Abstract

To investigate the clown ideologies that circulate in a hospital scenario, in this paper, we describe the origins of hospital clowns, evaluate their professional training, and discuss their contemporary role. For this descriptive, historical documentary, and qualitative study, we carried out searches in academic databases such as PubMed and LILACS in April 2021. The insufficiency of these results motivated our consultation of book collections and a documentary analysis of other sources related to clowns. Given their function of conveying lightness, humor, and comedy, we observe that hospital clowns, despite lacking a curative function, complement the treatment of patients and therefore require training in the fields of art and biosafety. Based on our bibliographic research, we also conclude that there is a great need for the training and continual education of hospital clowns who perform in a Brazilian context.

Key words:
Clown; Hospital; Health; Hospital Clown Ancestry; Professional training

Introduction

The arts, as promoters of health, have always accompanied humanity. They are not palpable like the medicine we receive in medical care, but in their peculiar way, they are beneficial to health because they calm the soul and balance us as human beings. They can also be perceived over time, from ancient cave paintings to the most modern animated messages sent via cell phones that cause lightness and harmony when they are observed.

Among the arts, we highlight clowning through the figure of the clown, a funny character present among all groups in all times. The clown exposes his or her weaknesses in a comical and humorous way. Through his or her mistakes, the clown demonstrates human fragility, disconnects us from the real world, and teleports us to the imaginary of our dreams via a more hopeful and fun vision that favors living color.

The clown does not ignore the difficulties that arise in daily life; in contrast, he or she learns to include them and vent them through humor. The clown emerges as a figure who uses parody in the face of tragedy. However, this does not imply that his or her problems are resolved but that he or she is learning to deal with diversity and realizes that every moment can be fleeting.

Clowns predate the existence of any show, although they are associated with the circus ring, circuses and itinerant parties. As an organized form of art, clowning has a social function because clowns condense and synthesize the possibility, given by language and human cohabitation, to imagine and live apart from the real world in another possible world¹1 Bergson H. O riso: ensaio sobre a significação do cômico. 2ª ed. Rio de Janeiro: Zahar; 1983.^,22 Kangussu I, organizador. O cômico e o trágico. Rio de Janeiro: Letras; 2008..

The clown appropriates art, whose word has a Latin origin, “ars”, which means technique or skill. According to the Houaise³3 Grande Dicionário Houaiss [Internet]. [acessado 2021 maio 15]. Disponível em: www.dicio.com.br/houaiss/.
www.dicio.com.br/houaiss/.... dictionary, art is the “conscious production of works, forms or objects aimed at the realization of an ideal of beauty and harmony or for the expression of human subjectivity”. Concerning the meaning of technique, the word has a Greek origin, thecne, entailing that the understanding that artistic practice requires minimal theoretical and practical knowledge. Thus, the clown’s ideology in a hospital setting expresses a specificity that reflects the practitioner of this art.

The function of the hospital clown has been defined as a parody of the figure of doctors by Michel Christensen. However, this definition should be approached with caution because the clown does not perform the same skills as health professionals. His or her work “is to stimulate the healthy side of the patient through the arts”⁴4 Masetti M. Boas misturas: possibilidades de modificações da prática do profissional de saúde a partir do contato com os Doutores da Alegria [dissertação]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2001. and is a complement to treatment; it does not have a curative function. For Adams⁵5 Adams H. Patch Adams: O amor é contagioso. Rio de Janeiro: Sextante; 1999., “the laughter provided by the clown can relieve pain and suffering” via the art of the clown, which conveys lightness, doses of good humor, injections of hope, comical reflections and parodies that reflect everyday life situations⁶6 Melo D, Silva MR. Sorriso de Plantão: Um sentimento que não pode parar. Arapiraca: Eduneal Editora; 2019.. The responsibility for healing permeates a broad and complex concept of health where the clown cannot assume this responsibility of curator.

In this context, it is necessary to clarify the importance of the artistic concept and purpose of the hospital clown by emphasizing that just as the doctor needs training to perform his or her work, the clown must receive training before entering the profession and the health service. Thus, “deromanticizing” clowning, corroborating the National Humanization Policy, suggests that its main function is to contribute to health care from the perspective of the concept of integrative medicine. This is based on knowledge provided by health professionals, whose goal is to offer comprehensive, individualized and holistic patient care⁷7 Otani MAP, Barros NF. A Medicina Integrativa e a construção de um novo modelo na saúde. Cien Saude Colet 2011; 16(3):1801-1811..

