The Therapy Beneath the Fun: Medical Clowning During Invasive Examinations on Children

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.

Improving the Scope of Child Mental Health Interventions in Our Modern World

Twenty years ago, an important systematic review showed that the empirical research evidence for interventions available for children and young people with mental health problems were rarely developed with their specific developmental needs in mind [...].

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.

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.

Butterflies, Dwarves, and Plastic Lollypops: A Case Report on Medical Clowning in a Children's Rehabilitation Hospital

Medical clowning has been evolving in the past three decades and now plays a significant role in the rehabilitation processes of children who have suffered injuries and undergone complex medical procedures. The current paper focuses on this topic by presenting a case study of a young girl who lost most of her functional abilities due to brain damage. During the child's physiotherapy sessions at the rehabilitation hospital, a medical clown was brought in to work together with the physiotherapist in providing the treatment. The case study brings an in-depth perspective on the therapeutic process, as it is based on documentation of the sessions while addressing key stages in the child's rehabilitation, alongside core concepts in drama therapy. The qualitative analysis shows how the playful space in the rehabilitation process enhanced the child's inner motivation, provided a space for role expansion, and promoted the connection between the child and the environment. This paper demonstrates how the involvement of medical clowns can promote the rehabilitation processes of children who have suffered traumatic injuries and help them cope with functional losses.

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.

Medical clown support is associated with better quality of life of children with food allergy starting oral immunotherapy

BACKGROUND

The start of oral immunotherapy (OIT) for food allergy is a critical period in the treatment process, with a potential to influence patient quality of life (QOL) and subsequently treatment outcome. The association of medical clowning with QOL at OIT initiation was examined.

METHODS

Children aged 4-12 years supported by a medical clown (MC) during the induction week of OIT for food allergy were studied. Children in the same age range starting OIT without the support of a MC served as controls. Parents of all children completed the Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF), and children aged 8-12 years completed the Food Allergy Quality of Life Questionnaire-Child Form (FAQLQ-CF). QOL scores of parents and children with and without a MC support were compared.

RESULTS

Children with (n = 88) and without (n = 212) the support of a MC were comparable in demographics and clinical characteristics. The study group had a significantly lower single highest tolerated dose compared to controls (57 ± 83 vs 162 ± 274 mg protein, respectively, P < .001). Parental perception of the QOL of children was not associated with a MC support (P = .81) but rather with previous reaction severity (P < .01). In contrast, the QOL of children aged 8-12 years (n = 119) was positively associated primarily with a MC support, total score 3.7 ± 1.1 vs 4.6 ± 1.3 (P < .001).

CONCLUSIONS

While the perception of QOL of parents of children with food allergy at OIT initiation is mainly associated with previous reaction severity, the QOL of the children themselves is primarily positively associated with MC support.

A review of the literature on good practice considerations for initial health system response to child and adolescent sexual abuse

BACKGROUND

Healthcare workers play an important role in responding to the needs of the millions of children and adolescents who experience sexual abuse around the globe. A supportive child and adolescent-centered initial response is crucial for the physical and emotional wellbeing of survivors.

OBJECTIVE

In 2017, the World Health Organization (WHO) published clinical guidelines for responding to child and adolescent sexual abuse. The review described in this paper informed the development of good practice statements on how best to deliver health care to survivors.

PARTICIPANTS AND SETTING

This review examined the values and preferences of children and adolescents who were sexually abused, and of their caregivers and healthcare workers, regarding: 1) initial response to children and adolescents who have been sexually abused; and 2) obtaining medical history, conducting physical examination, and documenting examination findings.

METHODS

Searches were conducted in Scopus, Pubmed, and the WHO's Global Index Medicus (1 January, 1995-15 July 2016). All articles in English that indicated preferences of survivors, caregivers and/or healthcare workers in ensuring empathetic and trauma-informed care were included.

RESULTS

Sixty-two articles were included and analyzed thematically. Key findings included the importance of providing care to survivors in a manner that respects the child or adolescent's autonomy and wishes, ensures privacy and confidentiality, and makes services and facilities appropriate and welcoming.

CONCLUSIONS

Findings indicate how evidence-based recommendations can be delivered in a child or adolescent-centred and trauma-informed manner.

Effects of Therapeutic Clowning on Pain and Anxiety During Intrathecal Chemotherapy in Turkey

PURPOSE

The aim of the present study was to explore the effect of therapeutic clowning on pain and anxiety during intrathecal chemotherapy.

DESIGN & METHODS

The study was conducted using a quasi-experimental method with a pretest-posttest control group design. The study sample was composed of children between 7 and 12 years old (N = 78) who had been diagnosed with acute myeloid leukaemia and acute lymphoblastic leukaemia and were undergoing intrathecal chemotherapy in a hospital in Turkey. The study was conducted with children who received services at this hospital. The results were obtained from 74 children (i.e. 36 in the control group, 38 in the clown group). The data were collected with a questionnaire developed by the researchers, the Visual Analogue Scale (VAS) and the Faces Pain Rating Scale (FACES). VAS and FACES were used to measure pain and anxiety levels. Therapeutic clowning was applied to children in the intervention group. Analyses included percentage distributions, mean, chi-square, t-test, variance, and correlation analysis.

RESULTS

Results showed that children in the clown group had significantly lower pain and anxiety than children in the control group (p < .001).

CONCLUSIONS

According to the results, therapeutic clowning was effective in relieving the pain and anxiety of children between the ages of 7 and 12 years who undergone intrathecal chemotherapy.

