Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 46(2): 197–205.
A narrative inquiry: How do nurses respond to patients’ use of humour? Gunilla Haydon and Pamela van der Riet School of Nursing and Midwifery, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia
Abstract: In today’s healthcare system where technical instruments and test results are used to implement care it is easy to lose the human aspect of nursing. Personal interaction can get lost and nurses sometimes miss humorous attempts made by patients. Humour is a very personal concept, what one person thinks is funny does not necessarily make another person smile, or might even be hurtful. Humour is an important communication tool for patients as it humanises the nurses, creates a bond and opens communication lines. Humour has the potential to change the hospital experience for patients. The aim of this paper is to highlight the importance of humour in the therapeutic relationship between patient and nurse. Semi-structured interviews were held with four registered nurses and narrative inquiry was used to analyse and present the findings because of its ability to capture human interaction and experience.
Keywords: narrative inquiry, humour, nurse, patient, therapeutic relationship
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umour is part of everyday living and working and as such is also an integral part of healthcare. It is used in every culture and in all aspects of life, and human interaction often includes humour to convey messages, is used as part of group bonding, and to improve quality of life. The humorous interaction between patient and nurse has a potential positive impact on the therapeutic relationship (Astedt-Kurki & Isola, 2001; Chinery, 2007; Dean & Major, 2008; Moore, 2008). This research has focussed on the spontaneous use of humour without pre-emption that appears in conversation in the clinical setting.
Background Humour is a diverse and multi-faceted word used to describe something humans find funny or entertaining. Humour can also be seen as a social process and a unique way of communication as well as a personal trait (Chinery, 2007). A reason to use humour in health is described by Astedt-Kurki and Isola (2001, p. 452) ‘Humour indicates mental wellbeing and reduces the impact of negative factors and difficulties.’ MacMillan online dictionary describes it as ‘the quality that makes a situation or entertainment funny’ and ‘the ability to know when something is funny and to laugh at funny situations’ (Humour, 2009). This description shows the many facets of humour as it indicates not only the physical attributes of humour but also the need to be able to interpret something as humorous.
Patient-initiated humour may well be used to alleviate stress or insecurity as well as initiate communication with the nurses (Astedt-Kurki & Liukkonen, 1994). Humour can help the patient cope and adjust to a different and often life limiting situation (Moore, 2008). Humour can support the patient to relay emotion and help maintain their dignity (Astedt-Kurki, Isola, Tammentie, & Kervinen, 2001; Astedt-Kurki & Liukkonen, 1994; Moore, 2008). Patients’ might use humour to challenge the nurse and ask questions without undermining the nurse’s authority (Mallett, 1993; McCreaddie & Wiggins, 2008). Anger and frustration can be dealt with by using humour. To express discontent in a socially accepted way, humour becomes a healthy coping mechanism (Buxman, 2008). Although the beneficial attributes of humour are many, humour can be derogative and hurtful in some situations and caution is needed in the application of humour (McCreaddie & Wiggins, 2008). Adamle, Ludwick, Zeller, and Winchell (2008) noted the ‘missed communication’ in their study. They found that patients used humour to communicate with their nurses but their attempts were missed or ignored by the nurses. During their investigation of nurse’s response to, and recognition of patient-initiated humour, they found that although nurses recognised the humorous invitation to engage in a dialogue, this was not necessarily followed by a conversation (Adamle et al.,
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2008). Dean and Major expressed the importance of patient-initiated humour as a way for the patient to communicate their anxiety, stress or embarrassment. The authors argue that use of humour is not to create a light hearted conversation but an attempt to minimise their feelings of dehumanisation. If the patients attempt to inform the nurses in this ‘light hearted’ way goes unnoticed, or does not create a response, this might inhibit the nurse–patient relationship (Dean & Major, 2008). While working in the clinical setting the primary author noted an obvious difference in patients’ behaviour depending on how nurses responded to their humorous antics. Patients seemed more settled in a humorous environment. This observation prompted a literature search and although there is much written about humour in healthcare, little is written about spontaneous humour, or the patients input to the therapeutic relationship. The literature review gave the motivation to the research question: How do nurses respond to patients’ use of humour? Aims and objectives The aim of this paper is to report on four Registered Nurses perceptions of patient-initiated humour; how they and nursing colleagues react to patients humour in the clinical environment. Research methods In this exploratory study four registered nurses were recruited from a local hospital. The participants met with the researcher for an interview of approximately 60 minutes. The semi-structured interview was recorded and later transcribed. Data collection ceased when sufficient data was gained to answer the research question. The transcribed data was coded and clustered in groups to be transformed into narrative text using narrative inquiry as a framework. Research question This research asks the question ‘How do nurses respond to patients’ use of humour?’ Research methodology Narrative inquiry Narrative inquiry was chosen as the preferred research methodology due to its ability to capture 198
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personal experiences that are difficult to describe in facts and figures (Hardy, Gregory, & Ramjeet, 2009; Lindsay, 2006; Warne & McAndrew, 2010). Narrative inquiry has the advantage of revealing complex layers of information with descriptions, binaries and stories linking past, present and the future with the cultural and social environment (van der Riet, Dedkhard, & Srithong, 2012). These consciously told stories support their own view of their reality and exclude events that are not comparable with their present interpretation of themselves. While their experiences and environment change so will their stories (Sinclair Bell, 2002; Warne & McAndrew, 2010). Narrative inquiry allows participants to reflect life experiences in their story as well as the social environment where it was experienced. This methodology also includes the researcher as an active participant in listening to the story being analysed (Clandinin & Connelly, 2000; Lindsay, 2006; Sinclair Bell, 2002; Warne & McAndrew, 2010). The stories people tell are influenced by past experiences, social background and current situation, including social network, working and living space and to whom they are telling their stories (Lindsay, 2006). Importantly, these stories are shaped by the interaction with the researcher and the participant. Narrative framework Using Clandinin and Connelly’s (2000) framework to present the findings, the participants’ stories have been explored using the contexts/dimensions of temporality, sociality and spatiality. Temporality in narrative inquiry considers the constant repetition of stories and how the story changes from the past, present and in to the future. Stories are frequently written and rewritten over time. The things we tell in our stories are what we find important and remember from our past, may it be many years ago or yesterday. As we tell our story, we also consider what implications the story will have for our future (Clandinin & Connelly, 2000). Sociality considers the individuals relations towards other people and how the story changes
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How do nurses respond to patients’ use of humour? depending on who receives the information and their reaction to it. The researcher is looking at the personal–social dimension, inwards–towards feelings, hopes, reactions and moral decisions and also outwards–towards our social network and personal connections (Clandinin & Connelly, 2000). Spatiality suggests that the story has a physical space where it takes place which also influences the story and how it is told. The place where the story is spoken also influences how the story is presented (Clandinin & Connelly, 2000). These three domains give structure to narrative inquirer’s analysis. Within this framework, four directions were considered in analysis of the data: Inside, outside, backwards and forwards; inwards to find the emotions and feelings, outwards to examine surroundings and social conditions influencing the story. Transitions backwards and forwards in time were used to examine changes of emotions within the story (Clandinin & Connelly, 2000). Ethical considerations The study was approved by the university’s ethics committee and the local area health’s ethics committee. Participation in this study was voluntary and no coercion was used to find participants. Pseudonyms have been used in the transcribed material to protect identity of the participants. Data findings The interviews were transcribed verbatim by the researcher. Attending to participants stories was an important part of this inductive process. First conversation The first story introduces Johanna. Johanna is the nurse with least nursing experience as she graduated as a Bachelor of Nursing in her late thirties 2 years ago. Johanna’s story I class humour as something that makes you laugh. Really something that makes you laugh, to feel better. In nursing that’s where humour is used most of the time. Patients use humour in hospital all the time! I
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think patients definitely use humour for stress relief and as an outlet of emotions. To help break down that barrier they have when in hospital. They are scared, they want to establish communication and discharge negative emotions. They are trying to keep it light, keep it positive. Patients use it as a defence mechanism. When patients use humour I try and go along with it as much as I can. Sometimes I find that difficult because I do not understand. The humour might be inappropriate. You try and read what is happening for them and what they actually want. I try to respond as they would like me to respond because that is OK for me to do that. If that makes their journey a little bit better, I usually go along with it. I have experienced where I did not realize until later it was something funny. You have to be quite witty to go along with humour and if you are busy you do not have time to be humorous. Sometimes it is all about time restraints. Humour is extremely important in the therapeutic relationship. Humour, it’s what gets nurses and patients through the hospital experience. I believe it just makes things better. You can have a four bedded room all bouncing off each other laughing. They all have life threatening illness and yet they are coping because they are laughing. The humour is not just between each other, if you walk in to that room as a nurse, you pick up on that and you just flow with it. They are all communicating and it is a really lovely atmosphere to be in. I have seen it happen where if you take over from a nurse, who may be having her own dramas and has not responded to their humour. They’ll go “That last nurse, she was not very nice” they misinterpret it for you not being polite. I think for them it is their ‘little light’ and it is very important to work with it. If you walk in there and just task orientate without interacting with the patients’ you have lost it before you even started. The patients definitely figure you out as a nurse and those first minutes are when they decide how they will treat you, what kind of a nurse you are. And if they decide to use humour and you do not get it – you have to do a lot of sucking up. I have seen my colleagues miss the humorous attempts and that is why I know that it does not go down very well. Not communicating, not responding, they pick up on it and they feel like you think they are nonimportant. By interacting with them they feel important and you see them as individuals.