A natural question thus follows: What ideology of the clown is disseminated in the hospital setting? To answer this, we seek to understand the concepts and patterns of behavior constructed and disseminated by hospital clowns. Studies with this theoretical impetus contribute to uncovering the historical matrix of the subject in question, fostering a reflection on the ruptures and permanences that have influenced and still influence the hospital clown, from antiquity to the present day.

Method

This is a descriptive, historical-documentary study with a qualitative approach. Initially, our searches were performed in academic databases such as PubMed and LILACS in April 2021 without restriction to annual period. The descriptors we used were “Ancestry of the Clown and Health”, “Trajectory of the Clown and Health”, “Relationship between Clown and Health”, and “Hospital Clown and Health”. Numerous works were found regarding the art of the clown and health from the perspective of physiological and psychological benefits to patients, companions and professionals. However, our results did not meet our proposed demands. It was thus necessary to consult a complementary collection of books and engage in a document retrieval of groups of salient clown references, which allowed the construction of a database that optimized the organization, interpretation and analysis of our data.

Because we consider it relevant, we highlight the work Elogio da Bobagem written by Alice Viveiros de Castro⁸8 Castro A. Elogio da bobagem: palhaços no Brasil e no mundo. Rio de Janeiro: Família Bastos Editora; 2005., a collection of books by the group Doutores da Alegria⁹9 Nogueira W. Doutores da Alegria. O lado invisível da vida. São Paulo: Grifa Mixer; 2006., reports on the work of Patch Adams⁵5 Adams H. Patch Adams: O amor é contagioso. Rio de Janeiro: Sextante; 1999. and Michel Christensen, and academic publications by Morgana Masetti⁴4 Masetti M. Boas misturas: possibilidades de modificações da prática do profissional de saúde a partir do contato com os Doutores da Alegria [dissertação]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2001. and Susana Caires¹⁰10 Caires S, Ribeiro S, organizadoras. Operação Nariz Vermelho:rir é o melhor remédio? 2ª ed. Vila do Conde: Lidergraf; 2016..

Such studies supported the writing of this article, as we considered these relevant publications to our proposed discussion of clowns in the hospital setting. Once the construction of the database was completed, we began a careful and selective reading of the content, which allowed us to segment the analysis process into two stages. First, we carefully evaluated the selected material by focusing on the content of the topic. In this thoroughly developed mode, we sought to identify differences and similarities among the authors as well as the textual transformations between each of the files. Specifically, we discerned the excerpts and chapters that reproduced conceptions about the ancestry of the clown in the hospital setting.

After completing these respective procedures, we discussed and listed topics, specifically, those in relation to our identification of prescriptive “concepts” and “patterns” of behaviors and attitudes that converged with the idea of the clown as a promoter of health and standards in the hospital setting.

The definition of a “concept” that we used implied that any procedure that allows identifying and classifying any “knowable” objects also has the function of describing such objects; thus, they are also recognized¹¹11 Abaggnano N. Dicionário de Filosofia. São Paulo: Martins Fontes; 2007.. Accordingly, we classified and presented our concepts in three categories: 1- ancestry of hospital clowns, 2- hospital clowns in contemporary times, and 3- professional training of hospital clowns.

Another definition used in this research concerned “standards”, i.e., everything that is configured as a basis or standard for an evaluation, always linked to an intended result. Thus, standards, the objects of analysis and emphasis as conceptualized in the archives, entailed a normative behavioral prescription to be adopted by the general public and followed by generations over time¹²12 Guerrero GP, Beccaria LM, Trevizan MA. Standard operating procedure: use in nursing care in hospital services. Rev Latino-Am Enfermagem 2008; 16(6):966-972..

When our analytical procedure was completed, the results were classified into three categories, which were then described and discussed based on the relevant scientific literature. Regarding an evaluation by the Human Research Ethics Committee (CEP), as determined by current legislation - Resolution No. 466/2012¹³13 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diário Oficial da União 2013; 13 dez., because this was not a research study involving human beings but only freely accessible documentary sources, it was not necessary to submit the project for such an assessment.

