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Humour: a phenomenological study within the context of clinical education
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Humour: a phenornenological study within the context of clinical education Violeta Lopez Nahas On reflection after a busy day in the ward, undergraduate nursing students concluded that having a clinical teacher who used humour helped them cope with their clinical experiences. This encouraged the author to look deeper into what humour is and describe the lived experiences of nursing students with teachers who used humour. A phenomenological study was undertaken to explore 48 Australian undergraduate nursing students' lived experiences of humour as used by their clinical teachers during clinical education. The data were collected by interviews. Colaizzi's phenomenological methodology was used to analyse the data. The results showed that humour makes it easier for the nursing students to cope with the anxiety-producing situations encountered during their clinical experiences. According to the results, the majority of nursing students preferred to be with a clinical teacher with sense of humour to facilitate/supervise them in the clinical area. However, a word of caution in using humour was revealed in this study because of the personal nature of this phenomenon. Therefore, this study is significant in that it provides a deeper understanding of humour as part of the teaching-learning process within the context of clinical education. The clinical teacher's use of humour during their encounters with the nursing students during clinical education is described and implications for nursing education is discussed.
introduction and background to the study
Violeta Lopez Nahas
BSN, Dip Teach (Nursing), MNA, PhD, FRCNA, Associate Professor. Department of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong (Requestsfor offprints to VLN)
Manuscript accepted: 5 February 1998
A high proportion of nursing education time is spent in the clinical area. Being a practice discipline, nursing students must be able to apply theory learned in the classroom to the actual clinical setting. However, clinical education o c c u r s within a different context than that of classroom teaching. Although clinical education is an extenuation of classroom teaching, the theory that is taught in the nursing laboratory aims to develop in the students the confidence and competence essential in providing future clientcentred quality nursing care. Thus, students are prepared as future professional nurses for the healthcare services. Currently, clinical placements aim to provide students with the opportunity to practice their clinical skills with actual clients rather than
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practice in a laboratory situation using mannequins. Students are faced with the everchanging reality of the clinical area, where the cost of a mistake may be a life and where problems abound even for the most routine tasks. The unpredictability of the clinical environment could be a very stressful experience for students. Nursing students, therefore, cannot safely and reliably practice in the clinical area without the facilitation of a clinical teacher. Thus, the clinical teacher is the vital link in this teaching-learning process. The p r o c e s s involves guiding the students through the experience based on the teacher's knowledge, clinical experience and expertise. Furthermore, the clinical teacher facilitates the learning process, motivates students with the desire to learn and encourages quality learning. Faculty teaching and student learning in the clinical milieu often place both the nurse faculty and student in a situation of pressure, which
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could result in feelings of stress and anxiety (Jacobsen 1966, Jinks 1991, Jones 1985). Students experience stress and anxiety depending on the nature and social environment of the clinical area. The effects of such anxiety on nursing students results in feeling nervous and sometimes in their inability to sleep prior to clinical placement (Windsor 1987). Beck and Srivastava (1991) identified from their study stressful events experienced by students during their clinical education. These events were academic workload as well as lack of clinical knowledge and expertise needed to accomplish tasks and clinical work expectations. In addition, nursing students in Birch's (1979) study stated that undergoing evaluations, meeting new staff and patients, dealing with doctors and being criticized in front of patients were incidents nursing students found distressing while on clinical practicum. Other studies revealed that the most anxietyproducing situation for nursing students was the initial clinical experience (Beck 1993, Kleehammer et al 1990, Pagana 1990, Selleck 1982). Many authors, however, discussed how to create a climate conducive to student learning (Metcalf 1990, Reilly & Oermann 1992). Villafuerte (1996) suggested that one way to lessen nursing students' anxiety was to structure a clinical preparation time to allow students to collect patient-care data and to familiarize themselves with the equipment and staff prior to commencing their formal clinical practicum. However, nursing students in Hart and Rotem's (1994) study stated that the clinical teachers' ability in building a positive relationship with the ward staff facilitated their learning. Other strategies discussed in the literature included identifying possible threats to student learning and selecting clinical sites appropriate to students' theoretical and practical knowledge (Walker 1990), as well as developing the positive characteristics of the clinical teachers (Jacono & Jacono 1995). Teachers' behaviours in the clinical area play an important part in the learning process of the students. It is assumed that teachers' behaviours in the clinical area can either facilitate or hinder students' learning. The literature has much to offer about what are the effective and ineffective qualities of a teacher in nursing. The most frequently mentioned effective behaviours of teachers were categorized into three main
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dimensions: (1) competence and knowledge, (2) interpersonal relationship and (3) personal attributes (Bergman & Gaitskil11990, Brown 1981, Dunlevy & Wolf 1992, Jarski et a11989, Kanitsaki & Sellick 1989, Krichbaum 1994, Nehring 1990, Swinehart & Meyers 1993). One of the effective teacher behaviours that nursing students rated as important is a good sense of humour (Gelazis 1990, Windsor 1987). Humour has been defined by Robinson (1991a, p 10) as 'any communication which is perceived by any of the interacting parties as humorous that leads to laughter, smiling, or a feeling of amusement.' Having a sense of humour and being able to make other people laugh is part of human behaviour. Laughter that arises out of humour is further defined by Johnston (1990: 13) as 'a universal language and a vehicle for communication capable to transcending our differences and highlighting our similarities.' Freud (1960) viewed humour as a coping mechanism and claimed that humour assists individuals in refocusing attention from unpleasant stimuli. Wooten (1996) stated that nurses work in stressful environments that place demands upon their physical, emotional and spiritual well-being and that humour in the workplace enabled nurses to experience joy even when faced with adversities. Freud (1960) concluded that as people grow up and become enmeshed in jobs, life can lose its joy and therefore people need to get back in touch with their lighter, childlike selves and be happy and laugh a lot. Hence, studies have shown that humour can have a psychotherapeutic effect on patients that alleviate pain, stress and depression (Cousins 1989, Ditlow 1993, Dugan 1989, Ferguson & Campinha-Bacote 1989, Pasquali 1990). In addition, the use of humour helped improve the client-therapist relationship by facilitating self-disclosure (Struthers 1994), breaking down barriers and establishing effective client-nurse rapport (Harris 1995, Gibson 1994), directing patients to focus away from problems onto joy and fun in life (Ruxton 1988), thereby increasing patients' threshold for pain (Kennedy 1995). Humour has also been noted to enhance the learning process. Rosenberg (1989, p 5), who was one of the first to encourage the use of humour in nursing education, posited that 'humour provides a non-threatening atmosphere, which increases
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the student's ability to participate and become a stimulated learner.' Leiber (1986) also suggested that humour could create a conducive environment for the retention of critical information. Moses and Friedman's (1986) study reported that humour was an effective strategy in assisting students in gaining control over stressful situations, such as during evaluation, thus increasing their ability to demonstrate necessary clinical competencies. The use of cartoon, jokes, humorous anecdotes, skits, riddles and puzzles were also documented in promoting students' comprehension and retention (Pease 1991, Kaplan & Pascoe 1977), promoting group unity, relieving tension (Rosenberg 1991), stimulating creative thinking (Pease 1991) and enhancing effective communication and problem-solving abilities (Balzer 1993, Struthers 1994). In addition, Watson and Emerson (1988) suggested that the use of humour in the clinical setting raises students' awareness of humour and its potential healing effects on the clients. This study focused, in general, on the encounters nursing students had with clinical teachers in the clinical area. The purpose was to discover, describe and explain nursing students' lived experiences of humour as utilized by their clinical teachers within the context of clinical education. For the purpose of this study, humour was defined as the quality of the clinical teacher to cause amusement or enliven a dreadful situation and the ability to express or appreciate what is amusing.