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Gunilla Haydon and Pamela van der Riet Sometimes it is culturally inappropriate to use humour or if a patient weren’t offering humour to you. As much as I see humour all the time, I see patients that don’t use it. In some instance a little bit easier to look after the patients’ that are humorous, but when you walk in to that room it is going to take a little longer with a humorous person. Where someone who do not want to chat much, is a little bit more reserved, you walk in, explain what you are doing, do the job and walk out. Another time when you definitely would not use humour is to parents with sick children. They are too worried and scared. Humour in those situations would be very inappropriate. I think that males use humour a lot more, like a joking kind of humour. Females use it for other reasons, to keep the family OK and not worry people. Definitely males use humour much more than females. Sometimes the male humour is a little derogative. I am not offended because it is just in the name of humour. Sometimes the humour can change and be a little bit sleazy. Humour like that would be the only time I would not respond. I do not go along with it but I don’t pull them up about it.
a Registered nurse she has noted the difference in the patients’ behaviour if their humorous attempts go un-noticed or does not get a response from the nursing staff. There is a noted difference in patients’ behaviour in regards to their surroundings. A patient in a single room seems to be more dependent on the nurse compared to a patient in a multiple bed ward. Josephine realise the need to interact and respond and not only be task oriented while performing her nursing duties. Josephine’s story also points out the differences in gender. Males use humour more often in, sometimes not, such a therapeutic way: Their humour sexualises nurses and the context of the care they deliver. Second conversation The second nurse is Katherine. She is in her early fifties and has 30 years nursing experience. Katherine’s story
Patients in single rooms can be very quiet and do not want to talk, other times they are happy and want to joke all the time. With the mixed wards, I do not know how many times I have said ‘you are going to be a thorn amongst the roses’ to patients’ because you have to break that up. It is not nice to be in a four bed ward with males/females. Although we have had some quite funny things happen where people have struck up a relationship as far as chatting and have even had people say ‘oh be careful, she might join you later tonight…’ and laugh it off.
Humour is laughter, happy, joyful. A good belly laugh is great. It is therapeutic. It is therapeutic for the nurses too. I think males use humour more than females. Depends on the situation, sometimes it is just a male thing with the female nurses. Just to see your reaction.
Humour is so subtle, even though humour happens so often it is kind of like that fly by night thing that happens and comes and goes. You do not retain it unless you need to. I am much more aware of humour and how it is happening now. I have been looking out for it so in the last week I have noticed so much more.
We have had some very young nurses. They have no life experience. It is obvious they do not know how to take patients. They will just stand there and think – What am I doing? … and the patient are going – What is she doing? A nurse who laughs and talk all the time, they can relate to the patients and the patients like that.
Reflection and analysis Johanna’s narrative demonstrates that she is quite aware of the use of humour. She is sensitive to the patients’ reactions and feels disappointed if she misses their humorous attempts. She does her best to accommodate the therapeutic relationship even if it infringes on her own personality and values. Although fairly new as
It is not only experience that influences the nurses’ ability to respond to humorous attempts. Some of the foreign nurses are very difficult to understand, there is no reaction from them because they do not quite understand our Aussie humour and that makes a BIG difference. It is a cultural thing as well. It is difficult with the mixed cultures. We do not notice it as much here, but in the cities it is a problem. I have nursed in the cities and I find it is very different.
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It depends on how you get along with the patient how you respond to their humour. Sometimes you are too busy you do not have the time to have that humour with that patient. If the patient does not get a response they think “what is wrong with her” “can’t she laugh.”
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How do nurses respond to patients’ use of humour? Patients, they do use humour to see what type of nurse you are and you will find a lot of nurse these days coming in to it have a very dry sense of humour. It makes it easier to look after a patient who is happy and laughter and chatty. I think if you got a room, let say you got a room full of men, they are bantering across from each other, and you get involved that makes for a better day as well. In the single room you do not interact with the patient as much, unless that patient is a joyful person anyway. It depends on a lot of things. Sometimes the mixed wards works, sometimes it does not, depending on the age and gender. It can be a good thing because they watch out for each other. It is tricky you can see the difference in the mix of patients. Years ago you would not joke with oncology patients’ but these days it makes their journey a bit easier if you have a laugh. I think it is therapeutic because it is a good medicine, it is good healing and you find that people that are happier get better quicker than those people who are miserable, unhappy and you think, ouch. A place you would never find any humour is when patients are in pain, when they are constantly in pain. Life-threatening things – there is no humour in that so that is another time where you would not use humour.
Reflection and analysis The enthusiasm Katherine shows while talking about humour demonstrates she is aware of the importance of humour, how it can heal and support patient’s hospital experience. Katherine talks about the significance of humour and how difficult it is for young inexperienced nurses to find the mental security to engage in the patients attempt to have a humorous conversation. Cultural differences both for patients and nurses are also discussed and how humour is often misunderstood. Katherine, like Johanna, talks more about the male patients and their humorous traits. Similarly she discusses the impact of time constraints preventing nurses from seeing the subtlety of humour and its effect on therapeutic interaction. The difference in patient behaviour in single, multiple and mixed wards are noted. Katherine understands patients dislike for mixed wards however she also sees the necessity of them. Katherine also reminds us that humour is not acceptable for some patients, for example when patients are in pain and for oncology patients.
