Journal of Pediatric Nursing (2015) xx, xxxxxx

Research Paper

Effects of a ClownNurse Educational

Intervention on the Reduction of Postoperative
Anxiety and Pain Among Preschool Children and
Their Accompanying Parents in South Korea1,2
O Bok Yun RN, MS a , Shin-Jeong Kim RN, PhD b,, Dukyoo Jung RN, PhD a
a

Division of Nursing Science, College of Health Sciences, Ewha Womans University, Seoul, South Korea
Department of Nursing, Hallym University, Chuncheon, South Korea

Received 9 January 2015; revised 23 March 2015; accepted 25 March 2015

Key words:
Children;
Day surgery;
Nursing;
Preschool;
Strabismus

This study examined the effects of a clownnurse educational intervention on children undergoing
day surgery for strabismus. This was a quasi-experimental study, using a nonequivalent control group, nonsynchronized design. Fifty preschool children and their parents were invited to participate. The children in
the intervention group (n = 23) received clown therapy and subsequently reported significantly lower states
of physiological anxiety, which was evidenced by systolic blood pressure, standardized behavioral anxiety
tests, and post-surgery pain, than the control group (n = 27). In addition, the parents in the experimental
group showed a low state of physiological anxiety, evidenced by systolic blood pressure, pulse rates,
standardized behavioral anxiety tests, and state-trait anxiety. The use of preoperative clown intervention may
alleviate postoperative problems, not only for children, but also for their parents.
2015 Elsevier Inc. All rights reserved.

Background
SURGERY IS CONSIDERED a negative life event, and
it can be a very threatening experience, usually causing
distress. It could be especially traumatic for children, as
demonstrated by reports that many children experience
significant anxiety in the preoperative period (Fortier, Del
Rosario, Martin, & Kain, 2010a; Lee et al., 2013). An
estimated 4060% of children who undergo surgery exhibit
high levels of anxiety (Wright, Stewart, Finley, & BuffettJerrptt, 2006). Such high levels of anxiety prior to surgery
can cause psychological and physiological problems for the

Corresponding author: Kim, Shin-Jeong, RN, PhD.

E-mail address: ksj@hallym.ac.kr.

http://dx.doi.org/10.1016/j.pedn.2015.03.003
0882-5963/ 2015 Elsevier Inc. All rights reserved.

children that may extend beyond the immediate surgical

procedure (Jlala, French, Foxall, Hardman, & Bedforth,
2010; Lee et al., 2013).
Children are usually more vulnerable to surgery-related
stress than are people of other age groups because of the
developmental characteristics, limited cognitive capacity,
lack of self-control, greater dependence on others, fear
of pain, and limited understanding of surgery (Fincher, Shaw,
& Ramelet, 2012; Ghabeli, Moheb, & Hosseini-Nasab, 2014).
In addition, the hospital environment is characterized by
unfamiliar faces, unfamiliar routines, surgical instruments,
hospital procedures, and fear of pain; all of these are possible
sources of stress (Ghabeli et al., 2014; Yip, Middleton, Cyna,
& Carlyle, 2009).
According to Piaget's theory (1972), preschool children
(i.e., 36 years old) are in the preoperational stage of cognitive
development. They typically engage in magical thinking and,

