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Arts & HealthAn International Journal for Research, Policy and Practice

ISSN: 1753-3015 (Print) 1753-3023 (Online) Journal homepage: https://www.tandfonline.com/loi/rahe20

Perceived changes in psychological and physicalsymptoms after hospital clown performances in acancer setting

A. Casellas-Grau, C. Ochoa, M. Lleras De Frutos, A. Flix-Valle, A. Rosales & F.Gil

To cite this article: A. Casellas-Grau, C. Ochoa, M. Lleras De Frutos, A. Flix-Valle, A. Rosales& F. Gil (2020): Perceived changes in psychological and physical symptoms after hospital clownperformances in a cancer setting, Arts & Health

To link to this article: https://doi.org/10.1080/17533015.2020.1744172

Published online: 29 Mar 2020.

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Perceived changes in psychological and physical symptomsafter hospital clown performances in a cancer settingA. Casellas-Graua,b,c,d, C. Ochoaa,e,f, M. Lleras De Frutosa,f, A. Flix-Vallea,e, A. Rosalesg

and F. Gila,b,d,h

aInstitut Català d’Oncologia, L'Hospitalet de Llobregat, Spain; bPsychosocial Observatory in Cancer, L'Hospitaletde Llobregat, Spain; cUniversitat De Vic – Universitat Central De Catalunya, Vic, Spain; dUniversitat AutònomaDe Barcelona, Cerdanyola del Vallès, Spain; eInstitut d’Investigació Biomèdica De Bellvitge, L'Hospitalet deLlobregat, Spain; fUniversitat De Barcelona, Barcelona, Spain; gPallapupas, Barcelona, Spain; hEscola Superior DeCiències De La Salut, Tecnocampus-Mataró, Universitat Pompeu Fabra, Mataró, Spain

ABSTRACTBackground: The therapeutic role of humor and hospital clownshas become a focus of interest in recent decades. Most of theresearch in the area has focused on children; here, we explore theinfluence of clown performances on adult cancer patients, theircompanions, and health-care staff.Methods: Ninety-nine cancer patients and 113 companions wereassessed pre- and post-interventions performed by professionalclowns; 31 health professionals were asked about the possibleinfluence of the presence of clowns in hospital on their work.Results: Patients felt that clowning performances helped to reducetheir level of psychological symptoms, but not their physical symp-toms. Companions reported improvements in all the psychologicalsymptoms explored. Health professionals reported that the pre-sence of clowns in the workplace improved their well-being.Conclusions: Clowning performances helped to improve psycho-logical functioning in all the populations studied, especially incompanions. Adult hospitals should consider promoting clowninginterventions to improve general well-being.

ARTICLE HISTORYReceived 17 January 2019Accepted 13 January 2020

KEYWORDSCancer; clowning; hospitalclown; healthcare;psycho-oncology

Introduction

Humor is an inherent social phenomenon that has been present in all cultural groupsthroughout human history (Adamle & Ludwick, 2005; Tanay et al., 2013). Its therapeuticrole was first studied in the 1960s, when research began to highlight its protective effectagainst certain illnesses and emotional alterations (Martin, 2001; McGhee, 1999; Tanayet al., 2013). Studies focusing on humor and laughter in health and illness, and on theirpsychological effects, have shown that they can function as a coping strategy to reducestress and psychological symptoms. These studies have also associated humor withphysical benefits such as triggering neurological or functional mechanisms by increasingin the activation of the mesolimbic dopaminergic reward system, as well as improvingimmune, cardiovascular, and respiratory systems (Boyle & Joss-Reid, 2004; Cann et al.,

