Clinical Clowning in nursing is an innovative complimentary approach that combines humour, compassion, creativity and enhances patient care. It combines the art of clowning with selective medical and psychological training. Clowns are included in health care teams to help alleviate stress, loneliness, fear and feelings of helplessness in hospitalised patients (Finlay et al, 2014; Goldberg Wiseman, 2014). Medical clowning is perceived to be a complementary approach which combines traditional medicine with various complementary and alternative medical techniques (Dionigi, 2017). Clinical clowns also called hospital clowns or clown doctors are trained professionals who aim to change the perception of the hospital environment by creating humouristic situations to elicit laughter and joy in paediatric wards as well as with adults and older adults (Dionigi et al, 2012; Dionigi Goldberg, 2019; Friedler et al, 2017;Lalantika Yuvaraj, 2020;Ofir et al, 2016). Many clown care units (CCUs) quickly emerged across the United States, with similar units also starting to appear concurrently in France, Germany, Britain, Italy, Spain, and Switzerland, Austria, Canada, Australia, Brazil and Israel (Ford et al 2014).
Therapeutic clowning is an interdisciplinary art that involves a wide variety of skills, such as humour, drama, music, and dance, aimed at providing a humour-based distraction to improve hospitalised paediatric patients moods and reduce their anxiety.
Historical Background
Clowning is a kind of ancient art that produces an interaction between people, play and above all laughter. The role of medical clowns in hospital wards has gained increasing prominence in recent decades. though their presence in medical settings is far from a new development. Historical records show that clowns were active in healthcare as early as the early twentieth century. In the 1970s, Dr Patch Adams integrated clowning into the treatment of children in Virginia hospitals, gaining international recognition for pioneering new approaches and elevating medical clowning to a standard practice in paediatric care. By the 1980s, the first training programme for medical clowns was established, leading to the creation of similar programmes around the world (LopezJ__ampersandsignuacute;nior et al, 2020).
Purpose of Clinical Clowning in Nursing
The purpose is to explore the stories of therapeutic clowns in an effort to discover how clowns and clowning techniques could inform nursing practice. It also explores the phenomenon of interest - therapeutic clowns and developing a rich understanding of a phenomenon.
Significance of Clinical Clowning
In general, clown doctors provide a complementary form of healthcare by using techniques such as music, juggling, improvisation, magic, storytelling, and puppetry to entertain children and teenagers in hospitals; they also visit adults in some hospitals. The clown doctors help create a positive emotional state and environment that promotes interaction between parents and child and foster a hopeful attitude. Clown doctors, with their remarkable adaptability, sensitivity and attentiveness, tailor their approach to each patient, situation, and medical procedure. Embracing the adage laughter is the best medicine, they harness the therapeutic power of humour to address the psychosocial needs of hospitalised patients, fostering emotional expression and empowerment. As hospital clowning continues to grow in many countries, studies on humour research, play research, and the physiological health benefits on laughter have also been conducted (Lopes-Junior et al, 2020). The medical clown reduces the physical and mental stress reactions of children, eases resistance during treatment, reduces post-operative pain, shortens crying time, and somewhat alleviates parents anxiety (Fang et al, 2022).
Research and Evidence Related to Health Care
Pre-operative anxiety is very common among children and can result in negative consequences that may last for months afterward. Multiple randomised studies by various researchers have demonstrated that having clowns present in preoperative settings helps reduce anxiety. A metaanalysis of these studies found that the presence of clowns before surgery significantly decreases children anxiety (Zhang et al, 2017). A 2015 study conducted in Israel involved children aged 2 to 16 undergoing outpatient urologic (penile) surgery. One group had a medical clown present in the operating room, while the other did not. The study found that the presence of the clown was associated with reduced anxiety in the children both before and after surgery, decreased operating room time, lower pain levels, and a shorter hospital discharge time. Additionally, cost savings were achieved due to the reduced time spent in both the operating room and postoperative unit (Kocherov et al, 2016).
Importance of Clinical Clowning
To recapitulate, benefits of clown care include creating a positive emotional state, promoting interaction between the parents and the child and fostering affirmative environmental condition. When children seek medical treatment, caregivers show excessive anxiety and tension due to a lack of disease-related knowledge and limited experience in providing care (Xiao-yan et al, 2023). Clown care translates professional medical knowledge into everyday language to enhance caregivers understanding of disease-related information and reduce their anxiety levels (Raisin et al, 2023; Xu et al, 2023).
