"Humor Skills for Surviving Managed Care"

Have you heard yourself saying these words more often than you used to?

We hear about the latest cutbacks, reorganization or mergers and our first statement of disbelief is: "You've got to be kidding." That reflex response provides a clue for how we can survive the stress and chaos created by managed care. Our sense of humor and an ability to laugh can nurture and protect our body, mind, and spirit during these times of rapid change. Moshe Waldoks states: "A sense of humor can help you overlook the unattractive, tolerate the unpleasant, cope with the unexpected, and smile through the unbearable."

I believe that laughter is the canary in the mines of health care reform. Let me explain . Many years ago, before sophisticated monitoring equipment was available, miners would carry a caged canary down into the earth as they searched for ore. Because the canary has a higher oxygen requirement than humans, it provided an accurate gauge of the life sustaining oxygen supply. If the atmosphere became toxic, the canary would die.

In today's rapidly changing environment of managed care, laughter is our canary. Think about your unit. Do you hear the sweet sounds of laughter? If not, the situation may be too toxic for your health. Laughter is essential for our physical, menta, and spiritual well being. The bible states, "A merry heart does good like a medicine." How then does this mirthful medicine improve our health, and what can we do to create a work space that is filled with healthy laughter?

Laughter is a smile that engages the entire body. At first, the corners of the mouth turn up slightly, then the muscles around your eyes engage and we can see a twinkling in the eyes. Next you begin to make noises, ranging from controlled snickers, escaped chortles, and spontaneous giggles, to ridiculous cackles, noisy hoots, and uproarious guffaws. Your chest and abdominal muscles become activated. As the noises get louder, you begin to bend your body back and forth, sometimes slapping your knees, stomping your feet on the floor or perhaps elbowing another person nearby. As laughter reaches its peak, tears flow freely. All of this continues until you feel so weak and exhausted that you must sit down or fall down.

Very strange behavior!

Of course, not everyone experiences such intense laughter every time they are amused. For example, if we are concerned about how others might judge this behavior; if we are concerned with maintaining a dignified image; if we feel others might be offended by our robust laughter; or if our culture places strong taboos on such behavior, then we may struggle to contain ourselves.

Humor is a complex phenomena that is an essential part of human nature. Throughout the ages, anthropologists have never found a culture or society that was completely devoid of humor. A sense of humor is both a perspective on life--a way of perceiving the world--and a behavior that expresses that perspective. It is a quality of perception that enables us to experience joy even when faced with adversity and to fully experience the joy that humor can bring, we must share that perspective with others and join together in the laughter. Barry Sultanoff MD, president of the American Holistic Medical Association states: "Laughing together can be a time of intimacy and communion, a time when we come forward, fully present and touch into each other's humanness and vulnerability. By joining in humor and acknowledging our oneness, we can have a profound experience of unity and cooperation. That in itself maybe one of the most profound expressions of healing energy of which we are capable."

When I was a student nurse, I worked at a hospital in San Francisco. The main street in San Francisco is called Market Street and originates in the hills and travels down to the wharf. As I was about to bathe my patient, I noticed a large scar from a previous surgery. The scar began just below her breastline and continued to her pubic region. I asked her about it, she said, "Oh I call that Market Street." Surprised, I asked her why.

and she said, "Because it goes from Twin Peaks all the way to the waterfront." Instead of seeing the scar merely as a ugly disfigurement, this woman used her sense of humor to gain perspective, saw it in another context and allowed herself and others to experience delight instead of horror or disgust.

The word humor itself is a word of many meanings. The root of the word is "umor" meaning liquid or fluid. In modern dictionaries, humor is defined as "the quality of being laughable or comical" or as "a state of mind, mood, spirit". Humor then is flowing; involving basic characteristics of the individual expressed in the body, emotions, and spirit.

I've noticed that patients with a keen sense of humor or playful spirit, seem to have a strength and resilience which helps them weather the difficult and frightening moments of illness. Janet Henry was a patient with breast cancer. She allowed her sense of humor to remind her of the many blessings in her life. This provided hope and courage for her to face the many challenges of illness and treatment. Janet was recovering from a mastectomy and chemotherapy when she wrote this poem:

Nurses, physicians, and other health care professionals cope daily with the reality and horror of illness, suffering, and death. If we are unable to cope effectively with this, we experience "burnout" or more accurately called "compassion fatigue". Our compassion and caring may leave us vulnerable to feelings of sympathy for those we serve. There is a great difference between sympathy and empathy. Both arise from compassion and caring, but they relate to the suffering person in different ways. Sympathy feels the "other's pain" as if it were our own; we feel frightened with them, angry with them, depressed with them. As you might imagine, sympathy decreases our effectiveness as caregivers because we lose our objective perspective. Empathy, on the other hand, employs a "detached concern." We still express our compassion and caring, but without identifying with the patient's pain as if it were our own.