CONTACT F. Gil fgil@iconcologia.net

ARTS & HEALTHhttps://doi.org/10.1080/17533015.2020.1744172

© 2020 Informa UK Limited, trading as Taylor & Francis Group

1999; Fry, 1992, 1994; Kamei et al., 1997; Savage et al., 2017). As a result, many studieshave found that humor has the power to enhance patients’ quality of life (Balick & Lee,2003; Bennet & Lengacher, 2009; Dixon, 1980). In the hospital context, humor releasestension, facilitates communication, and strengthens the relationship between patientsand medical staff (Dziegielewski et al., 2003; Pierlot & Warelow, 2014; Scholl & Ragan,2003). In the specific case of highly stressful illnesses like cancer, humor can ease thephysical pain and the shock of diagnosis, as well as the psychosocial effects of thetreatments in both patients and their companions (Lopes-Júnior et al., 2016; Nuneset al., 2018; Segrin & Badger, 2010; Segrin et al., 2012; Tanay et al., 2013). Kuiper andNicholl (2004) distinguish between two mechanisms that support humor as a copingstrategy in physical illnesses like cancer: cognitive appraisals, and distancing. The firstrefers to seeing the illness and its symptoms in a more positive way, as an opportunity forpersonal growth. For its part, distancing describes changes in the perspective from whichpatients observe their own illness. The changes deriving from humor reduce the impact ofthe illness, allowing patients to cope more effectively, as they can distance themselvesfrom the symptoms of their illness and from the cognitive evaluation of their currentnegative experience. In this regard, humor allows patients to see their illness asa challenge rather than as a threat, and may ease their worries and their fear with regardto it. Empirical research has historically supported this phenomenon; in their study,Thorson and Powell (1993) found that patients with higher levels of coping humorreported reduced anxiety about death.

Patients’ family members or close friends also experience the psychological consequencesof their relative’s illness (Northouse et al., 2007; Ochoa et al., 2013; Segrin & Badger, 2010), with40% of patients’ spouses showing symptoms of depression (Braun et al., 2007) or psycholo-gical distress (Bambauer et al., 2006; Sjövall et al., 2009). Humor is known to be used asa coping strategy by both patients and their family to decrease stress and anxiety, resulting ina wide range of positive emotional, cognitive and behavioral responses, such as feeling light-hearted and playful (Beach & Prickett, 2017; Gil et al., 2012; Nabi, 2016). Some authors whohave explored the effect of humor in cancer patients have shown that using it as a copingstrategy promotes the emergence of positive psychological responses, such as post-traumaticgrowth (Schroevers & Teo, 2008). Thus, humor not only has immediate benefits, but alsoprovokes long-term positive responses in cancer patients.

There are many ways of exposing cancer patients to humor, but the use of clownhumor is increasing in medical settings because of its power to facilitate coping with thedisease (Battrick et al., 2007; Dayton, 1997). In the time of Hippocrates (460 BC – 370 BC),clowns and musicians were used to promote healing (Warren, 2008), as doctors began tobelieve that humor contributed to better health states (Koller & Gryski, 2008; Kontos et al.,2017). More recently, in the early twentieth century, a famous clown trio called theFratellini Brothers began performing in French hospitals, visiting hospitalized children inorder to improve their spirits (Oppenheim et al., 1997; Warren, 2008). However, manyauthors consider that professional clowns first became members of hospital health-careteams in 1986, when a professional clown from the Big Apple Circus in New York, MichaelChristensen, founded the Big Apple Circus Clown Care (Koller & Gryski, 2008). Thisprogram aimed to train professionals for clowning in health-care settings (Dionigi &Canestrari, 2016). Soon, many healthcare clown organizations were established in coun-tries such as France, Germany, Britain, Spain, Australia and Brazil (Ford et al., 2014), with

2 A. CASELLAS-GRAU ET AL.

the primary aim of entertaining and relieving suffering in children, their parents, and otherpopulations in health-care settings, through the use of humor and clowning skills (Battricket al., 2007; Dionigi et al., 2013; Lopes-Júnior et al., 2018; Sridharan & Sivaramakrishnan,2016; Vagnoli et al., 2005; Zhang et al., 2016). Further, healthcare clown organizations holdregular meetings, conferences and workshops in Europe and elsewhere in order tomonitor the current state of clowning activities in patient care.

To date, research on clowning interventions in health-care settings remains scarce,although a growing interest in the application of humor in health-care settings hasidentified hospital clowning as a well-defined approach that is suitable for empiricalresearch. This research has focused on various clinical conditions and patient groups,but most has centered on the effect of clown interventions on children (Dionigi &Canestrari, 2016; Lopes-Júnior et al., 2018; Sato et al., 2016; Sridharan &Sivaramakrishnan, 2016; Vagnoli et al., 2005; Zhang et al., 2016), with adults and profes-sionals being secondary receivers. The few existing studies of adults have focused onparents of hospitalized children (Agostini et al., 2014), elderly geriatric patients (Kontoset al., 2017), or psychiatric patients (Higueras et al., 2006), among others. Empiricalevidence on the effect of clowning on health-care professionals is also being gathered(Angotti et al., 2015).

