Essential Tips, Techniques, and Policies for Training Hospital Clowns

By Richard Snowberg

Let me begin by setting the stage as to what caring clown work is like at this present time-2005-2006. Throughout the world, caring clowns in hospital environments find themselves in a variety of patterns of work and involvement in their respective health care facilities. (The key word here is variety, meaning there is a tremendous range in what they do, where they go, and whom they interact with.) They also find themselves under a diverse range of supervision, from highly supervised to hardly noticed or directed. And finally, but of least importance to their expertise and impact, is the fact that many of these clown workers are non-paid, while many of them are paid. (I prefer not to differentiate between these two types of arrangements with terms like ‘volunteers’ or ‘professionals’. Both of these terms are misleading and carry erroneous connotations.)

The terms hospital clowns, caring clowns, and visiting clowns may be all the same thing, or to some connote different meanings. For purposes of this paper all three terms will be used interchangeably. The latter term, visiting clowns, refers to clowns that visit hospital rooms of patients. It does not simply mean a clown that occasionally visits a hospital. In other words, visiting refers to something specific, not a general visitor who comes to a hospital.

Policies

While it is the ‘tips’ and ‘techniques’ that really are of most interest to aspiring hospital caring clowns, it is the policies under which they must work which will make it possible to share their ‘techniques’. So, let’s begin our examination of the world of hospital clowns by taking a short look at policies for caring clowns.

Oh no, not more ambiguity! Sorry, but the truth is that policies for caring clowns in hospitals vary tremendously-from no policies, to those that are extremely restrictive-to the point that a few hospitals deny clowns from being present in their facilities. This doesn’t help you much, so let’s get to some basic points.

I have found that hospital staff that initiate the concept to introduce caring clowning in their facilities, will be open to developing policies that maximize benefits to patients, while at the same time minimize negative effects to the overall hospital environment. And, isn’t this exactly what we desire for such programs. There isn’t a better starting point than when it is staff that want to develop and support a hospital clown program.

If it is hospital upper level administrators that introduce a caring clown program, oftentimes the nurses, doctors, and other support staff feel blindsided or apart from a decision that has been made for a new approach for treating their patients. It is important that when policy decisions are made regarding such a program, that they have wide based support, or include strong support from nursing personnel. Without a good working relationship with nursing staff members, the program will languish and fail.

If no program exists in a hospital, there are a couple of ways that a caring clown can go about attempting to gain entry into the hospital and perhaps lay the seeds for the development of an ongoing visitation program. First, one must determine if a clown can gain permission to make visits to patients. I’ve known some hospitals that won’t allow the clowns in patients rooms, but want the clowns in the emergency waiting room to entertain children either waiting for treatment or accompanying a family member that is there for treatment. On the other hand, I know of hospitals that allow clowns in patient’s rooms, but won’t allow them in the emergency waiting room. I call this difference to your attention, because hospital policies, whether written or just verbally accepted, are quite diverse. You must determine what policies or procedures are currently in place-both those that are written and those that are tacitly adhered to by staff and visitors.

In most general population hospitals, the easiest place to begin to appear as a caring clown is in pediatrics. Visit a head nurse, when you are not in clown wardrobe, and introduce yourself and offer your services. Bring along a photo of yourself in your character, and any letters of commendations or support that you might possess. Perhaps you’ve attended a training program of some kind from which you have a certificate of completion. Any of these items help to establish your credibility. If you are greeted with a positive reaction to your proposal, find out what time of day, and which day(s) are desirable for your visits. Ask whether there are specific things, such as balloons, which are not allowed in the ward. Suggest that you’d welcome a nurse, child life worker, or children’s therapist to accompany you on the rounds that you make. Also suggest that, in advance of your arrival, they may wish to put together a schedule of rooms for you to visit. In that way, the staff controls where you go, and where you do not go. Always, when arriving at a ward, go to the nurses’ station, and see if a schedule is available or if someone is going to accompany you on your rounds. In most cases someone will go with you, and not so much observe your work, as to assess patient reactions. Oftentimes these responses are documented in patient’s records.

