More than just clowns--Clown doctor rounds and their impact for children, families and staff

Jesters of Well-Being: Examining the Relationship between Clown Doctors and Patients

Clown doctors play a crucial role in enhancing the well-being of patients through the use of humor. However, little is known about how the use of humor by clown doctors changes in relation to the developmental age of patients. This research explores the interplay between the type of humor used by clown doctors, their experience (in terms of years of clowning and type of clowning), and the developmental age of the patients (children, adolescents, adults, elderly). Data for this cross-sectional study were collected through an online survey distributed to 210 Italian clown doctors (143 females, 67 males), aged between 18 and 75 years (M = 47.34, SD = 12.31), affiliated with different Clown Care Units. The survey included the Comic Styles Markers, questions on the patients' developmental age, type of clowning (Auguste vs. Whiteface), and years of experience. The findings enhance our understanding on how clown doctors interact with patients of different developmental ages. The discussion draws connections to previous studies conducted on groups of clown doctors, providing a broader context for understanding the implications of humorous interactions in this unique healthcare domain.

"I made you a small room in my heart": how therapeutic clowns meet the needs of older adults in nursing homes

Therapeutic clowns are increasingly common in nursing homes, where residents often encounter factors that can undermine their quality of life and dignity. We aimed to understand the strategies of successful therapeutic clowning with a diverse older adult population, and the unique contributions of elder-clowning to the nursing home experience. Using an interpretivist descriptive methodology, twenty-three (n=23) experienced therapeutic clowns from eight countries were interviewed to understand the needs of nursing home residents met by elder-clowns, and strategies and techniques the clowns use to address them. Participants identified five major needs: to escape routine; for reassurance of worth; for meaningful, personalized social interaction unrestricted by communication barriers; to have culturally meaningful opportunities for reminiscence; and to have a space where residents could be unapologetically themselves. The artistic and emotional strategies used by the therapeutic clowns to address these needs illustrate how creativity, imagination and relational presence can provide nursing home residents with a sense of being known and belonging. Elder-clowns also positively affect the nursing home staff and enrich the interpersonal interactions in the residence. Through their focus on the social and emotional needs of residents, elder-clowns can play an important and distinct role in creating an optimal nursing home experience.

The Impacts of a Clown Doctor Program on an Adolescent Psychiatric Unit: A Mixed Methods Investigation

Inpatient psychiatric care may be required to manage adolescents with severe mental health problems. As the ward can be a challenging environment, this study explored the influence of clown doctors on adolescents. Seventy-seven adolescents (13-18 years) and 22 staff from the Monash Health Stepping Stones Adolescent Unit, and 11 clown doctors from The Humour Foundation participated in the study. Bespoke surveys were developed by the research team to collect quantitative self-report data and qualitative responses. Descriptive statistics and thematic analysis suggested that adolescents experienced high levels of fun as well as positive mood during a clown doctor session. Clown doctor programs show promise within an inpatient unit with opportunities for further development being identified. With considerations of the findings, future clown doctor training could include tailoring sessions to the developmental needs of adolescents and developing strategies on how to interact with adolescents who have a mental health disorder.

Medical clowns in Coronavirus wards: A milestone in further integration into Israeli hospitals

BACKGROUND

During Covid-19, medical clowns disappeared from hospitals worldwide, ending their in-person visits. However, Israeli 'Dream Doctors' continued in children's wards and gained entrance to the Coronavirus wards.

METHODS

Using qualitative data from interviews and digital ethnography, the involvement of medical clowns in Coronavirus wards and their challenges were studied.

RESULTS

Medical clowns integrated mandatory protective gear and adapted their art: altering outfits, body language and interactivity. Spreading laughter and joy improved wards' ambience by uplifting patients', families' and staff's mood. Staff joined the clowns and loosened up in front of them. Reported need for this interaction was great and the clowns' intervention was crucial, leading to a successful trial in general wards, funded by one hospital.

CONCLUSIONS

Additional working hours and direct payment increased medical clowning's integration in Israeli hospitals. Entering the general wards evolved from the clowns' involvement in the Coronavirus wards.

