Turnover among medical clowns early in their career

Abstract

In recent years, several investigations of the medical clowning profession have appeared in the literature. However, few studies have focused on factors associated with turnover among medical clowns early in their careers. The current study examined whether individual differences in humor disposition predicted turnover behavior. Participants were 111 medical clowns in a three-phase longitudinal study. Humor disposition was measured in the first week of their training, clowns' job satisfaction two months later, and turnover six months after that. Results showed that humor appreciation decreased actual turnover through the mediating role of job satisfaction, whereas individual differences in humor creation directly decreased turnover. In addition, previous traumatic experiences moderated the associations between humor appreciation and turnover. Overall, our research findings support the notion that humor disposition can help predict which clowns remain in the hospital.

Keywords

Medical clowns humor turnover job satisfaction trauma

Introduction

As a relatively new player in the health field, the medical clown profession was established to help ease hospital patients' suffering, pain, and anxiety (Dionigi & Canestrari, 2016). Their work is grounded in the positive links between humor and health, present in suggestions like “laughter is the best medicine” and proverbs like “a merry heart doeth good like a medicine” (Martin, 2001, p. 504). Medical clowns' primary role is to give children, adolescents, and adults experiences of joy while mitigating the negative effects of a hospital stay (Nuttman-Shwartz, Scheyer, & Tzioni, 2010). Their presence has also been shown to contribute to well-being among parents and the medical staff (Ford et al., 2013) and to hospital cost-savings (Gomberg et al., 2020). All of these benefits are reflected in the last decade's rapid growth in the number of clowns, especially in pediatric settings (Linge, 2013).

Although the contribution of medical clowns in creating a positive atmosphere for both patients and the medical staff has solid support in the literature, few empirical investigations of the clowns themselves have been reported (e.g., Dionigi & Canestrari, 2016; Dionigi et al., 2014; Gomberg et al., 2020; Nuttman-Shwartz et al., 2010). These studies were mostly qualitative, and none reported on the relationship between humor and clown-related work outcomes. As a result, our research here has several clearly defined purposes. Specifically, a longitudinal study of the medical clown profession will examine the effects of humor on several work outcomes and the role that previous experience with traumatic stress plays in this relationship.

Some specific unique personality qualities are needed for being a medical clown. Being a good performer is insufficient, as medical clowns apply their humor skills in a very challenging health setting. Aside from the expectation that their patients will smile and laugh at some of their antics (Dionigi et al., 2014), they are often asked to deal with the patients’ negative emotions and challenging situations when dealing with families and medical staff (Dionigi & Canestrari, 2016).

Although several recent studies present therapeutic benefits associated with the use of clowns in (but not exclusively) pediatric settings (Ford et al., 2013; Linge, 2013), few studies have focused on clowns’ personal characteristics and behavior within the organization or profession (Dionigi & Canestrari, 2016). Linge (2008) conducted a qualitative study on 13 clowns and Nuttman-Shwartz et al. (2010) performed a content analysis of documentation regarding the work of two clowns. To better understand the clowns’ working experience, Nuttman-Shwartz et al. (2010) highlighted the need to examine the sources of medical clowns' job dissatisfaction and its potential effects on their turnover behavior. Finally, using the Big Five Inventory, Dionigi (2016) examined the personality dimensions of medical clowns and compared them with the general population. His findings indicated that medical clowns differed from the general population on all five dimensions and recommended that “as personality is a complex phenomenon, further research should explore specific personality traits that can play a role in clinic clowning” (p. 53).

The purpose of the current study is to expand on previous work by focusing on adaptive humorous styles as specific dispositions in medical clowning. From a traditional organizational perspective, the IO literature supports the potential benefits that employees can derive from humor and laughter. Specifically, a meta-analysis of the effects of adaptive humor styles that included 49 studies showed positive effects for performance, job satisfaction, group cohesion, and employees' health outcomes (Mesmer-Magnus et al., 2012). However, little is known of the impact of adaptive humor on voluntary turnover behaviors in general and among individuals who regularly use humor in their jobs in particular.

