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

Within the past decade, there has been a surge of interest in investigating the effects of clown intervention in a large variety of clinical settings. Many studies have focused on the effects of clown intervention on children. However, few studies have investigated clowning effects on adults. This paper presents an overview of the concept of medical clowning followed by a literature review conducted on the empirical studies drawn from three data bases (PubMed, PsycINFO, and Google Scholar), with the aim of mapping and discussing the evidence of clowning effects on non-children, namely adults. The following areas were investigated: Adult and elderly patients (mainly those with dementia), observers of clowning, namely non-hospitalized adults who are at the hospital as relatives of patients or health-care staff, and finally clowns themselves. The main results are that 1) clown intervention induces positive emotions, thereby enhancing the patient’s well-being, reduces psychological symptoms and emotional reactivity, and prompts a decrease in negative emotions, such as anxiety and stress; 2) clown doctors are also well-perceived by relatives and healthcare staff and their presence appears to be useful in creating a lighter atmosphere in the health setting; 3) few pilot studies have been conducted on clown doctors and this lacuna represents a subject for future research.


Literature Review
We first conducted a literature search in PubMed (using the publication dates January 1960-December 2015), since it is one of the most extensive and widely acknowledged databases used by science professionals with the aim to detect empirical studies that involved non-children. We used the following terms: "clown" OR "clown doctor" OR "clown therapy" OR "medical clowning" OR "hospital clown" OR "clinic clown." The search terms were used for all fields (including title, abstract, keywords, and full text), and only papers written in English were included.
The search revealed 115 reports. We excluded 105 papers: Some were not relevant (70); some comprised theoretical issues (15); and others concerned empirical studies conducted primarily on children (20). Therefore, we reviewed a total of 10 empirical studies. The literature search proceeded with a focused exploration using the same terms as noted earlier, with the following preliminary criteria: 1) peer-reviewed full paper published in an international venue; 2) empirical study included; 3) studies published in English. Dionigi & Canestrari 475 dence relating to the impacts and outcomes of clown intervention; (b) have been published during the period January 2005 to December 2015; c) include an abstract; and d) include participants over the age of 18 years.
Using these four conditions, we then screened titles, abstracts, and (where possible) the full text of the manuscripts in order to exclude non relevant reports. Five reports were excluded, resulting in a final total of 20 papers that met the inclusion criteria and were identified as relevant to the current review. Details of the chosen papers are given in Figure 1.

Results
Our literature review revealed that the 20 selected papers concerned one of the four following topics: 1) the effects of clown intervention on adult patients (for the most part, these studies mainly used experiments designed by the researchers); 2) research conducted on the elderly (mainly those with dementia); 3) the effects of clown intervention on health-care staff and relatives (these studies used either evaluative interviews or questionnaires); and 4) research conducted in respect of the psychological and artistic aspects of clowns. A brief summary of the main features of the studies reported in the 20 papers discussed is provided in Table 1. Table 1 Details of the Reviewed Studies Chronologically Listed.

Results and Conclusions Methods Aims/Objectives of study Sample Author(s)
Nurses' anxiety was not reduced in the clown group and some nurses even showed increased anxiety when working with clowns. Nurses Angotti et al. (2015) total of eight times each (4 times with clowns and 4 without).
The main important practice utilized by clowns was the "relational presence" that can be 23 elderly participants with dementia (16 female, M = 87.8 years SD = 8.0) were involved in the To examine elderly-clown practice and techniques based Elderly patients Kontos et al. (2015) achieved through specific strategies between study. A clown duo visited the residents twice on qualitative interviews and ethnographic observations. with dementia the clowns and the resident: (a) affective a week over a 12-week period. Each clown relationality; (b) reciprocal playfulness; and (c) co-constructed imagination. duo-resident visit was video recorded to facilitate subsequent analysis.
In the clown group the perceived stress and anxiety were reduced as well as anxiety and 25 mothers were included in the clown group (Age= 36.45 ± 5.71)   Nurses Blain et al. (2012) present. Nurses' negative moods were reduced emotion and anxiety were measured in 9 out of but no changes in anxiety were found. 13 nurses under two conditions (the presence or absence of clowns.) Qualitative data suggests that clown interventions also have a relational impact on nurses.
The clown was able to bring pleasure and peace. The clown and the person with dementia Clowns were required to report their activities and feelings experienced during their work.
To illustrate the effect of clowns on patients with dementia from escape, self-injury, and fighting were significantly reduced.

