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Open Access Research Article

Unmasked Connections: Piloting Virtual Interactive Artist Performances in Healthcare — A Feasibility Study

Rebecca MacDonald 1,2,3, Carol Wiebe 2,3,4,*, Gilles Comeau 1,2

  1. School of Music, University of Ottawa, Ottawa, ON, Canada

  2. Music and Health Research Institute, University of Ottawa, Ottawa, ON, Canada

  3. Radical Connections, Ottawa, ON, Canada

  4. Bruyère Research Institute, Ottawa, ON, Canada

Correspondence: Carol Wiebe

Academic Editor: Noah Hass-Cohen

Special Issue: Expressive Arts Therapies during and in the Aftermath of the COVID-19 Pandemic

Received: March 17, 2023 | Accepted: July 03, 2023 | Published: July 05, 2023

OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 3, doi:10.21926/obm.icm.2303026

Recommended citation: MacDonald R, Wiebe C, Comeau G. Unmasked Connections: Piloting Virtual Interactive Artist Performances in Healthcare — A Feasibility Study. OBM Integrative and Complementary Medicine 2023; 8(3): 026; doi:10.21926/obm.icm.2303026.

© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

The arts offer many health benefits and can be especially impactful in hospital or continuing care facilities through group art interventions or personalized art activities. Arts can also be socially prescribed to fulfill social needs, improve emotional well-being, and have a positive impact of the social determinants of heath. This feasibility study explores the value of a pilot program that brought personalized virtual 1-on-1 art performances to residents in long-term care (LTC) during the Covid-19 pandemic which limited social activities and caused feelings of uncertainty and stress for many people. The purpose of this study was to document the process of developing and executing this pilot program, to evaluate its feasibility, and to provide a testimony to the benefits of art programs in LTC. This study qualifies as a feasibility study because it aimed to evaluate the quality, efficiency, and financial feasibility of the pilot project, making the primary objective of this research quality improvement. Online surveys were completed by the participating LTC residents, the Recreation Staff in the LTC facility, the hired artists, and the organizing team (Radical Connections). The results of the surveys strongly indicate that the pilot was successful and proved to be viable; the sessions were high quality, person-centered artistic care was made accessible to a vulnerable population at a sustainable cost, and most importantly, a demand for this type of program was revealed.

Keywords

Long-term care; virtual; person-centered care; interactive art therapy; pandemic; social isolation; music; storytelling; poetry 

1. Introduction

The arts are vital in prevention of illness, promotion of health, and the management and treatment of illness throughout a person’s life [1]. The practice of implementing arts into health care has gained traction in recent years for the many health benefits it offers [1]. One approach that can utilize the arts to improve health is the person-centered approach, which is becoming increasingly more popular, especially in Canada [2]. Person-centered care promotes patient autonomy and allows patients to have a voice in their care plan by considering their needs, preferences, and quality of experience in the approach [2]. For example, art programs are being offered more and more to elders in long-term care (LTC) (especially those with dementia) with the goal of creating meaningful personal experiences [3]. Art activity (including dance, music and movement, and visual arts) has been shown to positively influence residents’ moods through increased social relationships and improved self-esteem [4]. Furthermore, the collaboration between artists and caregivers stimulates creativity, beauty, and learning from each other, as well as evoking emotions [4]. Murphy and colleagues also demonstrated that technology can be used to increase accessibility to arts interventions for LTC and improve residents’ health/well-being [4].

Individualized music listening is an intervention that falls under the umbrella of person-centered care. Individualized music listening is a promising non-pharmacological intervention studied primarily with people with dementia that coordinates personalized music selections for patients based on their preferences and experiences [5]. Weise and colleagues assessed the feasibility of offering individualized listening to residents of a LTC facility. They had the participants listen to individualized playlists on MP3 players through headphones for 20 minutes every other day. They concluded that individualized listening can be used in LTC as a non-pharmacological intervention to improve quality of life for people with dementia [5]. Likewise, listening to personally meaningful music can enhance social relationships and interactions [6], and stimulate positive emotions and memories as well as reduce stress, agitation, and anxiety in people with dementia [7]. Furthermore, individualized music listening interventions can promote alertness, relaxation, interest, and a positive mood since personally meaningful music prompts a complex interaction between brain regions [8].

Dementia is on the rise and the availability of at-home caregivers is declining [9]. The increasing prevalence of dementia requires interventions that maintain and enhance well-being and quality of life by improving negative and psychological symptoms associated with dementia [5]. Individualized music listening can be a non-pharmacological treatment for people with dementia and other populations. In a time when the overprescription of pharmaceuticals is so widespread [10], and research has revealed the impact of social factors on health and well-being (social determinants of health), it is important that we find effective non-pharmacological treatments and interventions, especially for vulnerable people such as those in LTC and those with dementia or other cognitive diseases/disorders. Elderly people in nursing homes are the most notable victims of the overprescription of psychotropic drugs [11], and people with dementia are even greater a victim [12,13]. Art therapy, individualized music listening, and other similar programs are all promising activities for social prescribing that if prescribed, may improve the overprescription crisis while also producing a more holistic approach to health that considers the mind-body relationship ― a connection between emotional states and physical heath where both factors have a direct influence on the other [14] ― and the social determinants of health.

1.1 Unmasked Connections

Unmasked Connections is a pilot project that contributes to a larger initiative to bring the arts into health care [15,16]. Art care in context of this project consists of personalized, intimate, and interactive virtual art performances (including music, storytelling, poetry, spoken word, and theatre) with willing residents of a LTC facility through Zoom videoconference platform. Unmasked Connections was launched by Radical Connections, a non-profit organization and registered charity, that aims to improve care and strengthen communities by bringing artists and healthcare workers together, to radically transform elder care through arts and culture-based healing, connections, and opportunities [17]. The name of the pilot was inspired by the barrier that masks have imposed on the quality of care and interpersonal connections in LTC. According to the co-founder of Radical Connections, many physician colleagues, including themselves, preferred to do counselling virtually and unmasked rather than in-person with masks on, due to the barrier that masks impose; hence the inspiration for a pilot that would facilitate unmasked connections between artists and LTC residents to supplement social connections through virtual art care.

Unmasked Connections aims to provide equitable access to the arts so that people in isolation or with physical limitations who cannot commute to an art gallery, concert hall, or theatre to experience art performances will be able to access the arts through Unmasked Connections [15]. With the long-term implementation of Unmasked Connections, Radical Connections will consider the evaluation, feedback, and recommendations outlined in this feasibility report to improve the quality of the program; therefore, the current study is characterized as a quality improvement study. This study was initiated by Radical Connections who sought out a third party to evaluate their pilot and provide feedback in order to improve their first implementation of Unmasked Connections, and consequently also improve the chances of success in the long-term implementation of the program. Radical Connections also wanted to have their Unmasked Connections pilot documented to bring awareness to current initiatives that bring arts into healthcare, to inspire more initiatives of this sort, and to serve as a testament for the value of such programs.

