Reflective practice simplifies an incident by segmenting it with the goal of gaining a new perspective. In this comment, the use of humour in paramedic practice is reflected upon through the use of a patient scenario, examined through the lens of the Driscoll (1994) model of reflection. Humour in health care can be controversial—and also rewarding.
Models of reflection
Several models can be used in health care to assist reflective practice. Some examples include the Johns Model (2004), The Gibbs Reflective Cycle (1988), and Driscoll's ‘The What?’ Reflective Model (1994).
Cyclic models such as Johns (2004) and Gibbs Reflective Cycle (1988) often too easily push the participant into a retrospective process and since the purpose of reflection is to improve future practice, equal consideration should be distributed to previous and future actions (Forrest, 2008). Heavily structured models such as these can often be found to be restrictive, confining the natural process of reflection.
Conscious knowledge
Cerebral imaging has shown that reflection is a continuously active process which occurs in most advanced parts of the brain (Johnson et al, 2002). It is how humans develop and learn naturally, but formally writing it down can enable us to become conscious of what we have learned. All models stand on the foundation that reflection will lead to an increased understanding and awareness of individual actions (Driscoll and Teh, 2001); consequently, reducing the theory-to-practice gap and cultivating conscious knowledge from tacit understanding (Ousey, 2000).
Person-centered reflection
Ultimately, while there are numerous advantages and disadvantages to each model, if reflection is a truly personal process, individual preference of reflection style must be the most compelling factor for choice of model. After all, the aim of all reflective models is to act as a guide for a natural process (Ousey, 2000).
Driscoll: ‘The What?’
Driscoll's (1994) ‘The What?’ (Table 1) model will be used to examine the patient scenario in this comment because of its concise structure and the freedom it allows the participant. It is not intended as the ‘right way to reflect’, but rather, a selection of signposts for entering meaningful exploration of events in clinical practice (Driscoll, 1994).
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‘So What?’ |
‘Now what?’ |
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What? Dissecting the scenario
The initial step of Driscoll's model of reflection, ‘What?’, entails a dissection of the scenario. The participant must undergo a return to the original situation, exploring what exactly happened, and one's own involvement, as well as that of other individuals, in the development of events. It sets the scene and forms the foundation of the reflective process.
The scenario
The scenario involved a 35-year-old male who had sustained a possible softtissue injury to his leg. The patient had been playing football the night before and had felt a tearing sensation in his lower leg. The following morning, he was unable to weight bear at all. On arrival at the scene, the patient was extremely agitated and distressed with his pain. Initial formation of patient rapport was difficult because of the patient's distress. So as the paramedic set about organising analgesia, the student paramedic went to assess access and egress from the property in order to use a carry chair to manoeuvre the patient to the ambulance.
There were several steps leading from the front door to the property, and the back door from the kitchen was reported to have none.
The first joke…
The student then asked a very poorly phrased question:
‘Is it possible to have a look at your back entrance?’
To which the patient replied:
‘But I've only hurt my back!” and laughed loudly.
The first joke sparked a cascade of humour. The atmosphere, which had been tense as a result of the patient's distress, was eased and the patient and his relative appeared to relax.
So what? Exploring the context
Progressing through Driscoll's (1994) framework, the next phase is entitled, ‘So what?’, and requires the participant to explore the context of the scenario. Including positive and negative consequences triggered by emotional responses and the research base behind the topic.
The therapeutic relationship
Initially, embarrassment was felt at what was thought of as a poorly phrased question, and fear of jeopardising the patient's view of the clinician's competence. It quickly became apparent there was no malice in the patient's jest and that a mutual ground for humour had been established. This caused a release of tension and facilitated an improvement of the therapeutic relationship (Jones and Tanay, 2016).
Now what? Modifying outcomes
‘Now what?’ is the final stage of Driscoll's model of reflection and involves considering modifying future outcomes of similar situations. It is the concluding segment and aims to solidify learning from the reflection. This scenario ultimately had a positive outcome in the context of using naturally occurring humour to benefit the patient's experience.
Humour with a patient
To initiate humour with a patient, the clinician needs to first establish from the patient, verbally or non-verbally, whether he or she will perceive it to be acceptable (Tremayne, 2014). In the event that the humour is not appreciated and any offence is made, the clinician should be prepared to apologise and have the interpersonal skills necessary to rectify the situation (Jones and Tanay, 2016). If not, the therapeutic relationship can be at risk. The most preferable scenario is when the patient initiates the humour (Buxman, 2008).
Benign violation humour
Humour is a subjective issue varied by situation and personal interpretation. McGraw's (2010) theory of ‘Benign Violation Humour’ might explain the humour interaction which occurred in the mentioned scenario. The basis of the theory is that something is found amusing when two conditions are met:
Benign violation occurred when the patient interpreted the student paramedic's comment as an innuendo. While the context of the comment was obvious, assessing access and egress out of the property but interpreting the comment in an inappropriate manner was humorous to the patient.
As the real intent of the comment was clear, the inappropriate interpretation of the comment was ‘non-threatening’ and violated the patient's expectations of what a clinician should say.
A social phenomen
Humour is fundamentally a social phenomenon, especially when spontaneous (Buxman, 2008). Shared humour is a building block of human interaction and strengthens social bonds. As we laugh and joke more when in others' company than alone, shared laughter can nurture a sense of community and belonging between individuals (Old, 2012). Humour also decreases the social distance between patient and caregiver, and lessens the hierarchy (Buxman, 2008).
Controversy around humour in health care
What not to say…
The use of humour in the clinical setting can be one of controversy, and its use is not always advised. Any humour that can be interpreted negatively such as sarcastic, racist, sexist or ageist comments should be completely avoided (Tremayne, 2014). Humour to ridicule others can seriously damage others' personality and disrupt or completely destroy therapeutic relationships (McCreaddie, 2011).
Religious beliefs of a patient are a vital consideration prior to inciting humour. It is understood that humour helps foster friendly relationships, but when this is between members of the opposite sex, this could conflict with religious beliefs. In Islam, while humour is still regarded as a pleasant attribute, when conducted between individuals of the opposite sex, for some Muslims it can be considered a sin (Dean, 2008).
Remaining professional
The most common cause of reluctance to use humour is concern over compromise to professional standing, and consequently casting doubt over a clinician's competency (McCreaddie, 2011). There can often be an assumption that humour and professionalism cannot thrive together. However, research suggests that cheerful and humorous clinicians reduced patient anxieties, improving perceptions of competency (Jones and Tanay, 2016).
The best medicine?
Research has shown humour to have ‘incredible health benefits’, and even to reduce pain, lower stress hormones and boost immunity (Old, 2012). It seems as though the saying, ‘laugher is the best medicine’ may not be completely unfounded. Laughter releases endorphins which diminish pain and produce a general sense of wellbeing (Ghaffari et al, 2015).
A funny contagion…
There is even some evidence to suggest that humour is contagious. Smiling and humorous interactions are known to be infectious, as mirror neurons in the brain can recognise smiles and positive facial expressions, and mirror the expression back (Old, 2012).
Conclusion
The research discussed within this reflection has largely supported the idea that good clinical practice requires empathy and the ability to connect with patients. This however, is not possible without providing a humanistic dimension to health care (Jones and Tanay, 2016). When appropriate humour, depending on individual circumstance and social environment, is combined with scientific skill, it can become an invaluable tool—but one which is not without risk. Managing that risk and minimising the potential for negative results is solely the responsibility of the clinician and use of humour is at each professional's discretion. However, one thing is certain—using humour in health care is a skill, and perhaps one that should be nurtured and valued as much as clinical expertise.