Healing Humor: The Use of Humor in the Nurse-Patient Relationship

Objective: To identify the importance of using humor in patient/nurse relationship, its factors, its conditions and the barriers that might limit its use. Methods: We systematically searched PubMed, Science Direct and Google Scholar, for relevant articles published in English between 2010 and 2019. We included the studies that investigated humor between nurses and their patient’s relationship. Results: From the initial 287 articles found, 15 were included for final revision. Data allowed retrieving information on humor definition; its applicability as a nursing intervention; humor as a tool to improve nurse-patient communication and relationship; influencing factors; humor benefits in health care context and the limits that come against its use. Conclusion: Humor is considered a powerful communication tool, it promotes well-being, relieves anxiety and stress, helps deal with stressful situations but it should be used cautiously in order to prevent undesired consequences.

• Humor
• Patient/Nurse Relationship
• Communication

1. Introduction

Humor is such a fundamental tool of communication. In fact, it holds an omnipresent place in human interaction relieves tension, reduces stress and depression and can even pass a message. Evidently, humor manifests during happy and tragic moments. To further understand humor, we have to dig deep into its phenomenology. Indeed, it consists of four important aspects humorous transformation of the world, intentional relationship between body and world, embedded in a social and historical context and humor and free will [1] .

Humor is important as it alters our perceptions of the world, making us associate enjoyment with those things and ourselves. Overall, humor is important to our interpersonal interactions and the maintenance of our relationships in social interactions [2] .

In health care in 1905, Freud [3] described humour as one of the strongest defence mechanisms and one which enables an individual to face problems and avoid negative emotions which are constantly used in the medical field. Also, it is often used among nurses to help them cope well and resist burnout as they must deal with death on a daily basis which is considered as a supremely oppressive force [1] .

Actually this is the reason why nurses laugh at jokes of their patients, they might have been exposed to similar jokes from other nurses, as well as during their education, emotions in general reveal our background valuations of the world [4] .

On the other hand, humor cannot be controlled, to find something funny happens in an instant it’s like all emotions in that humor exists below the level of the will, when we find something funny, our perceptions of the world can already be transformed before we become aware of our humor [1] .

Given its importance; humor has been identified as a nursing approach that improves the therapeutic relationship between nurses and their patients and it has been included in the nursing intervention classification as a valuable asset that allows nurses to build communication with patients, relieve stress that’s why so many of them interpret humor as an essential element in the medical field, also the use of laughter to build rapport, calm anxiety or reduce embarrassment in communications with their patients [5] .

Studies in the healthcare field recognized humor’s intervention as an essential communication skill and coping device for both patients and healthcare providers as it is a versatile communication tool used most the time in a lot of medical contexts. It can be beneficial in times of embarrassment, anxiety, uncertainty and pain, in addition patients and caregivers may use it in medical situations to “show that things are not so serious or institutional as they might seem” others showed that using humor as a coping method by patients and healthcare professionals has been proven by a study that showed that those who used humor were less likely to have malpractice issues and as for patients they indicate its importance to “lighten up the mood”, humor can enhance health promotion among nurses and the quality of patient care and is considered as a patient care strategy [6] .

The use of humor is considered an easy and cost-effective method that does not require professional skill and can easily change people’s moods but when used inappropriately it can be perceived as a negative intervention by patients that’s why it needs to have conditions related to the nurse, the patient and to the therapeutic relationship [7] .

Humorous communication shows every indication of being a productive strategy for workers in healthcare settings, as it can serve as means of alleviating tension as nurses are faced with more extreme forms of interpersonal stress, also the nurse’s job stress is a big contributor to job dissatisfaction added to that, health care providers usually suffer from burnout, which can be brought on by unresolved stress, the main consequence for not using humor by nurses who suffer from job burnout, is that they’ll treat their patients with less attention, less care and less patience, in addition the staff’s burnout could cause problems such as low worker morale, high absenteeism, and high job turnover [8] .

