Journal of Nursing Education

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RESEARCH BRIEF 

Humor in Clinical Nursing Education

Marie Hayden-Miles, PhD, RN

Abstract

As the nursing profession has evolved, the education of nursing students has become increasingly challenging. The complexity of this process makes it impossible to acquire a safe level of skill through classroom instruction alone. Therefore, students spend a significant portion of their learning experience in the clinical setting. The clinical learning experience is made more stressful due to the environment in which it occurs, an environment in which students frequently do not feel competent (Grassi-Russo & Morris, 1981) and fear a single mistake can harm a patient. A critical role of clinical instructors is to foster a learning environment in which students may apply their knowledge skillfully in the clinical setting. This article presente the findings of an inquiry into the meaning of humor for nursing students within the student-clinical instructor relationship.

Literature Review

The environment provided by nurse educators has been a concern of many authors (Bevis & Murray, 1990; Bevis & Watson, 1989; Diekelmann, 1988, 1989, 1990, 2001). Studies such as those conducted by Bergman and Gaitekill (1990), Kushir (1986), Nehring (1990), Nelms (1990), and Windsor (1987) indicate that the quality of the learning experience is affected by the student-clinical instructor relationship.

Authors including Leidy (1992), Watson and Emerson (1988), and White and Lewis (1990) proposed that humor enhances the learning environment. In addition, in a 1990 study, Halldorsdottir found that students described humor as one of the positive aspects of a caring teacher's personality. Robinson (1970, 1977, 1986, 1991) conducted an extensive investigation of humor in the health professions and maintained that humor is a way for studente to cope with the realities of nuraing. According to Robinson (1991), humor provides a caring environment within which criticism and values can be expressed and mistakes pointed out, without destroying students' self-image.

Plessner (1970) characterized humor as an embodied experience. This view is supported by Pollio (1983), who described the saying "you had to be there" as the core of the approach to humor and believed that "being there" suggests the embodied participation of an engaged person. Pollio (1983) emphasized that humor is a phenomenon dependent on the social and interpersonal conditions of a particular situation. Fine (1983) also stressed that humor is embedded in a particular social environment and the evaluation of humor is socially constructed in context.

Freud (1905/1960) extensively studied the psychological aspects of humor as a way of expressing unacceptable impulses in an acceptable manner through the release of psychic energy or tension. McGhee (1979) proposed that using humor allows people to step back from the seriousness of a situation, enabling them to cope with problems more effectively.

Martineau (1972), in an extensive study of the social functions of humor, found that humor can increase group morale and cohesiveness. Other authors support this finding. For example, Robinson (1977) proposed that humor establishes a feeling of camaraderie and Jl group cohesiveness. Holland (1982) stated that laughter creates a "bond among those who laugh at the same thing, and draws a line against outsiders, who either do not laugh or who are laughed at" (p. 92). In addition, Martineau (1972) maintained that humor helps offset the fear and tragedy of a situation.

Like many authors, Campbell (1968) linked comedy with tragedy, describing them as a single experience. Several philosophers have proposed that they must be understood together. In Plato's Symposium (1984), Socrates argued that the genius of comedy was the same as that of tragedy. Plato (1970) reiterated this belief when he stated, "anyone who means to acquire a discerning judgement will find it impossible to understand the serious side of things in isolation from their ridiculous…

As the nursing profession has evolved, the education of nursing students has become increasingly challenging. The complexity of this process makes it impossible to acquire a safe level of skill through classroom instruction alone. Therefore, students spend a significant portion of their learning experience in the clinical setting. The clinical learning experience is made more stressful due to the environment in which it occurs, an environment in which students frequently do not feel competent (Grassi-Russo & Morris, 1981) and fear a single mistake can harm a patient. A critical role of clinical instructors is to foster a learning environment in which students may apply their knowledge skillfully in the clinical setting. This article presente the findings of an inquiry into the meaning of humor for nursing students within the student-clinical instructor relationship.

Literature Review

The environment provided by nurse educators has been a concern of many authors (Bevis & Murray, 1990; Bevis & Watson, 1989; Diekelmann, 1988, 1989, 1990, 2001). Studies such as those conducted by Bergman and Gaitekill (1990), Kushir (1986), Nehring (1990), Nelms (1990), and Windsor (1987) indicate that the quality of the learning experience is affected by the student-clinical instructor relationship.

Authors including Leidy (1992), Watson and Emerson (1988), and White and Lewis (1990) proposed that humor enhances the learning environment. In addition, in a 1990 study, Halldorsdottir found that students described humor as one of the positive aspects of a caring teacher's personality. Robinson (1970, 1977, 1986, 1991) conducted an extensive investigation of humor in the health professions and maintained that humor is a way for studente to cope with the realities of nuraing. According to Robinson (1991), humor provides a caring environment within which criticism and values can be expressed and mistakes pointed out, without destroying students' self-image.