2. Materials and Methods

2.1 Facilitating the Pilot

Verbal consent to participate in this pilot was obtained from the residents who were deemed cognitively capable of consenting determined by a cognitive assessment using the Cognitive Performance Scale (CPS). This standardized scale is completed by a LTC nurse every 90 days as part of the Minimum Data Set (MDS), a federally mandated assessment for residents in Medicare or Medicaid certified nursing homes. The CPS scale is rated where 0 = intact, 1 = borderline intact, 2 = mild impairment, 3 = moderate impairment, 4 = moderate-to-severe impairment, 5 = severe impairment, 6 = very severe impairment. Residents who score 3-6 on this scale required consent from their power of attorney (POA) or a substitute decision maker (SDM). POAs would have been formally designated by each resident and their families prior to being admitted to LTC, and this information would have been collected and recorded on their chart during the intake processes. Common qualifying people for POA include family members, spouses, a long-time friend, a lawyer, or trust company. SDMs are typically the closest living relative (a spouse, child, or other family member) and are consulted for healthcare decisions if the resident is cognitively unable to consent or make their own decisions. Contact with POAs and SDMs was conducted by Recreation Technicians at the LTC facilities by phone, email, or in-person.

The artists were selected by the residents after being asked by the therapeutic recreation (rec) staff which type of art they preferred out of the options available (storytelling, poetry and spoken word, music, and theatre). Upon selecting an art type, the rec staff then showed the residents short sample excerpts of the artists that fall into that art category from the Unmasked Connections online artist directory to select the performer they want to connect with. After selecting the artists, an appointment time was agreed upon by the rec staff and the artist, and a 1-hour unmasked connection was scheduled.

The recruitment of artists was conducted through snowball sampling; Radical Connections recruited artists by first inviting artists they already knew, then through word of mouth, and through an ad at a theatre in Ottawa. A total of twenty artists were recruited from various cities across Canada. Artists were vetted through the completion of a questionnaire, the presentation of their artist portfolio, and a videoconference interview. The artists were required to sign a contract that outlined their responsibilities, terms and conditions, and rate of pay. This contract was developed based on the contract used in the Artist in Residence program which was part of the inspiration for this pilot. The artist in residence program was implemented in Bruyère’s Saint-Vincent Hospital in 2018 and aimed to improve quality of life for their residents by giving them the opportunity to express themselves, learn about art, and participate in the creative process.

All artists and Radical Connections members had to complete three online modules mandated by Bruyère that address the resident bill of rights, caring for people with dementia, and abuse recognition and prevention in LTC. Furthermore, the artists were required to participate in two virtual knowledge exchange sessions for healthcare and technology to equip them with the necessary information and instructions for the unmasked connections to run smoothly. The healthcare session was run by Bruyère and informed the artists about hospital policies, procedures, and the general demographic and conditions of the residents. The technology session was presented by an IT specialist to educate artists on the required technology.

This pilot was an interdisciplinary initiative that required the contributions of people with various specialties including backgrounds in business management, healthcare, long-term care, performing arts, research, and grant application writing. Bruyère contributed to this pilot in countless ways including: establishing and setting up the process for the program in the LTC facilities, organizing training for artists, training the rec staff for their roles in the pilot, scheduling and organizing password-protected Zoom meetings for the unmasked connections, IT setup and assistance and training, putting together short documents about each participating resident for the artists’ use during their sessions, and disbursing the grant funds as necessary to the artists directly for each Unmasked Connection that they conducted and for each of the mandatory training sessions that they attended.

Making decisions for this pilot required a great deal of constant back-and-forth communication between Radical Connections and Bruyère to explore all options and reach agreements and compromises. One example of this is the requirement for the artists to receive a background check before being fully onboarded and having contact with LTC residents. Bruyère’s hospital policy requires a vulnerable sector check for this type of contact with their resident, however this was too difficult for all the artists to obtain as they are spread out across the country, and some reside in municipalities where the wait time would be months. Bruyère eventually settled on an enhanced criminal record check as they recognized that the artists would not have direct in-person contact and they were all vetted upon recruitment. The enhanced criminal record checks were obtained through a third-party organization called Charity Village which conducted the record checks by the artists submitting their information and identification documents online.

When deciding upon the procedure and details of the unmasked connections sessions, the Radical Connections and Bruyère team tried to anticipate potential issues; some of the concerns included whether the residents would be disturbed by seeing themselves on Zoom (especially those with dementia who might not recognize what they look like anymore), and whether to mute the residents during the performance. The team determined that the video reflection would not be an issue for most residents and that if a resident was disturbed by it that their video would be turned off by their rec team support. Additionally, the team decided to not mute the residents during the performances to encourage a more interactive session. The Unmasked Connections were conducted on the hospital iPads which were protected in durable cases with a stand to hold the iPad up for hands-free use. We chose to use the hospital iPads since they can easily be transported and set up on a table beside hospital beds for the residents. Both the audio and video components of the sessions were received through the iPads. The standard speakers on the iPads were sufficient for all residents, even those with hearing loss.

The unmasked connections sessions began on July 19th, 2022, and the last virtual connection was made in February 2023. Over the course of the project, 11 artists provided 27 one-on-one virtual sessions to 14 different LTC residents at two affiliated LTC facilities. There were multiple Covid outbreaks in the LTC facilities throughout this period which resulted in approximately 5 percent of scheduled sessions being either cancelled or postponed. Furthermore, the internal outbreaks caused delays in the coordination of future sessions as the therapeutic recreation team was preoccupied with their increased workload. There were a few instances throughout the course of this pilot where no session took place for one-to-two weeks because of internal outbreaks; these delays likely could have been avoided had the facilities had more available staff members.

2.2 Materials, Measurements, & Analysis

The purpose of the Unmasked Connections pilot was to provide a supplemental social and artistic outlet to the residents of two affiliated LTC residences in Ottawa, Ontario during the Covid-19 pandemic. We accomplished this by delivering one-on-one virtual artist performances from award winning artists across Canada to LTC residents through the Zoom videoconferencing platform. The purpose of this study was to document the process of this innovative program, which to our knowledge is the first of its kind, while also assessing the feasibility of this pilot and conducting a quality improvement assessment. Secondly, this study aimed to report on the experience of the participants in all involved parties, including criticisms, and the factors that contributed to its success.

