One year on...
Using laughter as the best medicine
The Clown Doctors
Introduction “You do a great job, keeping people happy is as important as medical treatment.” (Relative, of patient aged 2) It can happen in the strangest of places. Standing in a carpark in Sunderland about to head off to a meeting, my phone rings. It’s a member of the Performing Arts Department of Arts Council England, North East enquiring whether I had time to meet up to discuss the possible development of a Clown Doctor Programme in the North East. “A clown what programme?” Two years later and TIN Arts have a key role in ensuring that over 1400 children and young people in hospital are being encouraged to play, have fun and fill the wards with one of life’s most truly amazing gifts…laughter. The Clown Doctors Programme has been life changing for myself and those of us who are privileged to be a driving part of its progression. It has presented us with a unique opportunity to make a large difference to young lives through the smallest of actions. My belief is that in a very short time we have taken a concept on paper and turned it into a reality, having a real positive impact on others’ lives and making a valuable contribution to health care and health care staff. But is my personal belief shared by others when they are asked about the programme’s success? In December 2006 TIN Arts commissioned the Centre for Arts and Humanities in Health and Medicine (CAHHM) to help us to reflect upon the initial period of set-up by TIN Arts and then our first year of delivery of the Clown Doctors Programme. The purpose of this reflection was to assess and document the strengths of the programme whilst also identifying areas that could be improved. Subsequently this process has helped us to highlight potential future research areas within the Clown Doctors Programme alongside recommendations from CAHHM for improving delivery processes and procedures. The major element of this evaluation process has been to engage the Clown Doctors and health care staff to openly discuss their thoughts and feelings about the set-up process and first year of delivery. Both of these groups are at the heart of the programme and have great insight into its effects and outcomes. I hope you enjoy a taste of what the last few years have been like for us. We have faced challenges, overcome barriers, discovered and created new processes where before there were none, but also we have been touched by the lives of many children and young people. We have seen the pure joy of a smile creep across a face where before there was confusion, isolation and pain. The signs are that over the next few years the programme will be expanding to cover more of the North East region. More children and young people will hopefully have the chance to engage in play and laughter at a very traumatic time in their lives. I look forward to it with tremendous excitement. Best wishes,
Martin Wilson Director
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Using laughter as the best medicine
The Clown Doctors
Successes of the programme During the formation of the Evaluation Report by CAHHM, the researcher (Esther Salamon) observed that the programme has been a success to date, and that everyone who has been directly involved should be congratulated on their commitment to ensuring the scheme benefits hospitalised children and their families. Out of the discussions held with TIN Arts, Mark Mulqueen (Arts Council England, North East), the artists and the health care staff, the following successes should be celebrated: Health care staff describe the programme as motivating, stimulating and empowering for children and young people, with expectations on the ward being met. The artists have experienced several positive changes which can be attributed to the programme, most notably: a greater maturity, a sense of pride and discernible emotional and professional growth. Managing the Clown Doctors programme has resulted in several positive outcomes for TIN Arts, including the expansion of its horizons and aspirations, increased sophistication, and its investment in its staff by enhancing and increasing their skills base through training. The artists are benefitting from being in a team who have different creative specialities. The work is described as fulfilling, rewarding and challenging. The scheme offers an opportunity to prove that the arts, performance, and clowning in particular, can have a positive physical and emotional impact. The work contributes to patients’ understanding of their treatment while providing stimulation: they are encouraged to be creative, imaginative and to explore ideas. The artists have provided new ideas for engaging children which have added to the service that the Play Specialists provide. The Clown Doctors successfully get the children to open up and have fun whilst enabling patients to take control of situations. The health care staff are learning different things about the children, and the programme helps them to see how the artists can help, despite being outside the medical field. The Clown Doctors offer health professionals a deeper insight into how other professionals engage patients in activity (therapeutic play), which is able to distract them from their illnesses whilst promoting the importance of play and fun.
