validated through comparison with the students’ anonymous course evaluations, to assess for bias. The evaluations, completed after the course had ended, were analyzed by two researchers not involved in the course itself [TA and AKS]. Themes were subsequently triangulated with informal follow-up email communication with former students. The Internal Review Board on Human Subjects Research of Indiana University reviewed and approved this study with exempt status.

RESULTS

Participants

Over three semesters from Spring 2017 to Spring 2018, 52 undergraduate college students completed the course. Of the 52 students, 28 were pursuing health sciences majors. Representative majors in the health sciences included biology, community health, healthcare management policy, neuroscience, pre-nursing, psychology, recreational therapy, and speech and hearing sciences. Representative majors from non-health sciences areas included folklore and ethnomusicology, music, audio engineering, business and finance, hospitality and tourism, Spanish, and computer science. 56% of the students were freshmen or sophomores.

Themes

Three overarching themes and one unexpected finding emerged in this study: (1) Music helps students connect with people with dementia in meaningful ways, (2) Filmmaking offers students the opportunity to share unique, person-centered stories about dementia and music that empower the voices of PWD, and (3) Reflective writing enables students to process new experiences and lessons learned. Table 1 provides representative quotes from each theme. In order to provide depth to the findings, we provide representative case studies.¹⁷ We also provide links to the films themselves. Unexpectedly, we found that many students stayed in contact with the professor (JG), reporting on the ways in which they continued to engage with PWD in their careers, families and communities after course completion.

Table 1:

Thematic examples from student reflective essays and short films

THEME	STUDENT QUOTES	REPRESENTATIVE FILM SCENES
Music helps students connect with people with dementia in meaningful ways	She was asking for Mary Poppins, so we decided to play “A Spoonful of Sugar.” This is where learned the most important thing about Judy. She was explosive. Though she didn’t have a strong ability to talk she belted out every single song we played.	This film shows Judy listening to “Hey Jude.” In the introduction she leans back in her chair peacefully and then smiles. Then, at the chorus she begins belting out the lyrics with her arms and hands outstretched with joy.
	It was amazing to see how [Mitch] reacted to the music. We learned from Cathleen that he had quite a lot of anxiety issues, but when he began to listen to music he seemed to become a different person. I was amazed to finally see the effect that this program had on those with dementia.	In this film, Mitch listens quietly to “Singing in the Rain.” As he smiles and begins to sing along, tears come into his eyes. In the next shot, his wife Judy explains that he loves music but that “the memories aren’t as fresh as they used to be.”
Filmmaking offers students the opportunity to share unique, person-centered stories about dementia and music that empower the voices of PWD	Glen didn’t have much reaction when we played the music so for a while, [we] were really stumped on what to do for his film. When we actually sat down to edit, we realized that Glen has such an incredible story to tell and that in order to make a meaningful film, he didn’t need to have this big reaction.	Glen teaches student Emily about his love for the opera singer Tetrazzini. His meaningful connection to music is clearly evident despite his subtle reaction. As he explains “I don’t have to hear the whole thing, she still gets me.” The focus on music transformed their relationship into teacher/student and allowed Glen to share his knowledge with Emily.
	The four of us sat and listened to music while Becky filled us in on Anita’s past. It was heartwarming to see them interact, Becky was incredibly patient, loving, and caring towards her mother. There was one point where they even danced together to “Ring of Fire.” Their relationship shaped the film. It became a hope of mine after this day to display their love on film.	Anita’s daughter describes how her parents used to love square dancing. We see pictures of them in dance outfits. Then when “Ring of Fire” comes on, Anita begins moving in her chair and her daughter asks her to dance. They dance hand-in-hand, Anita wearing headphones and fully immersed in the music/dance, her daughter engaging with a big smile.
Reflective writing enables students to process new experiences and lessons learned	When I first started this course, I had the idea built up in my head that music would act as kickstarter for memory recall…Over all the result I saw was vastly different. Music didn’t act as a tool to recall every memory that these individuals have had, it acted as a method to make life worth living again.	This film evokes intergenerational musical encounters with multiple individuals. The film closes featuring Bruce, 101 years old, wearing headphones and singing along to “It’s a Wonderful World” accompanied by a student and the Associate Director of the adult day center.
	I always just assumed people who have been diagnosed with dementia can’t remember anything or are just old, crazy people. This mindset is terrible to have but that’s just how the media displays dementia. Having seen these dementia people firsthand at Jill’s House, made these negatives thoughts go away. Ruth and Lynn live with dementia but they’re still people.	Lynn’s film features a playlist curated from a pocket notebook where, between visits, he enthusiastically jotted down all the songs he wanted the students to help him find. For Ruth, at 95 years old, music helped her reminisce about rural life growing up in the 1930s, including memories of her family’s first car radio and hearing fiddle music at the county fair.
	This course has changed the way I understand dementia as well as aging, [and] has allowed me to explore the wonders of working in geriatrics. Prior to this course, I had only learned briefly about dementia and other memory impairments in my recreational therapy courses. Yet, this course was an empowering reminder on the importance of viewing elders with dementia as whole people….I have never considered working with geriatrics, but after taking this course, I am more inclined to pursue my career with this wonderful population.	This student learned that Nancy used to play piano but had not played in years. In addition to building a playlist, the filmmakers decided to bring Nancy to a piano to play for them. She said she hadn’t played in years and the three of them shared in the excitement of reconnecting her to her old hobby. The short film illustrates the relationship they build through multiple creative encounters around live and recorded music.

