May 1, 2007
Alleviating Stress With Humour: a Literature Review
By Chinery, Winifred
KEYWORDS Alleviation, Humour, Operating theatre, StressThe use of humour was reviewed to establish whether it could be used constructively to reduce work-related stress within the perioperative environment. It is clear from the review that further research is required in order to gain a better understanding of the concept of humour and its uses in healthcare and it is hoped that this review will contribute towards the increasing body of knowledge in this field.
A comprehensive literature review was undertaken which revealed an established body of work on both stress and humour. The research on operating theatres showed that it is a stressful place to work with much of the focus on power relationships between medical staff and nurses. There is an increasing amount of literature which explores the concept of humour and its uses within healthcare settings. However, much of this is opinionated and anecdotal and is mostly North American and Canadian in origin.
In the author's experience the concept of humour is part of'theatre life' and I believe it is used spontaneously to help minimise the daily stresses faced by theatre staff. This inspired me to review the literature to find out how staff perceive stress in theatres and if they feel they use humour to alleviate that stress.
In recent years government initiatives have placed responsibility at local level to ensure that productivity is met (DoH 2004) and the need to expand and increase throughput places demands on staff in an area that is already stretched by resource constraints (Loxley 1997). Furthermore, operating theatres are an area where high levels of expertise are required and where issues of power and conflict add to an already stressful environment. Staff also have to endure many other stressors which are inherent within the nature of the work which include being faced with major injuries, emergency situations and death (Maslach cited in Wooten 1996).
Following a brief look at the literature it became apparent that humour is used constructively in many healthcare settings across the USA as an alleviator of stress. However, this was not evident in the UK due to lack of research. As a result of this there is clearly a need to explore how theatre staff in Britain feel about the use of humour and how it could be used constructively as a buffer against stress (Campbell & Wicker 1999, Holmes 2001).
Overall the literature reflects current views on stress and humour. Some papers deal with the causes and manifestations of stress at work, while others examine the various coping strategies. However, the literature that deals with humour is often opinionated, anecdotal and conflicting. Some deal with psychological and physiological effects of humour, while others explore the relationship in coping with stress using humour as a buffer. Some American papers explore the use of constructive humour in the healthcare setting focusing on patient outcomes and the relationships between patients and healthcare givers (Robinson 1993, Wooten 1996).
Theories of stress
Theories of stress were reviewed including Hans Selye's (cited in Bennett 2000) General Adaptation Model of Stress. However, although it is influential within the literature, it does not account for individual differences in tolerance levels to the same stimuli (Bennett 2000, Cooper et al 2001).
In the author's opinion, the Transactional Model makes provision for these shortcomings, as it perceives stress to be subjective to cognitive appraisal (Lazarus cited in Sutherland & Cooper 1990) and, because people vary so much in what is considered to be stressful, many researchers feel that perceived stress is a better measure of stress than instruments that measure whether people have been exposed to a particular stressor (Cohen et al 1983). Future research therefore needs to consider the exploration of the social experiences that individuals encounter in their workplaces and the meaning of these experiences for their wellbeing.
Manifestations of stress
The consideration of well-being is vital when discussing manifestations of stress and coping within the workplace. There is evidence that chronic stress is an important contributor to physiological and psychological distress and that positive coping mechanisms can counteract this. With this in mind, effective coping strategies were reviewed which included the use of humour (Pitts St Phillips 1998).
Within stress-coping research the social context in which coping occurs is frequently ignored and it often fails to adequately consider issues of power and conflict when considering the resources individuals may have in managing stress (Lazarus & Folkman 1984).
The social context of operating theatres
Within the context of operating theatres, a number of papers focus on power and conflict between anaesthetists and surgeons. Goodnough cited in Linguard et al (2002) discusses the hierarchy of decision making between these two groups, while others investigate the need for better communication to increase efficiency and improve team morale (Helmreich & Fox cited in Fox 1992). Katz (1984) and Fox (1992) studied the rituals of the American operating theatre, and although the focus is on medical staff, the research is valuable because it describes the interplay between the different disciplines involved and gives the feel of entering the operating theatre which is often described as a world of ritual and mythology.
Other researchers have studied the power relationships between doctors and nurses (Porter 1991, Tanner & Timmons 2000). These researchers spent time in a number of operating theatres in England with the purpose of identifying the skills and knowledge utilised by theatre nurses, but what they actually observed was relationships and communication between the doctors and nurses.
In some situations a lot of joking and ribbing took place. When one consultant intended to insert a rectal probe into the patient he said, 'This'll test the anaesthetic'. In another theatre a consultant intended to use an X-ray machine to identify any obstructions in the bile duct by injecting a radioopaque solution into the common bile duct. When he wrongly injected saline instead, a solution which would not be detected by the X-ray imaging, one of the junior nurses piped up, 'It helps if you use contrast'. It is valuable research as it provides further insight into the dynamic 'social' entity of British operating theatres which, not surprisingly, reveals that traditional structures of hierarchy between doctors and nurses are still in existence and where patterns of communication were found to be complex and socially motivated.
