“I made you a small room in my heart”: how therapeutic clowns meet the needs of older adults in nursing homes

ABSTRACT

Therapeutic clowns are increasingly common in nursing homes, where residents often encounter factors that can undermine their quality of life and dignity. We aimed to understand the strategies of successful therapeutic clowning with a diverse older adult population, and the unique contributions of elder-clowning to the nursing home experience. Using an interpretivist descriptive methodology, twenty-three (n=23) experienced therapeutic clowns from eight countries were interviewed to understand the needs of nursing home residents met by elder-clowns, and strategies and techniques the clowns use to address them. Participants identified five major needs: to escape routine; for reassurance of worth; for meaningful, personalized social interaction unrestricted by communication barriers; to have culturally meaningful opportunities for reminiscence; and to have a space where residents could be unapologetically themselves. The artistic and emotional strategies used by the therapeutic clowns to address these needs illustrate how creativity, imagination and relational presence can provide nursing home residents with a sense of being known and belonging. Elder-clowns also positively affect the nursing home staff and enrich the interpersonal interactions in the residence. Through their focus on the social and emotional needs of residents, elder-clowns can play an important and distinct role in creating an optimal nursing home experience.

KEYWORDS:

• therapeutic clowning
• nursing home
• elder-clowning
• loneliness
• social isolation
• arts-based intervention

1. Introduction

Older adults living in nursing homes (NH)—group residences that provide full-time staff and care support for their tenants—face a myriad of factors that can undermine their independence and quality of life. These include rushed care due to staffing shortages, loss of individuality and autonomy from inflexible routines, as well as loneliness and grief closely related to loss of cognitive or physical abilities and social environment (Drageset et al., 2015; Fosse et al., 2014; Lee et al., 2009; Milte et al., 2016; Paque et al., 2018; Shieu et al., 2021). Beyond the negative emotional experience, studies have linked loneliness and the associated construct of reduced activity engagement to frailty, putting the older adults at risk for further health complications (Lapane et al., 2022; Zhao et al., 2019). Complementary and alternative therapies such as laughter and arts-based interventions have been introduced into NHs to counteract these trends and to create a more individualized approach to care. A recent systematic review of arts-based activities demonstrated that residents’ participation therein supported their quality of life, benefiting their behaviour, cognition, overall health and social relations. In particular, the person-centred components of these care approaches were identified as the active ingredients in addressing residents’ feelings of loneliness and helplessness (Bhattacharyya et al., 2022; Curtis et al., 2018).

Therapeutic clowning is an arts-based intervention that may be particularly suited to addressing the loneliness, loss of dignity and loss of personhood commonly experienced in healthcare institutions. Therapeutic clowns (also often known as Clown Doctors, Hospital Clowns, and Medical Clowns) are trained professionals who are increasingly common across global healthcare settings. Although the specifics of therapeutic clowning vary according to local context, clown practices typically use embodied and artistic techniques to engage with patients, their families and healthcare staff (Donnelly & Vanden Kroonenberg, 2018; Koller & Gryski, 2008). Interactions often involve singing and instrumental music, physical comedy, imaginative play and improvisation, and are modified in pitch, speed and energy to target specific clientele (Blain et al., 2012; Holland et al., 2022; Kontos et al., 2017). Therapeutic clowns are not oriented to fixed, static therapeutic goals; instead, their artistic practice is improvised in the moment and focused on being physically, emotionally and sensorily in relationship with other people in time and space (Gray et al., 2019). Research studies have predominantly focused on the “curative potential of humour”, and on clowns as “bringers of happiness and humour” (Gray et al., 2019) in healthcare settings (Golan et al., 2009; Grinberg et al., 2012; Koller & Gryski, 2008; Pendzik and Raviv, 2011; Warren and Spitzer, 2011). However, several counternarratives have recently emerged that challenge these conceptualizations of the therapeutic clown as solely medical support in their role, and solely happy and funny in their affect. Recent studies (Gray et al., 2019; Kontos, 2005) have described how clowns also routinely engage with sadness, despair and discomfort, and suggest a role for “dark clowns” to enable the “witnessing [of] tiny moments of humanity”, including vulnerability, stripped dignity and tragedy (Davison, 2013, p. 300).

