Clowning as a Complementary Approach for Reducing Iatrogenic Effects in Pediatrics

Medical clowning in hospitals: practices, training and perception

Previous studies on medical clowning focused on patients, while research remains inadequate concerning clowning itself: training programmes and prerequisite requirements, clowning methods, deontology and accepted practices. Diverse approaches and paradigms in this field of complementary medicine are promoted by non-profit organisations worldwide. Based on an ethnographic study, we explore the current forms of medical clowning in 5 Israeli hospitals. The observed clowns are from the two Israeli organisations, Dream Doctors and Simchat Halev (in Hebrew: joy of the heart), consisting of paid professional medical clowns and volunteers, respectively. According to the findings, significant differences were observed to exist between the organisations. Dream Doctors is conceived and pursued as an expertise practised by performance art professionals, requiring extensive training. These clowns work unaccompanied, receive a salary, are considered members of the medical team, and, given their privileged status, have access to hospitals' open and closed areas. The Dream Doctors consider medical clowning as a paramedical practice, in which interventions are individually suited to the circumstances of each patient, and obtain therapeutic results. In contrast, Simchat Halev's medical clowns are volunteers with no prerequisite artistic background and undergo shorter periods of training. The access granted to these clowns, usually working in pairs, is restricted to open areas. Simchat Halev promotes medical clowning as a volunteer-based public practice, offering general entertainment to all patients indiscriminately, and their contribution is characterised as achieving basic entertainment value.

The Effects of Hospital-Based School Lessons on Children's Emotions, Distress and Pain

Lessons conducted in hospitals ensure school continuity for hospitalized children unable to attend regular school. Hospital-based school (HS) provides a tailored experience that ensures normality for children through education. The objective of this study is to evaluate the effects of the proposed lessons in reducing negative emotions, distress, and pain in children, as well as fostering positive affects. The study was conducted with 32 hospitalized children, aged 8-12 years, in the Onco-Hematology and Pediatric Unit of Meyer Children's Hospital IRCCS (Florence, Italy). Positive and negative emotions were measured using the Positive and Negative Affect Scale for Children; distress was measured using the Physiological Hyperarousal for Children; pain was measured using the Visual Analogue Scale for children. Variables were assessed before (T0) and after (T1) lessons, for three times; for each variable, collected data were averaged at both T0 and T1. Statistical analyses showed a significant increase in positive emotions in hospitalized children and a significant decrease in negative emotions, distress, and pain; nevertheless, only for pain the significant correlation between its scores before and after the HS lessons indicated that the detected change occurred for all participants in much the same way. These preliminary results suggest that HS lessons can promote hospitalized children's well-being, at least as far as pain reduction is concerned.

Amateur dubbing as a healthcare activity in the pediatric hospital setting: a pilot project

BACKGROUND

Dubbing is a mode of audiovisual translation (AVT) usually performed by experienced dubbing actors for professional purposes. Nowadays, thanks to advances in technology, everybody can create personal dubbed versions of audiovisual content for humorous and parodic as well as therapeutic and pedagogical purposes. The aim of this pilot project was to investigate the potential and applicability of amateur dubbing within the hospital setting, targeting children and adolescents.

METHODS

The project was carried out at Meyer Children's Hospital in Florence (Italy). Like other non-pharmacological activities, amateur dubbing was designed to make hospitalization a less traumatic experience for young patients and promote their general well-being. A research team (including psychologists, dubbing actors and a linguist) developed a theoretically sound and replicable set of procedures that combine new technologies with traditional pain management methods.

RESULTS

The amateur dubbing workshops, carried out from January 2017 until the end of December 2019, involved 297 children and adolescents (male=29.8%; female=70.2%), aged 6-17, from different wards (i.e. Oncology, Neuropsychiatry, Pediatric Unit, Diabetology, Neurology, Surgery, etc.). This pilot project has proven to be a positive experience for all the patients and their families, in terms of the children's well-being, quality of life and socialization (i.e. expression of emotions, distraction and reduction of distress).

CONCLUSIONS

Amateur dubbing as a healthcare activity has resulted in interesting recreational and psychological implications and benefits. Clearly, its implementation as a type of non-pharmacological technique needs to be further refined.

Medical clowning in hospitalized children: a meta-analysis

BACKGROUND

Medical clowning has been proven effective in reducing pain, anxiety, and stress in many sporadic, usually small-scale studies. Our meta-analysis aims to evaluate the efficiency of medical clowns in reducing pain and anxiety in hospitalized pediatric patients and their parents in different medical fields.

METHODS

A thorough literature search was conducted from different databases, and only randomized controlled trials (RCTs) were included with children aged 0 to 18 years old. A total of 18 studies were included, and statistical analysis was performed on the combined data.