Results and discussion

Exploring the ancestry of the hospital clown

For as long as they have existed, clowns have used parody in the face of pain, tragedy, suffering and the human condition. It is necessary for clowns to be present in various environments, such as hospitals, universities, war camps, prisons, “red-light” districts, orphanages, long-stay institutions (ICLs), courts, companies and other places where they are permitted. The ideology of clowning is to present a new landscape to deal with life, not to disregard its ailments; just as the health professional visits patients to identify their pathology and offer strategies to cure their disease, the clown is also a visitor. He or she visits “pain” and, in an artistic way, seeks to find something beyond suffering that is expressed in a physical or emotional way. With the art of laughter, empathy and love, he or she intends to soften the tragedy he or she observes¹⁴14 Thebas C, Dunker C. O Palhaço e o Psicanalista: como escutar os outros pode transformar vidas. São Paulo: Planeta Brasil; 2019.

15 Bastos R. Clown Terapêutico. Juiz de Fora: Editora Bartlebee; 2016.^-1616 Wuo AE. O Clown visitador no tratamento de crianças hospitalizadas. Campinas: Universidade Estadual de Campinas; 1999..

This is a search to find something good to stimulate the good energy that can positively spread to all affected organs, favoring moments of relaxation and deviation from suffering and tragedy. The clown is aware that he or she will not cure suffering, especially because his or her function is artistic, but he or she believes that his or her art, when presented to the patient, alleviates disillusionment and reduces dark days.

The figure of the clown in the hospital, although current, originated within the scope of philosophy, art and physical-mental health, that is, through the influence of medicine and the figure of the doctor. In Egyptian civilization, in 4,500 BC, for example, it is the figure of a clown - Bess, the god of joy - who represents the search for human balance. Regarding Greco-Roman mythology, in 400 BC, the Athenians sought healing of the mind and body in the sanctum of Asclepius, god of medicine and healing, where patients received the benefits of the healing force of humor. Among the indigenous Hopi and Tunis tribes, high-ranking priests, designated health caregivers of their tribe’s members, dressed as clowns⁴4 Masetti M. Boas misturas: possibilidades de modificações da prática do profissional de saúde a partir do contato com os Doutores da Alegria [dissertação]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2001..

There are late-nineteenth-century reports of the Fratellini brothers, a famous group of clowns who started working in hospitals in France by casually visiting the pediatric sector¹⁷17 Mansson ME, Elfving RN, Petersson C, Wahl J, Tunell S. Use of clowns to aid recovery in hospitalised children. Nurs Child Young People 2013; 25(10):26-30.. In 1908, there are reports that reveal the performance of clowns in hospitals, published in the Petit Journal, describing the performance of two clowns in a ward of a pediatric hospital in London¹⁸18 Spitzer P. Hospital clowns: Modern-day court jesters at work. Lancet 2006; 368(1):34-35.; however, this type of action is cited as rare.

Hospital clowns in the professional category emerged only in 1986, when Michael Christensen and the Clown Care Unit were integrated into the circus company The Big Apple Circus¹⁹19 Dionigi A, Canestrari C. Clowning in Health Care Settings: The Point of View of Adults. Europe's J Psychol 2016; 12(3):473-488.

20 Rodrigues AFA, Nunes Filho WJ. A utilização do palhaço no ambiente hospitalar. OuvirOuVer 2013; 9(1):72-81.^-2121 Tan Junior AK. A Qualitative Phenomenographical Study of the Experience of Parents with Children in Clown Care Services [tese]. Helsinki: Helsinki Metropolia University of Applied Sciences; 2014.. That year, the Babies and Children’s Hospital in New York requested a presentation for children in its cardiac surgery sector, and Christensen chose to parody a doctor. He was “introduced as the new chief physician, Dr. Stubs, whose stage was a room full of children with various clinical situations and [...] gave rise to playful irreverence toward the authority figure of the doctor and hospital standards”²²22 Hospital Clown Newsletter. Stubs Dr, Michael Christensen, of The Big Apple Circus Clown Care Unit. The Hospital Clown Newsletter: A Publication for Clowns in Community and World Service 1999; 4(1):5-9.. This activity generated surprising results, with an expressive acceptance and participation of the children in the clown’s play²⁰20 Rodrigues AFA, Nunes Filho WJ. A utilização do palhaço no ambiente hospitalar. OuvirOuVer 2013; 9(1):72-81.^,2121 Tan Junior AK. A Qualitative Phenomenographical Study of the Experience of Parents with Children in Clown Care Services [tese]. Helsinki: Helsinki Metropolia University of Applied Sciences; 2014.^,2323 Takahagui F, Moraes E, Beraldi G. Mad Alegria: Estudantes de medicina atuando como doutores-palhaços: estratégia útil para humanização do ensino médico? Rev Bras Educ Med 2014; 38:120-126..

