FOOLS RUSH IN: Exploratory Research, Change Moments and The Work of Fools for Health

ALL research is exploratory; However, some research is more exploratory than others as, rather than examining the known it takes a leap of faith, a step into the unknown. And while, not all exploratory studies reveal new information, you cannot know this until you are deep into the research itself. This article examines the murky world of exploratory research through an examination of some of the change moments and discoveries in the work of Fools for Health’s, “What’s the Value of a Smile” project.

Keywords:Exploratory Research; Clown Doctors; Humor; Healthcare Outcomes; Change Moments; Taoism; Complementary Medicine

to find the answer, you must first form the question … however, the question(s) you form, affects the answer(s) you are given. [1]

ALL research is exploratory, for exploration is the basis of all good research [2]. Research requires a starting point to test the waters of the question or idea being explored to find out more about its scope and shape. From this starting point, with good planning, one discovers nuances for further examination, and develops hypotheses and data to be examined.

However, some research is more exploratory than others. Rather than examining the known it takes a leap of faith, a step into the unknown. And while, not all exploratory studies reveal new information, you cannot know this until you are deep into the research itself. This article examines the murky world of exploratory research through an examination of some of the change moments and discoveries in the work of Fools for Health’s, what is The Value of a Smile project.

Exploratory research, as is often found in grounded theory approaches [4], is more like the young child trying to make sense of the world. For young children make the best researchers because they are unafraid of looking foolish. They form the best questions, “Why is the sky blue?”; and conduct the best critical analysis, often debunking an adult’s explanation with, “That makes no sense” or better yet, “That’s stupid!” When my daughter was five, she was walking across the university to come to see me. Her mother told her that this is where your daddy works, he’s a professor. She replied, “NO my daddy’s not a professor! He’s a clown!”. Her critical analysis was perfect for at the time, I was running Fools for Health and working in hospitals and healthcare facilities as a Clown Doctor, by the name of “Dr. Haven’t-a-Clue”.

My lifelong studies of Taoist and Buddhist thinking, began in1969 when I attended my first class in martial arts. From that moment on I began to understand that all things are connected [5,6,7]. This approach to life was enhanced when in 1982 I became part of Roy I Brown’s truly visionary multi and inter-disciplinary Rehabilitation Studies program at The University of Calgary.

This belief that all things are connected permeates my life. Starting almost 50 years ago, before it was ‘fashionable’, I started exploring multi- and interdisciplinary research, that did not fit into any convenient already developed “research box”. I developed and borrowed strategies and methodologies that crossed disciplinary boundaries and occasionally blurred the boundaries of what constituted accepted research praxis [8].

Grounded theory is an example of this, seeing the theory unfold as it is revealed from being grounded in the world around us, and then being able to shape practice with this knowledge. The research that began the work of Fools for Health illustrates the power of an exploratory journey into the abstract connections between humour, performing arts, and healthcare which produced useful findings for research, teaching, and practice across many settings.

Taoists believe that every moment that went before led to this one. And this moment will lead to all that follow. For as George Santayana suggests those who are unaware of history are destined to repeat it. [10]

I (BW) have been blessed or cursed with the mind of a child, with all that inquisitiveness about how things work? Why things are the way they are? questions which in themselves are the essence of exploratory research. All my life I have worked to identify the value of dramatic art to an individual’s personal development, especially in areas related to their overall sense of health, well-being, and quality of life. In 1990 - 1992 I conducted research into the role of humor and laughter in illness recovery and started to collect data on clowns working in hospitals around the world.

Often precipitated by a catalyst, Change Moments occur when not only is there a need to change but also a receptivity to the opportunities afforded by such change: where transformation and/ or change occurs creating a new thing, event, or way of doing [11].

The Change Moment for me occurred in 1999 at the World Symposium on Culture, Health, and the Arts at Manchester Metropolitan University [12]. Caroline Simonds and Dr. Patch Adams made back-to-back presentations about their work. I was wowed by Patch’s charismatic style, but I felt only Patch could do what he does. However, I remember thinking as I watched Caroline talk about the work of Le Riri Médecine that her work was attainable, transmittable, and more importantly that I could teach my students to do it! From the moment I saw that presentation I knew that, somehow, I had to bring Clown Doctors to Windsor, Ontario.

Based in Windsor Ontario, work on Fools for Health began in October 2000. Fools for Health was unique in several ways. The organization began as a collaboration between Windsor Regional Hospital and The University of Windsor, receiving funds from both institutions [13].

Fools for Health launched its first program in July 2001 with four Clown Doctors working on the adult in-patient rehabilitation unit at the Western Campus of Windsor Regional Hospital. Initially, Fools for Health began as a 6-week pilot/research project. The hospital did not know what exactly Clown Doctors did and if they would be able to fit into working with adults in Rehabilitation. For at this point, Clown Doctor programs were almost exclusively delivered in children’s hospitals in large urban centres.

