Post on 11-Mar-2016
description
1
An Investigation into the Clown Doctors Programme
Original Report by Elise Danks June 2010
Reviewed by Clare Andrews September 2010
2
Abstract
The aim of this research is to assess the effectiveness of the Clown Doctors Programme
currently ongoing in Newcastle. It will assess the impact that the Clown Doctors have on the children,
families and staff that have contact with. It is hoped the research will determine the effectiveness of
the Programme and highlight any possible improvements.
Research was conducted on Clown Doctors visits in the Freeman Hospital, Newcastle
General Hospital and the Great North Children’s Hospital. The research consisted of observations of
Clown Doctor’s visits, in depth interviews with patients and their caregivers, and questionnaires
issued to staff.
Importantly it was found that the Clown Doctors had a positive impact on the physical and
mental wellbeing of the children they visited and were generally well received by parents and staff.
Furthermore it was found that the effectiveness of the programme was due to features specific to the
Clown Doctors, such as their emphasis on interactive one-on-one visits that were specific to the
individual child’s needs.
Suggested improvements to the Programme include more contact time in the hospitals and
visits to a wider range of hospitals. This research had some methodological flaws in the recruitment of
participants and could be improved upon by increasing the sample size and issuing questionnaires to
a wider range of staff.
3
Introduction
Although numerous studies have suggested that clown doctor programmes throughout the
world have positive effects on the patients and families they visit, there has been no thorough
research into the effectiveness of the Clown Doctors Programme currently ongoing in the north east
of England. By observing Clown Doctors visits, conducting in depth-interviews with children and their
families, and issuing questionnaires to staff, this study will attempt to gauge the effect of the Clown
Doctors on those they have contact with. Previous research indicates that the clown doctors will
reduce the anxiety levels of the patients and parents (Vagnoli, Caprilli, Robiglio, & Messeri, 2005;
Fernandes & Arriaga, 2010), and generally improve the quality of the hospital stay for patients and
their families (Miller Van Blerkom, 1995; Koller & Gryski, 2007; Battrick, 2007). Previous research is
inconclusive as to whether staff will see the programme as improving their working atmosphere (Miller
Van Blerkom, 1995), causing a disruption to medical procedures, (Vagnoli, Caprilli, Robiglio, &
Messeri, 2005) or a combination of both (Koller & Gryski, 2007; Battrick 2007). However with a study
of this nature previous research can only provide a small amount of insight into the expected outcome
as different clown doctor programmes may vary greatly in the quality and type of care they deliver.
4
Section 1 - Observations
Participants
Thirty three observations were made from the Freeman Hospital, Great North Children’s
Hospital and Newcastle General Hospital. Some observations record the reactions of individual
children in one-on-one visits; some record the reactions of individual children who were part of group
visits, and two are overviews of large group visits.
Results
Figure 1 shows the percentage of observations falling into each category for how the child’s mood appears to change during observations.
Figure 1 shows that the majority of participants observed experienced a very positive change
in mood during the Clown Doctors visit (86%). Those categorised as having ‘no mood change’ were
often too ill or too young for the observer to really show any improvement in mood. The data implies
that the Clown Doctors have a very positive effect on the majority children they visit, however further
investigation may be needed to understand how they affect those children who are very young or very
ill.
86%
0% 14%
0% 0%
Yes, very positively
Yes, Somewhat positively
No
Yes, Somewhat negatively
Yes, Defiinitly negatively
Does the child's mood to change appear during the visit?
5
Figure 2 shows the percentage of observations falling into each category for how play-directed or appropriate to the child’s needs and/or interests the visit is.
Figure 2 shows that the large majority (90%) of the interactions were felt to be relevant to the
individual child. These visits were either directed by the child (this was often the case with children
more familiar with the Clown Doctors) or the Clown Doctor artists more generally responded to the
child’s interests or needs in terms of age, special requirements, ability, favourite toys etc. Of the two
visits categorised as ‘somewhat child directed/ appropriate’, one was to an older child in a room of
younger children and the play appeared too childish for him to engage with. On the other occasion the
child had special needs and was very demanding of the Clown Doctors’ time. It appeared that an
individual rather than a group visit, or a visit where he had his own time slot would have been more
appropriate. However this may not have been possible due to the nature of the hospital layout and the
fact that the child was in an open plan room.
