Therapeutic Doses of Humor

Humor is a healing force. There is research in a number of fields that supports the health benefits of humor including heart health, diabetes, allergies, and longevity. Humor has also been tied to better coping skills when faced with difficult circumstances like cancer. It can also help buffer the effects of stress. Humor also helps build a sense of community within health care settings—allowing patients to feel more at ease and comfortable with health care providers (HCPs)—and contributes to a sense of connection and trust. 

Using humor is not only helpful for patients and families, but for nurses as well. Humor can be a powerful form of self-care and can help those who have to work in difficult areas, such as emergency medicine. Examining some of the research conducted on the therapeutic benefits of humor can increase understanding of its usefulness. Exploring various case examples, guidelines, caveats, and common concerns will help make using humor easier.

Why do we laugh? Because laughter and humor are inherently pleasurable to experience. Laughter and humor bring joy and excitement and lighten the mood. Several studies have suggested that laughter activates the mesolimbic dopaminergic reward center in the brain that is responsible for laughter being experienced so pleasurably (Bartolo, Benuzzi, Nocetti, Baraldi, and Nichelli; Watson, Matthews, & Allman, 2007). The activation of the mesolimbic dopaminergic reward system may also be present in other species, including rats. In fact, rats show activation of this system in response to tickling. This likely indicates that pleasure from humor and laughter is biologically hardwired as part of the pleasure and reward system and that this system, as well as its activation by humor and laughter, has evolved (Burgdorf, Wood, Kroes, Moskal, & Panksepp, 2007, Burgdorf & Panksepp, 2006). 

Humor can be healing and benefits both physical and psychological health. Some of the positive physiological effects of humor are (a) helping with diabetic neurological issues, (b) improving pain tolerance, (c) controlling asthma, (d) reducing skin-based allergic reactions such as rashes or eczema, and (e) increasing the use of energy (Wilkins & Eisenbraun, 2009). 

One study (Miller, Mangano, Park, Goel, Plotnick, & Vogel, 2006), that took place at the University of Maryland, showed that negative emotions can impede the ability of blood vessels to dilate. In this study, a blood-pressure cuff was used to constrict blood flow in the arm while a different device measured how much the artery in the arm dilated to account for the increase in blood flow. The researchers then exposed the participants to a funny or stressful movie. Blood flow increased 22% after watching a humorous video compared with individual baseline measurements. 

However, blood flow decreased by 35% after watching a stressful video segment (e.g., the scene at the beginning of “Saving Private Ryan”) (Miller, Mangano, Park, Goel, Plotnick, & Vogel, 2006).   

Laughter can also help expel air trapped in the lungs. A large belly laugh in a healthy patient can even help expel any excess carbon dioxide or water vapor stored deep within the lungs. Laughter can help patients in the hospital that are having difficulty self-initiating deep breathing. However, in a patient with chronic obstructive pulmonary disease (COPD), air is not easily expressed rapidly from the lungs. A recent study that took place in Switzerland (Brutsche et al., 2008) determined that humor is safe for those with COPD, but that gentle laughter may be worse than deep belly laughter because it is more likely to contribute to trapped air. This was demonstrated when a group of adults with COPD and controls had their lung volumes tested prior to a visit by a clown. After the visit by the clown (and much laughter), lung volumes were tested in both groups and those with COPD showed significantly reduced lung capacity that was not shown in the control group. The lung function returned to normal 2 hours later. Only gentle laughter was associated with reduced lung volume; therefore, moderate laughter is recommended for individuals with COPD. However, these researchers also found that those patients who smiled the most during the clown’s visit had the least trapped air. 

Thus, smiling while breathing may be a helpful breathing technique for those with COPD, particularly when paired with a humorous stimulus such as a funny video or entertainer (Brutsche et al., 2008).

Stress has been associated with increases in allergic response (Buske-Kirschbaum, 2009). Laughter and humor can help control certain allergies and allergic responses. Research has shown that watching either a funny movie or a sad movie can help reduce allergic responses (Kimata, 2006). Atopic eczema may be related to low levels of dermcidin—a peptide that, at low levels, may increase skin bacteria. Watching funny videos increased the level of dermcidin from sweat glands on the skin significantly (Kimata, 2007a).

The researchers did a follow-up study that had 14 patients with atopic eczema watch funny videos every day for a week. They found that dermcidin levels increased on the skin of those watching the videos and showed a decrease in bacteria colonization of 28% of their previous levels. Thus, laughter and humor are helpful in controlling and balancing skin bacteria, which may be related to immune function improvement (Kimata, 2007a). People with eczema often have lower levels of melatonin than those without eczema. This increase in melatonin may help stop the reaction of mast cells, which mediate allergic responses (Kimata, 2007b).

Laughter and humor in breastfeeding mothers may help babies’ combat allergies as well.  

When researchers had mothers watch either a funny or neutral control film, they found that babies with atopic eczema were less allergically reactive to stimuli such as dust mites and latex after being breastfed by the mothers who watched the humorous films. This effect was not present in those babies whose mothers watched the control video. The researchers hypothesized that mothers watching the humorous films may have had increased levels of melatonin—which may lead to relaxation—in their breast milk.

