Humor intervention in the nurse-patient interaction

A intervenção humor na interação enfermeiro-paciente

La intervención humor en la interacción enfermero-paciente

Luis Manuel Mota Sousa Cristina Maria Alves Marques-Vieira Ana Vanessa Antunes Maria de Fátima Graça Frade Sandy Pedro Silva Severino Olga Sousa Valentim About the authors

ABSTRACT

Objective:

To describe the factors influencing the use of humor in nursing care, its applicability and benefits.

Method:

A scoping review was performed using the Arksey and O’Mally methodology. A search for articles published between 2008 and 2018 was performed using the platforms EBSCO Host, Virtual Health Library and Google Scholar.

Results:

From the initial 465 articles found, 17 were included for final revision. Data allowed to retrieve information on humor definition; its applicability as a nursing intervention; humor as a tool to improve nurse-patient communication and relationship; influence factors; type of humor interventions; humor benefits in health care context and; limitations and precautions of humor intervention.

Conclusion:

The use of humor promotes both communication and human interaction; it promotes well-being; helps deal/cope with difficult and unpleasant situations, reduces tension, discomfort and stress; and strengthens the immune system. This intervention should be used with caution.

Descriptors:
Communication; Nurse-Patient Relations; Wit and Humor as Subject; Nursing; Patient Outcome Assessment

RESUMO

Objetivo:

Descrever os fatores que influenciam o uso do humor no cuidado de enfermagem, sua aplicabilidade e benefícios.

Método:

Revisão escopo segundo a metodologia de Arksey e O’Mally. Foram pesquisados artigos publicados entre 2008 e 2018, nas plataformas EBSCO Host, Biblioteca Virtual em Saúde e Google Académico.

Resultados:

Foram identificados 465 artigos e incluídos 17 destes. Foi encontrada informação sobre definição de humor; sua aplicabilidade como intervenção de enfermagem; o humor como ferramenta para melhorar a comunicação e a relação entre o enfermeiro e o paciente; fatores de influência; tipo de intervenções de humor; benefícios de humor nos cuidados de saúde e; ainda as limitações e precauções de intervenção de humor.

Conclusão:

O humor promove a comunicação, as relações e bem-estar; ajuda a lidar com situações difíceis e desagradáveis, reduz a tensão, o desconforto e o estresse; e fortalecer o sistema imunológico. Esta intervenção deve ser usada com precaução.

Descritores:
Comunicação; Relações Enfermeiro-Paciente; Senso de Humor e Humor como Assunto; Enfermagem; Avaliação de Resultados da Assistência ao Paciente

RESUMEN

Objetivo:

Describir los factores que influencian el uso del humor en el cuidado de enfermería, su aplicabilidad y beneficios.

Método:

Revisión de alcance según la metodología de Arksey y O’Mally. Se investigaron artículos publicados entre 2008 y 2018, en las plataformas EBSCO Host, Biblioteca Virtual en Salud y Google Académico.

Resultados:

Se han identificado 465 artículos e incluidos 17 de ellos. Se encontró información sobre la definición de humor; su aplicabilidad como intervención de enfermería; el humor como herramienta para mejorar la comunicación y la relación entre el enfermero y el paciente; factores de influencia; el tipo de intervenciones de humor; beneficios del humor en la atención de salud y; las limitaciones y precauciones de intervención del humor.

Conclusión:

El humor promueve la comunicación, las relaciones y el bienestar; ayuda a manejar situaciones difíciles y desagradables, reduce la tensión, la incomodidad y el estrés; y fortalecer el sistema inmunológico. Esta intervención debe usarse con precaución.

Descriptores:
Comunicación; Relaciones Enfermera-Paciente; Ingenio y Humor como Asunto; Enfermería; Evaluación del Resultado de la Atención al Paciente

INTRODUCTION

The word “humor” has received many meanings throughout history. However, one of the more recent definitions refers to it as an emotional state, a state of humor that may be more or less stable, and also as an expression of feelings that can promote well-being in a person(11 José HM. Resposta humana ao humor: humor como resposta humana [Internet]. Loures: Lusociência; 2010[cited 2019 Mar 03]. Available from: https://www.lusodidacta.pt/enfermagem/152-resposta-humana-ao-humor-humor-como-resposta-humana
https://www.lusodidacta.pt/enfermagem/15...

