One of the most difficult types of clinical evaluations in nursing education is when the procedure being evaluated in both complex and technically demanding. Most students, in these cases, are highly anxious and because of their increased anxiety tend to perform more poorly than when more relaxed. Procedures we have noted which provoke heightened anxiety in the beginning Associate Degree nursing student include oral and intramuscular medication administration, sterile dressing changes, and gastric gavage (nasogastric tube feedings).
Our concern about how to help students perform more adequately when being evaluated in stress-producing situations led us to consider alternative strategies that instructors might use. Believing that heightened anxiety was the "culprit" that often compromised students' ability to perform in evaluation situations, we considered as a possible and promising teacher strategy, albeit untested in nursing evaluation, the use of humor. As both the layman and professional know, humor is a recognized tactic for helping people relax (Bernard, 1954; Robinson, 1977). Hence, we reasoned that the deliberate use of humor in evaluating students' performance could be an effective mechanism for reducing student tension and anxiety in stressful clinical evaluation situations.
This article describes the primary author's investigation of this clinical evaluation question. More specifically, the focus of this study was to investigate the effects of deliberate teacher humor during evaluation on anxiety and performance among beginning nursing students in a simulated stress-producing performance situation. In order to study the impact of deliberate use of humor during evaluation on students' anxiety level and task performance, the gastric gavage procedure was selected. Use of humor in the study referred to any communication which is recognized by the students as humorous, leading to laughing, smiling, or a feeling of amusement (Robinson, 1977). Anxiety is defined as those self-reported verbal indications of response to threatening conditions in the environment as measured by Spielberger's (1970) State Anxiety Inventory. Performance refers to the extent to which the student was able to carry out a nursing procedure, in this case the nasogastric tube feeding procedure, as measured by a researchergenerated observation performance checklist.
The importance of this study, from our vantage point, is that if using humor during evaluation of stressful clinical procedures reduces anxiety and enhances performance, the addition of this evaluative strategy into the educator's repertoire of tactics for evaluating student performance will serve to augment effectiveness in evaluation.
Freud (1928) was the first theorist to describe and analyze what people think, say, feel, and do into a single meaningful framework. He discusses the central role that humor plays as a coping mechanism in reducing anxiety and suggests that humor is tension reducing.
Based on the writings of Freud (1928), Bernard (1954), Coombs and Goldman (1975) and Smith, Ascough, Ettingel and Nelson (1971), we theorized that humor could be used as a means of intervening in the emotional process of heightened anxiety. Spielberger (1966) elaborates on the notion of what anxiety is and explains the relationship between anxiety and performance. He conceptually distinguishes anxiety as an emotional reaction involving both a transitory state (state anxiety) and a relatively stable personality attribute (trait anxiety). State anxiety is precipitated whenever a person perceives a particular situation as threatening (such as in the evaluation situation being studied).
Spielberger's theoretical perspective, that heightened anxiety involves both state and trait components, evolved from his recognition that heightened anxiety is a major problem for college students. High anxiety is seen by Spielberger (1972) as compromising learning and performance, in that highly anxious people become more concerned with the evaluation of their performance than with the performance itself. Sarason, Davidson, Lighthall, Waite & Ruebush (1960) theorized similarly. They asserted that when evaluative anxiety becomes heightened, the anxiety causes concerns about possible failure in testing, and hence, the student is often unable to satisfactorily deal with the demands at hand. Spielberger further contended that if an individual's high anxiety state can be lowered to a moderate level, improved learning is likely to occur.
Spielberger's theoretical explanation of how anxiety affects performance can be summarized as follows. He postulates that when an individual experiences an anxiety reaction (rise in anxiety to a moderate/high level), this leads to a cognitive reappraisal of the situation which is that the situation is stress producing. This, in turn, leads to primarily defensive or avoidance type responses. If the individual's anxiety level can be lowered, however, the cognitive reappraisal will be that the potentially stressproducing situation is less threatening. This "reframing" of the situation leads to increased coping (positive problem solving) behaviors, rather than primarily defensive or avoidance type responses. Greater coping and problemsolving responses enhance students' performance levels.
