Introduction

Cancer diagnosis and treatments not only affect patients physically but also psychosocially [1]. Patients report negative feelings such as tension, embarrassment, isolation, fear and uncertainty [1, 2]. Nurses can play a key role in helping mitigate such negative effects. The literature suggests positive outcomes related to the use of humour in a variety of health-care specialities and disciplines. Several studies have explored the value of humour for patients and nurses in a variety of areas including neurological units [3], palliative care settings [4–7], learning disability units [8], older people services [9], intensive care units [10] and cancer settings [11–13]. There are many factors that are known to affect the use of humour, for example, age, culture, social circumstances, beliefs, philosophy, attitudes and gender [7, 14]. Previous studies show that humour helps patients to enhance their ability to cope with stressful situations [4, 5, 11, 13]. It may encourage patients to participate more in their care [18] and become more open regarding how they feel about their illness, given that humour makes them feel closer to the healthcare team [3–14, 18, 19]. Equally, nurses have reported that the use of humour may help establish patient trust [14, 18], whilst humour amongst colleagues enhances relationships [20].

Methods

The study was conducted on an adult oncology ward in a specialist cancer hospital. Ethical approval was granted, and data were collected between June and August 2009, after all requirements of the local research governance committee approval were attained.

A modified ethnographic methodology was utilised in this study to explore humour in nurse–patient interactions in the clinical context. Ethnography is valuable in terms of looking at the context but also facilitates a holistic exploration of relationships and behaviours that surround the use of humour by nurses and patients in the clinical setting [21]. Data were collected using participant observation, informal interviews and semi-structured formal interviews.

All nurses on one ward who had a permanent contract with the hospital and had at least 1 year of experience in oncology nursing were approached. This ensured that they were familiar with the working environment and patient group. During the study period, there were 18 nurses working on the ward, and 9 nurses agreed to be observed (see Table 1). Two nurses refused to participate in the study due to concerns about being observed and were, therefore, not included in the observation field if they were working during data collection. A convenience sampling strategy was used in relation to the patient participants. This enabled exploration of the use of humour by patients across different cancer stages and types. All except one deteriorating patient admitted to the ward were approached (see Table 2). Twelve patients agreed to be observed. All patients who declined to participate in the study were excluded from the observation field. Observation of nurse–patient interactions were, therefore, only carried out when both the nurse and patient provided a written consent. Other members of the team and ward visitors were informed that a study which involves observation was in progress through a poster in strategic locations of the unit. Due to resource and time restrictions, the researchers focussed observations on nurse and patient interactions. In total, 30 h of participant observation was undertaken by the primary researcher. Informal interviews with both nurses and patients were conducted as part of every observation to validate observations [22]. Field notes were transcribed as soon as possible after each observation period. Field notes were discussed with the supervisor to ensure rigour in recording and depth of description.

Table 1 Staff nurses demographic profile
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Table 2 Patient demographic profile
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Of the nine nurses who participated in the observation phase and informal interviews, five nurses were also formally interviewed, whilst five patients out of the 12 who were observed were also formally interviewed. Formal interviews facilitated a fuller exploration of the topics identified during observation and used to elicit both nurses' and patients' views about humour. Formal semi-structured interviews were conducted in a private room in the unit to further explore the observed interaction (see Table 3). These were recorded digitally and were later transcribed verbatim.

Table 3 Formal interview schedule
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Thematic data analysis was conducted to identify key themes and categories [23]. Initially, the data sets were analysed separately by the primary researcher to identify individual themes. Two researchers undertook a preliminary analysis of a number of interviews. The data were then amalgamated and analysed as a whole. Data were read repeatedly in order to become familiar with the content, linking observations and responses in the context of the participants' environment and circumstances. Keywords or elements in the text were coded. Codes with similar meanings were linked and grouped together to form sub-themes. Taxonomic analysis was conducted whereby similar themes were grouped together, and contrasted themes were separated out. This was used to explore relationships and contrasts in the sub-themes. This typical ethnographic process has a classic ‘funnel structure’ (p. 160) [24] where the focus narrows as the research progresses. This demands that the researcher is reflexive and able to return to the data sets to verify the themes, which warranted the use of a reflexive journal and recording of an audit trail. Subsequently, two other investigators verified the themes.