However some studies show that humor intervention is not valued enough or even used for so many political, religious and even cultural considerations [9] [10] .

Within this systematic review we aimed to evaluate identify the importance of using humor in the patient/nurse relationship and describe the factors that influence its use and the conditions that must be applied when using it and the limits that nurses might encounter.

2. Methods

A systematic literature search was performed on PubMed, ScienceDirect and Google Scholar on May 2020 using the following search terms: (Humor) AND (Nursing), (Humor) AND (nurse/patient relationship). The research was conducted independently by the researcher, and the selection of studies and the whole process followed the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, the results were obtained from reading the title, abstract and the full and complete text.

Inclusion criteria:

• Articles reviewed include all the previously listed keywords.

• Full text versions of the article also had to be available through the search engines.

• Full text articles that were published in the last 10 years with some from the last years.

• Articles in French and English, peer-reviewed, published in scholarly journals that tackled the importance of humor, its factors, conditions of use in nursing practice and the barriers that they might face when using it.

• Each of these dimensions thus has been selected:

• Population: nurses and/or patients.

• Intervention: humour.

• Outcomes: factors that influence the use of humor in the nurse/patient relationship and his advantages.

Exclusion criteria:

• Duplicate articles.

• Articles that did not focus on the use of humor within a patient care setting.

• Articles that were written in other languages (Portuguese, Spanish, German, Italian…).

• Studies that address humor between patients or even between nurse or physician.

3. Results

Figure 1 presents an overview of the search and selection process. The search produced 287 articles. An initial screening of titles was carried out to exclude irrelevant articles and those who do not meet the inclusion criteria (n = 224) and also duplicate papers (n = 16) resulting in the retention of 47 records screening. Following abstract screening, 40 studies were retained for eligibility full review, during which 25 studies were excluded after reading full-text. Finally, 15 original research papers were included in the final literature review.

These articles were published as followed: one in (2006), one in (2008), one in (2012), two in (2013), three in (2014), two in (2015), one in (2016), one in (2017), one in (2018) and two in (2019). As far as method goes, four Systematic literature review, three narrative inquiry, one scoping review, one content analysis, one literature review in qualitative and one qualitative study, two articles (method not mentioned), one ethnographic method and one mixed-qualitative methods.

The articles present the impact of humor in nursing practice, to amplify humor as a nursing intervention. We included articles that identified its use in different healthcare departments such as palliative care, oncology, hemodialysis and pre-operative room; due to language barriers so many could’ve been added. They describe the factors that influence the use humor, conditions to usefully make use of it and potential barriers that come against it. All articles refer the use of humor only for nurses.

After selection of articles they were analyzed and information was gathered about author, year of publication, population, method, objective and important results that were obtained gradually from reading the title, the summary and full text (Table 1).

4. Discussion

Humor is an essential component of our everyday, as it is believed to facilitate feelings of well-being and happiness along with laughter, as a term, it is often associated with concepts of positivity and optimism.

For centuries, therapies primarily involving laughter and humor have been used in health care. This therapy has been used to decrease pain, anxiety, stress, depression, and fatigue, and improve immunity, quality of life, happiness, sleep quality, and resilience [23] . Humor has been used as a nursing intervention in several medical specialties. It is especially perceived by oncology nurses, indeed the diagnosis of cancer is extremely stressful and the treatments are difficult. Patients and nurses may use humor as a coping mechanism to contend with the stresses caused by cancer [13] . Humor helps them to make their working day easier and enjoy their work more. Cancer nursing is an emotionally challenging field which can lead to compassion fatigue and burnout [24] . For example, patients used laughter or humor to help discuss issues that they found stressful or embarrassing. The major topics where this occurred were death. The uses of humor about such topics have been suggested as being associated with acceptance of death [25] .