Methodology Research design The research design used in this study was a phenomenological approach in a form of a qualitative descriptive study. This method was chosen in order to obtain rich data that would reveal the use of humour by the clinical teachers, as experienced by nursing students during clinical education. This method is an inductive, descriptive research method that attempts to study the human experience as it is lived (Brockopp and Hastings-Tolsma 1995, Oiler 1982, Omery 1983). Within the phenomenological study, the researcher's preconceptions and presuppositions concerning the phenomenon studied were bracketed. Bracketing is a technique
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used to assist participants in describing their lived experiences as the researcher's focus is on what is happening and on what is important in the life of the participants experiencing the phenomenon being studied (Brockopp & Hasting-Tolsma 1995).
Sample A purposeful sample of 48 Australian nursing students enrolled in a Bachelor of Nursing course, who were currently or previously engaged in clinical practice, consented to participate in this study. The qualitative principle of purposeful sampling was utilized (Strubert & Carpenter 1995). The researcher selected the informants (Morse 1994) who met the informational needs of the study and who were willing to share their experiences through interviews (Brockopp & Hastings-Tolsma 1995). Because of the multicultural composition of the Australian nursing students, the researcher purposefully included nursing students from different cultural backgrounds. It was anticipated that the lived experiences of nursing students coming from different cultural background would further enhance the richness of the data being collected. For ease of data analysis, the number of participants were classified into two main groups: 36 of Anglo-Celtic background and 12 of Asian background. The participants ranged in age from 19 to 24 years with a mean of 21.6. In terms of gender, there were 15 males and 33 females. In this study, the participants will be referred to as informants.
Setting The setting for this study was a university in the Sydney Metropolitan region that offers both undergraduate and postgraduate nursing programs. All informants have completed a 12 week theoretical semester on campus and were completing their 5 week clinical practice component of the undergraduate curriculum.
Ethical considerations Approval to conduct this study was granted by the University Ethics Committee. To p~rotect the human rights and welfare of the individual, all informants selected were fully informed about the purpose of the study. Informants were also
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informed that the interviews would be taperecorded. The right to privacy and confidentiality was assured by using a coding system. Consent to participate was also solicited by asking informants to sign the consent form. To protect the rights and welfare of the clinical teachers, the informants were told not to mention the names of their clinical teachers during the interviews. If informants accidentally mentioned the clinical teachers' names, these were deleted when the tape-recorded interviews were transcribed.
Procedure The researcher conducted semi-structured, openended interviews. Nursing students were asked to reflect on and describe their experiences when their clinical teachers during their clinical practice used humour. All interviews were tape-recorded and lasted approximately 45 to 90 minutes. A semi-structured experiential questionnaire interview guideline was used to assist the researcher to focus on the phenomenon being investigated. The guideline included the following questions. From your experience: Can you describe a situation in which your clinical teacher used humour during clinical practicum? Can you describe how you felt or responded to this event? The interview guide was used and revised between first and second interviews to elaborate themes that were emerging from the data, which needed to be explored in detail.
Analysis strategy Colaizzi's (1978) phenomenological methodology was used to analyse the nursing students' descriptions of their clinical encounters where their clinical teachers used humour. His procedure of data analysis was followed by the researcher which included the following seven steps: Reading and re-reading all of the informants' transcribed data of the interview to obtain a feeling for them. Extracting significant statements or phrases that relates to the phenomenon under study from each of the informants' descriptions.
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Formulating meanings from these significant statements or phrases. Organizing these meanings into clusters of themes. Integrating results into an exhaustive description of the phenomenon under study. Returning to the informants to validate 'exhaustive description Including new and relevant data into the fundamental structure of the phenomenon being studied. The Ethnograph software (a program for the computer-assisted analysis of text-based data) developed by Seidel et al (1988) was used to analyse the data. By following the detailed directions in the accompanying manual, the Ethnograph allowed the researcher to number, code, recode and sort data files into analytic categories or themes as well as search for words and derive frequencies. The criteria for evaluating qualitative data by Lincoln and Guba (1985) were used in this study. Criteria used were credibility, audibility and fittingness. These criteria were extremely important to support and refute findings. Intersubjective agreement between the researcher and two expert judges was achieved at each phase of the data analysis. The expert judges were two postgraduate nurses with experience in phenomenological analysis.
Results and discussion of findings The content of the 48 interviews formed the basis of the data collected, which revealed nursing students' describing humour in 170 significant statements as used by the clinical teachers. From these statements, the researcher carefully formulated 18 meaningful statements that relate to the phenomenon and returned to the transcripts to ascertain their meaning. These formulated meanings were given to two expert judges who verified the reliability of the meanings. Five theme clusters emerged from the formulated meanings. The theme clusters appear in Box 1. These theme clusters contributed to the creation of an exhaustive description of the clinical teachers' use of humour within the context of clinical education. This description was sent to the participants for validation and this description appears in Box 2.
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1. Being human a. Clinical teachers shared themselves by laughing and crying with the students. b. Clinical teachers admitted their limitations and weaknesses. 2. Creating a positive clinical environment a. Clinical teachers were able to turn a stressful experience into a laughing matter. b. A positive clinical environment made learning a memorable experience. c. Clinical teachers created an opportunity for students to release tensions and frustrations during clinical education. d, The clinical teacher provided a caring and warm environment for the students. 3. Connecting with students a. The use of humour by the clinical teacher was experienced by students as an act of decreasing social distancing between students and teacher. b. The use of humour is an effective communication tool where respect and and understanding of each other's humour is maintained. 4. Facilitating learning in the clinical area a. Use of humour made it easier to accept laughing at ones mistakes. b. Laughter made chores easier to tackle. 5. Respecting personal nature of humour. a. Use of humour can be destructive that can hinder learning. b. Clinical teachers must be aware of the cultural taboos against use of humour. c. Clinical teachers must be aware of the students' cultural backgrounds before utilizing humour in teaching and interacting with students.
Humour and being human The 48 informants who contributed descriptions of humorous clinical encounters described their clinical teachers as being h u m a n when their teachers shared themselves by laughing and crying with them. Informants also felt that their clinical teachers were as vulnerable as they were when faced with a new situation in the clinical area. When clinical teachers admitted their weaknesses and limitations and turned these into something humorous, participants reflected that they actually learned from their experiences as one informant commented: After all, nurses are human themselves. They can laugh. They can cry and still remain
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professional. We shouldn't be serious all the time - even with our colleagues as well as our patients. I a m sure, they also appreciate a sense of humour every now and then. I sure do. I respected m y clinical teacher even more when she was not serious all the time but made an effort to make our clinical experiences enjoyable. H u m o u r and laughter are important aspects of h u m a n behaviour that is healthy and constructive (Kennedy 1995). Laughter stimulates positively all the systems of the b o d y (Cousins 1989). In the clinical situation, informants admitted Lhat they often watched their clinical teachers' behaviours towards others and towards the clients and stated that they could sense the genuineness of the teachers' attitudes towards others. When the clinical teacher tried to understand students' feelings and problems during clinical practice and m a d e an effort to help, the students felt: that the teacher was not only fulfilling the teaching role, but most of all exhibiting humane behaviour. And if such encounters with the clinical teacher were accompanied by some humour, informants felt that the encounters were normal day-to-day people encounters.
