So I observed Lory and Patrick at the Hôpital Jean-Verdier in Bondy. It is a teaching hospital that serves a very diverse and socio-economically deprived community in the North of Paris. That is to say that most of the families that the clowns see here are poor, and many don't speak French as a first language.

The clowns here take referrals from the medical staff - usually the Nurse in Charge - before changing into costume. I was struck how on each ward, the Nurse arrived without any prompting. It was clearly a regular part of their working week that they were expecting and gave time to.

The referral process was pretty full on - one child had been kidnapped by her father and taken abroad, only to be sent back to Paris covered in bruises and cigarette burns. Another boy was a suicide risk - age 9. Lory said that they are always relieved to leave at the end of the day, but that she loves to work here because of the relationships with the staff and the hospital, and the effect the clowns can have. As a teaching hospital it is very popular with medical interns, as they are all looked after well, and it is home to a huge amount of medical expertise, but it is clearly under-resourced in some respects. When I looked around me on the wards, it was clear to see how the clowns would have a positive impact.

And boy did they! Watching these two on the floor was a masterclass! Lory's physicality, clarity, use of Melodrama & sensitivity was totally delightful. Seamlessly adapting her level of play to suit each situation. A brilliant clown through and through, from the tips of her fingertips to the tips of her toes. Patrick totally embodied the pleasure to be there, always excited to see who was in the next room, and never wanting to leave once he was there! Their status switched throughout the day, but was always clear (although for me their play worked best with Tata Jeep as Boss Clown). I was transfixed. And despite really trying to be invisible all day, guffawed out loud on several occasions. They have both been working for the company for many, many years, and their experience shows. As a clown baby, I have a lot to learn from these 'dinosaurs' as Caroline calls them (and herself!) lovingly.

One of the very last visits of the day is especially worth recounting (although many were memorable). For reasons my french didn't stretch to understand, Broccoli ended up in 'clown jail' – trapped inside an unused babies cot. Tata Jeep was totally unwilling to help him out, pushing him out from this boys room and into the corridor, leaving him to his own devices, playing indirectly so that another boy stuck in his room with chicken pox could see. After a few minutes, the first boy came along from his room, quite serious and without a fuss, and released him. Broccoli exploded into celebration, Tata Jeep hailed the boy a hero, and he walked off down the corridor with a smile on his face. 

When we were all back in the changing room, chatting about the visit, we all remembered that this was the boy who was on the ward because he was a suicide risk. And what is more, his dad was in jail. If the clowns had remembered this detail when they were on the floor, almost certainly wouldn't have done a whole clown jail routine. If they hadn't been told at the start of the day, they might never have had the 'idea' to do it. Either way, in my mind, it was great that they did. The boy walked back to his room a hero, and about a foot taller.

The Le Rire Medécin team comprises of over 100 clowns, who visit hospitals across Paris, as well as in Nantes, Angers, Orléans, Tours, Nancy and Marseille (46 services in total). They visit every unit (with a few exceptions) twice a week. The same wards twice a week. Apparently, Caroline doesn't really consider it a 'programme' unless this is the case.  I have to agree that the difference in relations on the units we visit with more regularity is huge. Just the simple fact of being on the ward that often would have a huge impact on our integration on the wards.

As at ONV, the clowns give 2 months notice for 2 months of work. Continuity of partnerships and hospitals is ideal, but not always possible as many of the clowns are involved with other activities outside of the organisation. And it being France, as artists they are well supported by the state on the days they are not employed by Le Rire Medécin.

They can also put 'Clown' as their profession on their I.D cards and no-one bats an eyelid. Oh France!

They also run a hospital clown school. It is not a direct route into work with the company, but does totally prepare individuals to take the work out to hospitals on their own if they so wish. Le Rire Medécin do take on a percentage of new recruits from the course, but it's main focus is to maintain a high artistic quality of hospital clowning in France in general. It is a full time course, 19 weeks long, 665 hours of training in total...