RESULTS

A total of 912 children (14 studies) showed significantly reduced anxiety when procedures were performed with a medical clown compared with the controls (- 0.76 on anxiety score, P < 0.001). Preoperative anxiety was lower in 512 children (nine studies) with clown interventions than in the controls (- 0.78, P < 0.001). The pain scale was completed by 338 participants (six studies), indicating a trend toward reduced pain during procedures performed while the clown was acting compared to controls (- 0.49, P = 0.06). In addition, medical clown significantly (- 0.52, P = 0.001) reduced parental anxiety in 489 participants in ten studies; in six of the ten studies, with a total of 380 participants, medical clown significantly reduced parental preoperative anxiety (P = 0.02).

CONCLUSION

Medical clowns have substantial positive and beneficial effects on reducing stress and anxiety in children and their families in various circumstances in pediatrics.

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.

A feasibility study of the use of medical clowns as hand-hygiene promoters in hospitals

Healthcare-acquired infections (HAI) pose vast health and economic burdens. Proper hand-hygiene is effective for reducing healthcare-acquired infections (HAI) incidence, yet staff compliance is generally low. This study assessed the feasibility, acceptability and preliminary effect of employing medical clowns to enhance hand-hygiene among physicians and nurses. Staff perception of the intervention and its impact on hand-hygiene was assessed via self-report questionnaires. Nearly 1,500 hand-hygiene compliance observations were conducted in accordance with WHO guidelines before, during and after the intervention. In each of three hospitals in Israel, two departments were selected-one in which medical clowns routinely operate and one clown-naive department. Professional medical clowns acted as hand-hygiene promoters employing humorous tactics to encourage hand-sanitizing based on the WHO "5 Moments" model. The clown appeared in each department seven times during the 2-week intervention phase. Pre-intervention hand-hygiene compliance ranged from just over 50% to 80% across hospitals and departments. Overall, about 70% of nurses (N = 132) and 80% of physicians (N = 49) felt the intervention improved personal and departmental hand-hygiene, with large inter-department variation. Pre- to post-intervention hand-hygiene compliance increased by 4% -25% (3.5-14.8 percentage points) in four departments, three of which had low baseline compliance levels. Results of this feasibility study suggest that employing medical clowns as hand-hygiene promoters as a novel approach toward HAI prevention is feasible and welcome by hospital staff.

Clown therapy for procedural pain in children: a systematic review and meta-analysis

Among the distraction techniques used for the non-pharmacological management of acute pediatric pain, one of the most performed is clown therapy. Despite the presence in the literature of some systematic reviews that evaluate its effectiveness, none of them examines its outcomes on procedural pain which has therefore been investigated in this study. The literature search for randomized controlled trials (RCTs) was performed on the Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus over a time frame ranging from each database setup date to 31 July 2021. The primary outcome was the procedural pain of children. We used the Cochrane Risk of Bias tool to assess the risk of bias of the included studies. Six RCTs were selected for this review, which included a total of 517 pediatric subjects. Children undergoing clown therapy during the venipuncture or peripheral vein cannulation procedure reported less pain than those exposed to the standard of care (SMD =  -0.55; 95% CI: -1.23, 0.13) but the result was not found to be statistically significant. School-aged children and adolescent reported significantly less pain (SMD =  -0.51; 95% CI: -0.92, -0.09). Compared to the standard of care, children's anxiety was significantly lower with clown therapy (SMD =  -0.97; 95% CI: -1.38, -0.56).

CONCLUSION

Clown therapy seems effective in reducing procedural pain in children, particularly for older age groups, but due to poor methodological quality and the high risk of bias of the studies included, the results obtained should be considered with caution.

WHAT IS KNOWN

• Clown therapy is one of the most used techniques in the non-pharmacological management of acute pediatric pain. • Laughter physiologically stimulates the production of beta-endorphins, substances with an effect similar to opiates.

WHAT IS NEW

• Clown therapy seems effective in reducing procedural pain and anxiety in children. • The intervention in school-age children or adolescents produces a statistically significant decrease in the symptom.

Effectiveness of clown intervention for pain relief in children: A systematic review and meta-analysis

BACKGROUND

Pain is common in children receiving medical procedures, and there is a lack of adequate awareness and management. In addition, children who undergo medical procedures involving pain may also experience stress, crying and prolonged hospitalisation. Clown intervention is a promising nonpharmacological intervention. However, studies on the effectiveness of clown intervention in pain management have reported conflicting findings.

OBJECTIVE

To evaluate the effectiveness of clown intervention in relieving pain in children, as well as its effects on cortisol levels, crying duration and length of hospital stay.

DESIGN

Systematic review and meta-analysis of randomised controlled studies.

DATA SOURCES

PubMed, Web of Science (SCI), Embase, PsycINFO, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Weipu (VIP), Wanfang Data and SinoMed were systematically searched from inception date to December 31, 2020.