Laughter and humor may also have a positive effect on diabetes. In a study, participants ate identical meals and watched a comedy show. This resulted in lower glucose levels for those with diabetes, but in those without diabetes. This may be a result of increased glucose use in the muscles involved when laughing, or laughter may have kept blood glucose levels low by acting on the neuroendocrine system. This is especially relevant because negative emotions have a negative effect on blood glucose levels (Hayashi, et al., 2006).

Laughter and humor may even affect gene expression. Hayashi and colleagues (2007) looked at the effect of humor in the precursor of the enzyme renin found in the kidneys. The levels of this precursor, prorenin, had been higher in those with diabetes than normal controls. Prorenin levels were lowered significantly when people with diabetes watched a comedy show, regardless of whether they had experienced kidney damage previously. The prorenin receptors themselves were up-regulated after watching comedy, which, in effect, changed their gene expression (Hayashi et al., 2007).

Cancer survival may also be tied to having a better sense of humor. Psychologists in Norway followed 54,000 participants and their health statuses over 7 years. When examining only those who were diagnosed with cancer over the 7-year timespan, the researchers found that a better sense of humor at the beginning of the study was associated with a 70% greater chance of survival than for those who did not have a good sense of humor (Svebak, 2007). They also studied patients with end-stage renal disease and found that those with a good sense of humor survived longer. Those scoring in the upper half of the distribution of scores on The Sense of Humor Questionnaire 6 (SHQ-6), a measure of sense of humor, had a 31% increase in survival rate over those who scored in the lower half of the distribution of scores on the SHQ-6 (Svebak, Kristoffersen, & Aasarod, 2006). 

Laughter therapy generally includes the teaching of humor theory, meditations, activities, and stimulated laughter. Stimulating laughter through a variety of mechanisms, including watching comedic videos, visitations by clowns and other entertainers, and even tickling has been shown to have a positive impact on health. One study demonstrated that laughter is contagious by finding that the premotor cortical region was stimulated when hearing the sound of laughter when scanning participants in a functional Magnetic Resonance Imaging (fMRI). Essentially, the sound of laughing stimulates facial muscles (Wellcome Trust, 2006). Some research has shown that positive emotion follows the physical action of smiling, even when stimulated (i.e., by putting chopsticks in the mouth) (Association for Psychological Science, 2012). This may be because the human brain is hardwired to be social with others, and smiling is a social physical movement. In fact, at least one study has found that the reverse was true when they discovered that people who used Botox had blunted abilities to empathize and read other’s emotions (Neal & Chartrand, 2011).

One research study of the elderly looked into whether laughter therapy had benefits for depression, quality of life, cognitive functioning, and sleep. Participants included 109 individuals over age 65 and were divided into two groups—61 in the control group and 48 in the laughter therapy group. The treatment group had laughter therapy over 1 month, a total of four times. The treatment was performed by a nurse certified by a private Korean agency called the Laughter Therapy Professional Association and interventions included a review of the benefits of laughter, body awareness, laughter sessions, laughter meditation, information and techniques to improve positive thinking, and affirmation. 

Both groups were almost identical at baseline on levels of depression, insomnia, cognitive functioning, and quality of life. After treatment, the control group showed reduced insomnia scores, high quality of life, and significant reductions in depression, although they did not show significant improvements in cognitive functioning (Ko & Youn, 2011).

Another study examined laughter yoga, or the incorporation of yogic breathing with stimulated laughter. They examined 60 elderly women who were diagnosed with depression in Tehran, Iran, and sorted these women into three groups: one received laughter therapy, one received exercise therapy, and one received no therapy as the control group. The study found a significant decrease in depression scores with laughter, yoga, and exercise without any significant difference between the two treatment groups. However, only laughter yoga showed significant increases in life satisfaction, whereas these differences were not seen with the exercise intervention alone (Shahidi et al., 2010).

Humor in any of the forms explored above has been shown to have positive mental health effects and is used in many forms of therapy. Humor is actually one of the essential components of Dialectical Behavior Therapy (DBT), one of the most empirically supported treatments for a multitude of mental health issues, including borderline personality disorder. Marsha Linehan, PhD, who developed DBT, emphasized how the use of humor can help people feel more at ease with and trust their health care professionals. 

The use of stimulated laughter and smiling to experience positive emotions is used in DBT as a way of promoting mindfulness, or staying in the moment, as well as a means to regulate and control emotions by learning how to turn emotions when needed (Linehan, 1993). Humor also likely improves health outcomes through mental health support such as increasing social connections, improving mentality and mindset, and decreasing loneliness (Wilkins, 2009).

There is research that shows that positive humor promotes well-being and is adaptive and productive. Positive humor includes affiliative and self-enhancing humor styles. Positive humor styles were related to a better sense of interpersonal competence, better self-esteem, and lower levels of anxiety and depression. Negative humor, such as aggressive and self-defeating humor styles, were related to a worse sense of interpersonal competence, a lower sense of self-esteem, and increases in anxiety and depression. As such, a good and positive sense of humor is associated with improved emotional and personal outcomes. Therefore, it is important to note that although humor is generally a positive health influence, negative humor may actually harm health (Cann & Etzel, 2008).

