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

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.

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.

Constructed and disseminated behaviors of the hospital clown

To investigate the clown ideologies that circulate in a hospital scenario, in this paper, we describe the origins of hospital clowns, evaluate their professional training, and discuss their contemporary role. For this descriptive, historical documentary, and qualitative study, we carried out searches in academic databases such as PubMed and LILACS in April 2021. The insufficiency of these results motivated our consultation of book collections and a documentary analysis of other sources related to clowns. Given their function of conveying lightness, humor, and comedy, we observe that hospital clowns, despite lacking a curative function, complement the treatment of patients and therefore require training in the fields of art and biosafety. Based on our bibliographic research, we also conclude that there is a great need for the training and continual education of hospital clowns who perform in a Brazilian context.

Effects of clown activities on patients eligible for palliative care in primary health care

OBJECTIVE

Evaluate the effects of clown activities on quality of life, depression, stress, anxiety, aid, and social support in patients eligible for palliative care (PC) attended in Primary Health Care (PHC).

METHOD

A quasi-experimental study, with pre-intervention and post-intervention evaluation, carried out with 16 patients eligible for early PC in PHC in a Midwestern city. Patients received 24 visits with home-based clown activities.

RESULTS

The interventions evidenced improved quality of life and social support, with significant results for the Social Activities dimension (p = 0.023). Increased scores for Anxiety (p = 0.007) and Depression (p = 0.023) were also observed.

CONCLUSION

Clown activities can bring positive results for the quality of life and social support of patients eligible for PC at home. They should be encouraged to interact with family knowledge and enhance humanized care, integral and centered on human relationships in PHC.

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.

Coronavirus Disease Stress Among Italian Healthcare Workers: The Role of Coping Humor

The study aimed to understand how coping strategies in general and humor-based coping strategies in particular modulate the perception of pandemic-related stress in a sample of Italian healthcare workers during the coronavirus disease (COVID-19) outbreak in Italy. A total of 625 healthcare workers anonymously and voluntarily completed a 10-min questionnaire, which included psychometrically valid measurements preceded by a set of questions aimed at determining workers' exposure to COVID-19. The Perceived Stress Scale was used to measure healthcare workers' stress levels, and the Brief COPE Scale and Coping Humor Scale were used to assess participants' avoidant or approach coping style and verify the degree to which they relied on humor to cope with stress. The results show that (1) levels of perceived stress were higher in healthcare workers who were more exposed to COVID-19 (i.e., who came into contact with COVID-19 patients or worked in wards dedicated to COVID-19) in comparison to less-exposed workers; (2) participants who reported a higher use of avoidant coping strategies perceived the situation as more stressful than those who used them less; and (3) healthcare workers who reported higher use of humor-based coping strategies perceived the situation as less stressful in comparison with those who reported less use of coping humor. Such findings expanded other research studies by including coping humor as a potential factor to mitigate the perceived stress related to COVID-19. The paper concludes with a discussion of implications for future research and limitations of the study.

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.

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.

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.

The practice of the art of clowning by a person with aphasia: a case report

ABSTRACT This study addresses the effects of the art of clowning on the quality of life and wellbeing of a woman presented with aphasia and depression. She was discharged from individual Speech-Language Therapy due to improved language skills, but she continued expressing emotional complaints associated with communicative situations. The participant joined Palhafasia, a community project that welcomes aphasics for group clowning sessions. She participated for six months in once-a-week meetings that lasted three hours each. The comparison of pre- and post-intervention measures detected improvements in her quality of life, including communication and subjective well-being of the participant. This innovative case study provides a preliminary contribution that must be further investigated. The study points to the potential benefits of the practice of clowning to promote quality of life and well-being of people with aphasia who suffer from depression.

Robot Assistants for Perimetry: A Study of Patient Experience and Performance

Purpose

People enjoy supervision during visual field assessment, although resource demands often make this difficult. We evaluated outcomes and subjective experience of methods of receiving feedback during perimetry, with specific goals to compare a humanoid robot to a computerized voice in participants with minimal prior perimetric experience. Human feedback and no feedback also were compared.

Methods

Twenty-two younger (aged 21-31 years) and 18 older (aged 52-76 years) adults participated. Visual field tests were conducted using an Octopus 900, controlled with the Open Perimetry Interface. Participants underwent four tests with the following feedback conditions: (1) human, (2) humanoid robot, (3) computer speaker, and (4) no feedback, in random order. Feedback rules for the speaker and robot were identical, with the difference being a social interaction with the robot before the test. Quantitative perimetric performance compared mean sensitivity (dB), fixation losses, and false-positives. Subjective experience was collected via survey.

Results

There was no significant effect of feedback type on the quantitative measures. For younger adults, the human and robot were preferred to the computer speaker (P < 0.01). For older adults, the experience rating was similar for the speaker and robot. No feedback was the least preferred option of 77% younger and 50% older adults.

Conclusions

During perimetry, a social robot was preferred to a computer speaker providing the same feedback, despite the robot not being visible during the test. Making visual field testing more enjoyable for patients and operators may improve compliance and attitude to perimetry, leading to improved clinical outcomes.

Translational Relevance

Our data suggest that humanoid robots can replace some aspects of human interaction during perimetry and are preferable to receiving no human feedback.