The use of humour by the clinical teachers during clinical education facilitated the nursing students' learning. Facilitation of learning in the clinical area depended on the quality of the student-teacher interactions. The use of humour improved studentteacher relationships because the interactions were perceived by nursing students to be non-threatening and non-judgmental. There iis an appreciation of the clinical teachers' use of humour when they shared personal and humorous stories and experiences with students. The use of humour created a friendly encounter thus a positive clinical environment for nursing students to learn with less anxieties and uncertainties. The positive clinical environment was nurtured by the warm and caring attitudes of the clinical teacher who used humour in teaching. However, cautious use of humour is expressed by nursing students because of the cultural differences among students.
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Humour and creation of a positive clinical environment Two of the constituents of h u m o u r experienced b y the nursing students created a positive clinical environment for the students. These constituents included the clinical teachers' ability to turn a stressfffl experience into a laughing matter and the creation of a conducive environment that made learning in the clinical area a memorable experience. When the clinical teachers used humour, they created an environment conducive to students' learning. H u m o u r could aid in reducing fear of the unfamiliar hospital setting and encouraged a sense of trust. For the informants in this study, the use of h u m o u r by the clinical teacher provided students an avenue to release tensions, stress, hostility and frustration associated with clinical education. H u m o u r was also perceived as an effective means of support their clinical teachers used in dealing with their anxieties as one informant stated: I respect the clinical teacher who can make the clinical experience enjoyable and not boring. We had one clinical teacher who often sat with us during tea or lunch break and told us about some funny, funny stories during his nursing training years. This occasion made us feel relaxed before going back to the clinical area. It also m a d e us feel that we were not as stupid as we thought, because we could relate to our teacher's experience. During, clinical education, students took breaks during their shifts to recuperate or to attend debriefings scheduled by the clinical teacher. These times were valued by the nursing students as these were used not only to clarify issues occurring in the clinical area with their clinical teacher, but also to unleash pent-up feelings as a result of some situations experienced by the students. These sessions were not formal teaching sessions. Rather, they were used to allow students to reflect on their clinical experience and learn from each others' experiences. If h u m o u r is a means of stress management, participants suggested that their clinical teachers continue to use h u m o u r in clinical education. This helped allay students' anxiety and lessened stress during their clinical experience, especially during their initial clinical exposure to the clinical area, as well as when confronted with an unfamiliar
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clinical situation. This suggestion reflected the participants' orientation to the pursuit of healthy lifestyle as confirmed by the informant who commented that: 'More clinical objectives could be accomplished if there were no stresses.' Furthermore, humour also enhanced nursing students' process of socialization into the health profession, especially when humour was used not only by the clinical teacher but also by other healthcare personnel. The use of humour as a socialization process also conveyed to the students that the clinical area is a place not only for managing patients medically but also a place where patients are provided with a caring, humanistic environment.
Humour and connecting with students The relaxed atmosphere strengthens feelings of togetherness, closeness, w a r m t h and friendliness (Powell & Andersen 1985, Robinson 1991b). In this study, informants stated that their clinical teacher did not create a barrier or boundary between them. Informants felt that the informal nature of the encounters as a result of the sense of h u m o u r of their teacher did not lessen their respect for their teachers. H u m o u r was experienced as an act of decreasing social distancing by relaxing the rigidity of the educational social structure. With a sense of humour, the students did not undermine clinical teachers' authority. Consequently, this authority was further enhanced and emitted to the students when the clinical teacher had the ability to share his or her knowledge and expertise in clinical practice alongside the students in a non-threatening, informal and humorous manner. In addition, the use of h u m o u r resulted in developing connectedness with the clinical teacher, even if such connectedness was only for the short period of time within the clinical practice. On this topic, one informant said: Depending on h o w we felt about our clinical facilitator, it could facilitate whether you feel closer or start to form a friendship. But it is not really meant to be a strong friendship, only a friendship within that time period. The informants described 'connectedness' as an ongoing process facilitated by the clinical teachers' use of h u m o u r as an effective communication tool. The process was enhanced when reciprocity and openness between teachers
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and students developed as a mutual feeling. In addition, informants commented that respecting and understanding each other's humour meant that clinical teachers went beyond the expected role of the teacher to being a friend, no matter how short the friendship might be. Informants also felt that this lead to the development of an ability to relate in a warm and human ways with others. H u m o u r is catching. If the clinical teacher sees things from a different light, humorous instead of serious, I felt that I could relate to the situation and accept it quite easily. It sorts of 'rubs off' on you and you feel lighthearted by the end. I think our patients also appreciated a little sense of humour now and then.
that the solemnity of the educational system is driving hundreds of bright, laughing college students from colleges of education. He therefore urged that education should try to keep students alive and hopeful. This was evident in what Eble (1966: 114) stated: 'For serious as our strivings are, they should never be so serious that we cannot lean back and laugh at the absurdity of our being and doing. Education should teach us to play the wise fool rather than turn us into the solemn ass.' Informants in this study commented that it was easier for them to laugh at their own mistakes when their clinical teachers were also able to laugh at their own mistakes as this encounter promoted a sense of self-respect among themseIves.
Respecting personal nature of humour Humour and the facilitation of learning ~nformants described various clinical learning situations in which humour was manifested in the interaction between the nursing students and clinical teachers. One example was provided in which students carry out nursing procedures that were facilitated through the use of humour. Informants claimed that many daily chores were more fun when humour was involved. Informants felt that humour played a major role in helping them cope with hard and tedious work into an interesting chore instead of grumbling about the work at hand. I remembered a situation clearly when the clinical teacher used humour in her bedside teaching. She made the learning experience enjoyable and not stressful to us. The experience of laughing together during that encounter encouraged us to ask questions and not to be afraid of being labeled stupid. I felt that I learned 'a mile' more during this encounter than any other encounter. The use of humour in teaching was found to enhance learning (Parkin 1989, Pease 1991). According to Robinson (1978), the modeling of the use of humour by the teacher is a first step in teaching Students that the nursing profession must utilize humour as an effective nursing intervention in an acceptable and constructive way. Furthermore, Eble (1966) argued strongly that humour and laughter open pathways to creativity and discovery. He also regretted the fact
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H u m o u r is an individual and a personal matter and is a context-based phenomenon (AstedtKurki & Liukkonen 1994). Informants in this study reported that it was important for clinical teachers to have an awareness of their own understanding of humour in order to facilitate and understand humour in their students. However, although informants acknowledged that humour promoted students' involvement and motivation to learn, humour also could be destructive and could hinder students' learning in the clinical area. Some informants in this study reported that they did not appreciate tile sense of h u m o u r of their clinical teachers during some of their encounters. One informant commented: I did not find my clinical teacher as ihaving a sense of humour, no matter what my peers said. For me, her sense of h u m o u r was degrading and belittling and sometimes sexist and culturally inappropriate. In my culture, we take all things seriously, especially when looking after our patients. We never made fun about our patients nor tell jokes. Nursing students with different social circumstances and life experiences have varying reactions to the same piece of humour. Laughing at a student is very different from laughing with the students. Informants in this study ]perceived that their clinical teachers were making fun of their mistakes and took the teachers' sense of h u m o u r in a negative way. These 12 informants who perceived humour as unprofessional were of
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Asian background compared to the 36 participants who were of Anglo-Celtic background. This finding supports the premise that culture and ethnicity influence the kind of humour which is appreciated. In some culture, humour is considered a moulding force, a social release or a preventive mechanism to ward off anticipated attack (Robinson 1978). For example, within most of the Asian culture, humour was used to save one's self-respect by laughing with the jokes directed to them by the 'tormentor'. The person may laugh and at the same time, deep down inside, feel angry for being laughed at. The participants' responses in this study clearly showed that clinical teachers must be aware of the taboos against the use of humour, as well as be aware of their students' cultural backgrounds before utilizing hurnour in their teaching and their interaction with the students. The inappropriate use of humour has been cited in the literature. Harris (1995) warned that humour could be destructive when used to ridicule people. Haig (1986) drew attention to the negative effects of humour in terms of behaviours of denial, suppression, and undermining confidence. According to Powell and Andersen (1985) an unwise use of humour could result in students taking offence that could set up an emotional block which could inhibit the students' subsequent learning. In this study informants remembered embarrassing incidents during their encounters and distanced themselves from the clinical teacher.