2
therefore, cannot think logically and cannot adequately
distinguish between reality and fantasy (Lee et al., 2013).
For this age group, negative events such as surgery may lead to
preoperative anxiety. Based on previous research, younger
children tend to be more anxious and have more negative
reactions to surgery than do older children (Ahmed, Farrell,
Parrish, & Karla, 2011).
The number of same-day pediatric surgeries being
performed is increasing worldwide (Brewer, Gleditsch, Syblik,
Dietjens, & Vacik, 2006; William, Lopez, & Lee, 2007). The
introduction of pediatric day surgery brings some benefits,
including relatively short hospital stays, low predisposition to
hospital-borne infections, reduced healthcare costs, and
limited behavioral changes among the children involved
(Ghabeli et al., 2014). Despite these advantages, preoperative psychological preparation of children and their
caregivers is lacking (Ahmed et al., 2011; Jlala et al., 2010).
Nurses could provide psychological interventions aimed at
minimizing anxiety levels in the hours before surgery (Ghabeli
et al., 2014).
Parental anxiety is also a common problem during
pediatric surgery due to parental worries and fears, including
those related to the pain experienced by the child. Parental
anxiety can be quite frightening for children (Esteve,
Marquina-Aponte, & Ramrez-Maestre, 2013; Jlala et al.,
2010) and may ultimately increase children's anxiety
(Fincher et al., 2012; Fortier et al., 2010a). Helping children
and their families cope with the stress of surgery is one of the
most vital responsibilities assumed by nurses (Ghabeli et al.,
2014), and to this end, nurses could develop effective
preoperative preparation plans. To reduce the level of
preoperative anxiety in children, a number of strategies
could be employed (Koo, 2008).
Currently, humor is considered central to some of the
approaches and is the most widely used approach for reducing
fear, stress, and anxiety in the hospital context. Since the 1970s,
studies have reported that humor has positive effects on physical
and psychological health and well-being (Bennett & Lengacher,
2008). In pediatrics, the use of humor is quite prevalent, as
evidenced by the use of clowns (Golan, Tighe, Dobija, Perel, &
Keidan, 2009; Koller & Gryski, 2008; Meisel et al., 2010).
Therapeutic humor can improve patients' mental and
physical health (Ganz & Jacobs, 2014; Low et al., 2014).
This observation is linked to the assumption that humor and
patient well-being are closely related to one another (Bennett
& Lengacher, 2008). A clown doctor is a specially trained
professional artist who is a skilled and valued member of a
clinical team working in a therapeutic program within a
healthcare setting (Pendzik & Raviv, 2011). In pediatric
healthcare settings, clown doctors began to work in hospitals
in 1986, and the number of clown doctors providing services
has continued to increase (Dionigi, Flangini, & Gremigni,
2012). The provision of care to sick children by clowns is
one of the methods that can positively change the emotional
state of patients and their perceptions of the environment
during treatment (Koller & Gryski, 2008; Warren, 2008).

O.B. Yun et al.

Clowns spread happiness to children and alleviate their
suffering, thereby directly empowering recipients; clown
humor is also increasingly being recognized as beneficial for
children in hospitals (Dionigi, Saniorgi, & Flangini, 2014).
Studies on clown interventions suggest that these might
decrease distress among children and increase their cooperation during medical procedures (Bertini, Isola, Paolone, &
Curicio, 2011), helping to distract the children and create a
positive hospital atmosphere. Further, these interventions are
used in clinical settings in many countries, with the aim of
reducing anxiety among children who are undergoing surgery
(Dionigi et al., 2014; Fernandes & Arriaga, 2010; Meisel et al.,
2010; Pendzik & Raviv, 2011; Vagnoli, Caprilli, & Messeri,
2010). However, clownnurses are not currently used for
children in this manner in South Korean hospitals, and no local
research has examined the efficacy of such an intervention. For
these reasons, we examined the use of clowns as an
intervention for the prevention of preoperative anxiety
among children and its possible effects in decreasing the
development of negative problems post-surgery (Ahmed et al.,
2011; Brewer et al., 2006; Dionigi et al., 2014; Fincher et al.,
2012). Such efforts could increase knowledge regarding the
effectiveness of clown therapy as an alternative intervention
aimed at reducing surgery-related anxiety among both children
and their parents. In addition, it may accelerate attempts to use
clowns and humor in hospital settings.
Accordingly, the purpose of this study was to determine
the effects of clownnurse educational interventions during
the preoperative education process in day surgery and to
measure its effect on both children's and parents' anxiety
levels and children's post-operative pain.

Method
Design
A quasi-experimental, nonequivalent control group,
non-synchronized design was used. We examined the effects
of a preoperative clownnurse educational intervention on
the postoperative outcomes of preschool children undergoing
day surgery and those of their parents.

Setting and Participants

This study was carried out in one of the largest national
hospitals in Seoul, South Korea, which includes a children's
hospital (with 1,792 beds) with an established day surgery
unit. Participants, who were preschool children scheduled to
undergo day strabismus surgery, were recruited from a
national hospital located in Seoul, Korea. The participants
were assigned to the following two groups: (1) the
intervention group, comprising children who came into
contact with a clownnurse before entering the operating
room; and (2) the control group, comprising children who
had received routine preoperational care. Only one surgeon

