Using Humor to Promote Positive Doctor/Nurse-Patient Interaction
In addition to adopting specific kinds of "therapeutic humor programs" (discussed below) to support health and wellness and help patients cope, a growing number of hospitals are beginning to recognize the importance of having clinical staff who are comfortable using a lighter style of interacting with patients as a means of creating a more personalized and positive interaction with them. Humor used by nurses, for example, can be used to develop a sense of trust by patients.8 In one study, a little over 20% of nurses said they typically use humor during routine patient care.9 Some nurses purposefully use "standard jokes" or "light conversation and a little banter" to ease patients' worries and anxiety. For example, one nurse says to some of her patients, "Do you know the name of the person who invented hospital gowns? Seymour Heinies."
One rehabilitation unit of a hospital set up a humor program that was specifically designed to stimulate a more positive, patient-centered style of interaction with patients.10 Their view was that this focus on the patient relationship was more important than the specific therapeutic benefits resulting from humor per-se.
In the case of patients who know they are dying, nurses say that they use humor to both enhance the quality of patients' lives and to help foster acceptance of death.11 These nurses also stressed how important humor was for themselves in providing a necessary emotional counterbalance to the bleak nature of their job.
One physician has adopted the habit of helping his patients lighten up a bit by joking about the results of a brain scan. He says,
"There was nothing there whatsoever."
He then waits for a family member present to come up with a punch line. "Invariably, one of the kids will say, 'Well, mom, we knew you didn't have much up there all along.' I must have heard that 400 times; however, the family will laugh, smile, and someone will put their arm around their mom and hug her."12 Obviously, a good personal relationship with the patient must already be established before a doctor or nurse uses this kind of humor.
Answers to Jokes on Previous Page 1. you're sober. 2. take the spoon out.
Humor has long been known to be an effective ally in facilitating any kind of awkward or difficult communication. A common problem faced by physicians is how to ease patients into an understanding and acceptance of the fact that their condition is deteriorating. One doctor uses the following funny story (which you may already have heard) to help communicate this bad news.
"Timothy is in college and he calls home to his younger brother and says, 'Jon, it's your big brother Timothy. How are you doing?' 'Oh, Timothy [pause]. Timothy, your cat died.' Dead silence. There is a little bit of sobbing on the phone. Tim says, 'Jon, don't give bad news like that. You knew that cat was important to me. You should have said, 'The cat is on the roof and we have been trying, but we can't get the cat down; it's scared and we've called the fire department.' You leave the phone conversation like that, knowing that I'm going to call back in a couple of hours. When I called back, you could have said that the cat fell off the roof and it's badly hurt, and it's going to the veterinarian and everybody is concerned. Then when I called back a few hours later, you tell me that the cat died. That way, it comes in steps and it's not such a shock to me.' Jon says, 'Tim, you're right. I'm sorry. I don't know what I was thinking.' Tim says, 'You're young; you're my baby brother; you have a lot to learn.' He says, 'I learned, I learned.' Tim then says, 'Okay, what else is going on at home?' and Jon says, 'Mom's on the roof.'"13
The chuckle that generally follows opens the door to a more open discussion of the patient's condition.
Consistent with this view, there is some evidence that humor is viewed by cancer patients as an effective communication strategy - especially once the perception of physician competence and trust is established.14
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In spite of this growing conviction that humor has an important place in (at least certain) interactions between healthcare staff and patients, humor is still not a topic that is covered in American nursing schools that prepare individuals for their nursing career. Rather, nurses learn about humor once they begin their work in clinical settings.15 This is consistent with my own conversations with nurses following my presentations on humor and health/stress in hospital settings. I have consistently heard from them that humor was never discussed during their course work and that they were initially put off by the (macabre or "sick") humor they saw in their colleagues when they began their work in a hospital. That view quickly changed once they began to personally experience the emotionally draining work they are asked to do day after day.
One recent study suggests that humor actually plays several important roles in healthcare settings. Not only does it help humanize the healthcare experience for both the patient and care provider; it also helps reduce tension (for patients and staff), helps manage one's emotional state and helps staff work together as a team.16
Some nurses have genuine concerns about whether using humor with patients is appropriate - even though they understand how important it is for them in their work. The following concerns are typical of those expressed by nurses.
