Humour, as a phenomenon, has interested philosophers through the ages and been researched in many disciplines. It is a part of a person's identity, both social and personal. Social identity arises from the groups one belongs to, such as those defined by sex, age, religion or ethnicity, and personal identity from a person's own tastes, bodily attributes and so forth (Hay, 1995). Several authors have recognised these components of identity as influencing one's humour creation, recognition, understanding, appreciation and use.
Understanding these aspects of humour is important for student nurses, since they will be expected to have and develop the knowledge, skills and attitude to communicate effectively with all members of the general public, who may become service users (Nursing and Midwifery Council, 2018). Alongside this, policy and public priorities are focused on recruiting a certain type of person who holds particular values to preregistration healthcare programmes. Preregistration nursing students, like many others, claim to have a sense of humour, yet Astedt-Kurki and Liukkonen (1994) highlighted one student nurse's perception that she was not allowed to have a personality, let alone a sense of humour.
Given these issues, student nurses need to understand their humour use and that of those around them to participate in and contribute to person-centred care or as a team member.
Sex
Early research studies alluded to differences in how women and men use humour (Kotthoff, 2006). Kotthoff explained that traditionally held views involved actively joking men and a passive audience of women. Across the literature, much attention has been given to sex in comparison with humour activity and function. Table 1 summarises the humour activities and functions ascribed to men and women.
| Male | Female | ||
|---|---|---|---|
| Activity | Function | Activity | Function |
| Sarcasm |
Supportive |
Anecdotal |
Supportive |
Within healthcare empirical studies, Dean and Gregory (2005) concluded sex and ethnicity both play a role in the use of humour. Their study participants alluded to humour being a way for men to be open with each other and to cover up discomfort they were feeling. This echoed Astedt-Kurki and Isola's (2001) study in which men avoided or postponed a difficult emotional situation by using humour as a defence mechanism. In two studies of men with cancer (Chapple and Ziebland, 2004; Oliffe et al, 2009), the authors suggested that humour use afforded group cohesion and built solidarity while enabling emotional management of anxiety, tension and embarrassment.
Turning to female-focused studies, in Clark's (2017) grounded theory study of emotional turmoil felt by women with breast cancer (related to physical disfigurement), she revealed the women used sexualised joking about their bodies, especially their breasts, to bring their discomfort to the fore without having to tackle underlying issues. This face-saving mechanism allowed them to appear strong. Moreover, Clark concluded the women used humour as a coping strategy by targeting the changed areas of their bodies. These conclusions supported the findings of an earlier phenomenological study on humour use by women with recurrent ovarian cancer, who employed it to cope by using their diagnosis as a basis for humorous comments, making them feel less anxious (Rose et al, 2013).
However, although differences between the sexes' uses of humour have been noted, Crawford (2003) cautioned against an oversimplistic representation of sex because Hay (2000) demonstrated that both women and men use humour to create feelings of solidarity (as well as using it creatively), prefer it based on real-life events (Crawford and Gressley, 1991) and use it to keep or achieve status in the workplace (Holmes and Marra, 2002; Holmes, 2006). Therefore, no simple divisions can be made regarding the influence of sex on the creation, appreciation, type or purpose of humour.
Age
Many authors have highlighted the influence that age exerts on the use of humour, whether through the lens of cognitive function differences or the intended social purposes. Tennant (1990) proposed that one of life's most valuable assets is the ability to see humour in both ourselves and situations. The role of humour at different stages of life varies according to cognitive development, the ability to communicate and the biological influences of ageing; humour also serves different functions in one's lifetime (Martin et al, 2003).
Older adult humour can incorporate more than joke-telling; it can include a gentle recounting of everyday amusing tales of children or pet antics (Buckwalter et al, 1995). In addition, influences on an older person's receptivity to humour may include age, place of residence and health (as levels of frailty influence the type and function of humour) (Herth, 1993).
Nonetheless, the use of humour as a mature defence mechanism is suggested to be a predictor of successful ageing, so can contribute to the goal of adding ‘more life to years than years to life’ (Vaillant 2004: 561).
Culture and ethnicity
The universality of humour is well documented in humour literature (Campinha-Bacote, 1995) and no society or culture is without it (Alford and Alford, 1981; Wooten, 1997). Common themes relating to culture, such as disability or sexual orientation, and ethnicity, such as ethnic differentiation, can be categorised as intra- and intergroup (Apte, 1987). It is recognised that people can be part of many groups; a man might, for example, be black, disabled and gay. However, there may be times when an individual feels part of an ‘out’ group because of humorous occurrences, such as when their group identity was the butt of a joke. They then may no longer feel part of the original group because of their membership of a group at which the humour was aimed.
