"The role of a clown and a physician are the same - it's to elevate the possible and to relieve suffering."
The use of clowns as a service in hospitals is taken from the circus world and is 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 (3,4). Yet, it seems that only after the premiere of the movie Patch Adams in 1998, did people become more aware of the potential benefits of medical clowns (e.g., humor and laughter create an atmosphere of trust and love between staff and health consumers) (4,5). 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 (6). It has recently been suggested that medical clowns can also benefit a variety of health consumers with different health problems, including adults, in line with Adams’ approach (7–9).
A key precursor of purchase intentions for health services is consumer satisfaction (10), and so, just like other service organizations, health services must seek the satisfaction of their health consumers (11). Consumer satisfaction with the service a hospital provides is the sense a customer has that the hospital fulfills some need, desire, goal or so forth and that this fulfillment 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” (12, p.80). Service satisfaction indicates the extent to which the overall service that health consumers receive is congruent with their expectations, and so it is a subjective measure (13). As such, satisfaction contains the person’s appraisal, which includes both affective (or emotional) and cognitive (evaluative) components (14,15). Health consumer satisfaction is a unique structure, distinct from regular customer satisfaction since healthcare services have a major impact on physical wellbeing (16,17). 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 (18). The experience of health consumers creates satisfaction and usage of the service (19), and a clown can influence that experience (20,21). Specifically, the medical clown is an added service and part of the medical team that provides various “service” treatments for health consumers in specific wards (22,23). Health consumers’ satisfaction with each member of the medical team, which consists of several specialists, including their satisfaction with the medical clown, can influence their overall satisfaction with the hospital (24,25). Medical clown services are specifically known to have an impact on the satisfaction of health consumers with the hospital in general (26). The current study draws from literature in the fields of service management and organizational behavior to better understand the influence of medical clowns on the perceived satisfaction of health consumers in different hospital wards. This exploration is important as health consumers’ satisfaction measures can help identify the optimal health care audience (adults or children) that will most benefit from medical clowns.
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 (27). Previous research shows that medical clowns have a positive impact on the physical and psychological well-being of health consumers (25,28,29), reducing the need for pain medications (30), lowering negative affectivity levels (31,32), increasing positive feelings (20,33,34), and enhancing health consumer satisfaction with the hospital service (1). The positive effect of medical clowns on both health consumers and medical staff can improve the outcomes of medical interventions (16,20).
Clown usefulness can be measured by various measurements including physical well-being, psychological well-being, negative affectivity, levels of positive feelings, and overall satisfaction (18-26). As satisfaction plays an important role in physical and psychological well-being (35,36), it will be the focus of this paper in which we will explore medical clown usefulness as an indication of the optimal placement fit.
Most findings on medical clowns are 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: (8,33,34); only pediatric wards: (25,28,32,37)). Medical clowns are usually placed in pediatric wards (38), 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 (27), and chronic health consumers (24), more research examining the unique effect of medical clowns on adults vs. children is necessary.
The literature on the effect of medical clowns on adults is still in its infancy. The adult audience is insinuated as being less suitable for the services of medical clowns, as clowns reported both a need for greater creativity when working with adults compared with children, and more strain and feelings of frustration due to the effort required to continually make older people laugh (24). Others, however, have suggested that medical clowns may benefit adults as well (8), especially when considering specific individual differences in the receptiveness to humor (39). The literature on the effect of medical clowns on adults needs further investigation (26).
In the current paper, we aim to fill this gap by comparing the usefulness of medical clowns among adult and child 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 to both types of audiences. As managers in healthcare prioritize implementation processes (40), we aim to provide policy recommendations regarding the best placement fit of the medical clown. Building on previous literature according to which most clowns are placed in pediatric wards (27,41) and most pediatric health consumers are satisfied with the clowns’ performance (1), we expect that medical staff and clowns will report that pediatric child health consumers are more satisfied with clowns than are adult health consumers. Hence, we predict:
H1a. Medical staff will report that medical clowns will increase the satisfaction of children more than that of adults.
