Music as a transpersonal care tool-perceptions of hospitalized people assisted in the university extension

Objective: to analyze the perception of hospitalized patients about the care received through an extensionist musical visit under the perspective of the Theory of Human Caring. Method: a descriptive-exploratory-qualitative research conducted in a hospital of the state of Bahia, with 15 hospitalized patients, interviewed within 24 hours after receiving the extensionist musical visit. Collection involved semi-structured interview, analyzed through Discourse of the Collective Subject. Results: three axes emerged: Musical Care at the interface with Transpersonal Care; Music as a rescue element of hope during hospitalization; and Beyond music a meeting between care, art and human relations. The results show the feelings evoked during the experience of the musical visit and emphasize the importance of this activity. Conclusion and Implications for the practice: music as a Transpersonal Care strategy motivates patient-staff-family ties, encouraging optimism and hope by mobilizing feelings and sensations of body, mind and soul, enabling the emergence of resilient behaviors during the hospitalization process. The study promotes reflection and guidance for the most creative, sensitive and bold care in the hospital environment. It suggests greater use of music by the health staff meeting a care extended to human needs that transcend the physical.


INTRODUCTION
The word "music" comes from the Greek mousiké, which means art and science of combining sounds pleasant to the hearing. 1 This concept extends to the understanding that music is part of the human being, an instrument of union that brings together people, families, customs and cultures and that cherishes the soul, providing moments of pleasure and well-being. 2 In addition, music encourages brain areas such as the limbic system -the region responsible for mood, encouragement, affectivity, emotions and social behavior. Listening to any melody can give you a sense of well-being and pleasure that can in turn promote physical and psychological changes in the individual. 3 Several situations, such as fear, discouragement, anxiety, worry, stress and longing, as well as physical aggravation, can affect a subject during his hospitalization period. As it provides serenity and greater acceptance of treatment and hospitalization, music is considered an instrument of non-pharmacological therapeutic effect. 4 In this sense, it is referred to as music therapy. That is, the use of music in order to alternate, with physical and psychological discomfort, tranquility, well-being and some relief from anxiety, 5 through its ability to affect the emotions, attitudes and behaviors that generate a resilient atmosphere. 6 The Multidisciplinary Welcoming Grouping (AMA -Agrupamento Multidisciplinar de Acolhimento), an action of teaching-researchextension to care that faces the risk of hospital death, has, as one of its objectives to welcome families with hospitalized people at risk of death from the systematic praxis of transpersonal-systemic care. The project is formed by students of nursing and psychology courses at Universidade Federal da Bahia. Its performance setting is a public hospital in the countryside of the state of Bahia. Among the activities developed with families, is the Musical Visit inspired by Human Caring, which aims at the exercise of comprehensive care. That is, one capable of achieving the physical, mental and spiritual well-being of patients and their family.
This initiative meets the complex context of hospitalization involving physically and emotionally weak patients and families. Faced with an adversity, such as illness, they face a new process of self-knowledge, capable of revealing strategies for pain relief and resignification of the lived moment. Music, in this sense, represents an important device capable of providing relief, helping to evoke feelings and energy conducive to the optimism and hope needed in hospitalization moments. 7 Several national and international studies indicate relevant benefits of adding music to care such as stress reduction, anxiety and pain; increased quality of life of patients and families; improvement of interpersonal relationships; and stress reduction typical of the hospital environment. 3,[8][9][10] In this sense, musical care is in tune with the perspective of Human Caring, by contrasting the overly centered model on technologies that undermine the real meaning of care. Given this reality, it is extremely important that, during health care, creative elements such as music are adopted, optimizing a humanized posture, focused on the loving gaze that, beyond the physical, understands the intersubjectivity of the subject. Watson's Human Caring aims for a caritas model capable of a deeper appreciation of human complexity and experiences, valuing the care of the human body-mind-soul. It achieves from inner immersions in its own life and from the development of intersubjective meanings and responses to care, healing, illness, despair, disease, and death. [11][12] It is noteworthy that there are many contributions in the literature about the use of music in the health context. However, the relevance of this study is shown by its theoretical framework -Human Caring and the analytical context from the university extension. These characteristics are little observed in other research found in Scielo, LILACS and PubMed databases, in the last five years.
Thus, there is, as a problem, the question: "What is the meaning of care perceived by hospitalized patients after the experience of Musical Visit carried out by the extension project" Multidisciplinary Welcoming Grouping?".
From the guiding question, the general objective emerges to analyze the perception of hospitalized patients about the care received through an extensionist musical visit, under the perspective of the Theory of Human Caring. Knowing the perception of hospitalized patients of the care received through the musical visit and relating the musical care perceived through the musical visit with the theoretical assumptions of Human Caring are specific objectives.