In summary, the specific theoretical propositions underlying this study were: 1) that the deliberate use of teacher humor as an intervention in a stressful simulated task performance situation leads to a reduced anxiety state level among beginning nursing students; and 2) that this reduced anxiety state level, in turn, results in improvement of task performance.
Review of the Literature
There has been considerable interest in the concept of anxiety and its influence on learning, as evidenced by the increasing documentation of research in this area. However, nursing in general, and nursing education in particular, has only recently evidenced an interest in studying the role of humor. Robinson (1977), in a pioneering book in this area, reviews the functions of humor in health care settings and incorporates some guidelines for utilizing humor in teaching. Other health care professionals are beginning to promote the use of humor as a therapeutic tool; this has been best exemplified by the work of Norman Cousins, the eminent former editor of the Saturday Review and author of Anatomy of an Illness (1979). In spite of these beginning efforts to promote the use of the positive functions of humor, no research in nursing education relating to the use of humor as a teaching or evaluation strategy could be located. Even in the more general health area, published research is very limited.
HUMOR: The precise nature of humor has defied description since man began to communicate. Webster (1976) defines humor as "that quality which appeals to the sense of the ludicrous and absurdly incongruous." The Encyclopedia Britannica (1977, pp 5-11) defines humor as "that type of stimulation that tends to elicit the laughter reflex" and further classified humor as either verbal or situational. Verbal humor includes puns, comic verse, jokes, anecdotes, satire, and allegory. Situational humor refers to the practical joke, impersonation and parody, comedies, tickling, visual arts, and music.
Anthropologists and sociologists view humor as a means of reducing interpersonal tensions in a socially acceptable way. Humor may develop from a need for the sudden release from tension (Bergson, 1900/1960; Fry, 1963; Koestler, 1964).
Robinson (1977) identified humor as a complex coping mechanism operative in four areas: relief of anxiety, stress, and tension; release of hostility and anger; denial of reality; and as a means of coping with disabilities and death. With respect to humor operating to reduce anxiety and tension, Coombs and Goldman (1975) conducted a qualitative research study observing the use of humor by the hospital intensive care staff. They found that personnel commonly used humor to handle the emotional stress of caring for the critically ill and dying patients. Lightheartedness seemed to contribute to the quality of performance of the staff by reducing the emotional pressure and anxiety created by the constant contact with life-threatening circumstances. Coombs and Goldman (1975) suggested that laughter frees the individual from an "immense burden of anxiety, confusion, cruelty, and suffering." Humor operates in terms of psychic economy and offers ego comfort through its meaning: "Look here! This is all that this seemingly dangerous world amounts to. Child's play - the very thing to jest about!" (Freud, 1905A960, p. 220). Hence, the findings of this investigation demonstrated that the use of humor is an effective method for managing stress.
One of the potential problems concerning the use of humor in teaching and evaluation is that what is humorous to one individual may not be humorous to another. Crosscultural differences in humor are significant, and thus are important to consider when working with ethnically diverse groups of students.
ANXIETYAND PERFORMANCE: Sarason et al. (1960) found that in testing children: 1) high text anxiety interfered with performance on school tests or other "test-like" situations; 2) the greater the test-like characteristics of the task, the more the child's anxiety was manifested and the more it interfered with performance; and 3) conversely, reduction in the test-like characteristics of a task reduced the impairing effects of anxiety. Based on the above findings (Sarason et al., 1960), we speculated that the use of humor in teaching and evaluation would attenuate the testlike characteristics of the evaluation session, and, therefore, reduce the detrimental effects of anxiety.
Turning to other studies which focused on the relationships between anxiety and performance, Spielberger (1966) examined the effects of anxiety on academic performance among college students. The students were grouped according to low, middle, and superior abilities, based on their psychological examination scores. The highly anxious middle-ability students showed poorer performance than did the minimally anxious students. For the very superior students, increased anxiety levels appeared to enhance performance. Hence, the effects of anxiety levels seem to differentially affect students depending on their intellectual ability.
