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Art & science If you would like to contribute to the Art & science

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The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson

Using humour to enhance the


nurse-patient relationship
Tremayne P (2014) Using humour to enhance the nurse-patient relationship.
Nursing Standard. 28, 30, 37-40. Date of submission: October 8 2013; date of acceptance: November 28 2013.

response, which has multi-dimensional value in


Abstract cancer care. It can result from the recognition and
The appropriate use of humour is a valuable asset in nursing practice. expression of incongruities of a comic, absurd and
Used daily in interactions with patients, humour can help to develop impulsive situation, remark, character or action,
the therapeutic relationship and build resilience. This article discusses which enables feelings of closeness or togetherness
how humour can promote physiological and psychological wellbeing, when shared in the context of trust between the
while reducing stress and anxiety. Recommendations for including patient and nurse. Used throughout the working
humour in patient care are outlined. day, humour can help to create a natural
connection during patient interactions, which can
Author have holistic benefits.
Different types of humour may be relevant in
Penny Tremayne
different situations and to different people. For
Senior lecturer, Faculty of Health and Life Sciences,
example, children, older people and those with
De Montfort University, Leicester.
a learning disability may appreciate humour
Correspondence to: ptremay@dmu.ac.uk
that contains imagery, while the use of visual
aids or song may stimulate greater engagement
Keywords (Williams et al 2009, Killick 2010, Pryor 2010).
Communication, humour, resilience, therapeutic relationships, wellbeing McCreaddie (2010) described harsh humour,
which lacks aesthetic appeal and is ostensibly
Review unrefined and vulgar. This type of humour may
be used therapeutically to enhance healthcare
All articles are subject to external double-blind peer review and
interactions with disenfranchised groups such as
checked for plagiarism using automated software.
drug users (McCreaddie 2010). Williams (2009)
suggests that such male banter can have an
Online element of competitiveness within it, highlighting
Guidelines on writing for publication are available at for example how fathers use it to avoid disclosing
www.nursing-standard.co.uk. For related articles visit the archive their vulnerability, which can exacerbate stresses
and search using the keywords above. and strains.
Ford et al (2011) considered how children who
were given the opportunity to contribute to a
THE USE OF humour may appear slightly at odds childrens nurse job description stated that they
with The Code (Nursing and Midwifery Council must be able to make me laugh, have a smiley face
2008), which focuses on professional behaviour and be funny. While nurses are not necessarily
and practice. However, humour can enable the natural comedians, they may be involved in
nurse to treat people as individuals and develop interactions with patients that can provoke
the therapeutic nurse-patient relationship. gentle amusement and even laughter.
According to Tanay et al (2013), humour is a form Humour and laughing should be used with
of communication and is a subjective emotional caution, however, and implemented appropriately.