2 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
).

The Association for Applied and Therapeutic Humor (AATH) defines “Therapeutic humor is any intervention that promotes health and wellness by stimulating a playful discovery, expression or appreciation of the absurdity or incongruity of life’s situations”(44 Association for Applied and Therapeutic Humor (AATH). HOME: What is therapeutic humor? [Internet]. 2018[cited 2019 Mar 03]. Available from: https://www.aath.org/
https://www.aath.org/...
).

In Nursing Intervention Classification (NIC) this intervention is defined as the one that allows nurses to help the person to perceive, appreciate and express what is funny, entertaining or humorous, to establish relationships, relieve tension, release anger and facilitating learning or dealing with painful feelings, with the intention of promoting and maintaining health(55 Butcher HK, Bulechek GM, Dochterman JM, Wagner C. Nursing interventions classification (NIC) [Internet]. St. Louis: Elsevier Health Sciences; 2018[cited 2019 Mar 03]. Available from: https://www.elsevier.com/books/nursing-interventions-classification-nic/butcher/978-0-323-49770-1
https://www.elsevier.com/books/nursing-i...
).

Humor and laughter are intertwined, mutually influenced, yet they are not synonyms. Humor is an emotional response and can be translated by joy and laughter. It is a behavioral manifestation. These are influenced by a context or situation; however, they cannot be discussed separately(11 José HM. Resposta humana ao humor: humor como resposta humana [Internet]. Loures: Lusociência; 2010[cited 2019 Mar 03]. Available from: https://www.lusodidacta.pt/enfermagem/152-resposta-humana-ao-humor-humor-como-resposta-humana
https://www.lusodidacta.pt/enfermagem/15...

2 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
).

Studies carried out in the field of humor as a nursing intervention have demonstrated that it is beneficial for people’s health and well-being(11 José HM. Resposta humana ao humor: humor como resposta humana [Internet]. Loures: Lusociência; 2010[cited 2019 Mar 03]. Available from: https://www.lusodidacta.pt/enfermagem/152-resposta-humana-ao-humor-humor-como-resposta-humana
https://www.lusodidacta.pt/enfermagem/15...

2 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
-77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
).

Given its importance, it has been integrated into nursing practice and classified nursing languages, as an intervention in NIC(55 Butcher HK, Bulechek GM, Dochterman JM, Wagner C. Nursing interventions classification (NIC) [Internet]. St. Louis: Elsevier Health Sciences; 2018[cited 2019 Mar 03]. Available from: https://www.elsevier.com/books/nursing-interventions-classification-nic/butcher/978-0-323-49770-1
https://www.elsevier.com/books/nursing-i...
) and as a resource and intervention in the International Classification for Nursing Practice (ICNP)(88 International Council of Nurses (ICN). CIPE: Classificação Internacional para a Prática de Enfermagem: versão 2015[Internet]. Loures: Lusoditacta; 2016[cited 2019 Mar 03]. Available from: https://futurosenf.files.wordpress.com/2017/04/cipe_2015.pdf
https://futurosenf.files.wordpress.com/2...
).

However, in care, nurses do not value it(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
), as they are afraid of being unprofessional, so it is not systematized in the planning and provision of care(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
).

The benefits of humor in people’s health and life are as follows: it promotes well-being; helps deal with difficult and unpleasant situations; brings people together by leveling their roles; helps to share feelings; enables hope; promotes relaxation; reduces tension, stress and discomfort and, increases tolerance to pain and strengthens the immune system by increasing the activity of Natural Killer cells and increasing immunoglobulin levels(11 José HM. Resposta humana ao humor: humor como resposta humana [Internet]. Loures: Lusociência; 2010[cited 2019 Mar 03]. Available from: https://www.lusodidacta.pt/enfermagem/152-resposta-humana-ao-humor-humor-como-resposta-humana
https://www.lusodidacta.pt/enfermagem/15...
,33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
-1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
).

