Hospital clowning: a paediatrician's view

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.

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.

Fear of clowns: An investigation into the aetiology of coulrophobia

Introduction

Fear of clowns or coulrophobia is a little understood phenomenon despite studies indicating that it has a high prevalence in the general population. There have been no previous investigations into the aetiology of this fear, although several plausible hypotheses from the wider literature can be generated; the fear stems from media portrayals of scary clowns, from the unusual physical appearance or the unpredictable behaviour displayed, or it derives from an unpleasant personal experience.

Methods

The current study reviews the literature in this area and also pilots a new questionnaire (Origin of Fear of Clowns Questionnaire; OFCQ) to explore the causes of the fear of clowns in a sample of 528 participants who reported such a fear.

Results

Our findings suggest that uncertainty of harmful intent, media influences and unpredictability of behaviour play an important role in the origins of coulrophobia. There are also multiple features of clown appearance which produce a negative experiential state and a sense of a direct threat.

Discussion

We conclude that the origins of clown fear are multi-factorial and primarily relate to aspects of their facial appearance, their behaviour, and how they have been portrayed in the media. Surprisingly, fear derived from personal experience was not one of our main findings. Further research is focused on looking at associations between the level of fear and each aetiological category.

More Than Just an Entertainment Show: Identification of Medical Clowns' Communication Skills and Therapeutic Goals

Medical clowns (MCs) are trained professionals who aim to change the hospital environment through humor. Previous studies focused on their positive impact and began identifying their various skills in specific situations. When placed in pediatrics, MCs face various challenges, including approaching frustrated adolescents who are unwilling to cooperate with their care, dealing with their anxious parents, and communicating in a team in the presence of other health professionals. Research that systematically describes MCs' skills and therapeutic goals in meeting these challenges is limited. This article describes a qualitative, immersion/crystallization study, triangulating between 26 video-recorded simulations and 12 in-depth-semi-structured interviews with MCs. Through an iterative consensus-building process we identified 40 different skills, not limited to humor and entertainment. Four main therapeutic goals emerged: building a relationship, dealing with emotions, enhancing a sense of control, caring, and encouragement, and motivating treatment adherence. Mapping MCs' skills and goals enhances the understanding of MCs' role and actions to illustrate their unique caring practices. This clarification may help other healthcare professionals to recognize their practices and the benefits in involving them in care. Furthermore, other health professionals may apply some of the identified skills when faced with these challenges themselves.

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.

The beneficial effect of medical clowns on performance of EEG in young children: a randomized controlled study

Electroencephalography (EEG) is an important test in the diagnosis of epilepsy. To perform the test, many electrodes are placed on the child's scalp, a stressful situation that may contribute to uncooperative behavior. The aim of our study was to investigate the effects provided by a close collaboration with medical clowns on the performance of EEG in young children. A prospective randomized control study was conducted between July 2020 and September 2021. The study included children aged 1-5 years who were scheduled to undergo EEG testing at the Bnai Zion Medical Center. The children were randomly allocated to each group (study group with medical clowns and control group without medical clowns) according to the day of the test. The medical clowns, the EEG technician, and the children's caregivers all independently rated the entire process in designated questionnaires composed of items rated on a 5-point Likert scale. In addition, the technical quality of all EEG tests was evaluated and rated by one neurologist (G.J.) in a blinded manner. One hundred children participated in the study. Fifty children underwent the EEG accompanied by one of two medical clowns (study group), and fifty children underwent routine EEG, without medical clowns (control group). The physician-rated technical score of the EEG recording was significantly higher in the study group (p < 0.001). Among parents of the study group, 96% were highly satisfied from the presence of the medical clowns during the EEG (median 5). Both the EEG technician and the parents denoted a significantly higher cooperation rate in the study group children, of 72% and 82%, respectively, compared to the control group. The rating of child/parent's cooperation was not correlated with age, sex, or ethnicity of the child. There was no need for sedation in the study group.