The clowns on the team meet once a month for training and a catch-up, and have coaches who support them artistically. They don't have a formal emotional hygiene session, but instead, are each allocated a 'guardian angel' (another experienced clown on the team who wants to take on this role) who they meet with twice a year, and who is available to them whenever they need to talk about the emotional content of the work. 

The whole operation feels huge and I have to keep reminding myself how small Scotland is - that in many ways we are not comparing like with like. Paris alone has 21 services and 48 clowns working in them.

In my 2 days in Paris, I got to see 2 of them, Le Hôpital jean-Verdier and Hôpital Trousseau and 4 wonderful clowns: Lory Leshin is an extremely experienced clown, has worked with the company for years, teaches, directs, and is co-creator of the companies coaching programme (more on this later). Patrick Dordoigne has also been with the company for many years, and outside of this work is Artistic Director of Adhok street theatre company. Selena McMahon is the President of Clowns without Borders USA, and Marie-Elisabeth Cornet used to perform with Cirque du Soleil (and trained at the École Philippe Gualier with Magdalena all those years ago!) Paris is at the centre of the explosion of Theatre Clowning across Europe, and I can't help but be impressed by the breadth of experience Le Rire Medécin has at it's fingertips.

First up - I observed Lory and Patrick or Tata Jeep & Broccoli at Le Hôpital jean-Verdier in Bondy.  But now I have to get on a plane to Barcelona, so more on that tomorrow!

For starters, Caroline Simonds, Founder of Le Rire Médecin, Artistic Director and Artist met me for lunch on Sunday when she probably had a million and one better things to do. Workaholic springs to mind, but there is absolutely no escaping that this woman is extraordinary and inspiring and passionate. When I feel like I don't have enough hours in my day, I will think of her, and find some more!

Over lunch, she told me about how Le Rire Médecin came to be 26 years ago - she worked in New York with Michael Christensen at the Big Apple Circus Clown Care Programme for 3 years, (after having worked in as a street performer for 10 years before that) and decided to move back to Paris and see if she could make it fly there. And it did. Almost immediately they were up and running in three hospitals. (her version was much more entertaining, obviously!)

She talked with love about the clowns in the company and the ones I was off to observe, and with much pride in the artistic quality of the work, and the artistic support that her artists are entitled to. This, she says, is something she has had to fight for, tooth and nail, in a financial climate that is keen to make savings wherever it can, and commodify us as artists. Since she works on the floor 2 days a week, she is still totally connected to the work, the artists and the hospitals they serve. Trés cool. Trés, trés cool.

When I heard about O.N.V's big research project I was envious. The serious clown in me would love to have scientific validation of the work we do in Scotland. Of course, the assumption being that any study we did would prove that we had a hugely positive impact, and not the opposite...

I find myself caught between thinking, 'if i know the work has a positive effect, and the children, parents and healthcare staff that see us do, then why pay for a research paper to prove it?' and 'Academic research will give scientific weight to the work we do, contribute to the way people see clowning in hospital as a profession, and have a positive impact on relations with healthcare staff'.

When Beatiz Quintella and Susana Ribeiro started their research project in 2009, their mission was to increase knowledge of the work, and to be able to spread that knowledge to people who don't witness the effect of the work and to have scientific approval. They designed a research project with academics on board from the start, and with Doutores de Alegria as consultants (Mogana Massetti has been conducting academic research into their work in Hospitals for years). They were clear that they wouldn't interfere with the artistic programme in any way - no manipulating partnerships, for example. It was important that the research was a real reflection of the work.

I spoke to Susana, whose job it is to take care of research at O.N.V about the project.

The idea was to start working in a new hospital in Braga, financed by A Brazil/Portugal Social Exchange Fund. What started as a 3 year research project in one hospital, grew into a research project that spans all ONV's hospitals, includes 6 different studies and has taken 6 years.
Susana identifies one of the main reasons for this success is their good partnerships. With Morgana Massetti in Brazil, with the academics in Portugal, who really took care to understand clowning and the work they were researching, and the  Centro de Investigação em Educação da Universidade do Minho and the  Instituto Universitário de Lisboa (Cis-IUL).