As previous studies have not reported on the relationship between medical clowns' personality and their work outcomes, the current study has several clearly defined aims. First, the present study focuses on medical clowns and the effects of humor styles on voluntary turnover, above and beyond the Big Five personality dimensions of conscientiousness and openness. Second, whereas humor is generally considered a dispositional tendency (e.g., Kuiper, 2012) and likely to be analyzed as a causal/independent variable in research, a longitudinal study of the medical clown profession will clarify the effects of humor on turnover. Third, the current study incorporates potential moderator and mediator variables to better understand the associations between adaptive humor styles and turnover. Finally, these unique personal qualities might have greater influence on turnover early in the medical clowning experiences than in later stages, once the clowns have been exposed more fully to the clowning experience and have developed their own role identity and clown persona (Dionigi et al., 2014). Although the importance of extensive training for clowns before entering a medical setting has been acknowledged (Dionigi et al., 2012; Raviv, 2013), little is known about the psychological characteristics of these clowns (Dionigi & Canestrari, 2016). Our study is the first work to examine medical clowns during their early career stages by following them from the beginning of their training until the conclusion of their unpaid internship.

Humor styles

In the current study, we chose to examine the effects associated with the two-dimensional conceptualization of humor: humor appreciation (i.e., the ability to understand and enjoy messages containing humor) and humor creativity (i.e., the ability to perceive relationships between people, objects, or ideas in an incongruous way, as well as the ability to communicate this perception to others; Ziv, 1981, 1984). Whereas humor appreciation relates to the frequency and intensity of laughter and amusement (e.g., laughing easily, tearing during laughter), humor creativity relates to the effectiveness of entertaining others. Ziv’s conceptualization has been applied previously in the organizational domain (for a review, see Mesmer-Magnus et al., 2012).

This two-dimensional approach to humor also aligns with the adaptive framework that organizes humor into two broad concepts: humor used as a psychological mechanism to cope with adversity and stress and enhance one's relationships with others (Mesmer-Magnus et al., 2012). Cumulative findings appear to indicate that humor appreciation and humor creation indeed comprise distinct factors and can have a differential impact on employee outcomes (e.g., Ünal, 2014). Medical clowns act awkwardly and playfully to entertain the patients to mitigate their pain and anxiety. In addition, by facilitating the healing process, they enhance positive mood (Dionigi, 2016), and one can assume that the medical clown also benefits from both humorous aspects: humor creation and humor appreciation.

Adaptive humorous styles and turnover

Turnover is one of the critical outcome measures in organizational settings, as substantial financial costs are associated with recruiting and training new employees (Hom et al., 2012). In particular, medical staff turnover has been identified as a global concern with potentially negative implications for patient treatment and health outcomes (Dyrbye et al., 2017; Naburi et al., 2017). High turnover rates can affect intervention and treatment efficiency because of the costs associated with recruitment and orientation for the newly hired workers, often accompanied by a decrease in patient care effectiveness (Hassmiller & Cozine, 2006). As preliminary results have indicated that the medical clown job presents many work challenges and difficulties (Nuttman-Shwartz et al., 2010), it is important to examine turnover behavior among medical clowns and whether their ability to use humor does contribute to decreasing the negative effects of turnover.

Numerous formulations and models have been suggested for explaining and predicting turnover, with many of these including demographics, attitudinal indicators, and personality (such as the Big Five) with employee leaving or intending to leave the organization as outcome variables (e.g., Zimmerman, 2008). Although not a specific component in the Big Five model, humor personality trait clusters are associated with organizational outcomes. Humor has been found to be an aid in forming stronger friendship networks (Feeley et al., 2008) and social support (Caudill & Woodzicka, 2017), acknowledged to be associated with reduced work withdrawal and turnover (Ballinger et al., 2016).

