Humor Won, Humor Too: A Model to Incorporate Humor Into the Healthcare Setting

1 Humor Won, Humor Too: A Model to Incorporate

~

Developing the Humor Idea

Humor Into the Healthcare Setting

Michael H. Ackerman, RN, DNS, CCRN, Mary Beth Henry, RNC, MS, Kathy M. Graham, RN, MS, and Nancy Coffey, RN

The benefits of using humor in health care

include stress reduction and improved

psychological well-being for patients and the

nursing staff. The authors discuss model to

incorporate humor in to a specific heal th-care

setting, and include a detailed description of

two humor programs: the Chuckle Wagon and

Nursing Humor Resource Center.

Michael H. Ackerman, RN, DNS, CCRN, is an Advanced Practice Nurse, Strong Memorial Hospital, and Assistant Professor of Clinical Nursing, University of Rochester, Rochester, NY . M a y Beth Hen y, RNC, MS, is a Nursing Educator, Kathy M . Graham, RN, MS, is a Clinical Nurse Specialist, and Nancy Coffey, RN, is a Staff Nurse,Department of Veterans Affairs Medical Center, Buffalo, NY .

T h e concept of using humor to relieve stress and improve one’s emotional outlook is not new. As the healthcare industry is realizing the value of humor, hospitals and nursing homes, once viewed as too professional an environment in which to use humor, now encourage laughter. Humor between patients and staff members is promoted as an appropriate therapeutic technique (Buxman, 1991; Ferguson & Campinha-Bacote, 1989).

Over the past five years nursing literature has contained different recommendations on how to imple- ment the use of therapeutic humor in the healthcare setting. These recommendations have ranged from simple ideas like placing comedy books and maga- zines in visitor waiting rooms to more complex programs such as humor carts and humor rooms.

The authors’ facility developed a model to incorporate humor into a healthcare setting (Fig. 1) The model included two projects: one that focuses on patients and another that focuses on the staff. One project- the “Chuckle Wagon,” is directed by the “Hu- mor Won” committee: the second project, the Nurs- ing Humor Resource Center, is directed by the “Humor Too!” committee.

At the Department of Veterans Affairs Medical Center in Buffalo, NY, the idea to use humor with patients and nursing staff developed from two different arenas. An oncology clinical nurse specialist and an intensive care unit staff nurse presented nursing grand rounds on the benefits of humor in patient care delivery. They wanted to develop a mobile humor

Nursing Fodm Volume 28, No. 4, October-December, 1993 9

Humor Won, Humor Too: A Model to Incorporate Humor Into the Healthcare Setting

Ongoing Formulate objectives

Review literature

Operationalize plan

model humor

Facilitate Humor

Access

resources

Improved working climate

Planning 7 Project Evaluation

cart to bring various humor materials to the patients' bedside. A nursing educator was invited to collabo- rate with them in the planning and development of this hospital-wide project.

At the same time, the problems of declining morale and high turnover rate among staff nurses and nursing assistants challenged the nursing service Re-

cruitment and Retention Committee. Several committee members suggested that the systematic employ- ment of humor at the bedside may be a useful way to decrease staff stress and increase retention of nurses. Therefore, the idea of a nursing humor resource center was born to assist staff members in facilitating humor into their daily patient care.

10 Nursing Forum Volume 28, No. 4, October-December, 1993

Resource Development

Any good idea takes resources to turn it into a reality. Monetary and human resources were deemed essential for the ultimate success of the humor projects. Sources of monetary and human resources can come from a variety of areas. Exploration of all available sources of money and talents within the particular facility and community need to be explored. These sources might include educational grants, foundation accounts, healthcare provider sponsor- ships, volunteer donations, or hospital personnel ex- pertise.

Human resource development. To prevent dupli- cation of efforts and consolidate staff time and en- ergy, the clinical specialist, intensive care staff nurse, nurse educator, and a representative from the recruit- ment and retention committee joined efforts to begin investigating ways to incorporate humor into the medical center. These four individuals became the Humor Advisory Committee, and acted as coordina- tors for two large humor projects that were developed simultaneously. This advisory committee was actually divided into two ad hoc committees entitled ”Humor Won,” which dealt mainly with the patient humor cart, and “Humor Too!,” which pertained to the humar resource center for the nursing staff.

Represemtatives joined efforts to begin

investigating ways to incorporate humor

into the medical center.

Once the advisory committee was developed, the authors next task was to gain the support of the Chief of Nursing Service and to educate themselves in the various days to use humor in the healthcare setting. The chiee of nursing enthusiastically endorsed the

committee’s ideas and approved funding for three nurses to attend a two-day workshop on humor.