Robinson (1977) suggested popular humour is used as a cultural tool to express conflicts, concerns and aspirations, which is supported by Campinha-Bacote (1995). In his discussion paper, Mintz (1977) said ethnic humour served two functions: hostility (whether to mask, defuse or sanction it), and group identity (to reinforce a positive view of one's own group or a negative view of another). Apte (1987) debated the juxtaposition of two key cultural values: sense of humour (a key positive attitude when one is prepared to laugh with or be laughed at), and ethnic humour (defined as making fun of an individual or group based on their sociocultural identity), which can include ‘put-down’ humour, (Campinha-Bacote (1995). As many ethnic groups seek to maintain characteristics of their heritage while functioning within a wider society (Holmes and Hay, 1997), Apte (1987) noted societal changes mean ethnic groups are more empowered to challenge ethnically derogatory humour about them within the public domain. The inward (insider) use of humour within an ethnic group differs from its outward (outsider) use, hence it is the audience that makes the difference (Apte, 1987). Campinha-Bacote (1995) notes the role and type of humour in an ethnic group cannot be duplicated by an outsider as it can be deemed to be disparagement and having the potential to reinforce stereotypes and bias, and to maintain the dominant group's power (wider society).
Methodology and methods
There is a dearth of UK-based humour studies in nursing. One is by McCreaddie (2008), who focused on clinical nurse specialists. This study is concerned with student nurses' experience of humour use in the clinical setting.
Methodology
A qualitative approach of interpretative phenomenology analysis (IPA) was adopted, which draws on phenomenology, hermeneutics and idiography. IPA concerns itself with people as interpreters of the world around them. It is centred on an exploration about particular people, in a particular experience or context, and making sense of a particular phenomenon (Tuffour, 2017). In this case, these were student nurses, in the clinical setting and making sense of humour use. These represent the phenomenological tenet that is the lived experience and meaning of the particular.
Another integrative aspect of IPA is the active role of the researcher as they become the interpreter of the participant's sense-making, which reflects the double hermeneutic (Smith et al, 2009). Using IPA to investigate under-researched topics has been recommended by Smith and Osborn (2003).
A limitation of this study is the reliance on one data collection method so it is presented from only one perspective. The small sample size might also be considered a limitation if attempting to generalise the findings from 10 nursing students to the UK-wide student nurse body, although this was never an intention of this study, nor is it an aim of IPA.
Ethical considerations
Ethical approval was obtained from Cardiff University's School of Research's ethics committee and is underpinned by the key principles of autonomy, beneficence, non-maleficence and justice (Beauchamp and Childress, 2013). Participants' rights regarding informed consent, withdrawal, anonymity and confidentiality were upheld. Pseudonyms are used here.
Data collection
Ensuring homogeneity is imperative as it is a fundamental part of IPA (Smith et al, 2009). Therefore, using purposive sampling, the two inclusion criteria were that participants should be preregistration nursing students and have completed one practice placement.
Face-to-face, semistructured interviews with 10 nursing students were conducted and audiorecorded. There were nine women and one man, there were one paediatric and nine adult students, their ages ranged across four decades and they came from a variety of ethnic backgrounds. The interview durations were 25–60 minutes.
Data analysis
The interviews were transcribed verbatim. To gain familiarity, each transcript was closely read then a descriptive, linguistic and conceptual analysis followed (Smith et al, 2009).
Participants recounted stories involving their experience of humour use, which resulted in further analysis of these humour narratives.
Idiographic accounts were constructed (divergent phase) followed by a cross-group analysis to create superordinate themes (convergent phase).
Findings
Themes arising identified participants' use of humour and its influences. This section illustrates participants' references to identities that influence the use of humour.
Sex
Participants identified sex as influencing humour, seen here in Natalie's observation:
‘You probably wouldn't use the same humour on a male as a female.’
Natalie contemplated the increased likelihood of her using different types of humour based on the sex of her patient. Although Natalie's own sex was an indirect influence by association, none of the participants openly considered how their sex influenced humour use directly. However, Sylvie did recognise a male patient's use of humour to cope with the embarrassment during an intimate intervention, which could have been used because the patient wanted to ‘save face’:
‘I just joke about it, and men are much better at that than women, I have noticed. Men are much better at joking about situations than women, especially situations such as putting on a Conveen [urinary sheath] for example.’
The patient's use of humour could potentially have been influenced by a need to protect his image because the student was female.
Age
Another social identity group recognised was age, which highlighted the cross-generational effect of humour. Two perspectives arose: the age of the student/registered nurse; and the age of the patient. Sylvie expressed the first:
‘Not taking yourself really seriously in a clinical setting […] especially as a young person.’
The aim for Sylvie was not to lose her youthful optimism within the stressful healthcare field. Furthermore, she later expressed discomfort at her authority over people who were in a similar age range to her mother or grandmother:
‘Because I'm telling people who are old enough to be my gran and old enough to be my mum what to do and that can be really uncomfortable.’
Conversely, Belinda's experiences caused her to reflect on the patient's age as she perceived that the age of the patient affects the appreciation of humour:
‘What I found more interesting: the older patients love the jokes and they enjoy the jokes, unlike the younger patients.’
The convergence between these differing perspectives is that the ages of both the student and patient play a role in the use and appreciation of humour.
Culture and ethnicity
Cultural and ethnic influences concern the sociocultural context into which one is born and raised and how this in turn affects the development of one's sense of humour. This is shown in Laura's quote:
‘Because we do live in such a diverse society, that plays a big part on people's sense of humour.’