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Third conversation Madison is a middle-aged confident woman. She worked as an endorsed nurse for 20 years before she decided to continue her education and has been a registered nurse for 8 years. Madison’s story Humour is something that lightens the mood, is a way of connecting. It is a communication tool. I think patients use humour. It is a way of connecting with the nurse. Depends on the situation and the person how I respond to their humour. I think they are more open in four bedded rooms so there will be more humour there, whereas a single room is very intimate. I think as a communication and a relationship building tool it is very important. It is a ‘leveler’. It brings the nurse down from a position of authority. I think Australian culture has a bit of larrikin to it. It is our way of not taking our self so seriously. Men are much more humorous compared to women. I do not know if it is a gender thing because in hospital the nurse is in a position of power. Women can have a laugh but the humour is different, men tell stories and women just find something instantaneously funny. They are trying to work you out and see how you are reacting. Whereas woman on woman, we know each other’s thinking’s and it is very brief moment. Sometimes colleagues miss when a patient tries to be funny. The nurse was not that aware or conscious of the patient. Maybe she did not want to establish that connection with them. It could be the experience of the nurse. In my personal opinion it is a time management skill – if you are going to talk to a patient and discuss whatever they find funny, it takes time, if you cut them off you can move on. The patients’ change when you do not respond to their humorous invites. If a nurse does not respond the way patients intended, the patient will often comment ‘oh, that nurse before she is cold’. You really notice it. Your reaction to their humour makes a hell of a difference. Sometimes there are inappropriate remarks and rude comments. If it is rude or insulting you use your communication skills to stop that. I think sexism, bigotry and things like that, is very rife in the older Australian male. Especially since we are a female led profession there is a lot of chauvinistic attitude. They are trying to have a laugh and be funny but are actually putting you
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Madison sees the atmosphere in the multiple bed wards to be more conducive to humour.
Different culture groups too, Chinese people may not see our side of humour or what we find is funny, is not funny to them.
Fourth conversation The last interview was with Samantha. She is in her late fifties and has a lifelong experience in nursing.
You have to maintain your professional boundaries and I think more experience helps. It is like clinical experience, nursing diagnosis. But generally on the whole you have more of a good time with male patients. They are rougher full on, more larrikin than the female patients. It is interesting it is such a huge difference between males and females. I have actually never thought about it before. If you have a mixed ward, I think it is very demeaning. It is very impersonal and that’s when you see humour, to make it easier. Often with young men it is trauma injury anyway so there is a lot of pain involved and there is no time to be humorous. When they are in excruciating pain there is no humour. If they have been given a death sentence and they are trying to rally up what they need to do then they got a lot on their mind then there is not time for humour. This conversation made me aware of things I had never thought before. I think it is an Australian culture thing and because we are so multicultural you need to be aware about it. On the whole I think Australians are ‘larrikins’. I think humour is a survival mechanism for nurses and patients. It is a survival thing for them as well as a coping mechanism.
Reflection and analysis Madison’s story tells more about male patients and how they use humour to connect with the nurses. However, male patients often use it inappropriate ways to capture the nurses’ attention and exercise power. She sees nurses to be very strong and powerful. The cultural appropriateness of humour is discussed and she considers the specific Australian larrikin way of expression as an important way to understand patients. Once again Madison sees the nurses experience as important in how well they can interact with the patients humorous invitations to engage. Again time constraints are mentioned as an important factor to inhibit the humorous interactions. So are the patients’ surroundings. Compared to the environment of the single room
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Samantha’s story Humour is having fun. Banter with your patients backwards and forwards, that is what humour means to me. It makes you feel good. I think patients use humour in the hospital. Sometimes people use humour to mask their self. Maybe they are insecure too, maybe they are lonely. A nurse that is humorous brings out the humour in patients. If you got a nurse that is a bit stale, patients do not want to have a bar of them really. Its better interaction, better results and people become more compliant when you’ve got humour between you. Not everyone likes humour and some people use sarcastic humour. Occasionally I come across derogative humour. I never as a nurse take anything personally. I am pretty out there with the humour and the jokes and I rarely miss anything. I do notice it when my colleagues do. The younger nurses especially, it just goes over their heads. When it comes to single rooms I think they should be kept for the very ill. I think a ward is better. You get four blokes together in one room, roughly the same age, they can watch footy and talk about men stuff. They are not too bad the mixed wards. More often than not they are quite happy to be in a mixed room. They are not AS humorous as if it were four females or four males. I think the males are probably more humorous. I have nursed some funny ladies as well. If the nurse does not respond when the patient is trying to say something funny they change. When no one is responding to their banter and humour they are going to pick up on that. Most of the time they will be non-compliant – usually as a payback. They judge their nurses, too. They judge who you are, what you do for them, how you speak to them, how much time you spend with them. They say less to someone that is not as humorous. You’ve only got to be in a room an hour or so and they pretty much can tell what kind of person you are. If you are humorous they tell you more. To them it is really not a joke but they are just bringing it across in a way that they do not feel vulnerable. At the end
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How do nurses respond to patients’ use of humour? of the day they will only tell you what they want you to know. Who knows why they use humour. Cover up maybe. I rather look after a humorous patient any time. You will not be full of bloody humour if you got a death sentence are you. Last thing they want to do is laugh about it really. But sometimes it is better to laugh than to be miserable and cry.
Reflection and analysis Samantha is very proud to be a nurse and she talks about her patients’ with passion and warmth showing her empathy towards them. Her story follows the previous nurses themes although she also talks about female patients as humorous but like the others think male patients use humour more than females. In her story she talks about how humour is used for a variety of reasons and how personal humour is. She considers patients in the multiple bed wards to be more humorous and better for the patients as they can interact with each other. Samantha is well aware of the wide variety of patients that has come her way and how she interacts with them in her humorous manner. Samantha considers humour to be an important therapeutic tool in the interaction between patient and nurse and can see the positive aspects of its use on the ward. Discussion The researchers’ story In this narrative inquiry study, the nurses’ voices shines through to allow their personality to be part of their story. Although they are very different as individuals there are common themes that spans across all of their stories. The appreciation of humour is obvious together with the therapeutic nature of humour. They all agree humour makes you feel better and improves health outcome although the perceived positive influence humour has on health is accepted it is not yet confirmed (McCreaddie & Wiggins, 2008). During the interviews it was surprising to hear the male dominance as a plot line in the stories. The absence of the female patient was quite noticeable. Male patients are perceived to