Implications for nursing The use of humour is a major consideration for clinical teachers in providing clinical teaching to multi-cultural Australian undergraduate-nursing students. Incorporating laughter and humour into the clinical educational program was proven as one stress-reduction strategy that could provide an emotional and physical release of accumulated tension among nursing students during their clinical practicum. According to Warner (1983), students' nonsense remarks and jokes during practice were ways of students' gaining sense of control over anxiety-provoking situations. Therefore, nurse clinical teachers could use various techniques to enhance their teaching practice with humour. This could lead to an improved
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relationship with students by creating a relaxed atmosphere, thus allowing students to use laughter to overcome tensions and difficult feelings encountered during clinical education. However, according to Robinson (1991), in spite of recognizing the value of humour, nurses are afraid to use it, to take it seriously and to make a serious effort to use it as an effective means of communication and teaching tool in academia. In addition, humour does not come naturally to most nurses because of the nature of their work (Harris 1995). It also may not come naturally for nurse teachers whose cultural background may not support the use of humour in teaching. However, clinical teachers must also be cautious in the use of humour and be consciously aware of the destructive effects of humour, as well as its cultural implications. For some students, boundaries of appropriate and inappropriate humour are very clear especially in regard to telling ethnic, sexist or off-putting jokes. Inappropriate humour, such as making sarcastic comments about a student's clinical practice, could lead to embarrassment and withdrawal of the student. What the clinical teacher thought was funny may not be funny for the student at all and this could be taken differently leading to destructive rather than constructive effects on student's learning. Therefore, clinical teachers must restructure their ways of dealing with their students, especially those who come from a different cultural background where humour is considered unprofessional.
Conclusion Clinical education, in particular, can be a very stressful experience for the nursing students as well as for their clinical teachers. The study highlighted that humour and laughter during the teaching-learning process could create an atmosphere of pleasure in the shared learning experiences during clinical practicum. The concept of humour is inherent in the humanistic approach to education as reported by Reilly and Oermann (1992). Informants in this study clearly provided personal experiences to the effectiveness of using humour during clinical education not only by their clinical teachers but also between students and even with their patients. However, the findings from this study cannot be generalized but provided preliminary data about the
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importance of humour in clinical education. Clearly, in this study, the nursing students from the Asian background may have some personal feelings about the use of humour but, in general, they also agree that it could facilitate their learning. This finding questions Johnston's (1990) view that humour is a universal language and a vehicle for communication that can transcend differences. Therefore, identification of the essential structures of humour within a specific cultural context needs to be further explored as the type and timing of using humour could vary from culture to culture. In addition, even though the thematic analysis of the data reflected nursing students' positive experiences with clinical teachers who used humour during clinical education, it is also important to explore nurse teachers' perceptions and acceptance of using humour in their teaching. A rich body of literature exists to support the proposition that humour enhances creative teaching and problem-solving skills as well as comprehension and retention of learning. Further research is also recommended, using qualitative a n d / o r quantitative methods, to explore the relationship between the use of humour in teaching and (1) nursing students' level of comprehension and retention, (2) students' level of satisfaction from the learning experience in which humour is valued and (3) nurse teachers' perceptions of humour and the extent to which they use humour in their teaching. The study also highlighted that students respected the clinical teachers more if they are willing to admit their mistakes or share their concerns and limitations with them. The open dialogue enriches the student-teacher relationship that could create an honest relationship and mutually satisfying experience during their clinical placement. In this study, teachers' use of humorous stories to share their past experiences with students was considered an effective communication tool, a mechanism for coping with similar stressful clinical events and a valuable teaching adjunct by the nursing students. According to Kennedy (1995, p 30), 'I have learned to make those silly, but safe, errors that occur during the care of patients into methods of promoting laughter. This practice has never caused a patient to question my professionalism or ability, but rather help them see my humanness.' The informants in this study
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supported Kennedy's view when they explained that their clinical teachers are only showing their humanness when they can relate, and also laugh at, their mistakes. In addition, informants' description of their clinical teachers' warmth and friendliness implied an element of humour that did not break the teacher-student boundary. Rather, it facilitated human communication and a realization that their teachers can be very human after all. Clearly, it is a skill that needs to be developed and supported by all nurse teachers.
References Astedt-Kurki P, Liukkonen A 1994 Humour in :nursing care. Journal of Advanced Nursing 20 (1): 183-188 Balzer J W 1993 Humor: a missing ingredient in collaborative practice. Holistic Nursing Practice 7 (4): 28-35 Beck C T 1993 Caring relationships between nursing students and patients. Nurse Educator 18 (5): 28-32 Beck C T, Srivastava R (1991) Perceived level and sources of stress in baccalaureate nursing students. Journal of Nursing Education 30 (4): 127-133 Bergman K, Gaitskill T 1990 Faculty and student perceptions of effective clinical teachers: an extension study. Journal of Professional Nursing 6 (10): 33-44 Birch J 1979 The anxious learner. Nursing Mirror 148 (6): 17-22 Brockopp D Y, Hastings-Tolsma M T 1995 Fundamentals of nursing research. Jones and Bartlett, London, pp 238-241 Brown S 1981 Faculty and student perception of effective clinical teachers. Journal of Nursing Education 20 (1): 5-13 Colaizzi P (1978) Psychological research as the phenomenologist views it. In: Valle R, King M (eds) Existential Phenomenological Alternatives for Psychology. Oxford University Press, New York, pp 48-71 Cousins N 1989 Proving the power of laughter. Psychology Today 23 (10): 22 Ditlow F 1993 Humour is a form of creativity. Journal of Holistic Nursing Practice 11 (1): 66-79 Dugan D O 1989 Laughter and tears: best medicine for stress. Nursing Forum 24 (1): 18-26 Dunlevy C L, Wolf K N 1992 Perceived differences in the importance and frequency of practice of clinical teaching behaviours. Journal of Allied Health 21 (3): 175-183 Eble K 1966 The perfect education. Macmillan, New York Ferguson S, Campinha-Bacote J 1989 Humour in nursing. Journal of Psychosocial Nursing 27 (94): 29.-34 Freud S 1960 Jokes and their relation to the unconscious. Penguin Books, London Gelazis R 1990 Creative strategies for teaching care. In: Leininger M, Watson J (eds) The caring imperative in nursing education. National League for Nursing Press, New York. Gibson L 1994 Healing with humour. Nursing (9): 56-57 Haig S 1986 Therapeutic uses of humour. American Journal of Psychotherapy 40 (4): 543-553