This study's hypotheses further align with person-job fit theory (Edwards, 1991), which asserts that personality traits help determine how an individual will adapt to a specific job or organization. Extensive research in medical contexts has shown that the intention to choose or remain in a specific job is a function of the fit between personal characteristics and various training experiences (Doherty & Nugent, 2011) and work environments (e.g., Mullola et al., 2018). Finally, while there is some evidence to support the association between humor and lower levels of turnover among nurses in Korea (Kim, 2013), little is known about the impact of humor styles on the medical clowns themselves. As medical clowning is a profession that activates the clown persona under challenging hospitalized circumstances (Dionigi et al., 2014), it can be assumed that individuals having both humor creation and humor appreciation styles would be more willing to remain in their work. Following evidence indicating that personality is a strong predictor of newcomer turnover (Holtom et al., 2013), the present study examines medical clowns' turnover behavior early in their career.

Based on the noted research, we posit the following hypotheses:

Humor appreciation (H1a) and creation (H1b) decrease turnover rates among medical clowns early in their career.

The mediating role of job satisfaction

Job satisfaction is one of the commonly investigated organizational outcomes as it represents the employee’s “overall evaluation of the favorability of one’s job typically arrayed along a continuum from positive to negative” (Judge et al., 2017, p. 357). To a large extent, job satisfaction appears to be associated with both personal characteristics and affective states (Judge et al., 2017). We assume that humor-related personality traits play an important role in determining the medical clown’s work-related outcomes. Fredrickson’s (2001) broaden-and-build theory asserts that positive emotions broadened the individual attention, facilitate thinking of new opportunities and possibilities, and fosters psychological flexibility. These aspects allow the individual to act in more creative, integrative, and effective ways of dealing with work challenges (Fredrickson, 2013). For medical clowns, humor comprises their primary working tool for enhancing the positive affect of patients, their families, and even the medical staff (Linge, 2013). Therefore, the broaden-and-build theory implies that the continual expression of positive affect can also be expected to impact the medical clowns themselves. As applied to humor, the theory is consistent with studies reporting humor to be positively associated with job satisfaction by enabling one to cope better with workplace challenges and boredom and by viewing events more optimistically (Eliav et al., 2016; Robert & Motta Veiga, 2017).

Job satisfaction is also a central antecedent of voluntary employee turnover behavior because people who do not like their jobs tend to leave them (Rubenstein et al., 2018). Indeed, job satisfaction has been one of the most studied reasons for quitting, beginning with the classical turnover literature until the recently published meta-analyses on both general turnover and voluntary turnover (Hom et al., 2012; Rubenstein et al., 2018). In addition, previous meta-analytic findings indicated that job satisfaction could mediate the associations between personality dispositions (e.g., Big Five) and turnover behaviors, suggesting that personality impacts behaviors due to their influence on the individual’s affective work-related responses (Zimmerman, 2008).

We propose that adaptive humor would decrease medical clowning turnover, with job satisfaction acting in a mediating role. To control for common method variance and provide a better causal explanation of the benefits of humor at work, the present study assessed various aspects of humor in the first week of the medical clowns’ training, with the dependent measures––satisfaction and turnover––obtained later, during their actual work in the hospital setting. As such, we pose the following hypotheses:

Job satisfaction mediates the negative association between humor appreciation (H2a) and creation (H2b) and turnover among medical clowns.

The moderating role of traumatic stress

There are two different theoretical perspectives related to the impact of traumatic events on the individual. According to the first one, enduring traumatic experiences comprise a risk factor for psychological problems (Lee et al., 2017). An alternative perspective, stemming from positive psychology, suggests that some individuals are more resilient than others and can cope more effectively in the face of adversity (Fredrickson et al., 2003). For instance, positive psychological capital (e.g., the personality traits of optimism, hope, and ego resilience) are associated strongly with soldiers' increased well-being during high levels of potentially traumatic exposure (Schaubroeck et al., 2011).