Music helps students connect with PWD in meaningful ways

Music played an integral role in facilitating the development of meaningful intergenerational relationships. Field visits were spent talking about music and musical memories, listening to music with participants, singing and dancing, or observing participants sing and/or dance. Through the process of making individualized music playlists with and for PWD, students and participants used music as a shared creative space through which to get to know one another and build connections. As one student put it: “I wish I could meet everyone by learning their favorite songs because it tells you so much about a person, more than any conversation ever will. I also realized how many misconceptions I had about those living with dementia. It does not define them, it is just a piece of who they are, just as we are all made of different pieces.” Another student with a background in audio engineering bonded with a retired professor who attended an adult day program for people with dementia over their shared love of classic rock. For his final project, the student produced a short film emphasizing the professor’s love of rock music from Led Zeppelin to Jefferson Airplane, interspersing clips from classic rock music videos with footage of their encounters. Though he did not remember making the film, the professor laughed and smiled in enjoyment and surprise when they showed him the final film.

Filmmaking offers students the opportunity to share unique, individualized stories about dementia and music.

Filmmaking acted as a valuable learning tool to help students craft unique and individualized stories about their encounters with dementia and music. Students were taught to use filmmaking as an experiential medium capable of communicating stories of personhood through both verbal and non-verbal forms of expressive communication. As one student explained: “We wanted to exemplify the club members not only as dementia patients, but as individuals, music lovers, family members.” Through processes of filming, logging footage, editing and viewing short sequences for peer-feedback, students also pushed beyond preconceived ideas about the relationship between music and dementia. In allowing PWD to speak for themselves, another student emphasized how they wanted “Joan to tell her own stories rather than reporting them for her.” Another group of students decided to make a joint film about two retired interior designers who had befriended one another in a dementia care facility. In the film, the women laugh and sing songs together, as well reminisce on their friendship and share jokes about not being able to remember things anymore. There is no mention in the film of their dementia diagnosis. The strength of this and many of the student films is to teach students, and audiences who view these films that dementia manifests in many ways, and music has different effects on individuals with a dementia diagnosis.

Reflective writing integrated throughout course enabled students to process new experiences and lessons learned

Reflective writing exercises assigned throughout the semester provided students with space to process their experiences. The reflections asked students to write about challenges overcome during fieldwork and filmmaking, as well as to broader lessons learned about dementia in the context of their lives and careers. One student explored the impact of the film editing on her self-awareness: “By incorporating the filmmaking component into this project, I feel that my learning experience was deepened. I realized the importance of moments that did not seem significant at the time they happened when I watched the footage during logging and editing and this led me to think more about my interactions with people. I also have more appreciation and understanding for telling people’s stories… they reach far and wide and can change people’s lives.” Another student pursuing a nursing degree wrote about how the course gave her new perspective in her field: “…this film and project have had a huge impact on my life…Each time I watched our film, I grew to understand the Better Day Club members as individuals rather than as elders with Dementia and other disabilities. It taught me to look at people as people. In the nursing field, we are taught to learn a person’s disability, illness, or problem. They do not stress getting to know who the patient is as a person without their illness, and that is something that both Music and Memory program and our film have emphasized for me.” Since not all the films were shared publicly, the written reflections also allowed students a space to talk through their own decision, or family decisions, to keep certain films offline. Charlie and Lydia, for example, having worked with one woman in the last weeks of her life, decided to make one of their two films private even after a family had given their consent for public circulation. “We shortly realized that Sharon had a story to share with the world and [anonymous] had a story to share with her family.”