Sensitized by the activity and vision of a field of action for the clown, Michael Christensen created the Clown Care Unit “with the goal of bringing to the hospitalized children the surprise, the magic, the enthusiasm, the joy and the fun²²22 Hospital Clown Newsletter. Stubs Dr, Michael Christensen, of The Big Apple Circus Clown Care Unit. The Hospital Clown Newsletter: A Publication for Clowns in Community and World Service 1999; 4(1):5-9. based on the assumption that children, regardless of their situation, have in their essence play and that clowns make this dimension of health emerge”²⁴24 Masetti M, Caires S, Brandão D, Vieira DA. Confirmatory factor analysis of the questionnaire on the health staff's perceptions regarding Doutores da Alegria's Interventions. J Health Psychol 2019; 24(2):166-174.. The Clown Care Unit consisted of professional clowns who were specially trained to perform in the hospital setting. The pioneering artists in this study were of various nationalities and subsequently created programs in their respective countries²⁰20 Rodrigues AFA, Nunes Filho WJ. A utilização do palhaço no ambiente hospitalar. OuvirOuVer 2013; 9(1):72-81.^,2525 Masetti M, Caires S, Brandão D, Vieira DA. Confirmatory factor analysis of the Questionnaire on the Health Staff´s Perceptions regarding Doutores da Alegria's interventions. J Health Psychol 2016; 24(2):166-174.. Some examples of these were the projects of Wellington Nogueira, who foundd Doutores da Alegria in Brazil, Carolina Simonds’ Le Rire Medecin in France, and Laura Fernandez’s Die Clown Doktoren in Germany²⁶26 Caires S, Masetti M. Uma pedagogia atrave´s do olhar do palhaço no contexto de saúde: Subsídios para humanização pediátrica. Rev Cien Educ 2015; I(33):39-57.. Similarly, knowledge of the work of Michael Christensen and the Clown Care Unit led André and Jean Poulie to found the Theodora Foundation in Switzerland (which currently operates in eight countries worldwide), Yury and Vladimir Olshansky to create Soccorso Clown in Italy, Peter Spitzer and Jean-Paul Bell to start Australia’s Humor Foundation Clown Doctor Programs, and Sergio Claramunt to constitute the Paya Ospital in Spain. There are also other organizations, such as Fools for Health (Canada), Sairaalaklovnitry (Finland)²¹21 Tan Junior AK. A Qualitative Phenomenographical Study of the Experience of Parents with Children in Clown Care Services [tese]. Helsinki: Helsinki Metropolia University of Applied Sciences; 2014.^,2626 Caires S, Masetti M. Uma pedagogia atrave´s do olhar do palhaço no contexto de saúde: Subsídios para humanização pediátrica. Rev Cien Educ 2015; I(33):39-57., Ball Roja (Peru), Doctor Happy (Chile)²⁷27 García EAL, Valle JFT, Bermúdez CAR. Artículo de revisión Risa y salud: abordajes terapêuticos. Med Unab 2011; 14(1):69-75. and Operation Red Nose (Portugal).

In the same year that Michael Christensen founded the Clown Care Unit, 1986, another line of hospital clowns emerged in Toronto, Canada, with a therapeutic model, through a professional clown and teacher, Karen Ridd²⁸28 Langdon D, Gryski C. Forward. In: Ridd K, editor. There ought to be clowns: child life therapy through the medium of a clown. Winnipeg: The Canadian Association of Therapeutic Clowns; 2009.

29 Pendzik S, Raviv A. Therapeutic clowning and drama therapy: A family resemblance. Arts Psychotherapy 2011; 38(4):267-275.^-3030 Warren B. Treating Wellness: How Clown Doctors Help to Humanize Health Care and Promote Health. In: Twohig PL, Kalitzus V, editors. Making Sense of Health, Ilness Amsterdam. New York: Rodopi; 2004.. She developed her ideas in the context of the theory and practice of child development, approaching the Child Life Department of the Children’s Hospital of the Health Sciences Center of Winnipeg with a grandiose, daring and transformative idea: the clown’s intervention in this health context. Her proposal was supported by the head of the department, Ruth Kettner, and the director of Children’s Hospital Television, Renée Ethans²⁸28 Langdon D, Gryski C. Forward. In: Ridd K, editor. There ought to be clowns: child life therapy through the medium of a clown. Winnipeg: The Canadian Association of Therapeutic Clowns; 2009.^,2929 Pendzik S, Raviv A. Therapeutic clowning and drama therapy: A family resemblance. Arts Psychotherapy 2011; 38(4):267-275.. Through her innovation and endeavor, Ridd demonstrated the relevance of the clown’s role to a relationship with a hospitalized child through a clown’s “potential empowerment, facilitating adaptation to the clinical situation [...] by changing the perception of the child in a hospital setting and the needs of the family [...] as an educational and fun tool”²⁸28 Langdon D, Gryski C. Forward. In: Ridd K, editor. There ought to be clowns: child life therapy through the medium of a clown. Winnipeg: The Canadian Association of Therapeutic Clowns; 2009..