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Using laughter as the best medicine
The Clown Doctors
Background Following a seminar in 2004 and exploratory meetings with artists, health professionals, cultural organisations and others, Mark Mulqueen, Head of Performing Arts at ACENE, believed that a Clown Doctoring scheme in the North East of England was desirable, potentially beneficial and feasible. With funding from ACE secured for a three-year period TIN Arts, as TIN Productions, won the contract to deliver the scheme and has been managing the programme since September 2005. What is Clown Doctoring? The Clown Doctors offer hospitalised children and young people across the North East opportunities to take part in artistic play. The programme aims to relieve them of fear and insecurities and to empower them to understand and come to terms with their situation at a traumatic time.
What are the benefits to children? Whilst in hospital care children need to communicate, adapt to change and to have a sense of ‘self’. The Clown Doctors offer an impartial way of entertaining, supporting and empowering the children who may be struggling with these issues.
How does it work? The Clown Doctors work with children aged 6 months to 16 years and within a wide range of medical departments wherever there are young people. Each child has their own unique experience with the Clown Doctors. Play Specialists and Nursery Nurses based within paediatric wards in hospitals refer individual children to the Clown Doctors and give a reason for the referral plus basic information about the child's age, interests and medical condition. Some long-term children may be referred to the Clown Doctors on a regular basis during their stay. Successes or developments arising from the visit are fed back to the health care staff to form part of the child’s overall recovery care plan.
Who are the Clown Doctors? The Clown Doctors are professional artists who have been trained in the art of clowning, and have special skills and stories to share. They embody a range of ‘clown’ skills including song and dance, improvisation, puppetry, storytelling, circus skills, mime and movement. They all undergo police checks, and are trained to work with vulnerable children in a hospital setting.
About TIN Arts TIN Arts is one of the leading arts development companies in the North East. Dedicated to creating access to the arts for all, we act as a provider, supporter and adviser. We work with individuals, communities, arts organisations and government bodies to create, plan and deliver arts programmes that are accessible to all, regardless of age, gender and ability.
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Using laughter as the best medicine
The Clown Doctors
The Research In December 2006 we commissioned the Centre for Arts and Humanities in Health and Medicine (CAHHM) to evaluate the Clown Doctors programme. The purposes of this first evaluation were: To assess and document the strengths of the project To identify areas that could be improved if the programme was to continue or if future schemes were developed To identify areas requiring further research The research covered the period from 2004 until April 2007. On behalf of CAHHM Esther Salamon worked closely with the management team of TIN Arts, the Clown Doctors themselves and Play Specialists and paediatric staff. The research methods included: Desk-based research A review of evaluation forms and comments books and other documentation completed by artists, patients and their relatives and health professionals Structured interviews with the managers of the programme and its primary funder Separate focus groups with health professionals and artists Observation of a selected number of sessions in action A preliminary assessment of the impact of the programme on patients, their friends and relatives and artists The production of draft and final reports ‘One Year On…’ takes the core findings of Esther Salamon’s initial report and shares the key observations.
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Using laughter as the best medicine
The Clown Doctors
TIN Arts TIN Arts, the Clown Doctor artists and health care staff were asked to comment on the aims, objectives and aspirations that TIN Arts set at the beginning of the programme:
The substance of the Clown Doctors’ delivery must respond to the needs of each individual patient. They should be allowed to control the activity, including its tempo, direction, level of engagement and when it’s time to stop. The artists speak of constructing moments where the child is the expert, and is powerful in an environment where they may normally be powerless. They enable children to be children, rather than just patients. This demands high artistic standards and means that the artists are working on the ‘edge of their comfort zone’. Health care staff describe the programme as motivating, stimulating and empowering for children and young people with expectations on the ward being met. “To truly engage in play where the patient has control means that there is no time-defined space within which to work. The play gains a natural energy and tempo which will always be different according to each child.” (Martin Wilson, Director, TIN Arts)
The artists should be effective communicators, good listeners, highly sensitive and intuitive, self-aware, creative, responsive, playful, flexible, open, mature and secure. Health care staff appreciate the bonds that have been formed between the artists, staff, patients and families. The Clown Doctors engender a relaxed atmosphere in an environment that is often uncomfortable and daunting. The health care staff also believe the Clown Doctors to be brave, and admire their ability to talk to strangers – “kids warm to that” (Play Specialist) TIN Arts have seen several positive changes in the artists which can be attributed to the programme, most notably: a greater maturity, a sense of pride and discernible emotional and professional growth. Also the development of new abilities is enabling the artists to better understand individual children’s needs and to respond appropriately.