Clown Intervention on Adult Patients
Clinic clowning, which may on the surface appear to be only a children's issue, is increasingly being applied in the care of adults and the elderly. One of the first studies on the efficacy of clowning in the treatment of adult patients was conducted in Switzerland: Brutsche, Grossman, Muller, Pello, Baty, and Ruch (2008)  Clowning in Health-Care Settings 478 into account. Findings of this study need to be validated with larger samples and focused on a more reliable appreciation of the effect size and duration.
A study by Friedler et al. (2011) indicated that women entertained by a clown doctor after in vitro fertilization had more successful fertility treatments and increased pregnancy rates. This quasi-randomized study was conducted in an Israeli hospital and included 219 patients (110 in the intervention group and 109 in the control group) who underwent in vitro fertilization (IVF) and embryo transfer (ET). Only women in the intervention group received a clown visit after the ET. Each encounter lasted 12-15 minutes and included a routine based on jokes, tricks, and magic. Results showed that the pregnancy rate in the intervention group was significantly higher compared with that of the controls, perhaps due to stress reduction produced by the use of humor and medical clowning: Stress reduction, in fact, might improve fertility, resulting in positive effects on the engraftment. What seemed to work best was that, during the encounter with the medical clown, the patient was actively involved in the relationship in which she responds spontaneously to the ongoing interaction leading to a better involvement.
While the majority of studies conducted so far have investigated the role of clowns in reducing negative emotions, Auerbach, Hofmann, Platt, and Ruch (2014)

Clown Intervention on the Elderly and Patients With Dementia
Although few studies have been conducted on adult patients, research about clowns working in health-care has often focused on disabled patients, such as those affected by dementia or psychiatric diseases. Higueras et al. that it reduced only three specific behaviors significantly (attempted escape, self-injury, and fighting). That was the first study conducted to evaluate the use of humor as a tool in therapy for severely ill patients. Results are not equivocal as only some DB decreased. Nevertheless some DB's increased in frequency (such as refusal to cooperate and shouting) and authors related it to a higher disinhibition caused by the clown approach. However, the lack of control in the clown activity may have had an influence on this.
Clowning seems to also improve the quality of life of nursing home residents: Hendriks (2012) conducted an autoethnographic study in the Netherlands that focused on a special form of clowning for people who were at an advanced stage of dementia. The author revealed that the clown and the person with dementia were involved in a process of mutual articulation that helped patients to "be in touch" with their bodies. As a result of the clown activities, residents' bodies became engaged in sensory conversations with other people. Although the results are intriguing, they lack systematic rationale as well as solid methodology as the analysis primarily concerns sensory conversations in the here and now. Future research should try to optimize and present robust data and results in order to generalize these.
Low and colleagues (2013) in a recent Australian study used a single-blind, two-group, longitudinal cluster randomized controlled study to evaluate the effects of clowning on elderly residents in 35 Sydney nursing homes.
The intervention group comprised 189 elderly patients in 17 nursing homes; the control group consisted of 209 residents in 18 nursing homes. An integrated humorous approach that consisted of 1-day LaughterBoss training for each home's nominated staff member, followed by 9 to 12 humor-therapy sessions by an Elder Clown, was used with the experimental group. Participants were assessed for depression using the Cornell Scale for Depression in Dementia (CSDD) and for agitation using the Cohen-Mansfield Agitation Inventory (CMAI) at three different times: Baseline (Week 0), post-session (Week 13), and follow-up (Week 26). The humorous approach (both the humor session and the clown intervention) did not significantly reduce depression but significantly reduced agitation.
The authors pointed out that most of the subjects scored very low (floor effect) in relation to depression, as only 29% of the sample was assessed to have probable or possible depression, which could have influenced the results.
The limitations of this study concerned variations between residents in the number of Elder Clown sessions they received and unbalanced baselines in several outcome measures between the two groups. Kontos, Miller, Mitchell, and Stirling-Twist (2015) conducted a study to evaluate a 12-week Elder Clown program involving 23 residents of a dementia unit in a long-term care facility. The study involved 23 elderly participants (16 females and 7 males) who were primarily affected by Alzheimer's disease (73.9%); the mean age was 87.8 years (SD = 8.0). Two clowns visited the residents over a 12-week period, and each visit lasted approximately 10 minutes. In order to facilitate the analysis, every clown visit was video-recorded. The main finding of the analysis was what the authors have defined as "relational presence." This term captures "the reciprocal nature of engagement during plays, and the capacity of residents to initiate as well as respond to verbal, embodied, emotive, and creative engagement" (Kontos et al., 2015, p. 5). This peculiar presence is related to three core aspects: (a) affective relationality; (b) reciprocal playfulness; and (c) co-constructed imagination. Again, more than humor, in this study the opportunity to be "in touch" between the elder and the clown was the most important aspect. However, future re- Clowning in Health-Care Settings 480