Positive humor is considered a stress-resilient trait and a personality virtue in positive psychology (for a review, see Kuiper, 2012). The research literature has distinguished between self-focused humor and other-focused humor, with the former being more effective following traumatic events. Self-focused humor often serves as a means for coping and has been particularly beneficial in reducing stress by allowing the individual the opportunity to reframe the stressful stimuli, causing it to be perceived as manageable. A large part of the “self-protective” function of humor derives from the ability to distance oneself from a negative event and internalize a positive event (Kuiper, 2012). Consistent with this argument, external stressors interacting with self-coping humor were found to decrease burnout and PTSD symptoms among firefighters (Sliter et al., 2014), and the interaction between humor and stress in an army setting was found to significantly predict performance (Bizi et al., 1988). On the other hand, a humor style focused on creation might be less effective as a personal coping mechanism and more beneficial for encouraging an interactive environment (Ünal, 2014). Other evidence has shown that individuals engaging in positive reinterpretations of events are more likely to grow from traumatic experiences (Kuiper, 2012).

The current study aimed to evaluate the association between appreciative humor and turnover among those medical clowns who had experienced trauma. Various models in the field of vocational psychology emphasize the role that previous traumatic experiences, specifically during childhood, play in the process of career choice and among helping professions in particular (Braunstein-Bercovitz, Cohen, Geller, & Benjamin, 2014). These approaches argue that professionals who have experienced their own life struggles might be more motivated to heal the wounds of others, a phenomenon labeled in the Jungian perspective as the “wounded healer” (Sedgwick, 2016). This inclination comprises both conscious and unconscious motives, such as the opportunity to achieve a corrective experience, regulate the therapist's sense of self-worth, or attain a sense of power and control in inter- and intrapersonal relationships (Kottler, 2010). It has also been posited that researchers and educators need to consider experiences of early life difficulties and personal resilience to provide positive outcomes for the practitioner therapists (Thomas, 2016). However, the interactions between previous trauma, humor-related coping mechanisms, and career characteristics such as internship turnover remain understudied.

Medical clowns not only “provide the gift of laughter”, but it is widely believed that medical clowns also have the “power to bestow the gift of healing” (Dionigi & Canestrari, 2016, p. 473). We assume that medical clown trainees having previously undergone traumatic experiences and possessing adaptive coping mechanisms, such as appreciative humor, would be more attracted to this helping profession and, therefore, would be less likely to leave. As such, we posit the following hypothesis:

H3: The negative association between humor appreciation and turnover rates is stronger among medical clowns who have experienced traumatic life stressors than those who have not.

Conscientiousness and openness as control variables

The present study acknowledges the association between conscientiousness and openness to change and turnover as an outcome in the general population (Rubenstein et al., 2018) and among medical clowns (Dionigi, 2016). Highly conscientiousness individuals tend to stay in the organization because they consider it a moral obligation and perceive perseverance as a positive personal quality (Zimmerman, 2008). As for individuals who are higher in openness, they tend to leave their place of work more often and usually with unplanned quitting behaviors. They usually leave the organization to explore other opportunities or for personal growth reasons (Zimmerman, 2008). Therefore, we examine our research hypotheses by controlling for two recognized personality dimensions: conscientiousness and openness.

Method

Sample and procedure

In the study, 111 Israeli participants who had just started their medical clown training agreed to complete questionnaires (72% female; M_age 37.80, SD = 14.20). Three percent had a primary school level education, 27% had a high school level, 24% had post high school education, 30% had an undergraduate degree, and 16% a masters degree. The Israeli training program trains medical clowns in several dozen medical institutions country-wide. None of the participants reported any previous experience in acting or performing. The respondents participated in a 20-week course training program aimed to provide them with interpersonal connection tools based on modern clown performance techniques. Medical clowning skills are developed first within the training group, in a “safe environment,” and later during hospital visits with a live audience. Ten weeks following the training course conclusion, the participants completed questionnaires evaluating their training and their satisfaction with their actual hospital experience. Further, the training organization provided information regarding which clown left during the course of training, and which ones completed their internship and began working in the hospital.

Measures

Humor dispositions

The Sense of Humor Questionnaire (SHQZ; Ziv, 1981) measures humor appreciation and humor creation. Two 7-item subscales are presented on a 5-point Likert-type questionnaire, ranging from 1 (strongly disagree) to 5 (strongly agree). Item examples for humor appreciation include “I tend to laugh easily”. A sample item tapping humor creation is “My friends expect me to make them laugh.” After dropping two items that loaded on both subscales, factor scores were derived from a principal component factor analysis. Cronbach alpha for the Humor Appreciation Scale was .82. Cronbach's alpha for the Humor Creation Scale was .85.