Medical clowning influences the emotions of parents of children undergoing cancer treatment: A quasi-experimental study

BACKGROUND

Medical clowning for children has been found to be effective at enhancing parents' psychological well-being during preoperative preparation, but has not been found during cancer treatment. This study aimed to examine whether and how medical clowning influenced the emotions of parents of children undergoing cancer treatment.

METHODS

In this quasi-experimental study, 96 parents of children receiving inpatient cancer treatment were recruited, from June 2018 through April 2020. A demographic questionnaire measuring characteristics of parent and dyadic child, Brief Symptom Rating Scale measuring psychological distress of the parent, and Mood Assessment Scale measuring emotional status of parent and child were administered 1 day before a clowning service. The day after the clowning service, the Mood Assessment Scale again collected emotional status for parent and child. Descriptive analysis, bivariate analysis, and structural equation modeling to fit the actor-partner, cross-lagged model were used.

FINDINGS

Parents experienced a low degree of psychological distress that called for emotional management. The indirect effect of medical clowning on parents' emotions through children's emotions was significant, as were the direct effect and total effect of medical clowning on parents' emotions.

DISCUSSION

Parents experienced psychological distress during their child's inpatient cancer treatment. Medical clowning can directly improve children's emotions and through this pathway indirectly improve their parents' emotions.

APPLICATION TO PRACTICE

There is need to monitor psychological distress and provide interventions for parents of children undergoing cancer treatment. Medical clowns should continue to serve parent-child dyads in pediatric oncology practice and become members of multidisciplinary health care teams.

Do Clowns Really Taste Funny? An Investigation of the Relationship between Humor and Playfulness in Clown Doctors

Healthcare clowning represents a well-established method for relieving patients and their relatives of discomfort during hospitalization. Although studies concerning the effectiveness of this approach are increasing in number, state-of-the-art studies conducted to evaluate the psychological characteristics of clown doctors are scarce. In this cross-sectional study, a convenient sample of 210 clown doctors (143 females, 67 males) aged between 18 and 75 years (M = 47.34, SD = 12.31) completed a demographic questionnaire, the Comic Styles Markers, and the Short Measure for Adult Playfulness. The results demonstrated that clown doctors bring higher levels of fun, benevolent humor, and nonsense and a lower level of cynicism compared to the populace. Moreover, the participants with more experience tend to use less irony, sarcasm, and cynicism than those with less experience. Playfulness was primarily related to the lighter styles of humor, and specific differences between the Whiteface and the Auguste clown doctors were observed. The results are discussed with reference to previous studies conducted on groups of clown doctors.

Intervention and application of clown care in nursing homes: a scoping review

BACKGROUND

The purpose of this scoping review was to organize and describe the literature on the application of clown care to the elderly population in nursing homes, including intervention time, intervention methods and intervention effects, so as to provide reference ideas for other scholars to explore clown care programs suitable for the elderly population in nursing homes.

METHODS

Employing Arksey and O'Malley's methodology, we searched for PubMed, Web of Science, Embase, Cochrane, CNKI, WanFang, VIP, and CBM systematically and thoroughly, and the search period was from the establishment of each database to December 12, 2022. Two researchers with evidence-based learning experience independently conducted literature retrieval, information extraction, and cross-checking in strict accordance with the inclusion and exclusion criteria. The review process is reported according to PRISMA.

RESULTS

148 literature were initially obtained after searching, of which 18 were finally included. Among them, 17 were in English and 1 was in Chinese. There are 16 quantitative studies and 2 qualitative studies published from 2010 to 2022. It is found that the current clown care intervention program has not established a unified intervention standard and effective evaluation program.

CONCLUSIONS

The results of this scoping review conclude that clown care played a significant role in the nursing home. At first, it can reduce negative emotions, cognitive impairments and physical pain among older adults. In addition, it can improve their quality of life, life satisfaction, etc. It is suggested to learn from the advanced experience of clown care in foreign countries and carry out more clown care among the elderly population in nursing homes in China.