NURSING STANDARD / RCN PUBLISHING march 26 :: vol 28 no 30 :: 2014 37


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Art & science communication

McCreaddie (2008) advised that humour A perceptive nurse should acknowledge this
is inappropriate in psychological crises and fear and help to reduce the feeling by discussing
emergency situations. Williams et al (2009) it with the patient and informing him or her
advised against the use of humour following recent about the forthcoming surgery. Humour can be
abdominal or brain surgery and with symptoms a useful coping strategy during what can often
such as nausea and vomiting. Humour is personal, be a vulnerable time in a persons life (Moore
so sensitive areas that could compromise an 2008). For example, adjusting to life following
individuals morals and/or ethics should be a stroke and its many potential biopsychosocial
avoided, for example ethnicity, politics, sex and implications can be overwhelming for the patient
religion (McCreaddie 2008, 2010). and his or her family. Using humour to raise the
patients spirits can offer a distraction and may
ensure that a positive and encouraging approach is
Physiological and psychological benefits adopted (Pryor 2010).
Physiological Killick (2010, 2011) described an initiative that
Being in a healthcare setting can induce physical used improvised drama and humour. Funshops
and psychological stress. Graham (2010) were run in five centres 18 staff members and
summarised some of the positive physical 44 individuals with dementia took part in various
effects of laughter, such as improving immune, exercises and sketches. The aim was to relax
cardiovascular and respiratory function; people, giving them the opportunity to express
neutralising stress hormones and increasing the their thoughts and feelings, and to laugh. This
relaxation response; assisting with pain relief; initiative offered the participants some respite
lowering blood glucose levels after a meal; and from their difficulties and created a sense of
releasing endorphins, serotonin and dopamine. community by connecting with people.
The release of dopamine can promote positive
thinking and creativity, and reduce depression
(Old 2012). Social effects of humour
Using humour to invoke laughter can lower Humour can assist bonding on a personal level and
serum cortisol levels while increasing the number can be applied to clinical practice. Pryor (2010)
of T-cells and natural killer cells in the immune considered that an inclusive form of humour
system, thereby reducing stress levels (Old 2012). one that actively encourages patients to interact
The physical act of laughing can relax muscles with and support one another can result in a
and provide an effective internal massage to the camaraderie and beneficial peer support. This
digestive tract, as well as enhancing blood supply may be especially helpful for those patients who
to vital organs, including the liver, kidneys, are new to the clinical environment. Creating
spleen, pancreas and adrenal glands (Old 2012). an atmosphere in which patients feel safe and
Some patients may benefit from laughter yoga comfortable is something that nurses may take
this therapy combines laughter exercises and for granted, however, it can be beneficial to their
yogic breathing. While this is a more formalised health and wellbeing. Pryor (2010) explained that
approach in as much as the laugh may be forced, humour and laughter help to create a light hearted
the ethos is that the body will reap positive benefits atmosphere, which encourages patients to be
in terms of health and wellbeing because it cannot positive and happy. This is particularly relevant
distinguish between fake and genuine laughter in certain settings, for example keeping patients
(MacDonald 2004). spirits up can enhance the rehabilitation process
(Pryor 2010).
Psychological Using humour can also assist in promoting
Humour can be used as a coping mechanism health to groups who are difficult to engage with
during stressful situations (Tanay et al 2013). (Foster 2012). Oliffe et al (2009) described how
Reducing stress and anxiety through humour humour was used at prostate cancer support groups
and laughter can enable emotions to be released to introduce sensitive cancer-related issues such as
and increase a persons ability to cope, enhance urinary incontinence, erectile dysfunction and death.
memory, and increase self-esteem, optimism and However, it should be noted that while this form
vigour (Moore 2008, Oliffe et al 2009). of humour can create male banter that is valued
Davis-Evans (2013) considered how humour can by many, sometimes such an approach may inhibit
be assessed to identify any underlying messages those who have shared personal information or an
in patients undergoing surgery. Patients may hide experience only to feel belittled or embarrassed.
behind the facade of humour and use it effectively Caution with levity is therefore essential
to open up by making a joke about being scared. to prevent compromising a patients future