Effects of a ClownNurse Educational Intervention

was involved in this study, and thus, the surgical operations
of the children in the two groups were performed by the same
ophthalmologist.
We used a time difference to minimize the risk of
contaminating the control group by sampling sequentially.
Following completion of the recruitment process for the
control group, the experimental group intervention commenced. Although the data collection in the two groups did
not take place simultaneously, no events that occurred during
the data collection process for either group posed a threat to
the study's internal validity. Following ethics approval and
provision of parental consent, children, along with their
caregivers (mostly mothers), were assigned to the control group.
Using G*Power 3.1.7 (Faul, Erdfelder, Lang, & Buchner,
2007), 23 participants were required for each group so that a
medium effect size of .50 could be achieved. A two-sample
t-test was performed at a 95% confidence interval and a
significance level of .05. In consideration of the dropout rate,
we included 30 participants in each group. During the course
of the study, seven children in the experimental group
withdrew from the study (three refused to participate further
and four were not comfortable with the appearance of the
clownnurse). Three children in the control group withdrew
(refusal). Finally, there were a total of 50 participants in the
study, with 23 in the intervention group and 27 in the control
group; thus, the sample size was acceptable.
Criteria for inclusion of children in the study were as
follows: (1) aged between 3 and 6 years, (2) not showing any
fear of clowns, and (3) undergoing strabismus day surgery.
Children were excluded if they (1) had any history of chronic
illness, were born prematurely, or had been diagnosed with
developmental delays; (2) had significant hearing or visual
impairments; (3) had previously undergone surgery or been
hospitalized; or (4) did not speak Korean.

Ethical Considerations
Ethical approval of the study was granted by the
Institutional Review Board (IRB No: 1304-123-486) of
Seoul National University General Hospital, with which one
of the researchers is affiliated; voluntary participation,
anonymity, and confidentiality were ensured throughout the
study. The children and their parents were informed that they
had the right to withdraw from the study at any time. The IRB
confirmed that there were no elements of this study that would
violate human rights, and that all the materials and processes
conformed to proper ethical research procedures.

Data Collection
Children
Physiological anxiety was measured using blood pressure
levels and pulse rates based on findings in previous research
demonstrating that anxiety levels may be influenced by
blood pressure and pulse rates (Pal, Ganesh, Karthik, Nanda,

3
& Pal, 2014). Children's blood pressure was measured using
an electronic blood pressure barometer (Model: 640-0612-02
Rev B, Welch Allyn Protocol Incompany, Oregon, USA),
which, as a medical instrument, was tested and certified by
the Canadian Standards Association International to ensure
compliance with the applicable United States and Canadian
medical safety standards. To ensure accurate measurement,
the width of the cuff was 1/2 to 2/3 inches. The cuff was
sufficiently inflated, so as to enable measurement during two
consecutive readings by skilled nurses. Measurements were
taken with the participant in a seated position after s/he had
been sitting still for approximately 10 minutes. Participants'
blood pressure levels and pulse rates were checked
consistently, using the right arm, 1 hour before and
2 hours after surgery. Inter-observer reliability was determined using a correlation coefficient, which was .92 in this
study. Blood pressure levels and pulse rates were checked
1 hour before surgery because most children undergoing day
surgery arrive at the hospital at this time, and they were
checked 2 hours after strabismus surgery because, in the
postoperative period, children start to ambulate, go on an oral
diet, and feel a moderate level of pain. This is the optimal time to
check pain, using the Faces Pain Rating Scale, as well as anxiety,
using blood pressure and pulse rate (Ahn & Paik, 2000).
Behavioral anxiety among the children was checked using
the modified Yale Preoperative Anxiety Scale (m-YPAS). The
m-YPAS is an observational behavioral checklist developed by
Kain and Mayes (1996) for the measurement of five dimensions
of state anxiety among young children. The m-YPAS has been
revised and translated for use with Korean children undergoing
surgery and consists of four categories (i.e., activity, emotional
expressivity, state of arousal, and vocalization). It contains 17
items (Oh, 2001). A score on a 2-point scale is assigned to each
category according to the child's behavior; a score of one is
assigned if the child exhibits a behavior related to a given item,
whereas no point is assigned if the child does not exhibit the
behavior. Possible scores range from 0 to 17, with higher scores
indicating greater anxiety. The inter-rater reliability of the
YPAS has been reported to range from .89 to .96 (Kain &
Mayes, 1996) and from .86 to .96 (Oh, 2001). Previous studies
have reported reliability values of .73 (Kain & Mayes, 1996)
and .79 (Oh, 2001). In the current study, a Cronbach's alpha of
0.81 was reported. The validity was tested by two nursing
faculty members and three head nurses with more than 10 years
of pediatric nursing ward experience in general hospitals.
Parents
Physiological anxiety among parents was measured using
blood pressure levels and pulse rates. Skilled nurses
measured blood pressure using an electronic blood pressure
barometer (Model: 640-0612-02 Rev B, Welch Allyn
Protocol Inc., Oregon, USA) for adults. Measurements
were taken with the parents in a seated position after each
had been sitting quietly for approximately 10 minutes. Blood
pressure and pulse were checked consistently using the right
arm 1 hour before and 2 hours after the child's surgery.

