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Laughter can be the best medicine

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VOL: 97, ISSUE: 30, PAGE NO: 42

Carole-Lynne LeNavenec, PhD, RN, is associate professor, nursing, University of Calgary, Alberta

Susan Slaughter, MSc, RN, is gerontology adviser, Bethany Care Centre, Calgary, Alberta

The nursing profession has traditionally responded to the whole person and nurses know that to provide effective care they must be concerned with the body, mind and spirit. Instead of seeking alternatives to conventional health care, however, they should consider therapies that complement conventional care and focus on the integration of the body, mind and spirit, such as music, reminiscence and humour. Other interventions in this category include prayer, meditation, hypnosis and biofeedback.

The nursing profession has traditionally responded to the whole person and nurses know that to provide effective care they must be concerned with the body, mind and spirit. Instead of seeking alternatives to conventional health care, however, they should consider therapies that complement conventional care and focus on the integration of the body, mind and spirit, such as music, reminiscence and humour. Other interventions in this category include prayer, meditation, hypnosis and biofeedback.

The use of complementary therapies in long-term care settings may be initiated by the resident, a request from the family or staff seeking to enhance the care they offer. But before any complementary therapy is introduced, ethical issues need to be considered. First, it must be of benefit and do no harm and, second, the preferences of the patient are paramount.

Staff must be competent to practise the therapy and a protocol should be established.

Beneficial interventions
Interventions based on music, reminiscence and humour have been shown to be of benefit to patients and residents (LeNavenec and Vonhof, 1996), enhancing their well-being and quality of life. Other advantages include a healing environment or what is sometimes referred to as a 'therapeutic milieu'.

These interventions help nurses and the health care team to achieve the following aims:

- They strengthen the whole person (LeNavenec and Vonhof, 1996);

- The people involved find them meaningful (Dossey, 1998);

- They foster an environmental tone or climate characterised by hope, happiness (for example, a sense of inner joy, peace, security or comfort) and humour (Bruce and Cumming, 1997; Forbes, 1994; Herth, 1993).

Music therapy
Many nurses participate in and encourage musical activities with selected residents or refer them to music therapists. Music and sound can have the following effects:

- They can enhance the physical, psychological, social and spiritual well-being of people with various illnesses, including dementia and disabilities, such as those related to hearing, learning, sight and speech impairments;

- They can enhance cognitive skills;

- They can promote meaningful social interactions;

- They can promote spiritual well-being in palliative care (Gerdner and Buckwalter, 1999).

Gerdner (1999) provided a research-based individualised music intervention protocol that includes clear guidelines.

In the early planning phase, the frequency and timing of group sessions is important. Nurses in some settings have found that half-hour group sessions in the late morning or just before dinner fit in best with residents' daily schedules. Other centres hold musical evenings on a monthly basis.

One nursing home in Calgary, Canada, plays selected classical music via the intercom system in the day room before meals, during the afternoon shift change and just before bedtime.

But not all residents like the same music. For this reason it is important to individualise music interventions by providing, for example, headphones, personal stereos and an audiotape with recordings of each resident's preferred music.

Important assessment parameters include an exploration of the resident's background, musical interests and/or abilities. Carers must define the desired change in behaviour and choose music based on the resident's preferences. Such information may be provided by the family if the resident is unable to do so. The family or close friends of the resident may also be asked to prepare audiotapes or compact discs.

If personal stereos are used it is important that the volume level is not too high. Where desired, the music should also encourage the resident to participate by playing an instrument, singing or dancing. Even people with late-stage dementia can enjoy music and are sometimes able to sing along with old favourites or hymns.

Evaluation of the effectiveness of music interventions can be based on observation and feedback. Outcome indicators used by Gerdner (1999) to evaluate agitation in people with Alzheimer's disease after consistent and appropriate use of the individualised music intervention protocol showed decreases in combativeness, the use of psychotropic drugs and physical restraints, and the likelihood of wandering.

Reminiscence therapy
Reminiscence therapy is 'a planned strategy to help people recall past events, feelings and thoughts' (Snyder, 1992). Unlike 'life review' (Butler, 1963), which may provoke anxiety because of its emphasis on interpreting and working through feelings associated with the past, simple or non-evaluative reminiscence supports people's previous decisions and lifestyle.