Despite the growing number of clown programs, the research into the effects ofclowning on the adult population is limited. The effects refer to those psychologicalresponses in patients watching the performances (e.g., feeling more or less anxious)and their self-perception of their cancer symptoms (e.g., feeling less fatigued). Furtherevaluation is needed of the impact of hospital clowns in health-care settings, especially inadults with highly stressful diseases such as cancer. Given that humor contributes tocloseness and bonding (Chapple & Ziebland, 2004; Tanay et al., 2013), and that it may helppatients and their carers cope with the diagnosis and deal with the effects of oncologicaltreatment (Tanay et al., 2013), we believe that it would be useful to study the positiveeffects of clowning on this population.

To our knowledge, this is the first study assessing the possible changes in psychologi-cal and physical symptoms in adults with cancer and their companions after hospitalclown performances in waiting rooms. The present study also aimed to explore theopinion of health-care professionals regarding the presence of clowns in hospitals as anelement for improving the working environment. We hypothesized that 1) patients wouldreport an improvement in their psychological and physical symptoms after seeing hospi-tal clown performances; and 2) patients’ companions would report a reduction in theirpsychological symptoms. Finally, 3) it was hypothesized that health-care professionalswould positively value the presence of clowns in their workplaces.

Methods

Study design

The present study is a single-group, pre-post quasi-experimental study of a time-limitedintervention to explore whether clowning performances in oncology waiting rooms areassociated with improvement in psychological and/or physical state among patients andtheir companions. The aims of the present study were threefold: 1) to study the possible

ARTS & HEALTH 3

changes in psychological and physical symptoms in an adult cancer outpatient populationafter hospital clown performances in waiting rooms, 2) to investigate the possible changesin the psychological state of patients’ companions also in hospital waiting rooms, and 3) toassess the opinion of health-care professionals regarding the presence of clowns inhospitals as an element for improving the working environment.

To address aims 1) and 2), the study followed a pre-post design, assessing patients andcompanions just before and just after the clowning intervention. To address aim 3),health-care professionals were asked to answer a questionnaire exploring whether theregular presence of clowns in their workplace improved the working environment. In thisgroup an only-post assessment took place, as health professionals do not attend to clownintervention. For this reason, we asked them about the presence of clowns in theirworkplace (e.g., corridors, common areas), rather than about the performances.

Participants

Ninety-nine cancer patients and 113 companions were recruited over a five-month periodfrom the waiting rooms of the Duran i Reynals Hospital, an adult cancer hospital inBarcelona. During the same period, 31 health-care professionals in this hospital wereasked to participate in the study to explore the influence of the presence of clowns ontheir working environment.

The inclusion criteria for patients were: (1) having a diagnosis of cancer with norestrictions regarding age, gender, type of cancer, illness phase or type of treatment; (2)being in the waiting-room, waiting for a nurse/medical appointment; (3) being able tounderstand and answer the questionnaire. In turn, inclusion criteria for companions were:(1) having a personal relationship with the patient, with no restriction regarding age,gender, or the type of relationship (except for volunteers), and (2) being able to under-stand and answer the questionnaire.

From the 261 eligible participants (patients and companions in hospital waitingrooms), 212 (81%) finally entered the study. Patients or companions reporting cognitivedifficulties that might affect their response to the assessment tool were excluded from thestudy (N = 21), while 28 other declined to participate. Reasons for not participating were:(1) not wanting to answer a questionnaire; (2) being too worried about their illness; (3)being tired; (4) preferring to do other activities while waiting (e.g., reading, talking withtheir companion).

Health-care professionals were invited to participate if they frequently saw clowns intheir workplace. Only those who worked in the nurse/physician consultation area wereasked to take part. Of the 40 professionals contacted, 31 (77.5%) answered the ques-tionnaire. Reasons for declining to participate were: (1) lack of time, or (2) lack of interest.