Various online surveys were implemented throughout the duration of the pilot to the different groups of participants. The online survey format was decided based on the low availability of the participants in attempt to maximize the response rate. The survey questions were formatted in multiple choice, multi-select, Likert-type scales, and short answer depending on the nature of the desired information (e.g., yes or no, or descriptive), while also considering how to make the survey as quick and simple to complete for the various participant groups being surveyed.

The first artist survey was administered online through Google Forms in late-June 2022 after the completion of mandatory training including healthcare and tech information sessions and modules, but before the commencement of the unmasked connections (survey questions listed in appendix A). The purpose of this survey was to understand the artist’s expectations and perspectives beforehand to be able to compare them to the responses from the second survey at the end of the pilot program — this would help to identify consistencies/inconsistencies, to determine where expectations were met/unmet and what could be improved for the artists. The artists were not asked their names in the survey to ensure anonymity, and the form did not collect email addresses because that would limit responses to only those with Gmail addresses. Due to the inability to double check if one respondent’s survey was successfully recorded, as well as receiving the submission of a blank survey, all subsequent Google surveys in this study required a name to be provided; this also offers the ability to ensure that no respondent completed a survey more than once or completed a survey they were not supposed to have access to. Radical Connections staff were also interviewed in late June 2022 through Zoom with a semi-structured interview structure; this was feasible since there were only 3 members to interview which allowed for a more detailed discussion (interview questions listed in appendix B). This initial survey prior to the commencement of the program was also to gather expectations and perspectives that would be compared to the post-pilot survey responses to help to identify consistencies/inconsistencies, to determine where expectations were met/unmet and what could be improved.

The second cohort of surveys were administered in mid-November after months of unmasked connections were facilitated. All the surveys at this time were administered through the Google Forms platform for convenience and consistency. Each participant party (resident, artist, Radical Connections members, and Bruyère rec staff) received a slightly different survey that tailored the questions to their role. One of the artists with a visual impairment was sent the questions in a Word document by email for accessibility, and they recorded their responses in the document and returned it. The residents completed the survey with the assistance of a rec nurse who inputted their answers into the Google form. All survey questions are listed in the appendices (appendix c-f). The purpose of these artist and Radical Connections member surveys was to compare to the responses from the first survey to note and changes in expectations and perspective, and also to gain evaluative and critical feedback from the parties responsible for designing and administering the program. Furthermore, the purpose of administering the resident and Bruyère rec staff surveys was to gain evaluative and critical feedback from those who were coordinating the pilot onsite and those who the program was designed to benefit.

The responses for each survey question were gathered and the themes were drawn out question-by-question and organized by participant type (resident, artist, Radical Connections members, and Bruyère rec staff) and survey cohort (1 and 2).

2.3 Participants

An ethics exemption was granted by the Bruyère Research Ethics Board for this feasibility study on the grounds that this project qualifies as “quality improvement/assessment.”

2.3.1 Residents

Fourteen residents of two Bruyère LTC facilities consented to receiving unmasked connections. Residents with a CPS score of 3-6 required the consent of a POA or SDM to participate in this pilot. Survey responses from 6 residents were obtained, all of which has a CPS score between 0-2. Demographic information of the 6 surveyed residents is outlined in Table 1. Though the intention of the pilot was to have family caregivers accompany the residents in the sessions, only one of the residents’ family caregivers agreed to participate.

Table 1 Surveyed residents’ demographic information.

2.3.2 Artists

Twenty artists were recruited however one of the artists had to be let go for not attending the mandatory knowledge exchange sessions and not responding to email communications. This resulted in 19 artists, with the majority being musicians, but many specializing in more than one art; there were 5 storytellers, 15 musicians, 4 poets who perform spoken word, and 3 theatre performers. 13 of the artists were female and 6 were male.

The initial artist survey was emailed to all 19 artists, 14 artists responded. Another survey was emailed to the 19 artists 5 months later and the artists were instructed to only complete the survey if they had completed a minimum of 1 unmasked connection; 10 artists surveys were submitted. Of the 19 artists, 7 had not yet performed an unmasked connection at the time that the second artist survey was administered.

2.3.3 Radical Connections Members

Radical Connections members are those that run Radical Connections and were heavily involved in this pilot including the executive director, artistic director, and program coordinator; we did not survey board members, consultants, or unpaid workers/researchers. The initial interview of Radical Connections members included 3 members who were involved at the time of the survey. One of these members later retired their position and accepted a position on the board of directors. The second interview with the Radical Connections included the two remaining members.

2.3.4 Bruyère Recreation Staff

A survey was emailed to the 5 Bruyère therapeutic recreation staff (rec staff) who were involved with this pilot, and 4 responses were received.

3. Results

3.1 Cohort 1: Artist Survey

More than three quarters of the respondents had performed for LTC residents prior to this pilot, and one had no experience with people with cognitive impairments and/or physical limitations. The most reported motivation to join this pilot project was to make a positive impact in the lives of those in LTC. Other motivating factors included expanding the arts to more environments, paid work, improving the health and well-being of the residents, prior experience performing in LTC or in art care, the opportunity to meet new people and be part of a pilot project, and the opportunity to perform intimately rather than in front of a crowd. When asked how prepared the artists felt to begin their unmasked connections, all respondents reported feeling adequately prepared. The answer to this question was based on a Likert-type scale of 1-10 (1 is low); the lowest rating was 6 with 1 response, the highest rating was 10 with 1 response, and the most popular rating was 8 with 6 responses. The ratings were more varied when asked to rate their comfort with technology based on the same scale; the lowest rating was 3 with 1 response, the highest rating was 10 with 1 response, and the most popular rating was a tie between 8 and 9 with 4 responses each. When asked if there was anything that they felt they should have had training for that they did not, 8 respondents reported feeling like the training received was sufficient, 3 respondents reported that they will know after the performances began, 1 reported wanting more training with technology, and the last suggested that a practice performance with a LTC professional may have been beneficial.

The artists were asked to list their expectations for this pilot and to state what they hoped to achieve or gain from their participation. Half of the respondents reported hoping to gain experience, and other responses included making a positive impact, building relationships, engaging with their art more, becoming a better performer, and to share their art. The artists were asked what they thought would make this pilot sustainable and the most common response from half of the respondents was funding. Other responses included the demand for performances, constructive feedback from all parties, a demonstratable impact, and dedication to the vision. Ten respondents were not aware of any projects or initiatives that are similar to this pilot, and the other four listed similar programs. Lastly, we welcomed any feedback at this preliminary stage of the pilot and received only positive comments which complimented the preparation, flow of information communication, passion, and positive interactions.