According to Ridd’s proposal²⁸28 Langdon D, Gryski C. Forward. In: Ridd K, editor. There ought to be clowns: child life therapy through the medium of a clown. Winnipeg: The Canadian Association of Therapeutic Clowns; 2009., “the emotional state of the person interferes with their physical well-being. Humor and laughter create a positive affective valence and clowns have always occupied a central place in society throughout history, so they can constitute an aid to health professionals, breaking barriers, releasing stress, causing improvement in the well-being of patients, companions and health professionals”. Here, Ridd²⁸28 Langdon D, Gryski C. Forward. In: Ridd K, editor. There ought to be clowns: child life therapy through the medium of a clown. Winnipeg: The Canadian Association of Therapeutic Clowns; 2009. assumes that the intervention of the therapeutic clown creates the opportunity for the child to play various roles, gain control, consistency, and creativity, and develop a sense of humor while establishing positive relationships.

Organizations of hospital clowns have been expanding worldwide and follow the ideologies of either Michael Christensen or Karen Ridd³¹31 Ribeiro S, Masetti M, Caires S. International Survey of Hospital Clown Organizations: Preliminary results. In: Comunicação efetuada no First International Conference on Pediatric Hospital Clown. Firenze; 2014.. Currently, the expansion of the perspective of the clown and health in various scenarios is evident, extending from the pediatric context to encompass the following sectors: adult, geriatric, rehabilitation, children and adolescents with special needs, preoperative preparation, comatose patients, palliative care, patients who have suffered a catastrophe, isolation, and psychiatric contexts. Clowns’ impacts have not only improved these service environments but have also reduced the number of destructive behaviors²⁸28 Langdon D, Gryski C. Forward. In: Ridd K, editor. There ought to be clowns: child life therapy through the medium of a clown. Winnipeg: The Canadian Association of Therapeutic Clowns; 2009.^,2929 Pendzik S, Raviv A. Therapeutic clowning and drama therapy: A family resemblance. Arts Psychotherapy 2011; 38(4):267-275.^,3232 Simonds C, Warren B. The clown doctor chronicles: Probing the boundaries. Amsterdam: Rodopi; 2004.^,3333 Anes L, Obis M. Hospital clowning as play stimulus in healthcare. Children 2014; 1:374-389..

In 2011, the European Federation of Hospital Clown Organizations³⁴34 European Federation of Hospital Clown Organization [Internet]. 2011 [cited 2021 jun 20]. Available from: http://www.efhco.eu.
http://www.efhco.eu... was created. This group aims to protect and support the work of the professional clown in the hospital setting. The Federation is a reference for professionals who work exclusively in pediatric hospitals and “promotes good practices, assigning quality accreditation according to the fulfillment of rigorous criteria and disseminating the research developed in this professional area”³⁴34 European Federation of Hospital Clown Organization [Internet]. 2011 [cited 2021 jun 20]. Available from: http://www.efhco.eu.
http://www.efhco.eu... .

In 1991, in Brazil, “Doutores da Alegria” was founded. The creator claims to have used the term “Clown” to differentiate the hospital clown from the typical pejorative connotations of the word “palhaço”. Concerning the professionalization and appreciation of this topic, the school has offered space for the formation of clowns and discussions. For example, the “Escola de Palhaços” presents its own pedagogy in the teaching of the mask. It trains artists to intervene in different, improbable stages - wherever their choices take them. The NUFO (training and guidance center) and the “Palhaços em Rede” project aim to bring together groups of clowns who work in hospitals in the country to promote the exchange of their experiences and partnerships. Notably, Brazil has a larger number and greater diversity of groups than other countries.