The study was conducted in accordance with the latest version of the Declaration ofHelsinki. Approval was given by the ethics committee of our hospital, and all participantsprovided written informed consent.

InstrumentsSociodemographic andmedical information. a short ad-hoc questionnaire was createdto collect the patients’ and companions’ sociodemographic information. Medical

4 A. CASELLAS-GRAU ET AL.

information was obtained from the patients’ clinical history. The written consent includedpermission for the researchers in our study to access this information.

Symptoms and mood. The Spanish version of the Edmonton Symptom AssessmentSystem (Bruera et al., 1991; Carvajal et al., 2011) was adapted to evaluate changes in cancerpatients’ physical and psychological symptoms. On a 10-point Likert scale, respondentsrated the following areas: pain, fatigue, somnolence, breathing difficulties, discouragement,anxiety, boredom, sadness, anger, worries, deception, and fear. Answers ranged from 0 (nofeeling of the symptom; e.g., ‘No anxiety) to 10 (the worst possible feeling of the symptom;e.g., “Worst possible anxiety”). The version used in this study also included three itemsassessing well-being, feeling like laughing, and happiness. In these items, answers rangedfrom 0 (best feeling of the positive symptom; e.g., “Best possible well-being”) to 10 (worstpossible feeling of the positive symptom; e.g., “Worst possible well-being”). Patients wereassessed in all these areas. Companions were assessed using the same tool, but not for pain,fatigue, somnolence or breathing difficulties. Finally, the questionnaire was also adapted forprofessionals in order to rate the possible effects of the presence of clowns in their work-place on their mood. Thus, professionals rated the following areas: anxiety, boredom,sadness, anger, well-being, laughing, happiness, and worries.

Intervention

The intervention was performed by professional hospital clowns from the Pallapupasorganization. Pallapupas are all professional clowns and actors. They all have a solidgrounding in acting and considerable artistic knowledge of the technique, combinedwith medical and psychological training in the characteristics of the groups that they willvisit. Clowning is a profession that, like any other, needs many years of training.Pallapupas carry out castings and personal interviews in order to ensure that the perfor-mances will be highly professional. The clown intervention comprised three differentsections: (a) Pre-intervention transmission of information – first, the clowns entered theareas used by the health-care professionals to assess the current environment in thewaiting rooms, whether a performance would be appropriate, and the need to considerany circumstances in relation to patients. (b) Intervention – the intervention lasted15 minutes, and was played out by a pair of clowns. Pallapupas always work in pairs, asthis helps to balance the intervention. The two clowns share the weight of the perfor-mance with each other, actively listening to the public and if necessary, adapting theintervention to their needs. This is the technique known as “major and minor”, by whichthe main roles alternate throughout each intervention and the attentional focus goesback and forth between the two actors. The pairwork encourages creative performance,making it easier for people to feel involved and thus providing greater support (Koller &Gryski, 2008). These performances recreate day-to-day situations (e.g., clowns trying toinstall a new TV screen; one clown trying to make friends with the other; planning toinstall new chairs in the waiting room; planning a wedding between the clowns andasking the public for their ideas, etc.). The clown representations used adult humor suchas irony, parody, black humor, mischief, absurdity, and surrealism; clowns invited thepublic to interact with them, but did not insist when the spectator showed no wish toparticipate. Thus, the involvement of public had three different levels: as spectators,

ARTS & HEALTH 5

accomplices, or protagonists. The clowns responded to the public’s receptiveness toproposals, adapting the plot to their reactions, and always being considerate of thespectators’ privacy. They also complied strictly with hygiene standards in the hospital.(c) Closing – Clown interventions ended with specific closure of the performance, in orderto indicate to the audience that the session had finished and to promote a positiveenvironment in the waiting room after their departure. In some cases the clowns returnedto the waiting-room, creating a surprise effect.

The encounters between hospital clowns and health professionals were not specificallyplanned, as they were not performances. Their encounters were spontaneous and tookplace between performances, for example, when the clowns went to change. Duringthese spontaneous encounters, the clowns made gentle jokes with professionals orplayed little tricks on them. For this reason, in this study, professionals were askedabout their opinion of the presence of clowns in the workplace; they did not see entireperformances by the clowns, but just had spontaneous interactions with them.