Unexpected Outcome: 67% of the students have continued engagement with PWD through careers, families and communities

Following the completion of the course, former students have continued to stay in touch with the professor via email (JG). Most of these communications involve updates about how the students continue to implement skills learned in the course, or to request letters of recommendation for graduate level health sciences professional training programs. We have learned that 35 of the 52 students (67%), are continuing engagement with PWD in a variety of ways. 14 students (27%) continued to volunteer in the dementia care settings following course completion. 5 students shifted toward a geriatric focus in their clinical work. 10 students reported implementing skills learned with PWD in their families. 1 student completed an additional semester-long independent study in order to set up a Music and Memory program at a local low-income nursing home in Bloomington. After graduation this same student joined AmeriCorps and is now building and implementing a community-based dementia, music and gardening program in another state in collaboration with community organizations. 5 students sought and obtained positions working in dementia care facilities. In addition, 5 students have requested letters of recommendation from the music professor for medical school, rehabilitation school or healthcare management.

These unexpected results indicate the potential for undergraduate music and arts courses to positively transform student perceptions about dementia and encourage the growth of an interprofessional dementia workforce.

DISCUSSION

Through detailed examination of students’ narrative reflections and short narrative films, we analyzed how and why undergraduate university arts and music courses transform attitudes about dementia and impact engagement in dementia care. We found that arts and music courses have the potential to shift undergraduate perceptions about dementia and create new educational opportunities for engagement in identifiable and reproducible ways. The shared activity of developing individual music playlists helped students connect with PWD in meaningful ways. The process of filming, and film editing provided students with an experiential medium through which to push past preconceived ideas about dementia and create unique, person-centered stories. The integration of reflective writing offered students the space needed to process their experiences and lessons learned. Although not an objective of the course, over half of the students have remained engaged in dementia care as professionals, as volunteers and as family caregivers, an effect that was stable across the three semesters.

As has been shown with the TimeSlips creative storytelling project^13,15 the creative arts have the potential to change medical student attitudes about working with geriatric populations. This study expands upon that knowledge by bringing arts-based engagement models into undergraduate education. At the undergraduate level, previous studies of service-learning courses have similarly been shown to transform student attitudes about dementia^21–27. This study expands upon the existing literature by shifting the disciplinary foundation and campus location of these courses from the health sciences departments of gerontology, nursing, and speech and hearing therapy into arts and music departments. Furthermore, while studies have discussed filmmaking as a valuable methodology for teaching personhood in geriatric education^14,28, this study illustrates how filmmaking can be used as a productive educational tool in documenting and enhancing curricula involving other forms of arts-based engagement. With a curriculum designed by a professor specialized in intercultural music studies and ethnographic methodologies, students learn to understand music and filmmaking as more than just modes of entertainment. Instead, alongside training within critical disciplinary frameworks, they are taught to see the value of these methodologies in connecting across cultural and cognitive lines and as tools to empower the voices of their participants. When shared with the community at the end of the semester, the films experientially teach the community about creative approaches to dementia care.

Unlike the prior studies^{4,8–11,13–15}, this course was placed within the School of Arts and Sciences, rather than in the Health Sciences. As a result of the course placement within the undergraduate university system, the professor was able to engage a group of students who might not otherwise have thought to engage in dementia workforce. Beyond recruiting potential workforce, another advantage of positioning the course as an arts and culture elective is that students from creative and scientific backgrounds are given the opportunity to collaborate and learn from one another.

This study is limited by the lack of a pre-course assessment of student career goals or knowledge and attitudes about dementia. It also carries the risk that the students provided overly positive experiences in order to obtain a better grade. To address this limitation, we triangulated the content of the essays against the open comments of the anonymous, post-course evaluations (79% response rate) and found them to be consistent with the essays and overwhelmingly positive. Finally, the study is limited by its qualitative design. More vigorous mixed methods studies are needed to quantify the impact of arts-focused service learning courses against traditional curriculum.

With increasing efforts in many university systems to promote interdisciplinary and cross-disciplinary course listings, Arts and Music Departments represent an untapped resource for expanding dementia education at the undergraduate level. As arts electives are open to students across many disciplines and a requirement for graduation in many fields, we suggest that these kinds of courses represent new disciplinary avenues for encouraging growth of the geriatric workforce.

Figure 1:

Carl and Bill Listening to Jefferson Airplane

Figure 2:

Honey and Zetta singing “I’ve Been Working on the Railroad”

Impact Statement:

We certify that this work is novel and demonstrates how music and arts classes at the undergraduate level can be used to transform attitudes about dementia, suggesting how the arts can be leveraged to enhance engagement in dementia care and dementia education.