A hospitalização pode ser uma experiência traumática para as crianças e seus familiares. O objetivo deste estudo foi explorar a experiência da utilização da arte do teatro clown no cuidado as crianças hospitalizadas, a partir de uma atividade desenvolvida por alunos de cursos de graduação da área da saúde. Os dados foram obtidos mediante observação de 20 crianças e 11 alunos, personagens do teatro clown em interação na clínica pediátrica de um hospital-escola do interior do estado de São Paulo. Os dados empíricos foram analisados segundo a análise temática de conteúdo, os quais foram agrupados ao redor dos seguintes temas: expressões artísticas como forma de comunicação, participação do binômio criança e acompanhante e o clown como recurso terapêutico. Os resultados indicaram que esta experiência constituiu-se em uma intervenção concreta que valoriza o processo de desenvolvimento infantil, pois abre espaço para a fantasia, o riso, a alegria e a apropriação do cotidiano hospitalar; é um exemplo de ampliação do processo diagnóstico e terapêutico com a incorporação de intervenções que privilegiem as necessidades afetivas, emocionais e culturais da criança e sua família, na busca do cuidado atraumático.
Criança hospitalizada; Jogos e brinquedos; Enfermagem pediátrica
La hospitalización puede ser una experiencia traumática para los niños y sus familiares. El objetivo de este estudio fue explorar la experiencia de la utilización del arte del teatro clown en el cuidado de niños hospitalizados, a partir de una actividad desarrollada por alumnos de cursos de graduación del área de la salud. Los datos fueron obteni-dos mediante la observación de 20 niños y 11 alumnos, personajes del teatro clown en interacción en la clínica pediátrica de un hospital escuela del interior del estado de San Pablo. Los datos empíricos fueron analizados según el análisis temático del contenido, los cuales fueron agrupados alrededor de los siguientes temas: expresiones artísticas como forma de comunicación, participación del binomio niño y acompañante y el clown como recurso terapéutico. Los resultados indicaron que esta experiencia se constituyó en una intervención concreta que valoriza el proceso de desarrollo infantil, ya que abre espacio para la fantasía, la risa, la alegría y la apropiación de lo cotidiano en el hospital; además es un ejemplo de ampliación del proceso diagnóstico y terapéutico con la incorporación de intervenciones que privilegian las necesidades afectivas, emocionales y culturales del niño y su familia, en la busca del cuidado sin traumas.
Niño hospitalizado; Juego e implementos de juego; Enfermería pediátrica
Hospitalization can be a very traumatic experience for children and their family members. The purpose of this study was to explore the experience of using clown theater art in the care for hospitalized children, starting with an activity developed by undergraduate students in the healthcare area. Data were obtained by observing 20 children and 11 students, characters in the clown theater interacting in the pediatric clinic in a school hospital in the state of São Paulo. The empirical data were analyzed with the thematic content analysis, which were grouped around the following themes: artistic expressions as a form of communication, participation of the binomial child and accompanying partner, and the clown as a therapeutic resource. The results show that this experience was a concrete intervention, emphasizing the children's development process, since it opens up a space for fantasy, laughter, happiness and the appropriation of the hospital routine; it is an example of widening the diagnostic and therapeutic process with the incorporation of intervention focusing on the affective, emotional and cultural necessities of the child and the family, in the search for non-traumatic care.
Child, hospitalized; Play and playthings; Pediatric nursing
Regina Aparecida Garcia de LimaI; Eliete Farias AzevedoII; Lucila Castanheira NascimentoIII; Semiramis Melani Melo RochaIV
INurse. Associate Professor of the Maternal-Child and Public Health Nursing Department at Ribeirão Preto College of Nursing at University of São Paulo. Ribeirão Preto, SP, Brazil. firstname.lastname@example.org
IINursing undergraduate. Ribeirão Preto College of Nursing at University of São Paulo/WHO Collaborating Centre for Nursing Research Development. Ribeirão Preto, SP, Brazil. email@example.com
IIINurse. PhD. Professor of the Maternal-Child and Public Health Nursing Department at Ribeirão Preto College of Nursing at University of São Paulo/WHO Collaborating Centre for Nursing Research Development. Ribeirão Preto, SP, Brazil. firstname.lastname@example.org
IVNurse. Full Professor of the Maternal-Child and Public Health Nursing Department at Ribeirão Preto College of Nursing at University of São Paulo. Ribeirão Preto, SP, Brazil. email@example.com
Correspondence addressed to
Hospitalization can be a very traumatic experience for children and their family members. The purpose of this study was to explore the experience of using clown theater art in the care for hospitalized children, starting with an activity developed by undergraduate students in the healthcare area. Data were obtained by observing 20 children and 11 students, characters in the clown theater interacting in the pediatric clinic in a school hospital in the state of São Paulo. The empirical data were analyzed with the thematic content analysis, which were grouped around the following themes: artistic expressions as a form of communication, participation of the binomial child and accompanying partner, and the clown as a therapeutic resource. The results show that this experience was a concrete intervention, emphasizing the children's develop-ment process, since it opens up a space for fantasy, laughter, happiness and the appropriation of the hospital routine; it is an example of widening the diagnostic and the-rapeutic process with the incorporation of in-tervention focusing on the affective, emotional and cultural necessities of the child and the family, in the search for non-trauma-tic care.