Perceptions of Clown Intervention by Relatives and Health-Care Staff
The studies reviewed so far are related to clowning effects on patients, whether adults in general or elderly in particular, namely hospitalized people. Another set of empirical studies on -generally speaking-non-children, focuses on clowning effects on observers, namely non-hospitalized adults who are in hospital because they are relatives of patients or health-care staff. A Cochrane review (Yip, Middleton, Cyna, & Carlyle, 2011) showed that parental anxiety is common during a child's hospitalization and surgery due to parents' perception of the child's Humor is considered to be a positive trait that may help nurses and doctors to cope with their work and to create a better atmosphere on the ward (Ruch, Rodden, & Proyer, 2011). Some studies on the interaction between clowns, patients, families, and staff have revealed a general acceptance of the clowns. Battrick, Glasper, Prudhoe, and Weaver (2007)  tionships among the various participants. Moreover, the positive outcome of the clown interventions is based on the skills of the performer and it is not easy to evaluate the positive effect systematically. Koller and Gryski (2008) surveyed 143 staff members and 51 parents regarding the clown visits in a pediatric clinic in Toronto. Eighty-five per cent of the staff appreciated the clown visits, and nearly half of participants reported that the clowns supported their own work. Similar results were found for parents. In a German study (Barkmann, Siem, Wessolowski, & Schulte-Markwort, 2013), 87 hospital clowns, 37 parents, and 43 hospital staff members were recruited through an online survey aimed at clarifying the structural and procedural conditions of pediatric clowning. Both parents and staff indicated that they, as well as the patients, benefited from clown intervention.
Results from this study are positive, questionnaires were developed for the study's objective and frequencies about different appreciation variables were calculated. Again, the perception (in the two countries) is good and this speaks in favor of a greater inclusion of clowns in health settings. However, it would be helpful to have a higher correlation between the appreciation and psychological aspects (e.g. personality traits) for both clowns and participants.
A Canadian study by Blain, Kingsnorth, Stephens, and McKeever (2012) that involved 13 nurses investigated the effects of therapeutic clowns on hospitalized children. In addition to questionnaires, in nine cases, measurements of physiological arousal, emotion, and anxiety were obtained, both during the presence and the absence of clowns.
Results showed changes in the automatic nervous system signals of eight nurses during the clown interventions.
Moreover, the nurses' negative moods were also reduced, although no changes in anxiety levels emerged. The main concern about this study lies in the small sample utilized and the lack of investigations of further personal to 131 baccalaureate nursing students. They conducted an 18-month follow-up evaluation survey: Based on the 40 questionnaires returned, it was possible to establish that the majority of participants appreciated and went on to apply competences acquired during the workshop. The two studies vary in length and participation, but similar (four instances with clowns and four without). Results showed that, compared to the control group, the nurses' anxiety was not reduced but actually increased. This study shows specific limitations such as the very small number of participants and results which go in the opposite direction compared with the expected ones. Future research with larger groups must be conducted in order to improve understanding of the role of clowns in decreasing staff anxiety. It must be hypothesized that, since clown intervention is primarily directed towards the patients, nurses (even if involved) may not perceive the intervention as a coping strategy to deal with anxiety.

Studies Conducted on Clowns: Psychological and Artistic Aspects
Research has mainly focused on the overall effects of hospital clowns. Although the importance of extensive training for clowns before entering the medical setting is acknowledged as important (e.g. Dionigi et al., 2012), little is known about the psychological characteristics of clown doctors. Some pilot studies have been conducted on clown doctors; however, they have included only small groups whose members often belong to the same Clown Care Unit (sharing a common training and operative model). Linge (2008) conducted a qualitative study on 13 clowns (three males and 10 females) in order to evaluate significant aspects of their activity: In this research, the artistic and psychological potential of working in pairs clearly emerged.
Nuttman-Shwartz, Scheyer, and Tzioni (2010)  The two pilot studies show specific limitations due to the small number of participants, the relative restricted field of knowledge to be acquired and a lack of inter-difference in the approach utilized. However, the results may have an impact in developing more detailed and focused future research.
For example, starting with the assumption that a clown doctor capable of differentiating himself/herself from his/her playing a clown is more often perceived to be a good clown (Nuttman-Shwartz et al., 2010), Dionigi et al. (2014) designed a study aimed at capturing the essence of what it means to be a clown doctor. The authors claimed that assuming the clown role requires a cognitive shift that leads the clown doctor to perceive the world and to act in a different/unusual and foolish way, so that (almost) everything is permitted. The authors call this transition a "clown shift," which represents the cognitive change that occurs when a person leaves the habitual state of mind to enter the clown's state of mind and vice versa. People may differ in shifting in and out: Dionigi et al. (2014)  Secondly, the study refers to data coming only from a specific population (Italian clown doctors) and future studies with different participants are needed.

