Running Head: EVIDENCE-BASED PRACTICE PROJECT PROPOSAL

Evidence-Based Practice Project Proposal:

The Clown-Nurse Educational
Intervention

The Clown-Nurse Educational Intervention

EVIDENCE-BASED PRACTICE PROJECT PROPOSAL

Introduction
In every real man, a child is hidden that wants to play (Nietzsche, 1998). Play has
always been associated with children. Being a child health registered nurse and educator at The
Childrens Hospital, I have seen how play works wonders in pediatric patients. It has alleviated
their anxiety, doubts and fears of being in pain, undergoing a procedure or being in an unfamiliar
environment. Interestingly though, even the health care professionals, parents or significant
others taking care of these children also experience some form of distress or dread. Like
children, I believe that adults too need some form of distraction whilst assisting these children to
recovery. As a co-chair of the shared leadership unit-based committee, I want to propose an
intervention that will help allay the anxiety of both the patients and the significant others through
a play strategy making use of clowns, the clown-nurse educational intervention.
Background
The clown-nurse educational intervention makes use of nurse-clowns to provide
preoperative education. This strategy has been proven effective in reducing the anxiety and pain
level of preschool patients who underwent surgery. The study also showed a reduction in the
physiological anxiety of the parents. (Yun & Kim, 2015).
Reduction of post-operative anxiety is essential in reducing the pain felt by the patient
after surgery. Children with high levels of anxiety prior to the surgery experience higher level of
post-operative pain as compared to those with low anxiety levels preoperatively (Chieng, Chan,
Klainin-Yobas, & He, 2014). Consequently, the high pain level further increases the need for
additional analgesics and sedatives (Messina, et al., 2014). In another study, it was found out that
those children with high levels of anxiety preoperatively, exhibit higher incidences of negative

EVIDENCE-BASED PRACTICE PROJECT PROPOSAL

behavior manifestations such as aggressive and depressive behaviors to name a few (Zavras,
Tsamoudaki, Ntomi, Yiannopoulos, Christianakis, & Pikoulis, 2015).Additional detrimental
effects of untreated preoperative anxiety include sleep disturbances, enuresis, food intake
problems and indifference (Snchez-Garca, Segura-Flores, Len-Garrido, Rodrguez-Rosado,
Pena-Andreu, & Fontalba-Navas, 2015).
Managing anxiety is not only recommended for patients but for parents and significant
others as well. Clown intervention was found to decrease maternal anxiety and stress in the
preoperative period. Reducing parental anxiety levels is important preoperatively because it
decreases the chances of somatization (Agostini, Monti, Neri, Dellabartola, de Pascalis, &
Bozicevic, 2014). In a study by Baxter (2014), it was mentioned that parental anxiety increases
the childs anxiety by fifty percent, thereby, further creating additional unnecessary stress to the
child.
Proposal
Traditionally, in many health care settings, preoperative education is done both by the
nurse and the physician. These health care professionals were not being asked to include play,
costumes, magic tricks, jokes or games in preparing and educating the patients and the
significant others regarding the surgery. This tradition needs to change starting with how the
preoperative nurses dress up. Nurses uniforms evoke different feelings or emotions. White
uniforms were found to evoke negative emotions while more positive emotions were associated
with the colors blue, pink and yellow (Albert, Burke, Bena, Morrisson, Forney, & Krajewski,
2013). This study further supports the premise that nurses should try to be more creative in
addressing their patients needs. Hence, dressing up as a clown can elicit more positive emotions

EVIDENCE-BASED PRACTICE PROJECT PROPOSAL

instead of fostering anxiety and pain. The traditional clown face paint should be avoided by
nurses since it may frighten some children. It is suggested that the use of the big, red nose and
the traditional colorful costume will be more helpful in patient education (Lambert, 2015)
I also suggest that the clown-nurse intervention follows through until the patient is in the
operating room. The presence of a clown pre-operatively, decreases the needed anesthesia and at
the same time, speeds up the recovery process (Estrin, 2012). This study is further supported by
the fact that among parental presence, clowns or sedative medication, the presence of clowns still
remained the best treatment for preoperative anxiety (Vagnoli, Caprilli, & Messeri, 2010).
The clown-nurse educational intervention needs adequate and appropriate preparation
and training both for the staff and the institution. Therapeutic communication skills are required.
These skills will help nurses better understand their patients emotions and in turn, create a better
connection with them (Leef & Hallas, 2013), (Nogueira-Martins, Lima-Costa, Nogueira-Martins,
& Nogueira-Martins, 2014). Empirical studies suggest that clowns with no training only evoke
feelings of amusement. Nurses on the other hand, evoke feelings of appreciation and privilege
without being amusing. The combination of a nurse with a clown training thereby elicits feelings
of appreciation and privilege coupled by amusement (Auerbach, Hofmann, Platt, & Ruch, 2013).
These feelings cannot be stimulated neither by the nurse nor the clown alone. The nurse should
be trained as a clown in order to elicit these positive emotions from the patients and significant
others.