Key words:Child, hospitalized. Play and playthings. Pediatric nursing.
La hospitalización puede ser una experiencia traumática para los niños y sus familiares. El objetivo de este estudio fue explorar la experiencia de la utilización del arte del teatro clown en el cuidado de niños hospitalizados, a partir de una actividad desarrollada por alumnos de cursos de graduación del área de la salud. Los datos fueron obteni-dos mediante la observación de 20 niños y 11 alumnos, personajes del teatro clown en interacción en la clínica pediátrica de un hospital escuela del interior del estado de San Pablo. Los datos empíricos fueron analizados según el análisis temático del contenido, los cuales fueron agrupados alrededor de
los siguientes temas: expresiones artísticas como forma de comunicación, participación del binomio niño y acompañante y el clown como recurso terapéutico. Los resultados indicaron que esta experiencia se constituyó en una intervención concreta que valoriza el proceso de desarrollo infantil, ya que abre es-pacio para la fantasía, la risa, la alegría y la apropiación de lo cotidiano en el hospital; además es un ejemplo de ampliación del proceso diagnóstico y terapéutico con la incorporación de intervenciones que privilegian las necesidades afectivas, emocionales y culturales del niño y su familia, en la busca del cuidado sin traumas.
Descriptores: Niño hospitalizado. Juego e implementos de juego. Enfermería pediátrica.
INTRODUCING THE THEME
Nowadays, healthcare for hospitalized children has conferred significant importance to complementary therapies, the conventional diagnostic and therapeutic processes, with the purpose of privileging the affective, emotional, social and cultural necessities of the child in the search for non-traumatic care, defined as providing therapeutic care with interventions that eliminate or minimize psychological and physical discomfort undergone by the children and their relatives(1).
Some strategies can be implemented in order to minimize the aggravations that come with hospitalization, such as the constant presence of a family member with the child; precise information about the disease and treatment; respect for the evolutive stages and milestones of child development; offering a more comfortable environment, where the child can feel motivated and encouraged to play more actively(2-3).
Playing is quintessential in the life of the children in order to grow up and develop harmonically. When placed into a hospitalization context, where life routine is modified and changed because of the diseases, playing arises as a possibility of organizing such activities, being a fundamental way to comprehend the moment they are going through. The act of playing can help the child to enjoy the available resources in the context of hospitalization to elaborate the new situation(4).
The therapeutic value of the toy is evident, because it helps the child in the process of adapting to hospitalization. It allows for relieving fear, anger, frustration and anxiety; it facilitates communication between the child and the healthcare team; it stimulates the child's physical, psychological, social and moral development; it improves psychomotor skills and favors their physical balance so as to preserve and restore their organic integrity(1,4-6).
Playing is a serious activity. Contrary to what many think, it does not mean simply passing the time. The act of playing must consist of stimulating, fun, creative and constructive activities. At the hospital, playing makes the environment seem less traumatic and happier, which contributes for the recovery of the children(6) by providing them with moments of mental hygiene, space to express feelings caused by the disease and hospitalization and maintenance of a stable relationship between child, family(7-9) and healthcare team.