3.2 Cohort 1: Radical Connections Interview

The responses revealed that Unmasked Connections was made possible primarily because of successful grant applications which funded the project. Radical Connections received grants from the Ontario Arts Council and the Eldercare Foundation. Other factors identified by the Radical Connection team which made this pilot possible include great artists who were willing to participate, willing partners and connections outside of the arts (especially Bruyère who was very accommodating), the co-founders’ prior work experience and connections with Bruyère, Bruyère’s rec staff’s familiarity with recruiting musicians to perform at the hospital, a recognition of the need for improved care in LTC which was developed throughout the pandemic, and lastly, a belief in the vision.

The inspiration for this pilot is rooted in the potential benefits that the arts can offer people in LTC, especially when they are faced with isolation to any extent. The executive director and co-founder of Radical Connections is both a physician and a musician who envisioned the opportunity for people in isolation and those faced with accessibility barriers to have access to live performances while simultaneously offering artists the opportunity to perform/work when they otherwise would not be able to during pandemic. Furthermore, the other co-founder of Radical Connections had prior experience collaborating with people of other specialities and disciplines on meaningful art projects and played a key role in the development of the artist in resident program.

Many barriers were experienced during the process thus far as is expected when establishing a new program. Trying to obtain vulnerable sector checks for all the artists across multiple provinces and coming to an agreement between Radical Connections and Bruyère to accept the enhanced criminal record check was challenging and time consuming. Additionally, determining how the Zoom Unmasked Connections sessions would be coordinated and which Zoom account would be the most secure also proved to be difficult. Another significant barrier experienced was that 1 of the 2 grants received to fund this pilot was not permitted to be used to pay artists who resided outside the province of Ontario, and many of the artists in the Unmasked Connections directory resided in other provinces. This demanded more financial planning to ensure that funds were allocated to cover the various costs and salaries from the proper grant source. Having an extra person on the Radical Connections team from the beginning of the project would have made the workload lighter for all team members; a business manager was not recruited until shortly before the unmasked connections were scheduled to begin. Lastly, one artist was scheduled to attend the technology and healthcare knowledge exchange sessions but did not attend either sessions or respond to emails from Radical Connections. This resulted in Radical Connections having to cut ties with them as it was important to have artists that were reliable and would be present for their scheduled sessions. After this unfortunate incident, the Radical Connections team had to emphasize to the other artists that since their participation in this pilot was a paid employment, they were obligated to monitor their emails regularly if they were not already doing so, to ensure proper communication.

Despite these barriers, there were a few aspects of the project that unfolded better than expected including the organization and quality of the knowledge exchange sessions. Additionally, all surveyed members of Radical Connections stressed that the quality of the artist directory was much greater than hoped for as it contained Juno and Governor General award-winning artists. It was a pleasant surprise to have such great interest in participation from artists.

3.3 Cohort 2: Artist Survey

Of the 10 survey respondents, 7 had only completed 1 unmasked connection, while 2 completed 2 connections, and 1 had completed 5. The frequency of the artist’s performances was determined by requests of the residents. The artists were asked whether they thought their pay rate for the unmasked connections was reasonable and not a single respondent reported “no”; 8 of the respondents agreed, 1 somewhat agreed, and 1 artist agreed that the pay rate for the performances alone was reasonable, however this compensation did not consider the time required to set up for the performances and prepare material for the performances.

The artists were asked whether “[they] noticed or foresee their experience with unmasked connections feeding into their practice as an artist.” This question prompted encouraging responses including an overarching theme of how surprisingly intimate the connections were and the awareness of how performing is a two-way interaction. Some artists also touched on how every new experience broadens their perspectives on their work. All of the respondents reported that they were effectively able to share their art in a virtual setting through Zoom either completely (7) or somewhat (3). However, when asked whether they thought they were able to connect with the residents in a virtual setting better than they would have if they were in-person but wearing masks, 3 disagreed, 3 agreed, and 4 were unsure. Despite this division of opinions, all the respondents reported believing that the unmasked connections were beneficial to the residents they connected with; the artists described this benefit as nourishing and evoking happiness and enthusiasm, providing craved social connection, and providing comfort and inspiration. One particularly profound benefit that one artist reported was that their connection with one resident had helped the resident to navigate their emotions attributed to only recently having moved into LTC. Furthermore, the artists were asked what they gained from their unmasked connections and participation in this pilot. The main theme in the responses is the satisfaction and fulfillment of the intimate and powerful connections; one artist went as far as to say this this was the most rewarding part of their artistic career to date. Another important point mentioned was that this pilot gave the artists the opportunity to perform for an audience that they likely would not have encountered otherwise in a public concert for example.

The artists all reported feeling as though the training they received before commencing the unmasked connections was sufficient, however one artist reported that a bit more training specifically regarding sound problems through zoom would have helped. The artists were asked what should be done differently to improve the ease of the process if this pilot were to be launched as a program at another LTC facility. Although some respondents did not have any suggestions, the main theme regards the timeline of the project; the artists would have preferred the training and preparations (e.g., sound checks) to be much closer to their first performance. Additionally, they found the overall process of the pilot to be very drawn out since they were recruited in Winter 2022, received their training in May 2022, and the connections did not commence until Summer 2022 with some artists having their first performance in Fall 2022. Some of the artists also mentioned that the process would be much simpler for them had they had definite dates assigned to them for performances further in advance, in addition to knowing who they were performing for and knowing more about the resident beforehand. One last shared idea was the possibility for more staff members to coordinate the program on both the LTC and the Radical Connections ends. For example, having a rec staff member (or family member) assisting the residents during the unmasked connections and a person specifically dedicated to technology or to be the point of contact for the artists to reach out to for any questions or help.

Lastly, the artists were invited to share comments about their experience and feedback regarding the pilot. The most common theme in the responses was the reiteration of the value of this pilot for the residents. However, few artists were disappointed by the infrequency of performances or confusion surrounding which resident they were performing for as there were some mix ups and changes to schedules.

3.4 Cohort 2: Radical Connections Survey

Both survey respondents reported that their expectations of the unmasked connections were exceeded. Some of the aspects of the pilot that have gone especially well include surprisingly few difficulties regarding Zoom, the residents’ high levels of engagement during the sessions (especially those with dementia), how quickly relationships formed between the artists and residents and the level of intimacy in the relationships. However, there were many barriers and difficulties in the process of this pilot including coordinating times with all parties (artists, Radical Connections, rec staff) for various meetings or training sessions due to the vast difference between everyone’s schedules. Others include, getting access to the Bruyère’s Zoom business account, some technical difficulties for artists, and a lack of participation from family and caregivers for the residents. One especially prominent barrier was the time and effort required for the rec staff to coordinate unmasked connections with the residents and artists; this was amplified with all of the Covid outbreaks in the LTC facilities which drew the staff’s energy and time away from recreation to deal with the outbreaks, consequently resulting in many delays in the scheduling of the performances. When asked if they consider this pilot a success based on the progress to date, both respondents agreed, however one said that it was only a success in terms of the quality of the connections because logistically it was very challenging for the rec staff to facilitate the sessions; the goal would be to simplify this aspect of the program in the future.