Humor relieves stress for nurses in the operating room as they encounter additional stressors such as deaths or deterioration, pressure to work more quickly, equipment malfunctions. Nurses may educate patients, their family members, or caregivers about preoperative and postoperative care [16] . Humor therapy can reduce preoperative stress and anxiety in children who undergo surgical procedures. It could be a useful and cost-effective strategy to reduce the adverse effects

Table 1

Characteristics of studies analyzing the importance of humor in nursing practice

Author/year published	Aim and objectives	Methodology	Population	Results
Jones et al., boundaries 2016) [11]	Identify the perceptions of nurses about potential barriers to the use of humour in nursing practice	A literature review of qualitative research and thematic synthesis Four key databases were systematically searched and manual search conducted	7 articles	The results identified the perceptions of nurses about potential barriers that prevent the use of humor in practice. The extent to which nurses use humor is related to personality factors, but is also affected by external environment and social factors. Reluctance in its use in practice is influenced by views that humour is unprofessional; with senior nurses found to have a pertinent role in influencing its use.
(Ghafari et al., 2015) [7]	To describe nurses experience of humor in healthcare setting and factors influencing it	Qualitative study investigated nurses’ experiences of humour in five hospitals affiliated to Tehran University of Medical Sciences	17 nurses with masters and baccalaureate degrees in nursing	Understanding nurses’ approach and experiences of humor helps identify its contributing factors and provides valuable conditions for enhancing nurses and patient’s psychological and physical health. Spreading a culture of humor through teaching methods can improve workplace joy.
(Tanay et al., 2012) [12]	To report an analysis of the concept of humor in adult cancer care	Content analysis guided by Walker and Avant’s framework	12 articles	Humor is a subjective emotional response, resulting from the recognition and expression of incongruities of an absurd and impulsive situation, remark, or action, which boosts feelings of closeness when shared in the context of trust in the patient/nurse relationship and may be used as a coping mechanism in a stressful situation such as the adult cancer cure setting.
(Tremayne, 2014) [13]	To discuss how humor can improve physical and psychological wellbeing, meanwhile reducing stress and anxiety	Systematic literature review	Articles about humor	The proper use of humor is a valuable asset in nursing practice, used daily in nurse/patient interaction, it can help to develop the therapeutic relationship and build resilience. When used effectively, humour can lead to a more individualized, holistic and personal approach, which may result in patient care being more comforting and ultimately more compassionate.
(Sousa et al., 2018) [14]	Identify the factors that influence the use of humor and its benefits in the care based relationship	Systematic literature review	7 articles that use a qualitative method	Results showed that for nurse, humor is humanizes the therapeutic relationship, reduces tensions and improves communication and hospitalization experience. For patients, humour has benefits in therapeutic interaction and promotes participation in care.
(Buxman, 2008) [15]	Explore the use of humor in the pre-operating room	Narrative inquiry	Pre-operative nurses	In the pre-operative context, humor is used to relieve stress, facilitate learning and strengthens the trust relationship between nurse and patient.
(Haydon et al., 2015) [16]	Explore four registered nurses’ experiences of the use of humor in relation to gender differences and how it benefits the therapeutic relationship	Narrative inquiry	Registered nurses from a regional hospital	The results indicated gender differences in the way humor is used by patients. For female patients, humor is often instant and used as a reassuring discourse for others, whereas male patients’ humor through stories and anecdotes is designed to establish a sense of equalizing power between the patient and nurse.
(Sousa et al., 2019) [17]	Describe the factors influencing the use of humor in nursing care, its applicability and benefits	Scoping review	Articles published between 2008 and 2018	The results indicate that the use of humor promotes both communication and human interaction; it promotes well-being, helps deal/cope with difficult and unpleasant situations, reduce tension and stress, and strengthens the immune system.
(Linge-Dahl et al., 2018) [18]	Evaluate humor interventions and assessments that have been applied in palliative care and to derive implications for future research	Systematic literature review	Patients in a palliative care setting who received a humor intervention Studies assessing the perspective of caregiver on humor	Findings proved that humor had positive effect on patients, and professional caregivers, humor was widely perceived as beneficial in nursing practice.
(Hardy, 2019) [1]	Encourage the respectful use of humor in clinical setting and support its importance in medical practice	Article	Articles that support the use of humor in medical practice	Not mentioned.
(Tanay, MA et al., 2013) [5]	Highlights the importance of using humor between patients and nurses in the oncology ward	Ethnographic methodology	9 nurses and 12 patients in the adult cancer setting	Results indicate that: Patients consciously use humor during nurse/patient relationship in an attempt to aid nurses adapt to the anxiety they encounter in nursing practice The nurses needed professional guidance when using humor with cancer patients as they expressed concerns of its unprofessionalism.
(Bennett et al., 2014) [19]	Review the evidence related to humor as a therapeutic intervention the dialysis patient	Narrative inquiry	Articles about humor on different populations	Humor interventions that aid in therapy range from humorous videos to simulated laughter the effect of laughter and humor on depression, fatigue…may have applications for the context of dialysis and more research is recommend it.
(Evans, 2012) [20]	Identify the benefits and conditions of humor in gestalt psychotherapy	Article	Not mentioned	Results identified the benefits of humor in gestalt psychotherapy and that conditions that should be followed when using it.
(Patenaude et al., 2006) [21]	Drawing up a general description of scientific articles that deal with humor between nurse and patient	Systematic literature review	Studies on humor in the nurse/patient relationship in the context of daily care from both perspectives	The results indicate that humor in care depends on the situation and the context and can also be spontaneous. There are conditions when using it which are related to the nurse, the patient, the therapeutic relation and the situation.
(Branney et al., 2014) [22]	To explore how patient with penile cancer use humor to their favor while dealing with their diagnosis	Mixed-qualitative-methods	Patients with penile cancer	The results showed that humor helped patients cope with their condition, as they can laugh and joke about the consequences of treatment and build strong relationship with healthcare professionals. The findings suggest that in the appropriate moment, nurses can proceed to using humor to improve the patient’s state but be cautious of sexual and offensive jokes.