Plessner (1970) characterized humor as an embodied experience. This view is supported by Pollio (1983), who described the saying "you had to be there" as the core of the approach to humor and believed that "being there" suggests the embodied participation of an engaged person. Pollio (1983) emphasized that humor is a phenomenon dependent on the social and interpersonal conditions of a particular situation. Fine (1983) also stressed that humor is embedded in a particular social environment and the evaluation of humor is socially constructed in context.

Freud (1905/1960) extensively studied the psychological aspects of humor as a way of expressing unacceptable impulses in an acceptable manner through the release of psychic energy or tension. McGhee (1979) proposed that using humor allows people to step back from the seriousness of a situation, enabling them to cope with problems more effectively.

Martineau (1972), in an extensive study of the social functions of humor, found that humor can increase group morale and cohesiveness. Other authors support this finding. For example, Robinson (1977) proposed that humor establishes a feeling of camaraderie and Jl group cohesiveness. Holland (1982) stated that laughter creates a "bond among those who laugh at the same thing, and draws a line against outsiders, who either do not laugh or who are laughed at" (p. 92). In addition, Martineau (1972) maintained that humor helps offset the fear and tragedy of a situation.

Like many authors, Campbell (1968) linked comedy with tragedy, describing them as a single experience. Several philosophers have proposed that they must be understood together. In Plato's Symposium (1984), Socrates argued that the genius of comedy was the same as that of tragedy. Plato (1970) reiterated this belief when he stated, "anyone who means to acquire a discerning judgement will find it impossible to understand the serious side of things in isolation from their ridiculous aspect" (p. 309).

The Study

This study explored the meaning of humor for nursing students within their relationships with their clinical instructors. Participants, who were all female nursing students in their 30s, were recruited by asking the author's colleagues for volunteers. Approval to conduct the study was obtained from the appropriate Human Subjects Committee. Informed consent was obtained, and confidentiality was assured. To allow for sufficient diversity of experience, students were required to have completed at least 1 year of their clinical nursing education (also referred to as rlini«·»! or clinic, in this study). Students were asked to describe an experience in which they shared humor with a clinical instructor. Unstructured, audiotaped interviews were transcribed verbatim and analyzed using Diekelmann's (1992) process of interpretation.

Hermeneutice was the mode of inquiry selected to explicate the meaning of this experience. Heidegger (1927/1962) proposed that the primary basis for understanding the world is human experience. Human action bears meaning, which can be interpreted and understood. Because knowledge is secondary to involvement in the world, interpretive research is not a tool to access facts. Rather, it is a way to understand how human beings exist in the world, by virtue of the things that concern them. Hermeneutic inquiry, then, is a way to deepen understanding of the meaning humor holds for nursing students.

Findings and Discussion

All the students described humor as a positive experience. In no situation was ridicule or sarcasm described as humor. Furthermore, the students' descriptions of humor did not include uproarious laughter, but rather, they spoke of humor as "looking on the light side" of things. Interpretation of the narratives revealed two constitutive patterns, which express the relationship among the themes and are present in all the texte (Diekelmann, 1992).

The constitutive pattern- Teacher as Partner/Teacher as Despot: Connecting and Trusting- expresses the relationship among the three themes - We're All Adults, I'm Only Trying to Learn, and Looking Forward. Tb draw readers into a deeper understanding of this experience, examples from a paradigm case (Benner, 1984) are provided to provoke thinking, dialogue, and reflection about this phenomenon. The author of these narratives is called Ali.

Constitutive Pattern

The importance of building a trusting relationship with the clinical instructor emerged as a dominant pattern in each of the narratives. The education of nursing students evolves out of a partnership between students and instructors and involves cooperation and mutual responsibilities as both work toward their common goal. It is crucial to the clinical learning experience that students and instructors build a trusting relationship as quickly as possible.

Embedded in each of the texts is the ways the students and instructors worked together to build a relationship. Teacher as Partner describes how humor helped students and instructors come to know each other first as human beings. Working together as adults, they then were able to create partnerships in which there was mutual respect and trust. Students felt comfortable approaching instructors with questione and admissions of errors, and the instructors trusted that students would do so. Assured that their instructors always would be there to help them, students were more willing to try new things. Their confidence and self-esteem were enhanced, and they looked forward to the clinical experience, as well as to the day they would graduate. The students viewed their clinical instructors as partners in education who shared their knowledge and expertise and guided them along the way.

In sharp contrast to the pattern of Teacher as Partner, the narratives also describe experiences in which students had no relationship with their instructor. Teacher as Despot describes those situations in which absolute power rested in the n<rn«t« of the clinical instructor. Acting as tyrannical rulers, these instructors controlled the students and meted out punishment when students did not meet their expectations. The students felt subordinate to the instructors, whom they could not trust. The relationship was such that it transformed the primary objective of the clinical experience from caring for patients to avoiding the instructor at all costs. The students spoke of learning little or nothing from these experiences and of losing confidence in their ability to perform.