PRACTICE IMPLICATIONS

Due to its positive effects, therapeutic clowning could be explore for use in other areas of paediatric nursing for the children between the ages of 7 and 12 years as a complementary treatment.

Measuring patient experiences in a Children's hospital with a medical clowning intervention: a case-control study

BACKGROUND

Because the healthcare sector is shifting to a customer-oriented approach, it is important to understand experiences of children as users of healthcare services. So far, studies that measure the influence of medical clowning on patient experiences are scarce. This study aims to measure experiences of children and their parents during day-surgery in hospital setting.

METHODS

A case-control study was conducted in a large Finnish children's hospital. Seventy children aged 4-17 years coming for a minor operative procedure including pre-operative cannula insertion prior to surgery were included. Thirty-eight children were exposed to the medical clowning intervention and 32 children (the reference group) did not receive exposure to medical clowning. A novel digital survey tool was used to measure patient experiences before and after the insertion of a venous cannula needed for anaesthesia. The children were asked about their emotions, anxiety levels, the pain from the cannula insertion and the best and worst things about the hospital. The parents were asked about their emotions, expectations and the fluency of the procedure and the hospital day.

RESULTS

Before the procedure, 32% or 36% of the children in the intervention group and 44% or 28% of those in the reference group expressed positive or neutral emotions, respectively. After the procedure, 76% or 63% of children in the intervention group or reference group, respectively, expressed positive emotions. The intervention group rated the medical clowns as the best aspect of the hospital day. Both groups reported that the best aspects of the hospital day were related to the nurses and food and the worst were related to waiting and pain. Most commonly the parents felt uncertainty, anxiety or calmness before the procedure and relief afterwards. Their expectations towards the procedure related to its success and the certainty of the diagnosis.

CONCLUSIONS

The results show a trend towards more positive emotions in children with exposure to medical clowning. The digital survey tool was suitable for gathering information about the experiences of children and their parents. Information on emotions and expectations of children and parents during a procedure is useful when improving the quality of healthcare services.

TRIAL REGISTRATION

Current Controlled Trials NCT04312217, date of registration 17.03.2020. Retrospectively registered.

An ongoing WE: A focused ethnographic study of the relationship between child and hospital clown during recurrent pain‐related procedures and conditions

Aim

This study explored the interaction between child and hospital clown during recurrent hospitalizations for repeated pain‐related procedures and conditions.

Background

Despite improvements in the management of pain in hospitalized children, procedural pain in particular is a common experience for hospitalized children, and they continue to report undertreated pain. Hospital clowns are widely used as a nonpharmacological intervention in hospitalized children. Little research has examined the influence of hospital clowns during recurrent hospitalizations on repeated painful procedures.

Design and methods

Ethnographic fieldwork using focused ethnography was conducted. Data were collected during October–December 2017 using participant observation and informal interviews with children at one pediatric unit at a Danish university hospital. Data include 61 interactions between children aged 4–14 years and hospital clowns. The participants comprised 13 children undergoing recurrent hospitalizations. The data were coded using thematic analysis, and the research team verified the resulting themes.

Results

The overarching theme was defined as An ongoing WE, based on two identified themes, that is, Stronger in a WE and Hope in the WE. The WE was characterized by a responsive interaction between the child and clown, which evolved over the course of an ongoing relationship.

Conclusion

This study demonstrates how an ongoing WE was constructed with children during repeated painful procedures and conditions. Specifically, the study emphasizes the importance of developing a trusting relationship on the child's terms. Children seemed to experience enhanced coping with painful procedures during the recurring hospital clown encounters, thus reinforcing their competence and hope for coping with future painful procedures. These findings may improve psychosocial care for hospitalized children undergoing repeated painful procedures and conditions and may facilitate multidisciplinary initiatives, such as nurses’ advocacy for the inclusion of hospital clowns during recurrent hospitalizations for repeated painful procedures to ensure optimal pain management.

"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.

Strategies for diversity: medical clowns in dementia care - an ethnographic study

BACKGROUND

As nursing homes become increasingly diverse, dementia care needs a wider range of culturally responsive strategies for individual and collective social interactions. While previous studies conclude that medical clowns have positive effects on verbal and non verbal social interactions, research is lacking from the perspective of residents' cultural background. The aim of this study was to identify interaction strategies employed by medical clowns in culturally diverse dementia care settings.

METHOD

An ethnographic approach was used and data were collected through observation of interactions between medical clowns and residents with dementia in two nursing homes during a ten week period.

RESULTS

The observations showed that the medical clowns interacted with residents by being tuned in and attentive to the residents as individuals with a unique life-history, confirming each person´s sense of self. The clowns used sensory triggers, encouragement and confirmation in culturally responsive ways to bond socially with the residents in their personal spaces. The clowns involved objects in the daily environment that were meaningful for the residents, and paid attention to significant places and habits in the past. The clowns further contributed to joint interaction in the common spaces in the nursing homes, using music and drama.

CONCLUSION

The strategies employed by medical clowns in activities with older people with dementia appear to support social interaction. The medical clowns used the social and material environment in culturally responsive ways to strengthen individuals' sense of self, while contributing to a sense of togetherness and interaction among residents in the common spaces. Findings suggest that both verbal and non-verbal cultural content affected social interaction. The non-demanding encouraging way the clowns tuned in to the residents as individuals could help nurses and staff members improve ways of communication in social activities inside the nursing home.