The quality of the support given to the artists involves a high level of mutual trust between the artists and TIN Arts, alongside processes and procedures that enable them to perform to their full potential. The artists commented strongly on how the level of support from TIN Arts was high and exceeded their expectations. Alongside high quality training the programme ensures financial stability and security as an artist. The TIN Arts appraisal system ensures that the artists: (i) have an opportunity to air issues and concerns, (ii) are able to receive feedback on the quality of their work and (iii) are able to identify future professional development needs. “have never worked with a company who is so thorough, nurturing and supportive”. (Artist working as a Clown Doctor)
Play specialists, consultants and other medical personnel should understand the scheme and recognise its central role as part of a patient’s recovery programme, to the point where it becomes another part of their therapeutic referral service. The programme relies upon developing good working relationships with play specialists, nurses and other health professionals. It depends on them for referrals which serve to underpin and validate the programme. 6
Using laughter as the best medicine
The Clown Doctors
Play Specialists noted that they are learning new things about the children as well as gaining a greater understanding of how others outside the medical profession can help. Doctors, surgeons and health professionals expressed continued enthusiasm and support for the scheme. The most common feedback was a desire to have increased delivery from the Clown Doctors, reaching more children and young people over more days. “If referrals were not forthcoming, the programme would become dislocated, as the Clown Doctors would simply be working the whole ward and would not be targeting individual patients thus becoming divorced from one of its key principles” (Clare Andrews, Programme Manger, TIN Arts) Informal debriefing sessions take place regularly with participating hospitals’ play specialists, consultants, business managers, managers of children’s services and arts co-ordinators, at which changes and potential improvements to the scheme are discussed.
The Clown Doctor Programme should have a positive impact on TIN Arts as a progressive, innovative development company creating opportunities for TIN Arts to learn, share and lead where appropriate. Martin Wilson is convinced that TIN Arts is benefiting greatly from the programme. Prior to the Clown Doctors, the organisation was a dance facilitation and development company, and is now developing a much broader focus; most notably engaging artists and developing new programmes across disciplines. According to Mark Mulqueen, TIN Arts has changed beyond recognition since it began managing the Clown Doctors programme. He believes the experience has resulted in several positive outcomes, including the expansion of its horizons and aspirations, its maturation and increasing sophistication, and its investment in its core staff by enhancing and increasing their skills base through training. The scheme has surpassed several of its original targets, including (i) the number of hospitals participating in the scheme, (ii) the number of artists engaged, and (iii) the number of sessions each artist is delivering. Although the scheme has received a modicum of attention from North East media, questions arise about whether the aims of the project could be communicated more effectively to the medical profession, private sector, the arts community and the general public. “Not only within the Clown Doctors Programme but also with our other delivery strands, we are constantly trying to find the means of expressing the aims and activities in ways which can be understood by different sectors, i.e. ‘Nursing Times’, ACE’s ‘Client Briefings’, local/ national television and newspapers.” (Martin Wilson, Director, TIN Arts)
The programme should be financially viable and sustainable at all times to ensure a strong foundation upon which to build. Initial beliefs that the aims of the programme would be strong enough to attract a large amount of interest from funders and sponsors have not come to fruition. At the present time, income generated is a mixture of grants from Arts Council England and trusts / foundations, earned income and donations from charitable funding bodies attached to the hospitals. Though funding is sufficient to deliver the basic elements of the programme, a long-term fundraising strategy needs to show more robust methods of attaining and securing funds as opposed to short-term successes.