With its incorporation of elements of fantasy, surprise and storytelling, therapeutic clowning is often associated with paediatric populations; indeed, the majority of research to date has focused on the effect of therapeutic clowning in children’s healthcare institutions (Arriaga et al., 2019; Dionigi et al., 2014; Ford et al., 2014; Kontos et al., 2017; Lopes-Júnior et al., 2019; Mortamet et al., 2015; Newman et al., 2019; Pinquart et al., 2011; Scheel et al., 2017; Sridharan & Sivaramakrishnan, 2016; Wells et al., 2008; Yildirim et al., 2019). However, a handful of studies have shown that therapeutic clowning interventions are also relevant with an adult and older adult population. Therapeutic clowns working with older adults are often referred to as elder-clowns, and their practice as elder-clowning. Elder-clowns elicit joy, offer opportunities for connection despite neurological disorders, and have the potential to reduce disruptive behaviours, amongst other reported outcomes (Auerbach, 2017; Hendriks, 2012; Higueras et al., 2006; Kontos et al., 2017; Low et al., 2013).

Although emerging evidence supports the positive effects of elder-clowning on a group-level, the subtleties of successful interpersonal clowning with a diverse older adult population, including considerations for their cultural, personal, physical and cognitive needs remain unexplored. Furthermore, the unique contributions of elder-clowning to the nursing home experience have received little-to-no attention to date. The need for research on these topics has been highlighted in the field, with previous studies calling for investigations of the artistic and psychological process of large samples of elder-clowns, and their role in addressing the cultural needs of older adults (Dionigi & Canestrari, 2016; Rämgård et al., 2016). Thus, the objective of this study was to explore how elder-clowns understand and meet the unique needs of their older adult clientele within a nursing home setting, and to descriptively illustrate strategies that the clowns employ to this purpose.

2. Methods

This qualitative study used an interpretivist descriptive methodology to capture subjective experiences while identifying patterns and producing practical outcomes that can contribute to the advancement of knowledge (Thompson Burdine et al., 2021). In particular, we aimed to elicit narratives and stories from elder-clowns to understand their point of view and personal experiences in working with older adults in nursing homes. This approach has been argued to be especially effective in cross-cultural research (Mattingly and Lawlor, 2000). International therapeutic clowns with relevant experience working with older adults completed an individual semi-structured interview via the online platform Zoom, using the interview guide found in Supplementary Table 1. Data analysis in qualitative phenomenology research aims to reveal experiences and meanings; thus, we conducted a content analysis to conceptualize our data and reveal themes related to the phenomenon of identifying the needs of older adults in situ and the strategies elder-clowns employ in the moment to address them. This study was approved by the research ethics board of McGill University (A03-E05-21A).

2.1. Participants

Therapeutic clowns were recruited through social media posts on the Facebook pages of the International Elderclown Network and North American Federation of Healthcare Clowning Organization (NAFHCO), as well as through the professional contact list of MH, author from the Dr. Clown Foundation. Interested individuals were included in this if they: 1) had completed the local necessary training to be a professional therapeutic clown; 2) had at least 1 year of experience working with older adults as an elder-clown; 3) were able to speak English and/or French; and 4) had access to a computer/internet connection. Individuals were excluded if they had not worked with elderly clients in the past 5 years. Eligible clowns then provided written informed consent and scheduled an online interview.

2.2. Data collection

All interviews were conducted between May and July 2021, online via Zoom with at least one researcher; a second researcher was occasionally present to facilitate language translation. Video cameras were turned on to establish rapport and to enable non-verbal communication. Interview questions began broad and became specific, covering topics ranging from professional background, to clowning philosophy, to strategies of meeting various needs of elderly residents in nursing homes. Questions were designed to elicit detailed story-sharing by having clowns reflect on past significant experiences. Clowns were interviewed individually—though many work in duo—to encourage unbiased sharing of personally significant moments, as well as uninfluenced reflections on their process. Throughout data collection, three interviewers met on a bi-weekly basis to discuss the interview process, to ensure all participants were being presented with similar follow-up questions, and to ensure that the same level of detail was being pursued across all interviews. Interviews were audio recorded and transcribed.