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use humour more and it seems more important for males to build a relationship with the nurse. Lawler (1991) writes how masculinity and power is closely related. Humour is an important communication tool for the male patient, however, there can be a negative aspect in that sometimes there are derogative, inappropriate, sexist comments dressed up as humour (Lawler, 1991). The stories confirm that men tend to use humour to express concerns and fear about their health and to hide embarrassment (Williams, 2009). They can also use humour as a defence mechanism and to avoid or postpone a serious conversation (AstedtKurki et al., 2001; Astedt-Kurki & Liukkonen, 1994). The first encounter seems to be a crucial moment in the therapeutic relationship. If the nurse does not respond to the humorous invitations to interact from the patient not only may they become non-compliant to the requests from nursing staff, they also appear to become the topic of conversation between the patients. The patients’ behaviour seems to be a reflection of their perception of the nurse and their surroundings. Lawler (1991) and Astedt-Kurki et al. (2001) emphasise how patients use humour to influence their care and interaction with the nursing staff. All four nurses noted how colleagues missed humorous invitations to engage. Although nurses are aware of patient-initiated humour it is not always responded to. Time constraints or personality clashes are two obvious reasons. Inexperience and task orientation are also factors preventing nurses from responding to a humorous invitation. It was also revealed that humour is not used when a patient is in pain, in life threatening situations or towards parents with sick children as this could be seen to be very offensive. Caution was also needed when dealing with different cultures as humour is culturally specific and can be interpreted as insulting or derogative depending on cultural background. Dean and Major (2008) suggest that nurses should trust their instincts as to whether humour is appropriate or should be avoided. They argue that nursing ‘is enhanced when nurses allow themselves
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to be natural and rely upon their emotional intelligence’ (p. 1095). Yet another dimension of humour revealed in all conversations is the interaction between patient and nurse depends not only on personality but also on dormitory context: Single room or multiple bed wards; mixed or single gender rooms; they change the dynamics of how nurses and patients use humour. The use of humour is perceived to be more common in multiple bed wards. In the analysis of this study the dimensions of temporality (time), sociality (others) and spatiality (environment) are intertwined in participants’ narratives. In the stories, the nurses express how sociality and spatiality is a major factor in how humour is perceived. Humour is different in the single or multiple bed wards. The social norms in the mixed ward can hamper the humorous interactions. Temporality can be seen in the stories as limiting factor where the nurses do not have time to engage in the humorous invites from the patients. The culture of both interviewer and interviewee being nurses may influence how the stories have been told. The culture of others is a thread within the dimension of sociality. The three dimensions also influence how the stories have been told to the researchers. Conclusion With patient-centred care in focus the interaction between nurse and patient is an essential aspect of nursing care. It is commonly accepted, though not proven, that humour is beneficial to health (McCreaddie & Wiggins, 2008). The findings from this study imply the diversity and multiple uses of humour. Nurses’ response to patient-initiated humour often depends on time constraints, the experience of the nurse, and the environment in which the nurse–patient interaction occurred. In summary the following findings from this study provide valuable knowledge to nurses in practice. Humour is an important part of the therapeutic relationship and has a perceived positive influence on health. Nursing staffs’ experience impacts on their awareness
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of humour and their responses towards the patients as the humorous invites often are subtle and very fleeting; ‘caught in the moment.’ The interviews revealed that time constraint is an important factor affecting nurses’ responses to humorous invitations and that patients’ feel undervalued as individuals if their humorous attempts go unnoticed. Gender differences were seen in this study with humour playing an important communication tool more so for males’ patients than female patients. Importantly, if humour is responded to appropriately by the nurses it can potentially change and improve the hospital experience for the patient and nurses. The interaction between patient and nurse depends not only on personality but also on the spatial environment of the ward i.e., a single room or multiple bed wards, mixed or single gender rooms can influence how humour is perceived. Humour is culturally specific and can be seen as insulting or derogative depending on cultural background. When a patient is in pain, in life threatening situations or towards parents with sick children humour is commonly not used. Humour is an important communication tool for the patients and can if responded to appropriately by nurses potentially improve the hospital experience for both patients and nurses. Humour not only humanises the nurses, it also creates a bond and opens communication between them and the patient. Increased awareness amongst nurses in the use of humour could improve patient satisfaction. These narratives arising from this research confirm the value of using of humour in the clinical setting. Furthermore as McCreaddie and Wiggins (2008) write ‘Humour, somewhat paradoxically, is something that is generally not taken seriously. Yet humour could be the fulcrum for establishing the relationship that the individual patient desires’ (p. 591). Acknowledgement The research supporting this manuscript has not been supported by any source of funding.
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How do nurses respond to patients’ use of humour? References Adamle, K. N., Ludwick, R., Zeller, R., & Winchell, J. (2008). Oncology nurses responses to patient- initiated humour. Cancer Nursing, 31(6), E1–E9. Astedt-Kurki, P., & Isola, A. (2001). Humour between nurse and patient, and among staff: Analysis of nurses’ diaries. Journal of Advanced Nursing, 35(3), 452–458. Astedt-Kurki, P., Isola, A., Tammentie, T., & Kervinen, U. (2001). Importance of humour to client–nurse relationships and clients’ well-being. International Journal of Nursing Practice, 7(2), 119–125. Astedt-Kurki, P., & Liukkonen, A. (1994). Humour in nursing care. Journal of Advanced Nursing, 20(1), 183–188. Buxman, K. (2008). Humour in the OR: A stitch in time? Association of PeriOperative Registered Nurses, 88(1), 67–77. doi:10.1016/j.aorn.2008.01.004 Chinery, W. (2007). Alleviating stress with humour: A literature review. Journal of PeriOperative Practice, 17(4), 172, 174, 176–179. Clandinin, D. J., & Connelly, F. M. (2000). Narrative inquiry. San Francisco, CA: Jossey-Bass. Dean, R. A. K., & Major, J. E. (2008). From critical care to comfort care: The sustaining value of humour. Journal of Clinical Nursing, 17(8), 1088–1095. doi:10.1111/j.1365-2702.2007.02090.x Hardy, S., Gregory, S., & Ramjeet, J. (2009). An exploration of intent for narrative methods of inquiry. Nurse Researcher, 16(4), 7–19. Humour. (2009). MacMillan dictionary. Retrieved from http://www.macmillandictionary.com/dictionary/ british/humour
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Lawler, J. (1991). Behind the screens. Nursing, somology, and the problem of the body. Melbourne, VIC: Churchill Livingstone. Lindsay, G. M. (2006). Experiencing nursing education research: Narrative inquiry and interpretive phenomenology. Nurse Researcher, 13(4), 30–47. Mallett, J. (1993). Use of humour and laughter in patient care. British Journal of Nursing, 2(3), 172–175. McCreaddie, M., & Wiggins, S. (2008). The purpose and function of humour in health, health care and nursing: A narrative review. Journal of Advanced Nursing, 61(6), 584–595. doi:10.1111/j.1365-2648.2007.04548.x Moore, K. (2008). Is laughter the best medicine? Research into the therapeutic use of humour and laughter in nursing practice. Whitireia Nursing Journal, 15, 33–38. Sinclair Bell, J. (2002). Narrative inquiry: More than just telling stories. TESOL Quarterly, 36(2), 207–213. van der Riet, P., Dedkhard, S., & Srithong, K. (2012). Complementary therapies in rehabilitation: Nurses’ narratives. Part 1. Journal of Clinical Nursing, 21(5–6), 657–667. doi:10.1111/j.1365-2702.2011.03852.x Warne, T., & McAndrew, S. (2010). Re-searching for therapy: The ethics of using what we are skilled in. Journal of Psychiatric & Mental Health Nursing, 17(6), 503–509. doi:10.1111/j.1365-2850.2009.01545.x Williams, R. (2009). ‘Having a laugh’: Masculinity, health and humour. Nursing Inquiry, 16(1), 74–81. doi:10.1111/j.1440-1800.2009.00437.x Received 06 February 2013
Accepted 17 June 2013
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A narrative inquiry: How do nurses respond to patients’ use of humour? Gunilla Haydon and Pamela van der Riet School of Nursing and Midwifery, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia
Abstract: In today’s healthcare system where technical instruments and test results are used to implement care it is easy to lose the human aspect of nursing. Personal interaction can get lost and nurses sometimes miss humorous attempts made by patients. Humour is a very personal concept, what one person thinks is funny does not necessarily make another person smile, or might even be hurtful. Humour is an important communication tool for patients as it humanises the nurses, creates a bond and opens communication lines. Humour has the potential to change the hospital experience for patients. The aim of this paper is to highlight the importance of humour in the therapeutic relationship between patient and nurse. Semi-structured interviews were held with four registered nurses and narrative inquiry was used to analyse and present the findings because of its ability to capture human interaction and experience.