Job satisfaction

A 3-item job satisfaction scale adapted from Clary et al. (1998) was used to measure volunteer satisfaction (e.g., “I am very satisfied with the responsibilities given to me as a medical clown”). Items were presented on a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The scale had internal consistency reliability of .75.

Turnover

Participants were followed for six months from the beginning of their training. Turnover was coded dichotomously: 1 = left the program and 0 = stayed for 6 months. Of the study sample, 66 clowns (60%) reported completing the internship program and began working in the hospital.

Traumatic stressor event

All participants were asked whether they experienced a meaningful and traumatic event in their life that influenced their career choice (1 = yes, 0 = no). Approximately one-third of participants reported having experienced a traumatic stressor in their life. Using Kubany et al.’s (2000) conceptualization of traumatic experiences, responses were coded by a research assistant to determine whether the event was indeed a traumatic one (e.g., “I had a difficult and traumatic experience in the army” and “A parent recently died”), Previous work suggested that a structured inquiry of traumatic history yielded results comparable to a trauma-focused questionnaire (Kubany et al., 2000).

Control variables

Two Big-Five Inventory subscales, for openness and conscientiousness (John et al., 1991) were used as control variables. Both scales were presented in a 5-point Likert-type format, ranging from 1 (strongly disagree) to 5 (strongly agree): the 10-item Openness Subscale (e.g., “I see myself as someone who has an active imagination”) and the 9-item Conscientiousness Subscale (e.g., “I see myself as someone who worries a lot”). For the current sample, the internal reliability for openness was .72 and for conscientiousness, .77. Finally, educational level also was included as a control variable.

Results

Preliminary data analysis

To examine whether these humor styles can be differentiated, a principal component factor analysis using varimax rotation was conducted, yielding two factors, one associated with humor appreciation and the other associated with humor creation, explaining 58% of the variance. Factor scores were then determined. The means, standard deviations, and correlations for all study variables are presented in Table 1. As expected, job satisfaction was associated negatively with turnover. Humor creation was associated negatively with turnover. However, we did not find a significant association between humor appreciation and turnover behavior. While mostly supportive of our expectations, the bivariate correlations do not provide a complete account of these relationships; thus, we proceeded to test mediation and the indirect effects, as indirect effects can be observed even when the direct correlations are not significant (Rucker et al., 2011).

Table 1.

Means, standard deviations, and bivariate correlations.

	M	SD	1	2	3	4	5	6	7
1. Humor–Appreciation	5.06	1.32	(.83)
2. Humor–Creation	5.00	1.19	.00	(.82)
3. Job satisfaction	6.19	.86	.33**	.10	(.75)
4. Openness	4.17	.51	.12	.08	.24*	(.72)
5. Conscientiousness	3.85	.69	.14	−.13	.17	.27**	(.77)
6. Education level	3.31	1.12	−.01	−.15	.05	.06	.18	–
7. Traumatic stressor (# yes)	33 (30%)	–	−.02	.13	.14	.17	.22*	−.11	–
8. Turnover (# left)	45 (40%)	–	.05	−.20*	−.33*	−.19	−.12	−.20*	−.14

Note: *p < .05. **p < .01. ***p < .001; statistics in parentheses are reliabilities; means and standard deviations for humor scale represent unweighted values of the items in each factor.

The mediating role of job satisfaction

To test whether personality styles explained unique variance in medical clowning persistence behavior, a logistic regression analysis was performed (see Table 2). All measures were centered on their sample means to facilitate interpretation of the results and avoid multicollinearity. The first step of the regression included the control variables of consciousness, openness, and education. Humor appreciation and humor creation were included in the second step, followed by job satisfaction in the third. The logistic regression analysis was significant. The findings indicated that job satisfaction and humor creation negatively predicted turnover behavior.

