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Parents believed that their children were happier after the clown visits, and thought it was beneficial for the overall atmosphere in the hospitals [ 22 , 25 ]. Research thus substantiates that the presence of medical clowns promotes well-being in health care settings for children. They contribute to reducing stress for patients and supporting families.
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A number of studies on older people with dementia living in nursing homes concern the effects of humour therapy and quality of life [ 26 ]. For example, it was found that agitation levels decreased significantly in nursing homes where medical clowns worked with humour therapy, compared to homes where no cultural activities took place [ 27 ]. Findings in studies by Raviv [ 28 ] and Hendricks [ 29 ] confirm that medical clowns had a beneficial and effective impact when working with persons with dementia, integrating skills such as drama, music and dance.
Humour can stimulate social interactions in dementia care [ 30 ]. Positive emotions and laughter may enable people with dementia to cope better with their illness, improve immune defence, increase pain tolerance and decrease stress response. Such results point to effects that resemble intervention studies involving psychosocial interventions [ 7 ] where social activities reduce aggressive and depressive behaviour among older people with dementia.
Research on medical clowns in dementia care shows especially positive effects on psychosocial function, cognition and duration of agitation [ 1 , 27 ] A few recent studies on medical clowns in nursing homes look more closely at interaction between clowns and older people with dementia using ethnographic methods and observations [ 26 , 29 ]. These studies suggest that the relationship between staff and residents is improved, and that the presence of medical clowns helps staff to support the feelings and skills of the residents Results also indicate that medical clowns can support empowerment processes among older people with dementia, using the beneficial effects of elements in the environment on interaction.
Using the body is significant for the results [ 29 ]. The study adopted a focused ethnographic approach, enabling in-depth understanding of particular behaviours and processes in a smaller group of people in a distinct setting [ 31 , 32 ]. Focused ethnography is especially useful when the focus of a study is limited to a discrete community [ 33 ]. Observation allows the researcher to collect data on the context from a first-hand perspective, adding the extra dimension of the influence of the physical environment [ 34 ].
In addition, observations can help us to comprehend situations involving a vulnerable population, who may have difficulties in expressing their views verbally [ 26 ]. For older people with dementia, the ability to communicate may be reduced by diseases and conditions that also affect facial expression, body language and non-verbal communication more generally [ 26 ].
The purpose of the project was to develop new cultural activities for people with dementia, living in nursing homes run by the municipalities. One nursing home in an urban area had residents originating from several countries, while the other was located in a rural area, and residents had all been born in Sweden. The nursing homes had individual rooms, which the residents had furnished themselves, as well as common spaces with details intended to remind residents of what was in fashion when they were younger. Each nursing home had approximately 30 residents. At each site, the sessions were set up by two medical clowns working together and who returned to the same home for the duration of the project.
The clowns had professional backgrounds as musicians and actors, with an additional training within dementia care. They wore costumes that is usually recognised as clown attributes, for example shoes that are too large, baggy trousers, colourful shirts, and the red nose. The clowns were active both in shared spaces and the individual rooms within the nursing home. The clown visits took place once a week at the two nursing homes during a ten week long period during autumn and spring Each weekly session lasted for three to four hours.
The last author conducted all the observations, taking the role as an overt observer. Overt observation means that the participants know they are being observed, but the observer do not actively participate in any situation that might occur [ 36 ]. She visited the nursing homes during the sessions when the two medical clowns were active, following the clowns in their work and taking notes. During the observations, the nursing staff were present but not engaged in the interactions. On one occasion, two family members were visiting their relative during the clown session, and were thus part of the observation.
Observations were unstructured. No checklist was used, but observations were focused specifically towards interaction between clowns and the older persons [ 37 ]. Notes were taken directly, and reflections were added by the observer immediately after each session [ 34 ]. The last author EM is a novice observer; however, authors EC and MR are experienced observers and qualitative researchers and the research team met continuously during the time of data collection to discuss and reflect the progress of observations.
Following the ethnographic approach, data collection and analysis is a simultaneous process [ 31 ]. After each observed clown session, field notes were transcribed to a neat copy to guide coming observations and as a way to organize data in order to uncover patterns of interaction. The transcribed texts were read and reread several times to gain a general sense of data and ensure a deep understanding.