Humor is a coping tool that provides us with a similar "detached" perspective. Caregivers will often use humor as a means of maintaining some distance from the suffering and protecting themselves from a sympathetic response. Christina Maslach, in her book, Burnout: The Cost of Caring, describes how nurses use humor and laughter to cope with the stress and horror they frequently witness. "Sometimes things are so frustrating that to keep from crying, you laugh at a situation that may not be funny. You laugh, but in your heart you know what's really happening. Nevertheless, you do it because your own needs are important--we're all human beings and we have to be ourselves".

Our ability to laugh provides us with a momentary release from the intensity of what otherwise might be overwhelming. We use humor to gain a new perspective and to find a way to function in a situation that could otherwise be intolerable. "Gallows humor" is a type of medical humor usually seen as hostile, inappropriate, or "just plain sick," by the people who are unfamiliar with healthcare professions. Gallows humor acknowledges the disgusting or intolerable aspects of a situation, and attempts to transform it into something lighthearted and amusing

When I was working in the Emergency Room at a county hospital, an ambulance brought in a homeless person they had found unconscious in an alley. The man was filthy, his breath reeked of alcohol, and he had lice crawling on his body. It took two of us more than an hour just to clean him up enough for admission. It was difficult work and our senses were overwhelmed with unpleasant sights and smells. I read the intern's admission note on the way up in the elevator. It said, "Patient carried into E.R. by Army of body lice, who were chanting, "Save our host. Save our host." I laughed heartily at this amusing picture and suddenly my struggles of the last hours were put into a humorous perspective and I felt a lot less angry and a lot more compassion.

Humor is a survival tool for the health care professional who wishes to remain compassionate and caring. Lisa Rosenberg, R.N., Ph.D., is on the faculty of the Rush-Presbyterian-St. Luke's School of Nursing in Chicago. She studied the use of humor among staff in emergency rooms and critical care units. In her chapter in the book, Nursing Perspectives on Humor (Buxman, 1995) she states, "There is a goodness of fit between how the provision of care induces stress in the emergency care environment and how the use of humor intervenes in that process. Emergency personnel experience a wide spectrum of serious events--trauma, life-threatening illness, chaotic emotional situations--often all at the same time. There is no time to emotionally prepare for these events, and little time to ventilate afterwards or 'decompress.' The spontaneous way in which humor can be produced in almost any situation, and it's instantaneous stress-reducing effects are well suited to the emergency care experience."

I present humor workshops around the country, during one class, a nurse manager gave me a sign that had been placed by the staff in the waiting room for visitors and family members to read. The staff hoped to educate and reassure the visitors that their use of humor as a coping tool helped them provide better care for their loved ones. The sign read:

A sense of humor helps us to manage the stress of care giving. The "detached perspective" that humor provides helps us to disengage from the suffering we witness and, yet, still remain sensitive. When we allow ourselves to laugh about our situation, we can accept our inadequacies and forgive ourselves. Laughter fills us with joy which we radiate to others. It allows us to rise above our difficulties and experience the beauty of life beyond the hardships of giving care. We transcend our everyday problems and feel optimistic and hopeful. Searching for humor, looking for something to laugh about, keeps us from focusing on the elements that are overwhelming or depressing.

Doug Fletcher, a Critical Care nurse from Mesa, Arizona has created a journal to provide nurses with the opportunity to laugh about their struggles and frustrations. Now entering its seventh year of publication, the Journal of Nursing Jocularity has over 35,000 subscribers from each of the 50 states and across Canada. This quarterly journal is a collection of true stories, cartoons, parodies, book reviews, interviews and much, much more. It has the quality and substance to qualify for inclusion in the Cumulative Index to Nursing and Allied Health Literature. I am honored to be a contributing editor and featured columnist

Because this journal is written specifically for nurses, those who are outside the profession may not understand or appreciate the humor. In fact, even some nurses have difficulty accepting the importance and need for laughter about our profession. Letters to the editor are published in each issue. One nurse expressed, "I am appalled, . . . this is a crucial time for nursing. Many professionals are working diligently at demonstrating to the public the seriousness and importance of nursing. Now, you people are going to help our profession take several steps back by making fun of it. There is a time and place for laughing with one another, but publishing it is not the place. This will only serve to detract from the seriousness, critical analysis and professionalism of nursing." This statement proves just how risky humor can be. What is funny to one person can be offensive to another. Different jokes for different folks!