If the Radical Connections team were to restart this project, some of the changes they would make in their approach include determining how to connect directly with caregivers to improve the program, securing or allocating funds from the budget to specific staff members who would focus on scheduling the performances, provide artists with training to help them make conversation with elders, and likely only conduct one research project for the pilot rather than two (feasibility and quality of life) to reduce the work load for staff and residents in facilitating surveys/interviews, etc. If Radical Connections were to expand this pilot and recruit more artists, they would consider implementing an audition rather than an interview, especially for musicians to ensure smoothness without technical glitches in the performances.

The impact of this pilot was observed in the artists and the residents who were profoundly uplifted during the connections. An example of this would be the artistic inspiration that the artists sparked in some of the residents who had lost touch with their love of art which was being rekindled through the sessions. The rec staff were also impacted by the sessions by learning more about the residents they were caring for daily which in theory would result in improved care. Lastly, on a personal level this pilot has impacted one of the Radical Connections members by fostering the hope that this program will continue and grow to reach more isolated people and artists.

The participants were invited to share any comments about their experience or feedback regarding the process, and three critical comments were made; the first concerned the need to find some way to support the rec staff on site to relieve their burden and make the program run more smoothly. Secondly, money, advertising and convenience are three key factors for this project to succeed; money is required to ensure the artists are paid, advertising would raise awareness to the program, and convenience would persuade people to try it out. The last point regards the business case that can be made for person-centered artistic engagement in healthcare; further study could show support for the possibility that meaningful artistic activities could lessen residents’ need for medication and therefore require less attention and time from the nursing staff and less health complications or incidents that result in a visit to acute care.

3.5 Cohort 2: Bruyère Staff Survey

The rec staff were asked “what makes a project of this sort possible?” and a variety of different responses were recorded including: promoting the program to the residents, staff and care partners, ensuring good communication between all parties involved in the coordination of the project, having a variety of different performers and art performance types to ensure there is something that each of the residents would be interested in, and finally, grant money and funding is vital. The rec staff were asked to reflect on which aspects of the project have gone well and the difficulties or barriers in the process of the pilot. The aspects that have gone well include the unmasked connections themselves which always improved the mood of the residents and made artistic performances accessible to residents who otherwise did not have the opportunity to engage that deeply in creative activities. Furthermore, both the residents and the artists were able to adapt to the virtual platform, and the connections inspired residents, especially one who started to write poetry again after years of not engagement with the art.

The difficulties/barriers in the process were mainly communication and scheduling. Communication was a significant barrier in that matching the residents to artists and coordinating a meeting time that works for all parties involved was difficult and time consuming, and the fact that some artists live in different time zone across Canada exacerbated the situation. There were regular problems with the chain of communication which resulted in the delay of relaying important information as well as the continuously changing instructions; this was especially difficult to navigate because the rec staff had to share information with the residents’ families to maintain informed consent which resulted in many phone-calls each time the information changed. Scheduling was challenging due to communication and also because it required teamwork to ensure residents were ready for their unmasked connections and that the times did not conflict with meal or care time. Consequently, scheduling errors and delays in care have resulted in some residents being late to their unmasked connection. Planning and coordinating one-on-one activities versus group activities that include all the residents required a significantly larger time commitment. Covid outbreaks in the LTC facilities caused staffing shortages during the pandemic which also resulted in delays in care and prompted the cancellation of and lack of scheduled unmasked connections multiple times throughout the pilot. Other difficulties/barriers included: the time required to set up the required technology within Bruyère, addressing privacy concerns at the corporate level, and occasional technology issues.

Building upon the reflection of the process, the respondents were asked what they would recommend doing anything differently if they had to restart this project. The main theme in the responses was communication. Other recommendations included: a condensed and less time-consuming training for the artists, a document produced for the rec staff that outlined all of the steps required for booking and executing an unmasked connections, a virtual calendar for artists to insert their availability as far in advanced as they can, more concise consent forms, and designated time frames that unmasked connections can be booked (i.e., 10 am-12 pm and 1:30 pm-3:30 pm).

3.6 Cohort 2: Resident Survey

Of the 6 residents surveyed, 5 had participated in 2 unmasked connections, and the other had only 1. The survey responses revealed a preference for poetry and spoken word performances with four respondents preferring this category of art performance, 1 respondent preferring music, 1 respondent preferring storytelling, and no respondents preferring theatre. Of the 5 residents who had 2 unmasked connections, 3 reported selecting the same art and performer both times, 2 selecting the same art but a different performer, and none selecting a different art type. The residents were then asked if there was a different type of artistic performance that they wish had been an option to choose from; 2 respondents had no suggestions, 1 suggested crafts and big bands, 1 suggested group singing, another suggested live theatre, and the last suggested comedy. 2 of the residents thought the performances were a good length, but the other 4 residents wished the performances had been longer than the scheduled 1 hour. Regarding the frequency of the performances, half of the respondents suggested one performances every two weeks would be ideal, 2 residents preferred once per month, 1 resident preferred one per week, and none of the residents thought more than one per week would be necessary.

Of the 6 surveyed residents, only 1 had a family member participate with them. Furthermore, 5 residents believed that the unmasked connections would not have been a better experience with the participation of a family member, and the other was unsure. All residents agreed that Zoom is an effective and acceptable method of delivering artistic performances. 2 of the residents suggested that the performances might have been better in-person rather than via Zoom, however another resident acknowledged the need for having the performances on Zoom as a substitute for in-person performances due to the pandemic. When asked if masks make it difficult to connect and communicate with people, 5 of the residents agreed to some extent, and the other resident did not understand the broader context of the question. Lastly, the residents were asked if they believe Unmasked Connections is a valuable program that should be implemented into long-term care facilities permanently, and all 6 of the surveyed residents agreed.

The residents were asked how their unmasked connections affected them. All residents reported a positive impact in various ways including triggering inspiration and being an intellectual stimulus, cultivating a sense of accomplishment, being soothing and relaxing, evoking nostalgia and being energizing, and evoking a sense of hope. The residents were also asked to suggest ways in which Unmasked Connections could improve. Some of the responses echoed comments from previous questions (for example, longer performances and more artists including those from big bands). The other feedback concerned the logistical aspect of the project including having the artists show up for their sessions since one of the surveyed residents had a session booked and the artist did not show up or cancel. Another comment concerned the rec staff and having them provide the residents with more notice and prepare them earlier for their unmasked connections, so they have time to wake up and not feel rushed into it for example. Lastly, one resident thought it would be beneficial to forward more information to the residents regarding the program, but it is unclear whether this is referencing more advertising for the program within the LTC, or more communication with the residents who have unmasked connections booked.