The one visit which was categorised as being not ‘child directed/ appropriate’ to the child’s
needs was categorised in this way because the Clown Doctors engaged in a game to do with talking
about food after the parent had expressed it was a nil-by-mouth ward. Also this child was trying to
remove her bandage, something which the Clown Doctors could possibly have tried to distract her
from. However this was on the whole not a bad visit and the parent did not rate it negatively. On the
whole it was concluded that the Clown Doctors were very responsive to children’s individual needs.
90%
7%
3%
Yes
Somewhat
No
Is the play child-directed/ appropriate to the child's needs and/or interests?
6
Figure 3 shows the percentage of observations in which the child demonstrates each mood when the Clown Doctors visit finishes, immediately after the Clown Doctors leave the room.
Figure 3 shows that the majority of children (87%) were in a positive (either very positive or
fairly positive) mood immediately after the Clown Doctors left the room. The mood of children did
sometimes drop slightly though due to them being upset over the departure of the Clown Doctors. The
children whose mood after the Clown Doctors left was unknown generally had to leave for a medical
procedure before the end of the visit. The one child (3%) who was judged to be in a fairly negative
mood was particularly distraught at the departure of the Clown Doctors.
Figure 4 shows the percentage of children that interact with the clown doctors. ‘Not possible’ is defined as children who are too young, too ill or lack the understanding to interact regardless of the Clown Doctors performance.
Figure 4 shows that all children capable of interacting with the Clown Doctors did so in some
way. This ranged from younger children simply following the Clown Doctors with their gaze, to
children with impairments in verbal communication pointing and gesturing and older more able
55%32%
3%0%
10% Very postive
Quite positive
Quite negative
Very negative
Unknown
In what mood is the child when the Clown Doctors leave?
86%
0% 14%Yes
No
Not possible
Where possible does the child interact with the Clown Doctors?
7
children interacting verbally. Those children judged not able to interact were often very ill or very
young.
Figure 5 shows the percentage of those parents who stayed in the room according to whether they appeared to enjoy the visit. ‘Unsure’ refers to parents who showed no clear indication of either liking or disliking the visit.
Figure 5 shows that of those caregivers present for the Clown Doctor visit the majority
appeared to enjoy the visit (78%). A small proportion showed no real interest either way, of the three
participants who didn’t appear to enjoy the visit, two were very distressed by their child’s ill health and
the other seemed inconvenienced by the Clown Doctors’ arrival.
On the whole observations found visits were generally very positive with only a few minor
problems. These problems were not specific to any hospital, although the larger rooms in some wards
were responsible for the visits being less personalised. There was also one large-scale visit in the
Great North hospital that took place in a corridor and possibly inconvenienced some staff. It can be
concluded that visits nearly always improved the child’s mood, were well received by caregivers, were
directed to the individual child, encouraged interaction from the child, and left the child in a positive
mood.
78%
13%
9%
Yes
No
Unsure
Does the carer/parent appear to enjoy the visit?
8
Section 2- Caregiver Interviews
Participants
Thirteen parents or caregivers of patients were interviewed from the Freeman Hospital, Great
North Children’s Hospital and Newcastle General Hospital. Participants were opportunity sampled
from a number of caregivers who witnessed the Clown Doctor visits to their child.
Results/ Discussion
100% of participants said they would be happy for the Clown Doctors to see their child again,
often citing reasons to do with how happy the Clown Doctors made their child. Furthermore as Figure
6 shows participants tended to rate the Clown Doctors highly (around 5.5 on average), claiming the
Clown Doctors made their child happy or very happy and that they either liked or really liked the
Clown Doctors.
Figure 6 shows the average ratings of how participants think the Clown Doctors made their child feel on a scale of 1-6, and what their own personal opinion of the Clown Doctors Programme is.