REVIEW METHODS

Two reviewers independently used the Cochrane risk of bias tool to assess the risk of bias of the included studies. Meta-analysis was conducted when data were available, otherwise, a narrative description was provided. Data were analysed using Review Manager 5.3. The review process is reported according to PRISMA.

RESULTS

Nine studies including 852 children met the inclusion criteria. The results showed that compared with standard care, clown intervention was beneficial for relieving pain. Further subgroup analysis showed that it was more effective with children aged 2-7 years. The duration of crying after the procedure and the length of stay were shortened, but there was no significant difference in cortisol levels.

CONCLUSION

Clown intervention may be a promising way to relieve acute pain in children, especially those aged 2-7 years. It also seems to shorten the duration of crying and the length of hospital stays, but the effect on cortisol levels is still uncertain. More high-quality randomised controlled trials are needed to confirm these results and take into account different age groups, cultural backgrounds and specific populations.

Effects of therapeutic clowning on pain and anxiety during venous blood sampling in Turkey: Randomised controlled trial

PURPOSE

The research aim was to investigate the effects of therapeutic clowning on pain and fear during the process of venous blood sampling in children.

DESIGN AND METHODS

This study was conducted in a randomised controlled trial from January to March 2020. The study population consisted of children from 7 to 12 years of age who came to the research centre for blood sampling. The research sample consisted of 166 children (83 in the intervention group and 83 in the control group) who met the research criteria and came to the research centre on a specific date through probable sampling. For the data collection, a questionnaire form, the Visual Analogue Scale and the Children's Fear Scale were used. Therapeutic clowning was used in this process for the intervention group. There was no intervention for children who were in the control group. The calculation of percentage distribution and means, χ² test, analysis of variance analysis in repeated measures and least significant difference and independent t-test were used to analyse the data.

RESULTS

The results of the research indicated that children in the intervention group had significantly lower pain and fear than children in the control group (p < .001). Therapeutic clowning seems to effectively reduce pain and fear during venous blood sampling for children from 7 to 12 years of age. Our results support using therapeutic clowns which is an inexpensive, safe, and effective method for lowering children's pain and fear during venous blood sampling.

PRACTICE IMPLICATIONS

The use of therapeutic clowns could become the standard of care in blood sampling for children from 7 to 12 years of age in hospitals. Therapeutic clowning, which is an easy-to-use, low-cost and practical method to provide better communication and cooperation with the family and the child, can be used as a complementary therapy in all nursing areas, especially in the field of paediatrics. Nurses could be encouraged to be trained on the use of therapeutic humour based upon a standardised approach and offered guidance on how to apply entertaining methods such as clowns. Therapeutic clowning can be examined in other applications in nursing care in light of these results.

Exploring the usefulness of medical clowns in elevating satisfaction and reducing aggressive tendencies in pediatric and adult hospital wards

BACKGROUND

Most existing research on medical clowns in health care services has investigated their usefulness mainly among child health consumers. In this research we examined multiple viewpoints of medical staff, clowns, and health consumers aiming to identify the optimal audience (adult or child health consumers) for which medical clowns are most useful. We focused on exploring their usefulness in enhancing health consumers' satisfaction and, in turn, reducing their aggressive tendencies.

METHODS

We conducted three studies that examined the placement fit of medical clowns from different points of view: medical staff (Study 1, n = 88), medical clowns (Study 2, n = 20), and health consumers (Study 3, n = 397). The main analyses in Studies 1 and 2 included frequencies and t-tests comparing perceived adult and child satisfaction with clowns' performance. Study 3 used moderated-mediation PROCESS bootstrapping regression analysis to test the indirect effect of negative affectivity on aggressive tendencies via satisfaction. Exposure to the medical clown moderated this relationship differently for different ages.

RESULTS

Studies 1 and 2 show that the majority of medical clowns and medical staff report that the current placement of the medical clowns is in pediatric wards; about half (44% of medical staff, 54% of medical clowns) thought that this placement policy should change. In Study 3, data from health consumers in seven different hospital wards showed that clowns are useful in mitigating the effect of negative affectivity on satisfaction, thereby reducing aggressive tendencies among health consumers under the age of 21.6 years. Surprisingly, medical clowns had the opposite effect on most adults: for health consumers who were exposed to the medical clown and were above the age of 21.6 negative affectivity was related to decreased satisfaction, and an increase in aggressive tendencies was observed.

DISCUSSION

Medical clowns are most useful in elevating satisfaction and reducing aggressive tendencies of children. Older adults, on the other hand, exhibit lower satisfaction and higher aggressive tendencies following exposure to the performance of medical clowns.

CONCLUSION

Medical clowns should be placed primarily in children's wards.