The Humor-in-Hospitals Movement
Chances are that you have never been in a hospital with a "humor program." The very idea of humor in hospitals may even strike you as an oxymoron (like "giant shrimp," "smart bombs," "military intelligence," etc.). If ever there were two things that don't go together, it's humor and hospitals. After all, hospitals are places for the very sick.
The last decade, however, has witnessed a (slowly building) revolution in health care, as more and more hospitals become convinced of the therapeutic power of humor. The humor-in-hospitals movement has also gained support because of the trend toward depersonalization in hospitals in recent years, as focus has shifted away from the person and toward application of the latest technology. Patients now want a more personalized relationship with caregivers, and humor helps establish it.
Patients generally arrive at hospitals in a state of stress and anxiety, are placed in a strange environment, submitted to degrading and embarrassing procedures by people they don't know, have their independence and sense of control removed, and don't always get the kind of explanations that they would like. Humor provides a means of establishing a more personal relationship with hospital staff, easing tensions and anxiety, and helping patients cope. The nurse who maintains a high level of competence, but also has a "light touch," has an extra means of saying, "I care."
Many nurses and hospital administrators are concerned that patients will perceive them as unprofessional, and as unconcerned about their health problems if they show a sense of humor while interacting with patients. There is evidence, however, that patients welcome the opportunity for humor and laughter during their hospital stay. The figures in brackets indicate the percentage of patients in one study who agreed with the following statements: 1) "Nurses should laugh more often with patients" [80%], 2) "Nurses should try to get their patients to laugh" [83%], 3) "Laughing helps me get through difficult times" [83%]. The following statements generated strong disagreement by the same patients: 1) "Nurses who laugh with patients are unprofessional" [94%], 2) "Nurses who laugh are insensitive to patients who are suffering" [91%], 3) "Laughter does not belong in a rehabilitation hospital" [89%].113
Types of Hospital Humor Programs
The best-known approach to bringing humor and laughter to hospital settings is the use of clowns. Many hospitals now have volunteer clowns who visit patients in their rooms in order to boost their spirits and distract them from their anxieties and concerns. The Big Apple Circus Clown Care Unit was initiated in 1986, and has spawned many comparable clown units across the U.S. and around the world (e.g., the Fondation Thodora in France).
The power of clowns is evident in the following example provided by a clown from the Big Apple Circus. An 11-year-old boy had been doused with gasoline and set on fire by an older boy.
“He was conscious, but in terrible pain with major burns over more than half of his body. I went right into emergency with him. When the surgeons began cutting away dead flesh, I began telling funny stories and promising circus tickets and making scarves appear and disappear--anything to keep his mind off the agony. Pretty soon he was rolling his eyes in amazement and finally I got him laughing behind his medical mask. It was incredible. He was staring death in the face--and he was having fun!" 114
Another common approach to building a lighter touch into hospitals is to create a "humor cart." This is a cart which can be wheeled into patients' rooms, and which contains funny audio and videotapes, books of cartoons, games, funny props, etc. Several hundred hospitals around the country now have humor carts. Volunteers from the community often take responsibility for these programs.
A few hospitals have entire rooms devoted to fun and humor for ambulatory patients. These rooms are given such names as "The Lively Room," "The Living Room," or simply "The Humor Room." Sunnyview Rehabilitation Hospital, in Schenectady, New York even has a full-time humor coordinator, whose job is to be sure humor is made available to all of those patients who want it.
One of the first humor rooms was established at St. Joseph's Hospital in Houston. Representatives of this program have expressed their belief that the program leads to shorter hospital stays for many patients. The head nurse observed that some patients are able to reduce their pain and nausea medications following a visit to the humor room.
I know of one hospital, which has, a humor program built into its pediatrics department. The hospital recently was short of beds for adults, so a 70-year-old cancer patient was forced to stay in pediatrics for nearly a week. While he came in depressed, he had such a good time during his stay that when he was later re-admitted to the hospital, he specifically asked for a room in pediatrics.