So all of what I’ve stated in the above paragraph can be taken and used as a foundation for policies usable in organizing and structuring a caring clown program. For example two policies would be: Clowns will visit at predetermined days and times. Clowns will first come to the nursing station to receive instructions as to which rooms are areas to visit. Other policies might be acceptable props, the number of clowns in a given area, and possibly even the length of stay with individual patients. I have personally found that some hospitals have no idea what policies should be included for clown visitors. In those cases it is the professional thing to do and advisable to provide the facility with a suggested list of policies which they may wish to adopt in their hospital. At the end of this article, I’ll append a collection of such policies. Some will be contradictory, so select those that compliment your hospitals desires and needs.

Let’s go back for a moment to the question of how to first gain entry into a hospital. Assuming no clown visitation program exists in the hospital, take the initiative and visit a hospitalized friend in the hospitalwhile in your clown character. If that isn’t possible as all your friends are too healthy to be hospitalized, do you have an acquaintance that works in the hospital? This person may be able to serve as an entree for admission to the facility. Here in La Crosse, Wisconsin we gained entry into our first hospital over 25 years ago through the Medical Education Department. It just happened that two two staff members in that department showed a desire to incorporate clowns into the hospital environment, and a program followed.

Doing hospital visits and having a hospital program are two different things. A program denotes an established set of guidelines/policies, a schedule and a staff of one or more persons that are regularly making hospital rounds or visits. (A program may be staffed with either paid or non-paid clown arts performers. Just because the clowns are not paid, doesn’t mean you don’t have a viable and professional program.)

It is possible to provide hospital visits by one or more clowns, without having a program. However the benefits to the hospital, and more specifically to the patients is increased when the visits grow into an ongoing program. The program signifies continuation. It also usually signifies stability, an ongoing schedule and credibility. And finally, it signifies ownership of the program by the hospital.

All hospital programs, even those for caring clowns, have a home base in the facility. These programs may be in units of nursing, volunteer services, child life, recreation, pastoral care, social work, or even medical education. I have seen successful programs evolve from all of these units. There is no standard place for a clown. Clowns can fit into any of these areas and be productive contributors for patients and the general environment in a hospital.

Techniques

Okay, now that we’ve found a way to gain entry into a hospital, let’s see what it is we’ll do in our funny face. It’s time to begin to explore ideas for tips and techniques. I want to start by saying that we’ll look as techniques as different approaches to working as caring clowns. These may require some elaboration. As for tips, these will be short ideas that clowns have had success employing in hospital environments.

Techniques that are successful for caring clowns incorporate inclusion. When visiting a sick patient if you can include the patient, visitors or health care workers in your entertainment, you are almost guaranteed of a successful encounter. When an entertainer brings positive recognition to say a health care worker, it establishes a sense of closeness and acceptance. When playful situations can be developed between the clown and the patient or health care workers, a positive relationship is established. Sometimes the relationship between patient and nurse is improved, when the patient sees that the nurse can also be a fun person that enjoys entertaining with the clown.

It is extremely important that the clown visitor be an invited guest in the presence of a patient. If a hospital patient is in their room, whether a private room or one shared with others, it should be viewed as their home. As such, one should ask if it is okay to come in for a visit. The clown needs to carefully watch the patient’s eyes, to determine if there is fright or reluctance present. If you are unsure, don’t enter the room-at least not yet. Stay in the doorway and talk or entertain. It really isn’t necessary to enter most rooms. Allow your entertainment, at a safe distance, the opportunity to overcome a patient’s possible discomfort. If a feeling of comfort and ease becomes evident from the patient, then go ahead and move into the room.

Let’s face it, some healthy children and adults are afraid of clowns. Just accept this fact, so when we add illness or injury to the equation, we have an even more volatile situation. Clowns must be cautious and tread softly and with care when approaching not only hospital patients, but also nurses, doctors and others in the institutional environment. I even encountered a hospital administrator that was afraid of clowns. So be wary of your style and possible impact as you approach your audience.