4
The reliability percentage of blood pressure levels and pulse
rates was 99.0%.
Behavioral anxiety among the parents was measured using
an anxiety behavioral response developed by Finesilver (1980)
and translated by Koo (2008) for use with Korean mothers,
whose children were undergoing cardiac surgery. It consists of
the following five items: discomfort, degree of muscle
relaxation, vocalization, communication, and activity. Each
item is scored on a three-point scale (1 = no problem, 2 =
moderate, 3 = not stable), with scores ranging from 5 to 15,
and higher scores indicating greater anxiety. A previous study
(Koo, 2008) yielded a Cronbach's alpha of .74, whereas a
value of .87 was obtained in the current study. In this study,
correlation coefficients, indicating inter-observer reliability,
ranged from .85 to .90. Koo's (2008) study provided no
evidence of validity. In the current study, however, content
validity was ascertained twice by five experts, including two
nursing faculty members and three head nurses with more
than 7 years of experience in adult nursing departments in
general hospitals.
The State-Trait Anxiety Inventory. Parents' state-trait
anxiety was measured using the State-Trait Anxiety
Inventory (STAI), which is a self-report anxiety instrument
developed by Spielberger (1972) and consists of two 20-item
subscales that measure state (situational) and trait (baseline)
anxiety among adults. In this study, the Korean version of the
STAI, translated by Kim and Shin (1978), was used. The
STAI measures a transitory anxiety state (i.e., subjective
feelings of apprehension, tension, and concern, which vary in
intensity and fluctuate according to situation). The STAI's
trait subscale measures relatively stable individual differences in anxiety proneness (i.e., differences in the tendency
to experience anxiety). Parents respond on a 4-point scale
(1 = not at all, 2 = little, 3 = moderate, 4 = very). Total
scores on the state and trait sections each range from 20 to
80, with higher scores denoting higher levels of anxiety. The
STAI has been reported as having good internal consistency,
testretest reliability, and convergent and discriminant
validity (Barnes, Harp, & Jung, 2002; Hishinuma et al.,
2000; Spielberger, 1989). Cronbach's alpha in this regard
was previously found to be .92 (Spielberger, 1972); in this
study, a value of .98 was obtained.
Children's Postoperative Pain
Children's postoperative pain was assessed through the
Faces Pain Rating Scale-revised (FPS-R) developed by
Hick, Baeyer, Spafford, Korlarr, and Goodenough (2001).
This instrument comprises a scale of six child faces, ranging
from a happy face to a grimace on both the front and back
sides. The child points to a number, from 0 to 10, to indicate
the degree of pain that s/he is experiencing, with higher
scores indicating greater pain. Pain assessment was
conducted when the child expressed willingness to
cooperate. In this study, Cronbach's alpha was 0.78. The
validity of the FPS-R was supported by strong positive
correlations between the Visual Analogue Scale (r = .92,

O.B. Yun et al.

N = 45) and the colored analogue scale (r = .84, N = 45) in
Hick et al.'s (2001) study.

Training of the Research Assistant

The first author oriented the research assistant regarding
the study processes prior to the commencement of this study.
The research assistant worked as a registered nurse for
N 5 years in a general hospital, was a doctoral candidate, and
was blinded to the children's assignment to groups. The
training lasted 10 hours2 hours daily over 5 daysand
included the measurement of variables related to this study.
The research assistant obtained 99% accuracy on the
measurement of the children's and parents' blood pressure
levels and pulse rates. The behavioral anxiety of the children
and the parents was used to determine inter-observer reliability.
Inter-observer reliability was checked by calculating Cohen's
kappa coefficient, using the Cohen and Fleiss Kappa Program
(http://www.statstpdp.com/DohenKappa_Pgm.php). The measure's inter-observer reliability exceeded .85 for both children
and parents. According to Fleiss (1981), an inter-observer
reliability index exceeding .75 is excellent, an index ranging
from .40 to .75 is fair to good, and an index below .40 is poor.
Thus, the present study's index scores were regarded as
acceptable. The study commenced after reliability was
established and following verification of the training by two
professionals. In addition, the first author observed the research
assistant periodically to ensure that measurement was performed correctly throughout the study.

The ClownNurse Educational Intervention

The intervention consisted of a set of structured activities
designed to fit the psychosocial and cognitive development
of children aged 36 years. The children in the experimental
group received the usual care, as well as the clownnurse
educational intervention, approximately 1 hour before their
surgery. The clownnurse educational intervention involved
the use of a clownnurse who worked on a one-on-one basis
with each child. The children, along with one of their parents,
were invited to participate. The children and the parents were
taken to the reception area, which is near the operating room,
where the first author was made up as a clownnurse and
provided with educational information (Figure 1).
The first author was dressed as a clownnurse and had
undergone a course on pediatric distraction in the preschool
education department. The course was aimed at facilitating an
understanding of children's behavior and application of
various approaches (e.g., play, imagination using color,
sounds, and art) to distract children from their negative
feelings. The clown make-up was primarily applied to the face
to lessen the required preparation time. The make-up included
a hat, sunglasses, and a nose cap. The colors used in this
clownnurse educational intervention were chosen on the
basis of professional advice on child art education.