4. Discussion

The objectives of this feasibility study were to report on the process of a new phenomenon where virtual artist performances are introduced into LTC and to conduct a quality improvement evaluation so that Radical Connections can improve the quality of their first implementation of Unmasked Connections. This feasibility study documented the process of the pilot project Unmasked Connections for anybody to reference, learn from, or gain inspiration. Surveys were administered to artists, residents, rec staff, and members from Unmasked Connections’ governing organization Radical Connections to further elaborate on the successes, shortcomings, and value of this pilot and integrating arts into healthcare from the perspectives of all parties involved.

4.1 Benefits of this Pilot

The residents, artists, and rec staff all expressed feeling a positive impact from participating in this pilot. The artists communicated feeling a sense of satisfaction and fulfillment from their artistic connections with the residents, they gained a new perspective that will feed-back into their artistic practice, and they were able to connect with a population that they otherwise likely would not have. Furthermore, the artists expressed the value of this pilot for the residents while noting that they observed benefits including effects of nourishment, evoking happiness and enthusiasm, fulfilling social connection, and providing comfort and inspiration for the residents. The rec staff also observed an improvement in mood in the residents after receiving an unmasked connection. All surveyed residents reported their participation having a positive impact on them [13].

The residents outlined the ways that the unmasked connections positively impacted them, and they are consistent with prior literature regarding art interventions in LTC and the person-centered approach to art care. These benefits include triggering inspiration and being an intellectual stimulus, energizing, cultivating a sense of accomplishment, evoking a sense of hope [4], being soothing and relaxing, and evoking nostalgia [7,8]. The residents were asked if they believe Unmasked Connections is a valuable program that should be implemented into LTC facilities permanently, and all the surveyed residents agreed which again demonstrates the value of the program and its potential to be socially prescribed to LTC residents to improve well-being. Social prescriptions of interactive art care could help to mitigate the overprescription crisis that namely elderly people [11], and people with dementia are the most vulnerable to [12,13]; this has already been demonstrated through a 10-week interactive hospital-based group music intervention that offered creative freedom to dementia patients which demonstrated a reduced prescription of antipsychotic drugs to the participating patients as well as improved well-being [13].

From observing some of the unmasked connections, the Radical Connections team observed notable positive emotional connections that resulted in uplifted moods in both the artists and the residents during the sessions. The team also drew attention to the effect that these sessions had on the assisting rec staff who ended up learning more about the residents that they regularly care for which will likely result in the rec staff humanizing and sympathizing with the residents more deeply and thus providing better quality of care.

The collective testimonies and attestation for the value of Unmasked Connections is the most significant factor in assessing the feasibility of this pilot; it confirms the demand for programs of this sort and also suggests that there will be a long-term uptake and interest in the program which is critical for the financial sustainability of the program.

4.2 Avenues to Improve Unmasked Connections

Many suggestions for improvements were made by all surveyed parties, but most of the criticism concerned logistical difficulties, a lack of staff, and Covid outbreaks which resulted in delays. The overall timeline of the pilot was drawn out much longer than anticipated due to not addressing early enough some specific steps that ended up being more time consuming than imagined (e.g., background checks for artists), and the need for more staff members both in Bruyère and Radical Connections to balance the work-load more reasonably, especially when the rec staff were overwhelmed during Covid outbreaks in the LTC and could not direct attention to the pilot. Since hiring more rec staff is far outside of our control, having a Radical Connections member who was situated in the LTC facility(s) with the sole purpose of coordinating the pilot from within would have accelerated the communication between organizations and prevented some of the delays in performance scheduling during Covid outbreaks. Furthermore, creating other new positions including someone to schedule regular performances would ensure each artist and resident had ample opportunity to participate (until a virtual scheduling platform is established), and that performances were scheduled far enough in a advance for artists to prepare a more personalized performance for each resident, as well as an IT worker, a recruiter for both artists and residents, and having a business manager and financial coordinator from the beginning of the pilot (rather than recruiting one later on). Another way to reduce the workload on the rec staff would have been to have a family member of the residents participate on-site in the unmasked connections rather than occupying a rec staff member for assistance during each session. This was the original intention in the design of the program, however, the family members of the residents in the two participating LTC facilities did not demonstrate interest in participating, and the survey revealed that the residents might prefer not having their family members participating with them.

Only 1 resident had a family member participate in an unmasked connection when one of the goals of this program was to have family participate. Despite this goal, the intimate 1-on-1 setting of these unmasked connections might be more desirable to the residents than having family participate because the residents might feel a sense of judgement or lack of autonomy and control when their family is present. The perceived lack of autonomy and control is linked to negative physical and mental health side-effects, namely including depression [18] which has also been linked to dementia as a risk factor and symptom [19]. Giving the residents the choice to have their family participate and allowing them to choose which art type and performer to connect with is a form of person-centered care [2] which can mitigate the negative mental and physical health side-effects that result from a perceived lack of autonomy and control.

Training is another aspect of the pilot that could use improvement. The Zoom training and preparations (e.g., sound checks) took place too far in advance and should have occurred only a few days in advance of each artist’s first performance; this is a prime example of a situation where it would have been beneficial to have a full-time IT specialist on-board. The general training sessions and homework ideally could be shortened for the artists, especially considering this project is an occasional gig for them rather than a full-time job. Additionally, it would enhance the connections if the artists were provided with training to help them make conversation with elders and understand cognitive decline and disorders better.

Many artists in this pilot project did not have any experience interacting with people in LTC or with cognitive or physical limitations. Having some background knowledge of the types of limitations that their audiences face would not only make the artists feel more confident and prepared but could also enhance the audience’s engagement during the session. In a study of nursing assistants who received training on communication techniques, the nurses reported increased knowledge of the needs and abilities of the population they received the training for (dementia population) and were more capable of how to assess pain indicators, and how to approach and communicate with the residents [20]. This type of training would also be useful for performing artists since art (especially verbal art like storytelling and singing) are methods of communication.

Other ways to improve the program include implementing an audition rather than an interview for artists, especially for musicians to ensure smoothness without technical glitches in the performances. There were a few artists who although were excellent and possibly even award-winning artists, struggled greatly with the technological aspect of these performances which diminished the quality of their performances and placed a burden on the organizing members of the pilot. Having a virtual calendar for artists to declare their availability as far in advance as they know of would greatly help in the process of scheduling. Having auditions, a virtual calendar and someone whose sole objective is to coordinate performances would hopefully eliminate occasions of artists not showing up for performances and failing to cancel in a reasonable time. Furthermore, more consistent time frames for scheduling performances (e.g., 10 am-12 pm & 1:30 pm-3:30 pm) would reduce instances where the resident is late or cancels due to unanticipated mealtimes running late or rec staff not waking the resident up early enough.