Humor can help people increase their ability to cope with illness. Appropriate use of humor can help the patient and family cope with the hardships of illness. Humor can also help service providers (such as paramedics and emergency medical technicians [EMTs]) when they encounter suffering, accidents, illnesses, or even death (Scott, 2007).

Nurses, families, and particularly patients all need as much resilience and personal strength as possible. Nurses, especially, need to provide quality care within the context of shrinking budgets, staff, and support. Humor is clearly one of the things that can strengthen and enrich the resiliency of nurses, patients, and families. It is important for nurses to actively try to increase optimism and hope in their patients to improve care. There is growing support that hope can be a powerful, positive influence on health outcomes. Hope can be one of the most influential contributions to a patient’s ability to cope with difficult illnesses, injuries, and accidents. Without hope, patients stop focusing on healing and recovery and stop looking toward the future, which can result in giving up on life, recovery, or ever leaving the hospital again. Humor can help instill hope through establishing strong relationships with patients, encouragement, and demonstrating empathy and goodwill. Humor has been shown to be very helpful for nurses to instill hope and optimism for the future and to teach coping skills (Turner & Stokes, 2006).  

Humor can help in coping well with cancer and symptoms associated with cancer. In one study of how patients with recurrent ovarian cancer experienced humor when coping with cancer, the researchers found that humor helped those patients cope with anxiety more effectively (Rose, Spencer, & Rausch, 2013). Women with breast cancer that used humor to cope with the disease reported experiencing less emotional and mental suffering the day before surgery, 3 days following surgery, and 3 months after the surgery had been completed (Roussi, Krikeli, Hatzidimitriou, & Koutri, 2007).

Humor can be beneficial for caregivers, as well as patients. One study showed that humor helped adult caregivers of individuals with Alzheimer’s disease cope with their tasks (Tan & Schneider, 2009). In another study, researchers followed a neutral, negative, or strongly negative picture by either non-funny or funny stimuli. The humorous stimuli helped regulate the negative emotions caused by the negative pictures. It was hypothesized that this was accomplished because the funny stimuli was more distracting from the distasteful stimuli than the non-funny stimuli (Strick, Holland, Van Baaren, Van Knippenberg, 2009). The research indicates that humor can indeed help with coping and very likely helps people cope due to two reasons. First, it distracts them from whatever they are trying to cope with (like an illness). Second, humor elicits positive emotions in the individual, which help compensate for the negative emotions experienced due to the illness with the assistance of humor coping. 

Humor can help improve patient and nurse interactions and relationships. It can inspire, create, and manifest a sense of community in groups of people. Humor and laughter are social activities that promote bonding between people. Humor connects us all. This sense of community helps provide patients, families, and nurses with an organic and positive social support network. Humor can also help nurses and physicians connect with the patient and his or her family. It can also help improve relationships between nurses, between nurses and physicians, between nurses and patients or families, and even between nurses and other essential health care providers. Humor also offers opportunities for staff to form meaningful relationships with residents in long-term care and helps contribute to work satisfaction (Hegney, et al., 2006). In long-term care, sharing a smile and a laugh have the potential to reduce anxiety, creating an atmosphere of positivity and warmth between the older person and staff (Spitzer, 2011).

Hospital trends have moved away from personalized care toward care based upon technological innovation; however, patients are craving more human and personalized care from their health care providers. Humor helps establish the feeling of receiving personalized care and has been called “patient-centered care,” which is a renewed focus in many health care settings (Scholl, 2007). Humor contributed to patient-centered care through three means. Humor provides an irreverent environment that helps promote positivity and informality—helping providers get more information from patients through informal ways. It can also create an atmosphere where patients feel more comfortable taking an active part in their health care by asking more difficult questions. Humor also puts patient and provider on more equal footing reducing the power differential that is often present (Scholl, 2007).

Humor is actually preferred by patients and can help foster effective communication. Research in cancer patients indicates that humor is an effective strategy for communication once competence and trust in a physician is established (Oliffe & Thorne, 2007). Research in patients with recurrent ovarian cancer found that nurse and physician humor is experienced positively. In fact, nurses who work with patients who have a terminal diagnosis reported that those patients are often helped to both improve quality of life and accept death with the use of humor (Jones, 2008). Patients have positive reactions to both personal anecdotes and traditional jokes by nurses and physicians (Rose, Spencer, & Rausch, 2013). Another study looked at hospitalized children and found that almost half of the group studied reported that they found light-hearted interactions and humor with nurses and other staff members to be important in helping the child to adjust to staying in the hospital (Schmidt et al., 2007). The use of humor by pediatric nurses helps them develop trust with the child and helps to establish long-term bonds (Hamelin-Brabant, Patenaude, & Marchand, 2011).

Not only does humor promote a sense of community, it also humanizes health care for patients and providers. Humor makes everyone more human. 