Keywords: narrative inquiry, humour, nurse, patient, therapeutic relationship
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umour is part of everyday living and working and as such is also an integral part of healthcare. It is used in every culture and in all aspects of life, and human interaction often includes humour to convey messages, is used as part of group bonding, and to improve quality of life. The humorous interaction between patient and nurse has a potential positive impact on the therapeutic relationship (Astedt-Kurki & Isola, 2001; Chinery, 2007; Dean & Major, 2008; Moore, 2008). This research has focussed on the spontaneous use of humour without pre-emption that appears in conversation in the clinical setting.
Background Humour is a diverse and multi-faceted word used to describe something humans find funny or entertaining. Humour can also be seen as a social process and a unique way of communication as well as a personal trait (Chinery, 2007). A reason to use humour in health is described by Astedt-Kurki and Isola (2001, p. 452) ‘Humour indicates mental wellbeing and reduces the impact of negative factors and difficulties.’ MacMillan online dictionary describes it as ‘the quality that makes a situation or entertainment funny’ and ‘the ability to know when something is funny and to laugh at funny situations’ (Humour, 2009). This description shows the many facets of humour as it indicates not only the physical attributes of humour but also the need to be able to interpret something as humorous.
Patient-initiated humour may well be used to alleviate stress or insecurity as well as initiate communication with the nurses (Astedt-Kurki & Liukkonen, 1994). Humour can help the patient cope and adjust to a different and often life limiting situation (Moore, 2008). Humour can support the patient to relay emotion and help maintain their dignity (Astedt-Kurki, Isola, Tammentie, & Kervinen, 2001; Astedt-Kurki & Liukkonen, 1994; Moore, 2008). Patients’ might use humour to challenge the nurse and ask questions without undermining the nurse’s authority (Mallett, 1993; McCreaddie & Wiggins, 2008). Anger and frustration can be dealt with by using humour. To express discontent in a socially accepted way, humour becomes a healthy coping mechanism (Buxman, 2008). Although the beneficial attributes of humour are many, humour can be derogative and hurtful in some situations and caution is needed in the application of humour (McCreaddie & Wiggins, 2008). Adamle, Ludwick, Zeller, and Winchell (2008) noted the ‘missed communication’ in their study. They found that patients used humour to communicate with their nurses but their attempts were missed or ignored by the nurses. During their investigation of nurse’s response to, and recognition of patient-initiated humour, they found that although nurses recognised the humorous invitation to engage in a dialogue, this was not necessarily followed by a conversation (Adamle et al.,
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2008). Dean and Major expressed the importance of patient-initiated humour as a way for the patient to communicate their anxiety, stress or embarrassment. The authors argue that use of humour is not to create a light hearted conversation but an attempt to minimise their feelings of dehumanisation. If the patients attempt to inform the nurses in this ‘light hearted’ way goes unnoticed, or does not create a response, this might inhibit the nurse–patient relationship (Dean & Major, 2008). While working in the clinical setting the primary author noted an obvious difference in patients’ behaviour depending on how nurses responded to their humorous antics. Patients seemed more settled in a humorous environment. This observation prompted a literature search and although there is much written about humour in healthcare, little is written about spontaneous humour, or the patients input to the therapeutic relationship. The literature review gave the motivation to the research question: How do nurses respond to patients’ use of humour? Aims and objectives The aim of this paper is to report on four Registered Nurses perceptions of patient-initiated humour; how they and nursing colleagues react to patients humour in the clinical environment. Research methods In this exploratory study four registered nurses were recruited from a local hospital. The participants met with the researcher for an interview of approximately 60 minutes. The semi-structured interview was recorded and later transcribed. Data collection ceased when sufficient data was gained to answer the research question. The transcribed data was coded and clustered in groups to be transformed into narrative text using narrative inquiry as a framework. Research question This research asks the question ‘How do nurses respond to patients’ use of humour?’ Research methodology Narrative inquiry Narrative inquiry was chosen as the preferred research methodology due to its ability to capture 198
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personal experiences that are difficult to describe in facts and figures (Hardy, Gregory, & Ramjeet, 2009; Lindsay, 2006; Warne & McAndrew, 2010). Narrative inquiry has the advantage of revealing complex layers of information with descriptions, binaries and stories linking past, present and the future with the cultural and social environment (van der Riet, Dedkhard, & Srithong, 2012). These consciously told stories support their own view of their reality and exclude events that are not comparable with their present interpretation of themselves. While their experiences and environment change so will their stories (Sinclair Bell, 2002; Warne & McAndrew, 2010). Narrative inquiry allows participants to reflect life experiences in their story as well as the social environment where it was experienced. This methodology also includes the researcher as an active participant in listening to the story being analysed (Clandinin & Connelly, 2000; Lindsay, 2006; Sinclair Bell, 2002; Warne & McAndrew, 2010). The stories people tell are influenced by past experiences, social background and current situation, including social network, working and living space and to whom they are telling their stories (Lindsay, 2006). Importantly, these stories are shaped by the interaction with the researcher and the participant. Narrative framework Using Clandinin and Connelly’s (2000) framework to present the findings, the participants’ stories have been explored using the contexts/dimensions of temporality, sociality and spatiality. Temporality in narrative inquiry considers the constant repetition of stories and how the story changes from the past, present and in to the future. Stories are frequently written and rewritten over time. The things we tell in our stories are what we find important and remember from our past, may it be many years ago or yesterday. As we tell our story, we also consider what implications the story will have for our future (Clandinin & Connelly, 2000). Sociality considers the individuals relations towards other people and how the story changes
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How do nurses respond to patients’ use of humour? depending on who receives the information and their reaction to it. The researcher is looking at the personal–social dimension, inwards–towards feelings, hopes, reactions and moral decisions and also outwards–towards our social network and personal connections (Clandinin & Connelly, 2000). Spatiality suggests that the story has a physical space where it takes place which also influences the story and how it is told. The place where the story is spoken also influences how the story is presented (Clandinin & Connelly, 2000). These three domains give structure to narrative inquirer’s analysis. Within this framework, four directions were considered in analysis of the data: Inside, outside, backwards and forwards; inwards to find the emotions and feelings, outwards to examine surroundings and social conditions influencing the story. Transitions backwards and forwards in time were used to examine changes of emotions within the story (Clandinin & Connelly, 2000). Ethical considerations The study was approved by the university’s ethics committee and the local area health’s ethics committee. Participation in this study was voluntary and no coercion was used to find participants. Pseudonyms have been used in the transcribed material to protect identity of the participants. Data findings The interviews were transcribed verbatim by the researcher. Attending to participants stories was an important part of this inductive process. First conversation The first story introduces Johanna. Johanna is the nurse with least nursing experience as she graduated as a Bachelor of Nursing in her late thirties 2 years ago. Johanna’s story I class humour as something that makes you laugh. Really something that makes you laugh, to feel better. In nursing that’s where humour is used most of the time. Patients use humour in hospital all the time! I
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think patients definitely use humour for stress relief and as an outlet of emotions. To help break down that barrier they have when in hospital. They are scared, they want to establish communication and discharge negative emotions. They are trying to keep it light, keep it positive. Patients use it as a defence mechanism. When patients use humour I try and go along with it as much as I can. Sometimes I find that difficult because I do not understand. The humour might be inappropriate. You try and read what is happening for them and what they actually want. I try to respond as they would like me to respond because that is OK for me to do that. If that makes their journey a little bit better, I usually go along with it. I have experienced where I did not realize until later it was something funny. You have to be quite witty to go along with humour and if you are busy you do not have time to be humorous. Sometimes it is all about time restraints. Humour is extremely important in the therapeutic relationship. Humour, it’s what gets nurses and patients through the hospital experience. I believe it just makes things better. You can have a four bedded room all bouncing off each other laughing. They all have life threatening illness and yet they are coping because they are laughing. The humour is not just between each other, if you walk in to that room as a nurse, you pick up on that and you just flow with it. They are all communicating and it is a really lovely atmosphere to be in. I have seen it happen where if you take over from a nurse, who may be having her own dramas and has not responded to their humour. They’ll go “That last nurse, she was not very nice” they misinterpret it for you not being polite. I think for them it is their ‘little light’ and it is very important to work with it. If you walk in there and just task orientate without interacting with the patients’ you have lost it before you even started. The patients definitely figure you out as a nurse and those first minutes are when they decide how they will treat you, what kind of a nurse you are. And if they decide to use humour and you do not get it – you have to do a lot of sucking up. I have seen my colleagues miss the humorous attempts and that is why I know that it does not go down very well. Not communicating, not responding, they pick up on it and they feel like you think they are nonimportant. By interacting with them they feel important and you see them as individuals.