In week four, the Hospital told Fools for Health “you cannot leave, your work here is too valuable”. In a real sense this initial exploratory pilot research had already begun to exert a profound impact on the praxis of the hospital, the hospital staff, and on the lives of patients.

Fools for Health became one of the first Clown Doctor companies to work across the lifespan, and worked with adults and seniors as much, if not more, than with children. Between 2001- 14, Fools for Health Clown Doctors worked regular shifts in various local hospitals on oncology, palliative care, complex continuing care, I.C.U., medical, surgical, and paediatric units. They also worked occasional shifts in emergency, outpatient clinics, and even operating rooms.

Shortly after its inception as a program, Fools for Health started to offer programs for seniors in long-term care (LTC) homes. In 2003, the first familial clown program began. This change from Clown Doctor to Familial Clown was precipitated by a single event. Dr. Hoppy, sensing anxiety in the residents, took off her White Coat and became simply “Hoppy”. She rightly deduced that a doctor, albeit a Clown Doctor, was appropriate in a hospital setting BUT was inappropriate and disturbing when visiting a resident in their home [13]

Another important development was Fools for Health programs began to target the whole hospital rather than a single ward or unit. Also focus switched from the patient to [include]the staff. The rationale being that this helped staff on a long shift by resetting their clock. Eventually, Fools for Health was able to deliver Clown Doctor programs at five hospitals and familial clown programs at fourteen local area retirement/long term care homes.

From its inception, Fools for Health was committed to systematic, rigorous, and continuous research on factors that influence the efficacy of, and limits to, the role and benefits of clowns working in the healthcare system and the effects of the work on the Clown Doctors and familial clowns themselves.

“What is the Value of a Smile? was a 2004-2008 SSHRC funded Investigation of the Impact of Clown Doctors on the Lives of Patients, their Families, and the Healthcare Team in Windsor Hospitals” [14,15]. It began with the simple question ‘What is the value of a Smile?” – a completely abstract notion, which had no immediate guidelines to an answer. It required exploration of this idea to discover its scope and shape both in terms of its theoretical properties but perhaps more importantly its influence on praxis

While the notion of laughter as the best medicine is an old one, experimental evidence now shows that humor and laughter can improve individuals’ emotional states, their tolerance of pain, and various physiological processes [16-19]. In the What is the Value of a Smile project, researchers studied Windsor’s Fools for Health Initiative, Canada’s first “Clown Doctor” program, to determine its impact on the well-being of hospital patients, their families, and the health care professionals that serve them.

Fools for Health always kept detailed records of its programs to track its successes as well as determining areas of possible improvement. The data from this exploratory research was carefully analysed, using quantitative and qualitative methodologies, especially grounded theory, which led to several findings that added substantive theoretical and practice insights. This type of exploration led to finding change moments that shifted the shape and direction of the work.

Analysis of the data indicated that the Clown Doctors brought about change in the patients, visitors, staff and indeed, the entire hospital or long-term care atmosphere. Some of the areas identified included:
• The power of a simple wave and a smile.
o We discovered that when Clown Doctors sat in the memorial garden and waved as people walked past the windows of the hospital walkway, they stopped, smiled, and often waved back. A clear change in their mood.
• ‘Resetting the clock’.
o When a person has been waiting for a long time, they become bored and disgruntled and often take out their frustration on the staff, especially if they have been waiting for a long time e.g., an Emergency waiting room
o The Clown Doctors helped them forget about the time they’ve been waiting and ease their stress. So, when they finally saw a doctor, it felt like they’d been waiting a lot less time, in effect shifting their perceptions of time.
• Changing moods:
o Distressed patients were seen to visibly relax during visits by the Clown Doctors, and this relaxed mood persisted even after the clowns had moved on to other areas of the facility.
• Easing procedures:
o Healthcare staff identified being able to perform medical treatments more easily such as accessing ports or giving injections when the Clown Doctors were present.
• Easing symptoms:
o Patients reported less pain and discomfort during and immediately following
Clown Doctor visits.
• Promote recovery in treatment programs
o with patients with aphasia, Clown Doctors were able to get them to vocalize by involving them in singing or telling jokes.
o In rehabilitation programs, Clown Doctors have been able to encourage patients to move affected limb(s) or complete more repetitions of a therapeutic exercise.
• Reminiscence:
o Familial Clowns help people with Dementia connect to their immediate surroundings, recognize family members, remember the past, and improve general cognitive functioning and communication skills.
• Building Community.
o Clown Doctors engage everyone in a room creating a sense of ‘Communitas’ and stimulate neighbours to speak to each other, even after the clowns leave the room.
o Targeting the staff as much as the patients increased everyone’s morale and engagement.
• Reframing community perceptions of the hospital environment:
o Clown Doctors’ ability to diffuse patient’s tension/stress, boredom, or frustration with their hospital experience, helping improve the hospital’s image in the community.
Contributions of this research to broader theory and practice were that it suggested that:
• Smiles and laughter have the capability to cross all barriers (age, gender, language, culture, illness, pain).
• No two patients/residents, healthcare team members or units are the same.
• Patients/residents, nurses and doctors are part of the community in which they live, and they’re all inter-connected.
Moreover, each hospital is a focal point of the community, especially in a small rural community.
• Clown Doctors, like “mail carriers” in a small village, interact with all members of the “village,” spreading smiles and creating community in each room, ward and throughout the hospital.
• Each facility (hospital, nursing home) should be considered a unique “living organism” and each Clown Doctor program needs to be designed to try to meet the unique properties of that facility.