Effects of a ClownNurse Educational Intervention

The suggested preferable colors for preschool children were
red, yellow, blue, light green, and pink, which give warm,
friendly feelings and promote fun. In addition, if the child
wanted his or her own clown make-up, then we created a
clown-like appearance; this took approximately 2 minutes.
Among the 23 children in the experimental group, all except
one (n = 22) wanted clown make-up.
The clownnurse provided the educational intervention to
the children and each of their chosen parents who accompanied
them. The educational contents of this intervention are
described in Table 1. The children's education was provided
through a PowerPoint slide presentation consisting of 27 slides
1 hour before surgery, taking less than 8 minutes. The content
comprised the following four topics: before surgery, going
to the operation room, after surgery, and promises to keep
after discharge. Before surgery was concerned with the
surgery site and included changing into a patient gown, getting
an IV, and the checking of vital signs. Going to the operation
room dealt with preparations for surgery, including selfvoiding, administration of sedative injections, and an explanation of anesthesia as a sleeping aid. After surgery focused
on the protection of the surgical area so as not to injure it, as
well as compliance to prevent complications. Promises to
keep after discharge included information regarding what to
do after discharge. Education for the accompanying parent was
provided during the child's surgery through a two-page
information pamphlet (A4 size), containing information that
required less than 10 minutes to review. The educational
contents were divided into the following four topics: before
surgery, after surgery, precautions at home, and questions and answers. Before surgery dealt with information
relating to the operation. After surgery contained information regarding care for the child after surgery, such as
medication, diet, exercise, operation wound care, and visits
to the outpatient department. Precautions at home explained
what to do at home and which issues require medical/parent
attention. Questions and answers dealt with issues of interest

5
related to strabismus and answers related to the disease and
the surgery.
The information provided to the children and the parents
was reviewed by an independent group of expert pediatric
acute care nurses and two anesthetic consultants; the
information package was pretested and monitored for
intervention compliance throughout the study. A pilot study
was conducted so that the feasibility of the intervention could
be determined, and so that any problems could be identified.
The children and the parents in the control group received
routine care and preparation information when the former were
admitted to the day surgery unit. All the participants received
standard preoperative information and training from the nurses
and support staff during the admission process. This standard
of care is a brief overview of the three processes: preoperative,
intraoperative, and postoperative processes.

Procedures
Figure 2 depicts the procedures undertaken in this study.
The study took place from January 3 until March 30, 2013.
Patients scheduled to undergo general anesthesia for
strabismus surgery were potential participants, depending
on the set day of surgery.
Data, including the measurement of the children's and
parents' anxiety levels and the children's postoperative pain,
were collected by one research assistant to decrease the
testing effect in the waiting room.

Data Analysis
Statistical analyses were conducted using SPSS version
21.0 (SPSS Inc., Chicago, IL). A chi-square test and a t-test
were performed to ensure homogeneity of the two groups.
Descriptive statistics were used to summarize the demographic characteristics of the participants. In addition, in
order to compare the two groups' outcome variables, a paired
t-test was used in instances wherein the data met parametric
assumptions, whereas a MannWhitney U-test was used for
nonparametric assumptions. All the analyses were conducted
at a set significance level of = .05.

Results
Homogeneity Test of the Two Groups' Demographic
Characteristics and Preoperative Anxiety Levels

Figure 1 A child and an accompanying parent participating in the

clownnurse educational intervention.

Table 2 presents the baseline demographic characteristics

and preoperative anxiety levels of the children and parents in
the two groups. Fifty children (experimental group = 23,
control group = 27) and their parents (mothers = 46,
fathers = 4) took part in this study. No significant differences
between the two groups were found with regard to any of the
children's and parents' demographic characteristics. With

O.B. Yun et al.

Table 1

Educational contents for children and their parents (N = 23).