Field notes and transcribed interviews as well as categories and codes that emerged during analysis were checked and discussed until agreement by the three authors to ensure credibility [ 38 ]. The findings illustrate the strategies deployed by the medical clowns. The analysis of the observations showed how the medical clowns were tuned in and attentive in a culturally responsive way in all contacts with the residents in the nursing homes. They were attentive to individual needs on a personal level, so they could start building a relationship.
Relational strategies employed by the medical clowns in the interaction involved sensory triggers, encouragement and confirmation. Participants responded both verbally and physically, displaying a variety of emotions. The clowns payed attention to places in the past that were significant for the individual in the one-on-one interaction, as well as contributing to interaction among the residents in spaces of joint activities in the nursing home. When visiting the residents in their rooms, the medical clowns used different kinds of accessories related to the senses to initiate and support interaction, such as a red nose, a soft toy in the shape of a pig, a shawl and silk fabric.
Mostly, the residents were sitting in a chair looking at the door, but some residents were resting on their beds. When they entered the room, the clowns used sensory cues as an invitation to interact. For example, the clowns might point at their red noses, the resident would look at the nose, and this could serve to initiate interaction. In order to connect with residents with a Middle Eastern background, the clowns draped a shawl around their hips to mimic a belly dancer, singing and dancing.
Such strategies are exemplified by the following field note:.
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Nina started to laugh loudly but looked a little bit embarrassed, then laughed again. Now the other medical clown took the silk fabric around his hips and started to dance and shaking the hips. Nina who was sitting at the table next to her daughters then looked away and said something to her daughters and then laughed again. Field note, Oct. In order to reach an Arabic-speaking person, the medical clowns sang Arabic songs, which the resident responded to by smiling and expressing appreciation through facial expressions.
With residents lying in their beds, the medical clowns used physical contact to initiate interaction by stroking their cheek, and residents responded by smiling. The silk fabric was used as a sensory cue that the residents could touch with their hands. When the person expressed contentment at feeling the soft fabric, the medical clowns could proceed to interact in other ways. Several interaction sequences thus typically started by stimulating the senses, such as touch, sight and hearing, and using sensory cues in an individualised manner. The clowns also offered recognition and showed interest in the person as an individual by asking for their name, and then connecting it to something positive.
The clowns tried their best to understand and kept the dialogue going even when talking to one of the residents who could only mumble and was not able to speak clearly. An example of personalised recognition and confirmation was when the medical clowns were pointing at a boat sculpture in one of the rooms.
The resident reacted by suddenly starting to talk about fish, and the clowns then followed this line of thought, deepened the dialogue and expressed contentment and interest. What a handsome guy you have on the photo! He was my husband, replies Karin. He was not so old, she continues. Was he also from Scania south of Sweden?
Yes, she replies, and proceeds to explain that she had an earlier marriage as well. Was he also from Scania? No, she replies. Field Note, Nov. The medical clowns also encouraged the participants when saying goodbye, for instance by confirming how strong they were when shaking hands. One example was a blind person who had grown up in Italy:. The medical clowns came to Francesco after knocking on his door and introduced themselves, and Francesco replied that he remembered them from the visit last week then he became quiet.
The medical clowns then started to sing a song and Francesco then started to interact, he was smiling, laughing and mentioning that he remembered the song from Italy. Further on, Francesco told them that the song reminded him of the good old days in Italy and the specific Italian food and drinks. Field Note, Oct, 9th. Residents born in Sweden also started interact better when the clowns paid attention to significant places in their past.
When the medical clowns asked one of the residents sitting in a chair in her room if she came from a certain town in the north of Sweden, she answered yes. This question served as the start of a conversation about nature and the activities that used to take place in that part of the country, which then served as a focus for the interaction. She responded by smiling and looking content, reminded of this period in her life.
The medical clown continues to talk with Karin about the mountains and Karin discusses this further and smiles contentedly. Karin says that there were many people who went skiing in the mountains, but she went sleigh-riding, and she shows how it was done with her arms. Field Note, Oct 16th. It was generally observed that when the clowns started a conversation about places in their past, the residents remembered the places and that made them happy, supporting further interaction.