2.3. Data analysis

Three team members participated in the thematic analysis of the transcribed audio files. Themes were identified and iteratively refined through multiple rounds of coding. The initial coding guide was based on the interview questions, with each code accompanied by a “Rules of inclusion” description to clarify which units of meaning belong therein. Codes were added to the guide as new themes emerged during the process (see Supplementary Material Table 2). Each transcript was coded by one member and independently reviewed by another member to check for reliability and agreement. To summarize the data, group members compiled significant quotes and information from corresponding codes into four themes, organized according to the chronology of an elder-clowning visit (i.e., from before the initial interaction with residents to lingering effects observed by the clowns after they had left). The synthesized data was presented to an international group of elder-clowns via video-conference, who confirmed that it was representative of their practice. A final round of coding was performed to identify themes related to the needs of nursing home residents met by the participants’ clowning practices. All interviewers were naïve to elder-clowning prior to the study and built their understanding of the topic from what participants shared during their interviews.

3. Results

A total of twenty-three therapeutic clowns (n = 23) were recruited from eight countries. Participants were diverse in their professional background and geographical location, and were diverse in both their methods, and their clientele’s cultural, cognitive, and personal needs (see Supplementary Figure 1 for participant characteristics) Interviews ranged between 43 to 73 minutes in length. We identified five major needs of nursing home residents met by the therapeutic clowns: the need to escape routine; the need for reassurance of worth; the need for meaningful, personalized social interaction unrestricted by communication barriers; the need to have culturally meaningful opportunities for reminiscence; and the need to have a space where they could be unapologetically themselves. As each of these themes are described, we also illustrate the artistic and emotional strategies employed by the elder-clowns to meet these needs. Additionally, the complementary role the therapeutic clowns play in a nursing home setting emerged as an important theme across interviews.

3.1. Need to escape routine

Therapeutic clowns in nursing homes use their imagination and performance skills to inject play and silliness into the setting. Elder-clowns recognize that nursing home residents are subject to a mostly repetitive daily routine outside of their control, and that many appreciate opportunities to deviate from it. When appropriate, they offer imaginary scenarios to residents, many of whom joyfully engage with the silliness and immerse themselves in this co-constructed fictional escape from mundane, quotidian routines.

He’s waiting for the clowns. He always says the same thing (…) we know them, we’re ready, we know what to play with… like he is going to take us fishing and he’s going to pay for everything and then I got bumped off the boat last week but you know the clowns play with that. It’s really fun, it’s really fun. (Canada)

To this effect, many therapeutic clown personas are centred around their ability to uncover opportunities for ‘’mischief and shenanigans’’, doing so in a way that consciously aligns with their professional standards. In addition, their theatrical background makes them proficient in improvising and transforming spaces (e.g., turning a living room into a fishing pond) through the power of performance.

3.2. Need for reassurance of worth

The need for reassurance of worth encompasses two subthemes: 1) having control over one’s routine and environment (i.e., having agency); and 2) having an impact on other people. This need emergeed from nursing home residents’ experiences of standardized, depersonalized care, the often-involuntary transition to passively receiving services, and the loss of agency and power. Many clowns commented on the passive role of many residents, and the impact of time-pressured and resource-limited institutionalized settings on older adults’ sense of agency.

I remember, a lady, she said my dream is to eat what I want when I want. They are obligated to get out of bed (…) if there’s not enough staff, they have to stay in bed. They eat, it’s not very good, it’s not what they feel like eating. They have no power. They get showered, even if they don’t feel like it, get their hair brushed… (Canada, English translation)

Elder-clowns reported that their visits could empower residents and revive their sense of agency in daily life. Some intentionally created instances in which residents experienced having an impact on their surroundings, others responded to the need as it organically emerged in their interactions:

“I have a lady I am very close to. This woman, one time, she was seated in her wheelchair- (…) and the staff were really — it was moving fast. And they just took her chair, I was talking to her (…), I have my hands on her lap and all. And then the lady, she takes her chair and moves her. My lady, her eyes open wide, she leans and says: “You see, even here I don’t belong.” And she starts crying ‘’Where do I belong? I don’t belong anywhere, I’m not useful anymore.’’ And to respond to that, it’s almost violent to say “Oh no, of course not”. It’s not “Oh no”; it’s “Oh yes, you’re right, come on. You’re sitting in your chair and even there you’re in the way. Well Ms. X, I want you to know that you belong somewhere. And it’s somewhere where you will stay for a long time. I made you a small room in my heart.” So I said: “I’m taking care of you all the time, and in there no one will ever move you aside. I’m the one moving the walls to make you more room because your love makes me a better person.’’ In your humanity you tell yourself what is this all for? (…) When I left, she was sitting straight, to think that someone somewhere takes care of me and I live, you know, there’s a place where I make a difference.” (Canada, English translation)