Foster and colleagues (2016) outlined ten domains of music care: (1) community, (2) specialties, (3) music therapy [or art therapy], (4) musicking [or art making], (5) programming, (6) technology, (7) sound environment (8) music medicine, (9) training, and (10) research [2] — see Figure 1 for descriptions of each domain. They suggest that these ten domains together facilitate and constitute music care, and must be examined to identify, implement, and have accountability in music care [2]. This framework can also be applied to general art care and therapeutic art experiences including Unmasked Connections. All parties involved in programs such as Unmasked Connections should be aware of these domains to effectively implement these programs and ensure quality care. One of the most impactful ways that Unmasked Connections could be improved beyond the pilot phase is to onboard more team members who are knowledgeable in these domains to ensure the best quality of care in terms of art care for the participating residents.

Click to view original image

Figure 1 Table listing the “10 Domains of Music Care” as described in the research of Foster, Pearson, and Berends [2].

Some non-logistical suggestions for improvement provided by the residents include expanding with different types of artistic performances. Three of these art types are out of the realm/feasibility of this project. Live theatre and big bands are two of the types of performances that this project already aims to recreate and substitute through theatre and musicians/duets for people in LTC who cannot physically go to these types of performances. Hiring an actual theatre crew or a big band would not be feasible either economically or scheduling-wise for a 1-on-1 performance; therefore, the only way to bring these types of performance into LTC is through a livestream rather than a 1-on-1 interaction, which would not fulfill the intimate connection objective of Unmasked Connections. Group singing is another art that does not align with the objective of Unmasked Connections because it would require an online choir rather than a 1-on-1 performance with an artist, and that would require a great deal of additional resources and coordinating that again does not fit into the scope or objectives of this project. Residents were welcome to sing along with the artists performing for them. However, if residents were seeking a group experience, they should join an existing online choir, a community intergenerational choir (many welcome those with cognitive decline and dementia), or have their family caregivers petition to the rec board at their LTC facility to organize a choir with the hospital.

The other two suggestions include comedy which could be implemented as a sub-category of storytelling, and crafts which might be difficult to execute interactively in a virtual context. “ArtontheBrain” is a software program that runs on tablets, desktops, laptop using chrome and safari web browsers that also brings virtual art experiences into LTC. This program engages participants in activities centered on a user-selected visual artwork such as a photograph, painting, sculpture, and/or textile with options to learn, play, or mingle [4]. Murphey and colleagues used ArtontheBrain as a participatory virtual art intervention for a group of adults residing in LTC to measure its influence on well-being. This program implemented half-hour sessions twice weekly with a resident and a partner or group of residents. The results of this study indicate that the program significantly improved measures of well-being, and the participants greatly enjoyed the program and would recommend it to others [4]. LTC facilities could purchase this software or develop their own similar programs to address the desire for interactive arts and crafts in LTC.

4.3 The Effect of Masks

It is important for many LTC residents to be able to read lips and facial expressions either because they have cognitive impairments or are hard of hearing. Masks make it challenging for residents to communicate as they cover most of face making it impossible to read lips, difficult to interpret facial expressions, and muffles the projection of speech. With masks being a requirement in hospitals and LTC indefinitely, Unmasked Connections proves to be very important and useful for the health and well-being of residents, especially through the lens of communication and social fulfillment.

The residents and rec staff were able to adapt to the virtual platforms. Two-thirds of the surveyed artists agreed that they were able to effectively share their art in a virtual setting, and one third somewhat agreed, but none disagreed. Furthermore, there was a divide in opinion regarding whether performing virtually without masks was better than performing in-person wearing masks; 1 third agreed, 1 third disagreed, and another third was unsure. Although there was a divide in the artists opinions, the majority of the residents agreed that masks make it difficult to communicate with people, they all agreed to some extent that the virtual setting was effective, and they all fully agreed that the program should be implemented long-term.

These responses suggest that masks are a barrier in connecting and communicating with people. Unmasked Connections achieved its goal and successfully curated an artistic and social connection during the Covid-19 pandemic that was free of the barrier of masks. Zoom successfully served as a platform that facilitated intimate connections and allowed for the delivery of artistic performances during socially restrictive circumstances. Therefore, masks are more of a barrier than technology, and virtual art programs like Unmasked Connections increase accessibility to the arts and can function as a creative and social outlet for artists and LTC residents to improve well-being. This is also consistent with the results of the art intervention by Murphy and colleagues who demonstrated that technology can be used to increase accessibility to arts interventions for LTC and improve residents’ health/well-being [4].

4.4 Resident Artistic Preferences

Unmasked Connections shed light on the art performance categories that are preferred and those that are perhaps less accessible in LTC. Most of the artists on the roster for this pilot are musicians, however the poetry, spoken word and storytelling categories seemed to be the preferred art performance category among the surveyed residents. There were several musicians who were booked for performances, including pairs of musicians for duets, therefore, it is possible that the residents that were surveyed simply were not the ones who preferred music. However, one of the rec staff noticed the high interest in the poetry/spoken word/storytelling performances which will be taken into account by the recreation department at Bruyère when booking future entertainers/performers for the LTC facilities. The preference for these art categories compared to music might be an indication that music over Zoom simply does not measure up to live music which the residents are often able to experience in their facilities. Since all surveyed residents stated that they had selected the same art for each of their unmasked connections, it is possible that they had pre-conceived judgements of other arts and might have discovered the enjoyment of the music or theatre performances for example had they tried them. The most important takeaway from the topic of art preference is that Radical Connections should aim to maintain or increase diversity of art performance categories offered to their audience to appeal to a larger or more diverse population.

4.5 The Future of Unmasked Connections

As expected, this study revealed the value and demand for arts-based programs with LTC populations. The members of Radical Connections are addressing the criticisms and shortcomings of the pilot phase for long-term implementation. Unmasked Connections was launched during the lockdown period of the Covid-19 pandemic and the program was designed to only deliver virtual artist performances to a population that already faced social, cultural, and artistic inaccessibility; this is still the goal moving forward since masking is an indefinite restriction in local healthcare and LTC facilities, and this population suffered from inaccessibility to social, cultural, and artistic experiences even before the Covid-19 pandemic. Radical Connections, however, is adapting to the changing Covid-19 guidelines by bringing in-person concerts to one of the participating local LTC facilities. These concerts varied from a solo musician to a group of musicians. There were 10 in-person concerts at one LTC facility between September 2022 and June 2023. These in-person concerts only began once local public health authorities began to ease restrictions. The first in-person concerts required the use of masking for everybody and therefore no wind, brass, or vocalist musicians could perform. The gradual easing of restrictions eventually led to concerts that did not require the musicians to mask. Audiences at these in-person concerts ranged from 15 to 50 people. Additionally, 4 artists provided 4 in-person music workshops to residents at one of the participating LTC facilities. These workshops consisted of 7 to 15 people who were given performances of a variety of music in both English and French, and were invited to sing along, join in with a percussion instrument, and ask questions.