It is suggested by Lingard et al (2002) that because of its multi- disciplinary nature, the operating theatre team is beset by divisive elements, including gender, economics, politics and professional boundaries. Therefore it is not surprising that there are conflicts. Furthermore, communication and the coping process in areas of 'people work' are vital to its success and informal networks exist among colleagues in the form of social support. McGee (1994) interviewed theatre nurses in England and concluded that although these networks exist, they may not be effective for everyone. This is an area which needs further exploration within the context of operating theatres, in particular when considering humour as a coping strategy to alleviate stress.
Theories of humour
Humour is often referred to within the literature as 'mirth', a word which stems back to the 12th century and is defined as merry, gladness or gaiety shown by or accompanied with laughter. It has more recently been defined by the Oxford dictionary as 'that quality of action, speech, or writing which excites amusement; oddity, jocularity, facetiousness, comicality and fun' (Simpson & Weiner 1989).
There are many theories which attempt to address the concept of humour. Martineau cited in White and Howse (1993) conceptualises humour as a social process and specific medium of communication. Others conceptualise it as a personality trait, a situational stimulus variable, an emotional response or a therapeutic intervention. However, a limitation of these theories is that 'funniness' resides with the stimulus and not in the 'interpretation'.
As an alternative, Du Pre (1998) identifies that funny is essentially a constituent of awareness and perception which is not well addressed by existing theories of humour that are largely handicapped by the supposition of stimulus/response thinking of both stress and humour research.
Consequences of humour
Du Pre (1998) analyses that the function of humour depends on how the audience evaluates it, and it is generally accepted that shared values are essential or the communication of humour will fail (Woolen 1996, Du Pre 1998, Veatch 2000). The purpose of laughter - which is seen as part of the humour process - depends on a multitude of aspects, such as the communicator's and the receiver's different perspectives on humour and their different cultural heritages (Robinson cited in Olsson et al 2002).
Kurtz (1999) discusses the negative side of humour where insensitive and inappropriate use of humour has destructive potential. For example, in Tanner and Timmon's (2000) study, some of the topics of conversation in the operating theatre would be considered unprofessional and would not have taken place in otherareas of the hospital where patients and members of the public have access.
Humour and coping in healthcare settings
There is a popular notion that healthcare settings are as hostile to humour as to germs (Du Pre 1998). However, this was not found to be consistent with the literature reviewed (Moody cited in Wooten 1996, Siegel 1983, Robinson 1993, Cousins cited in Strickland 1999).
Wooten (1996) advocates that finding humour in our work and our life can be one way to lift the spirit's energy level and replenish ourselves from compassion fatigue. It can give us a different perspective on our problems and, with an attitude of detachment, we feel a sense of self-protection and control in our environment. As comedian Bill Cosby often said, 'If you can laugh at it, you can survive it'.
Using humour can be an effective way of coping with stress in the workplace
Using humour can be an effective way of coping with stress in the workplace
Humour and laughter can foster a positive and hopeful attitude. We are less likely to succumb to feelings of depression and helplessness if we are able to laugh at what is troubling us. Humour gives us a sense of perspective on our problems. It gives us an opportunity for release of uncomfortable emotions that, if held inside, may create biochemical changes that may be harmful to the body (Wooten 1996).
A Hawaiian saying goes: 'Where your energy goes, energy flows'. In essence, this is because joy and sadness pathways cannot operate simultaneously. Humour and anger, for example, are anti-thetical. Try holding onto anger during a prolonged belly laugh. Many studies reported that people who use humour as a coping mechanism are quick to laugh at commonplace situations in the workplace and enjoy a number of psychological benefits (Kuiper & Martin cited in Du Pre 1998). It is not because illness, suffering or death are funny but because through humour and laughter we adapt to them (Robinson cited in Du Pre 1998). Furthermore, humour is part of our lives even in times of stress and danger of death. Yet despite our recognition of its value we don't take it seriously (Dixon cited in Healy & McKay 2000).
Further to this, humour is used in healthcare as a strategy for coping with stress and managing the delicate and tragic situations that occur. Martineau cited in White and Howse (1993) found that in studies in hospital settings humour helped to develop cohesion between staff, and in certain situations it effectively neutralised conflict. However, argue White and Howse (1993), the evidence is conflicting. A limitation to this and other studies reviewed is possibly the sole reliance on self-report measures for perceived stress and humour.
