The SMILE Study

The SMILE Study – Sydney Multi-site Intervention of Laughter Bosses & Elder Clowns

From 2009 to 2011, The Humour Foundation was involved in world first quantitative research – the SMILE Study. The study measured the impact the Elder Clowns program had on residents living with dementia in aged care facilities.

Funded by the National Health and Medical Research Council, it was led by the Dementia Collaborative Research Centre at the University of NSW.


Single-blind clustered randomised control design
35 RACF units
Total of 398 residents
Professional Elder Clowns provided 9-12 weekly interventions
These were augmented by resident engagement by facility Laughter Bosses Control units received usual care.

The core findings from the study showed that agitation levels of residents significantly decreased to the same extent as using anti-psychotic drugs – but without the side effects.


Other results showed that interactions with an Elder Clown can:

  • Decrease depression in residents
  • Decrease behavioural disturbances of residents
  • Improve quality of life of residents
  • Increase happiness of residents
  • Increase positive behaviours of residents
  • Improve staff morale
  • Have a positive impact on facility atmosphere

Benefits to staff/Laughter Bosses were also reported:

  • Finding greater enjoyment at work
  • Satisfaction with what they had achieved in undertaking the role
  • Increased interest in the residents as unique individuals

There were also perceived effects on staff not directly involved in the study including:

  • Positive change in staff attitudes and approach to care delivery
  • Reduced stress levels
  • Improved communication, teamwork, relationships and empathy among staff.

The impact of Management was also observed:

In short, the greater the management support of those implementing the program, (especially the Laughter Bosses), the greater the impact and success of the program. This holds true for our ongoing programs.


In 2012 David Symons (Artistic Director of The Humour Foundation) received a Churchill Fellowship to investigate Elder Clowns programs in Scotland, the Netherlands, Canada and the USA.

His findings are detailed in his Churchill Report available here

Some of his key findings include:

  • Well-trained clowns have a powerful role to play in the psychosocial well-being of people living with dementia in aged care facilities.
  • Well-trained clowns do not infantilise people living with dementia. They affirm, empower, honour and delight these people. Doctors, nurses, care staff, activities coordinators and managers of aged care facilities are all amongst the people who see a significant role for clowns in the overall care of people with dementia.
  • Clown programs work most effectively when care staff receive thorough briefing and role play experience of a program prior to implementation and when management is clearly supportive of the program. Clown programs are also more effective when the clown visits are regular and frequent (at least weekly).
  • Care staff can significantly add to the well-being of people living with dementia in their facility when trained to incorporate performance principles into their work. Staff of aged care facilities also benefit from clown programs operating in their workplaces through the extra knowledge gleaned about residents by clowns and by the joy clowns bring to staff as well as residents.

Some comments about the Elder Clowns programs from staff within the facilities:

The Elderflowers (Elder Clowns) had an immediate impact on the ladies and gentlemen. They remembered the visits and it was wonderful for everyone to hear music and laughter on the ward.

The Netherlands
miMakker clowns (Elder Clowns) are part of the shift to person-centred care. They also play a role in transforming attitudes, in the shift of thinking from ‘difficult people’, to ‘people with difficulties’; and the notion that well-being ‘starts with a clean diaper, but includes a smile’.

Windsor, Canada
The key benefits the Elder Clowns bring are the quality of the one-on-one interactions and the laughter. Laughter is an important part of everyday life, even from a physiological standpoint; laughter crosses cultural boundaries – everyone laughs; and laughter makes the visit meaningful. Clowns are iconic and thus a good trigger of memory; and the costume is a great indicator of fun; an ice-breaker; and a conversation starter. The Elder Clowns discover secrets about the residents, such as the gentleman being able to play uke (with whom they now have regular jam sessions). These ‘secrets’ are then shared with the staff and the relationships between residents and staff improve.

The contact the clowns make is genuine and it is easy for the residents to let themselves go and to be in contact with them. I don’t know if it’s the red nose or if it’s just the fact that they are in character, but the clowns allow people to be freer in their interaction and communication.

The program is very beneficial. The clowns interact one-on-one; they go room to room, offer sensory stimulation and are very helpful to the staff, especially with bed bound patients. Doctors, families, physiotherapists are all complimentary about their work.

La Belle Visite (Elder Clowns program) plays a vital role in creating un milieu de vie (a home-like environment) and in attending to the psychosocial needs of the patients. Also, people with dementia have a lot of creativity. La Belle Visite acknowledges that creativity.

When the clowns are coming it is like I open the window and I can breathe more oxygen.”   Aged care resident

The clowns make the residents laugh, make them happier, and improve their moods. The impact can last for a few days. They’ll still be talking about the visits even a few days later. The Residents’ Council asks why aren’t they here more often.