Results

Final thematic analysis resulted in four main themes which will be presented and illustrated by exemplars from the data. These included (1) the benefits of humour in the nurse–patient relationship, (2) patients deliberately use humour, (3) humour and professionalism and (4) humour requires constant assessment and reflection. Extracts from the transcripts will be presented using the following identifiers: P (patient), N (nurse), FI (formal interviews) and FN (field notes).

The benefits of humour: “It creates a bond…”

Findings showed that both nurses and patients perceived humour as a sign of developing good interpersonal relationships. The process of relationship building occurred over time, and humour helped the patient feel comfortable with the nurse:

“I think it makes me feel a bit more comfortable and like you are developing a good relationship with the person” (P-08, FI).

Nurses perceived the importance of humour in helping establish rapport between the nurse and patient, making patients feel at home and relaxed. They viewed the use of humour as an indication that patients may be able to trust them:

“…it creates a bond…to be able to giggle with somebody, they must have some element of confidence in you. That promotes confidence and makes the patient like, trust and know what you can do” (N-05, FI)

and

“When they want to confide something a bit deeper…something more serious, they will trust you a bit more because you had a laugh or a joke” (N-01, FI).

For nurses, humour was a way of showing that they enjoyed what they were doing and that despite the busy nature of their roles, they still made time for the patients:

“It relaxes everybody. Your work is enjoyable; you don't just come in to do the shift” (N-02, FI).

Patients viewed humour as something that both nurses and patients need as part of their relationship:

“Nobody needs it more. It's part of…you're a team. One person is helping you getting better; the other person is trying to get better. And it's a team job” (P-10, FI).

On observation, it was apparent that nurses and patients who were seen laughing together appeared more relaxed and comfortable with each other. Both patients and nurses recognised the importance of humour in their relationships and its benefits.

Patients deliberately use humour: “You try to put some positive energy forward”

Data indicated that patients' views of humour were mainly positive. Keywords and phrases such as ‘positive’, ‘happy’, ‘lovely’, ‘raising spirits’, ‘makes it better’, ‘good mood’ and ‘more pleasant’ were consistently referred to by patients. Patients reported that they use humour because nurses like patients who have a sense of humour:

“It can make the nurses get to like you…” (P-08)

and

“Somebody with a sense of humour asking for a cup of tea is more likely to get one than somebody demanding a cup of tea” (P-10).

These patients were observed using humour regularly. On one occasion, P-08 was observed using humour to ask the busy nurses to expedite his tablets to take home. Another patient jokingly remarked that he will take his surgical drain home if the nurses don't remove it soon. In all occasions when patients utilised humour to ask something, nurses respond in more cheerful manner despite being very busy. For patients, nurses and patients laughing together was seen as a sign that they have a good relationship. Nurses, in turn, appeared to have a preference for humorous patients:

“Everybody wants to take his bloods because he has good veins and he is a happy and nice person” (N-06, FN).

Nurses voiced the importance of humour in helping them get through the day. Interestingly, patients showed an awareness of the stresses nurses and healthcare professionals face at work. They highlighted their intentional use of humour to help health-care professionals cope:

“…what happens to health professionals is that they are dealing with negative energy all the time. That is very tiring, very psychologically tiring and mentally tiring and so I think people will understand that…so you try to put some positive energy forward. Otherwise, apart from everything else, you will have tired nurses and doctors and workers which is not good for our healthcare” (P-04, FI).

Patients highlighted that both nurses and patients need humour. A patient cited an example when he had to use humour after a failed insertion of an intravenous cannula to minimise damage to a nurse's confidence:

“She hasn't done it before, she did it wrong. She was very upset. I made a big joke about it. She was ok…I did that exactly to make her feel better…No real damage was done, but it could've been done to her…to her confidence” (P-10, FI).

The researcher also observed on one occasion when a nurse accidentally knocked a bedside table, and several things dropped on the floor. After the incident, both nurse and patient were seen laughing and amused. By laughing together, the nurse admitted she felt less embarrassed by the situation (FN).

Humour, professionalism and cancer: “Humour is not as straightforward as you think it is…”

Despite reporting several positive outcomes associated with the use of humour, nurses in this study expressed concerns about compromising professionalism and how this may affect how they were viewed by their colleagues:

“People just don't have sense of humour at all at work because that's their way of being professional…they probably see it as less professional to be laughing and joking with patients” (N-01, FI).