The general consensus among educational researchers is that the extent to which performance is affected by anxiety depends primarily upon task complexity and the level of ego involvement (Gaudry & Spielberger, 1971; Mandler & Sarason, 1952; Sarason et al., 1960; Sinclair, 1965). Peplau (1952) discussed how ego involvement increases the likelihood of anxiety in interpersonal relationships, especially in situations where prestige and dignity are threatened by those from whom one cannot escape. She commented that when one's performance is not perceived as strongly threatening to the ego, an individual's anxiety level is generally lower. However, as ego involvement increases, anxiety level also increases with resulting alterations in performance. Likewise, when the task is complex, increases in anxiety are reflected in alterations in performance.
USE OF HUMOR IN TESTING SITUATIONS: Two studies were located which examined the effects of humorous tests with high, middle, and low anxiety groups of students. Smith, Ascough, Ettinger, and Nelson (1971) studied the tension-reduction effects of humor on the academic test performance of college-level students. During the first week of a psychology course, all students were given the Sarason Test Anxiety Scale. Control and experimental test groups were similarly apportioned by sex and anxiety level. At midsemester, the experimental group was administered a course examination containing humorous content items, and their performance was compared with that of the control group who received a form of the examination containing matched nonhumorous items. Both groups of students were told that results would contribute 50% to their course grade. Results indicated that high test-anxiety students receiving the non-humorous test form performed at a significantly lower level than did the high test-anxiety students who received the humorous test form.
In a second study related to use of humor in a classroom test situation, Townsend and Mahoney (1981) ranked students according to gender and anxiety level, and then randomly assigned them to either the humorous or nonhumorous test groups. The humorous tests differed in Townsend and Mahoney^ (1981) study (when compared to the Smith et al. study). In this case, Townsend and Mahoney included humorous supplements unrelated to the actual content of the test. In contrast, Smith et al. (1971) test items themselves were humorous. The findings of Townsend and Mahoney^ study differed from the previous study. Highly anxious students in this sample had lower achievement scores on the humorous test than the highly anxious students taking the non-humorous test. The reason for this conflicting finding, according to the authors, may be that the unrelated humorous content appeared as quite distracting to the highly anxious student.
In summary, humor has been shown to reduce anxiety and tension (Freud, 1928; Coombs & Goldman, 1975). Moderate to high anxiety has been shown to result in diminished performance when students are of middle ability (Spielberger, 1966), when tasks are complex (Sinclair, 1965), and when extensive ego involvement is present (Sarason, 1956; Peplau, 1962). Humorous tests, where humor was injected into the actual test items, were demonstrated to be helpful for highly-anxious students (Smith et al., 1971). No research studies were found which focused on the effectiveness of teacher's use of humor in clinical evaluations. Hence, this research was conducted to extend the present body of knowledge of clinical evaluation strategies applicable for nursing educators.
Description of Sample
The setting for this study was a community college in a large metropolitan area in Southern California. All of the entering class of nursing students in an Associate Degree program were invited to participate in the study. The actual sample included all 30 students who were enrolled, although one student was ill when the testing occurred, and so did not participate. Thus, 29 subjects constituted the sample. All students were female but one, and all were Caucasian with the exception of one Asian. The ages for the subjects ranged from 23 to 38 years with a mean age of 28.3 years. Sixty-five percent of the sample subjects were or had been married. Eight subjects reported prior nursing experience, but none at a level higher than nursing assistant.
A quasi-experimental design was used to study the effects of deliberate teacher humor on anxiety and performance levels (Table). We were not able to randomly assign students to groups. Students were arbitrarily preassigned by the college to a basic nursing skills class and divided into three groups on a random basis. These groups were utilized as the experimental and control groups in this study.