METHOD
This is a descriptive exploratory research with a qualitative approach. It was held in a general hospital in the countryside of the state of Bahia, specifically in its sectors of medical and surgical internment, which have a total of 90 beds. The research followed the theoretical framework of Watson's Theory of Human Caring, treated in this study as Human Caring. As a methodological reference, we adopted the Theory of Social Representations that supports the analytical technique chosen. Such framework has a cognitive dimension, as it favors an experimentation of the world and the world for the construction of a reality common to a social group, being a specific way of understanding and communicating what is known. In this respect, music is a phenomenon that contributes to this social communication, to the exchange of linguistic and nonlinguistic messages between subjects and groups, which seek to abstract meaning from social interactions and to introduce order and perceptions assumed as significant in the world. [13][14] Music in Hospital Human Caring Nunes ECDA, Oliveira FA, Cunha JXP, Reis SO, Meira GG, Szylit R The study followed the procedures provided for in Resolution 466/12. Approval by the Research Ethics Committee was given in Opinion 2,647,073, of May 2018, involving 15 patients hospitalized in these sectors. Inclusion criteria were: having the patient received the musical visit of the AMA project for a maximum of 24 hours, enabling the recent memory of the feelings mobilized; to be lucid, oriented and with their preserved verbalization. The selection of participants was non-probabilistic in nature, as the choice was made by random methods, with the choice of the individuals most accessible to the researcher, following convenience parameters. The researcher responsible for the collection was part of the AMA project, however did not participate in the musical visit that would be a reference for data collection. Thus, she conducted the interviews within 24 hours after the musical visit, dressed differently from the members of the troupe, in order to disconnect her image from the activity to be analyzed. This interviewer had experience with the method and subject of the study, and addressed patients who were awake and had no complaints at the time. After confirming that the patient had received/participated in the musical visit, the researcher presented the research to him, inviting him individually, through the Informed Consent Form (ICF), to participate according to his personal desire. The consenting subjects signed the informed consent form and were interviewed at the bedside. All hospitalized patients next to each interviewee were excluded from the study invitation, in order to reduce influences on their discourse due to the spatial proximity between them. The interviews were recorded and later transcribed for full analysis. The total number of interviews was defined by theoretical data saturation.
The interview was semi-structured, with the following questions: "How is your internment experience here?"; "How was it for you to receive a musical visit here? "; "What did you feel while listening to the songs?"; and "What did this moment mean to you?".
Data analysis was performed through Discourse of the Collective Subject (DCS), which is a proposal for the organization and tabulation of qualitative verbal data based on the Theory of Social Representations. It endorses the sense of speech socially attributed to a group of people who have something in common, in this case hospitalization. DCS was chosen for organizing the data concisely but simultaneously in-depth by gathering as many expressions as possible from the subjects, according to the core ideas or anchors identified in the analysis process. Core ideas (CI) are linguistic expressions that accurately describe the meaning of the statement or a set of statements. Anchoring (AC) is an explicit linguistic manifestation of a given ideology or belief of the discourse author, which is used to frame a specific situation. CI and AC function as themes that converge with speech categorization.
The key expressions (KE) are highlighted excerpts of the speech, which are organized according to the CI or reference AC, enabling the gathering of related excerpts, coming from different subjects, which converge in a single discourse, adjusted in the first person singular, although it carries expressions of multiple participants. Discourse of the Collective Subject (DCS) is the coherently arranged speech. 15

