The Effect of Humor as a Stress Management for Nurses Working in Hospital: Systematic review

Introduction : Nurses are one of the health workers who provide health services who encounter various conditions that can cause stress. Nurses who feel the stress certainly have an impact on the quality of health service that they are giving, therefore the stress management to overcome the stress is needed. One of the stress management that is cheap and accessible for nurses anywhere and anytime is humor. Method: This study uses a systematic review method. Result: Humor is a way that can change the psychological condition of individuals. Ways of this humor therapy is smiling and laughing. Nurses can smile and laugh by reading comics, joking, watching comedy filmsand or can be in the form of a fictional story told by a friend who is considered funny, and so on. In this study, the nurses believed that humour provides an opportunity for change. In relation to this, the results showed that the consequences of humour can range from revival to exhaustion. In addition to enabling mental rest, humour helps change patients’ perspectives regarding their health condition. Conclusion: Stress conditions experienced by nurses arise due to workload and so on. This will have an impact on nursing care services that will be provided to patients in the hospital. Humor is one of the most effective stress management tools to reduce stress. Humor that nurses do is just enough to smile and laugh, of course this method is very easy to do and does not require expensive costs.


Introduction
The hospital is one of the institutions engaged in the field of health services which has an initial goal of a social nature. However, with the increasing number of private hospitals that have sprung up and domestic and foreign investors finally turned the hospital into a company engaged in health services. Of course, hospitals are required to provide optimal health services, one of the strategies that can be taken to improve the quality of hospital services is to increase the professionalism of workers in hospitals (Lilis Dian Priahtini, 2007). It is estimated that one of the most workers in the hospital is a nurse, which is 60% of all workers in the hospital.
The nurse is one of the health workers who is always in the hospital and at the forefront of health services and is on duty in every service, both inpatient, outpatient (polyclinic) and emergency services (Haryanti et al., 2013). Nurses who work in health services have to deal with various situations that can cause stress, work more than one workload, and are constantly under emotional, physical, and mental fatigue (Deklava et al., 2014). Moreover, during the new normal era, many nurses experience work stress due to covid-19, this is evidenced by research conducted by Tia, Fathar, and Helena (2021) which explains that 30 (26.5%) people experience mild work stress. 56 (49.6%) people experience moderate work stress and 27 (23.9%) people experience severe work stress.
Munro in Laal (2013) states that nurses work in a work environment with high stress levels. Although every human being has a way of adapting to the environment, not everyone has the same in dealing with stressors. So stress management is a form or method that can be used to reduce stress. There are many kinds of stress management that can be used by nurses, one simple way that can be used to reduce stress is with humor. Humor is a form of cognitive, emotional, behavioral, psychological and social phenomena, which is an inseparable part of everyday life, but it is also defined as a person's ability to appreciate the funny side of a situation .
Based on these problems, researchers need to examine the influence of humor with the stress of nurses working in hospitals presented in the form of a systematic review. The hope is that with this humor, nurses will no longer experience stress and can improve the quality of health services in hospitals. Rany Agustin Wulandari, Hamidah Retno Wardani: The Effect of Humor as a Stress Management for Nurses.....

Search strategy
This study used a systematic review method which was carried out through the correct stages or research protocols. The procedure for this systematic review consists of several steps, namely: 1) setting out the background and objectives; 2) formulating research questions; 3) literature search; 4) selection criteria; 5) checklist quality and procedures; 6) extraction strategy. The researcher also did a screening on the reference list to match the citations related to the research objectives. The database search was conducted from January 25 to January 30, 2022. The keywords used were: 'Humor', 'Stress management', 'Nurse'.

Inclusion criteria and assessment quality
The inclusion criteria in this study were articles in English and Indonesian, full text, prospective studies, quantitative and qualitative studies, interventions using humor, respondents were nurses who worked in hospitals. The three main electronic databases used for identification of relevant sources are PubMed, EMBASE, Google Scholar published from 2001 -2021.

Data Extraction
Each journal was extracted separately by using parameters such as journals equipped with researcher information (author, year of publication), place of study, inclusion criteria, and screening results from the application of humor to nurses.

Result
This study identified 22 journals. This identification was carried out by means of eligibility screening according to the inclusion criteria so that 2 articles were obtained for further review (figure 1). The population in this study were all articles published by both international and national journals on the topic of stress management in nurses and the incidence of stress in nurses. The sample for this researcher is in the form of a journal article that presents the topic of humor intervention for nurses who are experiencing stress. In this study, we found full text articles, in English and Indonesian,  The level of stress on nurses was evaluated in both journals by using independent interviews from the experience of nurses working in hospitals. All studies report that humor can reduce stress levels in nurses. Based on table 1, there are 17 nurses who have a minimum of 12 months and a maximum of 4 years of work experience and work at night, after the nurse implemented a humorous intervention on the sidelines of carrying out their duties as a nurse, it showed a decrease in the stress level experienced by nurses. This is indicated by the results of interviews in the form of indept interviews conducted on 17 nurses who stated that humor makes their workplace more comfortable so that it can reduce the stress experienced by them. In the second article there are 35 nurses who are divided into two groups, namely in the control group there are 17 nurses and the intervention group 10 nurses, where in the intervention group the results are 4 (four) conclusions, namely: 1). Staff feel happy when working and interacting with coworkers, 2). There has been a positive change in the attitude and approach of staff when providing care, 3). Reducing nurses' stress levels and negative responses while  The results obtained in article 1 by providing humor interventions to 17 nurses are that humor provides an opportunity to change. Evokes enthusiasm from fatigue, helps change perspectives on health conditions, helps to reframe difficult situations and overcome challenges, increases job satisfaction and motivation, increases creativity, values, teaches ethical and responsible behavior, encourages trust, overcomes sadness, hopelessness, humor can give rise to reinforcement. In this article, the sample used is a nurse who has a minimum of 12 months of working experience and an average of night shifts. Article 2 samples taken are nurses who work in rooms with a load of <18 or >18 beds with high care, mixed high and low care types of care. The results obtained are that nurses give a happy response when working, enjoy interacting with practice colleagues, determine challenges after practice, feel enthusiastic about work, the workplace has a positive atmosphere (Table 1).