Participants Subject

Learning goals

Children

Children comply with received

information about what to do

Parents

Before surgery

Contents

Look at day surgery center

Change into the patient gown and check
the body weight & height
Check vital signs
-Get the IV
-Wait in the bed
Self-void
Going to the operation room
Children's separation anxiety
Go to the OR with parents
will be reduced by receiving
Sedative injection in OR
information about what to do
Sleep during operation
when going into the OR
Sleep with gauze packing
After surgery
Children's anxiety and pain
will be decreased by understanding Do not remove (open) the gauze after waking up
Get the IV
what to do after surgery
Exercise
Drink water
Discharge from hospital
Do not rub both eyes
Promises to keep after discharge Children comply well by
Wipe eye discharge with clean tissue
receiving information about
Wash face carefully, do not touch eyes with water
what to do after discharge
Shampoo hair while lying back
Take medicine
Apply eye drops
Before surgery
Parents comply with received
Look at day surgery center
information about what to do
-Care for children
-Medication
-Information about operation
After surgery
Parent's anxiety will be decreased Care after surgery
-Medication
by understanding what to
-Diet
do after surgery
-Exercise
-Operation wound
-Visit to the outpatient department
Management at home
Precautions at home
Parents can take care of their
-Medication
children better by receiving
-Matters that demand (special) attention
information about what
to do at home
Regarding strabismus
Q & A (questions & answers)
Parents understand by receiving
-Treatment of strabismus
further information through
-Surgery for strabismus
Q & A related to strabismus
-Management after surgery
-General anesthesia
-Child care after general anesthesia
-Questions & answers regarding strabismus

regard to demographic characteristics, the children in the

two groups were similar in terms of age, gender, number of
siblings, and birth order, while the parents in the two
groups were similar in terms of participating parent, age,
educational status, family income, type of religion, and
type of occupation.
There was no significant difference between the experimental and control groups with regard to the children's
preoperative anxiety levels and physiological anxiety,
including systolic blood pressure, diastolic blood pressure,
pulse rate, and behavioral anxiety. There was no significant

difference between the experimental and control groups

with regard to parents' preoperative anxiety levels and
physiological anxiety, including systolic blood pressure,
diastolic blood pressure, pulse rates, behavioral anxiety, and
state-trait anxiety.

Effect of ClownNurse Educational Intervention

The means and standard deviations of anxiety post-test
scores, as obtained by the children and parents in the two
groups, are presented in Table 3.

Effects of a ClownNurse Educational Intervention

Figure 2

Anxiety Levels Among Children and Parents

Children in the experimental group had significantly
lower physiological anxiety scores, as shown by systolic
blood pressure, than did those in the control group.
However, there was no significant difference between the
experimental and control groups with regard to diastolic
blood pressure or pulse rates, which also indicated
physiological anxiety. In addition, the experimental
group obtained a significantly lower behavioral anxiety
score than did the control group. The postoperative anxiety
score and physiological anxiety, inclusive of systolic blood
pressure and pulse rates, were significantly lower for
parents in the experimental group than for parents in the
control group. However, there was no significant difference between the experimental and control groups with
regard to diastolic blood pressure, which is related to
physiological anxiety. Moreover, the behavioral anxiety
and state-trait anxiety scores obtained by the experimental
group were significantly lower than were those obtained by
the control group. These results suggest that the children
and parents in the experimental group experienced
significantly lower anxiety scores than did those in the
control group.
Changes in Children's Post-Surgery Pain
The children in the experimental group obtained significantly lower scores on postoperative pain than did those in
the control group (U = 116.000, p b .001). The children in
the experimental group experienced significantly lower

Study processes.

postoperative pain than did those in the control group. The

results suggest that the clownnurse educational intervention
reduces anxiety, which is inclusive of worry, distress,
and negative affective responses by children and parents,
as well as post-surgery pain among children undergoing
day surgery.

Discussion
A significant number of children undergo surgery, and it
can be a devastating experience emotionally; many of these
children experience substantial anxiety (Wright et al., 2006).
Anxiety related to surgery must be prevented and reduced for
humanitarian reasons, and because of the psychological
trauma induced by anxiety. This study aimed to reduce
children's and parents' anxiety and children's pain related to
their day surgery.
In our study, the experimental group's overall anxiety
physiological anxiety (including systolic blood pressure) and
behavioral anxietywas significantly lower than was that of
the control group post-operatively in both children and
parents. This result suggests that a clownnurse educational
intervention may have positive effects in reducing anxiety
among children and their parents, as well as the pain level of
children after surgery. Another study reported that preoperative preparation has been shown to lessen children's and
parents' anxiety and postoperative behavior problems (Kain,
Mayes, Caldwell-Andrews, Karas, & McClain, 2006). A

O.B. Yun et al.

Table 2

Homogeneity test of the two groups' demographic characteristics and preoperative anxiety levels (N = 50).

