Practising with a smile

Authors

• Karen McKenzie, chartered clinical psychologist, professor of psychology, Northumbria University
• Matilda Moulam, researcher, Northumbria University
• George Murray, professor of psychology, Northumbria University

Key learning points

• The use of certain types of humour is related to wellbeing and can be perceived positively by patients
• Having an awareness of the relationship between humour and health can help primary care nurses to use humour more effectively
• Some forms of humour can be harmful, such as using it to belittle others

Humour is thought to serve a wide range of positive functions in health care. This includes providing comfort to patients and reducing anxiety in difficult situations, serving as a means of raising difficult topics that might otherwise be taboo, offering an outlet for negative emotions such as frustration and anger, enhancing working relationships by relieving interpersonal tension and challenging and maintaining the structure of professional relationships.¹ 

There is also a widespread belief in the beneficial effects of humour on health and wellbeing, hence the saying ‘laughter is the best medicine’. The proposed positive relationship, either direct or indirect, between humour and various health outcomes, such as pain and stress, is captured more formally in the ‘humour–health hypothesis’.² 

Reviews of the literature in this area, however, suggest that much of the early evidence, particularly in relation to the direct effect of humour on health, was anecdotal, based on small sample sizes or on studies that had a number of methodological flaws. There was also found to be very limited research relating to nurses.^2,3 The early evidence for an indirect impact of humour on health, for example as a coping mechanism that reduces stress, was also found to be limited and inconsistent.⁴  

This was thought to be because early research failed to fully acknowledge the complexity of the concept of humour,⁴ such as its different components (eg behavioural, emotional, social, cognitive and perceptual)⁵ and that some forms of humour may be detrimental to psychological and physical health, such as aggressive or excessively self-disparaging humour.⁴ With this recognition, and the development of measures of humour that included potentially maladaptive as well as adaptive qualities of humour (eg the humour styles questionnaire),⁶ a greater understanding of the nature of the relationships between humour, health and other factors began to develop. In addition, a more robust evidence base for the positive indirect effects of humour on health, particularly stress, began to develop.² 

What are the different styles of humour?

Martin and colleagues⁶ suggested that there are four main humour styles: affiliative, self-enhancing, aggressive and self-defeating. Both affiliative and self-enhancing are regarded as adaptive humour styles and aggressive and self-defeating are maladaptive humour styles.  Affiliative humour involves amusing other people (eg through telling jokes, saying funny things or engaging in witty banter) in order to make and maintain relationships. Self-enhancing humour is the tendency to maintain a humorous outlook on life and be frequently amused by its incongruities, again with the aim of facilitating positive relationships. 

Aggressive humour is a hostile form of humour involving the use of sarcasm, derision, put-downs, or disparaging humour for the purpose of manipulating others, without regard for its potential negative impact. 

Self-defeating humour is based on attempts to amuse others at the expense of the self, by doing or saying funny things at one’s own expense as a means of gaining approval.  

Both affiliative humour and self-enhancing humour have been shown to be associated with a number of positive variables including cheerfulness, self-esteem and psychological wellbeing and are negatively related to depression, anxiety, and bad mood.⁶ In addition, those with positive humour styles, compared with individuals with negative humour styles, were more successful at down-regulating negative and up-regulating positive emotion.⁷ These findings suggest that positive (but not negative) humour may be an effective form of emotional regulation.

By contrast, aggressive humour is found to be positively related to measures of hostility and aggression, while self-defeating humour is positively correlated with depression, anxiety, hostility, aggression, bad mood, psychiatric symptoms, and negatively related to self-esteem, psychological well-being and intimacy.⁶ More recently, it was found that individuals who were characterized by above-average affiliative and self-enhancing humour and below-average aggressive and self-defeating humour showed the most favourable associations with a range of well-being measures.⁸ 

Although the multifaceted nature of humour has been uncovered and is now consistently acknowledged in humour literature, there has only been limited research that investigates both adaptive and maladaptive humour styles in relation to stress. In a recent study by the authors of this paper, it was found that having maladaptive humour styles was associated with higher levels of self-reported stress, whereas having a self-enhancing humour style was associated with lower stress levels. No significant relationship was found between stress and affiliative humour (see box 1 for details).

What else can influence the relationship between humour and health?

As well as the humour style used by the individual, other factors have been found to influence the relationship with health-related outcomes. For example, the group to which individuals belong (eg students versus non-students) and whether they are experiencing health problems at the time can influence the relationship between humour and health, with indications that those who are in poor health or experiencing pain may be more likely to use humour as a way of coping.⁹ There also seem to be sex differences in the use of particular humour styles, with males tending to use more aggressive and self-defeating styles, while women use more affiliative and self-enhancing styles.^6,10 

What do patients think about the use of humour by health professionals?