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engagement in the process. Old (2012) explored are especially relevant for children when they are
how male patients may use humour to conceal engaged in a challenging and complex environment
their feelings, finding it difficult to express their such as a hospital (Ford et al 2011).
fears and suggests that they would find it easier
to discuss difficult matters with a nurse who has
a sense of humour. McCreaddie (2010) described Benefits of humour to healthcare staff
how patients humour in health care may differ The Royal College of Nursing (2005) has
from their normal humour, being more rehearsed acknowledged that nursing is a stressful profession
and less spontaneous. that places many physical, mental and emotional
Humour may also be beneficial for patients demands on nurses. Using humour may be a way
and staff coping with tense and sad situations. of enhancing job satisfaction by ameliorating the
While it seems contradictory that humour is demands placed on nurses. MacDonald (2008)
used in palliative care, a genuine connection outlined that for nurses to be effective and deal
between patient, nurse, and family or carer, can be with stress, time needs to be made for fun and
formed through sharing humour. Becker (2003) laughter, not only with patients but also with
explained that humour can embrace the essential colleagues and peers. Using humour and laughter
qualities anyone caring for a dying patient should as an emotional outlet may enable nurses to cope
demonstrate: warmth, compassion and humanity. with some of the difficult, painful and testing
Finding a commonality such as humour can foster situations they encounter (McCreaddie 2008).
rapport and communication, as well as helping Humour may contribute to a better overall
patients to face taboo subjects such as death and work-life balance, which is essential to resilience
dying. Dean and Gregory (2005) outlined how (Dean 2012). Becoming more resilient is not only
humour and laughter serve important roles in a important for the nurse but also for patients and
palliative care setting. They explained that humour service providers (Tanay et al 2013). Humour
can be used by the multidisciplinary team to can be a useful coping strategy and can help to
provide more meaningful support to patients and reframe and defuse a problem by putting it into
their families in a crisis situation. It can enable perspective. Humour can also enable individuals
communication that goes beyond the superficial to distance themselves from issues that can be
pleasantries and moves towards something deeper troublesome or emotive. While this may present as
and with greater meaning (Dean and Gregory a faade of partial disengagement from a problem,
2005). Humour can help preserve dignity even in it can also encourage problems to be shared, with
undignified circumstances and can acknowledge humour acting as a disguise to address problems
the person and his or her family as individuals. in a less confrontational manner (Grugulis 2002).
Grafton et al (2010) considered humour to be an
innate characteristic that helps people cope with
Humour in nursing interventions and recover from adversity.
Duffin (2009) discussed how nurses may focus Chinery (2007) outlined the benefits of
on the more task-oriented side of nursing at humour in developing team cohesion and in
times. In doing so, opportunities that can assist acting as a safety valve for nurses. For example,
in developing a therapeutic connection between in a theatre setting gallows humour is often used
the nurse and patient may be overlooked. as a means to relieve stress and tension (Chinery
An element of levity can be introduced if 2007). Dean and Gregory (2004) explained that
appropriate, helping to promote rapport. humour can lighten the working atmosphere and
Humour can be a positive distraction, for assist in developing closer working relationships
example when undertaking a clinical procedure with colleagues.
such as a wound dressing, or when undertaking Stein and Reeder (2009) suggested that at times
personal care. Humour can be a useful conduit nurses can take themselves too seriously and would
to communication with a patient and therefore benefit from recognising the healing effects of
influence all stages of the nursing process. laughter on their overall health and wellbeing.
Some authors have explained how laughter They recommended that educators need to
and humour can assist in promoting physical encourage novice nurses to laugh at themselves to
comfort (Williams et al 2009). Patients attending remain as themselves in the most difficult of
an inpatient cancer clinic who watched humorous situations (Stein and Reeder 2009). Tanay et al
films appeared to have improved wellbeing, (2013) considered that the benefits of using
demonstrating reduced levels of pain and anxiety, humour in adult cancer care may relate to the
increased comfort, satisfaction and ability to sleep reciprocity between the patient and the healthcare
(Moore 2008). Joke telling and other forms of play team in terms of developing feelings of wellbeing

NURSING STANDARD / RCN PUBLISHING march 26 :: vol 28 no 30 :: 2014 39


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Art & science communication

and happiness, resulting in a more open and closer and requirements, for example 30 minutes of
relationship with members of the healthcare team. comedy daily. By connecting with patients and
In such an enhanced working environment, the getting to know what may make them laugh,
team can work more effectively and may be humour could offer respite and diversion from
happier and more motivated to achieve positive personal anxiety, fear and, in some cases, the
patient outcomes (Tanay et al 2013). monotony of being a patient.

Recommendations Conclusion
Service providers could develop a bank of There can be a tendency to trivialise humour,
humour resources, which could include items however it has several benefits for patients and
such as humorous DVDs or books. Such resources nurses. While it is subtly interwoven in many
could be useful when a patient feels challenged nursing interactions, nurses should consider how
or anxious, or requires some diversion, and this overlooked resource could be used in a more
could be used individually or in a group setting structured and specific manner for patients. Service
(MacDonald 2004). The development of an providers need to recognise that humour and
appropriately located humorous file or bulletin laughter are important and relevant in contemporary
board could also be considered for clinical nursing. Humour and laughter are natural
staff (Chinery 2007). The development and expressions of emotion, which offer a genuineness
implementation of laughter sessions or funshops and authenticity, promoting a more human, mutual
may also be considered for appropriate areas, such and intimate connection between nurses and
as day centres (Graham 2010, Killick 2010, 2011). patients. When used effectively, humour can lead to a
The use of humour prescriptions may be more individualised, holistic and personal approach,
considered this would involve prescribing which may result in patient care being more
humour for patients that is tailored to their needs comforting and ultimately more compassionate NS

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