Abstract
Clown care has been shown to have health-related benefits and is a well-established part of the routine in many children's hospitals. However, children who have been admitted to general hospitals or who are being cared for at home cannot usually enjoy visits by Clown Doctors. Therefore, the aim of this work was to investigate whether an existing telemedicine network could be used to improve equity of access to humor for sick children, specifically those who are hospitalized away from the nearest clown-enabled hospital or who are being cared for at home. Using videoconferencing, we conducted regular clown outreach links from The Royal Children's Hospital in Brisbane, Australia, to children in regional hospitals and to sick children in their homes. Using a program of performance, which was modified for delivery by videoconference, teleclowning was found to be feasible. Further work is required to determine whether the health-related benefits that accrue from in-person clowning are successfully translated to the video-based modality.
Introduction
Humor has been shown to have physiological benefits, 1 including the potential to reduce the perception of pain; 2 reduce anxiety and stress; 3,4 and to benefit the immune system. 5 For hospitalized children, humor and an active role in play have been shown to be effective coping strategies. 6 Other studies have examined humor as a way to reduce distress and achieve cooperation during invasive procedures. 7,8
“Clown care,” or “clown therapy” as it is sometimes known, has been a successful vehicle for introducing humor within the healthcare setting. The protagonists of these mirthful interventions are typically professional performers, trained to perform in, engage with, and positively affect the entire hospital community. In Australia, they are known as Clown Doctors. They can unleash a wide range of skills such as music, song, magic, play, and joke telling. Using their skills with sensitivity, engagement, and improvisation, Clown Doctors engage with children who may be suffering serious illness or undergoing painful or distressing procedures. The Big Apple Circus Clown Care Unit in New York City pioneered a clown care program in 1986. Since then, many similar programs have been developed around the world. In Australia, The Humour Foundation was established in 1996 9 and its Clown Doctors now operate in all of the major children's hospitals throught the country.
The major children's hospitals enjoy regular clown visits, whereas many children are admitted as patients to smaller general hospitals in regional towns lacking a clown care program. In addition, some seriously ill children are cared for at home and have reduced physical contact with the hospital. For these children, there is an inequity of access to humor. This work aimed at assessing the feasibility of using telemedicine to provide clown outreach, or teleclowning, from a tertiary children's hospital to children in pediatric wards in regional hospitals and to children being cared for at home.
Methods
Through experimentation in a videoconferencing studio, Clown Doctors at the Royal Children's Hospital (RCH) in Brisbane developed and refined a program that could be performed by video. Subsequently, an existing pediatric telemedicine service was used to deliver humor at a distance. For children in pediatric wards in regional hospitals, existing child-friendly telemedicine systems were used. These units were wireless, able to be easily moved to the bedside, and were designed primarily for clinical consultations. 10,11 The clowns could be present, virtually, at an individual child's bedside or in a room containing several children, as appropriate on the day. For children who were being cared for at home, humor was delivered using a Webcam-based home telemedicine program that was ordinarily used for maintaining contact between the RCH healthcare team and the child and family at home. The Clown Doctors worked in pairs and were available to provide links once a week (Fig. 1).
Clown Doctors performing by video.
Results
Hospital Teleclowning
Pediatric wards in three regional hospitals, ranging in distance from the RCH of 160 km (99 miles) to 2,000 km (1,243 miles), had access to clown outreach. In the first 12 months of teleclowning, 29 sessions were held involving 92 children. The median number of children per session was 3 (range 1–6). Total session time was 670 min (median 20 min, range 10–30 min). Clowning was well accepted in two of the hospitals. One hospital had a small number of pediatric admissions and, hence, had a lower requirement for clown visitations. Overall, the clown doctors found it feasible to deliver their humor at a distance. Engagement with the youngest of the children was difficult, and this mirrors the experience of the Clown Doctors when working with children in the hospital wards. It can take time, repeated visits, and experimentation with a variety of different types of play to make a connection, and this may not be practical with telemedicine.
Home Teleclowning
In an 8-month period from the commencement of the pilot of the home teleclowning program, 28 sessions were held for two individual children. One of the children lived 8 km (5 miles) from the RCH, whereas the other lived 900 km (500 miles) distant. The total session time for both patients was 567 min (median 20 min, range 15–30 min). One child (aged 14) receiving palliative care for a Wilms tumor with lung metastases had only one virtual visit and despite enjoying the session had no further sessions, as it made her laugh too much, thus inducing a coughing attack. This highlights that laughter intervention does have limitations and also the importance of a working partnership between the healthcare staff and the Clown Doctor. The other child (aged 8) received the remaining 27 teleclowning sessions at weekly intervals. Feedback from the parent was extremely positive. The sessions had become the highlight of her child's week and she looked forward with great anticipation to each session.
Discussion and Conclusions
Using video, the Clown Doctors found it easy to engage with individual patients, this being a critically important facet of successful clown care. Clowning was feasible to both the individual bedside and a room containing several children. The clown doctors were able to develop a rapport with the child that they connected to regularly at home and iteratively tuned their program according to the child's needs over time.
Teleclowning did not incur the usual infrastructure costs associated with the development of a telemedicine service. Given that the facilities for telemedicine were already available at the RCH, our focus was on expanding the reach of the Clown Doctors beyond the wards in Brisbane for the benefit of children in regional areas of Queensland. For a hospital such as the RCH, with an existing Clown Doctor service and an existing telemedicine network, clown outreach may be provided at little overhead.
This work has shown that clowning at a distance is both technically and practically feasible albeit with modifications to the clowning routine. Having demonstrated feasibility, further work is required to examine whether the health-related benefits of in-person clown care translate to the video-based modality. If so, then clown doctors may provide additional value to existing telemedicine networks for the benefit of patients who are isolated by geography or illness.
Footnotes
Acknowledgments
In Australia, the Clown Doctors are funded by the Humour Foundation. We would like to thank the Clown Doctors at the RCH (Drs Bob, B Bubbly, Gizmo, Kerfuffle, Reddy, Tickle-me-please, and Wobble) for their hilarious contributions. In addition, we thank the ward staff at the regional hospitals for their assistance in facilitating the clown outreach. “Clown doctors” is a registered trade mark in Australia and other countries.
Disclosure Statement
No competing financial interests exist.