Participants also created numerous opportunities to restore agency and power to residents. It is rare in the nursing home setting that residents get a chance to turn down a service. Clowns take pride in providing and honouring that choice, and take it a step further by turning rejection into an opportunity for laughter and complicity:

There’s a very famous clown maxim its like a no is as good as a yes, (…)- we’re here to offer choice, if someone’s been in a hospital setting being poked and prodded, having to do tests, uncomfortable, to give the opportunity to be like ‘’No thank you’’, or like ‘’go away’’. We’re like,’’ great. We got you. Of course’’, (…) but also it’s an opportunity to be like, ‘’no yes of course but I’m sorry is this your giant pair of underwear we’re just trying to figure out who’s-’’you know like, a finding a way of like reading the room and putting out a tendril or a proposition. (United States)

True to their clumsy and naïve persona, elder-clowns jump on opportunities to exploit the concept of status to give power back to the older adult.

‘I often play (…) the clumsy one. So although they feel clumsy in and of themselves, if they can’t walk properly or can’t move, or they collapse a bit, I’m like ‘’Ooh you should see me!’’ and then I walk and then boom! I don’t even just fall; I fall over the couch and roll over and down. And I’ll have a gentleman who quickly comes and helps me and I’ll say ‘’thank you for helping me.’’ I’m changing the roles a little bit, right? So what are the roles when we are placed in a home, and how can we shift those roles?” (South Africa)

This approach not only minimizes the client’s experience of their challenges but also offers a meaningful opportunity to feel useful and have an impact on someone else. Elder-clowns will intentionally generate such feelings when they lend a genuinely curious ear to whatever expertise residents have to offer.

’‘They have a lot to offer in their uniqueness. And, to celebrate that [is important]. So, whether it’s teaching (…) or singing a song with us or dancing with us or teaching us a phrase in a different language, there’s a richness there as well of life experience. And whether it’s to help us resolve a conflict between two clowns or teaching [one clown] to propose to [another] and, how to decide where they’re going to go on their honeymoon (…) it’s amazing the things that come out. To be able to tap into that wealth of knowledge is really important.” (Canada)

3.3. Need for meaningful, personalized social interactions that are unrestricted by barriers to communication

Nursing home residents have variable access to interactions that go beyond receiving physical care. Nursing staff, activity coordinators and elder-clowns often work together to identify those living in a ‘’vacuum of loneliness and isolation’’; in other words, those who are unengaged in organized activities due to choice or lack of accessibility, who do not have regular visitors, or who may not speak a shared language with staff members. They are often high priority for visits from the therapeutic clowns in hopes of creating an added opportunity for human connection.

The clown’s approach is ideally situated to forge connections with residents, regardless of their communicative abilities, as illustrated by this story:

“It was a lady. She was in a room by herself, and I think she couldn’t see. And I think she didn’t speak English. She was an Asian lady. And when we walked in a room, you could see panic in her eyes. Like, I can’t see what’s going on, you know, you saw that she was stressed. So we leaned forward, and I don’t speak…there’s the language barrier too sometimes so I caressed her arm, and I looked at my partner and I said, ‘I’ll try singing something’. So, I started singing ‘Somewhere over the rainbow’ but very gently. And as I was singing, I was caressing her hair, and her forehead but very, very gently in her face, like so, the elderly, when you touch their face around this area; it brings us back to when we were kids when we were a baby or kids, our mothers do that. So, for them it’s very soothing. I mean, some of them, but it’s, especially this area here, so I was caressing your face and I was singing ‘Somewhere over the rainbow’. I mean, I don’t know if she understood what I was singing but she could hear that it was very gentle, and you just saw her whole face relax. She looked so relaxed and she had this little smile of well being and in French we say ‘béatitude’ you know. She looked like so serene and we left that room like, wow, that panic in her eyes, you know, was totally transformed into this look of like peace. It’s the most touching story, we didn’t do much, you know, it was just gentle and she knew when I touched her just by the way I touched her, that the person who was there was a safe person and we weren’t there to hurt or, you know, because she can’t see, she can’t speak the language and she can’t see.” (Canada)