Table 2.

Logistic regression predicting turnover behaviors via the mediating role of job satisfaction.

	Step 1			Step 2			Step 3
	B	SE	OR	B	SE	OR	B	SE	OR
Openness	−.24	.25	.89	−.15	.26	.86	−.04	.27	.96
Conscientiousness	−.11	.25	.79	−.22	.26	.80	−.22	.28	.80
Education	−.45	.24	.64	−.55	.25	.58*	−.65	.28	.52*
Humor–Appreciation				.10	.26	1.11	.42	.30	1.51
Humor–Creation				−.59	.26	.56*	−.55*	.26	.57*
Job satisfaction							−.105	.36	.35**
Change of χ²	5.79			6.07*			10.04**
Change of df	3			2			1
−2 log likelihood	105.48			99.41			89.37
Nagelkerke’s R	.09			.18*			.32**

Note: *p < .05. **p < .01. ***p < .001. N = 111; SE = standard error; OR = odds ratio.

To examine the indirect effects of humor on turnover through the mediating role of job satisfaction, Hayes’ (2017) Process procedure was applied. The indirect effects of humor appreciation and humor creation on turnover, via job satisfaction, were examined by accelerated bias-corrected bootstrap analyses. The procedure tests whether an indirect path is significantly different from zero by producing a confidence interval (CI) for the indirect effect. The significance of the mediation paths was estimated by bias-corrected bootstrap analysis with 5000 resamplings. Results indicated that job satisfaction mediated the association between humor appreciation and turnover (b = −.29, 95% CI −.73 to −.03) with the absence of a direct effect between humor appreciation and turnover after controlling for job satisfaction (b = .42, SE = .30, p = .16); thus, supporting H2a. The second bootstrap analysis revealed a significant direct path from humor creation to turnover (b = −.55, SE = .26, p = .03); however, the indirect path via satisfaction was non-significant (b = −.09, 95% CI −.38 to .09). These findings did not confirm H2b.

The moderating role of previous traumatic events

A binary regression was carried out to examine the moderating role of previous traumatic events. The control variables were entered in the first step of the regression. In the second step, humor appreciation, humor creation styles, and the trauma stressor were entered, followed by the interaction terms between humor styles and trauma in Step 3 (see Table 3). Results indicated that humor creation predicted turnover behavior. In addition, the hypothesized moderating effect of a traumatic stressor on the associations between humor appreciation and turnover behaviors was supported (b = 1.08, p < .001). A simple slopes analysis was conducted to further examine the effect of humor creation under different conditions of traumatic stress. Results indicated that humor appreciation as a predictor of turnover was significant only for individuals who had experienced previous trauma (b = −.2.04, p = .01), but was not significant for medical clowns who had not experienced previous trauma (b = .54, p = .07), thus supporting Hypothesis 3 (See Figure 1).

Table 3.

Logistic regression predicting turnover behaviors via the moderating role of previous traumatic events.

	Step 1			Step 2			Step 3
	B	SE	OR	B	SE	OR	B	SE	OR
Openness	−.30	.22	.74	−.25	.23	.78	−.09	.25	.91
Conscientiousness	−.16	.23	.49	−.13	.24	.88	−.25	.27	.77
Education	−.44	.22	.64*	−.59	.24	.56*	−.62	.28	.56*
Humor–Appreciation				−.04	.23	.96	−.23	.32	.79
Humor–Creation				−.41	.24	.66*	−.65	.29	.54*
Traumatic stressor				−.33	.24	.72	−.30	.29	.74
Humor–Appreciation × Traumatic stressor							−1.19	.41	.31**
Change of χ²	7.72*			5.74			15.44***
Change of df	3			3			1
−2 log likelihood	124.32			118.58			103.13
Nagelkerke’s R	.10*			.18*			.35***

Note: *p < .05. **p < .01. ***p < .001. N = 111; SE = standard error; OR = odds ratio.