RESULTS
The results of this research comprise 3 axes identified as: Musical Care at the interface with Transpersonal Care; Music as a rescue element of hope during hospitalization; and Beyond music -a meeting between care, art and human relations. . Axis 2 shows how much music mobilizes feelings. In the context of hospitalization, it can make the listener remember and exalt previous experiences -which have the power to renew energies and motivate the individual to better cope with life's difficulties, such as illness. Thus, the experience of being careful with playful elements such as music becomes special.
Listening to music during hospitalization is referred to as wonderful even when the patient feels hopeless. He demonstrates how difficult his internment is being, as she has the ability to bring back hope from meeting with good memories of what has been lived. Axis 3 presents the expectation of respondents as to the desire to be cared for through touch and artistic methodologies. For them, encountering activities of this nature during their hospitalization represents a differential that they want to encourage in the daily work of professionals who propose to take care of them in their entirety, promoting well-being to their minds and souls, in an attitude transpersonal.

Musical Care at the interface with Transpersonal Care
The comprehensiveness of care is evidenced by Watson, by the caregiver's commitment to engage with the other, from a subjective and humanized interaction, in which the patient is considered in its entirety. In this perspective, the value of care is present in the caregiver's ability to transform an attitude into an assiduous commitment to being cared for. 9 Thus, the playful and expressive care should be valued, especially in the contemporary hospital environment, highlighting the need for the development of nurses' skills regarding playful practices. 6,16 Among them, music can provide relief from pain and suffering by enabling the mobilization of inner energy, which emerges as a flame of hope in the face of problems faced in the hospital environment. 5 Thus, the use of music as a complementary care strategy is a resource that encourages the soul to direct a more resilient behavior in the face of adversity, by encouraging the spirituality of patients in the face of fear and anguish. While listening to these songs, there is a common desire among them to listen to religious songs, because they are more comforting, helping them to cope with the disease. Religious belief and practice act as facilitators of psychological adjustment. Thus, it is relevant that health professionals welcome the religious contexts of patients and their families, from the understanding of the influence of religiosity on health. 17

Music in Hospital Human Caring
Nunes ECDA, Oliveira FA, Cunha JXP, Reis SO, Meira GG, Szylit R However, regardless of the style of musical activities, its implementation within the hospital environment provides patients and staff with pleasure and interaction, as well as contributing to health promotion and preventing injuries. In this context, Caritas Process/Transpersonal Care provides an expanded view of care. It values subjective, creative and artistic aspects in the development of playful musical activities, highlighting a new way of exercising nursing, by enhancing the need for playful care. 16 Music therapy is revealed as a fruitful possibility for the promotion of innovative care that grasps, beyond the physical dimension, the mind and soul of the human person. Its therapeutic potential is capable of promoting physical and psychological changes, being a qualified instrument in health promotion in health context. 18 Bringing Jean Watson's theory as the foundation for nursing care enables care to be truly delivered in all its context, as this care constantly values the other in all their aspects and needs. When professionals become able to understand the importance of improving their care practices, their field of action will certainly be expanded. 19