When asked what they liked about the Clown Doctors a number of participants replied that
they liked specific games or toys such as the bubbles, the hand puppets and the music. Those who
had seen the Clown Doctors more tended to give more in-depth answers to this question, often talking
about how good the Clown Doctors were at addressing their child’s individual needs (39% of
participants mentioned this; all but one of them had seen the Clown Doctors before). This included
praise for how the Clown Doctors catered for their child’s special needs or level of understanding, that
0
1
2
3
4
5
6
How do you think the Clown Doctors made your child feel, on a scale of 1-6?
What is your personal opinion of the Clown Doctors Programme, on a scale of 1-6?
Rating
9
they played the games their child liked, talked to their child directly or improved their child’s education
by playing the same games with them week after week (it was also observed that Clown Doctors did
play games that were educational in their basis).
When asked what the participants didn’t like about the Clown Doctors the majority of
participants said there was nothing that they didn’t like. A further two participants mentioned that they
think the children would benefit from having something (more than a sticker) left behind as a token of
their visit such as a balloon animal or face painting. Indeed one participant’s child did get upset at the
Clown Doctors’ departure. One patient responded that the previous week the Clown Doctors did not
seem to realise that her child had special needs and dismissed him as too old to entertain, focusing
their attention on the other younger children in the room. This particular incident occurred in the
Freeman Hospital whilst the play specialist was on maternity leave which may have led to the problem
with referrals the participant reported.
In response to the question ‘in your opinion have the Clown Doctors had any impact on your
child’s physical or mental wellbeing?’ the majority of patients (84%) claimed they that they had, with
the remaining two saying they didn’t know. The most common response was that the Clown Doctors
had cheered their child up, with one participant saying,’ Last week [her child] was the most miserable
person on earth, the clown doctors were the first person [sic] to get a smile out of him’. Furthermore
one participant noted that the Clown Doctors had improved her child’s physical health because the
laughter helped her cough and was good physiotherapy. Results were less certain when participants
were asked if the Clown Doctors had changed their or their child’s opinion of hospital with most
parents saying they didn’t know the answer; others mentioning that they had never heard of anything
like the Clown Doctors before and that they had improved their child’s mood. Overall response to
these questions was poor and they may need to be reworded or omitted from future research.
Four of the participants had seen ward entertainment before (four had seen the Clown
Doctors, one had also seen the magician); all of these participants said there was nothing different
about the two visits. 84% of participants said that the arts should be included in hospitals, with the
remainder saying they didn’t know. Three participants specifically said they would like more arts in
hospitals. Figure 7 shows that the majority of participants thought that the Clown Doctors Programme
should be at least partially funded by the NHS; those who said charities should fund the Programme
10
explained their answer as due to lack of finance in the NHS rather than the Clown Doctors not being a
worthwhile programme.
Figure 7 shows the percentages of people who thought the Clown Doctors should be funded by charities, the NHS or didn’t know.
The final question asked participants what they would do differently if they were in charge of
the Clown Doctors Programme. Here there was a large proportion of people who didn’t know (46%),
and a number of people (39%) who thought the Clown Doctors should visit more often and/or be
available across a wider area. A further 15% thought the Clown Doctors should give the patient
something more when they finish a visit.
Overall all participants mentioned something positive about the Clown Doctors and 100% said
would be happy for them to visit their child again. Parents seemed to really like the Clown Doctors
and viewed them as very beneficial to their child’s mental wellbeing, cheering them up in this time of
need. The most common suggested improvements were that the Clown Doctors should visit more and
leave the child with something more on their departure.
31%
15%
54%
Who do you think should pay for the Clown Doctors?
Don't know
Charities
NHS
11
Section 3- Patient Interviews
Participants
Seven patients were interviewed from the Freeman Hospital, the Great North Children’s
Hospital and Newcastle General Hospital. Only a small number of patients visited were deemed
capable of participating in an interview as many were too ill or not capable of understanding the
questions and/or communicating answers. Of those eligible for interview, participants were
opportunity sampled from a number of patients across the paediatric wards.
