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Clown Intervention on Psychological Stress and Fatigue in Pediatric Patients With Cancer Undergoing Chemotherapy

Lopes-Junior, Luis C., PhD; Silveira, Denise S. C., PhD; Olson, Karin, PhD; Bomfim, Emiliana O., MSc; Veronez, Luciana C., PhD; Santos, Jéssica C., PhD; Alonso, Jonas B., BSc; Nascimento, Lucila C., PhD; Pereira-da-Silva, Gabriela, PhD; Lima, Regina A. G., PhD

doi: 10.1097/NCC.0000000000000690
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Background Clown intervention has been shown to enhance emotional and behavioral processes, but few studies have comprehensively examined the effectiveness of this practice using biomarkers.

Objective The aim of this study was to evaluate the effect of a clown intervention on the levels of psychological stress and cancer-related fatigue in pediatric patients with cancer undergoing chemotherapy.

Methods Sixteen patients who met all criteria from a pediatric oncology inpatient unit in a Brazilian comprehensive cancer care hospital participated in this quasi-experimental study. Eight saliva samples were collected, comprising 4 at baseline and 4 after clown intervention (+1, +4, +9, and +13 hours after awakening). Salivary cortisol and α-amylase levels were determined using high-sensitivity enzyme-linked immunosorbent assay kits. Stress and fatigue were measured by the Child Stress Scale-ESI and the PedsQL Multidimensional Fatigue Scale, respectively. Relationships among stress, fatigue, and biomarker levels were investigated using nonparametric statistics.

Results In comparison with baseline measurements, the total psychological stress and fatigue levels improved after the clown intervention at the collection time point +4 hours (P = .003 and P = .04, respectively). Salivary cortisol showed a significant decrease after clown intervention at the collection time points +1, +9, and +13 hours (P < .05); however, α-amylase levels remained unchanged.

Conclusion These findings provide preliminary evidence that clown intervention merits further study as a way to reduce stress and fatigue in pediatric cancer inpatients, and that self-report and biomarker measures are feasible to collect in this patient group.

Implications for Practice Clown intervention as a nonpharmacological intervention may improve stress and fatigue levels in pediatric inpatients with cancer undergoing chemotherapy.

Author Affiliations: Department of Maternal-Infant Nursing and Public Health, University of São Paulo at Ribeirão Preto College of Nursing–PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, São Paulo, Brazil (Drs Lopes-Júnior, Nascimento, Lima, and Pereira-da-Silva and Mr Alonso); Department of Biochemistry and Immunology, University of São Paulo at Ribeirão Preto Medical School, Graduate Program in Basic and Applied Immunology of the University of São Paulo at Ribeirão Preto Medical School, Ribeirão Preto, São Paulo, Brazil (Drs Silveira, Veronez, and Santos); Edmonton Clinic Health Academy, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada (Dr Olson); and Department of Community Health and Epidemiology, University of Saskatchewan, College of Medicine, Saskatoon, Saskatchewan, Canada (Ms Bomfim).

The authors have no funding or conflicts of interest to disclose.

Correspondence: Luis C. Lopes-Junior, RN, OCN, PhD, Department of Maternal-Infant Nursing and Public Health, University of São Paulo at Ribeirão Preto College of Nursing–PAHO/WHO Collaborating Centre for Nursing Research Development, Avenida dos Bandeirantes, 3900, Campus Universitário, Ribeirão Preto, SP, Brazil, 14040-902 (lopesjr.lc@gmail.com).

Accepted for publication October 24, 2018.

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