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One strategy used by the medical clowns in the shared spaces inside the nursing home was to use different kinds of music, instruments and songs. Shared spaces included the larger dining rooms with tables and chairs, but there was also empty space for people with wheel chairs. During one of the sessions, when the clowns began to play for a person in those spaces, the other residents in the nursing home suddenly began stomping to the beat of the music, rolling the wheel chairs, swaying their feet and singing along with the music, and also started to dance with each other.
This space of joint activities was seen through the fellowship that was first created between the medical clowns and one of the residents, but was then spread to the others in the same space. The way activities with a particular resident could contribute to the general atmosphere is illustrated in the following field note. Bassem started drumming to the musical tune and the medical clowns came along playing instruments and dancing. Bassem laughed afterwards and everyone was applauding.
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The medical clown went up to another person, Nilufer, sitting in the same room. She tried to say something quietly and the medical clown asked if they should play a song and she nodded her head. When the song began, Roger, a fellow resident, joined in by moving his wheelchair back and forth. Soon after, Farhad swayed his feet, and Lisa, sang along with the song, while sitting and touching the silk fabric. Lisa who was still touching the silk fabric talked quietly with one of the medical clowns.
The other medical clown continued to play, while several people continued to sing along with the song. Lisa, touching the silk fabric, took the initiative to sing another song and the medical clown started to play the song.
Field Note, Jan. This attention to each other was not only connected to the social interactions between the residents and the clowns generated by music, instruments and dance, but also related to rhythm and bodily movement in general. For example, when one of the medical clowns was stamping with her high heels while entering into the living room, this was followed by two residents, who started to sing along with each other.
In all these activities, the residents started talking in a more interactive way to each other. Using music and dance, the clowns were able to awaken culturally specific associations for individual residents, at the same time that they seemed to create a sense of togetherness shared by all the residents in the common room. In yet another situation, the medical clowns staged a fake wedding, involving the residents as audience and one person as a priest. The residents all showed signs of enjoying the show, smiling and talking to each other.
The wedding game and the interactions during the performance were commented on by several people in the room. These joint activities thus stimulated the social interactions among the residents in the whole nursing home. Research on medical clowns suggests that humour therapy reduces agitation, mood and anxiety, while improving life quality [ 26 — 30 ].
Empowerment mechanisms seem to play a role in these results. Culture, environment and social interaction are all elements of such empowerment mechanism [ 20 , 29 ]. The effects of humour therapy extend to other patients, family and staff [ 20 , 26 , 29 ]. Medical clowns thereby contribute not only to individual health and well-being, but to the environment as a whole [ 16 ].
This latter aspect clearly appears in the present study. The clowns created an attachment and a social bond in the relationship by using sensory triggers, encouragement and confirmation and by paying attention to places and habits in the past in personalised one-on-one interaction. Importantly, interaction was open-ended: it did not impose an agenda, nor was it intended to lead to a pre-established result.
This could affect implications for clinical practice. The observations showed reactions where residents responded positively, both verbally and physically, despite their cognitive problems and language barriers. This confirms findings from other research projects concluding that cultural activities are important for the well-being of people with dementia [ 2 , 4 , 7 , 26 ]. Observations further showed that foreign-born residents suffering from dementia can actively participate in cultural activities even when verbal proficiency in the second language is reduced.
The clowns confirmed the person's own identity by relating the sensory cues to something in the past such as specific music, dances and places , which resulted in improved social interaction. More general research on autobiographical memory concludes that stimulating emotions by remembering our attachment to places in the past could strengthen our sense of self in the present [ 40 , 41 ].
A problem in dementia care might therefore arise if caregivers and residents do not share sufficient cultural or geographical reference points to be able to work with reminiscence or give adequate responses and confirmations of self. With increased global mobility, caregivers will frequently have had geographical trajectories and cultural backgrounds that differ from the older people they take care of. A considerable body of research suggests that staff should encourage identity support activities for people suffering from dementia [ 42 — 44 ].
By strengthening each individual's perception of themselves, cognitive ability could increase, which in turn affects their social interaction [ 5 ]. They used specific sets of material objects, brought with them cultural artefacts associated to different places to form meaning based on earlier experience, and which helped to locate and bound reality conceptually. Since the present material world provides structure and continuity, as well as offering shared reference points in social interaction, objects and the physical environment could be used more consciously as a tool to strengthen people living with dementia.