There has been relatively little research of patients’ views about the use of humour by healthcare professionals in primary care. A study of the use of humour by doctors in primary care suggests that patients perceive doctors to be using humour more frequently than the doctors perceive themselves to be.¹¹ The authors suggest this difference in perception may arise because patients are stressed at the start of the consultation, so that even small attempts at humour by the doctor have a significant anxiety-reducing effect and so are magnified by the patient. This effect may be further amplified because of the potential difference between the power of the doctor and the patient.

One recent study of patients’ views of the use of humour by nurses⁵ found it was seen as integral to healthcare as a means of boosting morale and asserting individuality at a time of vulnerability. It was also a vehicle to promote positive interactions with the nurses, with the ultimate goal of being cared for in a more individualistic and effective way. It was found that patients wanted nurses to initiate and engage in humour more frequently than they did. The authors suggest this gap may relate to a lack of confidence on the part of nurses or a perception that humour is at odds with their professional identity. This latter concern was also expressed by health visitors, who felt that using humour with patients may be perceived as unprofessional.¹² The use of humour by health visitors was also found to be rare and mainly employed when there was potential for conflict between the health visitor and the patient, by testing out initial responses to potentially threatening topics.  

While the evidence about the use of humour by nurses is limited, the research above would suggest that humour is valued by patients and that they would like to see it used more frequently. Despite this, there is a significant amount of guidance for nurses that highlights the risks of using humour. As McCreaddie & Wiggens² note, this guidance often has no empirical basis. It is, perhaps, unsurprising that some nurses perceive the use of humour to be unprofessional or risky, and therefore use it infrequently.² This indicates a need for the development of a robust evidence base to guide nurses, to help legitimise the use of humour as one aspect of therapeutic relationships with and interventions for patients.⁵ 

What are the implications for the use of humour by nurses in practice?

The evidence base for the use of humour in healthcare is still developing and our understanding of the topic is growing. There is research that suggests that, depending on the style of humour used, it can be helpful in moderating relationships with colleagues, dealing with potentially contentious, difficult and sensitive topics with patients and colleagues and reducing stress. 

Primary care nurses can consider using humour in a number of ways in their work. They can reflect on their own humour style and try to adopt a style that facilitates positive relationships and enhances their own well-being. They can model these humour styles, where appropriate, to patients in order to help strengthen the therapeutic relationship and reduce anxiety. They may wish to educate patients about the potential implications of their own humour styles on their health and wellbeing. 

Nurses can be aware that patients may use humour as a way of asserting their identity in a time of crisis as a means of prompting individualised care and that their own attempts at humour may be amplified by anxious patients as a way of reducing anxiety.

References

1 Griffiths L. Humour as resistance to professional dominance in community mental health teams. Sociol Health Illn 1998;20:874-95.

2 McCreaddie M, Wiggins S. The purpose and function of humour in health, health care and nursing: a narrative review. J Adv Nurs 2008;61:584-95.

3 Snowden A. Humour and health promotion. Health Educ J 2003;62:143-52.

4 Martin R. Humor, laughter, and physical health: methodological issues and research findings. Psychol Bull 2001;127:504.

5 McCreaddie M, Payne S. Humour in health-care interactions, Health Expect 2011;17:332-44.

6 Martin R, Puhlik-Doris P, Larsen G et al. Individual differences in uses of humor and their relation to psychological well-being: Development of the Humor Styles Questionnaire. J Res Pers 2003;37:48-75.

7 Samson A, Gross J. Humour as emotion regulation: The differential consequences of negative versus positive humour. Cogn Emot 2012;26:375-84.

8 Sirigatti S, Penzo I, Giannetti E. Relationships between humorism profiles and psychological well-being. Pers Individ Dif 2016;90:219-24.

9 Boyle G, Joss-Reid J. Relationship of humour to health: A psychometric investigation. 2002. Available at epublications.bond.edu.au/hss_pubs/27.

10 Kakavand A, Shams Esfandabad H, Danesh E et al. Relationship between students’ humour styles and their general health. J Appl Psychol 2010;4:32-43.

11 Granak-Katarivas M, Goldstein-Ferber S, Azuri Y et al. Use of humour in primary care: different perceptions among patients and physicians. Postgrad Med J 2005;81:126-30.

12 Warner U. The serious import of humour in health visiting. J Advan Nurs 1984;9:83-7.

further resources

Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Beh 1983; 24:385-96.