This may be the reason why some junior nurses appeared more serious in their approach when more senior nurses were around. More humour and banter were observed in the clinic rooms when junior nurses are on their own. The type of leader was seen as a factor which affected the use of humour in clinical practice. Junior members of staff reported taking guidance from senior staff on whether humour was appropriate:

“And I think junior staff take a cue from senior staff, and then if you don't see humour, you might just think it's unacceptable so you might just tend not to use humour…so I think senior guidance really” (N-01, FI).

The researcher observed the abundance of the use of humour when nurses were making beds, especially at the start of the morning shift. Conversations such as about celebrities, personal stories and anecdotes, movies and the weather generated a lot of laughs and giggles in the ward. Nurses remarked that the use of humour may be too risky or dangerous and may offend or upset the other person. They perceived that humour was acceptable when it was about what they repeatedly referred to as ‘little things’ or ‘little situations’ such as their travel to work, beds, blood pressure monitoring, and patient gowns:

“I think hospital gowns…they put it on a wrong way and that can always be a bit of a laugh and sometimes actually when you have a little situation like that, it can help the patient, perhaps break how nervous they're feeling…” (N-02).

Study findings indicated, therefore, a process of classification or differentiation between little things and ‘serious things’. Some examples of what nurses refer to as serious things included matters such as: ‘pain’, ‘death’, ‘dying’, ‘discussing treatment plans’ and ‘breaking bad news’. Nurses generally perceived humour as inappropriate for serious things. Observation data indicated no use of humour when nurses were taking bloods, preparing drugs and providing discharge instructions.

Nurses also highlighted that humour in cancer may be different from other illnesses because of its effect on patients:

“…but here, it is different because it's a whole life changing experience for people…so it (humour) is needed, but I think it's not kind of straightforward as you think it is…” (N-05, FI).

In contrast, whilst nurses expressed concerns about compromising professionalism, patients considered humour a positive feature in a nurse. Patients associated humour with positive personal attributes, including being optimistic and relaxed. Table 4 summarises these.

Table 4 Humour and associated personal attributes
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Humour requires constant assessment and reflection: “You have to be careful about…”

Study findings indicated that nurses appreciate the value of assessment before using humour and of reflection to avoid inappropriate use. This helps create a plan of action to avoid damaging the nurse–patient relationship:

“I follow their (patients) lead…” (N-08, FI)

and

“…if in a group, you might say something and they laugh. But when you reflect on it, you shouldn't really be laughing at this” (N-05, FI).

Similarly, patients also acknowledged and valued the importance of constant assessment and reflection on the use of humour.

“It depends on the situation” (P-03, FI)

and

“So I'd perhaps wait a bit and find out how she (nurse) was, let her make the next move, basically” (P-10, FN).

Humour is subjective [5]; therefore, there are differences in how people express, appreciate and perceive humour. Although there are perceived therapeutic benefits of humour in the nurse–patient relationship, participants in this study acknowledged that humour may result in negative repercussions if not used appropriately. They identified that timing is important when assessing the appropriateness of humour. It was apparent, however, that timing was largely dependent on the patient's condition. During extremely emotional situations, for example, when one patient who was planning to go home, suddenly deteriorated, nurses who were observed previously making humorous comments ceased when the patient became unwell. Patients were observed to be using humour more to nurses who welcome it and vice versa.

To avoid damaging the nurse–patient relationship, pointers such as having an inner sense of what feels right before using humour, taking cues from the other person and choosing the right timing were identified as important. In this study, the benefit of continuous assessment and reflection were highlighted.

Discussion

This study revealed that nurses and patients in an adult cancer ward perceived the benefits of humour in terms of fostering the nurse–patient relationship. Participants did not, however, isolate humour as the only component of the nurse–patient relationship. This suggests that humour can be used as one of many communication tools to facilitate therapeutic nurse–patient relationships. Participants repeatedly associated humour with trust, either as a sign of trust or humour resulting in a trusting relationship. This is in line with definitions of humour in cancer care which point to trust as a critical attribute of humour [16]. When a trusting relationship is established, it is easier for nurses to assess their patients, given that often nurses are required to ask patients sensitive or personal questions [15]. Humour can become a vehicle to facilitate the process of therapeutic engagement. This process can help both the nurse and patient become more relaxed, develop trust and communicate openly [17]. Different perceptions, however, were also in evidence, and these potentially affect the use of humour in this context (see Fig. 1).