Leisure Programmes in Hospitalised People: A Systematic Review

Nurses carry out holistic assessments of patients during hospital admission. This assessment includes the need for leisure and recreation. Different intervention programmes have been developed to meet this need. The aim of this study was to investigate hospital leisure intervention programmes described in the literature in order to determine their effects on patient health and highlight the strengths and weaknesses of the programmes as reported by health professionals. A systematic review of articles in English or Spanish published between 2016 and 2022 was carried out. A search was performed in the following databases: CINAHL COMPLETE, PubMed, Cochrane Library and Dialnet and the Virtual Health Library and Web of Science resources. A total of 327 articles were obtained, of which 18 were included in the review. The methodological quality of the articles was assessed using the PRISMA, CASPe and STROBE scales. A total of six hospital-based leisure programmes were identified, including a total of 14 leisure interventions. The activities developed in most of the interventions effectively reduced the levels of anxiety, stress, fear and pain in patients. They also improved factors such as mood, humour, communication, wellbeing, satisfaction and hospital adaptation. Among the main barriers to implementing hospital leisure activities is the need for more training, time and adequate spaces for them develop. Health professionals consider it beneficial for the patient to develop leisure interventions in the hospital.

Seriously Foolish and Foolishly Serious: The Art and Practice of Clowning in Children's Rehabilitation

This paper interrogates and reclaims clown practices in children's rehabilitation as 'foolish.' Attempts to legitimize and 'take seriously' clown practices in the health sciences frame the work of clowns as secondary to the 'real' work of medical professionals and diminish the ways clowns support emotional vulnerability and bravery with a willingness to fail and be ridiculous as fundamental to their work. Narrow conceptualizations of clown practices in hospitals as only happy and funny overlook the ways clowns also routinely engage with sadness, despair, discomfort and many other ways of being and doing. Our exploration of clown practices as foolish exposes the ways children's rehabilitation upholds particular neoliberal models of success and invites a re-centring of rehabilitation and health care research and practice towards relationship building, supporting meaningful projects and a continued nurturing of aesthetic and pleasurable ways of being-in-the-world in the present moment as valuable unto themselves.

Turnover among medical clowns early in their career

In recent years, several investigations of the medical clowning profession have appeared in the literature. However, few studies have focused on factors associated with turnover among medical clowns early in their careers. The current study examined whether individual differences in humor disposition predicted turnover behavior. Participants were 111 medical clowns in a three-phase longitudinal study. Humor disposition was measured in the first week of their training, clowns' job satisfaction two months later, and turnover six months after that. Results showed that humor appreciation decreased actual turnover through the mediating role of job satisfaction, whereas individual differences in humor creation directly decreased turnover. In addition, previous traumatic experiences moderated the associations between humor appreciation and turnover. Overall, our research findings support the notion that humor disposition can help predict which clowns remain in the hospital.

Perceived changes in psychological and physical symptoms after hospital clown performances in a cancer setting

Background: The therapeutic role of humor and hospital clowns has become a focus of interest in recent decades. Most of the research in the area has focused on children; here, we explore the influence of clown performances on adult cancer patients, their companions, and health-care staff.Methods: Ninety-nine cancer patients and 113 companions were assessed pre- and post-interventions performed by professional clowns; 31 health professionals were asked about the possible influence of the presence of clowns in hospital on their work.Results: Patients felt that clowning performances helped to reduce their level of psychological symptoms, but not their physical symptoms. Companions reported improvements in all the psychological symptoms explored. Health professionals reported that the presence of clowns in the workplace improved their well-being.Conclusions: Clowning performances helped to improve psychological functioning in all the populations studied, especially in companions. Adult hospitals should consider promoting clowning interventions to improve general well-being.