Washing one’s hands is extremely important in North American Hospitals. I found that this was not nearly as much a concern or required practice in visits to some European and Asian hospitals. In the Americas, you may be required to wash your hands before interacting with each patient-whether you’ve touched anything or anyone. If the washing is in the presence of the patient, develop a comedy routine or monologue that you can share while doing this chore. Basically you want to stay in character and establish your identify as both a clown and one that follows the rules of the hospital. One clown that I know developed a bubble blowing routine with the liquid hand soap that had patients eager to have her teach to their parents.

You need to follow the rules of the house. Does the hospital have departments or areas that are out of bounds to your visits? Are there procedures that you need to follow when interacting with others in the hospital? Are you allowed to enter the hospital as a clown? Do you need an identification card produced by the hospital? Is there a training program that you must complete before starting to make rounds to patient’s rooms? All of these examples are subject to the rules in place at specific hospitals.

If you’ve started as the first clown in a hospital, and have established a continual pattern of visitations, perhaps it is time to begin developing program status for what you have been doing. This can effectively be done and incorporated for a hospital by either a single clown or a large number of clowns. Once the clown visits become part of a program, greater visibility takes place, more credibility becomes apparent, and generally it is just easier to become accepted.

Program status usually brings other clowns or persons interested in becoming clowns to indicate their interest in becoming part of the program. In most cases, hospitals want to develop a training program, or specific standards for visiting clowns. Some hospitals produce specific training programs for the apprentice clowns. Others have them attend training sessions provided through the volunteer office of the hospital. All hospitals in North American run criminal background checks on persons that they basically are going to have roaming their facilities-in disguise. Think about what fears some hospital administrators must have about who we really are!!!

Some clown units in hospitals are housed within the pastoral care department. To my knowledge, these are all Christian based programs. As such these training programs for clowns contains aspects of sharing Christian faith based beliefs, prayers, and perhaps medication. Counseling is often also a component of their training. Even in say a Catholic or Lutheran hospital, it is imperative that one not offend someone of a differing religion. Thus at this time, many hospitals are denying clowns the opportunity to express any religious leanings or beliefs. This is a very sensitive issue, and one that you need to clarify.

Establish and continue to develop allies with hospital employees. When you find someone that really appreciates and understands the impact you can make, get closer to that person. Ask them what else you might do to assist in the health care treatment of their patients. Be open for suggestions, and asks for ideas for expanding what it is that you can do. Your personal goal, and the hoped for goal of the hospital should be for you to become an important member of the health care team of this institution.

If you are establishing a hospital program, develop standards for visiting clowns. Have not only entry standards (background checks, training, mentoring, inoculations, and tests), but also quality and attendance standards that must be maintained. Put in place a means by which you can exclude or terminate a clown if he or she is not maintaining the level of performance you expect. Once you envision what a bad or poor clown might be like, you’ll be able to quantify the criteria.

In your training program, you might wish to include a mentoring phase. Here the new clown would accompany an experienced performer and watch how he/she relates with patients and staff. The person being mentored can, on a second visit, also be in makeup and begin to see how people treat she/he differently. Finally the new clown can begin to perform for the patients, while the experienced clown steps back and assists or provides support. Mentoring is a safe and valuable means to develop consistently good caring clowns.