One of the most effective means of making the therapeutic benefits of humor available to patients is through the daily interaction with hospital staff. Nurses and other staff members can have a powerful impact on patients' mood by bringing an occasional laugh to patients as they do their jobs. The Humor Skills Training Program provided in this book will help nurses find their own style of bringing humor to the bedside.
For a detailed discussion of guidelines for appropriate and inappropriate uses of humor in hospital settings, see a recent article in RN Magazine,115 as well as Part X of this course.
SMILE: A New Approach to Personalizing Humor Intervention Programs
If humor does have the power to reduce patient tension and anxiety, help cope with the life circumstances that result from a serious illness, and even promote healing, these benefits should be maximized when the humor made available to patients is the kind of humor they especially enjoy. For example, evidence presented in the next section shows that the amount of reduction of pain medication requested following watching comedy films was greater when patients were able to choose the films watched (presumably, they chose films that were funnier to them). A software package has recently been developed in order to help hospitals and other organizations provide a personalized humor prescription to patients.
The system is called SMILE, which stands for "Subjective Multidimensional Interactive Laughter Evaluation."116 Patients complete a brief survey, which touches on their recent emotional state, stress levels, support system, judgment of how well they're coping, attitudes toward humor, and more. The survey also obtains information on their favorite print cartoons, comedians, sit coms, etc. The computer provides a written summary of the information provided by the patient, including a specific recommendation of the kinds of humor and humorists preferred. This allows hospital personnel (usually volunteers) to provide comedy videos, cartoon books and other forms of humor, which precisely match each patient's unique sense of humor.
One of the questions in SMILE asks whether the patient would welcome a more humorous style of interaction from nurses and other staff. If they say yes, a clown sticker (the image shown above) is placed on their chart (or on the door to the patient's room), so that staff can tell at a glance that it's ok to laugh and share humor with this patient.
Impact on Patient Outcomes
The main purpose behind the addition of therapeutic humor programs to hospitals is 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 will be discussed first.
Other Mind-Body Approaches
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."117
Since most health management systems are concerned about length of hospital stays, 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 . . ."118 A different analysis of 102 studies showed that 79% of them revealed a shorter length of hospital stay because of the mind-body procedure used.119
The most effective of the various procedures used over the past two decades involve what have been called "psycho educational 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.120 An especially strong effect was found for the ability of these mind-body procedures to reduce medical complications and reduce the number of days after discharge before resuming normal activities. In a 1998 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.121 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.
Hospital 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 it saved the hospital money that would simply be icing on the cake.
As indicated earlier, Dr. James Walsh noted 70 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 that it may not be so much what positive emotion does that is the key, but what it prevents.122 He feels that the effect 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.
Humor's power to speed up wound healing may be due to its capacity to lower blood levels of cortisol (see section on stress hormones), 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.123
Several studies (discussed above) have documented humor's ability to reduce pain in many patients. 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, those who watched the comedies requested 61% less "minor" pain medication (aspirin and mild tranquilizers) over the next two days.124
Surprisingly, among those who watched the comedy films, the amount of major pain medication requested depended on whether patients were able to choose the funny movie they watched. Those who were able 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 patients' humor preferences before humor is introduced into a hospital setting." The SMILE software described above is ideally suited to do this.
Among a group of elderly residents who suffered chronic pain in a long-term care facility, watching a 20-minute comedy program 3 days a week for 6 weeks significantly reduced the amount of pain medication requested during this period.125 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 (see section on Sedimentation Rate).
Nurses have tremendous power to boost the spirits of their patients. And this, in turn, helps patients mobilize their own natural healing resources. If you are 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 the 8-Step Program to their patients. One nurse told me that her favorite line is, "I was going to tell you a joke, but I can see you're in stitches already."
Patients say that humor and shared laughter help raise their spirits, and take their minds off their illness and problems. In some cases, patients regularly exposed to hospital humor also leave the hospital earlier than they would normally be expected to. I know of a cancer center in Florida where the patients have such a good time while undergoing treatments that they often go back for visits long after their disease is in remission.
One physician observed that patients with spinal cord injuries 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.
"Have you ever been treated by a doctor for this condition?"
Sign in a doctor's office: "Amnesia patients must pay in advance."
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 recovery when you do get sick.