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Ornery A (1983) Phenomenology: a method for nursing research. Advances in Nursing Science 5 (2): 49-63 Pagana K D 1990 The relationship of hardiness and social support to student appraisal of stress in an initial clinical nursing situation. Journal of Nursing Education 29 (6): 255-261 Parkin C J 1989 Humour, health, and higher education: laughing matters. Journal of Nursing education 28 (5): 229-230 Pasquali E A 1990 Learning to laugh: humour as therapy. Journal of Psychosocial Nursing 28 (3): 31-35 Pease R A 1991 Cartoon humour in nursing education. Nursing Outlook 39 (3): 262-267 Powell J P, Andersen L W 1985 Humour and teaching in higher education. Studies in Higher Education 10 (1): 79-89 Reilly D E, Oermann M H 1992 Clinical teaching in nursing education. National League for Nursing Press, New York Robinson V M 1991a Humour and the health professions. Charles B Slack, New Jersey Robinson V 1991b Humour and the health professions: the therapeutic use of humour in health care. Charles B Slack, New Jersey Robinson V 1978 Humour in nursing. In: Carlson C, Blackwell B (eds) Behavioural concepts and nursing interterventions. J B Lippincott, Philadelphia, PA Rosenberg L 1991 A qualitative investigation of the use of humour by emergency personnel as a strategy for coping with stress. Journal of Emergency Nursing 17 (4): 197-202 Rosenberg L 1989 A delicate dose of humour. Nursing Forum 24 (2): 5 Ruxton J P 1988 Humor intervention deserves our attention. Holistic Nursing Practice 2 (3): 54-62 Seidel J V, Kjolseth R, Seymour E 1988 The Ethnograph: a program for the qualitative analysis of text-based data. Qualis Research Associates, Amherst, WI Selleck T 1982 Satisfying and anxiety-producing incidents for nursing students. Nursing Times 78 (2): 137-140 Struebert H J, Carpenter D R 1995 Qualitative research in nursing: advancing the humanistic imperative. J B Lippincott, Philadelphia, PA, pp 50-88 Struthers J 1994 An exploration into the role of humour in the nursing student-nurse teacher relationship. Journal of Advanced Nursing 19 (3): 486491 Swinehart S, Meyers S K 1993 Level I fieldwork: creating a positive experience. American Journal of Occupational Therapy 47 (1): 68-73 Villafuerte A 1996 Structured clinical preparation time for culturally diverse baccalaureate nursing students. International Journal of Nursing Studies 33 (2): 161-170 Walker P 1990 Student placements: the midwife's view. Nursing 4 (3): 15-18 Warner S 1983 Humour and self-disclosure within the milieu. Journal of Psychosocial Nursing 4 (3): 17-21 Watson M J, Emerson S 1988 Facilitating learning with humour. Journal of Nursing Education 27 (2): 89-90 Windsor A 1987 Nursing students' perceptions of clinical experience. Journal of Nursing Education 26 (3): 150-154 Wooten P 1996 Humor: an antidote for stress. HoIistic Nursing Practice 10 (2): 49-56
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Article
Humour: a phenornenological study within the context of clinical education Violeta Lopez Nahas On reflection after a busy day in the ward, undergraduate nursing students concluded that having a clinical teacher who used humour helped them cope with their clinical experiences. This encouraged the author to look deeper into what humour is and describe the lived experiences of nursing students with teachers who used humour. A phenomenological study was undertaken to explore 48 Australian undergraduate nursing students' lived experiences of humour as used by their clinical teachers during clinical education. The data were collected by interviews. Colaizzi's phenomenological methodology was used to analyse the data. The results showed that humour makes it easier for the nursing students to cope with the anxiety-producing situations encountered during their clinical experiences. According to the results, the majority of nursing students preferred to be with a clinical teacher with sense of humour to facilitate/supervise them in the clinical area. However, a word of caution in using humour was revealed in this study because of the personal nature of this phenomenon. Therefore, this study is significant in that it provides a deeper understanding of humour as part of the teaching-learning process within the context of clinical education. The clinical teacher's use of humour during their encounters with the nursing students during clinical education is described and implications for nursing education is discussed.
introduction and background to the study
Violeta Lopez Nahas
BSN, Dip Teach (Nursing), MNA, PhD, FRCNA, Associate Professor. Department of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong (Requestsfor offprints to VLN)
Manuscript accepted: 5 February 1998
A high proportion of nursing education time is spent in the clinical area. Being a practice discipline, nursing students must be able to apply theory learned in the classroom to the actual clinical setting. However, clinical education o c c u r s within a different context than that of classroom teaching. Although clinical education is an extenuation of classroom teaching, the theory that is taught in the nursing laboratory aims to develop in the students the confidence and competence essential in providing future clientcentred quality nursing care. Thus, students are prepared as future professional nurses for the healthcare services. Currently, clinical placements aim to provide students with the opportunity to practice their clinical skills with actual clients rather than
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practice in a laboratory situation using mannequins. Students are faced with the everchanging reality of the clinical area, where the cost of a mistake may be a life and where problems abound even for the most routine tasks. The unpredictability of the clinical environment could be a very stressful experience for students. Nursing students, therefore, cannot safely and reliably practice in the clinical area without the facilitation of a clinical teacher. Thus, the clinical teacher is the vital link in this teaching-learning process. The p r o c e s s involves guiding the students through the experience based on the teacher's knowledge, clinical experience and expertise. Furthermore, the clinical teacher facilitates the learning process, motivates students with the desire to learn and encourages quality learning. Faculty teaching and student learning in the clinical milieu often place both the nurse faculty and student in a situation of pressure, which
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could result in feelings of stress and anxiety (Jacobsen 1966, Jinks 1991, Jones 1985). Students experience stress and anxiety depending on the nature and social environment of the clinical area. The effects of such anxiety on nursing students results in feeling nervous and sometimes in their inability to sleep prior to clinical placement (Windsor 1987). Beck and Srivastava (1991) identified from their study stressful events experienced by students during their clinical education. These events were academic workload as well as lack of clinical knowledge and expertise needed to accomplish tasks and clinical work expectations. In addition, nursing students in Birch's (1979) study stated that undergoing evaluations, meeting new staff and patients, dealing with doctors and being criticized in front of patients were incidents nursing students found distressing while on clinical practicum. Other studies revealed that the most anxietyproducing situation for nursing students was the initial clinical experience (Beck 1993, Kleehammer et al 1990, Pagana 1990, Selleck 1982). Many authors, however, discussed how to create a climate conducive to student learning (Metcalf 1990, Reilly & Oermann 1992). Villafuerte (1996) suggested that one way to lessen nursing students' anxiety was to structure a clinical preparation time to allow students to collect patient-care data and to familiarize themselves with the equipment and staff prior to commencing their formal clinical practicum. However, nursing students in Hart and Rotem's (1994) study stated that the clinical teachers' ability in building a positive relationship with the ward staff facilitated their learning. Other strategies discussed in the literature included identifying possible threats to student learning and selecting clinical sites appropriate to students' theoretical and practical knowledge (Walker 1990), as well as developing the positive characteristics of the clinical teachers (Jacono & Jacono 1995). Teachers' behaviours in the clinical area play an important part in the learning process of the students. It is assumed that teachers' behaviours in the clinical area can either facilitate or hinder students' learning. The literature has much to offer about what are the effective and ineffective qualities of a teacher in nursing. The most frequently mentioned effective behaviours of teachers were categorized into three main
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dimensions: (1) competence and knowledge, (2) interpersonal relationship and (3) personal attributes (Bergman & Gaitskil11990, Brown 1981, Dunlevy & Wolf 1992, Jarski et a11989, Kanitsaki & Sellick 1989, Krichbaum 1994, Nehring 1990, Swinehart & Meyers 1993). One of the effective teacher behaviours that nursing students rated as important is a good sense of humour (Gelazis 1990, Windsor 1987). Humour has been defined by Robinson (1991a, p 10) as 'any communication which is perceived by any of the interacting parties as humorous that leads to laughter, smiling, or a feeling of amusement.' Having a sense of humour and being able to make other people laugh is part of human behaviour. Laughter that arises out of humour is further defined by Johnston (1990: 13) as 'a universal language and a vehicle for communication capable to transcending our differences and highlighting our similarities.' Freud (1960) viewed humour as a coping mechanism and claimed that humour assists individuals in refocusing attention from unpleasant stimuli. Wooten (1996) stated that nurses work in stressful environments that place demands upon their physical, emotional and spiritual well-being and that humour in the workplace enabled nurses to experience joy even when faced with adversities. Freud (1960) concluded that as people grow up and become enmeshed in jobs, life can lose its joy and therefore people need to get back in touch with their lighter, childlike selves and be happy and laugh a lot. Hence, studies have shown that humour can have a psychotherapeutic effect on patients that alleviate pain, stress and depression (Cousins 1989, Ditlow 1993, Dugan 1989, Ferguson & Campinha-Bacote 1989, Pasquali 1990). In addition, the use of humour helped improve the client-therapist relationship by facilitating self-disclosure (Struthers 1994), breaking down barriers and establishing effective client-nurse rapport (Harris 1995, Gibson 1994), directing patients to focus away from problems onto joy and fun in life (Ruxton 1988), thereby increasing patients' threshold for pain (Kennedy 1995). Humour has also been noted to enhance the learning process. Rosenberg (1989, p 5), who was one of the first to encourage the use of humour in nursing education, posited that 'humour provides a non-threatening atmosphere, which increases