According to the flexnerian medicine standards, everything that can be measured, objective and controlled by experiments is considered scientific, while emotions and subjectivity are refuted. With technologic advances, the healthcare professionals, having all the hospital technology apparatus are prepared to treat diseases; in this process, it is up to the patient to apply, accept and agree with the treatment. Other authors(1,4,6), with whom we agree, advocate the necessity of changing the focus, i.e., looking at the sick children and adolescents instead of the disease. In this perspective, art, fun, leisure and toys also become important. Healthcare institutions all over the world have already recognized the social and therapeutic value of art applied to medicine, and there is a growing tendency of including it among hospital activities. Several forms of artistic expressions have been developed in the hospital, from those considered classic, such as theater, painting, drawing, miming, literature, up to the clown theater, one of the most recent.
The Clown in the therapeutic process
In 1986, Michael Christensen, director of the Big Apple Circus of New York was invited to participate of the Heart Day celebrations at Columbia Presbyterian Babies Hospital, when he decided to satirize the medical and hospital routines using the clown theater. The results surprised everyone, because the children who were depressed and apathetic took active part in the proposed activities. After other visits, the hospital decided to invest in the continuity of the activity, with the Clown Care Unit(7) being created.
In 1998, Wellington Nogueira, a Brazilian actor living in New York at the time became a member of the Clown Care Unit troupe, and, upon his return to Brazil in 1991, created a program similar to the Clown Care Unit by Big Apple Circus, starting its activities at Hospital e Maternidade Nossa Senhora de Lourdes, in São Paulo. The purpose of the Brazilian project, christened Doutores da Alegria, was to use the art of Clown Theater to evaluate the necessity of hospitalized children and make magic, tricks and juggling available to them. As such, it would provide children with more control about their bodies and their disease, which is totally taken away from them when they fall ill and are hospitalized. It would also favor a more positive and active stand in relation to their disease and recovery. Humor is an essential resource in order to overcome the traumas inherent to the processes of disease and hospitalization, and also to restore happiness, part of the life of the child(8).
Results of the Doutores da Alegria project were analyzed in a master's thesis(7), and the noticeable change in the behavior of children was pointed as the most remarkable result: children who were lethargic became more active; the quiet ones became more communicative and to complain less about pain, and even started to eat better and to better accept the medication, exams and hospitalization itself. Overall, the image of hospitalization became less hostile, with direct reflexes in the acceleration of recovery and cure. For the healthcare team, routine stress was reduced, and this made the work easier, improving the integration among the professionals.
In 1995, a group of students of the Pediatric Nursing course, taught in the 7th semester of the undergraduate Nursing course at Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo showed interest in developing an activity with hospitalized children and adolescents, based on the original proposal by Doutores da Alegria.
Initially, a workshop named Healthcare for children: hospital humanization through art, with the objective of allowing the participants (undergraduate and graduate students, pediatric nurses and teachers of the Pediatric and Neonatal Nursing course) to experience hospital humanization through reports from the field, complemented by group dynamics with sensitivization activities. This workshop was coordinated by the head of the Doutores da Alegria group, along with other actors, members of the troupe(6).
Adding the knowledge of the Psychology and Pediatric Nursing to this experience, a group named Companhia do Riso (Laugh Company) was created, with the purpose of retrieving the laughter in hospitalized children and adolescents, their relatives and the healthcare team, through activities such as: music, magical tricks, improvisation, dancing, drama, children's games and songs, all supported on clown theater techniques. Each clown has their own identity and style, i.e., their own trademarks: a red nose, characteristic equipment of the hospital environment (colorful stethoscopes, large briefcases in loud colors), guitars, tambourines and whistles. Therefore, Companhia do Riso, with their clown characters, became a part of the infirmaries specialized in children and adolescents in a school hospital in the state of São Paulo, twice a week.
The objective of this study was to explore the experience of using clown theater art to care for hospitalized children, with activities developed by undergraduate students of the healthcare area (Nursing, Medicine, Medical Information Technology, Pharmacy and Biochemistry).
We chose the qualitative approach, whose basis is the knowledge about the individuals by describing the human experience, as it is experienced by their own authors(10). As such, the research cannot occur within a period defined artificially by the researcher. It demands observation of everyday situations in real time(11).
According to the legislation regulating research with human beings, the research protocol was submitted to the Review Board of the institution where the field study was executed. The research was approved and the study was performed.