Results/ Discussion
When asked how the Clown Doctors made them feel all the children selected the Very Happy
smiley face card from a range of cards depicting emotions from very unhappy to very happy. When
asked what they liked best about the Clown Doctors three children identified particular props the
Clown Doctors had used, another child claimed to like the music and the way the Clown Doctors
improvised. The rest of the children’s answers centred on how the Clown Doctors had improved their
mood, for example one child exclaimed ‘they make me laugh they are very funny and they make me
feel joyful, they make me like yippee!’ When asked what they didn’t like the majority of children
claimed that there was nothing; however one child said that the Clown Doctors should tell more jokes
and another said that the visits go on for too long. Three children dropped out after this section of the
interview because of a lack of understanding or attention.
When asked what they would tell people about the Clown Doctors the children all gave
positive responses focusing about how the Clown Doctors made them happy; for example one child
said ‘I've told everyone I know about the clown doctors, I see them every time I go to hospital and I tell
everyone they are hilarious, they come up with everything’. When asked what she would tell others
about hospital the same child went on to say that she would tell people about the Clown Doctors
because ‘they are the first thing I think of when I think about hospital’. Although responses to these
questions were limited this older child’s (age 12) answers show that Clown Doctors are an integral
part of the hospital experience for at least some children.
Of the four children asked what they would do if they were a Clown Doctor one child claimed
he simply wouldn’t do the job. The others talked mostly about making people laugh, for example one
eight year old said she would ‘make children happy and I'd make little babies laugh and giggle and
12
smile’; in this instance the child clearly saw the job of the Clown Doctors as making children happy.
As an interesting aside, when asking a parent who should fund the Clown Doctors Programme, one
nine year old girl responded ‘the NHS because the Clown Doctors make you better and it’s the NHS’s
job to make you better’, displaying that the child viewed the Clown Doctors as a very integral part of
her care.
Overall although the data is limited it does show that children generally have a very positive
attitude towards the Clown Doctors. This is supported by the findings of the observations that show
children’s mood generally appears to improve during visits, and parents’ claims that Clown Doctors
have a positive impact on their children. However more research is needed to better understand what
more children would like from the Clown Doctors.
13
Section 4- Staff Questionnaires
Participants
Ten members of staff from across the Freeman Hospital, Great North Children’s Hospital and
Newcastle General Hospital were issued with questionnaires (See table 2). Participants were
opportunity sampled from a number of staff on the paediatric wards which the Clown Doctors visit.
Only members of staff known to have contact with the Clown Doctors or known to have witnessed
them at work were recruited for the study.
Play Specialists Nurses Other Total
Freeman 1 1 0 2
Newcastle General 1 1 1 3
Great North Children’s Hospital 5 0 0 5
Total 7 2 1 10
Table 1 shows the number of staff, the hospital they work at and their job role.
Results/ Discussion
All participants claimed that the Clown Doctors had a positive impact on the mental and
physical wellbeing of the children they visit. Where comments were given participants tended to say
that patients mood improved during a visit. One participant, a play specialist, elaborated that the
Clown Doctors generally had a positive effect but it depended on the individual’s experience. 90% of
participants claimed that the Clown Doctors had a positive impact on a child’s experience of hospital,
with the one remaining participant answering that they didn’t know. Where staff went on to elaborate
emphasis they commented on how, over time, the Clown Doctors become ‘integral’ to the child’s
experience of hospital and that the children come to ask for them week after week. When asked
about the effect the Clown Doctors have on the experience of families the answers showed the same
pattern with one participant responding that they didn’t know and the rest claiming that the Clown
Doctors have a positive response. The comments suggest that the families enjoy the Clown Doctors
as much as the children; this is in concurrence with the findings from parent interviews.