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the student's ability to participate and become a stimulated learner.' Leiber (1986) also suggested that humour could create a conducive environment for the retention of critical information. Moses and Friedman's (1986) study reported that humour was an effective strategy in assisting students in gaining control over stressful situations, such as during evaluation, thus increasing their ability to demonstrate necessary clinical competencies. The use of cartoon, jokes, humorous anecdotes, skits, riddles and puzzles were also documented in promoting students' comprehension and retention (Pease 1991, Kaplan & Pascoe 1977), promoting group unity, relieving tension (Rosenberg 1991), stimulating creative thinking (Pease 1991) and enhancing effective communication and problem-solving abilities (Balzer 1993, Struthers 1994). In addition, Watson and Emerson (1988) suggested that the use of humour in the clinical setting raises students' awareness of humour and its potential healing effects on the clients. This study focused, in general, on the encounters nursing students had with clinical teachers in the clinical area. The purpose was to discover, describe and explain nursing students' lived experiences of humour as utilized by their clinical teachers within the context of clinical education. For the purpose of this study, humour was defined as the quality of the clinical teacher to cause amusement or enliven a dreadful situation and the ability to express or appreciate what is amusing.
Methodology Research design The research design used in this study was a phenomenological approach in a form of a qualitative descriptive study. This method was chosen in order to obtain rich data that would reveal the use of humour by the clinical teachers, as experienced by nursing students during clinical education. This method is an inductive, descriptive research method that attempts to study the human experience as it is lived (Brockopp and Hastings-Tolsma 1995, Oiler 1982, Omery 1983). Within the phenomenological study, the researcher's preconceptions and presuppositions concerning the phenomenon studied were bracketed. Bracketing is a technique
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used to assist participants in describing their lived experiences as the researcher's focus is on what is happening and on what is important in the life of the participants experiencing the phenomenon being studied (Brockopp & Hasting-Tolsma 1995).
Sample A purposeful sample of 48 Australian nursing students enrolled in a Bachelor of Nursing course, who were currently or previously engaged in clinical practice, consented to participate in this study. The qualitative principle of purposeful sampling was utilized (Strubert & Carpenter 1995). The researcher selected the informants (Morse 1994) who met the informational needs of the study and who were willing to share their experiences through interviews (Brockopp & Hastings-Tolsma 1995). Because of the multicultural composition of the Australian nursing students, the researcher purposefully included nursing students from different cultural backgrounds. It was anticipated that the lived experiences of nursing students coming from different cultural background would further enhance the richness of the data being collected. For ease of data analysis, the number of participants were classified into two main groups: 36 of Anglo-Celtic background and 12 of Asian background. The participants ranged in age from 19 to 24 years with a mean of 21.6. In terms of gender, there were 15 males and 33 females. In this study, the participants will be referred to as informants.
Setting The setting for this study was a university in the Sydney Metropolitan region that offers both undergraduate and postgraduate nursing programs. All informants have completed a 12 week theoretical semester on campus and were completing their 5 week clinical practice component of the undergraduate curriculum.
Ethical considerations Approval to conduct this study was granted by the University Ethics Committee. To p~rotect the human rights and welfare of the individual, all informants selected were fully informed about the purpose of the study. Informants were also
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informed that the interviews would be taperecorded. The right to privacy and confidentiality was assured by using a coding system. Consent to participate was also solicited by asking informants to sign the consent form. To protect the rights and welfare of the clinical teachers, the informants were told not to mention the names of their clinical teachers during the interviews. If informants accidentally mentioned the clinical teachers' names, these were deleted when the tape-recorded interviews were transcribed.
Procedure The researcher conducted semi-structured, openended interviews. Nursing students were asked to reflect on and describe their experiences when their clinical teachers during their clinical practice used humour. All interviews were tape-recorded and lasted approximately 45 to 90 minutes. A semi-structured experiential questionnaire interview guideline was used to assist the researcher to focus on the phenomenon being investigated. The guideline included the following questions. From your experience: Can you describe a situation in which your clinical teacher used humour during clinical practicum? Can you describe how you felt or responded to this event? The interview guide was used and revised between first and second interviews to elaborate themes that were emerging from the data, which needed to be explored in detail.
Analysis strategy Colaizzi's (1978) phenomenological methodology was used to analyse the nursing students' descriptions of their clinical encounters where their clinical teachers used humour. His procedure of data analysis was followed by the researcher which included the following seven steps: Reading and re-reading all of the informants' transcribed data of the interview to obtain a feeling for them. Extracting significant statements or phrases that relates to the phenomenon under study from each of the informants' descriptions.
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Formulating meanings from these significant statements or phrases. Organizing these meanings into clusters of themes. Integrating results into an exhaustive description of the phenomenon under study. Returning to the informants to validate 'exhaustive description Including new and relevant data into the fundamental structure of the phenomenon being studied. The Ethnograph software (a program for the computer-assisted analysis of text-based data) developed by Seidel et al (1988) was used to analyse the data. By following the detailed directions in the accompanying manual, the Ethnograph allowed the researcher to number, code, recode and sort data files into analytic categories or themes as well as search for words and derive frequencies. The criteria for evaluating qualitative data by Lincoln and Guba (1985) were used in this study. Criteria used were credibility, audibility and fittingness. These criteria were extremely important to support and refute findings. Intersubjective agreement between the researcher and two expert judges was achieved at each phase of the data analysis. The expert judges were two postgraduate nurses with experience in phenomenological analysis.
Results and discussion of findings The content of the 48 interviews formed the basis of the data collected, which revealed nursing students' describing humour in 170 significant statements as used by the clinical teachers. From these statements, the researcher carefully formulated 18 meaningful statements that relate to the phenomenon and returned to the transcripts to ascertain their meaning. These formulated meanings were given to two expert judges who verified the reliability of the meanings. Five theme clusters emerged from the formulated meanings. The theme clusters appear in Box 1. These theme clusters contributed to the creation of an exhaustive description of the clinical teachers' use of humour within the context of clinical education. This description was sent to the participants for validation and this description appears in Box 2.