It particularly makes providers more approachable and more relatable by those they are treating. It also allows patients to view the provider in a whole new light—they might see a nurse as not just a nurse, but a bringer of joy and levity, and may even begin to look forward to seeing the nurse. Additionally, humor helps make patients relate to providers in more positive and constructive ways. Humanizing health care humor helps patients see health care providers as human beings rather than as cold and clinical. This humanization of health care also helps providers see patients more as individuals rather than just as a number, bed, or chart. Humor also helps staff manage their emotions by providing coping mechanisms and when staff deals more effectively with their emotions, patient relationships benefit. Humor also helps maintain a sense of teamwork amongst staff, which also benefits relationships and a positive sense of community within the health care setting. Humor also helps reduce tension in patients, staff, and families, which makes everyone feel more connected and resilient (Dean & Major, 2008). Humor even helps maintain strength within the families of patients suffering from difficult situations. A study with parents of children with disabilities found that those families that coped with stressful situations with humor had higher levels of flexibility and cohesion within the family, both markers of better family functioning (Rieger & McGrail, 2013).

One of the most important lasting effects of humor is how it helps stress management. Stress can be one of the most difficult things to cope with when it comes to dealing with and treating illness. It silently undermines diligent efforts to treat the physical malady and causes ripples of physical and psychological symptoms throughout the body. These symptoms might include increases in blood pressure, cholesterol, pain, headaches, exhaustion, insomnia, anxiety, and depression. Research has suggested that up to 30% of the acute risk of heart attack can be attributed to stress. Stress can also adversely affect blood vessels, metabolic issues, and resistance to insulin (Das & O’Keefe, 2006). 

Using humor to deal with stress has many of the benefits of other mind-body interventions such as meditation. In fact, humor can be considered a type of meditative experience called mindfulness, which keeps the mind fully present in the moment. When the mind is anchored in the present moment it is not drifting off to worry about the future, which often turns into anxiety—or reminiscing wistfully about the past, which often turns into depression. Keeping the mind in the moment is one of the most successful strategies for lowering the impact of stress because it helps detach from future concerns and worries that stimulate stress. When people open themselves up to the random funny things going on in their world (perhaps they wore two different color socks that day), they can approach their life more openly and with a lighter spirit. Having a light and humorous approach to treatment can also provide lasting impact on both the provider and the patient.

The use of humor can be extremely beneficial for nurses to cope with job stressors. Dealing with death, illness, injury, and accidents all day is extremely stressful and draining. It is important for nurses to reduce the effects of such stress and humor may be one of the best ways to keep stress at bay. One study, looking at physicians, found that using humor during work to cope with stress and to lighten a situation was negatively associated with emotional exhaustion and had an equally strong negative association with emotional exhaustion as did talking through stressful events at work with colleagues. Conversely, this study also found that the three strategies most highly associated with emotional exhaustion were keeping stress and difficulty to yourself, focusing only on the task at hand, and ignoring the stress (Lemaire & Wallace, 2010). 

Mental toughness, or resilience, is the ability to spring back after difficulty or stress. Mental toughness is improved in people with positive humor styles. A study of genetic twins examined humor style and mental toughness. Researchers found that positive affiliative and self-enhancing humor styles were positively correlated with mental toughness factors. Mental toughness factors included: control over life, emotional control, control, commitment, confidence, interpersonal confidence, confidence in abilities, and challenge. Considered to be negative, the aggressive and self-defeating humor styles were negatively associated with mental toughness factors of emotional control, control, confidence in abilities, interpersonal confidence, and confidence. (Veselka, Schermer, Martin, & Vernon, 2010).

Burnout is a concern for any health care professional working with patients. Burnout is characterized by a lack of empathy, feeling disconnected, being exhausted, feeling overworked or taken advantage of, not caring as much about the quality of work produced, and reduced quality of care regardless of nursing type or location (Poghosyan, Clarke, Finlayson, & Aiken, 2010). Burnout is a serious issue and is a huge contributor to nurse turnover (Leiter & Maslach, 2009). 

The next section explores how humor can be used in practice through several case examples. These examples will help clarify how to use the principles explored above in practice and how they can be used to lead through example. 

John was diagnosed with kidney disease 8 months ago. He has had a difficult time coping with the disease. John is a quiet fellow who enjoys watching funny television shows, but almost never tells jokes or jokes around with anyone, even his friends and family. However, Fran, a nurse that John frequently comes in contact with, has noticed that recently, John seems far less angry and depressed than he once did about his diagnosis.

After learning about humor, Fran decides that she wants to try to use humor with John to help his health outcomes. Fran realizes that there are many reasons to implement the use of humor with John. First, John seems ready for the use of humor due to the reduction in difficult emotions. John also seems to enjoy humor as evidenced by his preference for comedic television shows. John has also had plenty of time to deal with the realities of his diagnosis and to come to terms with the seriousness of his disease. Fran approaches John tentatively and jokes about the show he is watching on television. 