Palhaçoterapia em ambiente hospitalar: uma revisão de literatura

Resumo A inserção do palhaço no hospital é relativamente recente e mais de 700 organizações realizam a palhaçoterapia nessas instituições no Brasil e em outras ao redor do mundo. Dada a ênfase na integralidade do cuidado e humanização da assistência à saúde, torna-se oportuno compreender e analisar a produção nacional e internacional do conhecimento científico sobre esta prática que desafia o modelo hegemônico de cuidado e potencialmente contribui na recuperação da saúde. Foi realizada uma revisão de literatura utilizando análise de conteúdo temática que analisou 18 publicações. As categorias que emergiram foram: respostas fisiológicas, comportamentais e emocionais; ansiedade pré-operatória; e ressignificação das práticas e do ambiente hospitalar. A literatura analisada aponta que a palhaçoterapia provoca diminuição significativa da ansiedade pré-operatória em crianças, comparativamente maior do que a obtida com o uso de um fármaco indutor de anestesia. A maior parte dos estudos investigou o uso da palhaçoterapia na adaptação à hospitalização, auxiliando na atribuição de novos significados. Apesar da baixa representatividade do tema no campo científico e mesmo não sendo amplamente aceita como prática de saúde, os resultados encontrados sugerem benefícios na utilização da palhaçoterapia em ambiente hospitalar.

Feeling happy and carefree: a qualitative study on the experiences of parents, medical clowns and healthcare professionals with medical clowns

Purpose: To explore the effect of medical clowns and its relevant actors and conditions.

Method: Semi-structured interviews were conducted with fourteen parents who had experiences with medical clowns in the Netherlands. Four focus groups were held with seven medical clowns and 25 healthcare professionals. The interviews and focus groups were audio-recorded and transcribed verbatim. Content analysis was used to analyse the data.

Results: Concerning the clown effect, we distinguished the following themes: happiness, distraction, carefree feeling and activation. This effect depended upon clown characteristics (appearance, tailoring, low-key play, making an effort); child characteristics (age, autonomy, fear, living cut off from society, communication); parent characteristics (autonomy, attitude); healthcare professional characteristics (attitude, communication); and organizational conditions (timing and planning, collaboration, accessibility, awareness).

Conclusion: This study shows that medical clowns are of value for children with serious illnesses or mental disabilities in several care settings. An asset of medical clowns is that they tailor their play to the child and situation.Support of and communication with parents and healthcare professionals is critical. The proposed model of the clown effect can help shape future research. The results can help medical clown organizations to enhance their services and optimize clown encounters.

Laughing away the pain: A narrative review of humour, sense of humour and pain

BACKGROUND AND OBJECTIVE

The link between humour and sense of humour with pain has been a topic of research for decades. The purpose of the present article was to review the different studies that have been conducted to date on the association between humour and sense of humour with pain.

DATABASES AND DATA TREATMENT

The literature search was conducted using the PubMed, Science Direct and ProQuest databases. Forty-one studies were reviewed, and the results are summarized and structured into three sections: experimental pain, chronic pain and pain in children.

RESULTS

For experimental pain, the findings support the idea that humorous distractions, such as watching a comedy clip, increase pain tolerance, although most of the studies indicate that other non-humorous distractions produce similar effects. Regarding chronic pain, humour has been studied as a way of coping with pain and the emotional distress produced by chronic pain conditions. The results of correlational studies show significant associations between the use of humour and main variables such as anxiety and catastrophizing. Finally, concerning pain in children, similar findings to those described for the previous sections have been reported, with a notable presence of studies on clinic clown interventions, which promote emotional well-being among children and their parents, although their effectiveness in pain reduction is controversial.

CONCLUSIONS

The study of the link between humour and pain is still on an early stage, and overcoming the limitations of previous studies is required to strengthen the promising results that have been observed up to date.

SIGNIFICANCE

This review summarizes all main findings regarding humour, sense of humour and pain up until the first half of 2018 and offers a list of aspects to be considered in further studies regarding the link of humour and pain to contribute to a more systematic research.

Is there a role for clowns in paediatric intensive care units?

Hospital clowning is a programme in healthcare facilities involving visits from specially trained actors. In the paediatric intensive care unit (PICU), clowning may appear inappropriate and less intuitive. The patient could appear too ill and/or sedated, the environment too crowded or chaotic and the parents too stressed. Relying on our experience with professionally trained clowns both in France and Canada, the purpose of this article is to offer a model for hospital clowning and to suggest standards of practice for the implementation of clowning in PICUs. In this work, we provide a framework for the implementation of clown care in the PICU, to overcome the challenges related to the complex technical environment, the patient's critical illness and the high parental stress levels. Regardless of the specifics of the PICU, our experience suggests that professional clown activity is feasible, safe and can offer multiple benefits to the child, his/her parents and to hospital personnel. Due to the specific challenges in the PICU, clowns must be educated and prepared to work in this highly specialised environment. We stress that prior to clowning in a PICU, professional performers must be highly trained, experienced, abide by a code of ethics and be fully accepted by the treating healthcare team.