CONCLUSION

Performing EEG in young children in collaboration with medical clowns can increase the quality of the EEG recording possibly due to higher cooperation rates, which in turn lead to mutual satisfaction of both parents and technicians with the procedure.

TRIAL REGISTRATION

NCT05257096.

WHAT IS KNOWN

• Performing EEG in young children may be a stressful experience. • Use of sedation during EEG may cause side effects. To avoid need for sedation various methods are used to overcome the stressful experience: Natural daytime nap, partial sleep deprivation, oral melatonine and reassurance of parents.

WHAT IS NEW

• Performing EEG in young children in collaboration with medical clowns can increase the quality of the EEG recording. • Medical clown intervention led to mutual satisfaction of both parents and technicians with the EEG test procedure.

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 hospital clowns for symptom management in paediatrics: systematic review of randomised and non-randomised controlled trials

OBJECTIVE

To evaluate evidence from randomised controlled trials and non-randomised controlled trials on the effectiveness of hospital clowns for a range of symptom clusters in children and adolescents admitted to hospital with acute and chronic conditions.

DESIGN

Systematic review of randomised and non-randomised controlled trials.

DATA SOURCES

Medline, ISI of Knowledge, Cochrane Central Register of Controlled Trials, Science Direct, Scopus, American Psychological Association PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature.

STUDY SELECTION

Randomised and non-randomised controlled trials were peer reviewed using the following eligibility criteria: children and adolescents who were admitted to hospital for acute conditions or chronic disorders, studies comparing use of hospital clowns with standard care, and studies evaluating the effect of hospital clowns on symptom management of inpatient children and adolescents as a primary outcome.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently screened studies, extracted data, and appraised the risk of bias. Methodological appraisal was assessed by two investigators independently using the Jadad scale, the revised Cochrane risk-of-bias tool for randomised controlled trials (RoB 2), and the risk of bias in non-randomised studies (ROBINS-I) tool for non-randomised controlled trials.

RESULTS

24 studies (n=1612) met the inclusion criteria for data extraction and analysis. Most studies were randomised controlled trials (n=13). Anxiety was the most frequently analysed symptom (n=13), followed by pain (n=9), psychological and emotional responses and perceived wellbeing (n=4), stress (n=4), cancer related fatigue (n=3), and crying (n=2). Five studies used biomarkers, mainly cortisol, to assess stress or fatigue outcome following hospital clowns. Most of the randomised controlled trials (n=11; 85%) were rated as showing some concerns, and two trials were rated with a high risk of bias. Most non-randomised controlled trials (n=6; 55%) were rated with a moderate risk of bias according to ROBINS-I tool. Studies showed that children and adolescents who were in the presence of hospital clowns, either with or without a parent present, reported significantly less anxiety during a range of medical procedures, as well as improved psychological adjustment (P<0.05). Three studies that evaluated chronic conditions showed favourable results for the intervention of hospital clowns with significant reduction in stress, fatigue, pain, and distress (P<0.05).

CONCLUSIONS

These findings suggest that the presence of hospital clowns during medical procedures, induction of anaesthesia in the preoperative room, and as part of routine care for chronic conditions might be a beneficial strategy to manage some symptom clusters. Furthermore, hospital clowns might help improve psychological wellbeing in admitted children and adolescents with acute and chronic disorders, compared with those who received only standard care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018107099.

Saving Costs for Hospitals Through Medical Clowning: A Study of Hospital Staff Perspectives on the Impact of the Medical Clown

This study explores the perspectives of doctors, nurses, and technicians on the medical clown. A total of 35 subjects were interviewed one on one. Interviews were transcribed and analyzed for common themes. Medical staff outlined novel limitations and views of future directions for the field of medical clowning. Most importantly, many previously unpublished benefits of medical clowns were described. These reported benefits included cost-saving measures for the hospital, increases in staff efficiency, better patient outcomes, and lower stress in medical staff. Given that most of the limitations on medical clowning are financial in nature, these findings have substantial implications for the future of the field. As medical clowning continues to grow, this study outlines the potential for various future research projects within this field of study.