The primary author carried out the experiment at the time in which each group was normally studying the Nutrition Module (where the procedure for nasogastric tube feeding was taught). The first group starting the Nutrition Module became the control group (Rl), and received traditional teaching and demonstration, followed by traditional evaluation. The second group starting the Nutrition Module became the first experimental group (R2) which received the traditional teaching and demonstration approach, followed by an evaluation in which two pause periods were interjected during the evaluation to simulate the pause periods inherent in the humorous evaluation group (R3). The last group of students starting the Nutrition Module became the second experimental group (R3), and received the traditional teaching and demonstration followed by evaluation where humor was interjected at the beginning of evaluation as well as during the two pause periods.
Students were told at the end of the teaching and demonstration presentation that they could familiarize themselves with the equipment without instructor assistance, and that the first student's task performance evaluation would begin in approximately 30 minutes, with the remainder of the students following one by one. For the control group (Rl), the subjects were asked to perform the nasogastric tube feeding procedure one at a time as demonstrated, without any pauses or humorous inserts by the instructor. For the pause-intervention group (R2), the task was performed sequentially in a nonhumorous environment with two intervening one- to two-minute pauses. The first of two pause interventions was introduced between the preparation (part 1) and the performance (part 2) on the performance check list. The second pause intervention occurred approximately at the end of the feeding procedure (part 2) and the beginning of the closure (part 3). The two pause periods were structured to be approximately of the same duration as occurred for the introduction of humor with the humor/pause intervention group (R3). For the third (humor/pause) group (R3), the procedure paralleled that for the second group except that the one to two minute pauses included instructor-interjected humor. The first exposure that the students had to humor was via a humorous doctor's order. At the times corresponding to the two pause periods outlined for the pause-intervention group, a humorous anecdote was shared by the instructor with the student. Humorous responses of participants in the humor/pause group were noted and recorded on the performance check list by the evaluator and observer.
Directly following the student's completion of the performance evaluation, a trained research assistant gave each student the Spielberger State Anxiety Inventory (1970) to complete. Each of the students in the R3 (Humor/ pause intervention) group was then asked by the research assistant to give his/her reactions to the humorous interventions. Several questions were asked. These were:
( 1 ) Did you notice any difference in the way the evaluation was conducted?
(2) If so, what was the difference and what was your reaction?
(3) If not, some humorous anecdotes were made during the evaluation. What was your reaction to these?
(4) Did this affect the way you felt?
(5) Do you think this affected your performance?
Any humorous response, as evidenced by smiling, laughing, chuckling, or other visible expression of amusement, was noted on the performance check list at the specified intervals by the observer and evaluator as described above. A maximum of one positive response constituted sufficient evidence that the student perceived the evaluator's behavior to be humorous.
Instruments for Data Collection
The instruments for data collection were (1) Spielberger's State Anxiety Inventory, Form X-I, which measures state anxiety only, and (2) a performance observation check list.
1. The State Anxiety Inventory, published in 1970, measures state anxiety levels and has acceptable reliability and validity. The state anxiety scale has been shown to indicate actual levels of anxiety induced by stressful procedures when administered during or immediately following the stressful situation.
2. A performance observation check list was developed by the first author to assess performance level of clinical skills relative to nasogastric tube feeding. This check list was based on procedures taught in the standard modular teaching/learning framework used in the course. The evaluation procedure exactly followed the content and format of the preceding lecture and demonstration.