Procedure

Patients and their companions were asked to participate in the study when waiting fortheir medical appointment in hospital waiting rooms. After explaining the aims of thestudy the researchers obtained participants’ informed consent and helped them toanswer the questionnaire. Participants were asked to answer the questionnaire immedi-ately before and immediately after the clown intervention, in order to detect changes inthe dimensions explored. Participants and their companions were asked about theirpsychological symptoms just before and just after seeing the performance. Patientswere also asked about their perception of physical symptoms before and after clowning.The details of these symptoms are described in the Instruments section. Finally, profes-sionals were asked about their perception of the presence of clowns in their workplace.They rated whether they felt that the presence of clowns in hospital (e.g., in waiting-rooms, corridors, building entrances) influenced their perceptions of their own psycholo-gical state by assessing the specific psychological areas described in the Instrumentssection. Hospital staff were asked whether the clowns’ presence increased, reduced, orhad no impact on these areas. As the aim of this assessment was to explore the influenceof the presence of clowns in the workplace rather than the clowning intervention itself theprofessionals were asked only once. Even though professionals could not see the clown-ing performance in the waiting rooms, it was hypothesized that the presence of clowns intheir workplace might also have an influence on them.

Statistical analyses

Statistical analysis was performed using IBM SPSS for Windows, Version 21.0 (IBM Corp.,Armonk, NY, USA). Descriptive analyses were used for sociodemographic and medicalsample characteristics. Repeated-measures ANOVA were used to explore the possibleinteraction effects of relevant sociodemographic and clinical variables on outcomes. Pre-post differences were explored using Student t tests in the paired modality. Effect sizeswere calculated using Cohen’s d. Between-group differences were analyzed with Student

6 A. CASELLAS-GRAU ET AL.

t tests using change scores. Responses from professionals were explored using chi-squared analyses. Statistical significance was assumed at a p-value <0.05.

Results

Sample

Sample sociodemographic and medical characteristics are reported in Table 1, differentiatingbetween patients and companions. Professional gender and role are also reported in Table 1.

Assessment of clowning interventions among patients and companions

PatientsRepeated-measures ANOVA indicated no interaction between sociodemographical andclinical characteristics and the outcomes, including age, gender, marital status, educationallevel, working status, primary cancer site and cancer stage, except for: a positive associationbetween female gender and fatigue (F = 7.81; p =.006), educational level and discourage-ment (F = 4.32; p = .04), and greater somnolence among patients with more advancedstages of cancer (F = 9.54; p = .003). The t tests showed significant differences between theoutcomes pre-intervention and the outcomes post-intervention in 11 out of 15 areas (seeTable 2): fatigue (t = 4.28, p < .001, d = 0.28), discouragement (t = 3.16, p = .002; d = 0.55),anxiety (t = 4.17, p < .001; d = 0.67), boredom (t = 3.97, p < .001; d = 0.68), sadness (t = 3.52,p = .001; d = 0.61), anger (t = 2.27, p = .026; d = 0.57), laughing (t = 4.35, p < .001; d = 0.79),happiness (t = 2.80, p = .006; d = 0.63), worries (t = 4.92, p < .001; d = 0.73), deception(t = 2.40, p = .02; d = 0.54), and fear (t = 2.79, p = .006; d = 0.51). In contrast, the interventiondid not significantly improve the following areas: pain, somnolence, breathing difficulties,and well-being.

Companions

Repeated-measures ANOVA indicated no interaction between age, gender or the type ofcompanions and the dependent variables, except for higher boredom among oldercompanions (F = 5.16; p = .02). The t tests showed significant differences between pre-and post-intervention outcomes in all of the 11 explored areas (see Table 2): discourage-ment (t = 6.17, p < .001; d = 0.81), anxiety (t = 5.82, p < .001; d = 0.79), boredom (t = 6.80,p < .001; d = 0.90), sadness (t = 6.43, p < .001; d = 0.91), anger (t = 2.77, p = .007; d = 0.72),well-being (t = 4.50, p < .001; d = 0.85), laughing (t = 7.01, p < .001; d = 0.92), happiness(t = 5.03, p < .001;; d = 0.79), worries (t = 7.28, p < .001;; d = 0.88), deception, (t = 3.76,p < .001;; d = 0.73), and fear (t = 3.61, p = .001;; d = 0.82).