Three questions were concerned with how the Clown Doctors affect the running of the
hospital rather than the effect on the children they visit. These were ‘In your opinion, do the Clown
Doctors have an impact on other hospital staff?’, ‘What effect do the Clown Doctors have on the
14
running of your ward?’ and ‘In your experience how well do the Clown Doctors interact with staff other
than yourself?’ Response to these questions was mixed. In response to the first question
participants who answered generally gave a positive comment however two members of staff from the
Great North Children’s Hospital gave less positive responses. One of these participants claimed the
Clown Doctors have a negative impact, with staff not always recognising the benefit of the Clown
Doctors; another participant claimed that staff generally appreciate the work the Clown Doctors do,
but prefer to have minimal contact with them. All participants who answered the second question
claimed the Clown Doctors had a positive effect on the running of the ward overall. However with the
third question the same pattern was found as for the first question and two participants from the Great
North Children’s Hospital claimed that staff didn’t always want to interact with the Clown Doctors.
However neither of these answers suggested that this was the Clown Doctors fault. It seems that in
the new and busier environment of the Great North Children’s Hospital members of staff are less sure
about the role of the Clown Doctors and how to interact with them. This is in no way representative of
the programme as a whole and across the hospitals the majority of staff were very much in favour of
the Clown Doctors, claiming that they improve the atmosphere of the ward and interact well with other
staff.
In concurrence with the results of the observations and interviews the responses to
questionnaires suggest that the Clown Doctors have a very positive effect on the recovery of the
children they visit. 100% of staff claimed that the clown doctors have a positive effect on a child’s
recovery. Indeed one participant claimed ‘children recover faster from surgery after a Clown Doctors
visit’. Others commented that the Clown Doctors aid a child’s physiotherapy by encouraging them to
get up and move around, and many members of staff commented on how the Clown Doctors improve
a child’s mood, making them feel better. Consistent with this, 90% of participants claimed the Clown
Doctors were very integral to the care of the children they visited, and the remaining participant
claimed they were somewhat integral. The fact that experienced staff see the Clown Doctors as so
important to a child’s care and recovery implies the programme works as an important part of a child’s
treatment.
15
Figure 8 shows the proportion of hospital staff who think the arts in general have a place in hospitals.
Figure 9 shows who the staff think should pay for the Clown Doctors.
As figure 8 shows the majority of participants agreed that the arts do have a place in hospitals
and some staff mentioned they would like to see more arts in hospital .When asked who should pay
for the Clown Doctors Programme response was mixed (see figure 9), however all those who had an
opinion on who should pay for the Clown Doctors believed it should be the NHS. No member of staff
believed that the Programme should be funded by charitable organisations. The fact that many
members of staff thought the Clown Doctors Programme should be funded by the NHS is of particular
relevance as they are all NHS employees and thus have some insight into the NHS, making them
likely to be better qualified than parents to judge which programmes the NHS should allocate money
to.
One important focus of this research was to understand how the Clown Doctors are perceived
in relation to other forms of hospital entertainment. Around half the staff participants had experienced
other forms of ward entertainment including a magician, musicians, and a scheme bringing pets into
90%
0%10%
Do you think that the arts in general have a place in hospitals?
Yes
No
Don't know
50%50%
0%
Who do you think should pay for the Clown Doctors?
NHS
Don't know
Other/Charities
16
hospital. Their responses indicated they generally viewed the Clown Doctors more positively than
other arts programmes, as Clown Doctor visits required less organisation, were more patient focused,
more personalised, and generally better received by the children, encouraging them to interact more.
Furthermore when asked how best to entertain children in hospital many staff claimed that the Clown
Doctors were ideal, or emphasized features of the Clown Doctor’s delivery such as play, humour, and
spending quality one-to-one time with each individual. When asked what they would change about the
Clown Doctor visits participants either answered nothing, or claimed that the Clown Doctors should
visit the ward more often. This is consistent with the findings from parents and shows there is call for
more Clown Doctor visits to the hospitals.
The final question participants were asked was if they would recommend the Clown Doctors
to another hospital. The answer was a resounding yes, will all participants saying they would
recommend the Clown Doctors. Many gave very positive comments such as ‘they are a breath of
fresh air’ and are consistently ‘sensitive and professional’. This finding has important implications for
the expansion of the programme, suggesting staff would like to see Clown Doctors be made available
to more hospitals.