The research they have undertaken is pretty comprehensive:

• MA degree concerning the expectations of healthcare professionals before the Clowndoctors started work in Braga
• MA Degree two and a half years later to asses whether the clowndoctors reached those expectations
• Phd that focussed on the actual work in Braga and how the children responded to the Clowndoctors.  
• Phd in oncology to look at the effect of clowning in this specific context. 
• Phd looking into the perceptions of healthcare staff of effect of the Clowndoctors on children, parents and themselves. This was done in collaboration with Morgana Masetti in Brazil, who has done similar studies with Doutores de Alegria. This study took in 10 hospitals and gained more than 300 responses.
• MA degree studying the perspective of the clowns –their difficulties, necessities and worries in relation to the work. This study is nearing completion now.

All of this, bar one PHD (where the funding was raised by the academic) has been funded by this international exchange fund.

The priority with the funding was to get the information out there in an open and accessible way. O.N.V published a book ('Rir é o Melhor Remédio?') with their findings, in both English and Portuguese, that is easily digestible to a non-academic. They distributed this to all of the units they work in, giving copies to staff after the presented their findings. They have also presented the data and distributed the book at the national paediatrics conference.

In the near future, they plan on publishing in scientific journals, to reach the scientific and medical community.

They are also keen to see if the data highlights any areas where O.N.V could improve,  but this requires a deeper and more specific look at the results.

As far as fundraising goes, it seems that at the very least, it is a good advert for the job - O.N.V are able to communicate serious content about the Clowndoctors, which helps people to see them as professionals. In fact, Susana said she sees that the biggest contribution of this research is that public and donors see this as an important job. It helps a lot to dispel the myth that anyone can do it. The results reflect the quality of the work, the training, skill and expertise that goes into it.

It has clearly taken a huge amount of work and resources for O.N.V to get this far. In an ideal world, we would all have the opportunity to gather this kind of data - not only as a way of selling ourselves and getting stakeholders to take us seriously, but to really see what works and how. What I was most excited by is to hear that as part of the data collection, O.N.V have huge amounts of film footage of the work. As an artist, that is like gold dust! So much learning potential!

I didn't bring my book out here with me, but will share some findings from it when I get home. And, of course, you can buy a copy for yourself!

I have to just put a caveat at the beginning of this post that I have taken the images below from google searches, and while I think each image corresponds with the campaigns I mention, they might not. But i reckon you'll get the gist...

TV Spots too:

Endorsement from young celebrities who use Social Media as second nature will also be doing a lot to raise awareness with young folk about the work, and I imagine that these endorsements have had a huge impact on ONV's Social Media following.

Magda emphasised that they do all of this with very little budget – all of the TV & radio spots, the website etc are done on a pro-bono basis. For her, this is frustrating as she is somewhat at the whim of these companies and their availability. From where I am standing, as an artist who knows absolutely nothing about these things, it seems very resourceful to even have TV spots and Radio campaigns, even if they do only air at 2am. ​

I was kind of bowled over by all of this. Just imagine if Hearts & Minds - and for that matter - other European hospital clown NGO's could use the Red Nose Day thing?! If we could have an international Red Nose Day for Hospital Clowns? 

And since that definitely isn't going to happen - what might the alternative be? 

 I think most hospital clown organisations, certainly ones affiliated with EFCHO, take relationships with hospital very seriously. We understand this as an essential part of the reach we can have, the subsequent positive impact and the sustainability of the work we do.
 
One of O.N.V's approaches is to have a full-time Hospital Relations Officer. Flávia's background is as a Producer, and her role is to, 'guarantee and promote the quality of relations with the 14 hospitals that ONV visit, so that they can serve with quality, care and dedication'.