H1b. 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 (42), leading them to a state of emotional negativity and dissatisfaction (43,44). In the hospital context, dissatisfaction is considered a central cause of health consumer aggression against medical staff (45). We define aggression, as per Rippon (46), 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" (p. 456). Aggressive behavior of health consumers towards medical staff in hospitals is a dangerous global problem that has potentially detrimental outcomes for staff (47–49), as well as high financial costs for the hospitals (50). This phenomenon is therefore labeled as an "epidemic" (51), which constitutes an occupational hazard (52). Health consumer aggression against medical staff affects all parties involved (53), ranging from the targeted staff who suffer verbal and physical abuse, to other health consumers who receive medical care from burnt-out staff with depleted cognitive resources (54), and the hospital that suffers from high staff turnover (47).
Health problems are considered among the top ten most stressful life events (55,56). 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 (57). Individuals who exhibit high negative affectivity tend to show distress, sensitivity to negative events, and a pessimistic view of events and their surroundings (58,59). When negative affectivity increases, individuals report lower satisfaction (for a meta-analysis, see (60)). In a meta-analysis examining the relationship between negative affectivity and satisfaction, in a different context, negative affectivity was consistently related to lower satisfaction (61). Specifically, this result was found when examining job satisfaction and not consumer satisfaction with a service, even though “satisfaction” shares the same definition of having an emotional and cognitive evaluation of an object (whether it is a job, a service, or even life as a whole) (14,15).
Indeed, negative affectivity was found to be correlated with service satisfaction specifically (62). Other scholars suggested that the negative affectivity of health consumers or their families (caused by a variety of reasons) is directly related to aggressive tendencies in the hospital setting (63,64). We define aggressive tendencies following (65) as the self-reported desire to act with aggression. We chose this focus since the desire to act with aggression is an important predictor of actual aggressive behavior (65), and as such, it is important to curtail this desire before it escalates into actual aggression. Aggressive tendencies can be expressed in a variety of forms, from interpersonal conflict to bullying or even physical assault (66). In hospitals, this aggression is frequently targeted towards those trying to help others, i.e. the medical staff. Research aimed at understanding aggression as a consequence of satisfaction, in service organizations in general, and in hospitals in particular, is scarce (51), 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 (67). Although health consumers arrive at the hospital with expectations of relieving their pain and illness and improving their overall wellbeing (68), hospitalization raises negative affectivity in general, and anxiety in particular (69). Negative affectivity includes a spectrum of negative emotions, ranging from anger to fear, to annoyance and anxiety (59). These negative emotions paint the health consumers’ experience (19,70) and lower their satisfaction with the service organization (71), which if low, can even elicit their tendency to behave aggressively. As the overall goal of the study was to identify the optimal health care audience (adults or children) that will benefit most from medical clowns, we examined specifically whether medical clowns can buffer the harmful effect of negative affectivity on health consumer satisfaction, and whether this buffering effect depends on the age of the health consumer audience. We propose 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 (42,57), yet very little research has been done to reduce such aggression. The few attempts that have been made, such as (72), 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 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 (1,19,20).
Most research on medical clowns focuses on children, showing the positive effect of medical clowns on young health consumers (21,27). For example, medical clowns reduced stress among 6-7 years old, as was evident in a study that measured children's cortisol levels following interaction with a medical clown (31). Moreover, medical clowns reduced pain, crying, and anxiety in children aged 2–10 years old undergoing venous blood drawing (37). A systematic review of medical clowns in pediatric wards shows their positive influence in reducing anxiety and pain (73).
Far less research examined the influence of medical clowns on adult populations, and the few studies that did, found positive effects (8,24,33,34). 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 (74,75), 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 pediatric health care consumers, and the tendency of children to seek play and humor (76). 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 Fig. 1.
Overview of studies
Using a multiple views research approach, we examined the optimal health consumer audience for medical clowns. Study 1 examined the perceptions of medical staff regarding the audience that would be most satisfied by the clowns. Study 2 examined the perception of the medical clowns regarding their optimal placement.
Study 3 examined the optimal placement of the medical clown from the health consumers' point of view, with both child and adult health consumer participants. In this last study, we examined the medical clown’s usefulness in enhancing health consumers’ satisfaction and, in turn, reducing their aggressive tendencies.
Availability of data and materials: Data can be found at https://osf.io/8j7ar/?view_only=c0cd6308be634b948235132df01612bd