PSYCHIATRIC NURSING

What is presently known on this subject? • Nurses work with patients and their relatives in palliative care units avoid using humor in their daily work and conversation. On the other hand, there are studies revealing the physiological, psychological and social benefits of humor on patients in palliative care. What does this article add to the existing knowledge? • There are uncertainties about how humor can be practiced in palliative care units. As explained in this review, diversifying daily life, which is perceived as serious when used positively, by using humor, may facilitate palliative care and increase their quality. What are the implications for practice? • Defining humor in palliative care includes information about how it can be used positively in application areas, and it is also thought to increase awareness on the subject. 174 Psikiyatri Hemşireliği Dergisi Journal of Psychiatric Nursing social and mental problems, to reduce / prevent the individual's suffering and to improve the quality of life of the patient and his family by evaluating and treating them.[4] Palliative care should be transferred to the practice of appropriate model approaches systematically as much as possible. Humor is one such approach. Considering the direct relationship between palliative care and death, the humor approach may not seem appropriate at first glance in nursing practices. Palliative care offered to individuals and their relatives who experience the terminal period bring the difficulty of coping with existential crises. It is important that patients and their relatives are supported in all treatment and care services that the individual methods they use to cope with their situation are respected. This includes humor too. In addition, there are studies revealing the physiological, psychological and social benefits of humor on patients in palliative care.[5,6] For example, Becker[7] emphasizes the positive effect that the use of humor in nursing interventions in palliative care relaxes the sick individuals and helps them to communicate with them better, especially as it facilitates speech in themes that are almost taboo to talk like “death”. In this article, the role of humor in nursing interventions offered to patients in these areas and how it can be carried to practice are discussed. Definition of Humors Humor, defined as laughter,[8] is a style of expression that can look at reality from a different point of view, make you smile while questioning, make you think while making you smile, and draw attention to different points while making you think. [9] In another definition, it is described as the ability of a person to laugh at herself/himself and what happened, without taking the things completely negative in order to cope with the difficulties of daily life and the misfortunes that these difficulties bring.[10] Since the dawn of humanity, humor has been considered a part of communication and healthcare in every culture. This is supported by proverbs or idioms in cultures. For example, with us ‘a laugh is worth a kilo of chops ‘; Laughter is the expression of health in Germans, while laughter is a good blood maker in Italians. In India, it is said that the best doctor lives inside the individual and laughs. In China, laughing for a minute extends an individual's life by an hour.[11] In Table 1, each of the theories about humor explains one aspect of humor. Each theory, related to cultural, philosophical, anthropological, biological, and instinct, is briefly summarized here. Functions and Effects of Humor in Palliative Care The possible effects of humor in palliative care services can be classified as social and psychological. Here, it is recommended to pay attention to the following points while being used in practice as an auxiliary factor that initiates communication. These are; • Communication with the patient should be clear. • The nurse should evaluate every aspect of the situation that humor will use. • The right time for humor should be chosen. • The patient’s humor should be carefully evaluated. • Counter reactions should be appropriate. Sense of Humor is described as a kind of seeing the world with flexibility, fun and funny filter and interacting from this perspective.[12] There are situations where these perspectives are both positive and negative. The positive side of humor is preferred while moving to nursing practice. Dark humor can be used as a protective mechanism when used in highly stressful environments.[13] Martin et al.[14] mentions four styles of humor (Table 2). Bischofberger[15] lists the emotional and cognitive effects of humor as follows: • Humor helps to integrate health problems into life. • Humor is an expression of honesty. With the humorous Table 1. Theories of humor Theory Definition Developing the theory The superiority The individual makes humor about the misfortune, failure, and poor quality of others Platon theory to show that he is superior to others. It is an expression of a certain degree Ancient Greek of aggression. The theory contains a certain amount of sarcasm, cynicism, and irony. Inconsistency The inconsistency theory is based on the assumption that sudden inconsistencies Theory and oddities will entertain people and ultimately make people laugh. 18th Century Emmanuel Kant Game Theory The theory states that humor contains a fun element. it considers humor as a form Max Eastman, 1936 of interpersonal communication in which a spontaneous and well-thought moment is characterized. The Relaxation The theory of relaxation is based on the assumption that in situations such as anxiety, Sigmund Freud, 1905 Theory tension and anger discharged for any reason, people will be relieved as a result of the use of humor and that this relaxation will cause laughter. Social Theory This theory supports that humor has a socially interconnected component. Avnev Siv, 1984 This situation is noticed by enhancing the feeling of solidarity and harmony within a group. 175 Beyhan Bag, The use of humor in palliative care services / dx.doi.org/10.14744/phd.2021.54036 "you can trust me" message, personality and illness are more easily accepted. • Humor is part of the inner harmony of the individual. • Humor helps change perspective in the face of any chronic illness. • Humor can reduce negative stress. • Humor can distract by reducing inner restlessness. • Humor can help regain control in anxiety situations. Humor can affect our spiritual life and understanding of illness in a variety of ways. An effective sense of humor can be a supportive element and also a protective factor for difficult moments in life.