Variables

Child
Gender
Age (years)

Birth order
Parent
Relation
Age (years)

Educational status

Family income (10,000 won)

Type of occupation

Child
Physiological anxiety
Systolic BP
Diastolic BP
Pulse rates
Behavioral anxiety
Parent
Physiological anxiety
Systolic BP
Diastolic BP
Pulse
Behavioral anxiety
State-trait anxiety

Classification

Experimental (n = 23)

Control (n = 27)

Total

n (%)/M (SD)

n (%)/M (SD)

n (%)

Male
Female
3
4
5
6
1st
2nd

13 (56.5)
10 (43.5)
5 (21.7)
4 (17.4)
11 (47.8)
3 (13.00
17 (73.9)
6 (26.1)

9
18
3
5
9
10
20
7

(33.3)
(66.7)
(11.1)
(18.5)
(33.3)
(37.0)
(74.1)
(25.9)

22 (44.0)
28 (56.0)
8 (16.0)
9 (18.0)
20 (40.0)
13 (26.0)
37 (74.0)
13 (26.0)

Father
Mother
2530
3135
3640
4145
High school or less
College
Graduate or higher
100199
200299
300399
Above 400
Housewife
Service
Office worker

3 (13.0)
20 (87.0)
1 (4.3)
8 (34.8)
10 (43.5)
4 (17.4)
2 (8.7)
19 (82.6)
2 (8.7)
2 (8.7)
4 (17.4)
6 (26.1)
11 (47.8)
12 (52.2)
1 (4.3)
10 (43.5)

1 (3.7)
26 (96.3)
0 (0.0)
5 (18.5)
14 (51.9)
8 (29.6)
2 (8.7)
19 (82.6)
2 (8.7)
0 (0.0)
2 (7.4)
12 (44.4)
13 (48.1)
20 (74.1)
0 (0.0)
7 (25.9)

4 (8.0)
46 (92.0)
1 (2.0)
13 (26.0)
24 (48.0)
12 (24.0)
2 (4.0)
45 (90.0)
3 (6.0)
2 (4.0)
6 (12.0)
18 (36.0)
24 (48.0)
32 (64.0)
1 (2.0)
17 (34.0)

2/t

2.710

.153

4.288

.232

.000

1.000

1.472

.322

3.394

.335

3.122

.210

4.542

.209

3.230

.199

103.78 (12.68)
64.22 (10.99)
104.61 (16.35)
6.61 (3.80)

107.00
61.78
103.04
5.33

(9.54)
(12.09)
(13.64)
(1.88)

1.023
.741
.371
1.539

.312
.462
.713
.130

114.00 (8.79)
75.13 (7.74)
74.96 (17.35)
8.04 (7.04)
43.78 (10.92)

115.30
71.74
80.30
7.19
48.93

(8.97)
(8.11)
(12.36)
(1.64)
(10.330

.514
1.504
1.267
.615
1.709

.610
.139
.211
.514
.094

BP = blood pressure.

number of anxiety-reducing intervention strategies have

been examined with regard to their potential in preventing or
alleviating this distress (Fincher et al., 2012; Koo, 2008).
In day surgery, other than the day of admission, the
children or parents may not have any contact with the nurse
or experience with the hospital environment prior to
surgery. Thus, preoperative interventions aimed at reducing
anxiety among children undergoing surgery seem to
positively affect the children's and parents' well-being
(Brewer et al., 2006; William et al., 2007). This study
demonstrated that clownnurse educational interventions
can be an effective tool in reducing children's distress,

as the children participating in the study benefited from

the intervention.
Pediatric surgery can also be stressful to parents.
Parental anxiety is believed to increase children's anxiety
(Fincher et al., 2012). Fortier et al. (2010a) demonstrated
that parents' anxiety predicts children's anxiety during
the preoperative period. Kain et al. (2006) found
that parents participating in an extensive preoperative
preparation program were significantly less anxious on
the day of the surgery. Therefore, it is important to
minimize parents' anxiety when caring for children
undergoing surgery.

Effects of a ClownNurse Educational Intervention

Table 3

Postoperative anxiety and pain levels among children and parents in the two groups (N = 50).

Variables

Child
Physiological anxiety
Systolic BP
Diastolic BP
Pulse rates
Behavioral anxiety
Pain
Parent
Physiological anxiety
Systolic BP
Diastolic BP
Pulse rates
Behavioral anxiety
State-trait anxiety

Experimental (n = 23)

Control (n = 27)

t or U

M (SD)

M (SD)

101.91
59.52
116.22
7.48
4.96

(10.69)
(12.75)
(16.32)
(2.68)
(2.38)

108.52 (9.37)
60.56 (10.09)
112.52 (22.67)
12.26 (2.09)
7.56 (1.40)

2.329
.315
.651
52,000
116,000

.024
.754
.518
b .001
b .001

112.17
72.83
75.22
5.91
36.30

(6.51)
(7.19)
(9.930
(1.28)
(10.00)

118.37 (9.28)
75.74 (5.83)
89.78 (11.32)
10.04 (1.65)
51.11 (17.94)

2.686
1.583
104,500
22,500
3.672

.010
.120
b .001
b .001
.001

BP = Blood pressure.