Twenty children admitted in the pediatric clinic of a school hospital in the state of São Paulo participated in this research, plus the 11 members of Companhia do Riso, consisting of students from course of the healthcare area (Nursing, Medicine, Medical Information Technology, Pharmacy and Biochemistry). The nuclear technique to interact with the researched subjects was participative observation(10), which made it possible to describe and locate unique and everyday facts so that chains of meanings could be built. This technique also allowed for monitoring and registering the movements, actions and discourses(12) of children, relatives, students and healthcare teams, as well as the relationships that were established in the time and space focused.
In order to meet the proposed objectives, some guidelines were established for the observation, i.e., the observation unit was directed to the interaction between children hospitalized at the Pediatric Clinic and the members of Companhia do Riso. At the time, we observed the type of activity developed; the degree of participation of the child and how the interaction occurred; if the mother needed to provide encouragement or the participation of other people. Each observation lasted 20 minutes on average.
Data collection occurred in the second semester of 2005, two days a week, by a student in a scientific initiation program that had been trained for this procedure. Initially, the study objectives were presented to the mothers or guardians of the children, and, with the agreement of the children themselves in participating in the research, the adults were asked to sign the term of consent. The same procedure was used to obtain the consent of the students involved in the research.
The data collection process was supervised every week, insisting on rigorous systematization. Initially, the operational stage occurred with the registry of the observations, organized in two parts: descriptive and reflexive. In the first, everything that happened in the field was registered in detail, i.e., the description of the participants, the reconstruction of the dialogues, the description of the locales, events and attitudes of the participants. The reflexive part of the notes included comments by the observed regarding feelings and doubts. In situations where it was impossible to perform simultaneous recordings, these were done as close as possible of the moment of observation, due to the possibility of memory failure in cases of long delays until the events can be registered. The observational steps were: 1) descriptive observation, whose function is to provide the researcher with guidance to develop research issues and concrete views; 2) focal observation, where the perspective progressively restricts processes that are essential to the research topic; 3) selective observation, which happens at the end of data collection and is concentrated in finding more evidence for the types of practices found in the second step(12).
The names of the children were replaced by letters in alphabetic sequence in order to guarantee their anonymity. The members of Companhia do Riso are identified with their fantasy nicknames. Also, for purposes of identification, we used the letter O (as in Observation) followed by a number representing the day when observation was performed.
The empirical material was typed and organized in individual files, with the analysis having followed the steps established by the content analysis technique: pre-analysis, analysis of the expressed and latent senses, elaboration of the themes and final analysis(12). Data were grouped around three themes: artistic expressions as forms of communication, participation of the child-and-companion binomial and the clown as a therapeutic resource.
Artistic expressions as a form of communication
In this item, we present the artistic expressions used in the interaction between the members of Companhia do Riso and the child who took part in the study: music, drama, children's literature and magic.
Music, the main expression used, was usually followed by musical instruments (guitar, flute and tambourine), gestures and representations, and it was the starting point for interaction in almost every visit, since Companhia do Riso would announce: We're coming!! For instance, the situation described below:
The child observed the clown girls
a() singingWho's knocking on the door. Then they hide, to reappear soon with a large smile (O.8, H).
The clown girls are at the infirmary's door, singing Who's knocking on the door. The child watches the clown girls coming in with a smile. (O.10, J).
We observed that music is a stimulus for the child to move, since many songs include gestures and body movements:
[...] the mother, smiling, says She likes that song about the Thumbs and sings along with the group. The child starts smiling and moving her fingers (O.11, A).
[...] the child looks at the movements of the clown girl's hands attentively and moves his arms while singing the song Mrs. Spider (O.3, C).
When the child has some type of physical limitation that prevents their participation in the activity, the group makes an effort to include them, but they respect said limitations, as described below:
It is the House song [suggesting movements of bodies crouching and standing up]; the child follows and repeats the gestures, always observing the movements of the clown girls and the other children. When it is time to crouch, she does it; when it is time to jump, she sits down. Even when the mother tells her to go back to the activity, she says no [...] [she has a thoracic drain] (O.12, M).
Some of the songs were composed by the students themselves, with specific purposes, such as encouraging the children to change their habits, to eat correctly or to satirize certain hospital procedures and routines.
Another strategy adopted was reading children's tales, often the product of the children's own imagination, improvised according to each specific moment. They were told to either distract the children or attract their attention:
Pipoca says she will tell the story of the ants (runs her fingers on the child's leg, tickling). The child laughs [...] (O.16, Q).