Doug has remained committed to his vision of providing a humorous look at health care and recently published a book containing the "best of" JNJ from 1991-1993. It is entitled, Whinorreha and Other Nursing Diagnosis. (London, 1995) He explains his philosophy about providing a humorous perspective on nursing: "Nurses should be able to enjoy their profession. The Journal of Nursing Jocularity was intended to look at the lighthearted side of our profession, and avoid the "terminal professionalism" that creeps in and squelches the ideals we once held as new grads. Because nursing is such a high stress profession, we have to publish humor that reflects the atmosphere prevalent in the nursing setting today. Because humor is one of our most powerful coping mechanisms, I feel that publishing gallows humor for health professionals is a risk we need to take. A humorless, burned-out nurse will be viewed as a heartless, cynical professional, and maybe even the proverbial battle-ax"

In 1997, for the first time in history, a group of nurses wrote and performed the very first nursing musical comedy. "Who's Got the Keys" is the story of a burned out nurse and a lovable gomer and their struggles to cope with the onslaught of managed care. The music, lyrics and script were written and performed by nurses. Simple proof that nurses can do just about anything they set they're minds to. A video of the live performance is available from the Journal of Nursing Jocularity.

Stress has been shown to create unhealthy physiological changes. The connection between stress and high blood pressure, muscle tension, immunosuppression, and many other changes (Berk 1989) has been known for years. We now have proof that laughter creates the opposite effects. It appears to be the perfect antidote for stress.(Wooten, 1996)

Lee Berk, associate professor at Loma Linda University School of Medicine, has produced carefully controlled studies showing that the experience of laughter lowers serum cortisol levels, increases the amount of activated T lymphocytes, increases the number and activity of natural killer cells, and increases the number of T cells that have helper/ suppresser receptors. In short, laughter stimulates the immune system, off-setting the immunosuppressive effects of stress. (Berk 1989 a, b, ) This research is part of the rapidly expanding field of Psychoneuroimmunology which defines the communication links and relationships between our emotional experience and our immune response as mediated by the neurological system. (Ader 1991, Soloman 1987)

We know that, during stress, the adrenal gland releases corticosteroids (quickly converted to cortisol in the blood stream) and that elevated levels of cortisol has an immunosuppressive effect. Berk's research demonstrates that laughter can lower cortisol levels and thereby protect our immune system. (Berk 1989 a, b)

Laughter stimulates an increase in the number and activity of natural killer cells (NK) NK cells are a type of immune cell that attacks viral or cancerous cells and do not need sensitization to be lethal. They are always ready to recognize and attack an aberrant or infected cell. This becomes very important in the prevention of cancer. Cells within our bodies are constantly changing and mutating to produce potential carcinogenic cells. An intact immune system can function appropriately by mobilizing these natural killer cells to destroy abnormal cells. (Locke 1984)

Receptor sites are important as a communication link between the brain and the immune system. Emotions can trigger the release of neurotransmitters from neurons in the brain. These chemicals then enter the blood stream and "plug into" receptor sites on the surface of immune cells. When this occurs, that cell's metabolic activity can be altered in either a positive or negative direction. (Pert 1985, 1997) Many cells within the body have different receptor sites on their surface; of particular interest in this research are those on the immune cells. (Berk, 1994 and Wooten, 1997)

Other researchers have supported these findings. Locke at Harvard, showed that the activity of natural killer cells is decreased during periods of increased life change which were accompanied by severe emotional disturbance; whereas subjects with similar patterns of life change and less emotional disturbances had more normal levels of NK cell activity. (Locke, 1984) At the VA Medical Center in San Diego in 1987, Irwin noted that NK cell activity decreased during depressive reaction to life changes. (Irwin, 1987) At the Ohio State University School of Medicine, Janice and Ronald Glaser studied the cellular immunity response patterns of medical students before examinations. Their work showed a reduction in the number of helper T cells and a lowered activity of the NK cell during the highly anxious moments just before the examination. (Glaser, JK 1987 and Glaser, R. 1985)