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Concerns about Using Humor in Healthcare Settings
1. Will patients (or colleagues) consider it unprofessional?
a. A brief explanation of the health benefits resulting from humor and laughter, and how humor helps manage tension and anxiety, helps counter this. This can also be handled by a small handout (made by the hospital) which explains why a lighter style of interaction by staff sometimes occurs. You can maintain your professionalism and still adopt a lighter style of interaction with patients and staff.
2. Will I be seen as incompetent?
a. Establish your competence first (especially among other staff) and then let your sense of humor emerge. Patients will generally welcome a lighter style of interaction.
3. Will patients misinterpret humor as indifference about their condition?
a. Shared humor should not replace your usual concern, care and respect for patients. It is added to it.
4. Doesn't improving my sense of humor just increase my workload?
a. Learning to lighten up will not take time away from your job. Quite the opposite, you will soon find that humor lightens your workload, because it enables you to sustain a frame of mind conducive to doing your work more efficiently. You will also begin to enjoy your work more as humor gives you a more frequent diet of positive interchanges with patients and staff.
5. Will patients think I won't consider them sick if we share some laughs together? Will they worry that I'll give them less attention than others who are "really" sick?
a. Assure them that this is not true and that you enjoy tending to patients who are in a good mood.
6. What should I do if I really don't think the patient's humor is funny?
a. Don't fake laughter, but smile and acknowledge it as a joke.
7. What should I do if the patient's humor is offensive, or goes too far in some way?
a. Be honest and tell them you really don't enjoy that kind of humor. Be flexible, open and supportive of their humor generally; but there are limits to joking, as with any other behavior.
The following general guidelines should be followed for any use of humor in hospitals or other healthcare settings.
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General Guidelines for Using Humor in Healthcare Settings
1. Always establish your competence in the eyes of every patient first; the lighter style of interaction comes later. Premature use of humor may undermine development of the patient's confidence or trust in you.
2. Be sure other nearby patients/family members are not facing a crisis at the moment.
3. Always adopt a "toe in the water" approach. Ease into a playful interaction to gauge whether any of your efforts at humor would be reacted to favorably.
4. Be sensitive to whether the patient is responding positively or negatively to humor.
a. Don't force humor or laughter upon the patient if s/he is not receptive. Think of humor as a medication. Some medications can be used with most patients, but others cannot. Two patients with the same symptoms don't always get the same medication. Some patients have allergic reactions. Be sensitive to the patient's humor allergies.
5. Remember that patients often don't feel like laughing. They may be nauseous, in pain or just not in the mood.
6. Remember that patients may not respond to humor until they have come to accept the fact of their disease.
a. Do not try to use humor to overcome their depression or anger in the weeks/months after their diagnosis. It is important for them to express these emotions. The time may come, however, when humor can help them turn the corner of acceptance.
7. Avoid joking with other staff in the presence of patients who are about to undergo a test, surgery, etc. - unless you already have a good joking relationship established with them.
a. Although you may need a good laugh, the patient doesn't understand that. If it happens, explain your laughter to the patient.
8. Laugh together at unexpected circumstances that arise.
9. Poke fun at yourself - but not in a way that suggests lack of competence.
10. Never joke about staff incompetence.
11. Never joke at the patient's expense.
12. Never use humor when you are about to deliver bad news; compassion and empathy are called for. Consider humor later, once the bad news has been fully taken in and accepted.
13. Do not use joking to avoid discussion of sensitive issues with the patient.
14. Remember that many patients have no history of using humor under stress. It may be unrealistic to expect them to react favorably to humor in a hospital or hospice setting.
15. Remember that patients may have religious convictions which stress reverence in the midst of serious illness. This may be incompatible with any form of lighter interaction.
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Conditions Where Hospital Humor is Always Inappropriate
1. During any acute crisis. (But it can help adjust to the crisis afterwards.)
2. When the patient needs to cry.
3. When the patient needs quiet time.
4. When a patient in an adjacent bed is very sick or coping with bad news.
5. When the patient is trying to come to grips with any emotional crisis.
6. When the patient is trying to communicate something important to you.
a. Nothing is more frustrating than having someone appear to not take seriously something that is very important to you and that you're trying to communicate. This can destroy your rapport.
7. Avoid:
a. Ethnic jokes, sarcasm and mockery.
b. Humor at the expense of any other person. Laugh with, not at.
c. Joking about any patient or their condition.
8. If you have any doubts about the appropriateness of humor in a situation, try another approach (e.g., compassion, concern, and touch).