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Using laughter as the best medicine
The Clown Doctors
The Clown Doctors The Clown Doctors are freelance artists contracted by TIN Arts to deliver the programme. As well as delivering on a weekly basis, they regularly meet to train, reflect and discuss matters relating to the programme. The artists were invited by CAHHM to attend a two-hour open group discussion with opportunities for individual, confidential responses to questions. The following comments are a summary of the discussion held and more detailed information is available upon request. Reasons for becoming a Clown Doctor and expectations of the scheme Artists were originally interested in being employed as Clown Doctors to make a difference to peoples’ lives while discovering the impact of the arts on health and healing. They wanted to challenge themselves as performers and to learn from other artists. The artists thought that the programme would be worthwhile, satisfying and personally rewarding. They recognised that the work might be emotional and challenging, and that it would demand high artistic standards.
Ways in which expectations are being satisfied The artists are benefitting from being in a team who have different creative specialities. The work is described as fulfilling, rewarding and challenging. While seeing sick children is often upsetting the hospital staff are very supportive of the artists. “We can help relax children and families to make their tasks easier; a happier child is easier to manage…they are more amenable to having procedures done to them.”
Strengths of the scheme The artists feel that they are making a difference (to patients, parents and hospital staff), and that this is only possible with the support of the hospitals. The scheme offers an opportunity to prove that the arts, performance, and clowning in particular, can have a positive physical and emotional impact. Benefits to participating children The work softens the hospital environment and gives the children something positive to look forward to. The work contributes to patients’ understanding of their treatment while providing stimulation: they are encouraged to be creative, imaginative and to explore ideas. This means that they may move, eat, or speak as a result of creative play, and they leave with a good memory of their time in hospital.
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Using laughter as the best medicine
The Clown Doctors Benefits to ‘non-involved’ children Observing the Clown Doctors creates a more relaxed, happier atmosphere on the ward. As well as interaction for patients, the programme can give siblings a chance to get some attention and have some fun while visiting a child in hospital. Benefits to families Families benefit from a respite from anxiety; a chance to relax; an opportunity to see their children enjoying themselves and a chance to improve their own playful interaction with their child. The programme allows them to take a break from their child’s bedside so that they can eat, talk to hospital staff etc. “I feel very passionate about what we do and I know everyone else does too – that’s very fulfilling.” (Clown Doctor)
Benefits to health professionals The artists are aware that they have provided new ideas on ways of engaging children and that this has added to the service that the Play Specialists provide. There is a visible impact on the health professionals, with the programme alleviating stress, breaking up the ward routine and bringing a smile to the faces of the staff. Suggested changes to the scheme All of the Clown Doctors believe the scheme should continue and many mentioned that the service should expand. Artists would like to see the number of sessions and hospitals increased. They would like to meet regularly with health professionals and Clown Doctors from other geographical areas. Final points The scheme’s profile needs to be raised so that more health professionals, families and children understand its benefits.
“It’s been a real privilege working on this project and being part of this team.” (Clown Doctor)
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Using laughter as the best medicine
The Clown Doctors
Health / medical professionals All health care professionals who were connected to the programme were invited by CAHHM to attend a two-hour open group discussion, with opportunities for individual, confidential responses to questions. One of the health professionals who was unable to attend the session submitted her answers via a confidential questionnaire. The following comments are a summary of the discussion held and more detailed information is available upon request. Expectations of the scheme Expectations were strong at the commencement of the programme. Health care staff believed that the Clown Doctors would work well with children, parents and staff and that it would be fun and entertaining. They also believed it would motivate, stimulate and empower children, leaving the patient with a good and happy experience of hospital. Ways in which expectations are being satisfied The Clown Doctors are working well with staff, patients and parents bringing laughter and fun to the wards and departments. The Clown Doctors successfully get the children to open up and have fun whilst enabling patients to take control of situations. The Clown Doctors have shown that they can make a huge difference.