Comparison of patients’ and companions’ changes

As mentioned above, companions reported positive changes in more areas than patientsafter having seen the clowns’ performances, and the effect sizes of these changes werealso greater in companions. Specific comparisons were performed between the twogroups, in order to assess the changes statistically. The results showed that companions

ARTS & HEALTH 7

Table 1. Sample characteristics.PATIENTS (n = 99) n (%)

AgeMean (SD) 58.14 (14.83)Min – Max 24-84

GenderFemale 52 (52.5%)Male 47 (47.5%)

Marital statusMarried/partnered 60 (60.6%)Single 14 (14.1%)Divorced/separated 12 (12.1%)Widowed 9 (9.1%)NA 4 (4%)

Educational levelHigh-school or less 32 (32.3%)Some college 31 (31.3%)University studies 26 (26.3%)No studies 6 (6.1%)NA 4 (4%)

Working statusPensioner 49 (49.5%)Sick leave 26 (26.3%)Employed 14 (14.1%)Unemployed 8 (8.1%)NA 2 (2%)

Primary cancer siteBreast 14 (14.1%)Lung 13 (13.1%)Prostate 11 (11.1%)Gynecological 9 (9.1%)Leukemia 7 (7.1%)Colon/rectum 6 (6.1%)Testicle 4 (4.0%)Non-Hodgkins Lymphoma 3 (3.0%)Hodgkins Lymphoma 3 (3.0%)Oral cavity 3 (3.0%)Other sites 26 (26.3%)

Cancer stage0 9 (9.1%)I 11 (11.1%)II 29 (29.3%)III 13 (13.1%)IV 23 (23.2%)NA 14 (14.1%)

COMPANIONS (n = 113) n (%)

AgeMean (SD) 52.68 (16.19)Min – Max 17-84

GenderFemale 71 (62.8%)Male 42 (37.2%)

Type of companionPartner 52 (46.0%)Son/daughter 31 (27.4%)Brother/sister 7 (6.2%)Friend 4 (3.5%)Parents 3 (2.7%)Cousin 3 (2.7%)Grandson/Granddaughter 3 (2.7%)Nephew 3 (2.7%)Others 5 (4.4%)NA 2 (1.7%)

Waiting roomPhysician/nurse office 69 (61.1%)Radiology 44 (38.9%)

(Continued)

8 A. CASELLAS-GRAU ET AL.

reported statistically greater improvements than patients in the following three areas:sadness (t = 2.28; p = .02), fear (t = 2.35; p = .02), and well-being (t = 2.15; p = .03). In theother areas explored, no statistically significant differences were found between groups.

Assessment of the presence of clowns in the workplace among professionals

Analyses were performed to explore the professionals’ perception of the presence ofclowns in the workplace. Data were collected on whether the professionals felt that thepresence of clowns would increase, reduce, or have no effect on the areas assessed (seeTable 3). The results showed that professionals felt that the presence of clowns in theirworkplace significantly reduced their levels of anxiety (χ² = 13.42; p < .01) and boredom(χ² = 3.90; p < .05), and increased their well-being (χ² = 20.97; p < .01), and laughing(χ² = 40.32; p < .01). Therefore, no significant improvement was observed in sadness,anger, happiness, and worries.

Table 1. (Continued).HEALTH PROFESSIONALS (n = 31) n (%)

RoleRadiologist technician 9 (29%)Psycho-oncologist 8 (25.8%)Administrative staff 6 (19.3%)Nursing assistant 5 (16.1%)Nurse 3 (9.7%)

GenderWomen 27 (87.1%)Men 4 (12.9%)

Table 2. Pre-post intervention comparisons in patients and companions.Patients Companions

Pre-interventionMean (SD)

Post-interventionMean (SD) t d

Pre-interventionMean (SD)

Post-interventionMean (SD) t d

Pain 4.17 (2.71) 3.86 (2.65) 1.83 .11 _ _ _ _Fatigue 5.28 (3.12) 4.44 (2.94) 4.28a .28 _ _ _ _Somnolence 4.06 (2.77) 3.93 (2.74) .79 .05 _ _ _ _Breathingdifficulties