Fig. 1
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Nurses' and patients' perceptions of humour

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In general and in line with other studies, patients perceived humour as something which is positive [11–13]. This echoes previous research findings which highlighted how humour helps in forming therapeutic relationships [5] and creating special bonds of friendships between patients and nurses [17]. Humour also serves as a supportive mechanism that facilitates a safe and comforting environment for patients [4]. The literature highlights its use as a coping strategy [12, 13], to manage other people's feelings towards the person's illness [11] or as a means of helping patients to regain a sense of control [4]. In addition, patients appeared to welcome humour and perceived it as a positive attribute in nurses. This may be due to many factors. Firstly, if a patient chooses humour to help cope with their illness, they are more likely to feel positive towards nurses who engage in humorous interactions. Secondly, patients may view a cheerful nurse as one who is less threatening. Studies show that humour can act as a levelling agent between nurses and patients [6, 7]. Thirdly, patients may use humour to help maintain a sense of normality, as humour can be a form of distraction from the serious nature of cancer and associated negative feelings.

Study results indicate that patients recognise that humour can be positive. Several studies showed similar results where humour was associated with positive emotions [17] and as a manifestation of positive thinking [18]. Humour has also been linked to ‘being a good patient’ [18]. Previous research reported that patients initiated humour in social interactions with nurses in hospice settings [4]. However, the literature mainly focuses on benefits to patients when they utilise humour, for example, as a coping mechanism when encountering difficult circumstances [5, 11, 19]. Interestingly, in the present study, findings showed the intentional use of humour by patients in order to be liked by nurses, but also, to help nurses cope with their day-to-day tasks. Patients indicated that they used humour to help nurses cope with work stress. For patients, the use of humour does not only benefit patients but also healthcare professionals. This is perceived as an important component of the nurse–patient relationship.

Whilst nurses acknowledged the beneficial effects of humour, they remained hesitant about its use due to issues of professionalism. The literature presents many possible negative outcomes associated with humour [3, 7, 8, 14, 24]; therefore, nurses' hesitation is perhaps not surprising. Negative outcomes include offending the other person and causing anger or confusion [7, 14, 24]. Humour is, however, a tool that can help nurses deal effectively with difficult situations and also helps create a sense of cohesion between nurses and patients and amongst nurses themselves [19, 20]. Nurses in this study felt humour helped make their working day easier and helped them enjoy their work more. Cancer nursing is an emotionally challenging field which can lead to compassion fatigue and burnout [25]. It has been suggested previously that the use of humour by nurses may be a means of coping with the high emotional demands of the role [26] and that humour promotes healthy working environments [16, 23].

Nurses reported that they would welcome encouragement and reassurance from managers that the use of humour in the cancer ward is acceptable. If nurse managers act as role models in the effective use of humour, their subordinates are better able to emulate their practice. Like any other communication skill, the use of humour needs to be practised in order for nurses to develop their ability to use it effectively. This can only be achieved with appropriate support from senior members of clinical staff.

Despite the expressed concerns of nurses about compromising professionalism, study observation data clearly indicated the use of humour in interactions with patients. Nurses also reported that the use of humour in little situations was acceptable whilst ‘serious situations’ such as death and dying and breaking bad news should be excluded from humour. The former is referred to in the literature as a ‘gentle humour’, which comprises of spontaneous remarks that arise in daily events, subtle comments and good-natured banter [7]. Nurses in this study learned to recognise the limitations of humour, including its ineffectiveness when patients have other care priorities.

Without sympathy and positive regard, humour cannot be emotionally supportive and caring [17]. Both nurses and patients highlighted the need for constant assessment and reflection when using humour. The literature suggests that humour is subjective and highly individual [24]; thus, sensitivity to patients' needs, cues and preferences should always be considered.

As previously mentioned, due to restricted time and resources, the researchers carried out a modified ethnographic approach where participant observations were focussed on nurse–patient interactions. Although the objectives of the research have been met, the researchers acknowledge that it has not been able to observe humour in its entire cultural context. Further research is recommended to understand the nature of humour and its use on interactions of nurses and patients with other members of the healthcare team and patients' families and significant others.

Conclusion

The benefits of humour can have a positive effect for both patients and nurses in the adult cancer setting; thus, its use should be encouraged. Nurse leaders and managers need to explore models to help guide junior nurses in the use of humour. Humour can be risky as it may result in negative outcomes, and participants in this study acknowledged the importance of constant assessment and reflection when using humour.