Music as a rescue element of hope during hospitalization
The hospitalization process brings out feelings of fear and anxiety of the patient. Faced with this, music becomes a complementary alternative of care when inserted in the hospital context. During hospitalization, it provides comfort and a sense of well-being to the patient, increasing individual care. 3 Music reduces the negative feelings experienced by the patient, such as anguish, and enables the expression of the most intimate feelings by recalling special situations experienced throughout life. [20][21] Before image formation, one has the music and its ability to remember memories already lived, places already known, besides telling stories, thrill and inspire those who sing and listen. Therefore, music serves as an instrument to access the patient's insides, strengthen the bonds created during hospitalization and encourage the good times, even in the circumstances surrounding him. 22 In this sense, it is important to consider aspects such as culture, variety, musical preference and clinical condition of patients in the planning of musical interventions. When the group or practitioners are unaware of the effects music has on people, or the context of patients, the activity can become a major challenge. 23 Some patients report that certain songs bring back feelings and memories that they would not want to have at the moment. In view of this, sensitivity and individualization are required regarding musical choice, as music will mobilize memories and feelings that may or may not help in coping with the disease. 16 From this care, music proves to be an efficient and economical therapeutic tool, being accessible, easy to use and without adverse effects, making it used in multiple contexts and as an adjunct in the patient's treatment. 24 Music leads its listeners to interact with their emotions, which configures the listening moment as a moment of leisure and relaxation, estimated by patients in the setting of such monotony that hospitalization consists. 12 Another interface provided by music and expressed in this category is the ability of this resource to establish communication with the family. This in its meanings present in the sick being, which evokes the strength and love inherent in his family system, as elements of well-being promotion mediated by music.
In this sense, the meeting promoted by music expands the possibilities of interaction between the subjects involved in the care process. It promotes dialogue by facilitating verbal and nonverbal expression, supporting family members in the elaboration of coping strategies in the transcendence of their vicissitudes, anxieties, sadness and joy, especially when they are away from their homes. In the family context, music emerges as a complementary and multidimensional therapy that influences the mood and mood of the sick person, just as drug therapy is for their suffering. Music feeds spiritually, making the patient and family member experience the presence of God and thus be able to withstand the pain and anguish of emerging adversity. 25 The benefit of music therapy in the hospital context is also directed to the family. Music brings improvement in weakened beings, as it emerges as an instrument capable of accessing the subjectivity of these individuals, as well as playing a therapeutic role, alleviating the various feelings of fear and anxiety of the patient and their families. 25 Therefore, musical care is a practice that motivates and rescues affective bonds, increasing the interaction of the professional, the patient and the family. It can encourage the individual to see 4their clinical condition positively, without highlighting their limitations, leading all to overcome the challenges in the care process of this subject.

Beyond music -a meeting between care, art and human relations
The insertion of art in the context of health care is recommended internationally. Studies state that hospitals must meet the increasingly complex needs of their patients, often with long stays in this space. These studies start from the understanding that overvaluing the focus on physical illness, efficiency, and tasks can divert attention from patients' psychosocial well-being. This concern seeks to encourage the use of approaches that recognize and value the hospitalized person, their life history, their relationships and the context of care. In this sense, the study emphasizes the importance of the arts for health and well-being, alerting professionals in the area to search for these skills and to exercise creativity in addressing the needs of the sick person. 6