Conclusion

EVIDENCE-BASED PRACTICE PROJECT PROPOSAL

Addressing pain and anxiety are essential in caring for pediatric patients and their
families. Being in the hospital is stressful enough. Nurses should be able to intervene and help
manage patient and parental anxiety to avoid more pressing physiological and psychological
problems. A clown-nurse can help address these issues and at the same time, help both the
patients and their families focus on something other than their disease or illness.

References

EVIDENCE-BASED PRACTICE PROJECT PROPOSAL

Agostini, F., Monti, F., Neri, E., Dellabartola, S., de Pascalis, L., & Bozicevic, L. (2014).
Parental anxiety and stress before pediatric anesthesia: A pilot study on the effectiveness
of preoperative clown intervention. Journal of Health Psychology, 587-601.
Albert, N., Burke, J., Bena, J., Morrisson, S., Forney, J., & Krajewski, S. (2013). Nurses'
Uniform Color and Feelings/Emotions in School-Aged Children Receiving Health Care.
Journal of Pediatric Nursing, 141-149.
Auerbach, S., Hofmann, J., Platt, T., & Ruch, W. (2013). An Investigation of the Emotions
Elicited by Hospital Clowns in Comparison to Circus Clowns and Nursing Staff. The
European Journal of Humour Reseacrh, 26-53.
Baxter, A. (2014). Common Office Procedures and Analgesia Considerations. Pediatric
Emergencies, 1163-1183.
Chieng, Y., Chan, W., Klainin-Yobas, P., & He, H.-g. (2014). Perioperative anxiety and
postoperative pain in children and adolescents undergoing elective surgical procedures: a
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Estrin, D. (2012, August 21). Israel Hospital Clowns Team With Doctors In New Medical
Treatments. Retrieved January 20, 2016, from The World Post:
http://www.huffingtonpost.com/2012/08/21/israel-hospital-clowns_n_1816596.html
Lambert, P. (2015). Managing Arts Programs in Health Care. New York: Routledge.
Leef, B., & Hallas, D. (2013). The Sensitivity Training Clown Workshop: Enhancing Therapeutic
Communication Skills in Nursing Students. Nursing Education Perspectives, 260-264.
Messina, M., Molinaro, F., Meucci, D., Angotti, R., G. L., Cerchia, E., et al. (2014). Preoperative
distraction in children: hand-held videogames vs clown therapy. Medical and Surgical
Pediatrics, 5-6.
Nietzsche, F. (1998). Quotations about inner child and play. Retrieved January 19, 2016, from
The Quote Garden: http://www.quotegarden.com/inner-child.html
Nogueira-Martins, M. F., Lima-Costa, D., Nogueira-Martins, A., & Nogueira-Martins, M. C.
(2014). Perceptions of Healthcare Undergraduate Students about a Hospital Clown
Training. Creative Education, 542-551.
Snchez-Garca, M. C., Segura-Flores, M. F., Len-Garrido, M. L., Rodrguez-Rosado, A. M.,
Pena-Andreu, J. M., & Fontalba-Navas, A. (2015). Reduction of Preoperative Anxiety in
Children Using NonPharmacological. Journal of Nursing Care.
Vagnoli, L., Caprilli, S., & Messeri, A. (2010). Parental presence, clowns or sedative
premedication. Wiley.

EVIDENCE-BASED PRACTICE PROJECT PROPOSAL

Yun, O. B., & Kim, S.-J. (2015). Effects of a ClownNurse Educational Intervention on the
Reduction of Postoperative Anxiety and Pain Among Preschool Children and Their
Accompanying Parents in South Korea. Journal of Pediatric Nursing, e89-399.
Zavras, N., Tsamoudaki, S., Ntomi, V., Yiannopoulos, I., Christianakis, E., & Pikoulis, E. (2015).
Predictive Factors of Postoperative Pain and Postoperative Anxiety in Children
Undergoing Elective Circumcision: A Prospective Cohort Study. The Korean Journal of
Pain, 244-253.