The child cries because her mother is not around, having needed to be absent for some time to deal with private issues [this is what the child said]. The student approaches the child and asks why she is crying. The child answers that she wants her mother with her, but she had to leave and is taking too long to come back. The student asks what she can do to help the child wait for her mother, and the child asks her to tell a story. Fraidei sits beside the child and starts to tell a story about a mother who had to work to make money and provide for her family. At the end, the child says that the mother in the story spent more time away from her children than her own mother (O.12, B).
This experience allowed the student to establish a differentiated form of communication with the child, since logical and rational arguments may not be the best source of information.
Magic tricks were also another resource used to encourage the children to interact and participate in the games. Children at ages 4 or 5 (or older) respond better to this type of activity, given their stage of development, according to the following observation:
Jubinha says: I'll do some magic! And the child says that she can do magic, too. Jubinha starts by closing her eyes, bobbles her head and moves her fingers over the playing cards [everybody is concentrating]. She asks the child to blow on the cards [everybody concentrates again] The child laughs heartily, when she sees the circles [in the card] changing colors [...] Later, the child tries to repeat the magic trick with his mother (O.15, P).
Pipoca and Jubinha do the changing color card trick and the child laughs and helps with the concentration, blowing on the card and moving her fingers [...] Pimentinha helps out giving advice, the child observes and follows all the rules. After Pipoca removes the card, she tries to mislead the child by saying that the card chosen is not the one she chose before. The child requests the trick to be repeated twice more, and, in the last time, since she cannot guess it, she wants to know how it is done (O.14, O).
Participation of the child and companion
In this topic, we address the level of participation of the child and her accompanying partner in the activities developed by Companhia do Riso, and we could also verify that the presence of a companion within the hospital environment eased the communication between the child and the students of Companhia do Riso; Often, the mother was this companion. In certain situations, the companion was the one who would bring the child to the students of Companhia do Riso, helping her to interact and participate in the games actively. For the mothers, the recreational activity is a strategy that distracts their children and minimizes the stress in the hospitalization processes(4), such as:
Mother and daughter come to the invirmary's door, both smiling at the sound of the Xópim Bom song [a parody of the hospital]. At the end of the song, the clown girls ask where everyone is, and the mother answers, smiling: at Xópim, asking her daughter if this answer is right (O.1, A).
The clown girls enter and ask what games the children want to play. Since the children do not respond, one of the mothers says that they want to sing, and calls the children of the infirmary to participate. When they start to sing "Alecrim" (a children's song), the mother tells her daughter to clap her hands along with the music, and all the children in the infirmary clap their hands to the rhythm of the song (O.7, G).
When the children established a previous contact with Companhia do Riso, both their participation and their companion were higher, according to the observations below:
The mother says that her son is rather shy and remains quiet during the games, but that he loves the visits of Companhia do Riso. He even asked her to help him wear the Corinthians jersey so that the clown girls could see it [...] (O.5, E).
The mother says that her son really likes the clown girls and that he asked if they would be coming today. She says yes and asks if he remembers any of the clown girls. He nods and says that he remembers one with a big yellowish hat who plays the guitar (O.15, P).
The individual who experiences a serious disease needs to be in contact with something that is opposite to it(7,13-14) and this can be one of the justifications for the presence of Companhia do Riso in the hospital environment, as observed in the excerpts below:
The mother says: It is so good that they came and sang for him, and the songs really soothe him! Going back to the infirmary, I heard other mothers saying that the songs soothed even them, as well (O.2, B).
The mother says that the best moment in the hospital is when the clown girls arrive, because there is always an atmosphere of sadness until they come. When they arrive the atmosphere changes, but when they leave, the atmosphere becomes sad again (O.12, M).
Some of the children come to meet the clown girls as soon as they hear the noise of the troupe. For example:
When one of the clown girls says we're going there, the child says: I'm coming, too! And runs to the room (O.15, P).
The clown as a therapeutic resource
As a therapeutic resource, the clown opens differentiated channels of communication, becoming an access that allows the children to manifest their fears, pain, grief and limitations.