of anesthetic induction in children [26] . For example nurses can use their musical talents and knowledge of healthcare humor to create a unique form of entertainment. The use of humor by perioperative nurses can serve both the nurse and the patient [15] . Humor also has physiological benefits for staff members as well as patients, including reduced stress, improved mood, enhanced sense of empowerment, improved respirations, improved levels of alertness, creativity, and memory; and decreased muscle tension [27] .

The use of humor to decrease anxiety could be also used with patients undergoing hemodialysis like patient’s first introduction to dialysis or those who suffer high levels of cannulation pain [20] . Confirming this point, Norwegian researchers monitored 52 dialysis patients for 2 years and concluded that an increased sense of humor had a negative association with mortality and disease-related stressors [28] . Similarly, in pediatric dialysis units, humor may be appropriate in decreasing anxiety related to needling and at a patient’s first dialysis treatment [29] . Some Therapeutic interventions in dialysis can be useful, for example stories can certainly be used as diversionary therapy, such as setting up a culturally appropriate humorous video during needling [30] . Clown doctors, are very popular in pediatric settings and dialysis context [31] . Laughter yoga, an increasingly popular laughter therapy, which includes deep breathing, meditation and simulated laughter leading to genuine laughter, a has been shown to be feasible in the setting of hemodialysis [32] . Increased immunity levels were found following the use of the Smile-Sun technique, a set of positive verbal and nonverbal communication techniques with positive humor as a component. However, it was positive to note that laughter therapy improved the quality of life of patient with kidney disease, immunity changes associated with laughter therapy may be a promising area to explore further [33] .

This is particularly important given that the indicators of health disease impact for cancer patients such as quality of life, symptom burden, morbidity, and mortality are comparable to those with end-stage kidney disease. Providing a comfortable environment can be beneficial for patients with cancer to fully open up about their life and care needs and for the caregiver to easily pass on information and perform tasks. In the field of palliative care, humor was viewed to be a valuable and successful way in handling the emotional burden [1] .