As nursing home environments become more diverse, the interaction strategies employed by medical clowns thus suggest a variety of approaches that can contribute to supporting intercultural dynamics among residents and improving interaction both for individual residents and in the environment as a whole. The transferability of this study could be limited since only two different nursing homes were represented in the study [ 38 ]. However the two nursing homes were located in different municipalities and residents had differing backgrounds, which could strengthen the credibility of the study.
Credibility was further ensured through several steps. During the analysis process, all data and emerging categories were checked and discussed until agreement was reached by all authors. The role of the researcher needed to be taken into consideration and reflected upon to ensure dependability [ 38 ]. This procedure also enabled reflections and discussions among all three authors concerning reflexivity. The question of reflexivity [ 45 ] has been addressed and discussed among the three authors based on the extensive field-notes that were made for each observation as a means to illuminate the interaction between the researcher and the studied group [ 34 ].
It is important to raise the question of reactivity as the presence of the researcher as observer may have influenced the behaviour of the studied group with the risk of altering the interaction between the medical clowns and the person with dementia. The author who collected data through observations emphasised throughout the data collection period that she was not an employee of the two nursing homes, and therefore could not participate in any nursing tasks or resident care.
None of the researchers had any previous experience from the studied nursing homes nor where they acquainted to the health care staff, the older people or the medical clowns participating in the study. All three authors are experienced qualitative researchers with a background as registered nurses, but without clinical experience from dementia care.
The medical clowns appeared to increase social interaction for people with dementia in the nursing homes investigated in this study. The study supports conclusions from earlier research suggesting that medical clowns contribute to strengthening social interactions within nursing homes for persons with dementia, adding a geographical and cultural dimension.
Medical clowns confirm the sense of self for persons with dementia, using encouragement, culturally anchored cues for interaction and by connecting to significant places in the past. Strategies that contribute to increased responsiveness and social interaction include sensory triggers, using meaningful objects in the present environment, shared activities, involving body, music and drama. The presented strategies appeared potentially useful for the staff to support the cognitive abilities of people with dementia.
Cultural background and geographical trajectories of nursing home residents need to be considered by stakeholders responsible for dementia care. More research is also needed to further evaluate the contributions of medical clowns for older people with dementia who are foreign-born or who spent their youth in other countries.
Professor Anna-Karin Edberg for important intellectual feedback on the final version of the manuscript.
Helen Avery for skill full language editing. MR and EM carried out conception and design of the study, acquisition, analysis and interpretation of data, and drafted the manuscript. EC participated in the analysis and interpretation of data, and revised the manuscript critically for important intellectual content.
All three authors read and approved the final manuscript, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Participants and their families were given oral and written information prior to the observations, including information on study purpose, publishing, assurance of confidentiality, and the right to withdraw from the study at any time without further explanation. Family members had to agree to the inclusion, and to confirm this by filling in a form of consent.
Persons with dementia represent a sensitive group of people. Since it could be questioned whether they remembered the information they received, consent should be repeated for each research encounter if necessary. The families as well as the nursing staff were therefore well informed, and able to remind the participants and explain the activity as well as the research process.
The observation was to be interrupted if any participant were to show discomfort at any point during the observation. In order to protect the confidentiality of the participants, pseudonyms have been used. The result from this study has been presented to the staff and the next of kin in the form of a popular science report written in Swedish before publication of this article. Elisabeth Carlson, Email: es. Elisabeth Mangrio, Email: es. National Center for Biotechnology Information , U. BMC Geriatr. Published online Aug Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Received May 4; Accepted Aug 8. Associated Data Data Availability Statement According to current national legislation, ethical review boards in Sweden do not allow public sharing of sensitive raw data. Abstract Background As nursing homes become increasingly diverse, dementia care needs a wider range of culturally responsive strategies for individual and collective social interactions.
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I will definitely buy more books like this!
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I have a soon to be first grader who needs more reading practice at home and these books are just the thing. The A, B, C levels are spot on and there are enough stories in each pack 25 to keep him from getting bored. Pictures help with context and give clues to words he doesn't know, but not everything in the story. He still has to read it. Includes mini parent guide.