When things don’t go the way we expect, we have to laugh! Socrates said, ‘As it is not proper to cure the eyes without the head, nor the head without the body, so neither is it proper to cure the body without the soul.’
If you go into a patient room to do the initial assessment, you want to be sure to assess the entire patient. In documenting the assessments, a clock model is used to reference the location of wounds, scars, devices etc. An actual clock does not work with only one hand nor does the body work without key body parts. If we do not address the heart, help to support the spirit and coping elements of the patient, we may ‘heal’ a short term medical problem but have ignored the patients emotional resolve to have long term success. Socrates knew his stuff!
History of Humor
A number of theories have been proposed to define the human condition and its use of humor. The word humor is derived from the Latin umor which means fluid or liquid, to be moist. As early as 2500 BC ancient Chinese, Greek and Ayurvedic medicines linked the body to the earth's elements, which were converted during digestion to three fluids; vatta (wind/breaths), pitta (bile) and kapha (phlegm). In 400 BC Hippocrates helped refine these into four humors which Gelan wrote extensively on in the 2nd century. It was ultimately determined that one’s fluid or ‘umor’ was thought to dominate personality and health problems. It should be the focus of physician and caregivers alike to keep the humor in balance. A diagnosis of ‘good humor’ did not imply the patient was funny, but doing well. Literally 4,500 YEARS later we use these same concepts to make an initial assumption of the patient. If one appears happy, carefree and lighthearted, one is judged to be fine, o.k., doing well and coping well, regardless of any ailment. If you look at the humors I am guessing it reminds you of someone, a patient or family member.
Humor as part of healing
Healing is the focus of medicine. We want to first, do no harm. ‘I shall be loyal to my work and devoted towards the welfare of those committed to my care’ is the last line of the Florence Nightingale Pledge. We see people in need and want to fix them. If we could define genuine success we would see a patient:
- Accept the difficult life situations
- Owning the actions and reactions to them
- Remaining open to others, understanding their point of view or decisions
- Laughing at or with others
- Able to problem solve, make the big decisions
- Empowered to do what is needed.
Adding humor improves the client's self-understanding and behavior such as pointing out absurdities, giving examples of illogical reasoning, or repeating an amusing punchline. Inoffensive humor or joke telling about common experiences can be a safe way to initiate assessment of coping and reduce anxiety. It helps to relieve tension and permit a more transparent conversation as well.
Laughter itself is therapeutic for any number of psychological and physical reasons. Huge to the healing process is the sense of power laughter provides. It is a spontaneous, physical exercise increasing cardiac circulation and pulmonary function. It also fosters a positive and hopeful attitude which can be replicated with each giggle and guffaw. Additionally, there is sound correlation between decreased depression or risk for depression in those populations that can see or express humor.
Perspective is everything. Both humor and the observation of those in situations worse or different than ours helps to keep emotion and acceptance more positively framed. And the most obvious benefit to humor is the ability to endure the uncomfortable emotions and situations that all patients encounter in healthcare settings. Face it, a colonoscopy has a room full of strangers focused on the wrong side of the patient. It is a very vulnerable situation, fortunately rarely critical but always humiliating. That same element of laughter helps when gowns fall open, gases pass and messes are made. I remind every patient that expels ‘anything’ ‘Better out than in!”
When emotions are part of the job
There is a risk to sharing emotions, good or bad, when we are in healthcare. The nurse or doctor can feel the same as the patient, feel failure in our efforts, feel anger and frustration when the patients don’t or won’t listen. We can grieve, often becoming attached to the patients or families, or both. Their loss becomes ours. The weight of day to day care of those in need can even lead to the physical and emotional distress we are trying to help the patients overcome. Planning for humor and those activities that permit decompression are critical if the nurses and providers are going to prevent burnout.
It is very easy to ‘wear’ the emotions of the patients, as well as to become hostile in response to their failure to follow orders. In a single day the nurse or provider can journey through the entire spectrum of emotions depending on each individual interaction that is experienced. One movie character said ‘I don’t just have one emotion. I am an actress, I have them all!’ Healthcare is the exact same. Depending on the patient load cared for each day every emotion can be experienced. This can result in ‘compassion fatigue’ which is the result of not caring for themselves. As a caution, this emotional anchor can also be placed on us by peers who are negative, hopeless, angry, etc. It can be an attack from both sides.
As a result, health professionals working in a stress-filled environment must have and mature the ability to see the humor in a situation and to laugh freely with coworkers and if appropriate patients. It can be an effective way to take care of your own body, mind and spirit. It can lift the spirit's energy level and avoid the complexities of emotional overload. It does not condone cruel, mean spirited or rude jokes but supports the common ground of the human condition.
Patients also have a risk to accepting humor as the stress they experience is not dependent solely on external events, but also on their own perception of what the events mean to them personally. The interpretation of stress is very individual. One person is having an appendectomy and they are smiling, joking a bit, light hearted. Another person, experiencing the same procedure but is very morbid, sad, uncertain of tomorrow. I have always referred to this as the ‘Tigger and Eeyore syndrome’. One person is bouncing off the walls, not touched at all by the circumstances of life while the other is feeling near death by the very thought of it. Basically, how the individual looks at the situation determines if it will be perceived as a threat or challenge.
From a health perspective, the emotions and moods experienced directly affect the immune system. Positive emotions can create neurochemical changes that may buffer the immunosuppressive effects of stress. Studies have demonstrated that when encouraged and guided to use humor there is an increased sense of ‘cognitive control’. They may not be able to control events externally but they can control how they view these events and what emotional response they choose to apply to them.
