Impact of Programs on Patient Outcomes
The main goal of therapeutic humor programs in hospitals is generally to provide a positive counter-weight to the negative circumstances that have brought patients to the hospital. But in the current climate of rising healthcare costs, it's also important to consider whether humor has any effect on recovery rate or other measures of improvement of one's condition. Since more work has been done on other mind-body approaches than upon humor, they are also briefly discussed here.
Humor Programs
In spite of the large number of hospitals around the world which have adopted clown visits or other types of therapeutic humor programs for patients, there has been little attempt to document their impact on such measures as speed of recovery, postoperative pain or wound healing. Hospitals have simply adopted humor programs because they can see from their own experience that these programs work in helping patients cope. If the program were to also save the hospital money, that would simply be icing on the cake.
As indicated in the Corexcel course Humor and Nursing I, Dr. James Walsh noted 80 years ago that laughter appeared to promote wound healing. Recent research in psychoneuroimmunology has confirmed this finding for positive emotion in general. One researcher has suggested, however, that it may not be so much what positive emotion does that is the key, but what it prevents.24 He feels that the positive effects found may be due to the disruption of production of neurotransmitters, hormones and other substances (associated with stress and negative emotion) which interfere with the healing process.
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Humor's power to speed up wound healing (also currently observed anecdotally by some physicians) may be due to its capacity to lower blood levels of cortisol (see section on stress hormones in Humor and Nursing I), which can suppress natural killer cell and lymphocyte activity and suppress the production of antibodies. This possibility is supported by a study in which surgical patients were given training in guided imagery and relaxation. It showed that these patients had more rapid wound healing than a control group and also had lower post-surgical levels of cortisol.25
Many studies have now documented humor's ability to reduce pain. In one study, patients were shown either comedy or serious movies (one in the morning and one in the afternoon) on two consecutive days following orthopedic surgery. In comparison with the serious movie group, those who watched the comedies requested 61% less "minor" pain medication (aspirin and mild tranquilizers) over the next two days.26
It is important to note that among those who watched the comedy films, the amount of major pain medication requested depended on whether they were able to choose the funny movie they watched. Those who were allowed to choose movies that were funny to them requested less major pain medication than those who were presented a movie to watch without choosing. According to the researchers, "This unanticipated result is probably due to the fact that humor preferences are idiosyncratic, and few things are as irritating as being exposed to material that fails in its attempt to be funny. From an applied standpoint, our results suggest that care should be taken to determine a patient's humor preferences before humor is introduced into a hospital setting."
In hospitals in which volunteers bring "comedy carts" stocked with funny DVDs, videos, books, etc., to patients' rooms, this consideration can be handled by simply asking patients who their favorite comedians, sit coms, etc. are and providing them with materials that come closest to matching their sense of humor.
_______________________________________________________________________ A gynecologist who had lost interest in his medical practice decided to change careers and enrolled in auto mechanic school. He performed well in the course but was still shocked when he got an off-the-chart 200 on his final exam. He asked the instructor to explain the grade.
"I gave you 50 points for taking the engine apart correctly," the teacher said, "50 points for putting it back together correctly . . . and an extra 100 points for doing it all through the muffler."
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Among a group of elderly residents who suffered chronic pain in a long-term care facility, watching a 20-minute comedy program three days a week for six weeks significantly reduced the amount of pain medication requested during this period.27 This reduction was, not surprisingly, accompanied by a more positive mood.
The research on blood pressure suggests that humor will help many patients keep blood pressure down as they prepare for stressful medical procedures. It may even help reduce inflammation levels (as indicated by a lower Sedimentation Rate), although this topic has not yet been systematically studied.
Nurses have tremendous power to boost the spirits of their patients. And this, in turn, helps patients mobilize their own natural healing resources. In your role as a nurse, you can use humor to help your patients cope. The catch is, of course, that you must first improve your own humor skills. Many nurses around the country are already transferring the benefits of my 8-Step Humor Skills Program (discussed below) to their patients. One nurse told me that her favorite line with patients following surgery is, "I was going to tell you a joke, but I can see you're in stitches already."