Regarding the clown in the hospital context, there is also the perspective of the activities of the doctor Patch Adams, whose work began in 1971. His story became famous and known internationally with the film Patch Adams: Love Is Contagious. In an interview with the program Roda Viva, on Brazilian television in 2007, he stated that his philosophy of life is love, not only in the hospital setting but also in social relationships as a whole, regardless of place. He believed that the doctor’s goal is not to cure but to care - caring with a large amount of love, touching the sick, looking into their eyes, smiling and characterizing the role of clown in the care of patients as a mode of interaction³⁵35 Adams P. Entrevista Roda Viva [Internet]. TV Cultura; 2007 [acessado 2021 jun 20]. Disponível em: https://tvcultura.com.br/videos/63868_roda-viva-patch-adams-2007.html.
https://tvcultura.com.br/videos/63868_ro... .

Given this context, there is currently a movement of hospital clowns, linked to universities, who use the art of clowning to develop humanistic values in health education, generating practices based on relationships of solidarity that allow the resignification of the concept of health care. Based on the breaking of the stigma that the hospital is a gloomy and sad environment, these university extension projects have emerged to determine how laughter can be therapy in hospitals and how the humanization of care can be addressed through the art of clowning³⁶36 Cavalcante AL, Valentim DS, Santos LGML, Albuquerque MCS, Silva MR. O Sorriso como Recurso Terapêutico à Criança Hospitalizada: lições dos palhaços doutores do grupo sorriso de plantão para um cuidado humanizado. CBioS 2016; 3(2):43-56..

Within these specific groups, the clown informs the perception of the emotions, life histories and desires of the patient, leading a student to characterize himself or herself as a clown and interact with a patient in the hospital setting without performing health procedures to encourage the use of creativity and emotional development by visualizing the human being beyond a disease³⁷37 Silva M, Sampaio J, Santos E. O nível de empatia de participantes do projeto de extensão universitária sorriso de plantão e sua contribuição para a formação em saúde. Rev Contexto Saude 2019; 19(36):79-90.. Therefore, clowning entails the development of empathy, the main element of the relationship between health professionals and patients, which helps health professionals find ways to help their patients cope with a disease and overcome their hospitalization situation, making them feel safer and more willing to interact, build a relationship, and trust to ameliorate their problems, symptoms and doubts³⁸38 Costa F, Azevedo R. Empatia, relação médico-paciente e formação em medicina: um olhar qualitativo. Rev Bras Educ Med 2019; 34(2):261-269..

Regarding the motivations of these students to join this hospital clown movement, a study by Takahagui et al.²³23 Takahagui F, Moraes E, Beraldi G. Mad Alegria: Estudantes de medicina atuando como doutores-palhaços: estratégia útil para humanização do ensino médico? Rev Bras Educ Med 2014; 38:120-126. among a group of students in the health field, characterized as doctor clowns, indicates that most of these participants seek, through clowning, their “personal and professional improvement” (83.34%) and “humanization in their personal relationship with the patient” (77.78%) to acquire communication skills that will help them establish a good doctor-patient relationship. Thus, through the training they receive for this purpose, as well as their experience in this new “skin”, students can acquire communication skills and competencies that are consistent with an integral and holistic view of user assistance⁶6 Melo D, Silva MR. Sorriso de Plantão: Um sentimento que não pode parar. Arapiraca: Eduneal Editora; 2019..

Furthermore, Masetti⁴4 Masetti M. Boas misturas: possibilidades de modificações da prática do profissional de saúde a partir do contato com os Doutores da Alegria [dissertação]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2001., in his studies on health professionals and humanized training, reports that medicine, similar to other health professions, is an art. Therefore, the association of academic care and playful activity that values laughter will certainly provide a more ethical and humanistic approach to the training of these professionals. According to the perspective of innovation in the teaching-learning process, at some institutions, there are movements that value laughter as a process of patient care. For the clown in the hospital environment, the focus is not on the diseased organ but on finding what has worked well to stimulate and value it. The arts have the power to deal with these various temperaments of being and, consequently, to improve and apply the vision of care.

Contemporary hospital clowns

Recently, there has been an expansion of hospital clowns, resulting in varying levels of professionalism and responsibility. The professionals considered therapeutic clowns are respected as complementary care providers who are trained to develop patient care as integral members of the health team. At the other end of the spectrum, voluntary and nonprofessional clowns, although well-intentioned, may only be costumed people without training and a real understanding of the clown’s role and all its therapeutic potential. Thus, the latter do not perform the clown’s expected work and compromise the figure of the clown who performs the activities properly. Notably, the role of the voluntary clown cannot be generalized, since there are volunteer projects linked to NGOs and university extension categories that offer “minimal” training and others that ensure the constant training of their work team, generating quality work.