OBJECTIVES

  • To describe the factors influencing the use of humor in nursing care and its applicability; and,

  • To identify the benefits of humor intervention in nursing care.

METHODS

Ethical aspects

Although this study did not involve people directly, ethical procedures were guaranteed.

Design, study location and period

We used the scoping review methodology. It is defined as a technique to ‘map’ relevant literature in the field of interest. It consists of five steps: identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarizing and reporting results(1111 Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol[Internet]. 2005 [cited 2019 Mar 03];8(1):19-32. Available from: https://doi.org/10.1080/1364557032000119616
https://doi.org/10.1080/1364557032000119...
).

The electronic research was carried out between May and June of 2018 using the platform EBSCO Host® (CINAHL Complete e MEDLINE Complete) and Biblioteca Virtual de Saúde (BVS), complemented in Google Scholar and university repositories.

Study protocol

The starting question was defined from the framework - Patient (P), Concept (C[1]) and Context (C[2])(1212 Sousa LM, Marques JM, Firmino CF, Frade F, Valentim OS, Antunes AV. Modelos de formulação da questão de investigação na Prática Baseada na Evidência. Rev Inv Enferm[Internet]. 2018[cited 2019 Mar 03];S2(23):31-9. Available from: http://hdl.handle.net/20.500.12253/1287
http://hdl.handle.net/20.500.12253/1287...
). In this sense, the research question was as following: what knowledge is produced regarding the integration of the humor intervention (C[1]) in the interaction (C[2]) nurse-person in a situation of disease (P)?

Two Boolean equations were used: [(Humor therapy) OR (Humor)] AND (review) AND (Nursing) AND (Wit and Humor as Topic) AND (Nursing). The descriptors were validated on platform of Health Science Descriptors (DeCS).

The research was conducted independently by two investigators from the research team, and the selection of the studies followed the same method, with the sequence suggested by international guidelines(1313 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Welcome to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) website! [Internet]. 2015[cited 2019 Mar 03]. Available from: www.prisma-statement.org
www.prisma-statement.org...
). The results were obtained in a phased manner, from reading the title to reading the full text.

Samples, inclusion and exclusion criteria

Full text articles published in the last 10 years, in Portuguese, English, French and Spanish, that addressed the use of humor in nursing, influence factors, precautions and benefits of this intervention in the health of adults in the process of illness, were included.

Analysis of the Result

After the selection of articles, they were analyzed, and information was gathered about author(s), year of publication, study location, population (care recipient group), aims of the study, methodology and important results.

The level of evidence was classified according to the Registered Nurses’ Association of Ontario’s (RNAO) guidelines: Ia - Evidence obtained from meta-analysis or systematic review of randomized controlled studies Ib - Evidence obtained from at least one randomized controlled trial IIa - Evidence obtained from at least one well-designed controlled study without randomization IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study III - Evidence obtained from a well-designed non-experimental descriptive study, such as comparative study, case; IV - Evidence obtained from reports of expert committees or opinions and / or clinical experiences of respected authorities(1414 Sousa LM, Marques-Vieira C, Severino SS, Antunes AV. Metodologia de Revisão Integrativa da Literatura em Enfermagem. Rev Inv Enferm[Internet]. 2017[cited 2019 Mar 03];S2(21):17-26. Available from: http://hdl.handle.net/20.500.12253/1311
http://hdl.handle.net/20.500.12253/1311...
).

The identification, selection, eligibility, inclusion of studies and summary chart for each article in order to systematize the relevant information was conducted independently by two investigators.

RESULTS

A total of 465 articles were identified. After reading the title, abstract and complete article, 17 articles that fulfilled the inclusion criteria were selected for final revision (Figure 1)(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
-77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
-1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
,1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...

16 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...

17 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...

18 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059
https://doi.org/10.1111/jan.12059...

19 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...

20 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...

21 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...

22 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...

23 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...

24 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
-2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
).

