# Clowning Restructuring in the Hospital Environment of Oncological Attention due to COVID-19

Felipe Calderon Scarin, Felipe Senra Santos, Carolina de Oliveira Azim

Schiller, Cristiane Marques De Sousa, William Augusto Gomes de Oliveira

Bellani

► To cite this version:

Felipe Calderon Scarin, Felipe Senra Santos, Carolina de Oliveira Azim Schiller, Cristiane Marques De Sousa, William Augusto Gomes de Oliveira Bellani. Clowning Restructuring in the Hospital Environment of Oncological Attention due to COVID-19. Revista Brasileira de Cancerologia, 2021, 67 (4), 10.32635/2176-9745.RBC.2021v67n4.1373. [hal-05102982](https://hal.science/hal-05102982v1)

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# Clowning Restructuring in the Hospital Environment of Oncological Attention due to COVID-19

doi: https://doi.org/10.32635/2176-9745.RBC.2021v67n4.1373

## Reestruturação da Palhaçaria no Ambiente Hospitalar de Atenção Oncológica em razão da Covid-19
Remodelación de la Payasada en el entorno Hospitalario de Atención Oncológica por la Covid-19

Felipe Calderon Scarin<fnref n="1" />; Felipe Senra Santos²; Carolina de Oliveira Azim Schiller<fnref n="3" />; Cristiane Marques de Sousa⁴; William Augusto Gomes de Oliveira Bellani<fnref n="5" />

## INTRODUCTION

Hospitalization is characterized by deprivation of privacy, spatial limitation, and loss of social contact. High rate of stress is triggered within hospital environment contributing for the appearance of anxiety and conflicting feelings<fnref n="1" />, moreover when patients diagnosed with cancer are involved. The complexity emerged in the oncologic hospital context goes beyond the clinical aspects: it requires social, psychological, spiritual, and economic approaches and facilitates interdisciplinarity². These aspects and the necessity to contribute for the quality of life during hospitalizations and favor the coping with the adversities<fnref n="3" /> call for clowns action.

Clowning is a form of reinventing this environment. Silence gives margin to songs, the introspection is overcome by interactions, crying gives space to smiling, health is promoted through fun⁴. It is attempted to offer humanized care, respect, and empathy. The clown is able to change the relations of hierarchy, redefine the environment, stimulate the communication, in addition to satirizing the human fragilities and bringing lightness to the somber feelings<fnref n="5" />. Although many projects are focused to children, there is a group dedicated to interactions with adults: Joy Experts. The organization was founded in 2012 and resignifies private values and objectives of the oncologic treatment⁶. The volunteers visit hospital sectors boosting self-esteem and well-being, in addition to health promoting events and prevention of diseases. According to the annual report of Hospital Erasto Gaertner of 2019⁷, nearly 62 thousand individuals were visited by 26 participants during the year.

However, in the first semester of 2020, the group had to face the COVID-19 pandemic. The risks of infection and contact with immunosuppressed patients led to

the suspension of in-person visits. But this scenario did not impede the transmission of hope and good mood to persons in the hospital context. The readjustment of the interaction and utilization of digital means were the solutions the clowns had found to strengthen the public during the pandemic.

It was attempted to understand the factors triggered through play therapy in the hospital environment, expanding the perception beyond the ill and reaching companions, healthcare professionals and volunteers and emphasizing the importance of technological means as coparticipants while coping with the difficulties the pandemic imposed over the contemporaneous society.

## DEVELOPMENT

The Institutional Review Board approved the study – consubstantiated report # 4.087.832, CAAE: 32121120.3.3003.5225 – which addresses the routine of volunteers of clowning for oncologic care within the hospital environment. The activity occurred in-person, four times a week (Tuesday afternoon, Wednesday and Thursday in the evening and Saturday morning) with groups of three clowns or more targeted to adults, regardless of gender. Songs, poetry, percussion instruments, relaxation routines, puns, body movements, magic, stories, and serenades were included in the agenda offered. However, the pandemic-imposed restrictions impacted the tasks and brought a new horizon to be explored by the clowns: technology.

The volunteers dedicated to creating audiovisual material. Four-minutes videos with plays in domestic environment were recorded individually. Most of them fit well to the new format although some felt unprepared or unskilled to manage technologic resources. At the start,

<footnote n="1">¹,²,⁴Universidade Federal do Paraná (UFPR). Curitiba (PR), Brazil. E-mails: felipe_scarin@hotmail.com; flpsenra@gmail.com; cris.marques86@gmail.com. Orcid iD: https://orcid.org/0000-0001-6109-2138; Orcid ID: https://orcid.org/0000-0002-4547-4539; Orcid ID: https://orcid.org/0000-0003-4097-1998</footnote>

<footnote n="3">³Secretaria de Estado da Saúde do Paraná (SESA)/Escola de Saúde Pública do Paraná (ESPP). Curitiba (PR), Brazil. E-mail: caroazim@hotmail.com. Orcid Id: https://orcid.org/0000-0001-5593-4191</footnote>

<footnote n="5">⁵UFPR. Centro Universitário UniDomBosco. Curitiba (PR), Brazil. E-mail: william.bellani@gmail.com. Orcid iD: https://orcid.org/0000-0002-1429-616X</footnote>

<footnote>**Corresponding author:** Felipe Calderon Scarin. Rua Fernando Amaro, 161, apto. 5 - Alto da XV. Curitiba (PR), Brazil. CEP 80045-080. E-mail: felipe_scarin@hotmail.com</footnote>
there were some difficulties to exhibit the videos because of the hospital's safety protocols. However, tests with tv sets were run and the presentations were accepted as adaptation to this period. Nursing teams liaise between the Joy Experts and the hospitalized patients, presenting the content produced in the room tv sets and in the common areas of the hospital. In addition, the videos were posted in the social media weekly, so the families were able to share with others hospitalized and watching for hygiene of the devices.