As cited in Esteves et al.³⁹39 Esteves CH, Antunes C, Caires S. Humanização em contexto pediátrico: o papel dos palhaços na melhoria do ambiente vivido pela criança hospitalizada. Comunic Saude Educ 2014; 18(51):697-708., the AATH, through the Therapeutic Clown Advisory Board, has identified potential problems associated with the performance of hospital clowns, which may occur due to several factors:

For Linge⁴⁰40 Linge L. Magical attachment: Children in magical relations with hospital clowns. Int J Qual Stud Health Well-being 2012; 7., hospital clowns need to adopt an appropriate posture and behavior during their interventions, respecting the integrity and will of each patient. The sensitivity and training of the clown are essential for him or her to perceive and meet the needs of patients, directing his or her efforts and energy to them and showing interest and attention. These are fundamental principles to minimize the risks of intervention and not harm a patient.

In addition, the use of work and safety instruments in the hospital environment is aided by obeying the regulatory norms (NR) peculiar to health professionals of the hospital setting, as dictated specifically in NR-32, and by applying minimal makeup that shows the personal characteristics of the clown without exaggeration so as not to cause fear due to excessive display and noise⁶6 Melo D, Silva MR. Sorriso de Plantão: Um sentimento que não pode parar. Arapiraca: Eduneal Editora; 2019..

Moreover, the use of musical instruments should ensure that sound levels do not disturb the different actors in a given context. Knowledge, understanding and respect for hospital hygiene rules are essential for quality work. Thus, the clown should also have the sensitivity to and awareness of when and how to use physical touch and whether it is desirable and appropriate in each situation by acting responsibly with the intentionality and meaning of care and love. Furthermore, the clown should not break the rule of respectfully maintaining his or her role as a clown³⁹39 Esteves CH, Antunes C, Caires S. Humanização em contexto pediátrico: o papel dos palhaços na melhoria do ambiente vivido pela criança hospitalizada. Comunic Saude Educ 2014; 18(51):697-708..

Being a hospital clown implies that intervention must include continuous and permanent training under the guidance and supervision of a professional with expertise in the subject in its technical aspect, in the specific artistic training of pediatric practice (depending on the public target), and in the health and hospital setting to ensure the safety and effectiveness of clowns’ actions according to the clinical situation and the emotional aspects they encounter, adapting their techniques and approach in a way that is sensitive to their circumstances⁶6 Melo D, Silva MR. Sorriso de Plantão: Um sentimento que não pode parar. Arapiraca: Eduneal Editora; 2019.^,1919 Dionigi A, Canestrari C. Clowning in Health Care Settings: The Point of View of Adults. Europe's J Psychol 2016; 12(3):473-488.^,2020 Rodrigues AFA, Nunes Filho WJ. A utilização do palhaço no ambiente hospitalar. OuvirOuVer 2013; 9(1):72-81.^,3939 Esteves CH, Antunes C, Caires S. Humanização em contexto pediátrico: o papel dos palhaços na melhoria do ambiente vivido pela criança hospitalizada. Comunic Saude Educ 2014; 18(51):697-708.^,4141 Achcar A. Palhaço de Hospital: Proposta Metodológica de Formação [tese]. Rio de Janeiro: UNIRIO; 2007.

42 Dionigi A, Flangini R, Gremigni P. Clowns in hospitals. In: Gremigni P, editor. Humor and Health Promotion. New York: Nova Science Publishers, Inc.; 2012.

43 Sridharan K, Sivaramakrishnan G.Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials. Eur J Pediatrics 2016; 175(10):1353-1360.^-4444 Warren B. Bring me sunshine: the effects of clown-doctor no the mood and attitudes of healthcare staff. In: Interdiscipliary Perspectives on Health, Illness and Disease. Amsterdam, New York: Rodopi; 2004. p. 83-94..

For intensive care units (ICUs), the training of the hospital clown must meet the “high professional standards [and provide] knowledge of particularities (critical situations, sedation), significant companions, uniqueness of the environment and restrictive factors (such as technology, equipment, movement, noise, among others), and infection control measures to allow [clowns] to overcome barriers and make the work of these professionals an asset for all stakeholders”⁴⁵45 Catapan SC, Oliveira WF, Rotta TM. Palhaçoterapia em ambiente hospital: Uma revisão de literatura. Cien Saude Colet 2019; 24(9):3417-3429..