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1. Being human a. Clinical teachers shared themselves by laughing and crying with the students. b. Clinical teachers admitted their limitations and weaknesses. 2. Creating a positive clinical environment a. Clinical teachers were able to turn a stressful experience into a laughing matter. b. A positive clinical environment made learning a memorable experience. c. Clinical teachers created an opportunity for students to release tensions and frustrations during clinical education. d, The clinical teacher provided a caring and warm environment for the students. 3. Connecting with students a. The use of humour by the clinical teacher was experienced by students as an act of decreasing social distancing between students and teacher. b. The use of humour is an effective communication tool where respect and and understanding of each other's humour is maintained. 4. Facilitating learning in the clinical area a. Use of humour made it easier to accept laughing at ones mistakes. b. Laughter made chores easier to tackle. 5. Respecting personal nature of humour. a. Use of humour can be destructive that can hinder learning. b. Clinical teachers must be aware of the cultural taboos against use of humour. c. Clinical teachers must be aware of the students' cultural backgrounds before utilizing humour in teaching and interacting with students.
Humour and being human The 48 informants who contributed descriptions of humorous clinical encounters described their clinical teachers as being h u m a n when their teachers shared themselves by laughing and crying with them. Informants also felt that their clinical teachers were as vulnerable as they were when faced with a new situation in the clinical area. When clinical teachers admitted their weaknesses and limitations and turned these into something humorous, participants reflected that they actually learned from their experiences as one informant commented: After all, nurses are human themselves. They can laugh. They can cry and still remain
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professional. We shouldn't be serious all the time - even with our colleagues as well as our patients. I a m sure, they also appreciate a sense of humour every now and then. I sure do. I respected m y clinical teacher even more when she was not serious all the time but made an effort to make our clinical experiences enjoyable. H u m o u r and laughter are important aspects of h u m a n behaviour that is healthy and constructive (Kennedy 1995). Laughter stimulates positively all the systems of the b o d y (Cousins 1989). In the clinical situation, informants admitted Lhat they often watched their clinical teachers' behaviours towards others and towards the clients and stated that they could sense the genuineness of the teachers' attitudes towards others. When the clinical teacher tried to understand students' feelings and problems during clinical practice and m a d e an effort to help, the students felt: that the teacher was not only fulfilling the teaching role, but most of all exhibiting humane behaviour. And if such encounters with the clinical teacher were accompanied by some humour, informants felt that the encounters were normal day-to-day people encounters.
The use of humour by the clinical teachers during clinical education facilitated the nursing students' learning. Facilitation of learning in the clinical area depended on the quality of the student-teacher interactions. The use of humour improved studentteacher relationships because the interactions were perceived by nursing students to be non-threatening and non-judgmental. There iis an appreciation of the clinical teachers' use of humour when they shared personal and humorous stories and experiences with students. The use of humour created a friendly encounter thus a positive clinical environment for nursing students to learn with less anxieties and uncertainties. The positive clinical environment was nurtured by the warm and caring attitudes of the clinical teacher who used humour in teaching. However, cautious use of humour is expressed by nursing students because of the cultural differences among students.
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Humour and creation of a positive clinical environment Two of the constituents of h u m o u r experienced b y the nursing students created a positive clinical environment for the students. These constituents included the clinical teachers' ability to turn a stressfffl experience into a laughing matter and the creation of a conducive environment that made learning in the clinical area a memorable experience. When the clinical teachers used humour, they created an environment conducive to students' learning. H u m o u r could aid in reducing fear of the unfamiliar hospital setting and encouraged a sense of trust. For the informants in this study, the use of h u m o u r by the clinical teacher provided students an avenue to release tensions, stress, hostility and frustration associated with clinical education. H u m o u r was also perceived as an effective means of support their clinical teachers used in dealing with their anxieties as one informant stated: I respect the clinical teacher who can make the clinical experience enjoyable and not boring. We had one clinical teacher who often sat with us during tea or lunch break and told us about some funny, funny stories during his nursing training years. This occasion made us feel relaxed before going back to the clinical area. It also m a d e us feel that we were not as stupid as we thought, because we could relate to our teacher's experience. During, clinical education, students took breaks during their shifts to recuperate or to attend debriefings scheduled by the clinical teacher. These times were valued by the nursing students as these were used not only to clarify issues occurring in the clinical area with their clinical teacher, but also to unleash pent-up feelings as a result of some situations experienced by the students. These sessions were not formal teaching sessions. Rather, they were used to allow students to reflect on their clinical experience and learn from each others' experiences. If h u m o u r is a means of stress management, participants suggested that their clinical teachers continue to use h u m o u r in clinical education. This helped allay students' anxiety and lessened stress during their clinical experience, especially during their initial clinical exposure to the clinical area, as well as when confronted with an unfamiliar
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clinical situation. This suggestion reflected the participants' orientation to the pursuit of healthy lifestyle as confirmed by the informant who commented that: 'More clinical objectives could be accomplished if there were no stresses.' Furthermore, humour also enhanced nursing students' process of socialization into the health profession, especially when humour was used not only by the clinical teacher but also by other healthcare personnel. The use of humour as a socialization process also conveyed to the students that the clinical area is a place not only for managing patients medically but also a place where patients are provided with a caring, humanistic environment.
Humour and connecting with students The relaxed atmosphere strengthens feelings of togetherness, closeness, w a r m t h and friendliness (Powell & Andersen 1985, Robinson 1991b). In this study, informants stated that their clinical teacher did not create a barrier or boundary between them. Informants felt that the informal nature of the encounters as a result of the sense of h u m o u r of their teacher did not lessen their respect for their teachers. H u m o u r was experienced as an act of decreasing social distancing by relaxing the rigidity of the educational social structure. With a sense of humour, the students did not undermine clinical teachers' authority. Consequently, this authority was further enhanced and emitted to the students when the clinical teacher had the ability to share his or her knowledge and expertise in clinical practice alongside the students in a non-threatening, informal and humorous manner. In addition, the use of h u m o u r resulted in developing connectedness with the clinical teacher, even if such connectedness was only for the short period of time within the clinical practice. On this topic, one informant said: Depending on h o w we felt about our clinical facilitator, it could facilitate whether you feel closer or start to form a friendship. But it is not really meant to be a strong friendship, only a friendship within that time period. The informants described 'connectedness' as an ongoing process facilitated by the clinical teachers' use of h u m o u r as an effective communication tool. The process was enhanced when reciprocity and openness between teachers
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and students developed as a mutual feeling. In addition, informants commented that respecting and understanding each other's humour meant that clinical teachers went beyond the expected role of the teacher to being a friend, no matter how short the friendship might be. Informants also felt that this lead to the development of an ability to relate in a warm and human ways with others. H u m o u r is catching. If the clinical teacher sees things from a different light, humorous instead of serious, I felt that I could relate to the situation and accept it quite easily. It sorts of 'rubs off' on you and you feel lighthearted by the end. I think our patients also appreciated a little sense of humour now and then.
that the solemnity of the educational system is driving hundreds of bright, laughing college students from colleges of education. He therefore urged that education should try to keep students alive and hopeful. This was evident in what Eble (1966: 114) stated: 'For serious as our strivings are, they should never be so serious that we cannot lean back and laugh at the absurdity of our being and doing. Education should teach us to play the wise fool rather than turn us into the solemn ass.' Informants in this study commented that it was easier for them to laugh at their own mistakes when their clinical teachers were also able to laugh at their own mistakes as this encounter promoted a sense of self-respect among themseIves.
