"The role of a clown and a physician are the same - it's to elevate the possible and to relieve suffering."
Patch Adams
Background
The use of clowns in hospitals is taken from the circus world an applied to contexts of illness, to improve people's mood and state of mind, as well as to promote health consumer satisfaction and compliance (1). Evidence for the existence of clowns in hospitals goes back to Hippocrates (2), or even prehistoric times (3). Yet, it seems that only after the premier of the movie “Patch Adams” in 1998, did awareness of the potential benefits of medical clowning become widespread (4). While Patch Adams referred to clowning for a variety of audiences, most medical clowns operate in pediatric wards and, accordingly, most studies focus on child health consumers (5). It has recently been suggested that medical clowns can also benefit adults, in line with Adams’ approach (6,7).
A key precursor of purchase intentions for health services is consumer satisfaction (8), and so, just like other service organizations, health services must seek the satisfaction of their health consumers (9). Consumer satisfaction from the service a hospital provides is the sense a customer feels that the hospital fulfils some need, desire, goal or so forth and that this fulfilment is pleasurable, or in other words, “satisfaction is the health consumer’s sense that the hospital provides outcomes against a standard of pleasure versus displeasure” (10, p.80) . Service satisfaction indicates the extent to which the overall service that health consumers receive is congruent with their expectations (11). Health consumer satisfaction is a unique structure, distinct from regular customer satisfaction, since healthcare services have a major impact on physical wellbeing (12,13). Hence, a bad service experience in the healthcare context is more threatening than a bad service experience in general, as it might constitute a life threat (14). The experience of health consumers creates satisfaction and usage of the service (15), and a clown can influence that experience (16,17). The current study draws from literature in the fields of service management and organizational behavior to better understand the influence of medical clowns on satisfaction in different hospital wards.
The use of medical clowns in hospitals is a growing phenomenon, used as a therapeutic method in addition to traditional medical practices and as a negative affectivity buffer (18). Previous research shows that medical clowns have a positive impact on the physical and psychological well-being of health consumers (19–21), reducing the need for pain medications (22), lowering negative affectivity levels (23,24), increasing positive feelings (16,25,26), and enhancing health consumer satisfaction from the hospital service (1). The positive effect of medical clowns on both health consumers and medical staff can improve medical intervention outcomes (12,16).
Most findings on medical clowns are, however, based on separate children or adult samples, rather than on integrated samples and the placement fit of the medical clown versus audience age has not been addressed (e.g. only adult wards: (6,25,26); only pediatric wards: (19,21,24,27). Medical clowns are usually placed in pediatric wards (28), and so the majority of research on medical clowns is based on children samples. Since the presence of medical clowns in adult wards has increased substantially in the past decade, especially with older (18), and chronical health consumers (29), more research examining the unique effect of medical clowns on adults vs. children is necessary. In the current paper, we aim to fill this gap by comparing the usefulness of medical clowns among these audiences and identifying the optimal placement of medical clowns.
In order to identify the optimal placement of medical clowns, we first identify the current placement of clowns in hospital wards, examine the medical staff’s perceptions regarding the usefulness of clowns among current audiences, and document the clowns’ experience of performing in front of both types of audiences. As managers in healthcare prioritize in implementation processes (30). We aim to give policy recommendations regarding the best placement fit of the medical clown. Building on previous literature that illustrates that most clowns are placed in pediatric wards (18,31) and that most child health consumers are satisfied with the clowns’ performance (1), we expect that medical staff and clowns will report that child health consumers are more satisfied with clowns than adult health consumers. Hence, we predict:
H1. Medical staff and medical clowns will report that medical clowns will increase the satisfaction of children more than that of adults.
Health Consumer Satisfaction and Aggressive Tendencies
Hospitals are a stressful environment for health consumers (32), leading them to a state of emotional negativity and dissatisfaction (33,34). In the hospital context, dissatisfaction is considered a central cause of health consumer aggression against medical staff (35). We define aggression, as per Rippon (36, p. 456) as "a behavior with intent that is directed at doing harm to a living being whether harm results or not…aggression can be physical or verbal, active or passive, and can be focused on the victim(s) directly or indirectly". Aggressive behavior of health consumers towards medical staff in hospitals is a dangerous global problem that has potentially detrimental outcomes for staff (37–39), as well as high financial costs for the hospital (40). This phenomenon is therefore labelled as an "epidemic" (41), which constitutes an occupational hazard (42). Health consumer aggression against medical staff affects all parties involved (43) , ranging from the targeted staff who suffer verbal and physical abuse, through other health consumers who receive medical care from burnt-out staff with depleted cognitive resources (44) , to the hospital that suffers high turnover (37).