Figure 1
Flow diagram of literature selection for scoping review

Qualitative studies(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
,1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...

16 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...
-1717 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...
,2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
), mixed(2121 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...
), narrative revisions(1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
,1919 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...
,2323 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...

24 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
-2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
), integrative(66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
), systematic(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
), meta-synthesis(77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...
) and concept analysis(1818 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059
https://doi.org/10.1111/jan.12059...
) were included.

Chart 1
Characteristics of studies analyzing humor intervention in nursing

These articles were published as follows: two in 2008(1919 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...
,2424 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
), two in 2013(66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
,1818 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059
https://doi.org/10.1111/jan.12059...
), five in 2014(99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
-1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
,1616 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...
-1717 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...
,2323 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...
), two in 2015(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
,1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
), four in 2016(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...

21 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...
-2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
) and two in 2018(77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
).

On what concerns country of origin, they were from Australia(99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
,1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
,2323 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...
), United States of America (USA)(1717 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...
,1919 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...
), Spain(2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
), United Kingdom (UK)(1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
,1616 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...
,1818 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059
https://doi.org/10.1111/jan.12059...
,2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...
,2424 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
) and Portugal(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
-77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,2121 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...
-2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
).

The articles present the definition of humor in nursing(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
-77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,2121 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...
-2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
) and its use in several contexts(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
-77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
-1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
,1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
,2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...
,2424 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
), or in a specific context such as the perioperative period(1919 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...
), in people with dementia(1717 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...
), in palliative care(2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
), in people with cancer(1616 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...
,1818 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059
https://doi.org/10.1111/jan.12059...
), in the context of orthopedics(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
,2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
), and in people undergoing hemodialysis(2121 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...
,2323 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...
).

They describe the use and function of humor as a nursing intervention(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
,1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
-1616 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...
,1919 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...
,2121 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...

22 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...

23 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...
-2424 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
), a communication(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
) and relation tool(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
-1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
), actors that influence its use(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
,2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...

21 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...
-2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
,2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
) and some barriers(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...
), the activities of humor intervention in the interaction with the person in the process of disease and its benefits(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
-77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
-1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
,1616 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...
,1818 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059
https://doi.org/10.1111/jan.12059...
-1919 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...
,2121 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...

22 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
-2323 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...
,2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
), as well as, the limitations and precautions with this intervention(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,1717 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...
,2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...
,2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
,2424 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
-2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
).

DISCUSSION

The discussion was organized according to the categories defined after reading the selected articles, namely: definition; use and function of humor as a nursing intervention; nursing-patient communication and improvement tool; factors influencing the use of humor; activities of the humor intervention; benefits of humor in the context of health care and; limitations and precautions of humor intervention.

Definition

The humor concept in the treatment of cancer in adults(1818 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059
https://doi.org/10.1111/jan.12059...
) is a subjective emotional response, resulting from the recognition and expression of incongruities of a comic, absurd, impulsive, observational or action situation. It fosters feelings of proximity or union when shared in a relationship of trust between the person in situation of illness and nurse, being able to be used in situations of stress, as, in the care of the person with cancer. This definition fits into the definition of NIC(55 Butcher HK, Bulechek GM, Dochterman JM, Wagner C. Nursing interventions classification (NIC) [Internet]. St. Louis: Elsevier Health Sciences; 2018[cited 2019 Mar 03]. Available from: https://www.elsevier.com/books/nursing-interventions-classification-nic/butcher/978-0-323-49770-1
https://www.elsevier.com/books/nursing-i...
) and AATH(44 Association for Applied and Therapeutic Humor (AATH). HOME: What is therapeutic humor? [Internet]. 2018[cited 2019 Mar 03]. Available from: https://www.aath.org/
https://www.aath.org/...
) in which they humor is defined as an emotional response resulting from appreciation, recognition of incongruity, comprehension, and expression of what is funny, amusing, or comical(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
-33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
,2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
). Together with people with cognitive impairment emerging themes of humor include nonsense, sarcasm and comments on the difficulties of dementia. Laughter was identified in moments with and without humor(1717 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...
).