3.11 (2.39) 3.00 (2.37) 1.02 .05 _ _ _ _

Discouragement 4.62 (3.10) 2.99 (2.76) 3.16a .55 4.42 (2.67) 2.48 (2.07) 6.17a .81Anxiety 4.91 (3.01) 2.99 (2.74) 4.17a .67 4.70 (2.91) 2.65 (2.21) 5.82a .79Boredom 4.89 (3.18) 2.85 (2.81) 3.97a .68 4.96 (3.18) 2.35 (2.22) 6.80a .90Sadness 4.37 (2.87) 2.70 (2.62) 3.52a .61 4.57 (2.89) 2.27 (1.82) 6.43a .91Anger 3.71 (2.78) 2.22 (2.40) 2.27a .57 3.39 (2.62) 1.78 (1.75) 2.77a .72Worries 6.23 (3.04) 4.01 (3.01) 4.92a .73 6.96 (3.22) 4.20 (2.95) 6.28a .88Deception 4.41 (2.88) 2.88 (2.78) 2.40a .54 4.40 (2.58) 2.56 (2.44) 3.76a .73Fear 4.81 (3.12) 3.27 (2.95) 2.79a .51 5.15 (3.01) 2.88 (2.47) 3.61a .82Well-being 4.68 (2.77) 5.10 (3.08) 1.87 .14 2.88 (2.36) 5.04 (2.66) 4.50a .85Laughing 4.20 (2.94) 6.60 (3.08) 4.35a .79 3.75 (2.62) 7.01 (3.29) 7.01a .93Happiness 3.80 (2.71) 5.56 (2.87) 2.80a .63 3.61 (2.45) 5.68 (2.78) 5.03a .79

aStatistically significant pre-post changes (p <.05)

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Discussion

The present study is a single-group, pre-post, quasi-experimental study of a time-limitedintervention to identify any associations between clowning performances and improve-ments in psychological and/or physical state among patients and their companionsawaiting oncology appointments in hospital waiting rooms. We also aimed to recordthe opinions of health professionals on the possible effects of the presence of clowns inthe hospital on their work. The study design did not allow the inclusion of a control groupor any longitudinal assessments, and the findings must be considered within this limitedcontext.

The study consisted of within-subject analyses of both patients and companions. Inpatients, 11 out of the 15 areas explored were reported to be improved as a result ofclowning performances (fatigue, discouragement, anxiety, boredom, sadness, anger,laughing, happiness, worries, deception, and fear). The results also showed that thelargest improvements were related to psychological rather than physical symptoms.These results support the idea that a 15-minute clowning intervention may prompt animprovement of patients’ psychological outcomes (including improvements in bothnegative psychological symptoms – discouragement, anxiety, sadness, anger, worries,deception or fear – and the positive symptoms – feeling like laughing, happiness), but nottheir physical symptoms (only reporting an improvement in fatigue). Similar data was alsofound in a study by Dionigi et al. (2014), in which hospital clowning reduced anxiety inyoung children awaiting surgery in hospital waiting rooms, but not their physical pain.However, some studies have found that clowning may reduce pain perception in inpa-tient samples, as well as anxiety (Koller & Gryski, 2008). Therefore, it seems that clowninghas an influence on psychological areas, but there is no consensus about its power interms of the perception of physical symptoms in ill people.

The results also showed that clowning had similar or even greater effects on compa-nions than on patients. Specifically, companions showed an improvement in all thepsychological outcomes explored, including both the negative (discouragement, anxiety,boredom, sadness, anger, worries, deception, and fear) and the positive ones (well-being,happiness, and feeling like laughing). The effect size of clown performances was alsogreater among companions than among patients. These results may be explained by thefact that significant others also suffer from some emotional consequences of their lovedone’s cancer (Northouse et al., 2007; Segrin et al., 2012; Sjövall et al., 2009). Then, althoughsuffering is greater among patients than in their companions, companions may feel that

Table 3. Professional’s perception of the presence of hospital clowns in their workplace (N = 31).Increases (N; %) No effect (N; %) Reduces (N; %) χ2