17
General Discussion
Overall the data from observations, caregiver interviews, patient interviews, and staff
questionnaires shows that the Clown Doctors generally have a very positive impact on the wellbeing
of the children they visit. There is evidence from all four sources that they improve the mental
wellbeing of the patients, provide relief from the pressures of the difficult hospital situation, and
making children smile, laugh, and play. This is perhaps well summarised by the comments of one
parent who told the researcher that her son had just lost his father and the Clown Doctors made him
laugh for the first time since the bereavement. Many similar declarations of praise for the Clown
Doctors were received. There was also evidence that the Clown Doctors are beneficial to the physical
health of the children they visit with parents and medical staff commenting that they aid physiotherapy
and speed recovery. Furthermore the research suggests the Clown Doctors Programme is also
providing respite for parents and generally improving the working environment of staff. Although there
were a limited number of children’s interviews the responses showed that the Clown Doctors improve
children’s perceptions of hospital.
Importantly it seems that it is more than just the presence of any intervention that causes the
positive effects associated with the Clown Doctors; instead many parents and staff pointed out that
particular features of the Clown Doctors Programme were responsible for the improvement in the
patients, such as their personalised approach and the emphasis on interactive, child directed visits.
Observations show that the way the Clown Doctors focus their attention on individual children and
allow them to determine the course of the visits empowers children.
A further finding from the research is that the Clown Doctors work well as a long term
intervention. Observations, staff questionnaires and caregiver interviews tended to show that some
children were cautious of the Clown Doctors when they first met them but gained more from them as
time passed. It seemed that children were more responsive to the Clown Doctors and interacted with
them more when they had seen them over a number of visits. This suggests children take more from
the Clown Doctors visits if they have continuing experience with them, and Clown Doctors should
make an effort to repeatedly visit an individual child over the course of their stay.
There was little variation in the Clown Doctor performances across the three different
hospitals with the same positive effects found in all wards; however some comments by staff
suggested that the Clown Doctors were less well received in the Great North Children’s Hospital
18
compared to the other hospitals. This may be linked to the observation that on one occasion the
Clown Doctors caused an obstruction in the hallway of this hospital. Furthermore the large rooms in
the Great North Children’s Hospital made the deliveries seem less personal on some occasions.
Overall it seems that the Clown Doctor artists may need more time to adjust to this new location and
to familiarise themselves with staff, although this is understandably difficult in this larger, busier
hospital where the Clown Doctors meet more staff and have less chance to interact with them.
The most significant methodological problem of this research was in the recruitment of
participants because the pressures of the hospital environment imposed many restrictions on which
people could be used as participants. Firstly with regards to recruiting staff for the study there was a
difficulty caused by the fact that staff were often busy with patients and other duties and thus it was
often inappropriate to issue them with questionnaires. The data obtained is therefore not
representative of the entire proportion of hospital staff that has contact with the Clown Doctors.
Furthermore when judging which staff had knowledge and/or contact with the Clown Doctors
the selection process relied mostly on observing who the Clown Doctors talked to during their visits.
Again this sample may not be representative of all the staff who has contact with the Clown Doctors; it
is possible that this sample is somewhat biased in that those staff who were seen interacting with the
Clown Doctors are likely to have a more favourable opinion of them than others. Efforts were made to
counteract this potential for bias by including a question in the questionnaire which asked participants
how well they thought the Clown Doctors interacted with staff other than themselves, thus giving staff
the opportunity to report any problematic encounters between the Clown Doctor artists and the wider
staff population. Furthermore an effort was made to interview staff that did not interact with the Clown
Doctors specifically but were simply in the room during one of the Clown Doctors visits with a child.
However this did not occur often and when it did these staff members were often busy with medical
procedures. In addition the researcher approached nursing stations and asking staff located there to
fill in the questionnaires. This method was somewhat flawed in that many members of staff did not
have knowledge of the Clown Doctors Programme and hence did not want to take part. Nonetheless
this method adds to the process of interviewing only staff who seen to interact with the Clown Doctors
and should be persevered with in future research.