In practice, this means that Flávia visits the hospitals she is responsible for (she shares the role with Sílvia Carvalho who takes care of the hospitals in the North) once a month, accompanying the Clowndoctors on their rounds. She checks-in with the Nurse in Charge, the Doctors, the PR manager of the hospital, the teachers on the wards, and whoever else might like to know more about the work. She has no artistic role, but also makes sure that the Clowndoctors are following good hygiene protocols, have clean and ironed costumes, and good relationships with staff. She also compiles, distributes and collects questionnaires that go to healthcare staff in each unit, to check-in on their perceptions of the work - and this ranges from how effective they feel it is, to whether they feel the clowns are too repetitive, or loud, for example. 

She fields and organises any requests for special or extra visits, such as their Christmas Choir, and on the day I was visiting, was distributing the ONV annual report, which is a summary of the work the Charity has been doing over the year.

As well as that, she is responsible for the Rota, which, if it is anything like ours, is no mean feat. She does this every 2 months, trying to ensure that each Hospital has the same pair of Clowns for 4 months at a time. At the end of the 4 months, one Clown will move on, and one will stay, so that there is some continuity with children and staff. To maintain this artistically and logistically, Artists are only allowed to swap or give away 1 shift per 2 month period. They are guaranteed 8 shifts per month.

This caught my attention. I would LOVE more continuity of partnerships. I think it is good for the children, good for hospital relations and good for us artistically. But as freelance artists, it is very difficult to commit in advance to being available, and then potentially give up theatre work that might pay more, and be creatively and professionally exciting. At the moment, at Hearts and Minds, we are asked not to make swaps, but the office is in no position to stop us if something comes up. The complexity of the rota also means that continuity of partnerships can't always be there from the start anyway.

I don't know what the solution is, but i have a hunch that more continuity would be a positive thing. We would need to really commit to it as artists though...interesting!

Flávia has been in her role for 18 months and has clearly built good relationships at the Instituto Portuguese de Oncologia. But she said it wasn't easy. It has taken time, and patience. She talks about her job a little like us artists talk about ours, 'each hospital has its own culture, way of being - you can't just use the same approach with each one - you have to learn each hospital' - just like each room and child we visit as Clowns!

I was really struck by the referral process here. The nurse and the Clowndoctors sat together for a good 15 minutes, talking through the patients. I am told that this was unusually long, but even so, I was impressed by the time and commitment the nurse gave to the handover – especially since this would be the second visit of the week.​

I found it interesting that after referrals, where they might be told that a child they know had died (this happened yesterday) or any number of other things about the children they are about to visit, the clowns pop their noses on and head off onto the ward. I realised that I rely on the process of changing into costume after referrals - warming-up, having time for information to sink in (sometimes this is just that we might have been referred to lots of teenagers or babies, and this has a baring on the artistic focus for the day) switching into Clown - before heading out onto the floor. I suppose we each get used to the rhythm of our day. The O.N.V way of doing things certainly seems to work well for them – they went on to have a lovely morning, full of giggles.

I was struck by the response and playfulness of staff on the ward. This is a special ward in a certain way, as the head Doctor (Dra Philomena) was a great friend of the founder of ONV, Beatrice. The trust in the Clowns and the work they do is highly evident. At one point, the Clowns picked up one of the Doctors, swung her to and fro and sang her a lullaby for a young girl in an isolated room. The Doctor and the girl were delighted. It must have such a positive effect on a child to see her Doctor play in this way. Equally enlightening was another point in the morning, when Dra Philomena came out of a meeting room to tell the Clowns to be quiet. It was done with total respect and playfulness. I think this is a good sign of a good relationship, where the Clowndoctors are seen as part of a team, and communication happens easily and seamlessly. I sometimes feel so aware of the high status of Doctors in hospitals at home, that the idea of interrupting a meeting by making too much noise is mortifying and to be avoided at all costs. I guess this would be the approach of most Hospital Clowns – but we know that sometimes it happens in the service of the child and the game. It was so great to see this response from Dra Philomena, rather than the resentful silence or glare that I fear we might get at home.