Use and function of Humor as a nursing intervention

In the oncology context, two studies in the UK try to show how humor is used in people with cancer. One study explains how men with a diagnosis of penile cancer use humor in relation to their diagnosis and treatment and it is noticed that their use allows them to dedramatize diagnosis and treatment and improves the therapeutic relationship with healthcare professionals(1616 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363
https://doi.org/10.1111/jan.12363...
). In this context nurses should use humor to build the therapeutic relationship but should avoid jokes about the sexual or urinary functioning of the person with penile cancer.

In a study about the influence that laughter therapy and humor therapy have on people undergoing hemodialysis, it has been confirmed that the use of these therapies in the form of humorous videos, stories, clowns and laughter yoga have positive results in depressive states, anxiety, pain relief, immunity, fatigue, sleep quality, and other physical aspects related to respiration and blood glucose(2323 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...
).

The use of humor in the context of care improves the experience of hospitalized patients(77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
,2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
), contributing to their satisfaction, increased participation and adherence to the therapeutic regimen. Humor can play an important and even decisive role in the promotion of presence (present moment) that facilitates learning.

Nursing-patient communication and improvement tool

It is understood that both humor and laughter play a role in creating a safe social environment(1717 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075
https://doi.org/10.1177/0898010113500075...
). Another study explores the experience of four nurses using humor in their practice. It tries to understand whether there are gender differences in its use and if the humor intervention influences nurse / patient therapeutic relationship(1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
).

For nurses humor is humanizing, manages emotions, reduces tensions, and improves communication during hospitalization(77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
).

Factors that influence the use of humor

Humor is influenced by personal factors such as personality, age and gender characteristics, in which men have a greater ability to use humor than women(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
).

In another study, it was found that regarding gender, women in situations of illness use humor spontaneously related to the situation they are experiencing and to relativize the situation when speaking to others(1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
). Men use humor in the form of anecdotes and stories, in order to establish a balanced sense of power between nurse/patient(1515 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436
https://doi.org/10.1080/10376178.2015.10...
).

The circumstantial factors that influence humor are: the level of stress and perceived difficulties; duration of limitations resulting from the disease process; previous experience; ability to use verbal and non-verbal communication strategies; amount of physical symptoms and negative attitudes before illness; disease severity, pain, disability and psychic suffering; liking humor and; ability to perform executive functions(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
).

Factors that influence the use of humor have been identified and humor is influenced by gender, context, culture, self-esteem and the nurse’s confidence(77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
).

Another study was conducted people with chronic kidney disease undergoing hemodialysis(2121 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622
http://hdl.handle.net/10400.17/2622...
) and the factors that influence the appreciation of humorous films by these people were identified. It was found that people with chronic kidney disease who enjoy humorous movies consider themselves to be more cheerful and fun, report having a sense of humor, like to play and laugh, like to be with people who make them laugh and with a sense of humor, enjoy reading comic books and listening to funny anecdotes and stories.

When planning humor intervention, nurses must take these factors into account, not only in the decision to include this intervention in the care plan, but also in its construction and implementation to ensure personalized care.

Activities of the humor intervention

Another study describes the types of humor nurses identify in their practice. Nurses mentioned that humor manifests itself through laughter, smiling, joy, as a state of mind and well-being(22 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015
http://hdl.handle.net/10884/1015...
).

The strategies and benefits of humor intervention used in the orthopedic service in a Portuguese hospital(2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
) are play, slap sticking, jokes, anecdotes, puns, surprises, funny situations, personal experiences, comic comments, spontaneous comic expressions, music and movies. Laughter and humor therapy are used by people undergoing hemodialysis in the form of humorous videos, stories, clowns and laughter yoga(2323 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194
https://doi.org/10.1111/sdi.12194...
).

Intervention activities can be based on verbal and nonverbal humorous situations, images, photographs, riddles, songs, mental enigmas and riddles, and the construction of a portfolio of funny books and photographs, jokes, comedy films, cartoons, funny news stories and articles(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
).