Culture and humour
Much of the literature relating to the use of humour in healthcare settings is descriptive and anecdotal. There is little evidence to support the many opinions on the outcomes of humour used in healthcare to alleviate stress (Robinson 1993, Woolen 1996). Descriptions of the types of humour used in American operating theatres are rich, and the gallows, sexual, hostile and scatological themes that emerge from the research are, in the author's opinion, very much part of the British culture.
Take the example where during a major case, the surgeon yelled at the scrub nurse that he 'could train a monkey to do what she did: Later that day, during a different case with the same surgeon, the nurse was still upset. When the surgeon asked why she was upset, she said, ' What do you expect? I haven't had my bananas yet!' To which they both laughed and got on with the case in hand, thereby dissipating the hostilities (Robinson 1993). Hostile humour is often used to help staff cope with their frustrations and to get their messages across. It is also a safety valve.
Back in the days when we used to sterilise and pack our own instruments, an Irish scrub nurse who worked in my unit vented her frustrations on an ear, nose and throat consultant who was a perfectionist and insisted on every detail being perfect for every procedure. One April fools' day, she sterilised an Auvards (a rather large gynaecological vaginal speculum) for a very delicate ear procedure. When the tray was opened, the consultant was aghast and asked her what this monstrosity of an instrument was for. To which her reply was, ' Would you like me to get up on the table and show you?'
Moreover, gallows-type humour is described as being used in any society where there is a tragedy, and laughing at the horrors reduces the stress that can paralyse and overwhelm us (Robinson 1993, Beitz 1999). Woolen (1996) similarly describes humour used in the healthcare setting as a major relief mechanism.
In one situation staff tried desperately to save the hand of a young man who had been severely injured in a car accident. Eventually however, his hand had to be amputated. The surgeon stood there for a moment holding the amputated hand and said, 7 always did say I could use another hand' (Robinson 1993).
During an open heart surgery procedure, an electrical short circuit resulted in a loud shot-like noise and an electrical flash. The entire team stood frozen until the anaesthetist stood up, looked over the drape, and said in a booming voice, ' Will someone please pass the toilet paper?' (Robinson 1993).
Humour is a way of 'mastering the horror' when we feel helpless and know there is nothing we can do to change the situation. It reduces anxiety and tension and is a healthy outlet for anger and frustration. It is described as a 'healthy' denial of reality - lightening up the heaviness related to crisis, tragedy or death and is a safety valve both emotionally and physically. However, the emotional and physiological effects of humour remain inconclusive.
Constructive use of humour
Wooten (1996) and Robinson (1993) have contributed a great deal to the literature focusing on the constructive use of humour in US healthcare settings and claim that caregivers can consciously change their behaviours to provide more laughter and cheer in their work settings. They claim that by using humour 'workshops' it is possible to affect the caregivers' sense of power and control and enhance their appreciation of humour.
In support of this Robinson (1993), Wooten (1996), Strickland (1999), Beitz (1999), and Burchiel and King (1999) all give examples of constructive uses of humour being used in US healthcare settings to combat stress, some of which focuses in operating theatres. They give some wonderful anecdotal stories to support their opinions, while referring to other research conducted within the field of humour research. These include:
* developing a humour 'file' where humorous materials are purposely sought out
* using humour bulletin boards (which have been adopted very successfully in our operating theatres)
* best joke contests.
Many other simple strategies have been used formally to foster an openness and creativity and increase receptivity to new ideas and information. Burchiel and King (1999) suggest that although we may not be able to control events we can control how we view them. Humour assists us in choosing responses to stress with the result that we balance out emotions which results in us feeling relaxed, confident and in control.
The literature reviewed suggests that there is a strong connection between the stress experience and the use of humour as a buffer. However, there is still much uncertainty surrounding the use of humour in healthcare and questions about its appropriateness. The effects and the functions remain unanswered which represents a serious gap in our understanding of mis phenomenon. Much of the literature is opinionated and anecdotal and many of the studies reviewed are not without design and methodological problems. The literature on the constructive use of humour in the operating theatre is sparse which constitutes a serious gap in the current literature. Through the literature reviewed, the author gained a valuable insight into the world of humour and life in operating theatres. However, the author feels that from a UK perspective, the original questions remain unanswered as there is very little published.
The use of humour as a means of communication and as a coping strategy needs further research. By employing a naturalistic paradigm we may be able to gain an understanding into the subjective meaning of the concepts of stress and individual perceptions of the spontaneous and constructive use of humour within the operating department by exploring experiences and feelings. In the author's opinion this would help to close the gaps in the current literature while publication of the findings would contribute to a greater understanding of the communication and coping process within the social context of the operating theatre.
Effective coping strategies were reviewed which included the use of humour
There is a strong connection between stress and the use of humour as a buffer
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About the author
RGN, DipN. IHSM,
Copyright Association for Perioperative Practice Apr 2007
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