“I feel my expectations are being met, as I have long-term patients on my ward and they love the Clown Doctors, they meet their needs and are sensitive to their needs accordingly.” (Play Specialist)
Ways in which expectations are not being satisfied A few parents, patients and staff are a bit anxious about the Clown Doctors, but are now getting to know what they are all about. There is also scope for the Clown Doctors to work with patients with more complex problems. Strengths of the scheme It provides laughter and therapeutic play to seriously ill children and young people and improves patients’ experience of hospitals. The health care staff are learning different things about the children and it helps them see how others outside the medical field can help in many ways. The Clown Doctors are sensitive to each individual patient’s needs – some children are too ill to participate, but the Clown Doctors will peer through their cubicle to make sure they are not left out.
“Many of the younger children love the “magic tricks”, it’s like having a tonic when the trick works!” (Play Specialist)
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Using laughter as the best medicine
The Clown Doctors
The unexpected There is great delight in the enthusiasm and support expressed by doctors, surgeons and other health professionals. Many staff, children, young people and parents have totally changed their views, thinking they wouldn’t like the Clown Doctors and now finding that they actually do! Impact on professional practice When patients respond enthusiastically, positive attitudes are palpable on the wards. Working with Clown Doctors can be time consuming (particularly when the scheme began) as health care staff are having to think about which children to refer them to, and why. The Clown Doctors offer a deeper insight into how other professionals engage patients in activity (therapeutic play) which is able to distract them from their illnesses whilst promoting the importance of play and fun. Benefits to participating children Over the past year health care staff have seen how patients have had fun and can be happier following a Clown Doctor visit. The Clown Doctors give children and young people something positive to look forward to and after a visit the patients appear more relaxed and talkative. The Clown Doctors also provide an opportunity for patients to interact with and establish good relationships with non-medical staff.
“Kids love them, they are a great asset and the children look forward to them brightening up their day.” (Play Specialist)
Benefits to ‘non-involved’ children The children enjoy watching the Clown Doctors, they have fun, laugh and are entertained. Often if a ’non-involved’ child is watching, they are also participating and can enjoy the session. In several instances children who have observed the Clown Doctors have asked to see them the next time. Benefits to families Activity relieves parents’ stress and provides fun and entertainment for parents and siblings. Families are able to develop relationships with the Clown Doctors, particularly if their child has a long-term illness. Suggestions for increasing the benefits of the scheme for all Engage more Clown Doctors– this would enable more wards to be covered. Consider ways of involving parents more in the activity alongside the patients. More clowns could be on hand at ‘needed times’, especially with play programmes where the children need an ongoing development plan to help their way to recovery. More flexibility around delivery days and times in hospitals. Have a closer look at methods for evaluating the impact of sessions.