Discussion of Findings
The following discussion of the data analysis and findings includes both quantitative and related qualitative results. Comparisons of the effects of the teaching strategy on state anxiety were performed using three separate measures. First, ANOVA compared the unadjusted post test state anxiety scores of the three groups. Second, ANCOVA procedure using pretest state anxiety scores as a covariate was used to compare the posttest state anxiety scores of the three groups. Third, ANOVA was utilized to compare the state anxiety change scores of the three groups. There were no statistically significant differences among the experimental and control groups for any of these comparisons on state anxiety. However, trends toward a significant difference in state anxiety change scores between groups R2 and R3 and between groups Rl and R2 were found. Although the required significance level of .05 was not reached, further evaluations using t-test gave a probability of 0.084 which was sufficiently high to indicate a likelihood of significance using larger group samples. This indicates that the pause intervention group (R2) had a significantly higher state anxiety posttest score than did either group Rl or group R3. The pause intervention strategy was specifically designed to isolate the effects of the humor strategy from the effects of a pause or supportive opportunity to "regroup," or "collect one's thoughts." Such an opportunity was expected to contribute to the evaluative situation a nonthreatening, caring milieu. Although the subjects in the pause group (R2) did not appear any more anxious or uncertain than did the subjects in the other groups, the state anxiety reaction was higher; this might be due to the students' perception of the pauses as being perplexing or disturbing, rather than supportive.
Even though no significant quantitative group differences in state anxiety scores were demonstrated (i.e., the humorous intervention teaching strategy did not appear superior), pertinent subjective comments were made by five of nine students in the humorous intervention group, suggesting that humor had possible positive effects. For example, comments include "it calmed me"; "it let me know everyone is human and makes mistakes"; "the humorous stories put me at ease"; "I felt more at ease"; "I thought they (the evaluators) were trying to add a little levity to make me feel less anxious."
Turning to the question of whether humor assisted students to perform better, ANOVA procedures were performed. Among the three student groups, the humor/pause group (R3) showed the best overall performance, while the no-intervention group (Rl) showed the next best performance, and the pause/intervention group (R2) performed most poorly. More specifically, comparison of task performance between groups R2 and R3 using ANOVA showed a significant between-group difference. A similar comparison between groups Rl and R2 evidenced statistical significance using a t-test. Also, comparison of groups Rl and R3 indicated a near significance at ? = 0.065 using a t-test. Although the study failed to demonstrate the required level of statistical significance (p = <.05) in performance between the Rl and R3 students, there was a sufficient difference to indicate a likelihood that with a larger sample, statistical significance could have been demonstrated.
Qualitatively, we do know that the humor was reported as helping five out of nine students during the task performance. Nevertheless, it is not possible to separate out the effects of the humor (true experimental effects) in group R3 from the possible unintended effects of the pause in the R2 group. It should also be noted that the humor/pause students (R3) were initially uncertain about how to respond to the "doses" of humor. If the evaluator had introduced the anecdotes with a phrase such as "let me tell you something funny that happened to another student," the subjects in the humorous intervention group might have perceived a sense of permission to respond with a smile, chuckle, or laugh. Moreover, although the anecdotes were specifically related to task performance, beginning nursing students may not have been able to distinguish between those experiences which were humorous and those which were inappropriate.
Additionally, Pearson correlational coefficients were computed to assess the association between 1) posttest scale anxiety scores and performance, and 2) state anxiety change scores and performance. No association between these variables was found, hence, the expected positive relationship between anxiety and performance did not materialize.
In searching for reasons why the humorous intervention did not have any demonstrable effect quantitatively on anxiety, there are several possible explanations. One certainly may have been the small sample size. In addition, the humorous insertions may not have been as humorous as they might have been. Third, the humorous insertions were related to, but not an integral part of, the actual task/ activity, and as Townsend and Mahoney (1981) demonstrated, these humorous insertions may have been distracting to some students, thereby cancelling out any possible effects on anxiety.
IMPLICATIONS: Based on these rather suggestive findings, there are implications relevant to nursing education in both the academic and practice setting. The nurse educator needs to be aware that humor may be effective as a cognitive strategy to assist students in stressful situations to gain control over anxiety, thus increasing their ability to demonstrate necessary competencies. The nursing inservice educator should also be aware that humor may be useful in helping instructors and staff alike deal with stressful performance evaluations. The qualitative findings, in particular, lend support to the idea that this additional evaluative strategy may enhance the nurse educator's effectiveness in carrying out stress-producing evaluations.
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