Participants revealed that a range of intentional techniques and principles aided them in reaching outcomes such as this one. First, they paused when establishing initial contact to present themselves as playful and intriguing and show the resident their intentions within this fast-paced environment: ‘’We have time for you’’. This was particularly important when interacting with residents living with dementia or cognitive disabilities, who may experience slower processing and reaction times. Although some therapeutic clowns prefered to design and rehearse performances for their older adult audience, flexibility within the interaction was agreed upon as necessary to form a connection. Therefore, clowns entered without a fixed plan and used astute observation of physical cues such as direction of eye gaze, posture, facial expressions and gestures to identify the client’s emotional state and intent to connect. From there, a dynamic process unfolded as the clown used their creativity, theatrical expressivity, and improvisation skills to follow the residents’ cues one by one, allowing them to direct the interaction, without the need for clear verbal instructions. At times, the popular duo clown approach was cleverly used to further broaden the potential reach of the clowns’ intervention:

’‘Artistically when the patient isn’t capable of interacting, (…) having a [partner] allows for humor to be shared between the duo (…) and give [the resident], an opportunity to enjoy that interaction. If you’re solo, it’s just you and that patient. And if that patient really isn’t capable to interact, your effectiveness or your ability to offer lightness and humor is diminished.” (United States of America)

By mindfully tuning into the resident’s communicative intents, from loud verbal request to subtle changes in breathing, the clowns manageed to tailor a moment of lightness for the resident, a meaningful and personalized social interaction, some respite from the isolation.

This need related to the basic human desire to communicate. For many residents, opportunities for meaningful communication with staff, volunteers and family is limited by cognitive and physical factors. With their finetuned eye for reading non-verbal communication, and their fluency in using physicality, musicality and mirroring as means of expression, elder-clowns offered to residents of all communicative abilities a chance to meet that powerful need for reciprocal social interactions.

3.4. Need to have culturally meaningful opportunities for reminiscence

Inspired by the work of pioneering elder-clowning groups, elder-clowns internationally incorporate culturally and historically relevant dance, music, fashion, and mannerism from the residents’ youth to create opportunities for reminiscence and spark a connection.

“The songs are so powerful. We have a song, here in Portugal. It’s from the 60s. It was sung by a lady in one contest, European contest of songs, and that was quite important in that time. (…) This song was very, it was very powerful (…) for the 60s in Portugal we were under a tyrannic regime, very closed. (…) When we started to take this song to the hospital, we were very surprised. Everybody was singing but very low because it’s a difficult song of singing, but everybody was singing, and most women were with tears in their eyes”. (Portugal)

Elder-clowns were well equipped to target this human affinity for reminiscence in part because of their theatrical and often musical background and training. Many clowns described making efforts to expand their musical and linguistic repertoire, as well as their understanding of cultural norms when working in multicultural centres, as they recognize this to be a powerful tool to connect with as many residents as possible.

3.5. Need to have a space where they can be unapologetically themselves

From both their training and professional experience, elder-clowns were familiar with the fluctuations in mood, memory and cognition that accompany the ageing process, especially in the presence of a degenerative condition. They recognized that many of the residents’ daily interactions with family or staff can generate feelings of incompetence or frustration because they rely on the residents’ recollection of previous events, their understanding of reality and their ability to conform to acceptable behaviours. For this reason, clowns intentionally created a space in which residents can enter as their authentic self and where no way of communicating, no topic or behaviour needed to be corrected.

“In the beginning, there was this woman who would see us and just throw insults at us in French … we turned it around so that we would yell back at her but using vegetables as insults. So we’d say like “Choufleur!” and then she’d be like, “Oh! [gasp]”, and then she would say, “Carrotte!” We would go back and forth and just throw insults. So she loved that. Her family said that twice because they’ve witnessed this at some point and they thought it was hilarious but then they also said “We’re always embarrassed because you know our mother was always so prim and proper and since she’s developed dementia or Alzheimer’s she’s just angry all the time and yelling all the time.” And so they’re always like “Oh mommy you can’t swear” and “Don’t say that and don’t say this”. But by turning it into a game or by meeting her where she’s at, and by not treating her with kid gloves, but throwing back at her what her energy was and reflecting back to her what she’s given to us was satisfying. I think like “Okay, I’m being seen and being heard. I’m not being told to shush or say I can’t say these things.” (Canada)

Some of the clowns’ training came in particularly handy when faced with residents experiencing strong negative emotions.