"You like South Park?” she asked him one day. “I love it,” he responded. “Which character is your favorite? Mine is Cartman since he’s the most ridiculous. I could totally envision Chris Farley playing him in a live action version of South Park.” John begins laughing at his remark and continues joking with Fran about how comedic the concept of Chris Farley as Cartman is and begins to do impressions of Cartman playing several of the roles that Chris Farley made famous on Saturday Night Live.

When John undergoes difficult treatments from that point forward Fran does a brief impression of these characters to distract John from pain and discomfort. John reports that his pain levels decrease when they discuss their shared love of South Park. He also has noticed that his allergic skin reactions have begun to subside, including the eczema he has suffered with since he was a child.   

Beth was diagnosed with leukemia 14 months ago. She finds dealing with the diagnosis to be taxing and exhausting. Adam is a nurse who works frequently with Beth. He has begun singing to Beth whenever he sees her. At first Beth only smiled at Adam’s attempts to make her chuckle. But eventually, Beth would look forward to Adam’s hilarious songs. She found that this anticipation of these funny incidents helped her feel more positive about coming to the hospital and getting treatment. She even began to smile even when Adam had a day off. When Adam first began singing to Beth, he was nervous that he would be seen as silly or that her family would misunderstand the intentions behind his silly songs. However, once he dipped his toe in the water of comedic singing he saw clearly that Beth and her parents appreciated his levity and welcomed it. Beth’s family began to realize how helpful this lightheartedness had been with Beth’s difficult diagnosis and hired a singing telegram to be delivered to Beth in the hospital when she was recovering from her first bone marrow transplant. 

Carlos had had enough with his job. He hated going into work and found working on the second floor of the hospital to be exhausting and stressful. He also didn’t feel like he belonged. His negative feelings affected his desire to go to work and to take on extra responsibilities. That is, until Howard came onto staff. Howard was a natural comedian. He always knew how to make others smile and feel included. Howard would have the entire staff in stitches with his stories about his adventures being a new father. One day, Howard told a particularly funny anecdote about his young daughter making a mess by emptying out the refrigerator onto the living room carpet. Carlos began laughing and then looked around and noticed that he wasn’t alone. He laughed harder as he heard his voice join in with the half dozen other staff listening to the story. Just as he was quieting down, an old woman sitting in the hallway in a wheelchair tugged at Carlos’ arm. She asked whether he could help her find her daughter. 

This was the kind of request that would have received a sharp retort from Carlos in the past. But this time, because of the pleasurable feelings associated with the extended laughter, Carlos saw the old woman in a new light. He realized how vulnerable she was and how little effort it would take to make her happy. He happily helped the old woman find her daughter. The next week, Carlos received a letter recognizing the time and attention he had paid to a little old woman who couldn’t find her daughter. It turned out that the woman had died several days earlier and that Carlos’ interaction with her helped her feel more at ease and comfortable in her last days. Realizing the positive results of humor, Carlos began interjecting it into his work with patients and approaching them with a gentler and more generous attitude. Carlos’s improved sense of humor began to create better relationships with his coworkers. 

Jenny was always stressed out. She looked at other nurses and didn’t understand how they kept it together so well. She would go home and have difficulty sleeping, have no appetite, and even felt like her personal relationships were suffering. Jenny got so worked up at work one day that, as she was rushing around, she stumbled and tripped over a chair. She was so stressed that the incident made her furious and the laughter of the other nurses made her seethe with anger. The stress was so intense that she began to feel disconnected from everyone around her at work. She went home that night and composed her resignation letter. She sealed it up in an envelope intending to deliver it the next day. But, the next day, she forgot the letter. Already feeling defeated, being rather pressured for time, and stressed to the gills she told one of her patients “I always feel like a chicken running around with its head cut off—flailing around and bumping into things completely blind.” 

And just as she said this, she knocked over an entire container of latex gloves, dumping them all onto the floor. Her patient let out a huge belly laugh and began to laugh more and more uncontrollably. Through tears the patient explained to Jenny “You! I just keep picturing you as a nurse chicken. A nurse chicken with no head running around and bumping into things, and knocking things over!” Jenny began to picture what the patient had described and began to giggle until she was laughing so hard she was turning red. As she laughed, she began to laugh even harder realizing how amusingly absurd her accident was. As her laughter subsided, she began to realize that she didn’t need to take every single aspect of her job so seriously and that she might be better off if she could just learn to laugh at herself. She went home and tore up her resignation letter that night, realizing that if she just learned to shake things off and take herself less seriously she would feel much better about her work environment. 