Additional qualitative findings

At the conclusion of the internship, after six months of volunteering, 40 participants responded to two open-ended questions. In the first, we asked them to describe the factors that helped them persist with their internship. Their answers were divided and coded into themes. The first theme was positive feedback from the patients, described by 68% of participants e.g.:

I was working in the geriatric department, and it is very difficult to make patients laugh there. I entered the room. A man was lying in bed, and his wife told me not to try to talk to him because he hadn’t spoken for more than two days, and she believed these were his final days. I didn't give up and tried everything. Finally, as I was leaving the room, he rose and greeted me. I was excited. I stayed there for four hours. He eventually had a full recovery.

The second theme, social support (17%), explicitly linked the need to receive social support from family member as well as from other medical clowns. The third theme, positive feedback from hospital staff (15%), highlighted the interns’ need to receive recognition and acknowledgment from the doctors, nurses, and other professional employees in the department.

We included an additional question for future exploration, asking them to identify the difficulties they anticipated facing in future employment as medical clowns. About 39% of the responses focused on the distress and potential burnout that stems from the need to be funny in such a stressful hospital environment:

“Some of the things that I see affected me. I saw amputees, and it was very difficult for me; it stayed with me for a long time”, “Sometimes, I want to be an introvert and sad, but this work does not allow such behavior.”

Nearly 29% of the respondents focused on the difficulties that stem from the lack of appreciation by the rest of the medical staff:

At the beginning, I had very low expectations from the medical staff. I felt that I actually did not exist for them. I know that in other hospitals, the staff use medical clowning and offer them assignments such as getting involved with the family or making a child happy. This kind of involvement makes you feel wanted and needed. I did not receive that.

About 20% focused on organizational constraints and bureaucracy, and close to 12% focused on the difficulties of getting negative responses from the patients.

Discussion

Clowning is a relatively new practice in hospital settings and is growing worldwide; however, only minimal research in this area has been conducted to date (Dionigi & Canestrari, 2016). The current study expands the current knowledge by learning more about clown characteristics and predictions of their job satisfaction and turnover. Other studies supported the argument that self-focused and other-focused humor are distinct factors and have a differential impact on employee outcomes (Robert & Wilbanks, 2012; Ünal, 2014). Specifically, the current data indicated that humor appreciation, which is considered an intra-psychic phenomenon, predicted decreased turnover through the mediating role of job satisfaction. Similar findings have been reported in other contexts, where humor appreciation was also related to greater satisfaction at work (Ünal, 2014). Moreover, according to the broaden-and-build theory (Fredrickson, 2013), frequent positive assessments can lead to resource building and might serve as an antidote to negative emotional states, such as strain responses. Accordingly, humor appreciation that evokes positive feelings contributes positively to employee job satisfaction and appears to decrease turnover rates among those with previous traumatic experiences.

In contrast, the humor creation style was not found to predict turnover via job satisfaction but rather to impact turnover directly. As humor creation is considered an interpersonal and social component of humor, it is expected to increase positive patient feelings and reduce the tension associated with the hospital environment (Dionigi, 2016). Thus, humor creation might be less centered on the clowns' own feelings of happiness (Ünal, 2014).

Upon The moderation revealed that higher levels of humor appreciation were negatively associated with turnover ratings. The ability to look at life from a more humoristic perspective enhances the self and provides an alternative perspective on one’s personal difficulties (Kuiper & McHale, 2009). These findings are consistent with the notion that putting a positive take on difficult life events might lead to a positive outcome (Thomas, 2016). Indeed, experiencing adversity might even facilitate our resilience and hardiness, and resilience to trauma experience might enable even those with multiple adverse childhood experiences to thrive (Prescod & Zeligman, 2018).

The implications derived from our statistical analysis appear to be supported by the qualitative analysis obtained from the open-ended questions. Individuals with the ability to create humor will be less likely to leave because they can regularly develop new activities (e.g., “Something in my character attracted me to study medical clowning because I always wanted to make people laugh”). However, humor appreciation is strongly associated with decreased turnover among individuals who had experienced traumatic events. For example, “I had a very difficult time during my army service” and “I felt that I lost my joy in life”.