Music in Hospital Human Caring
Nunes ECDA, Oliveira FA, Cunha JXP, Reis SO, Meira GG, Szylit R The introduction of musical practice in the hospital is one of the possible artistic modalities and provides a better interaction between hospital staff, musicians, the sick and their companions. It favors the bond and promotes a humanized and integrative environment among the actors involved. Music is thus shown to be a beneficial means for human relations, with the ability to transform psychic suffering into a moment of pleasant and comfortable relaxation, providing humanized health care. 6,24 Therefore, it contributes to the broader care, in a biopsychospiritual proposal, which raises its relevance with the professional practice in the health area, from the moment it is presented as an interactional form of treatment to the hospitalized individual. 25 Music promotes awareness not only in the patient, but motivates the nursing professional regarding the responsibility of maintaining a therapeutic, more communicative, respectful and ethical environment. 6 Therefore, music visits promote important benefits for the better relationship between patient, family and staff. For patients, improvement of mood, smiles, improvement of self-esteem, distraction, opportunity to forget, for a few moments, the disease situation to remember good moments; relaxation and tranquility. For the health staff, music promotes relaxation, joy and wellbeing, renewing self-confidence in the care process. 26 The presence of music in the hospital environment has the power to reduce feelings of sadness, dissatisfaction and discouragement, thus improving the quality of life of the hospital community. In other words, it transforms the hospital's formal environment into a warm and welcoming place. 6 For all these properties, music can be used as an alternative way to bring people together and welcome. It has the power to facilitate communication, bonding and touch, through which a timely message that is independent of words can be conveyed among those who care and are cared for. 27 Touch has been the subject of other studies, which already classify it as therapeutic because of its properties in considerably reducing anxiety, fatigue, sleep disturbance and stress and for being a useful treatment in the relief of psychophysiological symptoms. It has a comprehensive care strategy that is increasingly discussed in the health context, but that does not yet integrate care protocols and research effectively. 28 In this sense, the musical intervention, besides bringing benefits to the patients, also arouses, in the professionals, the reflection on trying new possibilities of intervention, besides the daily practice, which results in self-realization, moments of happiness, satisfaction and pleasure. 6 By choosing musical care, the professional broadens his or her philosophy of care beyond an act that begins and ends in itself. He challenges himself to care as an attitude that integrates caring, kindness, zeal, interest and commitment, based on sensitivity, appreciation and affection for the other in his multiple care needs. 29 Thus, Transpersonal Care converges to musical care, aiming for a scientific care model that allows the emergence of an evolved caritas nursing. Thus, nursing develops a deeper appreciation of human complexity and experiences, of inner immersions in one's own life and of the meaning of intersubjective responses to care, healing, illness, despair, disease, and death. It is this model that truly honors and opens the door to the union of mind-body-soul-spirit and our human to human connection as 'Source' that unites us all. 10 Caritas involves the meaning of appreciation and attention -it represents charity, compassion and generosity. It is indeed something important that needs to be cultivated and sustained in each individual, since caring for the other and showing love is a form of Transpersonal Care, in which the relationship between love and care give access to the caregiver's inner healing and caring. 30 In this perspective, music, as a care intervention, provides a humanized and comprehensive assistance. In addition to being a resource accessible to hospitals, its use enables interaction between staff and patients, providing the physical and emotional well-being of individuals.

CONCLUSIONS AND IMPLICATIONS FOR THE PRACTICE
Musical care in the studied context contributed to motivate and rescue the affective bonds, increasing the interaction of the professional, the patient and the family. The strategy was also able to encourage the individual to cultivate spirituality, mobilize his sources of resilience and resize his hope.
As for the implications for practice, the study promotes reflection and guidance for more creative, sensitive and bold care in the hospital environment. It is suggested greater use of music by the health staff, meeting a care extended to human needs that transcend the physical.
It highlights the importance of nursing professionals seeking the development of artistic skills, as well as the interest in producing a creative and expanded care that seeks a therapeutic encounter with the body-mind-soul of the hospitalized person. The search for knowledge of theories of the area, as well as the implementation of their methodologies should be cultivated by these professionals, highlighting the timely association of the Theory of Human Caring as a triggering element of this happy experience.
The study revealed the fruitful relationship between Human Caring and music care, both sharing the goal of promoting hope, faith and resilience in the face of illness or hospitalization, leaving explicit the effects of music on the total body-mind-soul of the human being.
The limitations of this study are related to the restricted context of data apprehension and the cultural and geographical specificities of the study setting. However, the results are relevant because they emerge from a Watson-based extension action assessment proposal that corroborates the national and international literature.

Music in Hospital Human Caring
Nunes ECDA, Oliveira FA, Cunha JXP, Reis SO, Meira GG, Szylit R The development of new research and actions in the area is encouraged, aiming to explore other nuances of this important theme. Investment in the training of nurses is encouraged for greater artistic reflection-action in their care praxis, whether through curricular or even extracurricular activities (research, extension, internships) that maximize the looks and ambitions of these professionals.