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Gunilla Haydon and Pamela van der Riet Sometimes it is culturally inappropriate to use humour or if a patient weren’t offering humour to you. As much as I see humour all the time, I see patients that don’t use it. In some instance a little bit easier to look after the patients’ that are humorous, but when you walk in to that room it is going to take a little longer with a humorous person. Where someone who do not want to chat much, is a little bit more reserved, you walk in, explain what you are doing, do the job and walk out. Another time when you definitely would not use humour is to parents with sick children. They are too worried and scared. Humour in those situations would be very inappropriate. I think that males use humour a lot more, like a joking kind of humour. Females use it for other reasons, to keep the family OK and not worry people. Definitely males use humour much more than females. Sometimes the male humour is a little derogative. I am not offended because it is just in the name of humour. Sometimes the humour can change and be a little bit sleazy. Humour like that would be the only time I would not respond. I do not go along with it but I don’t pull them up about it.
a Registered nurse she has noted the difference in the patients’ behaviour if their humorous attempts go un-noticed or does not get a response from the nursing staff. There is a noted difference in patients’ behaviour in regards to their surroundings. A patient in a single room seems to be more dependent on the nurse compared to a patient in a multiple bed ward. Josephine realise the need to interact and respond and not only be task oriented while performing her nursing duties. Josephine’s story also points out the differences in gender. Males use humour more often in, sometimes not, such a therapeutic way: Their humour sexualises nurses and the context of the care they deliver. Second conversation The second nurse is Katherine. She is in her early fifties and has 30 years nursing experience. Katherine’s story
Patients in single rooms can be very quiet and do not want to talk, other times they are happy and want to joke all the time. With the mixed wards, I do not know how many times I have said ‘you are going to be a thorn amongst the roses’ to patients’ because you have to break that up. It is not nice to be in a four bed ward with males/females. Although we have had some quite funny things happen where people have struck up a relationship as far as chatting and have even had people say ‘oh be careful, she might join you later tonight…’ and laugh it off.
Humour is laughter, happy, joyful. A good belly laugh is great. It is therapeutic. It is therapeutic for the nurses too. I think males use humour more than females. Depends on the situation, sometimes it is just a male thing with the female nurses. Just to see your reaction.
Humour is so subtle, even though humour happens so often it is kind of like that fly by night thing that happens and comes and goes. You do not retain it unless you need to. I am much more aware of humour and how it is happening now. I have been looking out for it so in the last week I have noticed so much more.
We have had some very young nurses. They have no life experience. It is obvious they do not know how to take patients. They will just stand there and think – What am I doing? … and the patient are going – What is she doing? A nurse who laughs and talk all the time, they can relate to the patients and the patients like that.
Reflection and analysis Johanna’s narrative demonstrates that she is quite aware of the use of humour. She is sensitive to the patients’ reactions and feels disappointed if she misses their humorous attempts. She does her best to accommodate the therapeutic relationship even if it infringes on her own personality and values. Although fairly new as
It is not only experience that influences the nurses’ ability to respond to humorous attempts. Some of the foreign nurses are very difficult to understand, there is no reaction from them because they do not quite understand our Aussie humour and that makes a BIG difference. It is a cultural thing as well. It is difficult with the mixed cultures. We do not notice it as much here, but in the cities it is a problem. I have nursed in the cities and I find it is very different.
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It depends on how you get along with the patient how you respond to their humour. Sometimes you are too busy you do not have the time to have that humour with that patient. If the patient does not get a response they think “what is wrong with her” “can’t she laugh.”
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How do nurses respond to patients’ use of humour? Patients, they do use humour to see what type of nurse you are and you will find a lot of nurse these days coming in to it have a very dry sense of humour. It makes it easier to look after a patient who is happy and laughter and chatty. I think if you got a room, let say you got a room full of men, they are bantering across from each other, and you get involved that makes for a better day as well. In the single room you do not interact with the patient as much, unless that patient is a joyful person anyway. It depends on a lot of things. Sometimes the mixed wards works, sometimes it does not, depending on the age and gender. It can be a good thing because they watch out for each other. It is tricky you can see the difference in the mix of patients. Years ago you would not joke with oncology patients’ but these days it makes their journey a bit easier if you have a laugh. I think it is therapeutic because it is a good medicine, it is good healing and you find that people that are happier get better quicker than those people who are miserable, unhappy and you think, ouch. A place you would never find any humour is when patients are in pain, when they are constantly in pain. Life-threatening things – there is no humour in that so that is another time where you would not use humour.
Reflection and analysis The enthusiasm Katherine shows while talking about humour demonstrates she is aware of the importance of humour, how it can heal and support patient’s hospital experience. Katherine talks about the significance of humour and how difficult it is for young inexperienced nurses to find the mental security to engage in the patients attempt to have a humorous conversation. Cultural differences both for patients and nurses are also discussed and how humour is often misunderstood. Katherine, like Johanna, talks more about the male patients and their humorous traits. Similarly she discusses the impact of time constraints preventing nurses from seeing the subtlety of humour and its effect on therapeutic interaction. The difference in patient behaviour in single, multiple and mixed wards are noted. Katherine understands patients dislike for mixed wards however she also sees the necessity of them. Katherine also reminds us that humour is not acceptable for some patients, for example when patients are in pain and for oncology patients.