1. Be determined to use humor for the benefit of patients, and not just for personal reasons. Some of the common reasons humor is used in practice is to help patients marshal their own internal healing processes; to help patients manage their own fears, worries, anxiety, and stress; establish a connection that is personal, human, and warm with patients; and provide a normalized environment for the patient.
2. Be sure there is an established record of competence with the patient first. Humor should never get in the way of a patient’s perception of a nurse’s competence and professionalism. Establishing a patient’s confidence often does not take long and usually happens once the patient starts to relax a bit. If humor is used prematurely, it can weaken the developing relationship between patient and nurse and reduce their confidence and trust.
3. Be sure that any crises have passed and that there has not been a recent crisis in a family member’s life. An easy way to establish this is simply asking “How are we doing?” when entering a room with patient and family and gauge how they react to determine whether or not to use humor.
4. Baby steps are important when implementing humor—do not just jump in head first. It is important to gauge little-by-little how comfortable patients and families are with humor to see if these overtures will be received positively.
5. Be aware of the patient’s reaction to humor. Be understanding and gentle if they are not into humor or not in a laughing mood. Do not force humor, as it can cause discomfort and self-blame for the patient. Humor is like any other medical treatment—not all patients react the same. Some patients will be intolerant of certain types of humor (or of humor in general). Be sensitive to these intolerances.

6. Be cognizant of the fact that laughing may be difficult, uncomfortable, or painful for patients. Some patients may not feel like laughing due to discomfort, pain, traumatic memories, sadness, or even nausea.
7. Remember that patients who are still in denial about their diagnosis will probably not be receptive to humor. Patients who have accepted their disease, illness, or injury are far more receptive to a humorous approach.
8. Do not try to quiet or ignore pain, sadness, or anger with the use of humor. Some patients will shut down when they feel that their feelings are the butt of a joke and a shutdown patient cannot help with their treatment. It is important for patients to feel that they can express their difficult physical and emotional feelings. However, humor can be used to help turn a patient from prolonged anger or depression once they have had adequate time to reflect on and express these difficult feelings.
9. Unless a joking relationship with a patient has already been established, do not joke in front of them when they are about to undergo a treatment, surgery, test, or scan. Often, staff joke with one another without contemplating who is around to hear them. If this does happen by accident, explain it to the patient so that they can understand the context (rather than thinking the joke was on them).
10. Make fun of yourself in a way that does not erode your competence.
11. Laugh at unexpected events.

12. Never joke about incompetence or laugh at, or joke about, patients.
13. Do not use humor to help with the delivery of bad news. This can trivialize the patient’s experience. Empathy and compassion are important at this juncture unless the patient initiates the humor.
14. Do not make patients uncomfortable or embarrassed about their bodily issues with jokes, as this may make them less likely to report serious complaints that are embarrassing. It is also important not to avoid sensitive topics by using humor.
15. Be patient with those patients that may not be used to using humor in serious or stressful situations. They may not be capable of humor at the moment.
16. Reverence of illness may be both a cultural and religious issue that deserves sensitivity and may make humor unacceptable or distasteful. This is the reason that treading lightly is important. For example, as discussed earlier in the course, there is a cultural “reverence for illness” in Taiwan that generally makes the use of humor with patients unacceptable. 

1. Thinking that colleagues or patient will see you as unprofessional if you use humor. Discussing the benefits of humor on the health and well-being of both patients and health care staff can be helpful in situations like this. Many people do not understand the benefits of humor. Even a brief memo or posting can help other staff understand how and why to use humor in practice with patients. Promoting this type of change of practice can be a way to provide leadership within the nursing community or health care setting.
2. Thinking that you will be seen as incompetent. This is why it is essential to establish competence before using humor, especially with other staff.
3. Thinking that patients will see you as cold or indifferent about their disease. First, do not use humor too soon after diagnosis. Second, humor actually makes health care providers seem warmer and connected to their patients.
4. Thinking that patients will think using humor with them diminishes your respect for their illness. This is the same as being concerned that laughing with patients means you are taking them and their illness less seriously. If this is a serious concern, reassure patients and families. However, realize that many patients experience humor positively and as a relief and do not use humor with patients who are not open to it.

5. Thinking that using humor will result in more work. Although using humor may take a bit more thought, humor is tied to stress relief, a stronger sense of community, and teamwork, all of which make your job easier. Keeping stress under control will actually make work seem easier and may make everything go smoother since there will be fewer mistakes caused by stress.
6. Worrying about being confronted with humor that is not funny or is off-putting. Be honest with your humor and let the patient know if their humor goes too far (gently). Be open minded, flexible, and support efforts toward humor by patients in a nonjudgmental way. But do not force a laugh, just smile and nod.
7. Worrying that humor will not be received in the right way or will offend or be unfunny to a patient. This is something to be prepared for, especially patients not finding you funny. Having a joke fall flat is one of the quickest ways to determine whether humor is appropriate with a given client. To avoid offending patients, avoid all topics of humor that might be seen as offensive including race, sex, gender, ethnicity, or joking at anyone’s expense (but yourself). If a joke is taken the wrong way, just explain this to the patient. Most patients will be very understanding

1. Never use humor during a crisis. Humor is never appropriate during the delivery of a difficult diagnosis or prognosis or when there is uncertainty about a patient’s health (such as using humor with the family when the patient is in life-threatening surgery).
2. Never use humor when a patient is crying or just wants to have some peace and quiet.
3. Do not use humor when the patient in the next bed is in crisis or extremely ill.
4. Do not use humor when a patient is trying to tell you something important. This can decimate rapport with patients.
5. Never tell jokes at other’s expense. Do not make fun of other patients or coworkers.
6. Never use humor that involves sarcasm, mockery, or dark or demented humor. Joke about things you would joke with an average grandmother about.  