Parental perceptions of clown care in paediatric intensive care units

AIM

The objective of this study was to report family satisfaction with regards to the presence of clowns in the paediatric intensive care unit (PICU).

METHODS

This is a single-centre survey-based study, conducted over 4 months in a 12-bed third level PICU in a university hospital. All parents present at the bedside of their child during clowning were considered as potential participants. Eligible parents were approached by one of the two intensivists as investigators and asked to complete a survey within the 48 h following the clowns' intervention.

RESULTS

Thirty-three parents consented to complete the survey. Median age of children was 14 months (15 days to 16 years) and median Pediatric Logistic Organ Dysfunction (PELOD) score was 1 (0-22). Twenty-four (72.7%) were considered as clinically stable while the clowns intervened. Twenty-eight parents (84.8%) and 27 (81.8%) considered that clowns had a positive effect on themselves and on their child, respectively. Clown care was considered as necessary in 19 cases (57.6%), optional in 13 (39.4%) and unnecessary in 1 (3.0%). The degree of parental satisfaction was not significantly associated with the child's clinical stability.

CONCLUSION

We suggested that medical clowning in the PICU is well accepted by parents, regardless of severity of their child's condition. This study supports the adoption of medical clowning in PICUs as a patient- and family-centred care practice.

Hospital clowning: a paediatrician's view

This study investigates the current position of hospital clowns from the perspective of paediatricians and paediatric residents. A total of 14 attending paediatricians and paediatric residents participated in two focus group sessions. Data were analysed using Atlas.ti 5.0. In general, physicians reported positive experiences regarding the interaction between hospital clowns and paediatric patients on the ward. Physicians were more interested in research on children's perception of hospital clowns than in research on the clinical efficacy of hospital clowning. No direct collaboration between physicians and hospital clowns was reported. However, physicians proposed conditions which may streamline their encounters with hospital clowns such as clear communication prior to hospital clown visits, and the condition that visits do not impede medical interventions.

CONCLUSION

Overall, paediatricians and paediatric residents view the positive impact on paediatric patients as the most important aspect of hospital clown visits, rather than the clinical efficacy of hospital clowning. In light of the growing number of hospital clowns worldwide, this article provides recommendations for arranging their encounters with paediatricians and paediatric residents to maintain optimal health care. What is known: • Previous studies show a clinically significant pain- and anxiety-reducing effect of hospital clowning in paediatric patients admitted to hospitals or undergoing (invasive) medical procedures. • In general, paediatricians have positive ideas about hospital clowns, aside from personal prejudices. What is new: • This novel study gives deeper insight into day-to-day interaction between paediatricians and hospital clowns on the ward. • This study provides recommendations for clinical practice to arrange encounters between physicians and hospital clowns during hospital clown visits.

Clowning in Health Care Settings: The Point of View of Adults

Within the past decade, there has been a surge of interest in investigating the effects of clown intervention in a large variety of clinical settings. Many studies have focused on the effects of clown intervention on children. However, few studies have investigated clowning effects on adults. This paper presents an overview of the concept of medical clowning followed by a literature review conducted on the empirical studies drawn from three data bases (PubMed, PsycINFO, and Google Scholar), with the aim of mapping and discussing the evidence of clowning effects on non-children, namely adults. The following areas were investigated: Adult and elderly patients (mainly those with dementia), observers of clowning, namely non-hospitalized adults who are at the hospital as relatives of patients or health-care staff, and finally clowns themselves. The main results are that 1) clown intervention induces positive emotions, thereby enhancing the patient's well-being, reduces psychological symptoms and emotional reactivity, and prompts a decrease in negative emotions, such as anxiety and stress; 2) clown doctors are also well-perceived by relatives and healthcare staff and their presence appears to be useful in creating a lighter atmosphere in the health setting; 3) few pilot studies have been conducted on clown doctors and this lacuna represents a subject for future research.