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Using laughter as the best medicine
The Clown Doctors
Recommendations Although the researcher identified several recommendations and issues that needed to be considered, CAHHM’s view is that the programme has been a success to date. Its recommendations can be gathered under several key headings: Research Consideration should be given to undertaking research into (i) the clinical impact of humour/laughter on hospitalised children (ii) the short, medium and long-term effects of Clown Doctors’ programmes (iii) gaining a greater understanding into the needs of the NHS and how Clown Doctoring could potentially fulfil a vital role within future NHS service delivery (iv) TIN Arts’ notion of an interconnectedness between play and art/artists’ practice, and the subsequent relationship and impact (if any) of these on hospitalised children In order to understand the long-term clinical impact of the programme, consideration should be given to monitoring its effect on children and young people once they have been discharged from hospital. This research would also provide an opportunity to discover the degree to which hospitalised children and young people share their experiences of the Clown Doctors programme with their peers and others in their communities. Communication In order to provide health professionals with a more thorough understanding of the programme and of artists’ skills, it is recommended that prior to the start of the scheme they be given a broad understanding of (i) the importance of creative expression and the role of the arts in developing and maintaining good physical and mental health (ii) the differing roles, aims and objectives of professional artists, art teachers and play specialists To ensure that those health professionals who are not directly involved with the programme understand the aims, objectives and merits of the scheme, consideration should be given to holding occasional meetings and events during the programme. To assist ‘on the ground’ delivery, an appraisal of how Clown Doctor time is allocated may help all parties to achieve greater benefits from the programme. Training Prior to new Clown Doctors working in hospitals, an enhanced induction period should be considered. Information on the following should be included: (i) hospitals’ procedures (ii) the workings of the NHS (iii) the artists’ and health professionals’ respective roles, responsibilities and constraints Additional training should be provided during the programme including the development of artists’: (i) ability to read situations and respond appropriately, expanding their sensitivity and intuition and their empathetic abilities (ii) time management and communication skills, professionalism, organisational acumen (iii) understanding of successful collaborations/partnerships and team working (iv) use of peer-to-peer mentoring for their professional and creative development purposes
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Using laughter as the best medicine
The Clown Doctors
Developing models of good practice In order to identify best practice and to further develop the North East programme, it is suggested that a targeted number of programmes operating nationally and internationally be identified, compared and contrasted. Sustainability In order to develop and sustain the Clown Doctor programme, consideration needs to be given to identifying a variety of funding sources. The researcher believes that TIN Arts needs to examine several options, including those identified below: Consider developing infrastructure and delivery capabilities to be in a position to deliver training for clowning to generate new income whilst also creating a higher number of artists skilled in the art of Clown Doctoring Consideration should be given to developing robust targets and instituting rigour in capturing, measuring and interpreting the quantitative and qualitative data/ evidence in order to confirm: (i) the numbers of patients referred by each hospital against each hospital’s target (ii) the reasons behind any fluctuations (iii) whether the Clown Doctors were able to see all of those referred in the time allocated (iv) the quality and impact of the work (v) whether examples of good practice were replicable It is believed that measuring the project’s effectiveness against its aims and objectives would enable TIN to better develop current and future practice and, if adequately considered, could attract financial and other support. To ensure the Clown Doctors programme becomes integrated within the NHS, consideration should be given to further developing and formalising relationships with Strategic Health Authorities and individual hospitals by entering into Service Level Agreements.
Acknowledgements Clare Andrews Karen Bell Dafe Bullock Lynn Dutton Tracey Gothard Mark Labrow Laura Lindow Rosa Stourac McCreery Alison McGowan Joanne Moore Mark Mulqueen Sandra Myers Pady O’Connor John Quinn Marie Samuels Elaine Sweeting Martin Wilson Initial report from which this evaluation document has been drawn was produced by Esther Salamon, Cultural Partnerships & Development, 0191 413 9484. August 2007.
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And finally... There are eight Clown Doctors working in the North East region.
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Using laughter as the best medicine
The Clown Doctors
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Clown Doctors operate across the world, including in Australia, Brazil, France, Turkey and Aruba (but they’re not all ours!).
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Using laughter as the best medicine
The Clown Doctors
“I just love what you do. It makes us really happy. It’s the first time I’ve smiled since we got here”. (Parent who had earlier received some bad news from medical staff)
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That’s more than 1 day of delivery for every 2.5 days!
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Between September 2006—July 2007, the Clown Doctors were in hospital for 133 days out of a possible 334.
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TIN Arts Shakespeare Hall North Road Durham DH1 4SQ 0191 384 0728 info@tinarts.co.uk www.tinarts.co.uk www.clowndoctors.co.uk