This is supported by Gaynor's perspective on the ‘audience’, because of the individuality of humour and the context:
‘What I might find acceptable would be very different to what, you know, my granddad, if he were alive still, would find acceptable and funny or a teenage girl might find offensive or, you know, someone, devout Muslim might find, you now, appropriate or offensive […] it's about the audience.’
Belinda explained how ethnicity plays a role in her judgment of when to use humour:
‘Race is also very… plays a big role in humour.’
Although she used the word ‘race’, Belinda goes on to speak mainly of ethnicity in the form of cultures such as Asian, English or French.
For the participants, understanding the cultural triggers of humour assisted them and whoever they were interacting with in recognising or appreciating the humour initiated by either person.
Discussion
The discussion concentrates on the influences on the use of humour. The participants recognised that humour is a unique human phenomenon and present across the lifespan.
There has been great emphasis on how sex influences humour creation and appreciation (Martin, 2007). In the study here, only two participants specifically mentioned sex; however, the wider findings found that participants shared humour equally with women and men. From Sylvie's interaction with the male patient and the application of the urinary sheath, it can be suggested the patient's use of humour had as its conversational goal the maintenance of a positive self-image (Tannen, 1990; Martin, 2007) which allowed him to cover up his embarrassment. Ensuring a positive image was a male-gendered function of humour, as Hay's (2001) study highlighted.
The participants' individual humour stories do reflect, to a certain extent, the humour activities and functions by sex shown in Table 1. In this way, they support the extensive studies that have focused on gendered humour's creation and appreciation, highlighting a difference between how women and men use it (Hay, 2000; Crawford, 2003; Martin, 2007). However, in a similar way to Hay's (2000) study, these stories also demonstrate that the male and female instigators of humour (whether patient or participant) overlapped in the types of humour used and the purposes for which they used it, giving support to Crawford's (2003) assertion that there is no simple gender dichotomy of humour use.
Within the findings, there were strong indications that the age of both the student and the patient influenced the use of humour. Older people require the majority of bed-days within British hospitals, and this is the clinical environment in which the participants were most likely to spend the majority of their practice hours.
Thorson and Powell's (1996) study found that the most common function of humour in older people was coping; this may be reflected in the fact that people used humour during intimate acts of care, as participants reported. This draws on Herth's (1993) explanation that ageing is a time of coping and adaption. This may be the case but none of the participants in the present study indicated they thought of this as a function of older people's use of humour.
The social contact older people experience depends on their environment. Residents of sheltered housing in Sweden reported only meeting one to two people apart from the usual care staff each day, while those in their own homes meet five or six people a day (Petzäll and Olsson, 2007). This decreased social contact for the older person potentially explains why older people laugh less in the evening, or it may be they go to bed early (Greengross, 2013). In addition, older people in care homes have limited opportunities to enjoy humorous exchanges as care staff are required to balance meeting the individual needs of numerous patients against achieving employers' service targets (Backhaus, 2009). These combined factors have the strong potential to create a power bias towards the nursing and care staff within care institutions.
The power asymmetry experienced by the participants in this study (they told patients what to do and when to do it) is one that a student will be exposed to on many levels as a part of a hierarchical institution or profession, so there is a need for people to be able to recognise such situations.
Older people's enjoyment and receptivity of certain humour types change over the years and their use of humour is influenced by their frailty. Across the narratives, consideration was given to how age might affect a patient's cognitive ability and how this affects the creation and appreciation of humour in a situation. Therefore, a student's ability to reduce the social distance between themselves and an older person through humour is aided by recognising the patient's cognitive ability and their desire for company; this may help the student to overcome communication barriers.
Participants defined culture as either a nationality (for example Asian or British) or a religious group (for example Muslim). This is in keeping with Nahas' (1998) findings, which highlighted cultural influences on humour use as well as how the cultural background of a person can mean something is not amusing to them but may be humorous to someone of a different culture. The participants in the present study recognised the influence of ethnicity and culture when using humour, which may enhance or detract from the patient's experience. They also expressed the desire not to be offensive to anyone. In relation to the wider healthcare literature, Dean and Gregory (2005) noted that it is generally recognised how ethnicity can affect the appreciation and effectiveness of humour. One patient in their study stated humour was more difficult when speaking to people of different cultures because of language barriers.
Concerning the minority ethnic students (African), Ethel openly challenged a hostile comment based on her ethnicity, with a humorous retort, while Belinda saw the ethnicity of others as both a guide to what humour they might understand and a potential barrier to humour creation and appreciation. Therefore, an understanding of cultural or linguistic influences and how they affect humorous exchanges is advantageous to healthcare students.
Conclusion
These nursing student participants have begun to realise the multiplicity of humour and understand influences on the use of humour. An understanding of how culture and ethnicity affect humour is advantageous to ensure humorous interactions are appropriate.
Understanding humour across the generational divide is fundamental to implementing humour and to discern the potential of power asymmetry in interactions between the humour creator and appreciator.
Women and men are similar regarding their use of humour and its functions; it is therefore better to recognise the individuality of the person with whom one is dealing and not, for instance, rely on simple assumptions about gendered humour use.