The Humor Advisory Committee realized a hospital-wide humor project would not be successful without the support of additional hospital personnel. It quickly became apparent that committee members would need to gain the backing of other medical center departments. This support was accomplished through by numerous telephone conversations and personal contacts made by committee members to gain visibility and support from for the projects various department heads. In retrospect, it may have been advantageous actually to have had a written contract between department heads, outlining agreed responsibilities. This practice prevents misunder- standing of expectations in the future.

Financial and material resource development. Since the humor projects targeted two distinctly different populations, the committee recognized during the early phases of planning that it needed two separate sources of monetary funding. The hospital’s Oncology Service had an existing avenue of funding through an established account, under the Voluntary Service, containing a large amount of funds designated to be used for patient projects. A portion of this money had previously been used to develop a small humor cart for patients on the oncology nursing unit. The Oncology Service offered $500 from its account and the Voluntary Service agreed to match the dona- tion to sponsor the larger hospital cart. In addition, Nursing Service purchased a television monitor and VCR for the cart.

After considering several options, the committee decided to design a humor cart rather than purchase one from a supply company. The desire was to have the cart be as artistically creative and colorful as pos- sible. We decided on a wooden cart with enclosed shelving to facilitate locking of supplies. The top of the cart was designed to resemble an open scrolled carousel. Colorful toys and caricatures could then be suspended from the top of the cart when it was wheeled out on the hospital nursing units. The cart

Nursing Fohm Volume 28, No. 4, October-December, 1993 11


was built by a volunteer carpenter according to the authors’ specifications and then hand painted by a hospital employee with animated carnival caricatures around the entire periphery of the cart. The name of the humor cart, ” The Chuckle Wagon,” was painted on both sides of the carousel top (see Table 1).

After the humor cart was in place, the Humor Won Committee requested that a separate account through Voluntary Service be designated for support of the humor projects. Funding for the nursing humor resource center came from a different area. A grant pro- posal was written to the Humor Project in Saratoga Springs, NY, outlining a plan for the use of humor by the nursing staff. This grant was funded to establish a Nursing Humor Resource Center, which consisted of a library of various humor references to assist nurses at various levels of practice to incorporate humor into their patient care. The center also contained a computer package designed as a tool to allow nurse consultants or lecturers easy access to humorous materials to enhance their presentations. It is anticipated that in the future the use of the resource center will expand from Nursing Service to other medical center departments. Table 2 lists some of the material found in the Nursing Humor Resource Center.

Ongoing Planning

Incorporated into this model is the concept of ongoing planning. The dynamic nature of a humor project requires that continual planning, assessment, and evaluation take place. Included in this area is objec-

Table 1. Items on the ”Chuckle Wagon”

Various comedy videos, books, and audiotapes Magic tricks Hand-held games, puzzles, cards Minature wind-up toys

tive formulation, review of the literature, and making the plan operational.

Objective formulation. Once resources have been obtained, objectives must be formulated. A plan without objectives will have little direction and most likely not fulfill the desires of the organization. Ob- jective formulation can be done separately from the resource development; more likely, the two facets will take place simultaneously. Table 3 outlines the general objectives developed for the humor projects. It is also important to develop a time line in order to keep the project on track.

Review of literature. Literature available on the therapeutic effects of humor ranges from physiologic information about the effects of humor to autobio- graphical testimonials about how humor has assisted in aspects of an individual’s everyday life (Cousins, 1979; McGhee & Goldstein, 1983). Journals and peri- odicals dedicated to the topic of humor are also available, such as Laughing Mutters. The literature review can provide specific ideas and ways of doing things, including how to distribute materials, and how to involve staff members in projects. The literature can also provide valuable information regarding the types of things to avoid, such as inappropriate times to visit

The dynamic nature of a humor project

requires that continual planning,

assessment, and evaluation take place.

Table 2. Items in the Nursing Humor Resource Center

books and videotapes A computer program for creating jokes Creativity textbooks


Table 3. General Humor Committee Objectives

1. Obtain administrative approval for humor projects. 2. Develap a mobile humor cart to be used at the patients’

3. Develop a nursing humor resource center to be used by

4. Increase patient and staff morale throughout the med-

5. Develap a group of volunteers for ongoing work with

bedside.

nursing service personnel.

ical center through the use of humor.

patients. The authors found that the best source of information was from nursing and psychology literature.