Cancer nursing is an emotionally challenging field which can lead to compassion fatigue and burnout [26] . This suggests that humor can be used as one of many communication tools to facilitate therapeutic nurse-patient relationships. Humor can become a vehicle to facilitate the process of therapeutic engagement. This process can help both the nurse and patient become more relaxed, develop trust and communicate openly [34] . For example, in cases where brain metastases affect a patient’s speech or maxillofacial surgery results in physical speech difficulties, patients may use humor using non-verbal forms of communication such as winking, eye contact or movements, or hand gestures [12] . In case of penile cancer, patients tend also to use humor when speaking of their diagnosis/treatment as it helps dedramatize their situation, cope with their current and everyday stressors and improve their nurse interactions, in this context nurses can strengthen the therapeutic relationship but should avoid sexual and urinary infections jokes [24] .

Otherwise, humor indirect benefits are numerous, it establishes and strengthens relationships of trust between nurse and patient, relieves anxiety, as well as some physiological and psychological benefits that consist of the reduction of anxiety, and burnout; mood improvement; increased self-esteem also it enhances a sense of empowerment. Nursing is a stressful profession that can place many physical, mental and emotional demands on nurses [11] . As a result, nurses often use humor as a coping mechanism to overcome stressful situations in the workplace and the long shifts [7] using humor allow a higher rate of job satisfaction and a positive working atmosphere [6] . Therefore, humor helps nurses build a sense of community through mutual support and understanding [35] .

Physiologically, evidence shows that when laughter erupts in response to humor, endogenous hormones (endorphins, serotonin and dopamine) are released [14] . Dopamine can cause an increase in both positive thinking and creativity, in addition to reduce depression [36] . There is also evidence of analgesic benefits, with humor proving to be an effective method of pain-relief [37] . For example, humor has been found to facilitate feelings of well-being and happiness as well as enhancing patients’ ability to cope with the stresses of ill-health [13] . Using humor to invoke laughter can lower serum cortisol levels while increasing the number of T-cells and natural killer cells in the blood and boosts the immune system, thereby reducing stress levels. Studies have shown that laughter can decrease resting blood pressure, reducing the risk for heart disease it can also relax muscles. The increase of oxygen from laughter helps improve brain function, including memory [29] .

The majority of studies about the use of humor in the nurse/patient relationship admit that it has specific characteristics; it can be spontaneous and situational. Robinson (1991) reports, following the analysis of 1060 anecdotes observed or told, that in 87.4% of the cases, the humor was unplanned, spontaneous and linked to the context [38] . It surges from everyday situations and is inspired by the moment’s circumstance. The humor can be light or vibrant depending on the situation, [39] or sometimes with the intention to relieve the stress and even cheer the patient’s mood as nurses express using it intuitively and not as a conscious act; it can also be planned or guided by a routine [40] .

On the other hand, there are many factors that are known to affect the use of humor, for example, age, culture, social circumstances, beliefs, philosophy, attitudes and gender characteristics as it is perceived that men tend to use humor more often than women it is thought men use humor to deliver a more relaxed zone even in their everyday lives, they tell stories, use anecdotes and black humor whereas female nurses use wordplay, situational or even surprise humor because it’s considerate unlady like for the ladies to use harsher humor toward patients [17] . Some factors can influence the use of humor such as ethnicity, psychological state, age, gender characteristics and individual’s own definition of humor context, culture, self-esteem and the nurse’s confidence.

When it comes to using humor in nursing there should be some conditions and guidelines for the nurse and others related to the therapeutic relationship. First of all, It is important to pick the best time to use humor as it enhances a mutual trust between the nurse and the patient; not considering the proper timing may lead to anger, misunderstanding and relationship breakdown with the patient, recognizing a suitable time depends on so many factors such as a patient’s physical, mental and psychological state, as well as his diagnosis and disease progression [37] . Secondly, it is believed by nurses that assessing the situation as in analyzing and understanding the patient’s mood, personality and personal features is necessary when using humor as it could prevent misunderstanding also the individual’s own cultural beliefs must be considered because for some patients they perceive jokes against them as rude and uncaring and might seem like a violation of their privacy [5] . Thirdly, is an essential condition within the context of humor, one of its features is that it gives us a deep insight into the receiver’s emotional state, this further amplifies parse’s human becoming theory, that by relying on empathy while using humor nurses can fully immerse themselves with the patient’s experience of health and pain and by that they humanize the nurse/patient relationship which results into an effective use of humor and more importantly an enhanced quality of care and health for the patient [41] . Finally, Humor is subjective so it may vary from one person to another, depending on the content nurses should be careful to which type of humor to use if needed, as it is seen as an anti-therapeutic use toxic humor that might criticize or even humiliate a patient [21] .