19
Perhaps the best method for improving the sampling procedure would be to issue the
questionnaires on a wide scale, for example by distributing them across the staff via email or by
leaving them on desks along with post boxes so people could submit their comments anonymously,
however this may be difficult to implement. A more feasible method of recruitment of staff as
participants could be to issue a number of questionnaires to nurse’s desks to be filled in throughout
the day or week and then collected again by the researcher.
There were challenges in the recruitment of children for interview. One of the main constraints
was that children were often unable to participate in questionnaires because they were too young or
did not have sufficient communication skills. It may be that the experience of the Clown Doctor artists
with these children differs greatly from the experience of the children who were able to participate in
the questionnaire, thus the results of the children’s interviews may not be representative of all the
children the Clown Doctors visited. However data from both observations and caregiver interviews
found that both young children and patients with communication difficulties often appeared to have a
positive response to the Clown Doctors implying that their experience of the Clown Doctors might be
similar to the experience of the children capable of interview who rated the Clown Doctors positively.
Another constraint to the recruitment of children and caregivers for interview is that some
children were too ill to be interviewed, had to leave for a medical procedure during or just after the
Clown Doctors visit, or were in isolated cubicles in which non-medical staff were not permitted to enter.
Furthermore parents were often too distressed or busy to be interviewed. All these factors meant that
not everyone who had contact with the Clown Doctors was interviewed. It is possible that children and
caregivers who are in these situations have different experiences of the Clown Doctors than those
children who were interviewed, for example the Clown Doctor visits may not be as rewarding, or may
be more welcome for children whom are very ill or in isolated cubicles. There is observational
evidence that those children in cubicles do appear to have positive interactions with the Clown
Doctors, however it was not often easily to detect the reaction of those children who were very ill.
As well as constraints on the number of children interviewed, there was the larger problem
that during the researcher’s visits to the hospitals many children were not even available for a Clown
Doctor visit. For example children were often too ill, asleep, or had visitors at the time the Clown
Doctors were arriving. This resulted in the number of participants for this study not being very large,
and although observations were conducted on the visits to waiting rooms made by Clown Doctors in
20
quiet times, research was restricted to the number of in-depth observations of how Clown Doctors
interact with individual children. This study could be improved by increasing the number of
participants via continued data collection which could obtain a larger sample, over more research
days in the hospitals.
Another methodological flaw of this study is that it uses only one researcher to conduct the
observations and interviews. Although a large effort was made to keep these observations and
interviews unbiased and objective, the study could be further improved by using a number of
researchers to reduce the possibility of any unintentional observer bias or misinterpretations of
situations which may affect the results. An effort was made to reduce the potential bias of only having
one researcher by getting an impartial confederate to perform a reliability check on the data. Although
this doesn’t remove any bias in the recording of the observations and interviews it does remove bias
in the interpretation of this data. In this case the reliability check showed a high level of concordance
between the ratings given by the researcher and those given by the impartial confederate, implying
that the data was objectively categorised.
An impact of the research process is that the Clown Doctors may perform differently if they
know they are being observed. This could work in two ways, it could result in social facilitation making
the Clown Doctors perform better, or it could make the Clown Doctors more anxious and reduce the
standard of their performance. However there is no way to avoid overtly witnessing the Clown Doctors
as any attempt to conceal the observation would be deceitful to both the performers and the child, and
would sacrifice the ethics of the experiment. This problem is somewhat reduced by the fact the Clown
Doctors are used to being observed by other people and are accustomed to this.
A final issue with the methodology of this study is that there is the possibility some
participants perceived the researcher as being involved directly with the Clown Doctors Programme
and were thus reluctant to divulge certain information, in particular any criticism. This was
counteracted somewhat by the description in the brief describing what the aim of the research was
and who the researcher was. To avoid this problem in future, observers should strive to maintain a
neutral stance at all times, limiting interactions with the Clown Doctor artists in the presence of
participants.