Nervousness/anxiety 1 (3.2%) 13 (41.9%) 17 (54.8%) 13.42**Boredom 0 (0%) 10 (32.2%) 21 (67.7%) 3.90*Sadness 0 (0%) 12 (38.7%) 19 (61.3%) 1.58Anger 0 (0%) 14 (45.2%) 17 (54.8%) .29Well-being 22 (70.1%) 7 (22.6%) 2 (6.5%) 20.97**Laughing 27 (87.1%) 2 (6.5%) 2 (6.5%) 40.32**Happiness 20 (64.5%) 11 (35.5%) 0 (0%) 2.61Worries 0 (0%) 17 (54.8%) 14 (45.2%) .29Working-time perception 0 (0%) 12 (38.7%) 19 (61.3%) 1.58

*p <. 05; **p <.01

10 A. CASELLAS-GRAU ET AL.

the performance is beneficial for their significant other. Therefore, clowning may havea double effect on companions: improving their own psychological state, and makingthem feel that their loved one is having an enjoyable experience. Some studies supportthis latter statement; Koller and Gryski (2008), for instance, found that most parents of sickchildren (94%) reported that they enjoyed clowning and were also happy to feel that theirchildren enjoyed the performances and were happier after clowning visits. In the quali-tative study by Tan et al. (2016) parents of sick children also reported that clowninginterventions not only improved their children’s well-being, but that of close familymembers as well.

With regard to the health-care professionals, the results showed that the presence ofclowns in the workplace had a positive effect on workers, who felt greater well-being, feltmore like laughing, and were less anxious or bored. These results are consistent with thestudy by Tanay et al. (2013), who found that humor helped to lessen work-related stress,build a good working atmosphere and promote happiness, and also with the study byWarren (2008), who reported that hospital clowns brightened the mood of nurses, doctorsand other health-care staff. Similarly, Koller and Gryski (2008) stated that health-careproviders showed positive changes in their behavior and mood when clowns were present.However, in our study, some professionals questioned the presence of clowning in hospital.Koller and Gryski (2008) also found that not all professionals favored the presence ofclowning in health centers, some considering that clowning interfered with the proceduresin spaces such as operating rooms. Professionals in Battrick et al. (2007)’s study, and some ofthe staff who participated in our study, disapproved of the presence of clowning in theirworkplace. It is important for clown teams to be aware of any difficulties they might cause.

In general, in agreement with other studies (Higueras et al., 2006), we found thathospital clowns are well regarded in the hospital context. It would be worthwhile toconsolidate their presence in adult health centers since patients, companions and healthprofessionals all feel better as a result of their performances or their presence in theworkplace.

Although this study yielded meaningful findings, it is not without limitations. First, norobust causal relationships can be identified due to the absence of a control group.During the study period, the waiting rooms for cancer patients did not have free hoursfor the clown performances, and so a control group could not be created. So, if we hadwanted to keep some patients from viewing the clown performances, we would havehad to place them in separate areas not designated as waiting rooms; this would havecaused disruption for these patients and would have created an unnatural conditionthat reduces the ecological validity. We suggest that future studies include a controlgroup by assessing patients who do not see the clown performances, and explore theirchanges between two assessment times (as in the intervention group). This designwould indicate causality between clown performances and psychological/physicalchanges among patients or companions. Second, the cross-sectional design precludesany conclusions regarding long-term effects of clowning on patients, companions, andprofessionals, and so longitudinal studies should be designed in order to obtain causalexplanations of these effects. Third, the study was conducted at a single center,a circumstance that limits the extrapolation of results to other contexts. Finally, theparticipants’ responses may be biased by social desirability, a common problem inpsychological studies.

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Acknowledgments

We thank CERCA Programme/Generalitat de Catalunya for institutional support.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Funding

This work was funded by Fundació Nous Cims, Pallapupas, and by Instituto de Salud Carlos IIIthrough the project (FIS PI15/01278) Co-funded by European Regional Development Fund. ERDF, “away to build Europe)//FONDOS FEDER “una manera de hacer Europa”). It is also partially supportedby grants from Asociación Española Contra el Cáncer [the Spanish Association Against Cancer](AECC)-Cataluña. Grup de recerca consolidat: Recerca en serveis sanitaris en càncer.2017SGR00735.

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