Finally, our qualitative and quantitative findings support Gray et al.'s (2019) conclusion that medical clowning is indeed “serious business.” They argued that the narrow conceptualization of clown practices as being happy and funny overlooks how clowns help patients deal with pain. Thus, we encourage practitioners, educators, and researchers to reconceptualize the essence of the medical clowns' “therapeutic” role.

Practical contributions

Well-defined guidelines for effective medical clown selection should be grounded in evidence-based standards, and systematic criteria should be adopted for different patients and hospital contexts (Raviv, 2013). Thus, our findings can contribute to improved methods of recruiting. First, the selection process might want to identify those candidates possessing resilient personality traits (e.g., appreciative humor) and the capacity to establish positive interactions with patients (as derived from our qualitative findings).

Second, as approximately 33% of respondents reported having experienced traumatic events in their lives, these findings also raise questions regarding implications. Do medical clowns' previous traumatic experiences exacerbate their vulnerabilities over time? Can a history of trauma predict other potential work-related outcomes, such as more effective job performance throughout their career? Further, as previous traumatic life events also have been found to lead to negative outcomes, such as work related stress (Lee et al., 2017), it might be necessary to carefully monitor clowns so as to determine whether and how they are coping with their job challenges.

Our research findings can also contribute to developing more effective training. As medical clown training exposes them to “an interior journey to discover the inner clown” (Raviv, 2013, p. 99). Our findings support this contention, that the trainees' ability to modify their perspective on life (i.e., humor appreciation) and their inclination to create humor positively impact this process, making their “journey,” at least in its initial stages, more enjoyable and facilitative of their persistence in this career.

In addition, our results provided further empirical support to Raviv’s (2013) conclusion that future medical clown training should adopt a wider perspective to include clowning language and humor tools, as well as basic background in mental and emotional processes. Specifically, Raviv (2013) recommended that six elements of medical clowning training need to be addressed: pleasure (being able to restore or maintain the connection to pleasure and freedom), empathy, active listening, diag-red-nosis (the diagnosis obtained from the clown's red nose), rapport (the good relationship the medical clown creates with the patient), and the clown interaction (the clowning creativity and artistic performance). By expanding this line of reasoning, we argue that resilience training should be incorporated into the training curriculum.

The study's qualitative aspects highlighted the need to address organizational issues during the internship and the initial stages of the medical clowning career. The medical clown, unlike the medical staff, works alone and is typically not integrated into the institutionalized work system. At times, their work is not valued by the medical staff, nor even by patients and their families. Medical clowns have no clear protocol, leaving them to invent work patterns and create their own system of professional maintenance, often resulting in a sense of role ambiguity (Nuttman-Shwartz et al., 2010). Neglecting these concerns might be a factor in fomenting increased medical clowning turnover.

Research limitations and future directions

Despite the sample comprising about a third of the entire Israeli medical clown population, it remains relatively small. Further, the study examined medical clowns early in their career, during their training and internship, both of which are considered fundamental for shifting from one’s own persona to the clown persona (Dionigi et al., 2014). Finally, the study was conducted within a particular segment of medical clowns––unpaid interns. Whether unpaid interns can truly be considered volunteers can be debated, but given that unpaid interns can technically fall into the definition of work performed for no pay (Rogers et al., 2021) and that internship is considered the first stage of one's career (Oren et al., 2017), future studies might address the unique aspects of this unpaid internship. Finally, future work would also benefit from investigating medical clowning in different career stages.

Unlike most other occupations, the humor component of medical clowning is inherent in the job description. The research here adds to the growing number of studies by underscoring several contributions. Given the early stages of this healthcare research field, we anticipate that future studies will provide additional evidence for hiring, training, and integrating medical clowns into the hospital setting more effectively.

“Clowning is a trick to get love close. I can hug 99 percent of people in the first second of contact if I'm in my clown character. The clown assumes your humanity. It assumes that, whatever trauma you've had, you can still love yourself.” Patch Adams.

Figure 1.

Traumatic stressor moderated the associations between humor appreciation and turnover.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Abira Reizer

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