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Third conversation Madison is a middle-aged confident woman. She worked as an endorsed nurse for 20 years before she decided to continue her education and has been a registered nurse for 8 years. Madison’s story Humour is something that lightens the mood, is a way of connecting. It is a communication tool. I think patients use humour. It is a way of connecting with the nurse. Depends on the situation and the person how I respond to their humour. I think they are more open in four bedded rooms so there will be more humour there, whereas a single room is very intimate. I think as a communication and a relationship building tool it is very important. It is a ‘leveler’. It brings the nurse down from a position of authority. I think Australian culture has a bit of larrikin to it. It is our way of not taking our self so seriously. Men are much more humorous compared to women. I do not know if it is a gender thing because in hospital the nurse is in a position of power. Women can have a laugh but the humour is different, men tell stories and women just find something instantaneously funny. They are trying to work you out and see how you are reacting. Whereas woman on woman, we know each other’s thinking’s and it is very brief moment. Sometimes colleagues miss when a patient tries to be funny. The nurse was not that aware or conscious of the patient. Maybe she did not want to establish that connection with them. It could be the experience of the nurse. In my personal opinion it is a time management skill – if you are going to talk to a patient and discuss whatever they find funny, it takes time, if you cut them off you can move on. The patients’ change when you do not respond to their humorous invites. If a nurse does not respond the way patients intended, the patient will often comment ‘oh, that nurse before she is cold’. You really notice it. Your reaction to their humour makes a hell of a difference. Sometimes there are inappropriate remarks and rude comments. If it is rude or insulting you use your communication skills to stop that. I think sexism, bigotry and things like that, is very rife in the older Australian male. Especially since we are a female led profession there is a lot of chauvinistic attitude. They are trying to have a laugh and be funny but are actually putting you
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Madison sees the atmosphere in the multiple bed wards to be more conducive to humour.
Different culture groups too, Chinese people may not see our side of humour or what we find is funny, is not funny to them.
Fourth conversation The last interview was with Samantha. She is in her late fifties and has a lifelong experience in nursing.
You have to maintain your professional boundaries and I think more experience helps. It is like clinical experience, nursing diagnosis. But generally on the whole you have more of a good time with male patients. They are rougher full on, more larrikin than the female patients. It is interesting it is such a huge difference between males and females. I have actually never thought about it before. If you have a mixed ward, I think it is very demeaning. It is very impersonal and that’s when you see humour, to make it easier. Often with young men it is trauma injury anyway so there is a lot of pain involved and there is no time to be humorous. When they are in excruciating pain there is no humour. If they have been given a death sentence and they are trying to rally up what they need to do then they got a lot on their mind then there is not time for humour. This conversation made me aware of things I had never thought before. I think it is an Australian culture thing and because we are so multicultural you need to be aware about it. On the whole I think Australians are ‘larrikins’. I think humour is a survival mechanism for nurses and patients. It is a survival thing for them as well as a coping mechanism.
Reflection and analysis Madison’s story tells more about male patients and how they use humour to connect with the nurses. However, male patients often use it inappropriate ways to capture the nurses’ attention and exercise power. She sees nurses to be very strong and powerful. The cultural appropriateness of humour is discussed and she considers the specific Australian larrikin way of expression as an important way to understand patients. Once again Madison sees the nurses experience as important in how well they can interact with the patients humorous invitations to engage. Again time constraints are mentioned as an important factor to inhibit the humorous interactions. So are the patients’ surroundings. Compared to the environment of the single room
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Samantha’s story Humour is having fun. Banter with your patients backwards and forwards, that is what humour means to me. It makes you feel good. I think patients use humour in the hospital. Sometimes people use humour to mask their self. Maybe they are insecure too, maybe they are lonely. A nurse that is humorous brings out the humour in patients. If you got a nurse that is a bit stale, patients do not want to have a bar of them really. Its better interaction, better results and people become more compliant when you’ve got humour between you. Not everyone likes humour and some people use sarcastic humour. Occasionally I come across derogative humour. I never as a nurse take anything personally. I am pretty out there with the humour and the jokes and I rarely miss anything. I do notice it when my colleagues do. The younger nurses especially, it just goes over their heads. When it comes to single rooms I think they should be kept for the very ill. I think a ward is better. You get four blokes together in one room, roughly the same age, they can watch footy and talk about men stuff. They are not too bad the mixed wards. More often than not they are quite happy to be in a mixed room. They are not AS humorous as if it were four females or four males. I think the males are probably more humorous. I have nursed some funny ladies as well. If the nurse does not respond when the patient is trying to say something funny they change. When no one is responding to their banter and humour they are going to pick up on that. Most of the time they will be non-compliant – usually as a payback. They judge their nurses, too. They judge who you are, what you do for them, how you speak to them, how much time you spend with them. They say less to someone that is not as humorous. You’ve only got to be in a room an hour or so and they pretty much can tell what kind of person you are. If you are humorous they tell you more. To them it is really not a joke but they are just bringing it across in a way that they do not feel vulnerable. At the end
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How do nurses respond to patients’ use of humour? of the day they will only tell you what they want you to know. Who knows why they use humour. Cover up maybe. I rather look after a humorous patient any time. You will not be full of bloody humour if you got a death sentence are you. Last thing they want to do is laugh about it really. But sometimes it is better to laugh than to be miserable and cry.
Reflection and analysis Samantha is very proud to be a nurse and she talks about her patients’ with passion and warmth showing her empathy towards them. Her story follows the previous nurses themes although she also talks about female patients as humorous but like the others think male patients use humour more than females. In her story she talks about how humour is used for a variety of reasons and how personal humour is. She considers patients in the multiple bed wards to be more humorous and better for the patients as they can interact with each other. Samantha is well aware of the wide variety of patients that has come her way and how she interacts with them in her humorous manner. Samantha considers humour to be an important therapeutic tool in the interaction between patient and nurse and can see the positive aspects of its use on the ward. Discussion The researchers’ story In this narrative inquiry study, the nurses’ voices shines through to allow their personality to be part of their story. Although they are very different as individuals there are common themes that spans across all of their stories. The appreciation of humour is obvious together with the therapeutic nature of humour. They all agree humour makes you feel better and improves health outcome although the perceived positive influence humour has on health is accepted it is not yet confirmed (McCreaddie & Wiggins, 2008). During the interviews it was surprising to hear the male dominance as a plot line in the stories. The absence of the female patient was quite noticeable. Male patients are perceived to