Putting the plan into operation. A key factor related to the planning and making the project operational was actually to get involved in each aspect of the project. It’s extremely important to ”live” your project to make it totally successful. This hands-on approach means being involved in every aspect: ordering the supplies, helping build the humor cart, training volunteers, etc. In the authors’ case, the committee took the humor cart out themselves and experienced what the volunteers were experiencing. This feedback was invaluable; it demonstrated how difficult it was to get supplies back from patients, and how the cart was received by patients and staff members. In addition, the experience provided the authors with information about the types of patients who should not be visited by the cart, e.g., immedi- ate postoperative patients, because laughing made their incision hurt, or extremely depressed patients.

Facilitating Humor

Creating a supportive humor network of patients, staff, and administration is a strategy that needs planning. Thef advisory committee’s strategy was to sponsor a carpval open to all hospital personnel. The event cedered around clowns, magic acts, children’s

groups, and singers who were brought in to enter- tain. The carnival was highlighted by the dedication of the Chuckle Wagon and the opening of the Staff Humor Resource Center. This kickoff party provided a great opportunity to showcase cart contents and humor resource materials. This event also created the perfect climate for networking of the Chuckle Wagon volunteer staff, the Nursing Humor Resource facili- tators, and hospital personnel. Administrative staff members in attendance, along with the festive environment and an atmosphere of camaraderie, helped to demonstrate hospital-wide acceptance of this humor project.

The healthy benefits of the humor projects were highlighted by media coverage. The hospital community relations representative designed newspaper ar- ticles, television reports, and radio coverage on the various strands of the humor project. The media reports helped focus attention on the theoretical and practical applications of humor and health care. A video was also produced, which detailed the project from idea inception to completion. This video has been useful for communicating the essence of the humor project to volunteers, the hospital staff, and community groups.

The most intense facilitation of humor

was accomplished by bringing the

Chuckle Wagon out onto the hospital

wards.

The most intense facilitation of humor into the healthcare setting was accomplished by bringing the Chuckle Wagon out onto the hospital wards. The common bond of humor has definitely increased communications between patients and the nursing

Nursing F o b Volume 28, No. 4, October-December, 1993 13


staff. Patients ask each other about their cart selections and before long, other patients and staff members on the unit are asking to see what is causing that hearty laughter. The authors have found that the tell- ing of jokes emerges naturally with the appearance of the wagon. This "feel good" environment usually piques staff interest for the utilization of staff humor resource materials on the unit.

Role modeling humor. The universal language of humor should not need a translator. Yet, often we find what is funny to one person is not amusing to another. Understanding the distinction between mirthful, "feeling good" humor and inappropriate humor need to be addressed in any program that incorporates humor into a healthcare setting. Like- wise, the presence of environmental rigidity may "prohibit" the use of humor. This mind-set may view humor as an element that might decrease productiv- ity. These two issues need to be a considered when engaging in role modeling of productive humorous behaviors.

Inservice classes for volunteers reviewed content of the physical and emotional effects of humor. Chuckle Wagon operations were also reviewed- e.g., when and where to take the cart out and how to retrieve cart supplies. Open discussion of therapeutic versus nontherapeutic humor was encouraged. Lively interchange on the appropriateness of ethnic, religious, and political humor materials ensued. Time was allotted for volunteers to familiarize themselves with the humor cart contents, including practice time with the toys and magic tricks they would be dem- onstrating. The next step in this inservice process was for experienced staff members to accompany the volunteers on their first Chuckle Wagon outing. Humor role modeling by project staff members decreased volunteers' anxiety that they needed to be stand-up comics to be effective with patients. The most important behavior that was encouraged was good listening skills. A good listener will ease anxieties the same as a good laugh.

Humor can redirect fears and anxieties, but it is

also crucial to emphasize sensitivity to those patients for whom humor is not appropriate. Nursing staff members helped volunteers to make this distinction.

Inservice on humor for the nursing staff took place at team meetings or in more informal settings such as during lunch breaks or via the telephone. These discussions identified available resources and method- ologies for effective incorporation of humor into their particular setting. The discussions also provided an opportunity for the project staff to glean new creative ideas on healthcare humor.

Accessibility. The authors recognized that inqui- ries concerning the availability and application of humor project ideas need to be addressed quickly and humor materials made readily available. Direct easy access promotes the positive experience a humor committee strives to achieve. Prompt, supportive humor consultation decreases needless anxieties and promotes project expansion. This area was facilitated in a number of ways. First, a phone extension of a humor consultant need to be easy to remember when it is connected to your project. "Laff" or "haha" are examples that could be used.

