The patient experience of maintenance hemodialysis is frequently described as stressful, depressing and replace with monotonous. Ways to improve the patient experience through laughter therapy programs have not formally been put into practice. This pilot study explored the feasibility, safety, acceptance and patient experience of laughter therapy in two hemodialysis centers in California from September 2016 to April 2017.

Laughter therapy sessions were implemented weekly for 30 minutes per session. Evaluation consisted of surveying and interviewing patients (n=58) and staff (n=25).

The results indicated that 70% of surveyed staff and patients agreed the laughter therapy program had a positive impact on patient mood and would recommend it for future centers. Intradialytic laughter therapy is safe and feasible and can improve perceptions of mood in patients on dialysis and dialysis staff.

Background

Laughter therapy is a wellness therapy gaining popularity around the globe. It is based on the concept that intentional laughter, used as a component of a wellness program, can be therapeutic when performed in a systematic and coordinated way. The inclusion of laughter as a therapy can be provided in different forms and has variously been termed as laughter wellness, laughter recovery, laughter yoga, gelotology, conscious laughter, mirthful laughter and voluntary simulated laughter.

Foley and colleagues found that laughter therapy can provide respite from the adverse emotional effects associated with illness by improving mood. De La Fuente Mochales found that laughter therapy decreased pain, and Shahidi M and colleagues found it reduced depression and Walter and colleagues noted an improved overall quality of life for patients who had laughter therapy.

Bennett and colleagues found that intentional laughter has been used widely for people with mental health conditions, chronic disease and cancer across a range of ages from pediatrics to geriatrics.

Intentional laughter is used in most forms of laughter therapy. It is also referred to as conscious, simulated, mirthful or voluntary laughter. Intentional laughter consists of “deep belly laughter” practiced over a sustained period of time to enhance the many benefits associated with laughter. The brain knows it is not genuine laughter, but the body does not. This activity can offer benefits for patients who report low levels of happiness, particularly in life satisfaction, life achievements and relationships, according to Bennett and colleagues. Laughter elevates mood, energy and vigor and increases memory, creative thinking and problem-solving skills. Neuhoff and colleagues found that intentional laughter can change our mental map from a negative to a positive mental attitude that may assist people affected by end-stage kidney disease.

Why laughter therapy in hemodialysis?

According to Bennett, undergoing maintenance hemodialysis thrice weekly is a life-sustaining therapy dreaded by many patients, resulting in loss of control over their life and increased fatigue and unhappiness. Adaptation to the dialysis reality varies, but overwhelmingly, adjusting to the hours required on dialysis is a common challenge for patients, partly due to the lack of constructive activity while dialyzing. Trials to increase activity and decrease the boredom during hemodialysis have included seated Zumba, book clubs, exercise activities and bingo. The aim is often to enhance the patient experience and quality of life or simply humanize the therapy and take advantage of the time spent on the machine.

Bennett and colleagues also found that laughter therapy on dialysis can be viewed as physical activity or as an exercise program. Dialysis patients have poor muscle function because of the symptoms of age, kidney disease and the long hours attached to a dialysis machine. Intentional laughter can create a heightened total-body response by exercising the facial, chest, abdominal and skeletal muscles, improving tone. It can also help to improve cardiovascular function, respiratory function, elevate pain tolerance and increase the body’s immune defense systems.

Dunbar and colleagues found that intentional laughter can foster better communication which leads to a less confrontational approach in tense situations and a change from individual competitiveness to team cooperation. Thus, in hemodialysis centers, laughter has the potential to improve interpersonal interaction, relationships, increase friendliness, helpfulness and can help build group identity, solidarity and cohesiveness.

There has been limited experience of laughter therapy outside of the United States (Israel and Australia) where laughter has been shown to be feasible in outpatient hemodialysis centers, according to Bennett and Dahan and colleagues. One Australian program consisting of 30 minutes every dialysis for 4 weeks was associated with a decrease in intradialytic hypotension and showed trends in decreased anxiety and increased mood.

U.S. clinics are commonly larger than Australian clinics, designed to service between 24 and 48 patients at a time. These are frequently designed to physically separate patients, resulting in decreased intradialytic interpersonal communication between patients. Thus, it can be a challenge to promote a group therapy, such as laughter therapy, in a clinical context where mandates for infection control, personal protection and staffing determine the workflow processes.

The aim of this report is to summarize 6 months of experience of laughter therapy in two Satellite Healthcare hemodialysis centers in California.

‘Laugh Out Loud’ Hemodialysis

Laughter therapy sessions were performed at mutually agreed upon times by staff, patients and therapists and performed once weekly. Each 30-minute session consisted of breathing and stretching exercises that facilitated intentional laughter exercises and laughter meditation (Table 1). At Satellite Dialysis Vallejo, morning and middle shift patients on both Thursdays and Fridays participated. At Satellite Dialysis Sacramento, early morning and middle shift patients on Friday only participated. Participation varied from 50% to 100% of patients on any given shift.

One laughter therapist was contracted for each center. The therapist then chose from one to three trained assistants, depending on the size of the clinic and the number of patients per shift. Laughter therapists were educated and orientated to the dialysis center, which included talking and listening to patients, policy and procedure orientation, infection control and mandated flu vaccinations.

