Assessing Emotions and Attitudes
Towards Using Therapeutic Clowns in the
Pediatric Emergency Department (PED)
A CROSS BORDER SURVEY-BASED STUDY
IPEME 2011 PROJECT
Roni Shreberk (Tel Aviv University, Israel)
Anas Al Karasneh (Jordan University of Science and Technology, Jordan)
Dahlia Balaban (University of Toronto, Canada)
Background – Emotions in the ED
Illness + Visiting the PED Anxiety (Hatcher et al., 1989).
Children in the PED fear pain, hospitalization, undressing, parental
separation, strangers, talking about personal problems and getting
shots (Magaret et al., 2002).
Emotions in the PED = ???
Children with pain and trauma are more likely to experience clinical
anxiety (Nager et al., 2010).
Caregivers experience greater anxiety with longer wait times and think
about wait times before bringing their children to the PED (Parkinson
et al, 1999).
Background – Complementary Therapies in Clinical
medical clowns = therapeutic clowns = clown doctors
Background – History of Therapeutic Clowns
Use humor and laughter to positively affect well-
being and health (Fry, 1992).
1986: "Big Apple Circus" in New-York.
1998: Movie about Patch Adams, the medical clown.
2011: Medical clowning is now wide-spread.
Background – Specific Uses of Clowns
In induction of anesthesia (pre-operatively)
(Yip et al., 2010)
In children’s mental health (Tener et al.,
In adults (haematology, geriatrics, IVF) (eg.
Friedler et al., 2011)
Background – Therapeutic Clowns in Israel
2000: 1st medical clown started to work in "Assaf Haroffe" medical
2009: Haifa University launched a B.A. program in medical
2011: Medical clowns are found in almost all pediatric wards
around Israel, even in some PEDs.
Dream Doctors, North of Israel
Background – Therapeutic Clowns in Canada
1986: 1st program founded at Winnipeg Children's Hospital.
1993: Therapeutic Clown Program launched at Sick Kids Hospital.
Flora the Clown - Camilla Gryski, Sick Kids
Background – Therapeutic Clowns in Jordan
No formal use of medical clowns, but Jordanian visitors in
Israeli health centers express interest in the possibility of
medical clowns being used.
Clown Required, Jordan
Background - Emergency Department Models
Canada Jordan Israel
Model Patients wait many Patients see MD in Patients see MD in
hours before shared area and private area and
seeing MD in return to waiting return to waiting
private area area to await tests area to await tests
Waiting Times Patients spend 11 Patients see MD Patients see MD
hrs in the ED for after 1hr and leave after >30 mins and
complex problems the ED after 3 hrs spend 3-4 hrs in
and >4 hrs for the ED
(From Ontario Health (From News Article in
Few studies have assessed emotions in the PED, but
we know it is a stressful environment.
Medical clowns have been used effectively in clinical
settings, mostly in paediatric wards and rarely in the
Patients and families spend many hours in the PED
and medical clowns could help address negative
1) What emotions are experienced by adults
accompanying children in PEDs?
2) Are adults accompanying children in PEDs aware of
the existence and use of therapeutic clowns?
3) Would they see value in the addition of therapeutic
clowns to PED waiting areas to address their
Study Design – Needs Assessment
Where: PEDs in Israel, Jordan and Canada.
Population: Adults accompanying children.
Sample Size: > 50 responses per region (simultaneously in each
region, in 3 shifts).
Method: Survey (in English, Hebrew or Arabic) given during
waiting times to be filled out on the spot.
Consent: Implied (by filling out survey).
Immediate Intervention: Educational pamphlet to take home.
Geneva Emotions Wheel
Disappointment No Emotion Felt Enjoyment
Remorse Other: Feeling love
Shame Feeling awe
Worry Feeling disburdened
Characterize emotions in the PED.
Jordanians will have little knowledge but will be
interested in learning more about medical clowns
Some Israelis and Canadians will be aware of the
existence of therapeutic clowns and will be open to
having them in the PED.
Only surveying adults (not the patients)
Survey will only be available in English, Hebrew or
Coulrophobia= fear of clowns
Use results to inform a new study with a greater
sample size and greater scientific validity.
Similar survey of pediatric emergency physicians.
Use the data to support the implementation of
therapeutic clowns in PEDs.
Dr. Joy Fitzgibbon
Dr. Dennis Scolnik
Dr. Rahim Valani
Dr. Sarah Khan
Members of IPEME 2011
Quotes about Laughter