Background
Children and adolescents who are severely physically ill and require hospitalisation represent a special responsibility for the health care system and the people working in it for a number of reasons: In addition to the illness itself, the young patients are also stressed by the separation from their parents, the strange environment, the fear of painful treatments and/or the uncertainty of the treatment outcome e.g. [
1,
2]. Hospital clowns, also known as clown doctors, can help paediatric patients with these stressors and to circumvent the accompanying feelings of fear, helplessness and sadness, thus supporting the healing process. They can be friends in need who help to bear a difficult situation more easily or simply offer a welcome distraction from the ward routine e.g. [
3,
4].
Hospital clowning was developed in 1986 in the United States by Michael Christensen, a co-founder of the New York-based Big Apple Circus, and spread quickly from there throughout Europe. The first German association of clown doctors was founded in 1994 by a student of Christensen’s named Laura Fernandez. In the meantime, according to estimates of the umbrella organisation “Clowns für Kinder im Krankenhaus Deutschland e. V.” [Clowns for children in hospitals Germany], founded in 2004, there are roughly 250 hospital clowns working around the country. Most of them are members of one of the approximately 40 regional associations and work not only in hospitals but in dialysis centres, children’s hospices or paediatric emergency rooms. The specific work of a clown can be described well by three different role models: (1) the entertainer uses the performing arts, e.g. magic/sleight of hand, (2) the auguste, who makes children laugh using humour and slapstick acts, and (3) the clown as an ally who offers the child emotional support [
5].
The mode of action of hospital clowning can be specified at four different levels of impact (see also [
3,
6‐
10]). At the physiological level, laughing stimulates and modulates the immune system via the release of endorphins. At the emotional level, laughing replaces negative feelings with positive ones. At the cognitive level, the performance distracts the patient from his own situation, fosters imagination and supports the learning of new ways to express oneself. At the social level, laughing creates a connection between the children and clowns and stimulates further interaction. For each of the four levels of impact, there are an entire series of independent studies in which specific aspects were empirically tested and the corresponding hypotheses regarding the modes of action were confirmed (e.g. [
11], on laughing and muscle tension; [
12], on laughing and breathing; [
13], on humour and fear, [
14], on laughing and immunoglobulin A; [
15], on laughing and pain).
In addition to the aforementioned primary effects, side effects can also occur. For example, the offer of a clinic clown in a hospital has the effect of creating publicity for the relevant institution. For the parents of paediatric patients and the hospital staff, the clown’s visits likewise provide distraction, stress relief and support. However, if a clown does not comply with the rules of a hospital or crosses the personal boundaries of a patient, there may be negative side effects. These include, for example, wasting money, disruption of workflows, annoyance and irritation among hospital staff and parents as well as helplessness, overtaxing and discontent among patients.
A search in the relevant abstract databases Embase, Medline and PsycINFO revealed a multitude of comments and case reports in predominantly low ranked journals. However, there exist several sample studies fulfilling more rigorous scientific criteria. These can be divided thematically into two groups, namely, controlled trials and evaluations of effectiveness under routine conditions. Systematic reviews or meta analyses do not exist to date.
Currently, there are a total of nine randomized controlled trials on the effect of hospital clowning during specific medical interventions. Five of these investigations deal with the presence of hospital clowns before, during, and/or after surgery or anesthesia induction and the possible reduction of anxiety [
16‐
20]. One study analyzes the effect of clown intervention during botulinum toxin injections [
21]. Three trials [
22‐
24] investigated a possible long-term effect (up to one day later) in the context of an in-patient hospital stay. Overall, the fear-and stress-reducing effect of hospital clowning could be detected in most studies, but not in all. In particular, a long-term effect beyond the actual duration of the clown visit has not been identified conclusively.
With regard to the attitudes and subjective assessments of the impact by the patients, parents and hospital staff that are of interest in the context of the present study, four independent studies have been published up to now:
-
Loidl-Keil et al. [
25] evaluated the performances of hospital clowns in three different hospitals in Upper Austria. They surveyed n = 37 patients (3–20 years old, M = 11 year) and n = 98 nurses using a questionnaire on the acceptance and subjective experience of efficacy of the clown visits. The results of the evaluation were very positive overall. The clear majority of the children enjoyed the clown performances, wanted more frequent clown visits and preferred these to other entertainment activities on the ward. Only a small number of respondents reported feeling unwell or ill at ease or disturbed. The nursing staff gave comparable assessments.