Patients commonly say that humor and shared laughter help raise their spirits and take their minds off their illness and problems. (I have heard this most often following my programs for cancer patients on National Cancer Survivors Day.) I know of a cancer center in Florida where the patients have such a good time undergoing their treatments (while watching comedy videos and laughing with staff) that they often go back for visits long after their disease is in remission.
One physician reported to me that among his patients with spinal cord injuries, those who were able to laugh about their circumstances were much better at absorbing and dealing with the humiliation and frustration they often felt. They also had fewer complications than patients who were unable to find a light side of their condition. This doctor is convinced that humor and laughter play an important role in their recovery.
Build Your Humor Skills 1. How is a hospital gown like health insurance? You're never _________ as much as you think you are. Clue: You should not need a clue for this one. 2. Two podiatrists opened up offices on the same street. As you might expect, they soon became ______ enemies. Clue: Part of the bottom of your foot.
[Work on both jokes before checking the answers below.]
Many hospital staff are convinced that while humor helps both staff and patients relieve some of the tension that builds up, it also adds a more human touch to the hospital experience. The important point for you to consider is that if health care experts all over the country now see enough therapeutic value in humor to build it into hospital settings, it's certainly worthwhile to improve your sense of humor so that you can get this therapeutic effect into your own life every day. It will help you remain healthy and support your own recovery when you do get sick. And, of course, it will also boost your ability to provide quality care to your patients day after day - even on the tough days.
Using Humor to Promote Hope and a Positive Outlook
Many nurses make an active effort to instill a sense of hope and optimism in their patients.28 The growing conviction that it is important for nurses and doctors to cultivate a sense of hope in patients is - at least in part - due to the large body of research documenting the health-promoting power of hope and other positive emotions. The initial impetus for this emphasis on hope came from Dr. Bernie Siegel's observation that a strong sense of hope and optimism characterized many cancer patients who beat the survival odds given to them by their doctors.
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Many other strategies have also been adopted by healthcare professionals to instill hope in their patients. These include prayer, discussions with other survivors of their disease, providing a good understanding of the disease, providing care options, showing empathy, establishing a strong caring relationship, offering encouragement and cultivating good coping skills.
Other Types of Mind-Body Programs
Humor, of course, is just one among many approaches to bringing the known benefits of mind/body medicine to hospital patients. In one analysis of 191 different studies (involving 8600 patients), a wide range of mind/body interventions before and after surgery (e.g., guided imagery, hypnosis, relaxation procedures, biofeedback and giving information) were found to be effective in improving surgery outcomes. "These interventions have been shown to work for virtually every imaginable kind of surgery - from back surgery to coronary-bypass operations to cancer resections."29
Since most health management systems have become increasingly concerned about length of hospital stays in recent years, it is important to note that one analysis of 13 different studies showed that "psychosocial interventions reduced hospitalization by an average of 2.4 days . . ."30 A different analysis of 191 studies showed that 79% of them revealed a shorter length of hospital stay because of the mind-body procedure used.31
The most effective of the various procedures used over the past 25 years involve what have been called "psychoeducational interventions." These involve providing patients health-related information about their condition and surgical procedure, as well as some kind of skill or exercise that helps them reduce pain or cope better. In one analysis of 102 different studies, such interventions were found to have a significant positive impact on recovery rate, pain reduction, psychological well-being and satisfaction with care. This was found for abdominal, thoracic, orthopedic, gynecologic, cancer, and eye-ear-nose-throat patients.32 An especially strong effect was found for the ability of these mind-body procedures to reduce medical complications and reduce the number of days following discharge before resuming normal activities. In one review of all the research in this area, Henry Dreher concluded that in addition to providing preparatory information about the upcoming surgery, the provision of coping and rehabilitation skills plays a key role in the gains shown.33 (Italics are McGhee's.) Relaxation techniques alone showed only mixed success, in spite of the fact that they are one of the most popular approaches used in many healthcare settings.
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The positive outcomes associated with many so-called "complementary" or "alternative" medical treatments has led to a steady increase in patient interest in such techniques over the past two decades.34 By the late 1990s, one survey indicated that 87% of cancer patients in the rural Midwest were using some kind of complementary intervention to cope with the stress associated with cancer. Prayer was the most common approach; humor was second, with 50% of patients using humor to cope.35 A larger follow-up study found that 21% used some form of humor or laughter therapy.36
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