Integration into Nursing Practice
When dealing with patients, a clinical clown must blend artistic skills such as music, comedy, mime, magic, or puppetry that foster positive emotions, with personal qualities like empathy, emotional intelligence, and intuition. This combination allows clinical clowns to build therapeutic relationships with patients, helping to reduce pain and other negative effects of illness, while also enhancing their well-being and creating a more uplifting environment (Finlay et al, 2014).
Education Training Programmes
Medical clowns are highly specialised, trained and qualified professionals. International scientific research has shown that medical clowning has a significant positive impact in improving mental, emotional and physical health. Stress, anxiety and depression decrease, along with a number of conditions and illnesses including high blood pressure, heart disease, diabetes and infertility. They gain a basic understanding of the ethics, drivers and structures of the organisation as well as the theoretical knowledge of the healthcare clowning. A series of workshops led by internationally acclaimed artists and instructors are conducted to teach artistic skills and techniques along with a specialised knowledge on clowning in health care and crisis situations. The integration of clowning in Nursing enhances patient experience, promotes healing and contributes to compassionate and patient centred approach care. Thus, it plays a vital role in transformative holistic approach to care and creates a ripple of hope and healing that medicine alone cannot achieve.
Roles and Responsibilities of Clinical Clowning
The clinical clown role is to help restore and strengthen the spirit, to touch deeply the feeling heart, to bolster resilience and to counter the negative effects that illness, trauma, aging and institutionalisation. Clowns may have positive cognitive, physiological, social and emotional effects.
A review of the paediatric literature reveals their value in the following areas:
Challenges and Considerations
Cultural sensitivity is crucial in medical clowning, requiring an understanding of cultural differences and patient backgrounds. This necessitates providing clowns with training on cultural competence to ensure they respect the diverse backgrounds of patients. It also involves encouraging clowns to adapt their performances to be culturally appropriate and inclusive. Ethical considerations are paramount in medical clowning. Obtain informed consent from patients or their guardians before any clowning intervention. Prioritising patient comfort and respecting their boundaries, with the option for patients to optout if they do not wish to participate, is crucial. Maintaining patient confidentiality and ensuring that interactions respect patient privacy is also vital. Overcoming logistical challenges is essential for the smooth implementation of medical clowning programmes. This involves ensuring adequate resources, including funding and space for medical clown programmes. Coordinating with healthcare staff to integrate clown visits into the overall patient care plan without disrupting medical procedures is also necessary.
Training Programmes in Clinical Clowning
MeDiClown Academy offers a wide range of training programmes and workshops and services ranging from working with corporate executives, healthcare professionals, patients, educators, students, retirees and people wanting significant transformation, mid-life change or alternative career.
Fellowship in the Art and Science of Medical Clowning (FASMC), a certified programme is offered for the first time in India. MeDiClown Academy is a registered activity of the Auroville Foundation, incubated as a social startup by Fif Fernandes and Hamish Boyd. Currently, hospitals, healthcare and corporate sectors, and educational institutions are some of the key beneficiaries of its services (https:// www.mediclownacademy.org/who-are-we/).
Recommendations
Clown care as a research area is interesting and offers a wide range of research possibilities. Since there is still a scarcity of information, this study suggests several areas for further research including examining the role of nurses in clown care; exploring nurses and medical staff perspectives and experiences with clown care; developing tools to assess and measure perceptions, experiences, barriers, benefits, and factors that facilitate clown care to validate qualitative findings. Additionally, interventional studies on the impact of clown care in reducing pain, stress, and fatigue are strongly recommended. These investigations could help advance evidence-based practices in clown care.
Conclusion
Clinical Clowning in nursing serves as a complimentary approach that enhances patient experience, improves outcomes and enhances the wellbeing of both patients and healthcare providers. Research shows that highly trained professionals play a vital role in the treatment of children and adults who are hospitalised or in other healthcare facilities, helping the patients, their families, and the medical staff working with them. Employed properly, Clinical clowns can serve as important members of clinical care teams in a wide variety of health care settings. Clinical clowning can also be incorporated into the nursing curricula at the institutional level.
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