-
Battrick et al. [
26] evaluated the clown visits in an English hospital using a questionnaire from the point of view of n = 49 children, 43 parents, 93 hospital staff members and 17 physicians. The results showed a very positive reception by all groups. The vast majority (82%) of the children enjoyed the clown performances. Only 3 (6%) stated that they didn’t like the clowns. Almost all of the parents and hospital staff claimed that the presence of a clown doctor had a positive influence on sick children and their families. The physicians made comparable statements.
-
Glasper et al. [
27,
28] studied the topic in three different study modules at an English children’s hospital. The result of two focus groups with n = 5 and 7 clowns showed that hospital clowns are well trained and take their profession very seriously. They believe they can improve the children’s care and perceive themselves as valued members of the hospital team. However, problems with scheduling appointments and prejudices of hospital staff were also mentioned. The survey of various groups of people (n = 17 physicians, 93 nursing staff, 43 parents and 49 children) confirmed the assessments of the focus group. Nearly all of the respondents valued the work of the clowns and believed that the performances would have a positive influence on the health of the patients. However, a few of the physicians stated that they personally did not like hospital clowns. In the third study module, n = 20 patients between the ages of 4 and 11 were asked to show in drawings and stories how they felt about a hospital stay before and after a clown visit. Before the clown visit, mostly negative comments (28 of 35) such as “sad”, “nervous” or “worried” were made, but after the clown visit, a significantly more positive perception appeared (57 positive and 3 negative comments).
-
Koller and Gryski [
3] surveyed n = 143 staff members and 51 parents regarding the clown visits in a paediatric clinic in Toronto. The vast majority (85%) of the staff had no concerns with respect to the clown visits. Just under half stated that they experienced the clowns as a support for their own work and almost all of them evaluated the clown program as beneficial to the hospital. The parents expressed equally positive opinions: more than three quarters reported that their children and they themselves enjoyed the clown visits and almost all parents considered their children to be happier after the performances than before (94%).
Previous results regarding efficacy under routine conditions show that clown doctors do valuable work and are appreciated by patients as well as parents and hospital staff. However, up to now there have been almost no such systematic, empirical, scientific studies in Germany on the use, effect and side effects of hospital clowning for hospitalised paediatric patients under routine conditions comprising more than one hospital. The present report describes an initial evaluation of the actual state of care provision in this field.
The initial questions of the present study were:
1.
What is the care provision situation with regard to hospital clowning in Germany?
2.
How do hospital clowns, parents and ward staff rate the intervention?
Discussion
Nationwide survey
The information about the general conditions convey a clear picture of the actual structure of the clown visits. Most clowns stated that they had undergone extensive training and regularly attended advanced training courses. Because membership in a clown association frequently requires regular participation in advanced training courses (the umbrella organisation requires at least one year of coaching), there is a functioning quality control mechanism. With the documentation of the hourly wage, previously non-existent transparency has been achieved, and with average rate of € 43.00 per hour, the clowns have been given a yardstick with which to assess their individual earnings. It is noteworthy that every seventh clown is a volunteer working without pay, which speaks for the high personal commitment of the clowns. Unfortunately, there is no direct and reliable standard of comparison available from similar professional groups.
The majority of the hospital clowns stated that they usually perform in a duo. The result can be explained by the fact that performing as a duo is a “desirable” acceptance criterion of the umbrella organisation. This is also described in the literature as being the most useful procedure [
3,
30], e.g. to relieve children of the pressure of active participation. Elements of the performances named, in addition to music and magic tricks, included pantomime, acrobatics, improvisation, slapstick and dance. The hospital clowns thus have a broad repertoire and must therefore document good training with regard to these skills. Based on the information collected, the low rejection rate can be explained by the generally high acceptance of the clown performances. However, other factors such as a preselection by the nursing staff or the strategic avoidance of potential rejection are also conceivable.
According to the assessments of the clown doctors, the clown visits had predominantly positive effects on patients, parents and hospital staff, especially with regard to mood. This assessment matches the evaluations of the parents and the hospital staff from the Hamburg hospital survey on the one hand and the results of other studies on the other (see introduction). In agreement with this, from the point of view of the hospital clowns, their work is greatly appreciated. They receive in relative terms the least appreciation from physicians, but this value is still on the positive half of the rating scale. This assessment on the part of the physicians is probably related to the rather sporadic contact between the two groups.
The hospital clowns are very satisfied with their work on the whole. Relative dissatisfaction and thus potential for improvement in the work situation exist with regard to recognition of their work, interdisciplinary contact and financial support. While the first two aspects could be resolved via a reorganisation of the collaboration of the professional groups involved, an improvement in pay can hardly be expected in financially difficult times. Comparable information about the satisfaction of hospital clowns or comparable professional groups are unfortunately not available.