Discussion
Nurses are one of the many health workers who have more than one type of work that concerns the survival of patients but on the other hand the psychological condition of nurses must be maintained (Lovy et al., n.d.). According to Higley in Haryanti et al., (2013) nursing is a profession that is full of stress because every day nurses face unpleasant patient conditions and lack of appreciation for their work and are often underestimated. In addition, a work environment that does not support the performance of nurses has the potential to cause stress in their work (Haryanti et al., 2013). Notoadmodjo (2002) explains that this stress can be reduced if you know how to manage, overcome or prevent stress so that in the end it does not interfere with work [7]. Seyle in Haryanti et al., (2013) explains that the body's response to stress is divided into three stages, namely the response to danger (ala, reaction), the physical response or resistance stage, and the fatigue stage. However, these three stages are not always experienced by humans depending on the mental resilience of each human (Suyono, 2002). Work stress that occurs in nurses which will continue to occur will have an impact, it can be in the form of emotional outbursts which one day can interfere with the provision of health services (Lovy et al., n.d.) Because of the importance of nurses not to be stressed, it is necessary to have a form of intervention for nurses themselves in dealing with stress which is called stress management. Where in the form of stress management can be in the form of therapeutic and non-therapeutic. One form of non-therapeutic stress management is humor, where humor is the most important part of providing care that was introduced four decades ago. In this humor, nurses are asked to smile and laugh at the stimuli given to them, where these stimuli can be in the form of reading funny comic books, seeing comedy dramas, hearing jokes from friends and other things that can cause a laugh response in nurses (Erman, 2012). The method is very easy and can be done anywhere and anytime.
There are four kinds of themes that need to be considered in humor, including: including the dynamics of humor, limitations, instrumental use of humor and humor as an opportunity for change   This study found that nurse respondents who were given an intervention using humor interventions elicited a positive response. Qualitative data shows the responses generated in the form of Evoking enthusiasm from fatigue, helping to change perspectives on health conditions, helping to reframe difficult situations and overcoming various challenges, increasing job satisfaction and motivation, increasing creativity, values, teaching ethical and responsible behavior, encouraging trust, Overcoming sadness, hopelessness, humor can lead to reinforcement. This is in line with research conducted by Widyowati and Priambodo (2016) showing that a sense of humor is significantly related to work stress, or is effectively used to deal with work stress problems, anxiety, and helps someone to deal with problems better (Tengah, 2007).
Coser was the first to use humor related to illness and stress in hospitalized patients. According to Coser, humor and laughter have psychological benefits, which can reduce anxiety, reduce stress, increase self-esteem, and self-motivation (Chenoweth et al., 2014). Humor by nurses can create a good feeling, a more positive work environment, reduce tension, create a work environment that does not cause stress . According to Ramdhani in Lovy et al., n.d. When someone laughs, endorphins, which are hormones produced by the pituitary gland, are released. These endorphins create feelings of pleasure and positive emotions, besides that they will stimulate the hormones cortisol, adrenaline, and epinephrine to decrease or decrease their production so as to reduce nurse work stress (Lovy et al., n.d.). Humor can make nurses feel happy at work and enjoy interacting with coworkers. In addition, with humor there is a positive change in the attitude and approach of nurses when providing care, reducing nurses' stress levels and negative responses during providing care, and being able to improve communication, teamwork, relationships and empathy among nurses . In addition, because humor also causes the desire to laugh and smile. Smile is a positive emotional form that is very high and strong, because it contains high emotional content, because not all individuals are able to smile well. Smiling can make a person improve his health and make life more enjoyable. There are several benefits obtained from a smile, namely being able to relieve stress, being able to boost the immune system, a smile being able to lower blood pressure, and being able to release endorphins and pain-relieving hormones as well as serotonin, so as to make people think more positively and reduce negative thoughts (Setyowati & Hakim, 2021).

Conclusion
Based on the search results from a systematic study by reviewing the publications of the last 10 years, it was found that there was an influence of humor on nurses' stress, where the humor therapy applied was smiling and laughing. Humor carried out by nurses is able to create good feelings, create a positive work environment, do not give pressure and cause stress