Although building a trusting relationship with the instructor emerged as a dominant pattern, each student also described a need to move beyond the traditional student-instructor relationship and connect with the instructor as an adult. The theme We're All Adults expresses the desire of these adult learners to relate to the instructors as colleagues and describee how humor helped the students and instructors to connect quickly with each other, in an effort to forge a successful partnership.

Themes

We're All Adults

The lack of congruence between nursing's professional practice philosophy and some of the teaching practices is a source of confusion to many students. Although the philosophy of many nursing programs is based on caring and holistic values, nursing students and their instructors often relate to each other in an adversarial manner (Diekelmann, 1989). Ali was not prepared for the oppressive teaching practices that are often a part of nursing education. She was acutely aware of the disparity between the progress women have made as a group and the authoritarian manner in which she was treated in the clinical setting. Ali especially resented being treated like a child by a woman her own age. She wanted to be treated as an adult and be respected for the life experience she brought with her to nursing. Ali reported:

Everything didn't have to be so serious. You know, there're lsic] different ways to deal with everything, and I just felt that the laughing helped out a little bit.... It makes me much more comfortable with them [the inetructors], I feel more friendly with them... I mean we're adults now; we're women. We're not, "You're the little kid, and I'm the teacher, and you're going to do what I say and like it." I don't like to have that [kind of) relationship with women that are a few years older than me. I feel like I'm not a kid, and I shouldn't be treated like a kid. I mean, I'm not saying we should be buddy-buddy and have a cup of coffee together, all the time, or do lunch, but it makes you feel so much better when you're on more or iesa the same level as they are, you know I'm not the dumb little stupid student, and you're not the higher-up person with all the degrees.... This isn't the 1950s or 1960s anymore. And like I said- we're women, not children. And you know, they !the instructors) can learn some things from us.

I'm Only Trying to Learn

In addition to relating to the clinical instructor as an adult, students also need an instructor they can trust, one who understands that mistakes are opportunities for learning, rather than occasions for punishment. Students need to trust that they can ask questione without fear of reprisals as Ali described·.

[The teacher's sense of humor] made me feel better. I wasn't scared inside anymore. It was funny. I felt comfortable with her, more at ease, and I didn't feel like an idiot either.... It's nice not to feel stupid, very nice. She was just so good with us. If we asked a question, she wouldn't make us feel stupid. She would explain it to us. You know, we're there to learn. There are reasons why we ask questions.

Ali also spoke of how one instructor's openness helped her:

She was cute and comical and very nice, and she knew a lot. She wasn't too easy, but she was approachable, and I didn't feel intimidated by asking her anything... I would feel butterflies at first, going into a new situation... but then after that it disappeared. Humor helps because you're not miserable in the situation. You realize other people feel very intimidated and very scared, and it helped out a little bit if we, if everything, didn't have to be so serious. You know, there are different ways to deal with everything, and I just felt the laughing helped out a little bit, with the clinical especially.

Ali also described a contrasting experience with a stern instructor:

I would never ask questions, never. And that was really pitiful because there was a lot of stuff I could learn if I asked the question. But I wae too intimidated.

Every day I was frightened. I would have butterflies in my stomach, and I just felt like nothing I did was right. And it was a great learning place. One of the nurses taught me a lot, and she was very comical. I learned a lot from the nurses. I wasn't afraid to aak them questions, but I would never ask [my professor] for anything because I was so afraid of her response. You know, we shouldn't have to know everything; none of us knew everything. But I was just so afraid to ask her anything. It seemed like anybody who asked her a question was treated negatively. And [iti turned out I didn't learn as much as I probably could have because of this intimidation. And there was no humor, ever at all, None.

It is important to understand how practices that are meant to encourage learning can have the opposite effect. Although the manner in which this clinical instructor related to AH prevented her from even asking a question, the narratives did not suggest that this instructor intended to discourage learning. In fact, the author has heard stern instructors express the belief that "being hard on the students makes them better nurses." However, the students in this study reported learning little or nothing from instructors who related to them in this manner. Educational practices that close off the possibility of learning, even if they are unintentional, need to be eliminated.

Looking Forward

All the students described the influence humor had on the passing of time. Time is much more than the actual ticking of a clock. It includes one's sense of past, present, and future. The clinical experience is not a singular event. It is a part of a process, of moving toward the day one becomes a nurse. Viewing the clinical experience within this larger, future-oriented context, one can understand how the behavior of clinical instructors influences students' either looking forward to or dreading the clinical experience.

