Constructing knowledge and moral skills through hospital clown interventions: a qualitative study

Hospital clown practice is grounded in a form of situated wisdom that extends beyond entertainment. Through their interventions, hospital clowns develop and enact moral know-how that enables them to interpret clinical environments, respond to uncertainty, and make respectful decisions in real time.

This qualitative study explores the moral know-how and skills developed and enacted by hospital clowns during clinical encounters and examines how these extend beyond technical and communicative performance.

A qualitative study inform by a phenomenological perspective was conducted. Semi-structured interviews were carried out with 7 hospital clowns, 10 patients, 17 family members, and 17 healthcare professionals (8 nurses, 3 physicians, and 6 medical students). Interviews were transcribed verbatim and analyzed using inductive thematic analysis following Braun and Clarke's six-phase framework, supported by Atlas.ti software.

Five core competencies emerge: (1) Knowing how to embody the character, is understood as an ongoing process of emotional self-awareness and authenticity. (2) Knowing how to connect, is defined as the capacity to read one's own and others' emotions, self-regulate, and intuitively adapt to the environment. (3) Knowing how to err, recognizing mistakes as an integral part of relational engagement. (4) Knowing how to adapt, demonstrating sensitivity, recognition of the other, and care for the relational context. (5) Knowing how to arrive and how to leave, referring to the ability to discern when presence was appropriate and when withdrawal was needed.

The moral know-how enacted by hospital clowns reflects essential moral skills relevant to clinical practice. Some of them are emotional regulation, situated empathy, and acceptance of fallibility. These experiential forms of learning offer a complementary approach to traditional dilemma-based models of clinical ethics and support the development of more relational, context-sensitive, and person-centered forms of care. Additionally, these competencies may have important implications for medical education.