Discussion
Humor is an important part of life. In the last 30 years there has been a growing interest in its application in several contexts such as hospitals and homes, healthcare clowning now represents a well-defined approach. The small number of papers identified using our search terms confirmed that although there has been a surge of interest in healthcare clowning, as clowns are involved worldwide, little research has been conducted so far: Empirical evidence of such interventions is very sparse. A large amount of studies (not related to this paper's aim) is related to studying the efficacy of clown interventions on children (see Finlay et al., 2014;Sato et al., 2016). One possible explanation is that clown intervention is generally addressed to children: Kids tend to be enthusiastic when encountering a clown who is able to capture their attention through comedy, gags, magic and props. Nevertheless, the first clown care unit (set up in New York) worked specifically with children. This may have led to imprinting the use of clowns in health settings. However, the healthcare clowning movement is increasing as are the application fields: Adults, the elderly, psychiatrics, healthcare staff are only some of the recipients of this approach, who have also received more attention from research.
Across the breadth of the literature reviewed, some studies have been conducted with the elderly or with patients suffering from psychiatric diseases: The core aspects of these studies were not restricted to the use of humor but also involved relational competences that every Healthcare Clown must possess. Clown intervention with adults and the elderly is a promising practice for improving the quality of life of recipients. From a broader perspective, in fact, the work of clown doctors aims to empower interpersonal relationships and to modify the atmosphere A number of studies conducted on relatives of hospitalized patients has focused on assessing whether this approach may be useful to them as well as to children. The literature review presented here shows how clown intervention is helpful in reducing stress and anxiety in parents of hospitalized children, although this evidence is very sparse.
Rigorous evaluations of the therapeutic effects of clowning are complex, as clowning is a multimodal intervention that is set according to medical conditions, procedures, family functioning, and health-care teams (Ford et al., 2014). Moreover, clown intervention covers a large variety of activities: During their performances, clown doctors are required to adapt their techniques while keeping in mind that their goal is to change the emotional state of the patient and to improve the patient's environment.
Finally, there is a paucity of studies about clown doctors themselves: Two out of the three studies evaluated in this literature review are qualitative studies and have been conducted on very small samples (two and 13 clowns).
However, these two studies provided the basis for a subsequent research about important aspects for playing the role/dressing the part of the clown (Dionigi et al., 2014) even though specific limitations emerged about the construction of the main questionnaire and the sample involved. In this regard, further research should be undertaken to shed light on the psychological and artistic skills of clown doctors, which may contribute to identify those characteristics required to hire the best candidate with the potential to lead to positive patient interventions.
To sum up, research in the field of healthcare clowning is very young: The first published article evaluating the efficacy of a clown intervention in decreasing children's preoperative anxiety dates back to 2005 (Vagnoli et al., 2005). Since then there has been a growing number of studies, and these studies concerning the efficacy of clown doctors have indicated a general effectiveness in several fields. However, according to the presented results, further research should focus more on adult patients, within different hospital departments (such as oncology, orthopedics, etc.) on elderly and disabled people, where clowns have proven to be effective in inducing positive emotions, as well as on the perception of relatives and healthcare staff. In this regard, it would be important to set protocols and standardized approaches founded on evidence-based results in order to establish well-defined guidelines for different patients.
From a broader perspective, the work of clown doctors aims to empower interpersonal relationships and to modify the atmosphere within the care setting by bringing something positive, unexpected, and unconventional (Warren & Spitzer, 2013). Although research is progressing, there is still a gap in determining which aspects are more relevant in leading to positive results. Undoubtedly, humor is an important aspect but not the only one: Further studies should consider which features of affectivity are induced, as well as which positive emotions are elicited during the different gags.

Funding
The authors have no funding to report.