In this context, the clown who is trained to exercise his or her function stimulates the quality of health care. Therefore, the insertion of the clown with the use of his or her art aligned with conventional treatments favors expanded care that is less traumatic and welcoming to the hospitalized patient.

Professional training for hospital clowns

Given the expansion of the work of clowns in the hospital setting, specifically in Brazil, there is a diversity of groups and a lack of adequate knowledge opportunities for all. There is thus a need for “minimal” training to provide this service that complements health care. It is necessary to democratize this art, whereby the reference groups in their states can support beginners to be aware of the responsibility of the work they perform. For the intention of enhancing knowledge, art is favored.

The NGO Doutores da Alegria, when asked about its legal point of view, explained that in Brazil, there is no specific labor legislation for the professional category “hospital clown”, as the profession entails great inconsistency. This is, artistic training in the language of the clown (regardless of its origin, whether theatrical or traditional through a circus, for example) forms clowns. The chosen field of action may therefore be broad and diverse. Language is the basis of training, and the field of action is a choice. Being included “symbolically” as a health professional depends on the field of action. In Israel, for example, the Dream Doctors group suggests that the performance of a clown has a very therapeutic character when the clown is included on a team and accepted and respected as an “employee” of a hospital.

Regarding this perspective on the formalization of a hospital clown service, Law No. 14,726⁴⁶46 Buenos Aires. Lei nº 14.726, de 3 de junho de 2015. Labor del payaso de hospital [Internet]. La Plata; 2015 [acceso 2021 jun 21]. Disponible en: http://www. hcdiputados-ba.gov.ar/refleg/l14726.pdf.
http://www. hcdiputados-ba.gov.ar/refleg... , sanctioned on May 13, 2015, in Buenos Aires, Argentina states the following:

Unfortunately, this kind of law may not be adequate to the Brazilian reality because it may be restricted to professional groups in large urban centers. However, there is an urgent need to control the work that has been developed in the country. That is, the work performed in the absence of specific knowledge compromises the continuity of the “serious” groups. It is thus necessary to develop real support networks in favor of this category.

There is also a need for communication and partnership with hospitals in agreements of the work to be developed to explain clowns’ functions and patient assignments. Since managers select the professionals who will work in their hospital, clowns must be trained to perform their skills and abilities. Their interventions need to be validated by groups with seriousness, commitment and dexterity before they join the hospital service.

Conclusion

In the material we have studied, it is evident that many clowns in Brazil perform their function without specific training to perform this activity. This is perceived as an inheritance of the historical origins of the clown category, where many clowns have had the “gift” to provoke laughter due to their humorous and wise postures but have been illiterate. Therefore, in the present day, low quality clown training and may compromise the practice of qualified professionals. We thus suggest that people who wish to perform this type of activity in a peculiar scenario such as a hospital seek technical training with a performing arts professional to provide them the expertise and tools for the development of artistic skills and abilities.

Training in biosafety is necessary to understand NR-32 and prevent cross-contamination via proper hand and work object hygiene, minimal use of adornments, up-to-date immunization, and the use of personal protective equipment (PPE) and respect for isolation. The conduct of a hospital setting should be respected and followed, according to a protocol of norms and routines.

It is also important to avoid postures that involve political, religious, or speculative questions regarding the pathology of a patient, respecting ideologies and beliefs while never offering food without proper nutritional guidance. Accordingly, it is necessary to include a perspective of continuing and permanent education among clowns where they discuss relevant topics, such as playing according to age, learning magic and mimicry, musical play therapy, storytelling, group work, leadership and interpersonal relationships, and thanatology. In short, we recommend that clowns participate in events that discuss the clown theme in all its breadth.

The perspective presented in this article, by addressing the main research question, implies that the concepts and patterns constructed in and disseminated by the hospital clown archetype are representative of society and have been legitimized in the cultural sphere as a multiplier of a project for the formation of volunteer activities with university, NGO and religious support. However, even amid all this goodwill, sympathy and altruism, commitment, responsibility and professional training are essential to ensure the correct exercise of the art of good humor. After all, the desire to be and make a clown is different, in fact, from being and making a clown.

Acknowledgments

We thank Fundação de Amparo à Pesquisa do Estado de Alagoas (FAPEAL) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for funding the doctoral research.

References

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