Based on the belief that laughter fades, but a smile lingers, Fools for Health’s Clown Doctor’s sought not to generate laughter, but rather to deliver smiles to all they met. The findings generated by this exploratory research, over time, created a profound and tangible impact on the praxis of hospitals, staff, and on the lives of patients.

This started to be noticed. In 2007 the Canadian Council on Health Service Accreditation cited Fools for Health’s Clown Doctors and their praxis as:
• one of the major reasons a Rehabilitation program was given an “excellent” rating
• an example of “a Leading Practice”, identifying their work as a “Standard of Care”

Without exploratory research, as evidenced in the research of Fools for Health, the possibilities for practice and research discussed in this short article would not have been realized. There had to be a leap into the unknown world of the abstraction of “what is the value of a smile?” to lead to the discoveries that influenced all of those whose lives were touched by the work of Fools for Health.

None.

No conflict of interest.

1. Attributed to “Alfred North Whitehead” but probably a variation on, “To find the exact answer, one must first ask the exact question.” -- S. Tobin Webster.
2. Swedberg R (2020) Exploratory Research. In C. Elman, J. Gerring, and J. Mahoney (Eds.), The production of knowledge: Enhancing progress in social science, 17-41. Cambridge University Press.
3. Attributed to Albert Einstein.
4. Charmaz K (2014) Constructing Grounded Theory, SAGE.
5. Lao Tzu (Laozi) “Tao is both the way of nature – the fundamental principle underlying the natural world – and the way of life that human beings should follow to lead a fulfilled life in harmony with the natural world.
6. Warren B, et al. (2018) Seeking the Dragon’s Pearl: Reflections on The Benefits of Taijiquan & Qigong for University Students International Journal of Complementary and Alternative Medicine 11(2): 57-60.
7. Warren B, et al. (2019) Lovely by the Water- Reflections on the Pleasures and Benefits of Doing Qigong in Natural Surroundings. J Complement Med Alt Healthcare. 10(3): 555787.
8. Praxis can be viewed as a progression cyclical process of cognitive and physical activities namely:
   • Taking action
   • Considering the impacts of the action
   • Analysing the results by reflecting upon them
   • Altering and revising conceptions and planning following reflection
   • Implementing these plans in further actions
9. African Proverb
10. Santayana G (1905) The Life of Reason: Reason in Common Sense. New York: Scribner's, USA.
11. Warren B (1997) Change and Necessity: Creative Activity, Well-Being, and the Quality of Life for Persons with a Disability. In: Brown. R.I. (Ed.), Quality of Life for People with a Disability. Stanley Thornes, London, pp. 271-290.
12. Warren B (2000) Discovering connections between eastern and western approaches to promoting health. In: F Turner, P Senior (Eds.), A Powerful Force for Good, Manchester Metropolitan University, Manchester.
13. Warren B, Hind C (2019) Walking the memory bridge: How ‘elder clowns’ work with seniors to help improve memory and communication. Med Clin Arch: 1-4.
14. Warren B (PI) 2000-01 Developing A Pilot Clown Doctor Project at Windsor Regional Hospital, funded by University of Windsor Research Board & Windsor Regional Hospital Foundation.
15. Warren B (PI) 2004-08 What is the value of a smile? An investigation of the impact of Clown Doctors on the lives of patients, their families, and the healthcare team in Windsor hospitals. c.
16. Berk L S, Tan S A, Fry W F, Napier B J, Lee, J W, et al. (1989) Neuroendocrine and stress hormone changes during mirthful laughter. American Journal of the Medical Sciences 298(6): 390-396.  
17. Dowling J S (2002) Humour: A coping strategy for pediatric patients. Pediatric Nursing 28(2): 123-131.
18. Fry W F (1992) The physiologic effects of humour, mirth, and laughter. Journal of the American Medical Association 267(13): 1857-1858.                                                                   
19. Miller M, Mangano C, Park Y, Goel R, Plotnick G D, et al. (2006) Impact of cinematic viewing on endothelial function Heart; 92(2): 261-262.