Overall despite some methodological flaws this research found that the Clown Doctors are
incredibly well received by those they have contact with, have benefits to the mental and physical
21
welfare of the children they visit, particularly over the long term, and that these benefits are due to
specific aspects of the Clown Doctor’s performances rather than simply being due to the presence of
any form of arts programme. This research also found that there is much call for the Clown Doctor’s
Programme to be expanded in future to reach more children, both within the hospitals they already
visit and across a wider area. Further research into the Clown Doctors Programme should look at how
this could be implicated. There was also call from parents and staff for the programme to receive NHS
funding in the future.
22
Appendix 1 - Comments from Parents/ Caregivers
He really looks forward to the visits and talks about it throughout the week. Good for children like him who are only in for a short time as all the other children on the ward are too ill to play and he needed some stimulation. He really likes the bubbles game, it’s good how they go by what games he likes, and he's learning new games which he can ask for, it’s really bringing him on in terms of learning. It cheers him up; it’s a different way of stimulating him from what normally happens. Not sure how it is currently funded, but ideally it should be NHS funded. Yes, found other hospitals boring that didn't have clown doctors. Should give him something to keep, I know they gave him a sticker, but maybe something a bit more permanent to stop him being sad when they leave. The NHS should really [fund the Clown Doctors], it’s part of the care. It’s all very good but they could leave the child with something to avoid disappointment. [The hospital is] a more cheerful place [when they are here]. They knew his special needs and catered to them, the entertainment was appropriate for his needs. It gives parents respite you don't get elsewhere. They could visit more often. They cheered her up; they were also really good physiotherapy, because with all the laughing she was able to cough. Appendix 2: Comments by Children I've told everyone I know about the clown doctors, I see them every time I go to hospital and I tell everyone they are hilarious, they come up with everything. The first thing I think of when I think of hospital is the clown doctors so I'd talk about them. They make me laugh they are very funny and they make me feel joyful, they make me like yippee! [If I was a Clown Doctor] I'd make children happy and I'd make little babies laugh and giggle and smile. I think the Clown Doctors should make the babies go to sleep so they don't keep me awake. I wouldn't change anything they are just funny. [When her mother is asked who should pay for the Clown Doctors] The NHS because it’s the NHS job to make you feel better and Clown Doctors make you feel better.
23
Appendix 3: Comments by Hospital Staff Very family friendly, everyone involved in fun. Children lying in bed or not keen to walk often get up to see the Clown Doctors. They just fit in with ward life. (In response to what would you change?) Only extra days! They are great and improve the patients stay and experience of hospital. Bring them to the ward more often. Parents love the interaction just as much as the children. Children recover faster from surgery when they have been visited by the Clown Doctors. (The ward is) a happy environment when they are on. They are a great team of people who do a great job, well done. After surgery children need encouragement to mobilise. The Clown Doctors are helpful, encouraging movement etc. Children who spend long periods in hospital enjoy interaction. Spending quality time with each individual makes them feel better. Sharing interests and showing interests I would have the Clown Doctors every day. Have always had a very positive experience working with Clown Doctors, they have used the information given about individual children and have been sensitive and professional. Their presence on the ward uplifts and boosts children and young people's morale. As I work on a ward with long term patients, they become familiar to the hospital and embrace the Clown Doctors as part of their experience in hospital. The impact of hospital is not always as daunting, as they understand that we gave positive influences to make the stay more enjoyable and less stressful. Families are often traumatised and anxious when they have been in hospital for a long term periods. However when I have spoke [sic] to parents they have been very positive about the Clown Doctors and said they lifted their spirits when they were down. As our staff have become accustomed to the Clown Doctors, they feel they would be lost without them as they are part of the team now. When children are at their lowest and the [Clown] Doctors appear, they make them feel happy and for that short period of time, the children forget about their illness and feel better. They are part of our team and their role is vital within our ward as they are positive, motivated and enthusiastic. (In response to ‘would you recommend they to another hospital?’) Definitely! They are a breath [sic] of fresh air!