Ali spoke of her clinical experience with a stern instructor. During that semester, the prospect of becoming a nurse seemed hopeless. The instructor provided no positive feedback and constantly pointed out Ali'e mistakes. Ali described:

We dreaded [those days]; they dragged, and it was horrible. I hated going to clinic. I was there for what, 4 or 5 hours, but it felt tike a longer day. [WhenJ I would come home, I would want to take a nap. I was tired; I was drained, and I was miserable. It was just a horrible, horrendous experience.

I didn't even know if I wanted to do this anymore after that. I thought I wasn't good at it. I really had a miserable time. And then when 1 started doing good [the next semester] I still didn't have too much confidence in myself.

I don't remember learning anything from it. I just remember being so miserable that I wanted to quit.... I did not want to go back at all. I was made to go back [by her mother]. [Her mother] said, "This is going to happen. Just chin up and go back."

We would watch that clock go by, and it was horrible. The fact that this professor didn't have a sense of humor, I would say that had a lot to do with it, because since then Tve had three professors, who have had a sense of humor, and Tve enjoyed all three. I've enjoyed clinic. It was fun; it was learning. It was what Tm supposed to be there for. I didnt dread going to clinic even once. I looked forward to it.

The process of becoming a nurse can be challenging at times, fraught with uncertainty, fears, and mistakes. When students say they dread the clinical learning experience, they are referring to more than a bad semester. They are saying they can no longer foresee the day they will become nurses. However, being able to laugh in the clinical setting helps students continue to look forward. Embedded in these narratives are students' hopes for success and fears of failure.

Hermeneutic Interpretation

The hermeneutic perspective allows researchers to draw on the insights gleaned from the participants' lived experiences to interpret their meaning and evoke a new understanding. This shared understanding enables researchers to penetrate the surface meaning of the text and achieve a deeper understanding of the phenomenon.

In this study, the studente repeatedly described the importance of their relationship with the clinical instructors and the quality of their learning experiences. In addition, they reported the significant contribution humor made to fostering this relationship. The narratives also revealed that humor changed the fundamental nature of this relationship.

The student-instructor relationship can be viewed from two possible perspectives - one in which the student and instructor relate to each other and one in which they are involved in a relationship with each other. In the former, there is essentially no relationship. In the latter, there is an ongoing process of being involved with each other in a positive way.

Initially, all students are intimidated by clinical instructors. No matter how hard they try, every clinical instructor is perceived as a threat by students. Students resent relating to their instructors in this way. Although students respect the instructors' knowledge and experience, nursing students, as adults, have moved beyond being subordinate to their teachers. More important, relating to the instructors in this way interferes with learning.

Humor helped students and teachers progress from merely relating to each other to being in a relationship with one another. Acoerding to Belenky, Clinchy, Goldberger, and Tarule (1986), women learn best within an empathie, connected relationship. For these students, humor was an essential part of such a relationship.

The instructor's way of being is of paramount importance in the clinical setting because in that environment students become socialized to the profession and its values (Reilly & Oermann, 1992). Through their relationships with their clinical instructors and the behaviors the instructors model, students come to understand what it means to be a nurse.

When humor existed within the relationship, the instructor was considered an authority, a skilled and knowledgeable nurse, whom students respected, rather than an authoritarian, who demanded unquestioned obethence. Humor meant students were free from intimidation and free to learn. It transformed their relationships with their clinical instructors into ones in which they were empowered, rather than dominated. By permanently transforming their relationships with their clinical instructors, humor established a way for these students to become nurses.

Implications

The narratives revealed that humor, as a way of instructors being open and present to students, powerfully affected the students. When students and instructors shared humor, the students believed they were in a respectful relationship with an adult and a colleague, an important finding considering the recent trend toward older students entering nursing education.

In a sense, nurse educators practice in two professional arenas. In addition to being instructors in the clinical setting, they also are nurses who model professional Bursing behavior. The behaviors nurse educators model in the clinical setting are important because embedded within their actions is an understanding of what nursing is and how it is practiced. Although traditionally theory has been the way to articulate nursing, theory only tells what nurses do. Nurses' actions tell how they practice. Therefore, nursing actions become a primary medium of communication. The manner in which clinical instructors behave is interpreted by students as how nursing is to be practiced. Teaching professional values in a formal, didactic manner is inadequate. The significance of clinical instructors' professional decorum cannot be overemphasized. Nurses are their shared practices, and it is essential that caring, respectful, professional behaviors be embodied in every way nurse educators behave in the clinical setting.

This inquiry speaks to the power of interpretive research to lend comprehensibility to students' experiences. Through hermeneutical interpretation, individual student's stories become intelligible by examining them within the context in which they have occurred. The findings of hermeneutical inquiry can deepen understanding of the significance this experience holds for nursing students such that nurse educatore are impelled to change some of their teaching practices. Exploring other aspects of the clinical teaching-learning situation offers continued hope of improving the way nursing students are educated.

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10.3928/0148-4834-20020901-11

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