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use humour more and it seems more important for males to build a relationship with the nurse. Lawler (1991) writes how masculinity and power is closely related. Humour is an important communication tool for the male patient, however, there can be a negative aspect in that sometimes there are derogative, inappropriate, sexist comments dressed up as humour (Lawler, 1991). The stories confirm that men tend to use humour to express concerns and fear about their health and to hide embarrassment (Williams, 2009). They can also use humour as a defence mechanism and to avoid or postpone a serious conversation (AstedtKurki et al., 2001; Astedt-Kurki & Liukkonen, 1994). The first encounter seems to be a crucial moment in the therapeutic relationship. If the nurse does not respond to the humorous invitations to interact from the patient not only may they become non-compliant to the requests from nursing staff, they also appear to become the topic of conversation between the patients. The patients’ behaviour seems to be a reflection of their perception of the nurse and their surroundings. Lawler (1991) and Astedt-Kurki et al. (2001) emphasise how patients use humour to influence their care and interaction with the nursing staff. All four nurses noted how colleagues missed humorous invitations to engage. Although nurses are aware of patient-initiated humour it is not always responded to. Time constraints or personality clashes are two obvious reasons. Inexperience and task orientation are also factors preventing nurses from responding to a humorous invitation. It was also revealed that humour is not used when a patient is in pain, in life threatening situations or towards parents with sick children as this could be seen to be very offensive. Caution was also needed when dealing with different cultures as humour is culturally specific and can be interpreted as insulting or derogative depending on cultural background. Dean and Major (2008) suggest that nurses should trust their instincts as to whether humour is appropriate or should be avoided. They argue that nursing ‘is enhanced when nurses allow themselves
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to be natural and rely upon their emotional intelligence’ (p. 1095). Yet another dimension of humour revealed in all conversations is the interaction between patient and nurse depends not only on personality but also on dormitory context: Single room or multiple bed wards; mixed or single gender rooms; they change the dynamics of how nurses and patients use humour. The use of humour is perceived to be more common in multiple bed wards. In the analysis of this study the dimensions of temporality (time), sociality (others) and spatiality (environment) are intertwined in participants’ narratives. In the stories, the nurses express how sociality and spatiality is a major factor in how humour is perceived. Humour is different in the single or multiple bed wards. The social norms in the mixed ward can hamper the humorous interactions. Temporality can be seen in the stories as limiting factor where the nurses do not have time to engage in the humorous invites from the patients. The culture of both interviewer and interviewee being nurses may influence how the stories have been told. The culture of others is a thread within the dimension of sociality. The three dimensions also influence how the stories have been told to the researchers. Conclusion With patient-centred care in focus the interaction between nurse and patient is an essential aspect of nursing care. It is commonly accepted, though not proven, that humour is beneficial to health (McCreaddie & Wiggins, 2008). The findings from this study imply the diversity and multiple uses of humour. Nurses’ response to patient-initiated humour often depends on time constraints, the experience of the nurse, and the environment in which the nurse–patient interaction occurred. In summary the following findings from this study provide valuable knowledge to nurses in practice. Humour is an important part of the therapeutic relationship and has a perceived positive influence on health. Nursing staffs’ experience impacts on their awareness
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of humour and their responses towards the patients as the humorous invites often are subtle and very fleeting; ‘caught in the moment.’ The interviews revealed that time constraint is an important factor affecting nurses’ responses to humorous invitations and that patients’ feel undervalued as individuals if their humorous attempts go unnoticed. Gender differences were seen in this study with humour playing an important communication tool more so for males’ patients than female patients. Importantly, if humour is responded to appropriately by the nurses it can potentially change and improve the hospital experience for the patient and nurses. The interaction between patient and nurse depends not only on personality but also on the spatial environment of the ward i.e., a single room or multiple bed wards, mixed or single gender rooms can influence how humour is perceived. Humour is culturally specific and can be seen as insulting or derogative depending on cultural background. When a patient is in pain, in life threatening situations or towards parents with sick children humour is commonly not used. Humour is an important communication tool for the patients and can if responded to appropriately by nurses potentially improve the hospital experience for both patients and nurses. Humour not only humanises the nurses, it also creates a bond and opens communication between them and the patient. Increased awareness amongst nurses in the use of humour could improve patient satisfaction. These narratives arising from this research confirm the value of using of humour in the clinical setting. Furthermore as McCreaddie and Wiggins (2008) write ‘Humour, somewhat paradoxically, is something that is generally not taken seriously. Yet humour could be the fulcrum for establishing the relationship that the individual patient desires’ (p. 591). Acknowledgement The research supporting this manuscript has not been supported by any source of funding.
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How do nurses respond to patients’ use of humour? References Adamle, K. N., Ludwick, R., Zeller, R., & Winchell, J. (2008). Oncology nurses responses to patient- initiated humour. Cancer Nursing, 31(6), E1–E9. Astedt-Kurki, P., & Isola, A. (2001). Humour between nurse and patient, and among staff: Analysis of nurses’ diaries. Journal of Advanced Nursing, 35(3), 452–458. Astedt-Kurki, P., Isola, A., Tammentie, T., & Kervinen, U. (2001). Importance of humour to client–nurse relationships and clients’ well-being. International Journal of Nursing Practice, 7(2), 119–125. Astedt-Kurki, P., & Liukkonen, A. (1994). Humour in nursing care. Journal of Advanced Nursing, 20(1), 183–188. Buxman, K. (2008). Humour in the OR: A stitch in time? Association of PeriOperative Registered Nurses, 88(1), 67–77. doi:10.1016/j.aorn.2008.01.004 Chinery, W. (2007). Alleviating stress with humour: A literature review. Journal of PeriOperative Practice, 17(4), 172, 174, 176–179. Clandinin, D. J., & Connelly, F. M. (2000). Narrative inquiry. San Francisco, CA: Jossey-Bass. Dean, R. A. K., & Major, J. E. (2008). From critical care to comfort care: The sustaining value of humour. Journal of Clinical Nursing, 17(8), 1088–1095. doi:10.1111/j.1365-2702.2007.02090.x Hardy, S., Gregory, S., & Ramjeet, J. (2009). An exploration of intent for narrative methods of inquiry. Nurse Researcher, 16(4), 7–19. Humour. (2009). MacMillan dictionary. Retrieved from http://www.macmillandictionary.com/dictionary/ british/humour
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Lawler, J. (1991). Behind the screens. Nursing, somology, and the problem of the body. Melbourne, VIC: Churchill Livingstone. Lindsay, G. M. (2006). Experiencing nursing education research: Narrative inquiry and interpretive phenomenology. Nurse Researcher, 13(4), 30–47. Mallett, J. (1993). Use of humour and laughter in patient care. British Journal of Nursing, 2(3), 172–175. McCreaddie, M., & Wiggins, S. (2008). The purpose and function of humour in health, health care and nursing: A narrative review. Journal of Advanced Nursing, 61(6), 584–595. doi:10.1111/j.1365-2648.2007.04548.x Moore, K. (2008). Is laughter the best medicine? Research into the therapeutic use of humour and laughter in nursing practice. Whitireia Nursing Journal, 15, 33–38. Sinclair Bell, J. (2002). Narrative inquiry: More than just telling stories. TESOL Quarterly, 36(2), 207–213. van der Riet, P., Dedkhard, S., & Srithong, K. (2012). Complementary therapies in rehabilitation: Nurses’ narratives. Part 1. Journal of Clinical Nursing, 21(5–6), 657–667. doi:10.1111/j.1365-2702.2011.03852.x Warne, T., & McAndrew, S. (2010). Re-searching for therapy: The ethics of using what we are skilled in. Journal of Psychiatric & Mental Health Nursing, 17(6), 503–509. doi:10.1111/j.1365-2850.2009.01545.x Williams, R. (2009). ‘Having a laugh’: Masculinity, health and humour. Nursing Inquiry, 16(1), 74–81. doi:10.1111/j.1440-1800.2009.00437.x Received 06 February 2013
Accepted 17 June 2013
FORTHCOMING Exploring the Human–Environment Connection: Rurality, ecology and social well-being A special issue of Rural Society – Volume 23 Issue 2 – 128 pages ISBN 978-1-921980-29-9 – February 2014 Guest Editors: Shelby Gull Laird (Environmental Sciences, Charles Sturt University) and Angela Wardell-Johnson (Sustainability Research Centre, University of the Sunshine Coast) Exploring the complex nature that exists between humans and their physical environment is the topic of this exciting special issue from Rural Society. Articles explore the nexus between the well-being of individuals, communities and environments. Disciplinary approaches include human geography, environmental sociology, ecopsychology, policy studies, planning, cultural studies and other perspectives which advance knowledge in human-nature-animal relations using high quality social science research methodology – qualitative, quantitative and mixed. http://rsj.e-contentmanagement.com/archives/vol/23/issue/2/marketing/ eContent Management Pty Ltd, Innovation Centre Sunshine Coast, 90 Sippy Downs Drive, Unit IC 1.20, SIPPY DOWNS, QLD 4556, Australia; Tel.: +61-7-5430-2290; Fax. +61-7-5430-2299; [email protected] www.e-contentmanagement.com
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