The participation of the children in the activities of Companhia do Riso (games, drama and others) can change the focus of the hospitalization routine. In the following report, we can observe the role reversal, when the child finds her clown in a doctor-and-patient game, when she plays the dominating role and the clown girls have the submissive role. During the interaction, the child demonstrates knowledge about her disease, the medication in use, the hospital routines and even stressful situations, such as notifying the diagnosis of a grave disease, such as a tumor, for example. Another characteristic that is present in this observation is that the child becomes the center of attention. Everyone is submissive to her, to her orders, conclusions and decisions, as mentioned in the following report:
The clown girls enter the infirmary and the child is standing by her mother with a pink plastic stethoscope around her neck. She says: today, I'm the docta. Fraidei insists she has a bellyache and the child says, let me examine it! The puts the stethoscope to Fraidei's stomach and exclaims: Dear God, I'll have to order some exams Fraidei, with a grieving voice, says: If I'll have to undress, I'm not doing it! Firmly, the child says: Do you want to be cured or not? The exams are due on Thursday, only. The patient agrees and the docta calls up the next patient. Flaflu, pointing at her knee, says: it hurts in here! And the child says: I'll examine your knee, where is it? Flaflu says: I don't know! The child, very determinedly, says: Your problem has no cure, it's hereditary! [the child has cystic fibrosis]. Everybody laughs! The child calls out: next! Xeléia sits down on the chair while the docta asks her name and comes closer. Xeléia says it hurts and cowers, not allowing the child to examine her. The docta insists and puts the stethoscope to Xeléia's stomach. Child says: there! You've got something rare, which everybody has. You can't go to the bathroom! Xeléia cries: what can I do? Child says: go to the bathroom! Everybody laughs. The child, with a serious tone, says: I have to talk to one of your in private. She tells Fraidei that Xeléia has a tomor [tumor] and she'll need an operation, but she is not supposed to know it. Fofolete also says that her body hurts all over. The docta tells Fofolete to sit on the chair and, after the examination, writes a note with the name of the medication that she will have to take: Propovit [Protovit] 29 drops, at 3, 2, 6, 8 and midnight, and later calls out: next! A nursing assistant watches the consultations with a smile (O.4, D).
Literature(1,6-7) showed evidence of the superiority of drama when compared to verbal communication, especially in dealing with preschoolers and schoolchildren. Therefore, the proposal of Companhia do Riso, as mentioned before, is to use techniques of the clown theater with the goal of promoting and encouraging the laughter and imagination of the children during the hospitalization process. It is also worth noting that current hospital functions must be reviewed, since it is not only a place of pain and suffering.
We observed that praising is a strategy that improves self-esteem and self-confidence in the child. As such, it must also be used in the hospital. For example:
Flaflu and Xeléia approach the child and say that her hair is beautiful. That even in the hospital she can take care of her hair. The child smiles at the clownish praise (O.9, I).
Pipoca says: you have such a cute smile [...] you should smile more often! You can cry when you are hurt or afraid, but remember to smile more often [...] And the child smiles again (O.1, N3)
This observation leads us to reflect about the benefits of joy, humor and laughter in our lives. These manifestations make us human(7). In the hospital context, the smile resulting from the interaction between the child and the clown theater art reveals that, somehow, the child conquered her fear and difficulties to share an attitude of life, a possibility that is also extended towards her relatives and the healthcare team.
The themes presented in the results are consequences of the third step of the data collection technique: selective observation. The purpose of this technique was to meet the objectives of the study, which were to demonstrate aspects of the interaction between clown theater characters and hospitalized children.
Advances in medical practice are unquestionable, especially in the past three decades, but this medicine cannot answer a number of issues involving falling ill and hospitalization(4). By trying to transform the hospital into a therapeutic space, the medicine of the 20th century transformed it into a biologicist entity, with the production of care based on specialized and highly expensive technologies. In the hospital, the established rules of discipline, efficiency and hierarchy produce routines that usually allot little space for the users to express their uniqueness and autonomy(15).
In the case of children and adolescents, the daily activities are programmed around the diseases. For example, the simplest routines such as hygiene, dieting, sleeping, resting, going to school and playing are changed, as well as the schedules. Regarding sleep and dieting, the first may be interrupted because of the procedures, and food can be restricted or even suspended. In such conditions, child may see the hospital as a place associated with pain, suffering, punishment and isolation(1-2).
The production of care focused on the humanization requires quality service, social participation of the user, improvements in the relationship between users and professionals and respect to the uniqueness and the rights of each user. A hospital that complies with the philosophy of humanization contemplates, in its physical, technological, administrative and human structures, the respect and valuation of the human being, either a patient, a relative or a healthcare professional. The observance of these requirements can guarantee conditions for quality service and respect to dignity(16).