In this continuing education course, you have learned how to use humor in practice. You have learned how humor benefits health, stress, community, and coping. You have learned how humor can benefit hospitals and the entire health care staff. Also, you have learned how humor contributes to a sense of connection and teamwork amongst staff and that humor can help buffer nurses from burnout, a major concern in terms of nursing turnover. This knowledge can help you lead more effectively in your nursing community or health care setting. Leadership is essential in nursing and each nurse is a leader. Leadership helps to elevate the profession and improve the dissemination and usefulness of professional development. Consider explaining to others both how and why to use humor in practice as a way you can show leadership within your nursing community or health care practice. Creating a brief handout to educate others can help bring them up to speed. 

Using humor in practice can be intimidating if you are not used to it. The information provided in this course shows the positive effects of humor on the health of patients, families, and nurses. Consider integrating humor into your practice in a way that updates and changes your practice for the better. Although humor is not yet taught formally in nursing education, it has enough research and anecdotal evidence to provide solid reasoning for changing the way you practice. It has also been shown that both patients and staff have positive perceptions of the use of humor in the workplace and that there are benefits in terms of teamwork. These benefits make the use of humor in practice essential to providing quality patient-centered care that prioritizes the health of everyone involved. 

• Humor has many benefits including helping with allergies, diabetes, and pain management.
• Coping is improved through the use of humor.
• Building a sense of community and patient-centered care is easier with the use of humor.
• Humor is helpful in dealing with stress and avoiding burnout.
• There are guidelines that can help implement humor in practice with patients.
• Many people are concerned about using humor in practice, but these concerns can be overcome.
• There are times using humor in practice is completely inappropriate and could be potentially damaging.  

1. Bartolo, A., Benuzzi, F., Nocetti, L., Baraldi, P., & Nichelli, P. (2006). Humor comprehension and appreciation: An fMRI study. Journal of Cognitive Neuroscience, 18(11), 1789-1798.
2. Burgdorf, J. & Panksepp, J. (2006). The neurobiology of positive emotions. Neuroscience & Biobehavioral Reviews, 30, 173-187.
3. Wilkins, J. & Eisenbraun, A.J. (2009). Humor theories and the physiological benefits of laughter. Holistic Nursing Practice, 23, 349-354.
4. Miller, M., Mangano, C., Park, Y., Goel, R., Plotnick, G.D., Vogel, R.A. (2006). Impact of cinematic viewing on endothelial function. Heart, 92, 261-262.
5. Brutsche, M. H., Grossman, P., Muller, R.E., Wiegand, J., Pello, Baty, F., & Ruch, W. (2008). The impact of laughter on air trapping in severe chronic obstructive lung disease. International Journal of Chronic Obstructive Pulmonary Disease. 3(1), 185-192.
6. Buske-Kirschbaum, A. (2009). Cortisol Responses to Stress in Allergic Children: Interaction with the Immune Response. NeuroImmunoModulation, 16, 325-332.
7. Kimata, H. (2006). Emotion with tears decreases allergic responses to latex in atopic eczema patients with latex allergy. Journal of Psychosomatic Research, 61, 67-69.
8. Kimata, H. (2007a). Increase in dermcidin-derived peptides in sweat of patients with atopiceczema caused by a humorous video. Journal of Psychosomatic Research, 62, 57-59.
9. Kimata, H. (2007b). Laughter elevates the levels of breast-milk melatonin. Journal of Psychosomatic Research, 62, 699-702.
10. Hayashi, T., Urayama, O., Kawai, K., Hayashi, K., Iwanaga, S., Ohta, M…..Murakami, K. (2006). Laughter regulates gene expression in patients with type 2 diabetes. Psychotherapy & Psychosomatics, 75, 62-65.
11. Hayashi, T., Urayama, O., Hori, M., Sakamoto, S., Nasir, U.M., Iwanaga, S., Murakami, K. (2007). Laughter modulates prorenin receptor gene expression in patients with type 2 diabetes. Journal of Psychosomatic Research, 62, 703-706.
12. Svebak, S. (2007). Sense of humor and mortality: A seven-year prospective study of an unselected county population and a sub-population diagnosed with cancer. Psychosomatic Medicine, 69, A-64.
13. Svebak, S., Kristoffersen, B., & Aasarod, K. (2006). Sense of humor and survival among a county cohort of patients with end-stage renal failure: A two-year prospective study. International Journal of Psychiatry in Medicine, 36(3), 269-281.
14. Wellcome Trust (2006, December 13). Laugh And The Whole World Laughs With You: Why The Brain Just Can't Help Itself. Eureka Alert press release. Retrieved from http://www.eurekalert.org/pub_releases/2006-12/wt-lat120806.php
15. Association for Psychological Science (2012). Grin and Bear It! Smiling Facilitates Stress Recovery. Retrieved from http://www.psychologicalscience.org/index.php/news/releases/smiling-facilitates-stress-recovery.html
16. Neal, D.T. & Chartrand, T.L. (2011). Embodied Emotion Perception: Amplifying and Dampening Facial Feedback Modulates Emotion Perception Accuracy. Social Psychological and Personality Science, 2(6), 673-678.
17. Ko, H. & Youn, C. (2011). Effects of laughter therapy on depression, cognition, and sleep among the community-dwelling elderly. Geriatrics & Gerontology International, 11(3), 267-274.
18. Shahidi, M., Mojtahed, A., Modabernia, A., Mojtahed, M., Shafiabady, A., Delavar, A, & Honari, H. (2010) Laughter Yoga versus group exercise program in elderly depressed women: a randomized controlled trial. International Journal of Geriatric Psychiatry, 26(3), 322-327.
19. Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press. 