“There was a woman who said: “Be careful with Mr. T because he’s feeling very aggressive today, he hit like two residents already today, so there’s something – he’s just really aggressive so just keep your distance. (…)” So I went beside him in his wheelchair and went down to his level so we were eye to eye, which was something that a technique that we learned in training that, especially with people with dementia that are aggressive or kind of stuck in a mode like not to be frontal with them but to sit in the problem with them. I like to be on the side with them. So I went on the side and Dr Pompidou stayed in front. And I said “You’d like to hit him wouldn’t you?” And he said, “Yeaah….” I was like “Me too. Let’s do it together.” So we like reach back and we went in slow motion [makes punching sound] and pretended to hit Dr Pampelmousse. And we have slapstick workshops, so of course he went like this [makes sound effect of being hit] and he flew back over the table. He’s a dancer so he landed perfectly fine. And then the guy still had a look, and I was like “That wasn’t enough - you want to hit him again, don’t you?” and he said “Yeah” so we were active. I swear it must have been like 10–15 times that poor Dr Pompidou went over that table. And at the end, you could see that Mr T. was tired and so he said “Well, it’s lovely to see you, bye-bye.” (Canada)

To create a space in which residents can behave authentically, many clowns adhered to the idea that they should not have specific goals or outcomes in mind prior to the interaction. This allowed them to focus closely on meeting the residents where they were, rather than imposing a direction for the interaction. Additionally, because the clowns’ standards for professional behaviour were not the same as those by which nurses or other staff are expected to abide, elder-clowns could dive into ‘’taboo’’ topics without needing to redirect the resident. This understanding of the demands of typical interactions on the residents and the flexibility with which elder-clowns approached and navigated their interactions make offering a space for authenticity and acceptance a priority.

Bound by their own professional standards and guiding principles, which deviate from the medical model in part through the absence of pre-determined therapeutic goals, elder-clowns are free to engage in whatever scenario arises, without correcting behaviours. They create a unique opportunity for residents to be their true current self, regardless of who they were or could be.

3.6. How elder-clowns complement the nursing home setting

Through their creativity, imagination and spontaneity, therapeutic clowns have the potential to bring joy and lightness to individuals in nursing homes, but their contribution to the residents’ well-being goes beyond those individual moments. The final noteworthy theme highlighted the clown’s impact on the nursing home environment beyond individual interactions and the typically expected laughter and joy. Significant moments shared by the clowns revealed that their presence contributed to creating positive shared memories in a space often associated with loss and isolation, as well as having the potential to enhance the quality of residents’ future interactions with staff and family by highlighting their communicative potential.

As the name implies, nursing homes are intended to serve as a home for residents. The presence of elder-clowns contributed to the association of positive collective experiences with that space.

“It’s always a very impactful moment when the clowns leave (…) Everybody sits up (…) People start talking amongst each other more. We create bonding moments between people and the staff, between residents. There’s really an effect, maybe not long term, like they’re on a high for a week, but it lasts, the scent lingers.’’ (Canada, English translation)

Through their interventions, elder-clowns also noticed their ability to contribute positively to the staff’s experience in the nursing home. The following example illustrates how trust and collaboration between professionals can enhance situations for all those involved:

“One time we came and we knocked on the door, (…) the nurse was in changing the bandages on this lady. And we said ‘Oh, we won’t bother you, [we] know you’re working, we’ll come back later’ and the nurse said ‘No, come in’. And so while we interacted with the woman, you know, talking about bingo and what have you, she was able to change the bandages on her sores on her leg which is generally very painful. And she said ‘That’s it, we’re working as a team. I have my thing to do but if you can come in and bring a bit of joy, bring a bit of happiness, even distraction, while I’m doing this thing that’s particularly unpleasant.’” (Canada)

In addition, clowns reported that at times, their unique approach and methods of interacting with older adults allowed them to “uncover” information regarding residents’ communicative abilities, and their interests. By relaying these details to the rest of the staff or even family members, elder-clowns contributed to significant improvements in the meaningfulness and quality of future interactions for the resident.