Benefits of medical clowning in the treatment of young children with autism spectrum disorder

We investigated the contribution of group therapy delivered by a medical clown to young children diagnosed with autism spectrum disorder (ASD). So far, scientific publications regarding medical clowning focus on general health advantages. The current study is the first controlled research examining the use of medical clowning in the therapy for children with ASD. Twenty-four children aged 2-6 years old with ASD enrolled in our special education intensive program were examined before and after group sessions with clown intervention (CI) and other intervention (OI). We tested stereotypic behaviors, verbal expression, play reciprocity, and social smiles. Data was collected during 12 weeks of intervention, and the trajectory of change was evaluated in addition to the pre-/post-intervention.Conclusion: improvement over time in all measures: Significant increase in word production, play reciprocity, and amount of social smiles during CI as compared with OI. We also found a reduction in frequency of stereotypic behaviors during and following CI as compared with before CI. These preliminary results indicate that medical clowning may be beneficial for young children with ASD, since it promotes communication and social reciprocity in a fun and lively interventional setting. What is Known: • Many therapies are used and proven as efficacious interventions for children with ASD. • So far, medical clowning was not tested as an intervention or therapy for ASD. What is New: • Medical clowning sessions with children with ASD elicited enhanced communication during the interventions as compared with other interventions. • Medical clowning sessions contributed to a decrease in frequency of stereotypic movements over time, in children with ASD.

"WE do it together!" An Ethnographic Study of the Alliance Between Child and Hospital Clown During Venipunctures

PURPOSE

Hospital clowns are widely used as a means of non-pharmacological intervention in the treatment of hospitalized children. However, little research has examined the impact of clowns on common painful needle-related procedures. This study explored children's pain experience and their ability to cope during a venipuncture while interacting with a clown in the acute admission unit.

DESIGN AND METHODS

An ethnographic fieldwork study was conducted. Data were collected over a 10-month period through participant observation and informal interviews, supplemented by video recordings. The participants comprised 38 acutely admitted children aged 4 to 15 years undergoing a venipuncture in the presence of a hospital clown. Analysis was structured in three stages: before venipuncture; during venipuncture; and after venipuncture.

RESULTS

The development of a responsive interaction between child and clown, identified as a WE, was found to be beneficial to the child during venipuncture procedure. The WE was characterized by three themes "How do WE do this together?"; "WE are together"; and "I/WE did it!"

CONCLUSIONS

The study emphasizes the importance of a WE established between child and hospital clown from the first encounter until a final evaluation. This WE was verbalized repeatedly by the clown and the child and was essential in shaping a tailored approach which met the needs of each child. This approach seemed to strengthen the child's competence in pain management and ability to cope, thus building competence for future venipunctures.

PRACTICE IMPLICATIONS

Establishing a WE might advance the psychosocial care of hospitalized children undergoing acute painful procedures.

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.

Disaster zones-should we be clowning around?

Medical clowns have an important role in helping patients cope with their pain and distress. This is especially true in the pediatric population. However, their activity in a disaster area is unheard of. Following the Nepal earthquake in 2015, the Israeli field hospital set up in Kathmandu, Nepal was joined by five volunteer medical clowns. They were active in all parts of the field hospital. Following the hospital's activity, an online questionnaire was sent to the field hospital members to assess the impact of medical clowning on the hospital in general and its members' individual performance. Physicians and nurses found that medical clowning had a positive impact both generally and personally. (65.4 and 78.3% respectively on general impact.) Personnel that were not previously exposed to medical clowning also found them to have a positive impact; however, they were less likely to view it as impacting their personal performance.

CONCLUSION

Medical teams in disaster areas may benefit from the presence of medical clowns. What is known about this topic: • Medical clowns are used for alleviation and distraction in painful and distressful medical procedures and treatments. Its positive effect on patients, and their families are well established.

WHAT THIS STUDY ADDS

• This is the first description of medical clowning in a disaster area. In addition, the impact of medical clowning on the medical staff working in a disaster area is evaluated. No previous studies have explored the impact of medical clowns on the medical staff.