Health problems are considered among the top ten most stressful life events (45,46). When an illness is serious enough to warrant an individual's confinement to a hospital, the mere process of hospitalization may produce even greater negative affectivity (47). Individuals who exhibit high negative affectivity tend to show distress, sensitivity to negative events, and a pessimistic view of events and of their surroundings (48,49). When negative affectivity increases, individuals report lower satisfaction (for a meta-analysis, see (50)). In a meta-analysis examining the relationship between negative affectivity and satisfaction, negative affectivity was consistently related to lower satisfaction (51). Other scholars suggested negative affectivity is directly related to aggressive tendencies in the hospital setting (52,53), in the form of interpersonal conflict, bullying and physical assault (54,55). In hospitals, this aggression is frequently targeted towards those trying to help others, i.e. the medical staff. Research aimed at understanding aggression in service organizations, as a consequence of satisfaction in general, and in hospitals in particular, is scarce (41), even though an understanding of this issue would help in developing active attempts to curtail aggression.
Health consumer satisfaction is a product of the interaction between health consumers and medical staff (56). Although health consumers arrive at the hospital with expectations of relieving their pain and illness and improving their overall wellbeing (57), hospitalization raises negative affectivity in general, and anxiety in particular (58). Negative affectivity includes a spectrum of negative emotions, ranging from anger to fear, to annoyance and anxiety (49). These negative emotions paint the health consumers’ experience (15,59). and lower their satisfaction with the service organization (60), which if low, can even elicit their tendency to behave aggressively. In this study, we examine whether medical clowns can buffer the harmful effect of negative affectivity on health consumer satisfaction, and whether this buffering effect depends on health consumer audience age. We aim to identify the mechanism by which negative affectivity elicits aggression. To this end, we suggest satisfaction as the underlying mechanism that explains why negative affectivity influences aggression:
H2. Health consumer satisfaction mediates the indirect relationship between health consumers’ negative affectivity and their aggressive tendencies towards medical staff.
Medical clowns as moderators of the relationship between negative affectivity and satisfaction
A practice commonly used to enhance health consumer satisfaction is the use of medical clowns in hospital wards. As noted, hospital wards are characterized by high stress, negative affectivity, and aggression (32,47), yet very little research has been done to reduce such aggression. The few attempts that have been made, such as (61), focused on providing health consumers with information to enhance perceived justice, and did not focus on elevating their satisfaction. As a result, the emotional state of the health consumers was never fully examined in this context. In the current study, we aim to fill this gap by empirically testing the medical clowns’ ability to buffer the harmful effect of negative affectivity on satisfaction. We predict that the medical clowns have this ability since they are known to create a positive mood and change people’s negative state of mind to more humorous, thus promoting health consumer satisfaction (1,15,16).
Most research on medical clowns focuses on children, showing the positive effect of medical clowns on young health consumers (17,18). For example, medical clowns reduced stress among 6-7 years old, as was evident in a study that measured children's their cortisol levels following interaction with a medical clown (23). Moreover, medical clowns reduced pain, crying, and anxiety in children aged 2–10 years old undergoing venous blood drawing (27). A systematic review of medical clowns in pediatric wards shows their positive influence in reducing anxiety and pain (62).
Far less research examined the influence of medical clowns on adult populations, and the few studies that did, found positive effects (6,25,26,29). Strikingly, these studies examined either children or adult samples, separately, without comparing the two age groups or examining the placement fit of the medical clown to audience age. Indeed, humor and laughter are known to have a positive effect on both populations (63,64), and research that empirically tests the unique effect of medical clowns on adults versus children is necessary. In the current paper we aim to fill this gap by comparing the usefulness of medical clowns among these audiences and identifying the optimal placement of medical clowns. We predict that medical clowns affect both populations positively, with a stronger positive influence on children, due to the common placement of clowns in pediatric wards, the large body of research examining child health care consumers, and the tendency of children to seek play and humor (65). We therefore predict:
H3. The usefulness of medical clowns in enhancing health consumer satisfaction and, in turn, in reducing aggression, depends on the health consumers' age, such that the positive effect of clowns on the relationship between negative affectivity and satisfaction will be stronger among children compared with adult health care consumers.
See Figure 1 for research model.
Overview of studies
In a 360-degree research stream, we examine and the optimal health consumer audiences for medical clowns. Study 1a examines the perceptions of medical staff regarding the audience that will be most satisfied by the clowns. Study 1b examines the perception of the medical clowns regarding their optimal placement. Study 2 examines the optimal placement of the medical clown from the health consumers' point of view, with both child and adult health consumer participants.
Availability of data and materials: Data can be found at: https://osf.io/8j7ar/?view_only=c0cd6308be634b948235132df01612bd