The solution to shedding the negative and putting on the positive starts simply with reflection. ‘How did we get here?’ To have the best response leave your computer at the door and pull up a chair, 5 minutes! Encourage discussion, emotions, assess the patients view of the situation (threatened or challenged) then help the patient and family to reframe it. Often that is identifying the meaning in the process or chain of events. The patient may feel that coming to the hospital is a punishment for eating the wrong foods when they are diabetic rather than seeing that coming to the hospital is what has caused them to understand the disease, take their diabetes mores seriously. They have the opportunity each day to make new decisions and control their outcomes! That is power.
What is appropriate humor?
So, what exactly is humor? Great question. There is certainly a great diversity in what each person finds funny. Laughter itself is a sound that can occur on its own merit. It does not require a joke, it is the physical chortle that can occur. Humor on the other hand, is the interpretation of what someone says, does, thinks is funny. Your sense of humor is developed in early years by external (parents, teachers) and internal (emotional, spiritual) influences.
Humor cannot always be shared. It is subjective and dependent on personal preference. To use humor for healing, it may take a couple of attempts to find what the patient, family or your colleagues think is funny. Good listening and observation skills can usually provide a sense of connection and idea of typical interactions. No one who has met my family would doubt we deal with life with humor. We tease, joke, find the positive in the ‘negative’ and laugh, often! We choose that reaction to the things we experience and frankly I am so glad we do!
A great exercise is to read some cartoons, bumper stickers, tv shows, etc and see how they make you feel. Were they funny to you? Then ask your social group or peers what they think about those same things. It is an easy and sometimes eye-opening way to get to know each other but also helps to contrast what funny is to the people around you. Of course, it never hurts to just laugh, for practice! There are certainly lots of health benefits. Laughter has been called the latest weapon in the fight against heart disease once the University of Maryland researchers reported that heart-healthy people are more likely than those with heart disease to laugh frequently and heartily, and to use humor to smooth over awkward situations.
There's even hope, the scientists say, for cranky people who rarely laugh and for those without a sense of humor: They can learn! Some evidence suggests that the effects of a chortle, snicker, or guffaw include reduction in stress hormones such as cortisol, and reduction in blood pressure. That in turn may reduce heart disease risk. It has been reported that mental stress can impair the endothelium, the protective barrier lining the blood vessels. Usually, you laugh in a group or with at least one other person (although Clark is quick to point out there's nothing wrong with a good belly laugh when you're by yourself). In his oft-quoted study, published in the American Journal of the Medical Sciences in December 1989, he found that laughter is a good kind of stress: It reduces blood levels of cortisol, epinephrine, and other substances. Increased cortisol and epinephrine levels tend to suppress the immune system, so decreasing their levels is believed to be beneficial. Laughter may go a long way to reducing pain, as well. At UCLA, a five-year program called UCLA/Rx Laughter, in which researchers studied the effects humorous videos have on young patients' perception of pain.
Application of humor
Application of humor should be easy, but clearly many struggle. We are faced with any number of opportunities to lighten the mood, some we may have experienced ourselves in the course of our lives. I have observed some easy examples from the bedside. One was a patient who complained about the inadequate length or coverage of their gown to which the nurse responded: "Well, you know your doctor admitted you for observation." Or on another occasion I heard " It's a designer creation by Seymor (Butts)." Another moment of humor presented itself after a difficult procedure to which the nurse said, ‘I bet it is hard to believe I am on your side!’ By acknowledging the patients circumstance and making a subtle barb can demonstrate confidence and can give the message that it’s ok and you are in control.
To gain confidence in this whole laugh at work concept, there are many books written by former patients, themselves inspired by their circumstance. They found humor and storytelling to be a way to validate their experience and share their perspective. Some personal favorites include:
- Surviving the Cure by Janet Henry
- They Tore Out my Heart and Stomped the Sucker Flat by Lewis Grizzard
- Patients at Large by cartoonist Tom Jackson
- Please Don't Stand on my Catheter by T. Duncan Stewart
- Have a Heart by Wilford Nehmer Jr
- I would like to Buy a Bowel by Brenda Elsagher
George Bernard Shaw wrote "Life does not cease to be funny when someone dies, as it does not cease to be serious when people laugh." I would modify this by saying "Life does not cease to be funny when someone has cancer, as it does not cease to be serious when people laugh." Dr. Bernie Siegel, a cancer surgeon wrote "Show me a patient who is able to laugh and play, who enjoys living and I’ll show you someone who is going to live longer. Laughter indeed can make the unbearable bearable!
Finally, respect the boundaries of humor. It certainly produces a bond between the nurse and the client. It also facilitates rapport and self-disclosure, it helps establish a more collaborative and friendly relationship. That being said we should not forget to be cautious. Humor can be used if the client "invites it". Culture, generation, age, religion, ethnicity, disability and other population factors or differences can influence both the type of humor and the initiation into the nurse patient relationship. By using keen observation skills, you can tell a lot about what would be appropriate for the patient. As the moment presents itself you are able can introduce levity and have some fun, for the patient’s sake and for yours!
Guest Post: Judy Gates, RN, MSN is a Banner Health Clinical Education Director and is accountable for providing managerial and clinical education support. She has worked as a pediatric and trauma ICU nurse and wound care consultant. She is a published author and thought leader.