In Portugal a doctoral research created the “mobile smile”, which consisted of a car similar to medication cars, which had books, magazines, films and other humorous material that was distributed to people who were hospitalized according to their preferences(11 José HM. Resposta humana ao humor: humor como resposta humana [Internet]. Loures: Lusociência; 2010[cited 2019 Mar 03]. Available from: https://www.lusodidacta.pt/enfermagem/152-resposta-humana-ao-humor-humor-como-resposta-humana
https://www.lusodidacta.pt/enfermagem/15...
).

These activities are in line with the 15 activities outlined and recommended to implement the humor intervention classified in the NIC(55 Butcher HK, Bulechek GM, Dochterman JM, Wagner C. Nursing interventions classification (NIC) [Internet]. St. Louis: Elsevier Health Sciences; 2018[cited 2019 Mar 03]. Available from: https://www.elsevier.com/books/nursing-interventions-classification-nic/butcher/978-0-323-49770-1
https://www.elsevier.com/books/nursing-i...
).

Benefits of humor in the context of health care

For people experiencing a disease situation, humor brings benefits to the therapeutic interaction, leading to greater collaboration / participation of the sick person(77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
). Nurses report that humor is an excellent working tool as it facilitates communication, humanizes care and promotes the therapeutic bond / relationship(77 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011
https://doi.org/10.1016/j.refiri.2017.07...
).

The use of humor in nursing practice has also been a concern in the USA, as in 2008 an article(1919 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004
https://doi.org/10.1016/j.aorn.2008.01.0...
) emerges that seeks to evidence the benefits of using humor in a perioperative context. It concludes that humor is used to establish relationships, alleviate anxiety, release anger in a socially acceptable way, avoid or deny painful feelings and is a way to facilitate learning.

In a study conducted in the UK(1010 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412
https://doi.org/10.7748/ns2014.03.28.30....
), the author advocates using humor in nursing practice as it, helps to develop the therapeutic relationship and building resilience, promotes physical and psychological well-being, and reduces stress and anxiety.

The main indirect benefits of humor are: improving relationships, trust, participation and involvement in care, proximity, motivation, breaking barriers, optimism, good disposition and adherence to treatment. The main direct benefits mentioned were: recovery improvement, stress reduction, relaxation and relief of tension, distraction, pain reduction, exteriorization of feelings, adaptation mechanisms, quality of life improvement, learning facilitator, reduction of anxiety(2222 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623
http://hdl.handle.net/10400.17/2623...
).

Another study(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
) describes the benefits of humor in organizations and health care. It shows that when using humor teams are more productive, cohesive, show less stress and are more motivated and satisfied. In health and people’s life humor promotes well-being; helps to deal with difficult and unpleasant situations, reduces tension, stress and discomfort; increases tolerance to pain, and strengthen the immune system.

Limitations and precautions of humor intervention

Nurse’s perceptions regarding the use of humor in the context of care indicate that humor is something very personal. What makes one person laugh, can cause discomfort and suffering in another(99 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197
https://doi.org/10.5172/conu.2014.46.2.1...
). This situation reveals the paradoxical character that humor can have(11 José HM. Resposta humana ao humor: humor como resposta humana [Internet]. Loures: Lusociência; 2010[cited 2019 Mar 03]. Available from: https://www.lusodidacta.pt/enfermagem/152-resposta-humana-ao-humor-humor-como-resposta-humana
https://www.lusodidacta.pt/enfermagem/15...
), that is, what is motive for humor in one person may not be for another(33 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992
http://hdl.handle.net/10884/992...
). In this sense, the use of humor must be appropriate to each situation due to the fact that it is a multifaceted phenomenon(11 José HM. Resposta humana ao humor: humor como resposta humana [Internet]. Loures: Lusociência; 2010[cited 2019 Mar 03]. Available from: https://www.lusodidacta.pt/enfermagem/152-resposta-humana-ao-humor-humor-como-resposta-humana
https://www.lusodidacta.pt/enfermagem/15...
).

In the UK a study demonstrates that the humor in the medical / patient interaction should be cautiously used, especially with regard to self-deprecating humor. Therefore, nurses must be prudent and use an evidence-based approach during humor intervention(2424 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x
https://doi.org/10.1111/j.1365-2648.2007...
).