20. Cann, A. & Etzel, K. C. (2008). Remembering and anticipating stressors: Positive personality mediates the relationship with sense of humor. Humor: Int. Journal of Humor Research, 21(2), 157-178.
21. Scott, T. (2007). Expressions of humour by emergency personnel involved in sudden death work. Mortality, 12(4), 350-364.
22. Turner, de S. & Stokes, L. (2006). Hope promoting strategies of Registered Nurses. Journal of Advanced Nursing, 56(4), 363-372.
23. Rose, S.L., Spencer, R.J., Rausch, M.M. (2013). The use of humor in patients with recurrent ovarian cancer: a phenomenological study. International Journal of Gynecological Cancer, 23(4) 775-779.
24. Roussi, P., Krikeli, V., Hatzidimitriou, C., & Koutri, I. (2007). Patterns of coping, flexibility in coping and psychological distress in women diagnosed with breast cancer. Cognitive Therapy Research, 31, 97-109.
25. Tan, T. & Schneider, M.A. (2009). Humor as a coping strategy for adult-child caregivers of individuals with Alzheimer’s disease. Geriatric Nursing, 30(6), 367-408.
26. Hegney, D., Eley, R., Plank, A., Buikstra, E., & Parker, V. (2006). Workforce issues in nursing in Queensland: 2001 and 2004. Journal of Clinical Nursing, 15, 1521–1530.
27. Spitzer, P. (2011). The LaughterBoss. In T. Adams and H. Lee (Eds.) Creative Approaches in Dementia Care (pp. 32-53). New York: Palgrave MacMillan.
28. Scholl, J. C. (2007). The use of humor to promote patient-centered care. Journal of Applied Communication Research, 35(2), 156-176.
29. Oliffe, J. & Thorne, S. (2007). Men, masculinities and prostate cancer: Australian and Canadian patient perspectives of communication with male physicians. Qualitative Health Res., 17(2), 149-161.
30. Jones, C. D. (2008). The secret source of humor is sorrow: Humor as a coping mechanism in the dying process. Dissertation Abstracts International: Section B: Sciences & Engineering, 69(2-B), 13090.
31. Schmidt, C., Bernaix, L., Koski, A., Weese, J., Chiappetta, M., & Sandrik, K. (2007). Hospitalized children's perceptions of nurses and nurse behaviors. American Journal of Maternal/Child Nursing, 32(6), 336-342.
32. Hamelin-Brabant, L., Patenaude, H., & Marchand, H. (2011). Experiences of humor in pediatric nursing care. Soins. Pediatrie, puericulture, 6(263), 41-44.
33. 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.
34. Rieger, A., & McGrail, J.P. (2013). Coping humor and family functioning in parents of children with disabilities. Rehabilitation Psychology, 58(1), 89-97.
35. Das, S. & O’Keefe, J. H. (2006). Behavioral cardiology: recognizing and addressing the profound impact of psychosocial stress on cardiovascular health. Current Atherosclerosis Reports, 8(2), 111-118.
36. Lemaire, J.B. & Wallace, J.E. (2010). Not all coping strategies are created equal: a mixed methods study exploring physicians’’ self-reported coping strategies. BMC Health Service Research, 10, 208.
37. Veselka, L., Schermer, J.A., Martin, R.A., & Vernon, P.A. (2010). Laughter and resiliency: a behavioral genetic study of humor styles and mental toughness. Twin research and human genetics: the official journal of the International Society for Twin Studies, 13(5), 442-449.
38. Poghosyan, L., Clarke, S.P., Finlayson, M., & Aiken, L.H. (2010). Nurse burnout and quality of care: Cross-national investigation in six countries. Research in Nursing & Health, 33(4), 288-298.
39. Leiter, M.P. & Maslach, C. (2009). Nurse turnover: the mediating role of burnout. Journal of Nursing Management, 17(3), 331-339. 

You have nearly completed the Therapeutic Doses of Humor course.

What steps are left to complete this course?

• Complete the following Self-Assessment Questions.
• Return to "My Courses" to complete your course affirmation or final exam (depending on your state’s requirements).
• Complete your course survey in order to receive your completion certificate.

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1. Pass your test or affirm that you have completed the material (depending on your state's requirements). 
2. Complete your course evaluation survey. 

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