As the correlation analyses show, the suspected effect on patients from the standpoint of the clowns can hardly be explained by any of the data collected. There is a small effect only for gender, indicating that female clowns rate their effect more highly than male clowns do. However, this effect should be interpreted with caution because of multiple testing. It is not possible to draw any conclusions in this study as to whether this is an effect of self-evaluation or corresponds to reality. The low predictive value of the variables involved may be a consequence of a reduced variance due to the effect of social desirability. In contrast, the work satisfaction can be somewhat better explained. The two predictors “experienced appreciation” and “experienced sustainability” are directly plausible and together are responsible for 20% of the effect variance.
Hamburg hospital survey
In the Hamburg hospital survey, the participating parents stated that they could assess the effect quite well. The ratings of the parents confirm the assessments of the hospital clowns in the nationwide survey, according to which hospital clowning first and foremost boosted morale and relieved stress. Negative effects of the clown visits are hardly perceived at all. As mentioned above, these results match those of previous studies (see introduction). Visits from hospital clowns are thus a good intervention to improve patients’ moods at least in the short term. Parents also stated that most of the children had “no fear at all” during the first clown visit. This confirms the low rate of rejection stated by the clowns in the online survey and matches the controlled studies on fear reduction via hospital clowning. Thus, coulrophobia, the fear of clowns sometimes mentioned in this context, is generally not an issue. The actual rejections expressed were very few in number and were based on various reasons of a more practical nature. The statements regarding parental satisfaction confirmed the assessments of efficacy.
According to the assessments of the nursing staff, a clown visit has a uniformly positive influence on paediatric patients. Procedural disruptions or stress caused by the hospital clown occur only in individual cases. Overall, the hospital staff in the present study thus rated the work of the hospital clowns as very positive. As a result, more than two thirds of the respondents would like more hospital clown visits. Almost exclusively positive opinions of the hospital staff are found in the literature as well [
10,
12,
13,
17]. There is only one study [
19], in which the medical staff primarily rejects clown visits, as they would disrupt the workflow. Thus, clown performances generally appear to be very compatible with ward routine. However, in the Hamburg hospitals, more than two thirds of the surveyed staff replied to the question of whether they called hospital clowns for specific interventions with “not at all”. Yet, the effect of fear reduction before surgical interventions was documented in several controlled studies (see also current state of research). The results thus also show that the hospital clowns are not yet fully integrated in the ward routine and that the potentials of this intervention have not yet been fully utilised.
Conclusions
When interpreting the results, the following methodological problems must be taken into account:
-
As is usual with surveys, an effect of social desirability which distorts the results in an positive direction cannot be excluded for the two sub-studies. An analysis of the n = 50 clowns who did not complete the questionnaire revealed that these were less likely to be a member of a clown association (a variable which did not influence the outcome estimation, see 3.1.4).
-
Originally, a survey of patients was also planned. However, it turned out that there were such large selection effects influencing the practical implementation (approx. 20% return) that the data collected in this manner would not have had any significance.
-
In the Hamburg hospital survey, the dependence of clown performances and parental evaluations could not be analysed at multiple levels due to the low number of responses. A group comparison subjected to an analysis of variance showed, however, that parental satisfaction did not depend on the clowns who performed.
Overall, based on the data available at the present time, the use of hospital clowns in paediatric wards can be recommended. In locations where hospital clowns work, interdisciplinary communication and integration as well as respectful and appreciative interaction are essential. Explicit rules of conduct as well as a professional feedback mechanism would help to prevent potential negative side effects. Moreover, it should be checked whether hospital clowning could also be used to reduce fear, anxiety and stress before and during stressful interventions under routine conditions. There is still an enormous amount of research to be done: hospital clowning should be seen as a regular supportive intervention to be studied using standardized methods of evaluation, intervention and health care provision research just like traditional medical measures. Especially the effect of clown visits during intrusive medical procedures seems to be a promising research target. The present study generated health care data on hospital clowning in paediatrics in Germany for the first time, showing that it is easy to implement, is perceived as effective in the short term and thus a useful and practical measure to help suffering children in the hospital system to cope better with their situation.
Competing interests
This study was conducted with the financial assistance of the registered association “Humor Hilft Heilen”. The authors declare that they have no further competing interests.
Authors’ contributions
CB was responsible for the conception, study design, calculations and the final manuscript. AKS participated in the study design and the calculations, carried out the collection of data and drafted the manuscript. NW participated in the design, performed additional analyses and revised the manuscript. MSM conceived the study, participated in the coordination and revised the paper. All authors read and approved the final manuscript.