Salivary immunoglobulin A is our first-line defense against the entry of infectious organisms through the respiratory tract. At SUNY, Stone revealed that salivary immunoglobulin A response level was lower on days of negative mood and higher on days with positive mood. (Stone, 1987 and Martin, 1985) This finding was quickly confirmed by two other researchers. Dillon, working at Western New England College; found subjects showed an increased concentration of salivary IgA after viewing a humorous video (Dillon, 1985); while Lefcourt, from University of Waterloo in Onterio, showed that subjects who tested strong for appreciation and utilization of humor had an even stronger elevation of salivary IgA after viewing a humorous video. (Lefcourt, 1990)

All this research, done in the last ten years, helps us to better understand the mind-body connection. The emotions and moods we experience directly effect our immune system. A sense of humor allows us to perceive and appreciate the incongruities of life and provides moments of joy and delight. These positive emotions can create neurochemical changes that will buffer the immunosuppressive effects of stress.

Dr. Berk describes his research results: "Essentially, we found that mirthful laughter serves to modulate specific immune system components. By modulate, we mean that chemicals released during the emotional experience of mirth can connect to receptors on the surface of the immune cells. This connection stimulates a change in the molecular machinery inside the cell. Specific molecules known as immunoregulators are like plugs that fit into receptors and subsequently increase or decrease the immune cell activity. One metaphor for modulation of immune activity is the conductor of an orchestra. Although the conductor does not actually play an instrument, he influences the tempo, harmony and volume of the music produced by the orchestra. Mirthful laughter would be like the conductor who enhances sonic integration and brings out melodious harmony. Whereas distressful emotions would be like the conductor who brings out harsh, disharmonious sounds. Emotions, like a conductor, modulates the activity and effectiveness of the immune cells although it does not directly protect the body from insult or infection." (Wooten, 1997)

We will increase our success of stimulating laughter with patients if we first answer the following questions.

• Has your patient given you any clues that indicate they are receptive to humor?

• Do they attempt to share humor with staff or visitors?

• What is your patients' ability to perceive and understand humor?

• How does the patient use humor? Is it cynical and sarcastic or absurd and foolish?

• Observe the kind of humor your patient chooses to create. Do they tell jokes, play pranks, or bring playful items into the hospital?

• Are there any humorous topics the patient might consider taboo? Avoid sexual, ethnic and religious humor to decrease chance of offending them.

• Do you find your patient has a preference for a particular type of humor?

• Do they prefer a certain comedy artist?

• Will the humor be perceived as annoying? Will it indicate Caring?

Matching our humor interventions with the patient's preferred humor style is essential if we wish to stimulate laughter and its therapeutic potential. Humor preferences vary tremendously. For that reason, the author and a team of humor experts created a computer based humor prescription tool. The name of the program is - SMILE - an acronym for Subjective Multidiscipline Interactive Laughter Evaluation. After the patient has answered 40 questions, the computer will then match the patient's stated preferences with specific recommendations from an extensive database of humorous video tapes, audio cassettes and books in print. A complete report is then printed to give to the patient and place in the chart. This program will guide the clinician toward prescribing an effective therapeutic humor program. (Touchstar, 1997)

• Create a scrapbook of cartoons. Place the cartoons in a photo album with plastic "peel back" pages. This will protect and keep them clean.

• Develop a file of funny jokes, stories, greeting cards, bumper stickers, poems and songs.

• Collect or borrow funny books, videos and audio tapes of comedy routines. These can be found in libraries, humor sections of book stores, mail order catalogs, or at humor conferences. Develop a lending library in your facility.

• Keep a file of local clowns, magicians, storytellers, and puppeteers. Invite them to entertain at your facility, the patients' home, or for a group function.

• Collect toys, interactive games, noise makers, and squirt guns. Keep them available to play with. If you will be sharing these toys with a patient, keep in mind safety and cleanliness factors

• Create a humor journal or logbook to record funny encounters or humorous discoveries. On days when you really need a laugh, but can't seem to find anything funny, you will have a collection of amusing stories at your fingertips.

• Establish a bulletin board in your facility to post cartoons, bumper stickers and funny signs. If the display is public you must consider the sensitivities of the audience and be careful to exclude potentially offensive (ageist, sexist, ethnic) material.

• Educate yourself about therapeutic humor. Attend conferences, workshops, and conventions.

As you embark upon this journey into therapeutic humor, remember you may have to create the map as you go along. Each individual and situation is unique and the terrain will change from day to day. It is important to collect a variety of tools and resources. And most of all, be sure to travel lightly and be prepared to change directions if needed. Most of all, have fun along the way!

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The above was first published in 1997 as an article in Dermatology Nursing. [Vol.9 #6, pp423-429]