In this study, the experimental group's parental anxiety

scores were significantly lower than were those of the
control group. These scores included physiological anxiety
(i.e., systolic blood pressure and pulse rates), behavioral
anxiety, and state-trait anxiety. The results indicated
that the clownnurse educational intervention was useful
for reducing parental anxiety. These findings are very
similar to those obtained by Vagnoli and Caprilli (2005),
indicating that the clown intervention had an effect not
only on children's reactions, but also on their parents'
surgery-related anxiety.
In another randomized controlled study on 70 children,
children and parents exposed to two clowns showed low
levels of preoperative worrying (Fernandes & Arriaga,
2010). A quasi-experimental study indicated that children
who received a clown intervention and were accompanied by
their parents experienced less pain and fear as compared to a
group who did not receive this intervention (Tener,
Lang-Franco, Ofir, & Lev-Wiesel, 2011; Vagnoli & Caprilli,
2005; Vagnoli et al., 2010). The clown was perceived as an
effective intervention for managing children's and parents'
anxiety. The results of existing studies concerning clown
performances suggest decreased distress among children and
parents and increased cooperation by children who undergo
medical procedures (Fernandes & Arriaga, 2010).
Anxiety has been shown to have a strong positive
correlation with pain, with more anxious children shown to
experience more pain in the postoperative period (Fortier,
Del Rosario, Rosenbaum, & Kain, 2010b; Kain et al.,
2006). Postoperative pain is a preventable postoperative
complication; however, if it remains unrelieved, it can
cause physical and psychological complications (Khan
et al., 2011). Thus, decreasing children's anxiety in the preand perioperative periods is an important intervention that

could aid the management of children's postoperative pain.

The preoperative clownnurse educational intervention can
serve as an outlet for children's potential pain.
The present study demonstrated that children in the
experimental group experienced lower post-surgery pain
than those in the control group. Clowning is based on
imagination; it is funny and makes children laugh and feel
good. If a child is in a state of pain or distress, such as when
facing surgery, the clownnurse can serve as a resource for
counteracting the painful experience and blocking sensations
of pain (Dionigi et al., 2012; Dionigi et al., 2014; Fernandes
& Arriaga, 2010). Similar to this, children engaging in play
therapy as members of the experimental group obtained
lower mean pain scores than did children in the control group
(Kain et al., 2006; William et al., 2007). In our study, the
preoperative preparation programnamely, the clown
nurse educational interventionwas designed mainly for
children, with parents being indirectly involved in the
intervention through their presence. This might explain
the decrease observed in the anxiety levels of the parents in
the experimental group. Moreover, along with the clown,
the parents encouraged their child's comfort and distraction
levels, thereby enhancing the positive aspects of the
intervention. In this study, we did not separate the
interventions for the parents. Further research may attempt
to provide nursing interventions separately.
In conclusion, the findings in this study indicate that
children and parents who received the clownnurse
educational intervention before surgery might have
perceived the surgery to be less threatening than did
those who received routine preparation information. Based
on these findings, the authors suggest that some form of
preparation is needed to reduce the anxiety and pain
related to surgery.

10

Limitations
There are some limitations regarding the generalization of
our findings. One limitation was that a nonequivalent control
group, pretestposttest design was adopted, instead of a
randomized controlled design. The participants were not
assigned to the control and experimental groups simultaneously. This may have posed threats to validity (e.g., history
effects). Other limitations were the fact that trait anxiety was
not controlled for, which could have affected the result, and
that we only targeted participants at one national hospital.
Further, children aged 36 years have considerable fear and
anxiety regarding surgery as compared to children of other
age groups, and most were accompanied by their mothers
(i.e., the primary caregiver), therefore, these anxieties may
have decreased. Finally, we used a clownnurse educational
intervention; had we used a clownnurse intervention only,
without the educational component, the results might not
have been significant. Thus, further studies are needed to
address the above limitations.

Conclusion
With its focus on the use of a clownnurse educational
intervention, this study evaluated children's and parents'
anxiety and post-surgery pain during day surgery for
strabismus. This study provides some empirical evidence
that preoperative clown nursing may be more effective than
routine care alone in minimizing children's and parents'
anxiety levels and decreasing children's surgery-related pain.
Therefore, our findings may be tentatively applied to
demonstrate that clowns may be an option in the reduction
of fear, stress, and anxiety in the hospital context.

Acknowledgments
We would like to thank the Seoul National University
Hospital for permitting our research and the participants for
their cooperation in our work.

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