Tips

Determine what is permitted and what is not allowed in the hospital. a. Latex Balloons? b. Bubbles? c. Plush animals? d. Live animals? e. Gifts to patients?
Don’t overstay your visit with sick patients-5 minutes may be a maximum limit for most.
Be aware of any props that a patient may touch, so that you can sanitize them upon leaving the patient’s room.
Carry a supply of zip-lock bags into which to place any contaminated props that you’ll have to launder in order to sanitize.
Collect a variety of comedic props that appeal to differing ages. You never know the age or interest of your next patient.
Share riddles and stories which you can recite or read from notes.
Have a puppet to share with shy children, or those that are non-verbal.
Small music boxes are very effective with the very young and the elderly
Take notes and write a follow-up report after the visit, even if the hospital doesn’t require you to do so.
Don’t leave a floor or ward before going back to the nurses’ station and indicating where you have visited and that you are preparing to leave unless they have someone else they wish you to visit.
Determine whether the hospital wants you to enter and exit the facility as a non-clown, putting your make-up and wardrobe on in-house, or have you arrive ready to begin to work.
Find out where you need to check-in prior to starting to make rounds.
Carry some free give-away items for sharing with patients, nurses, doctors, etc. These might be small prescriptions for happiness, stickers, fun quotations, etc.
Always, whether you see them or not, know that someone is watching your movements and actions. Thus always be on in terms of your behavior and character.
Wear an identification badge that tells people your name. Even if the hospital doesn’t provide or require this tag, it is extremely helpful and reassuring to the staff to know who you are.
As a clown, don’t provide any medical assistance, unless at the direction of a health care professional. Some patients may want you to get them a drink, adjust their bed, or help them to the toilet. Share your inability to assist, but offer to immediately find someone that can help meet their need.
Don’t expect that you’ll always receive a laugh, smile, or even any reaction from each person you visit in a hospital. The energy may just not be there. However, we often hear later that a patient that we thought was perhaps even unaware of our work later reported on the nice clown that came to visit.
Don’t overlook sharing a smile and some fun with the professional staff members. Just be aware that you don’t want to interrupt their work. You want to augment their work.
Enjoy the smiles you’ll get and positive reactions you’ll receive when you give some attention to housekeepers, cooks and other lower level employees in the hospital. These often-unseen workers really appreciate the recognition. You can bet they will be looking for you the next time you are around.
Be prepared for the unexpected. While you can’t anticipate what might be next, around the corner, you need to accept the fact that something unexpected is likely awaiting you. Caring clown work is absolutely, positively never boring. It is always different. It is always challenging, and always energizing.
Become an asset, not a liability as you work in the hospital. Your goal is to be a positive contributor to the care, treatment and recovery of patients. As an asset you will begin to become more inclusive in the care and treatment of patients. You will likely even become a team member reviewing strategies for the care of specific individuals.

Hospital Policies in Use in a Variety of Facilities (Some of these contradict one another)

Clowns are not to wear wigs
Clowns are to check in at the volunteer office to receive their assigned rounds
Clowns are to check in at the pastoral care office to receive their assigned rounds
Clowns are not to give any gifts or prizes to patients, except those provided by the hospital
Clowns are to enter by a specific entry door.
Clowns are to apply their makeup at the hospital and remove their makeup before leaving the facility
Clowns are not to sit on beds or the floor
Clowns must wash their hands while in the presence or visible to patients.
Clowns must wash their hands upon leaving a patient’s room.
Clowns can go into any patient’s rooms where the door is open
Clowns can only go into rooms with a green code color on the door.
Clowns, with permission of nursing or other professional staff members, enter rooms with other color designations.
Clowns must ask staff members if Polaroid photos can be taken and left with patients.
Clowns may enter an area of urgent care, burn ward, or critical care, if permission is granted and proper sanitation and apparel conditions are met.
Clowns are not to ask patients their names in a psychiatric ward.
Clowns are not to ask patients their names in a general ward.
Clowns are not to indicate any religious beliefs to patients.
Clowns may share a prayer or indications of their faith-if asked by a patient.
Upon leaving a room, clowns must sanitize any props touched/handled by patients
Clowns must conduct visits during hospital prescribed times
Clown visits are to be pre-arranged, not spur of the moment occasions
Clowns are to work in teams of two or three
No more than two clowns should be in any one patient’s room
Clowns may visit in any hospital waiting room areas
Clowns are not allowed in the emergency room area.
Clowns are allowed and often asked for assistance in the emergency room area.
Clowns must be prepared to identify themselves via their birth names (not just clown names)
Clowns must receive training and be able to follow all emergency procedures of the hospital
Clowns are not to report to the hospital for room visits if they have a cold or other illness.
Visiting clowns can’t be minors.
A child life worker must always accompany visiting clowns in pediatrics.
While not being disruptive to normal hospital workflow, clowns are encouraged to share some happiness with staff members.
Clown visitors are to report any patient information shared with them that might be vital to the care and treatment of said patient.
Clowns are not to share privileged patient information to those outside the hospital.