The caregiver/patient relationship should be built on trust between both parties so that any usage of humor or jokes could be appreciated and not rejected and nurses believe that without trust, affection and positive regard the use of humor cannot be emotionally supportive [19] .

Some of the patient’s features can be classified as guidelines that might encourage or limit the use of humor.

Ÿ Patient Sense of humor: when a patient is familiar to using humor in his/her daily lives and can even initiate it himself that can be beneficial and give an effective result in the therapeutic relationship

Ÿ Patient’s timidity: humor serves as a powerful communication tool for patients that are too shy and difficult e it can help them open up about their needs in a comfortable environment.

However the use of humor has certain limits and conditions; some nurse’s approach to humor indicate that it’s a very delicate and personal matter that differs from one person to another what one can find funny could be a source of discomfort for another [17] this situation further amplifies the paradoxal character that humor possesses [18] and that it should be used cautiously depending on the situation due to it being a multifaceted concept. A study conducted in Tehran stated that the time pressure is one of the boundaries when using humor in clinical settings, it is believed that humor can happen when nurses and patients share pleasant memories that require extended and intimate relationships that can’t happen due to nurse’s shortage of time, also social beliefs form a barrier especially for female nurses when sharing humor with male patients can often lead to a misunderstanding so it’s avoidable to protect nurses from the potential negative consequences of humor like harassment or even the defamation of their professional identity, in addition the cultural and religious considerations can make nurses associate humor with shame and criticism which leads to a limited use of it that in return leads to lack of trust, confidence and feeling of insecurity in the nurse/patient relationship [12] . when using humor some barriers may arise, such as its use in inappropriate situations and by unprofessional or new nurses that don’t know when and how to make use of it also the personality differences might interfere because some are too serious in their jobs and everyday lives that for them it might seem unprofessional and not worthy to use humor in the nursing practice [11] .

Our study has some limitations;

First, we focused mainly on the nurse’s perspective of humor and it would have been wise to include the patient’s own point of view and benefits of such a term for them, all this could have led to knowledge of the importance of humor not only from the caregiver’s point of view but also the care recipient’s.

Due to limited translation resources, many relevant studies not written in English or French were excluded; those articles could have added the impact of humor in nursing practice in other populations and cultures. To put in consideration that the time range of 10 years might have limited the process of finding more articles and it could show the difference between the usage of humor then and now.

Despite these limitations, our study also has strengths; the use of the scoping review that’s also a type of literature review was a new experience and an alternative to the qualitative method that was going to be adapted due to the Covid-19 pandemic, this new method is highly relevant in nursing research and serve as an appropriate alternative to a systematic review when literature is vague, vast and complex also it is a perfect method to explore a topic in depth and most importantly it serves as a starting point for further investigations that contribute to more enriched research in the future.

5. Conclusion

Nursing practice nowadays is technically driven that the nurse/patient interaction is often limited, the use of humor within the therapeutic relationship/process humanizes the situation and allows for a better understanding of the patient’s care needs and also it aids the nurse in relieving their stress and anxiety. Humor as a term is influenced by many factors mostly personal such as gender, age and personality and although its applicability is highly recommended, it should be used cautiously personality following some conditions and there might be barriers that may prevent using it.

Ethics

Although this study did not involve people directly, ethical procedures were guaranteed.

Conflicts of Interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

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