The Clowndoctors eat their lunch in the staff canteen in costume (noses off!). This is another way they can be visible as professionals, doing their job, having a break. At one point a nurse came over to say hello with a huge smile on her face. When she left, Fernando said he had never met her before.​

And when they and walk outside along the road to their next ward, they share a joke with the ambulance drivers as they pass by and with various Doctors and Nurses as they go to and fro. 

It was so lovely to see smiles spreading around the hospital as they went.

I was accompanied on my visit by Flávia Diab, whose full-time role is Hospital Relations. She is the link between The Artists, The Hospitals and The O.N.V office. More on that to come!

I am so happy to be here again, on the final leg of my Winston Churchill Travel Fellowship.
And I am here to visit Operacão Nariz Vermelho as part of my ongoing research into the integration of hospital clowns into healthcare units, and all the ways organisations do this well.

I am principally here to talk to ONV about:

1. their ongoing research projects, and the impact that has had on perceptions of the work for stakeholders
2. their communications strategy, which seems to be really great (over 500,000 followers on Facebook is no small feat considering how relatively few people actually see the work in action. Even my Airbnb host made a point of telling me how great she thought the work was when I said what I do! (At home the response would be more like, 'what? You are a clown for doctors?! Do you wear big shoes? Don't you scare everyone?').

But more on that later!

Yesterday I had the treat of meeting with one of the clowns on the ground, and had a wonderful chat about hospital clowning and the importance of making sure that we are looked after as artists. It felt like kind of a delicious indulgence - we are not in this work for our Egos, after all. But sometimes if is good to remember that everything – the communications, the research, the fundraising, the artistic director – is there to make sure we can keep doing what we are doing. And we need to make darned sure that we are doing it well.  (I should say also that they do a completely wonderful job, and of course, if it wasn't for them, we wouldn't be doing what we are doing at all!).

I was amazed to hear that ONV offer their clowns a 2 week workshop every year with an outside clown teacher. They also have monthly training days, and are paid to observe each other working. We talked a lot about the importance of this last one. It was a revelation to me how much watching the work of Alegria Intensiva in Buenos Aires had a positive impact on my own practice.

I worry that as competition for funding increases, as artists, we will have to carry on with less input and training. Our creativity, our strong clown practice, our strong partnerships – all of these things are also our protection in a job that puts us face to face with very vulnerable people on a regular basis. They mean our days clowning in hospitals can be, and often are, full of laughter and joy. 

But on days where the clown feels distant, or the partnership is difficult, or creativity and presence is buried under 'make something happen, do something good, be funny' that protection is diminished. You know you haven't delivered to the high artistic level possible. And it feels really awful because you are in hospital, and your audience is vulnerable and captive.

It is a difficult job, and even the most motivated and passionate hospital clown can't always find the artistic resources on their own to keep moving forward creatively, or solve a partnership conundrum.

I think things like observing one another working could have really positive impact on the quality of the work we do:​

1. Being able to see the impact of clowns in hospital from the outside is motivating. People who observe us always say such wonderful things – it would be great to see it for ourselves.
2. Practice at being a creative 'outside eye' – seeing what works well or not and giving partnerships feedback or playful provocations. This will help create or sustain a culture of artistic rigour in the hospital clown team.
3. Seeing our colleagues success and failure is immediately relatable to ourselves and our work on the floor.
4. Observations will give confidence to newer practitioners who will see that they have valid and valuable artistic input to give more experienced team members, enhancing a sense of equanimity in the team
5. Relations with healthcare staff will improve, as the observer can check-in as they go, make contact and do positive PR.

Rest assured though, that before I had any of these thoughts, the first thing I did was eat a Pastel de Nata!

More soon. More thoughts, I mean...