4. Discussion

Nursing homes are intended to be places of residence, where the creation of a home environment is prioritized, and the management of medical needs is supported but secondary. In practice, the physical and medical needs of NH residents are typically foregrounded and consume the majority of the financial and personnel resources of these institutions. This research examines the role of an arts-based intervention—therapeutic clowning—in complementing existing nursing home services and attending to the unmet needs of NH residents. Through interviews with an international sample of elder-clowns, we identified five major needs of NH residents that were met through the art of therapeutic clowning: the need to escape routine; the need for reassurance of worth; the need for meaningful personalized social interaction; the need for culturally appropriate opportunities for reminiscence; and the need for a space to be unapologetically themselves. Narrative descriptions of the strategies employed by therapeutic clowns to meet these needs reveal a shared philosophy across practitioners of creating a meaningful connection that acknowledges the intimate social and cultural realities of the resident, meeting the resident as they are, and cultivating a physical, emotional, and sensorial relationship with them.

To date, the majority of studies on the efficacy of therapeutic clowning practices with adults or elders has focused on biomedical outcomes, including reductions in undesirable behaviours, and positive physiological changes (De Mauleon et al., 2021; Kontos et al., 2016; Low et al., 2013). For example: hospital clown interactions have been shown to significantly improve physiological measures associated with chronic obstructive pulmonary disease (Brutsche et al., 2008); and group-based clowning interventions have been associated with reduced disruptive behaviours (i.e., attempted escape, self-injury, and fighting) in adult psychiatric patients (Low et al., 2013). However, a significant body of this work has also reported nonsignificant or negative changes in behaviour of adults after therapeutic clown interactions (De Mauleon et al., 2021; Efrat-Triester et al., 2021). The results of this study suggest a compelling explanation: our participants reported an explicit intention to avoid correcting behaviours and imposing pre-determined outcomes on their interventions. In light of this mandate, the inconsistency of behavioural results across previous studies is unsurprising, as the goals of therapeutic clown interactions are not targeted at achieving a pre-defined change. Our results illuminate the social and emotional outcomes that are actually targeted by therapeutic clowns and suggest non-biomedical constructs to be measured in future research to assess the efficacy of this intervention. The handful of studies that have expanded their lens outside of biomedical outcomes of elder-clowning have reported similar results to our study. Elder-clowns have been shown to give legitimacy to older adult’s right to play, provide self-confidence by encouraging reminiscence and sharing of past accomplishments, and create a social atmosphere favourable to a sense of belonging (Babis, Korin, Ben-Shalom, & Gruber, 2022). Therapeutic clowning interventions with persons with dementia have reported new ways to sensorily engage this population, explore their relationality, and provide evidence for their ability to engage with humorous content (Baumgartner & Renner, 2019; Hendriks, 2012; Kontos et al., 2017). Elder-clowns have also been shown to improve NH residents’ well-being and social interactions (Low et al., 2013), though it is interesting to note that the conclusion of this study promotes therapeutic clowning for its potential to reduce agitation. Our research contributes to this nascent body of work that foregrounds the unmet emotional and social needs that therapeutic clowns notice and palliate using their unique skillset in nursing homes.

The strategies of creating connection and relational presence described by our participants largely parallel the active ingredients of other successful initiatives to generate well-being in nursing home residents. Creative expression and reminiscence such as through personal storytelling were associated in a recent scoping review with improved self-esteem and self-efficacy in an adult and older adult population respectively (Vaartio-Rajalin et al., 2021). Opportunities for reassurance of worth, including experiencing a sense of competence, were found to be effective at addressing loneliness in older adults living with cancer (Drageset et al., 2015). Similarly, experiencing a sense of control and a sense of mastery has been linked to feelings of empowerment and positive health outcomes (Cohen, 2006). The therapeutic clowns’ focus on creating highly personal, intimate encounters with each NH resident is also richly supported by research on well-being in older adults. The individuality of the experience of loneliness in older persons emerged in a recent scoping review, which emphasized the necessity for tailored interventions to uniquely address each person’s needs (Fakoya et al., 2020). Nurse interactions with NH residents that demonstrate recognition of the individual’s unique personhood have been associated with lower depression scores (Haugan et al., 2013). The parallels between the active ingredients of these established well-being practices and the in-action strategies described by our participants illustrate the potency of the therapeutic clown’s co-creative, responsive, and deeply personal approach to NH residents. It is noteworthy that most interventions that improve well-being are expected to be implemented by existing NH staff members, such as nurses, in addition to their job-related responsibilities. The range and depth of otherwise-unmet needs identified by our participants illustrate the unique potentiality that therapeutic clowns have to complement existing NH care staff and focuses, and to create a sense of belonging and home in NH environments.