Training

Staff education at the Vallejo center consisted of a 30-minute PowerPoint presentation for all staff and a short laughter therapy demonstration held in the conference room. In Sacramento, we added two practical laughter sessions at the nurse’s console in full view of the patients. Both clinics had two laughter champions assigned whose main responsibility was to liaise between the center and the laughter therapists. These champions were patient care technicians, registered nurses, dietitians and social workers. Posters were developed to both advertise and educate patients and staff.

Staff were encouraged to participate in the laughter therapy sessions for a portion of time during each 30-minute session. Allied health staff, such as social workers and dietitians, assisted by organizing their patients’ appointments around the pre-arranged laughter therapy session times. Nephrologists also assisted by ensuring that patient care rounds were not scheduled during laughter therapy. Where possible, staff assisted the laughter therapists in engaging and encouraging patients.

Patient and staff perceptions

Patient and staff views on the program were gathered using questionnaires and semi-structured interviews. A Californian State independent review board approved the evaluation process. All respondents signed informed consent forms prior to completing questionnaires and interviews. Fifty-eight patients returned completed questionnaires from a total of 95 eligible patients (61% response rate).

Results from the patient questionnaires can be found in Figure 1. Overall, 63% of responding patients believed the laughter therapy had a positive impact on their mood during dialysis, with 68% recommending laughter therapy for other patients. Twenty percent of patients had concerns regarding laughter therapy in the dialysis centers.

In interviews, some patients expressed their frustration with the boring aspects of dialysis and said laughter therapy helped pass this time in a fun and engaging way. Patients also noted increased staff and patient comradery and stated that the laughter therapy made people feel happy and helped them forget about their problems or worries. Patients noted that the program worked well for some patients but not others, and those who were indifferent still recommended continuing laughter therapy for the benefit of other patients who they knew enjoyed it.

Staff

Twenty five out of 47 staff members (53% response rate) completed and returned evaluation questionnaires. Respondents included 11 patient care technicians, six nurses and eight ancillary staff (dietitians, social workers, biomedical technicians and administrators). Results from the questionnaires can be found in Figure 2. More than 70% of staff believed the laughter therapy had a positive impact on patients’ mood, with a similar number recommending laughter therapy for other patients. Twenty-four percent of the staff had concerns regarding the safety of laughter in the dialysis centers, although there was a strong interest by the center staff to learn more about the physical and psychological benefits of laughter therapy.

As a follow-up to the questionnaire, 10 staff members agreed to be interviewed using a semi-structured interview format. Staff were positive regarding laughter therapy, even commenting that the positive effects of laughter continued even on non-laughter therapy days. Overall, staff members interacted with each other more positively, often invoking language used in the laughter therapy sessions, passing each other on the treatment floor with a “ho, ho, ho, ha, ha, ha.” Staff also reported attitude changes in some patients who were initially resistant to the therapy but ultimately embraced it. Laughter therapy helped these patients “come out of their shell” and engage with their other patients and staff.

Staff noted the importance of providing in-depth education at the start of the program, including the health benefits of laughter therapy. At one of the centers, patients who were spoken to individually regarding the pilot program and laughter benefits began to participate when initially averse to the program. Interestingly, as staff and patients became more familiar with the program, staff commented on the noise level on the treatment floor. Some staff felt laughter therapy was too loud while others felt that the noise was a positive change.

Improved patient experience

The 6-month experience with two intradialytic laughter pilot programs has demonstrated the potential for laughter therapy to be integrated into a hemodialysis center’s every day work. However, to ensure success, a program must be more than just placing a laughter therapist into a hemodialysis clinic. Requirements needed to succeed include executive support, medical director buy-in, patient education, staff education, appropriate scheduling, access management, new laughter exercises each session and potentially a time limit of 3 months. A full set of recommendations can be found in Table 2.

The capacity for laughter therapy to improve patient experience as measured by the Core ICH-CAHPS Survey, according to the 2017 In-Center Hemodialysis CAHPS Survey Administration and Specifications Manual from CMS, needs to be seen. Future surveys measuring patient depression, stress and anxiety are also needed in the future to better assess the value of such programs.

Although most patients and staff found laughter therapy to be positive, we found a small percentage of patients who did not want to be included. We recognized the importance that some patients just aren’t in a good space and laughter may be too intrusive. Our experience found that with the right amount of education and preparation for patients and staff, most patients will participate. Importantly, the patients who did not wish to participate still encouraged others to participate and they stated that they enjoyed hearing other patients participating and laughing.

Conclusion

Laughter therapy can improve interpersonal interaction and relationships, increase friendliness and helpfulness, and help build group identity, solidarity and cohesiveness. Although not for everyone, laughter therapy has been shown to be a positive therapy and can be seen as an important element to efforts in humanizing hemodialysis care and improving the experience of patients on dialysis.

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For more information:
Paul H. Bennett, RN, MHSM, PhD, is director of medical clinical affairs at Satellite Healthcare in San Jose, California and honorary professor in faculty of health at Deakin University in Melbourne, Australia. Toni Luckett, RN, is the manager of the Satellite Dialysis center in Vallejo, California; Joy Cunanan, RN, is the manager of the Satellite Dialysis center in Sacramento. Christine Kalife, BA, is a research associate with Satellite. Brigitte Schiller, MD, FACP, FASN, is the dialysis provider’s chief medical officer and a member of NN&I’s Editorial Advisory Board. Disclosures: The authors report no relevant financial disclosures.