In the case of pediatric care, the promotion of strategies that contemplate the necessities of the child, it is worth noting the basic activity of childhood - playing. In our country, the 9th article of the Declaration of Rights of Hospitalized Children and Adolescents deals with the right to enjoying some form of recreation(17). However, the reality of a large share of the Brazilian hospital institutions has not allowed them to pursue the determinations of the aforementioned declaration.
The importance of the clown in the care for the hospitalized child was noted in an article in the Lancet magazine, which describes a few interactions between clowns and children, and shows how they can help the children cope with the disease and the hospitalization process. They help the children to find themselves and become proprietors of the hospital environment, as well as how to cope with sounds and silence; how to preserve their intimacy; how to live with the medical theories and their own fantasies; how to facilitate the children's experiences with their own bodies and emotions, and how to transform the hospital environment and collaborate with the healthcare team(9).
The origins of the clown, a humanizing element in the relationships, are rooted in purity and naïveté. The clown provides the pleasure of the laughter to the patient, broadens his perspective of life and shows him other possibilities in the process of cure. When the child and the adolescent laugh, they show that their position as patients are transferred to that of agents of their own happiness, turning their body of pain into a body of laughter(7).
Nowadays, pediatric nurses have asked themselves whether the clinical aspects by themselves are enough to perform their activities, considering that the humanistic and artistic elements could be a part of education, and consequently, of the nursing practice. In this perspective, nursing care cannot be developed only by knowing physical and social sciences, neglecting arts and humanites(18). In this sense, arts and philosophy are fundamental to develop integral and individualized care, as proposed by Companhia do Riso, since they allow one to reach broader and more precise knowledge of the human reality, the individual and collective world.
In the specific case of music, its usage as a therapeutic resource has been a part of the whole history of medicine in each civilization and age. As an example, there are biblical reports that, around 1000 BC, David played the harp to soothe and ease King Saul from evil spirits. Currently, studies(13,19) point to evidence that music can be employed as another instrument to treat several diseases, especially when it is necessary to establish strategies to relieve pain.
When children are hospitalized, they can manifest protests, fear, apathy, escapism, feelings of guilt and sadness(1,4), and, when they experience different and painful routines due to invasive procedures, they become concerned about their physical integrity, especially with the possibility of mutilation. Recent research(13,19) notes that music can reduce stress, anxiety and distressing situations, such as hospitalization, as well as relieving pain and improving the quality of sleep, being therefore a valuable method of distraction. A randomized study(19) including 40 children aged 5 to 12 years, hospitalized for small surgeries in an Italian hospital, demonstrated that the presence of the clown and the parents, during the anesthetic induction, was an effective intervention to reduce anxiety of both children and parents.
Therapeutic reading, another resource used to communicate with the hospitalized children, makes a more intuitive relationship with the children possible, since it facilitates the comprehension of non-verbal concepts. Therefore, they must take advantage of literature, because, through the fables and fantastic tales, accessible to their comprehension, they can soothe strong emotions such as pain, fear, anger and suffering.
Participative observation does not apprehend the universe of the physical and social environment; it is restricted to particular case studies instead of population samples. Its results, therefore, must be confronted with literature for the apprehension of whatever is comparable with the knowledge produced in this area and the produced knowledge that is applicable to the specific case.
Advances in child healthcare do not eliminate the necessity of hospitalization in certain cases, and, when it occurs, the child may be exposed to risks. If a child feels playful and happy, her stay in the hospital becomes easier, and her process of development will be favored as well.
Interacting with the hospitalized child, through the clown theater arts can be improved with the participation of parents or caregivers and the healthcare team itself. Bringing the healthy side of the children to light, as well as that of their parents or caregivers, contributes to resize the working process with the composition of technical and ludic aspects.
The hospital is not simply a place of pain and suffering. There is always room to be used for the development of ludic, pedagogic and recreational activities, as hospitalization cannot interrupt child development. Even if the clown is not present all the time, the professionals may become therapeutic by using other types of artistic expression, such mediation of children's and adolescent stories, music, drama, appropriate hospital ecology and toys, among others. As such, artistic expressions as forms of communication, participation of the child-and-companion binomial, and the clown as a therapeutic resource reveal the possibilities of using the clown theater as a therapeutic modality in the complex hospital care.
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Publication in this collection
09 Apr 2009
Date of issue
16 Apr 2008
29 Aug 2007