Clown Doctors Abstract of Evaluation Report 2010

An Investigation into the Clown Doctors Programme

Original Report by Elise Danks June 2010

Reviewed by Clare Andrews September 2010

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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.

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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.

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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

Does the child's mood to change appear during the visit?

0% 0% 0%

Yes, very positively 14%

Yes, Somewhat positively No Yes, Somewhat negatively Yes, Defiinitly negatively 86%

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.

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Is the play child-directed/ appropriate to the child's needs and/or interests?

3% 7% Yes Somewhat No

90%

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.

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In what mood is the child when the Clown Doctors leave?

0%

3%

Very postive

10%

Quite positive Quite negative Very negative 55%

32%

Unknown

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.

Where possible does the child interact with the Clown Doctors?

0%

14%

Yes No Not possible

86%

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

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children interacting verbally. Those children judged not able to interact were often very ill or very young.

Does the carer/parent appear to enjoy the visit?

9% 13%

Yes No Unsure 78%

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.

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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.

6 5 Rating

4 3 2 1 0 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?

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

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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

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explained their answer as due to lack of finance in the NHS rather than the Clown Doctors not being a worthwhile programme.

Who do you think should pay for the Clown Doctors?

31%

Don't know Charities

54%

NHS 15%

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.

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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

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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.

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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

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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.

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Do you think that the arts in general have a place in hospitals?

0% 10% Yes No Don't know 90%

Figure 8 shows the proportion of hospital staff who think the arts in general have a place in hospitals.

Who do you think should pay for the Clown Doctors?

0%

NHS 50%

50%

Don't know Other/Charities

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

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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.

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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

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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.

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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

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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

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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.

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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.

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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!

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