It is interesting to note that the humor cart

may be most successful in areas that were

not considered initially.

Second, to ensure rotation of materials to various departments. It is interesting to note that the humor cart may be most successful in areas that were not considered initially. For example, patients awaiting surgery might well decrease their preoperative jitters while listening to a classic Burns and Allen tape. One of the project's staunchest supporters was a termi- nally ill oncology patient who took great delight in not only using humor materials but in stories of how


other patients and staff were reacting to the programs.

The advisory committee lent materials out to patients and staff members for 2-7 days. The committee wanted people to use and enjoy their selections without feeling rushed, although the committee is cur- rently grappling with the problem of retrieving materials. The committee members still are trying to re- solve the problems of how to “find” the materials when patients are transferred or discharged. In one incident, some materials were sent through the hospital mail system and were never located.

Nursing staff members used the materials from the Humor Resource Center in a variety of ways. For example, they developed a hallway comic bulletin board and they learned scarf juggling from a video in order to promote humor and ease stress on the nursing unit. Comedy texts are widely used to gather material to add creative, humorous touches to formal presentations. A special endeavor undertaken by the “Humor Too!” group is the “Lunch and Laff” ses- sions, which showcase staff humor talents.

Evaluation

The authors decided that this particular model requires two forms of evaluation: one from the patients and one from the staff. Traditionally when looking at outcomes related to health care, a common measure is patient satisfaction. The authors devised a brief patient satisfaction tool (Table 4) that was evaluated by one of their Nursing administrators responsible for quality improvement and research prior to its implementation.

The second part of the evaluation involved the evaluation of the effectiveness of the project with the staff. The authors have an informal evaluation in place at the unit level for projects that have been implemented. Nursing staff members who have used humor resource materials are contacted by “Humor Won” mpmbers. Informal communications yield in- formatiob on how their project progressed, what

Table 4. Chuckle Wagon Evaluation Tool for Hospitalized Patients

Recently, you were visited by the humor cart designed for hospitalized patients. We would like your help in making the “Chuckle Wagon” a success. Please take a minute and fill out this survey after you have had a chance to use any item on the “Chuckle Wagon”. Your opinion is very important to the members of the Humor Committee. We will use this information to make our humor cart better for future patients.

Please place the number that most closely reflects your amount of agreement to the statements below.

1. Agree 2. Undecided 3. Disagree

- The Chuckle Wagon staff was friendly.

- There were items that interested me on the cart.

- There was enough time to use the items I signed out from the cart.

- I felt better after using something from the Chuckle Wagon.

- I would like to use the Chuckle Wagon again.

Please complete the following remarks. (The more information the merrier!!)

1. My favorite items on the cart were .

2. Some suggestions I have to make the Chuckle Wagon better are . . .

3. How did using the Chuckle Wagon make you feel better?

Please place this survey in the envelope provided and give it to the ward secretary.

Thanks . . . your help is greatly appreciated!

Nursing Fc(nun Volume 28, No. 4, October-December, 1993 15


materials were used, and which items would be help- ful for future projects.

Conclusion: The Model at Work

The humor model is meant to be a guide for individuals interested in incorporating humor into the healthcare setting. For successful implementation of the model it is essential that the hospital management accepts the concepts of the humor project. Once a project is underway, constant problem solving must take place to assure that the project is meeting the needs of the medical center. However, regardless of how good the idea is, the project will never become a reality without resources. Therefore, sources of po- tential human and financial resources are needed early in the planning. Once all the details of resources and project objectives have been finalized, the project team needs to role model and show people that it’s all right to use humor in their work setting. In addition, materials need to be readily accessible to staff and a great deal of visibility for the project is needed. Once the project is implemented, evaluation of outcomes need to be assessed. The authors hope that this model will assist others in the incorporation of humor in the healthcare setting.

However, regardless of how good the idea

is, the project will never become a reality

without resources.

References

Buxman, K. (1991). Making room for laughter. American loumal of

Cousins, N. (1979). Anatomy of an illness. New York Bantam. Ferguson, S., & Campinha-Bacote, J. (1989). Humor in nursing.

Journal of Psychosocial Nursing and Mental Health Services, 27(4),

McGhee, P., & Goldstein, J. (1983). Handbwk of humor research: Applied studies and basic issues. New York Springer-Verlag.

Nursing, 91, 46-51.

29-34.

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Humor Won, Humor Too: A Model to Incorporate Humor Into the Healthcare Setting