During the pandemic, the clowns, aware of their responsibility, also held virtual monthly meetings to consolidate new techniques and incorporate the knowledge. This activity is essential to face the daily challenges since the hospitalized patients or even healthcare professionals can resist.

The restructuring is summarized as a process of great learning, mainly for the group of volunteers. Learn to deal with the camera, interact with the electronic device, limit the performance to a specific framing, and not counting with the laugh of their audience portray a novel reality but necessary for the safety and well-being of those who live in the hospital environment.

Although the means have not been changed, the ends continue in synchrony with the pre-pandemic results: it is possible to feel the satisfaction when the clown shows up⁸. They minimize the sadness and solitude, become source of support, encourage the coping with the disease and provide emotional help to the patients. The ludic activities are responsible for improvements in the adaptation and recovery, further to being capable of bringing back the positive thinking in relation to the specific outcome⁹. Past memories, childhood, and youth where no disease existed, concern with the future or even the loneliness of the hospital bed have their bearing. They break the current context, allow a constructive digression for the ill, and de-construct the negative emotional status¹⁰. Therefore, the clowns help to complement the whole care, involving biopsychosocial dimensions and amending the fragmentation of the hospital approach.

The satisfaction with the project is not restricted to the oncologic patient but reaches relatives and friends as well. The companions accept positively the actions, seeing in them the ethical, holistic, social, and humanitarian facet¹¹. The reclaiming actions amuse the relatives and friends, opening space for them to unburden and receive comfort from the clowns¹².

Healthcare professionals (doctors, nurses, dentists, surgeons, physiotherapists, technicians among others) are also imbued with stamina, improved interaction in the multiprofessional team and reduction of the stress within an environment encumbered with tension and

anguish¹³. They reinforce the perspective of the full care, draw attention to the importance of practicing humanist values and construction of experiences. A refined view is developed, opened to the needs that go beyond clinical diagnosis, encouraging the ethics of joyfulness in the role of the professional.

And thus, the origin of the laughter is also renewed, reflecting the satisfaction even of the volunteer clowns who, apart from their professions, separate a period of their weeks to change positively the hospital ambient of those in distress. The laughter therapy becomes love therapy, effective all around: the one who smiles and the one who is smiled at with sincerity. It would be shallow to reduce this work to a mere mood job. They carry sympathy, humbleness and involvement¹⁴. The clowns are appreciated, and their performance conquer space even within a chaotic pandemic scenario, recognized by the society and also by the scientific community that already proves how beneficial it is the playfulness interaction for the health of the hospitalized, a clear example of the social role and promotion of health connected to art¹⁵. The ludic work aggrandizes the holistic formation of the clown and contribute for the improvement of communication skills¹⁶. Although it is a loosened performance and full of improvisations, the clowns do it diligently, with professionalism and confidence.

However, the presence of the clown can be seen as inconvenient and possibly leading to insecurity and obstacles to the ludic approach. There are contexts where outsourced professionals are inflexible in relation to these activities while procedures are being made¹⁷, and a few interviewees claim that humor projects are ineffective because there are patients who do not connect with the clowns and others deeply immersed in the sickness that are unable to involve themselves in the plays⁸. Because of this, the clowns are constantly attempting to increase their technical skills to deal with these conditions. Particularly in the context of the Joy Experts, these conflicts did not occur while the activities were in-person, the volunteers were already accepted in the hospital for many years, there was a strong relation with the nursing teams that directed them to specific cases, circumventing potential issues. The clowns were always careful with the noise and reviewed the general context to stay within the goal of the project.

## CONCLUSION

Clowns' performance in oncologic hospital environment has positive results reflecting the broad array of benefits of play therapy, revealing the achievement of the objectives initially proposed by the volunteers. Clowning leads to improvements to the ill, either physical, psychological,
or emotional. Companions, relatives, and friends are well-come and have the chance of expressing the anguish caused by the infirmity. In addition, the doses of humor reflect positively in healthcare professionals who receive them gladly and with gratitude, leading to more interaction among the multi-professionals teams and appreciation for the services offered. Together with the clowns, healthcare professionals discharge their duties with humanization and emphasizing the integrality of the care provided.

Although the COVID-19 pandemic has limited the in-person ludic activities, the Joy Experts succeeded in circumventing the physical isolation through digital means. In the Information Era, nothing better that using the state-of-the-art technological devices to ensure well-being and quality of life for all involved, either the public, extras, or crafters of the art of smiling.

## CONTRIBUTIONS

The authors contributed equally through all the stages of the manuscript and approved the final version to be published.

## DECLARATION OF CONFLICT OF INTERESTS

There is no conflict of interests to declare.

## FUNDING SOURCES

None.

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Recebido em 30/12/2020
Aprovado em 22/2/2021