Respecting personal nature of humour Humour and the facilitation of learning ~nformants described various clinical learning situations in which humour was manifested in the interaction between the nursing students and clinical teachers. One example was provided in which students carry out nursing procedures that were facilitated through the use of humour. Informants claimed that many daily chores were more fun when humour was involved. Informants felt that humour played a major role in helping them cope with hard and tedious work into an interesting chore instead of grumbling about the work at hand. I remembered a situation clearly when the clinical teacher used humour in her bedside teaching. She made the learning experience enjoyable and not stressful to us. The experience of laughing together during that encounter encouraged us to ask questions and not to be afraid of being labeled stupid. I felt that I learned 'a mile' more during this encounter than any other encounter. The use of humour in teaching was found to enhance learning (Parkin 1989, Pease 1991). According to Robinson (1978), the modeling of the use of humour by the teacher is a first step in teaching Students that the nursing profession must utilize humour as an effective nursing intervention in an acceptable and constructive way. Furthermore, Eble (1966) argued strongly that humour and laughter open pathways to creativity and discovery. He also regretted the fact
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H u m o u r is an individual and a personal matter and is a context-based phenomenon (AstedtKurki & Liukkonen 1994). Informants in this study reported that it was important for clinical teachers to have an awareness of their own understanding of humour in order to facilitate and understand humour in their students. However, although informants acknowledged that humour promoted students' involvement and motivation to learn, humour also could be destructive and could hinder students' learning in the clinical area. Some informants in this study reported that they did not appreciate tile sense of h u m o u r of their clinical teachers during some of their encounters. One informant commented: I did not find my clinical teacher as ihaving a sense of humour, no matter what my peers said. For me, her sense of h u m o u r was degrading and belittling and sometimes sexist and culturally inappropriate. In my culture, we take all things seriously, especially when looking after our patients. We never made fun about our patients nor tell jokes. Nursing students with different social circumstances and life experiences have varying reactions to the same piece of humour. Laughing at a student is very different from laughing with the students. Informants in this study ]perceived that their clinical teachers were making fun of their mistakes and took the teachers' sense of h u m o u r in a negative way. These 12 informants who perceived humour as unprofessional were of
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Asian background compared to the 36 participants who were of Anglo-Celtic background. This finding supports the premise that culture and ethnicity influence the kind of humour which is appreciated. In some culture, humour is considered a moulding force, a social release or a preventive mechanism to ward off anticipated attack (Robinson 1978). For example, within most of the Asian culture, humour was used to save one's self-respect by laughing with the jokes directed to them by the 'tormentor'. The person may laugh and at the same time, deep down inside, feel angry for being laughed at. The participants' responses in this study clearly showed that clinical teachers must be aware of the taboos against the use of humour, as well as be aware of their students' cultural backgrounds before utilizing hurnour in their teaching and their interaction with the students. The inappropriate use of humour has been cited in the literature. Harris (1995) warned that humour could be destructive when used to ridicule people. Haig (1986) drew attention to the negative effects of humour in terms of behaviours of denial, suppression, and undermining confidence. According to Powell and Andersen (1985) an unwise use of humour could result in students taking offence that could set up an emotional block which could inhibit the students' subsequent learning. In this study informants remembered embarrassing incidents during their encounters and distanced themselves from the clinical teacher.
Implications for nursing The use of humour is a major consideration for clinical teachers in providing clinical teaching to multi-cultural Australian undergraduate-nursing students. Incorporating laughter and humour into the clinical educational program was proven as one stress-reduction strategy that could provide an emotional and physical release of accumulated tension among nursing students during their clinical practicum. According to Warner (1983), students' nonsense remarks and jokes during practice were ways of students' gaining sense of control over anxiety-provoking situations. Therefore, nurse clinical teachers could use various techniques to enhance their teaching practice with humour. This could lead to an improved
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relationship with students by creating a relaxed atmosphere, thus allowing students to use laughter to overcome tensions and difficult feelings encountered during clinical education. However, according to Robinson (1991), in spite of recognizing the value of humour, nurses are afraid to use it, to take it seriously and to make a serious effort to use it as an effective means of communication and teaching tool in academia. In addition, humour does not come naturally to most nurses because of the nature of their work (Harris 1995). It also may not come naturally for nurse teachers whose cultural background may not support the use of humour in teaching. However, clinical teachers must also be cautious in the use of humour and be consciously aware of the destructive effects of humour, as well as its cultural implications. For some students, boundaries of appropriate and inappropriate humour are very clear especially in regard to telling ethnic, sexist or off-putting jokes. Inappropriate humour, such as making sarcastic comments about a student's clinical practice, could lead to embarrassment and withdrawal of the student. What the clinical teacher thought was funny may not be funny for the student at all and this could be taken differently leading to destructive rather than constructive effects on student's learning. Therefore, clinical teachers must restructure their ways of dealing with their students, especially those who come from a different cultural background where humour is considered unprofessional.
Conclusion Clinical education, in particular, can be a very stressful experience for the nursing students as well as for their clinical teachers. The study highlighted that humour and laughter during the teaching-learning process could create an atmosphere of pleasure in the shared learning experiences during clinical practicum. The concept of humour is inherent in the humanistic approach to education as reported by Reilly and Oermann (1992). Informants in this study clearly provided personal experiences to the effectiveness of using humour during clinical education not only by their clinical teachers but also between students and even with their patients. However, the findings from this study cannot be generalized but provided preliminary data about the
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Humour: a phenomenological study
importance of humour in clinical education. Clearly, in this study, the nursing students from the Asian background may have some personal feelings about the use of humour but, in general, they also agree that it could facilitate their learning. This finding questions Johnston's (1990) view that humour is a universal language and a vehicle for communication that can transcend differences. Therefore, identification of the essential structures of humour within a specific cultural context needs to be further explored as the type and timing of using humour could vary from culture to culture. In addition, even though the thematic analysis of the data reflected nursing students' positive experiences with clinical teachers who used humour during clinical education, it is also important to explore nurse teachers' perceptions and acceptance of using humour in their teaching. A rich body of literature exists to support the proposition that humour enhances creative teaching and problem-solving skills as well as comprehension and retention of learning. Further research is also recommended, using qualitative a n d / o r quantitative methods, to explore the relationship between the use of humour in teaching and (1) nursing students' level of comprehension and retention, (2) students' level of satisfaction from the learning experience in which humour is valued and (3) nurse teachers' perceptions of humour and the extent to which they use humour in their teaching. The study also highlighted that students respected the clinical teachers more if they are willing to admit their mistakes or share their concerns and limitations with them. The open dialogue enriches the student-teacher relationship that could create an honest relationship and mutually satisfying experience during their clinical placement. In this study, teachers' use of humorous stories to share their past experiences with students was considered an effective communication tool, a mechanism for coping with similar stressful clinical events and a valuable teaching adjunct by the nursing students. According to Kennedy (1995, p 30), 'I have learned to make those silly, but safe, errors that occur during the care of patients into methods of promoting laughter. This practice has never caused a patient to question my professionalism or ability, but rather help them see my humanness.' The informants in this study
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supported Kennedy's view when they explained that their clinical teachers are only showing their humanness when they can relate, and also laugh at, their mistakes. In addition, informants' description of their clinical teachers' warmth and friendliness implied an element of humour that did not break the teacher-student boundary. Rather, it facilitated human communication and a realization that their teachers can be very human after all. Clearly, it is a skill that needs to be developed and supported by all nurse teachers.
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