A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children's anxiety and pain levels in emergency department

The aim of the study is to investigate if the presence of medical clowns during painful procedures in the emergency department (ED) affects children's anxiety and pain. Forty children (4-11 years) admitted to the ED with the need of painful procedures were prospectively enrolled. They were randomly assigned to the clown group, where children interacted with clowns or to the control group in which they were entertained by parents and ED nurses. The children's anxiety was assessed by the Children's Anxiety and Pain Scales; pain was evaluated with the Numerical Rating Scale and Wong-Backer Scale, according to the children's age. Staff and clown's opinions were evaluated by means of dedicated questionnaires. Children's anxiety levels in the clown group were significantly lower than those compared with the control group, while children's pain levels did not change between the two groups.

CONCLUSION

The presence of clowns in the ED before and during painful procedures was effective in reducing children's anxiety.

WHAT IS KNOWN

• Anxiety and fear caused by medical procedures exacerbate children's pain and may interfere with the procedure. • To reduce anxiety, fear, and pain and to facilitate patient's evaluation, different non-pharmacological approaches have been proposed and positive effects of laughter and humor have been reported. What is New: • The presence of clowns in the waiting room and in the ED during medical evaluation and painful procedures helps to reduce children's anxiety.

Palhaços: uma revisão acerca do uso dessa máscara no ambiente hospitalarPayasos: una revisiónsobre el uso de esa máscara en el ambiente hospitalario

Grupos de artistas profissionais ou voluntários têm-se formado com o intuito de visitar, como palhaços, pacientes em hospitais ao redor do mundo, fazendo uso do humor como ferramenta a favor do cuidado e do processo de recuperação. Há poucos estudos relacionados ao tema na literatura científica. Assim, a construção de um campo teórico capaz de subsidiar essas atuações ainda é incipiente. Realizamos, portanto, uma revisão bibliográfica, a partir de 33 artigos, sobre a atuação de diferentes grupos de palhaços em vários hospitais do mundo, a fim de compreender melhor como se dão estas visitas e de que modo podem efetivamente trazer resultados positivos. Foi observado que estes encontros podem estabelecer relações profundas capazes de ressignificar o ambiente hospitalar, empoderar os pacientes e servir como modelo de relação para toda a equipe de saúde envolvida.

[Clowns in the pediatric intensive care unit in France]

INTRODUCTION

In recent years, in children's hospitals, clowns are involved in pediatric intensive care units (PICUs), at the bedside of the most severely ill children. This study is the first that addresses the work of professional clowns in the PICU. Its aim is to describe this practice in French hospitals.

METHODS

This study is a descriptive and prospective study conducted in December 2013 involving all the pediatric PICUs in French hospitals. A survey was emailed to all the PICU department heads in France.

RESULTS

Questionnaires were sent to 32 PICUs (21 pediatric and neonatal intensive care units and 11 pediatric intensive care units). The response rate was 81.2% (26 questionnaires completed). Among the 26 units that responded to the survey, clowns intervened in 13 of them (50%). Eight had an exclusive pediatric activity and five had both pediatric and neonatal activities. The clown visit was twice a week in six units and once in seven (missing data: one unit). The head doctor was satisfied or very satisfied in 92.3% of the cases (n=12/13). Medical clowns were trained and professional artists in all of the units. They worked in duo in most units (n=12/13) and solo in one unit. The clown rounds were preceded by a meeting with a healthcare worker in 12 of the 13 PICUs in which the clowns worked. They dialogued with a doctor in four and a nurse (or head nurse) in eight.

DISCUSSION

Prior to implementation, the clowns' work should be understood, accepted, and supported by each PICU team, to be validated in the overall care plan for each child.

CONCLUSION

Despite the severity of the situations met in the PICU, the instability of patients and the technical environment, clowning in PICUs appears to be a common and worthwhile practice in most French pediatric hospitals.