Radical Connections is now also organizing and selling tickets to in-person artist performances at local venues, as well as online live streams. One of the most notable expansions of Radical Connections is their Healing Interactive Performances series, Get HIP. There are both virtual and in-person concerts in the Get HIP concert series, as well as an annual subscription option to purchase. Artists who participated in Unmasked Connections were invited to participate in Get HIP.

The vision for Unmasked Connections is to create an app that can present all of the information currently on the online artist directory, as well as function as a booking system that clients can use to contact Radical Connections, view artist availability, schedule sessions, automatically generate videoconference meeting links for clients and artists to be accessed through the app, process payments, and process direct deposits to artists after the completion of a session. Additionally, we hope that we will be able set up a short satisfaction rating survey that clients will be redirected to after exiting a session; we envision a pop-up window with a 5-star Likert-type scale rating option that is similar to other videoconferencing software including Facebook Messenger’s video call function. After the user rates their satisfaction with the quality of the session on a scale of 1-5, a text box will appear where they can share positive feedback and criticisms. Radical Connections has been working with a group of Carleton University READi students (Research and Education in Accessibility, Design and Innovation) to discuss options and costs to create an accessible app that is capable of these functions.

Another vision for Unmasked Connections is to expand to LTC facilities across Canada, and possibly to other countries once the app is developed, or another system is developed that can support the administration and logistics of such a large-scale expansion to the program. To make this financially feasible, we are working towards creating a subscription that LTC facilities, hospitals, retirement homes, organizations, and even individuals can purchase. Offering a subscription service would be the most hassle-free way for organizations to buy into our program, and subscriptions would guarantee patronage for Unmasked Connections. Although we hope to gain most of our funds through subscriptions, we plan to also offer gift certificates and one-time service purchasing options for non-subscribers. Additionally, we have been making efforts to gain local awareness of Unmasked Connections (i.e., through participation in community arts panel discussions and local partnerships) which we hope will compel the community and arts organizations to either utilize our programs or to make charitable donations to Unmasked Connections.

5. Conclusions

This pilot was a successful pilot in terms of the quality of the sessions, the quality and of number of artists onboarded to the artist roster, and the positive impact that the program had on all parties which broadened perspectives and beliefs concerning the quality of healthcare and the value of implementing art into healthcare. Furthermore, Unmasked Connections achieved its goal to curate person-centered art care through personalized interactive artistic experiences to a vulnerable population during the restrictions of the Covid-19 pandemic; this is a major success within the organization’s larger objective to radicalize healthcare and provide equitable artistic opportunities to populations in LTC facilities. However, the most obvious evidence of success from this pilot is the significant positive impact the performances had on the residents, despite the unideal irregularity and quantity of the unmasked connections; this demonstrates a profound impact of intimate and interactive 1-on-1 art performances in a virtual setting on residents in LTC facilities and confirms the demand for the continuation of the program.

The weaknesses of this pilot were logistical (e.g., communication, estimating timelines, planning, collaboration between organizations) which can be learned from and improved. Therefore, the Unmasked Connections pilot proves to be a valuable asset in integrating art into healthcare to serve modern needs, and the long-term implementation of Unmasked Connections or any similar program hinges on the ability to market the program to parties including healthcare boards, charitable donors, grant organizations, individuals/family members that gain interest and invest into the program. Integrating performing arts into healthcare is an interdisciplinary process that requires the cooperation of many people with varying expertise and experience. Securing funds through grants, public patronage, donations, and especially long-term hospital subscriptions will cover the costs to continue running the program while enabling Radical Connections to enhance the program by hiring more specialists to improve the logistical aspect of the program making it an overall success.

This feasibility study revealed that the Unmasked Connections pilot program is viable and should continue to be implemented. Radical Connections should consider the recommendations and feedback outlined in this report to enhance and strengthen the program and ensure long-term success and growth.

6. Limitations

The number of people surveyed, especially in the category of residents was less than the desired number for reasons including the slow roll-out of the pilot resulting in a significantly fewer performances over the time frame of this study. Additionally, the survey method caused some barriers in the response rate; the research for this feasibility study was conducted completely remotely due to the pandemic which influenced the decision to have the surveys administered through an online survey platform (Google Forms). The nature of this platform required survey participants to login through a Google account which some people did not have. Furthermore, the residents were unable to access and complete this format of survey on their own, therefore the rec staff onsite had to assist the residents in completing the survey through Bruyère devices which were set up with Microsoft accounts rather than Google. The additional time and effort designated to completing the resident surveys, paired with only few residents having had unmasked connections, and some of those residents not at a cognitive level to accurately answer the survey questions resulted in only 6 resident survey responses.

Limitations and barriers regarding the implementation of this study included having no previous applicable program model to learn from, lacking the necessary number of people to make the process run optimally and in a timely manner, delays caused by the Covid-19 pandemic (including internal LTC outbreaks, backlogs in external organizations due to work closures and work-from-home workplace transitions, and delayed communication by relying on email communication for the bulk of communications), and technological barriers including a lack of familiarity and practice with technology. Additional limitations that were not anticipated included the difficulty of coordinating training and performances with artists in different time zones, as well as determining how to pay artists who were not residents of Ontario because the terms and conditions of the provincial grant received for this pilot required that it be used only to pay Ontario artists.

Acknowledgments

This research was made possible by the cooperation of residents and family members of Bruyère LTC, the Unmasked Connections artists, as well as the dedication of the Bruyère rec staff, and on-going support of the kind members of Radical Connections and the Music and Health Research Institute at the University of Ottawa.

Author Contributions

Rebecca MacDonald designed and coordinated this feasibility study, collected, and analyzed the data, and drafted the article. Dr. Carol Wiebe and Dr. Gilles Comeau were supervisors and mentors who assisted in the project design and provided feedback for the article draft.

Competing Interests

The authors have declared that no competing interests exist.

Additional Materials

The following additional materials are uploaded at the page of this paper.

1. Appendix A: Cohort 1 artist survey questions.

2. Appendix B: Cohort 1 survey questions for Radical Connections members.

3. Appendix C: Cohort 2 artist survey questions.

4. Appendix D: Cohort 2 survey questions for Radical Connections members.

5. Appendix E: Cohort 2 resident survey questions.

6. Appendix F: Cohort 2 Bruyère rec staff survey questions.

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