Another study identifies barriers to the humor intervention in nursing practice, such as its use in inappropriate situations, the use of humor by a new or junior nurse, the impact of humor on the nurse’s professionalism, personality differences and environmental factors(2020 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235
https://doi.org/10.1080/10376178.2016.11...
). These barriers may influence the non-use of humor in nursing practice, as they may associate their use with an inadequate professional practice.

In Spain and Portugal, the importance of using humor in nursing practice has also been investigated. In Spain the applicability of humor in palliative care was studied and it was concluded that it plays an unquestionable role in this context. Nevertheless, its use still requires training and an appropriate use for each situation(2525 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414
https://doi.org/10.1177/1049909118764414...
).

The articles in Portugal show the use of humor intervention in the practice of nursing care, in different contexts. The humor intervention is complex, since humor is paradoxical, situational, multifaceted and its use must be weighed in some situations, namely in people with cognitive impairment, mental illness and in situations of severe illness. However, when nurses make an appropriate assessment, it seems to have numerous benefits to health and well-being(66 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018
http://hdl.handle.net/10884/1018...
).

Study limitations

The limitations of this study are related to the exclusion of incomplete articles, abstracts and those in languages other than English, French, Portuguese and Spanish. The time horizon may also have limited the research as only articles published in the last 10 years have been included. Finally, all studies were accepted without making a quality appraisal.

Contributions to the sector of nursing, health, or public policies

This scoping review allowed us to retrieve information on humor definition; its applicability as a nursing intervention; humor as a tool to improve nurse-patient communication and relationship; influence factors; type of humor interventions; humor benefits in health care context; and limitations and precautions of humor intervention.

The results of this review may contribute to improve the planning and implementation of humor intervention in nursing care practice. It may give important contributions to the humor intervention described in NIC(55 Butcher HK, Bulechek GM, Dochterman JM, Wagner C. Nursing interventions classification (NIC) [Internet]. St. Louis: Elsevier Health Sciences; 2018[cited 2019 Mar 03]. Available from: https://www.elsevier.com/books/nursing-interventions-classification-nic/butcher/978-0-323-49770-1
https://www.elsevier.com/books/nursing-i...
). On the other hand, it can help in the justification of three NANDA-International(2626 Herdman TH, Kamitsuru S, (Eds.). NANDA International - Nursing Diagnoses: Definitions and classification 2018-2018. Eleventh Edition. New York: Thieme; 2018.) diagnoses: in terms of promotion, prevention and change of sense of humor.

The synthesis of these results may boost the implementation of humor intervention in the nursing curriculum, since it describes the main indications / applications of humor, factors that influence humor, the most used activities and their benefits, as well as, the precautions to be taken within its use. On the other hand, this systematization may provide clues for future research in the context of nursing care.

The use of the scoping review methodology in this study highlights not only its contribution to the development of qualitative research, but it also evidences the practical implications of using humor as a nursing intervention, in improving the relationship and experience of patients.

CONCLUSIONS

Humor is a subjective emotional response resulting from the recognition and expression of incongruities of a comic or absurd situation.

Humor is humanizing, it allows the bettering of the experience lived in hospital context; it also allows the improvement of the communication and the trust between the nurse and the person during the process of care. On the other hand, it increases the person’s participation in care.

The use of humor favors communication, which plays an important role in human interactions. It helps to promote well-being; dealing with difficult and unpleasant situations, reducing tension, stress and discomfort; increases tolerance to pain, and strengthens the immune system.

It is influenced by internal (personality), external and social factors. However, nurses should use it with caution, since it requires training and individualized strategies.

Humor is a complex nursing intervention, which should be used when appropriate. It deserves caution, training and adaptation to the person and must be integrated into its concrete and singular situation.

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Publication Dates

  • Publication in this collection
    19 Aug 2019
  • Date of issue
    Jul-Aug 2019

History

  • Received
    09 Apr 2018
  • Accepted
    03 June 2019
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