The results of our study need to be interpreted in light of several limitations. First, although participants were recruited internationally, our language inclusion criteria (English or French) necessarily biased our sample. We found strong overlap and coherence in the tenant principles and methods of elder-clowning across our sample of eight countries, which clowns adapted to local cultural and society contexts. This coherence may dissolve upon including a broader international sample of therapeutic clowns. In future work, we encourage a targeted sampling across elder-clowns from different countries and an analysis of the cross-cultural differences in philosophy and practice. Second, narrative interviews were only collected from therapeutic clowns; we did not include the perspectives of nursing home residents or staff in this study. Triangulation across reports from the other actors in NH settings would strengthen the evidence for the effectiveness of elder-clowning and the needs that they meet in NH residents. Third, nursing home residents can include middle-aged individuals and even young adults living with severe disabilities. The interview questions in this study focused on therapeutic clown interactions with older adults; the results may not be generalizable to other NH residents. Finally, data collection relied on participants’ recollection of events; some significant moments shared by clowns may be embellished or omitted. However, each theme in our analysis reached saturation, suggesting that individual recall inaccuracies were limited.

5. Conclusions

Nursing home residents have a range of emotional and social needs that are often unmet in the largely biomedical and safety-oriented environment of their residence. Therapeutic clowns are uniquely positioned to address these needs using a large repertoire of artistic and emotional strategies, and can play a leading role in transforming nursing homes into places where residents feel that they matter and that they belong.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/17482631.2023.2238989

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Ludivine Plez

Ludivine Plez, MSc in Occupational therapy, first got involved in research as a research assistant at McGill's Child Language Development and Disorders Lab. She discovered the field of elder-clowning in the context of her Master's research project. Now a school-based occupational therapist in the US public school system, she applies insight from this research project to create playful, child-led opportunities for success and growth for her students.

Melissa Holland

Melissa Holland is a therapeutic clown and co-founder of the Dr Clown Foundation based in Montreal, since 2002. She has a BFA and a B.Ed. respectively from Concordia and McGill Universities. Through her studies she discovered and fell in love with the art of clown and was trained by several clown masters. While living in Scotland, she was hired by the Hearts and Minds organisation as a clown-doctor, and discovered her vocation. Melissa works regularly as a therapeutic clown with children and the elderly in health-care settings as well as Co-Artistic Director in development, promotion, training and research for the Dr Clown Foundation. She was a pioneering member of the Canadian Association of Therapeutic Clowns, and the North American Federation of Hospital Clown Organisations.

Priyanka Kulasegarampillai

Priyanka Kulasegarampillai, B.Sc, M.Sc.A, is an occupational therapist specializing in private practice. She works with individuals with mental health diagnoses and individuals recovering from car and work accidents. Her ultimate goal is to address both physical and mental barriers, facilitating their return to work and engagement in other meaningful activities. Her approach combines evidence-based therapeutic techniques with empathy and understanding, creating a supportive environment for her clients to open up about their experiences, and equipping them with preventive strategies to foster long-term well-being.

Thun-Carl Sieu

Thun-Carl Sieu, BSc, MSc, is a McGill University alumnus with a focus in Rehabilitation Sciences. As an Occupational Therapist and Case Manager at the Jewish General Hospital's Outpatient Psychiatry department, he coordinates care for patients with psychotic disorders, striving to optimize their therapeutic outcomes. His professional interests intersect mental health and occupational therapy, particularly emphasizing improved quality of life and functional independence.

Stefanie Blain-Moraes

Stefanie Blain-Moraes is an Associate Professor at McGill University, where she leads the Biosignal Interaction and Personhood Technology lab. She hold a Canada Research Chair (Tier II) in Consciousness and Personhood Technologies. Her research focuses on the assessment of consicousness and development of novel assistive technologies for minimally communicative persons. She also focuses on arts-based engagement and knowledge translation with the target populations of her research.