It is important to assess society's and individual's views on reminiscence, including our own. Some people may have a negative attitude to reminiscence, which can be reflected in statements such as: 'He won't do any of his care these days because he is so engrossed with his days in the second world war.' Others have a positive attitude, which may be expressed as: 'I love hearing about the good old days, which may be gone but are definitely not forgotten. I know it keeps her in good spirits talking about them.'

Perhaps the most common belief about reminiscence is that 'talking about the past is a sure sign that you are getting old', despite research findings that 'reminiscence begins at about age 10 and continues throughout life' (Snyder, 1992).

Older people have a wealth of memories 'but few friends left to share them with', so both staff and relatives involved in their care need to find ways of 'valuing and using their memories to enhance the quality of their lives' (Gillies and James, 1994).

Reminiscence therapy, which can take place individually or in groups, offers a number of benefits, including an enhanced ability to cope with or adapt to change and 'opportunities for integration by offering people a chance to be given attention, to be seen and recorded as existing, and to integrate and reconstruct historical experiences - thereby manifesting a valuable identity' (Soltys and Coats, 1994).

It also increases nurses' understanding of residents, including how past beliefs, experiences or practices may be impinging on their current behaviour (LeNavenec and Vonhof, 1996; Moore, 1992).

Several stimuli can be used to elicit memories, such as photographs, music, arts and crafts, videotapes and journals. Nurses can also foster reminiscence during routine care by discussing with residents any photographs or souvenirs that they have on display.

Active listening and related communication skills are important for nurses as they allow reminiscence to proceed effectively, giving residents an enhanced sense of identity, greater self-esteem and better communication skills.

Humour as therapy
Many of us think of humour as having fun, finding a situation funny or having a good time because we are surrounded by smiles, laughter or tears of joy. These situations can be created by engaging in non-competitive games, such as playing cards; observing, reading or listening to what we consider funny, for example radio or television programmes; or creating verbal, written or visual materials that evoke laughter, such as telling jokes, dressing up in costumes and changing our hair colour or style.

In a therapeutic context this is defined as enabling residents and their families or friends 'to perceive, appreciate and express what is funny, amusing or ludicrous in order to establish relationships, relieve tension, release anger, facilitate learning or cope with painful feelings' (McCloskey and Bulechek, 1996).

The nature of humour means that something may not be considered funny by all residents or consistently humorous to the same person over time (Snyder, 1992). This is illustrated by statements such as: 'At the time it wasn't funny, but now I can laugh about it.'

The main obstacles to the use of humour as a therapy are a lack of humour on the part of the nurse, who may believe that laughter is not consistent with professional behaviour, and not knowing the resident well enough (Astedt-Kurki and Liukkonen, 1994).

Before using humour as an intervention, a number of parameters may need to be considered. McCloskey and Bulechek (1996) suggest that nurses may wish to consider the following:

- Determine the person's typical response to humour as this may range from a smile to roars of laughter;

- Find out what time of day they are most perceptive;

- Identify, and therefore avoid, anything that may be sensitive because of cultural or spiritual beliefs;

- Discuss the advantages of laughter, with the expectation that eventually the person may start to self-evaluate such changes as levels of pain during good times;

- Make a selection of humorous games, records, cartoons and videotapes available as a humour first-aid kit and ask staff and family members to contribute to it twice a week;

- Respond positively to healthy attempts at humour made by residents.

Humour therapy can be evaluated by recording observational data on smiles and appropriate laughter as well as verbal reports on residents' decreased levels of discomfort or changes in depressive and related symptoms.

Discontinue a humour strategy if it appears to be ineffective or the person is becoming too euphoric. Snyder's (1992) Situational Humor Response Questionnaire may also aid evaluation.

Conclusions
An important principle of holistic care is that the nurse enables the resident and his or her family or friends to be in the best state for healing to take place (Dossey, 1998). She maintains that nurses must develop their personal healing qualities and increase awareness of healing in their own lives. When this is done, they become effective guides.

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