[16] Understanding the humor approach, psychological and social function will increase the quality of nursing interventions in palliative care units. Social Function of Humor Humor in sociology is considered as a formative social-relationship. There are various tasks such as humor, holding the group together, approving or disapproving of behavior in the situation. Humor functions as a social unifier according to social theories. It strengthens the feelings of solidarity and harmony in the group. The use of humor is important in terms of the social functionality of humor, especially in groups working in services where issues such as dying, death and mourning are experienced intensely. Because individuals working in these fields find it difficult to find the methods they will use to deal with the pain and grief of others due to their daily exposure. If a space is created for humor in the teams working in the services where such issues are intense, psycho-hygiene will contribute to the success of the group. Robinson[17] finds that humor positively supports cohesion in the group by reducing the tension and stress at work in nurses. In this sense, humor has a preventive function against the development of a possible burnout syndrome. Müller[18] states in her study that nurses working in institutions where palliative care units are provided see humor as the second important factor in dealing with death. On the other hand, Aulber[19] states that tumor pain seen in palliative patients is generally associated with anxiety. The experienced pain is often interpreted by the patient's relatives as the progression of the disease. However, pain should be perceived as a phenomenon that has a social, psychological, cultural and spiritual dimension as well as a physical condition. Here, factors such as withdrawal, isolation, economic concerns, reactions of patients' relatives to pain, stigma and patient expectations are effective on the individual. The feature of humor to distract attention and initiate communication, and to ensure the continuation of contact with life in individuals facing death, the use of palliative care in planned nursing interventions will reveal its social functionality clearly supportive. In Conclusion, according to the palliative care approach, death is a part of life. Patient humor in palliative care can functionally bridge between death and life in a social context. The Psychological Function of Humor An approach or a sense of humor is often used in expressions as a personality trait. Nevo et al.[20] reported that humor includes motivational, cognitive, emotional, social and behavioral components. From a psychological point of view, humor encourages people to look from a different perspective by relieving tension in the environment and interpersonal contact by reducing timidity. According to Zimmer,[21] humor has a healing effect, initiating and reconciling communication in interpersonal relationships. Humor is a good resource to cope with stress in daily life, as it activates the resources in the individual. Also, humor can quickly find “resources and new perspectives."[22] Humor ist the importance of in coping with stress. For example, in palliative care, cancer patients see themselves as a burden for their relatives and feel guilty about it. However, the reason that led to this situation; It is the perception that the patient has failed to the outside because the symptoms and pain he experiences make his life difficult.[23] Since a possible Table 2. Humor styles [14] Humor styles Definition Spontaneous humor It is used to Show better the individual in a way that does not harm others. Individuals who use this type of humor turn to humor to deal with the difficulties in their daily lives. Usually displays a positive attitude. Most individuals in this group have a realistic perspective and use humor to regulate their own emotions. Social humor It is used to improve the relationship with both ourselves and others. People who use this kind of humor like to tell jokes or funnies. The goal is often to relax and create a pleasant atmosphere in difficult situations. For them, humor functions as a social operator. Social humor is often used in a non-hostile way. In addition, such individuals do not take themselves too seriously. Offensive humor Used to be little other people around them. This can be accompanied by sarcastic and biting, as well as sexist and racist features. These people prefer impulsive jokes without thinking they can hurt others. Sometimes they threaten, harass or intimidate others, using offensive humor. Self-humiliating humor This style of humor is used to gain acceptance by doing or saying funny things that involve and misrepresent yourself. People who use this kind of humor are insecure, they want to fool themselves by letting others make fun of them. 176 Psikiyatri Hemşireliği Dergisi Journal of Psychiatric Nursing communication problem will cause the patient to withdraw and isolate herself, it is obvious that it will be beneficial for the nurse to use approaches such as humor to relax communication. Good communication is an important step in determining the patient's needs and supporting the patient. Freud,[24] for example, assumes that humor is one of several methods an individual uses to prevent the painful. Some studies[25] on humor are examined. Their psychological components can be listed as follows; • Humor Creation/Humor production; describes an individual's ability to create a state of humor like a comedian or by joke telling. • Humor Appreciation; the ability of the individual to perceive, appreciate and interpret humor stimuli and situations. • Humor coping; is the individual's use of humor in stressful and tense situations.[26] According to Dean and Major,[27] the value of humor in palliative care lies not in its capacity to change reality, but in promoting emotional and psychological changes that facilitate humane investigation of disease for both healthcare professionals and patients. Humor also helps healthcare providers reduce the stress caused by end-of-life care.[28] Considering all these reasons, it can be said that there is a good reason for the use of humor in palliative care services in our country. Use of Humor in Palliative Care Practices Nurses, doctors, therapists, volunteer hospice staff who work with patients and their relatives in the end-of-life period avoid using humor in their daily work and conversations. The dominant opinion is that an individual facing death as a result of an incurable disease has nothing left to laugh. In fact, considering the potential of humor to be useful in situations where it is used positively, making brighter the extremely serious daily life by using a little humor will facilitate palliative care and increase its quality.[29] Humor helps an individual to relax cognitively by affecting their physiological and psychosocial state. Nunes et al.[30] as a result of their studies with 66 nurses who experienced at least one death in palliative care wards, they found that humor can be used in supportive and nursing practices in the process of death and grief. According to the result of the study, nurses stated that they did not see humor alone enough to cope with stress, and they needed problem-focused coping mechanisms. As summarized briefly in the theories about humor section, the individual who uses humor does not set herself/himself a goal to be perfect. He / She doesn't take herself too seriously and can laugh at himself/herself with others. Since he/she is open to other people other than himself/herself, he/she is voluntary in evaluating events from a different perspective. Humor develops an attitude of reading between the lines (with gestures and facial expressions) in communication with the observer and the other, with a curiosity open to the new and different. On the other hand, humor may be considered as the last care approach for the individual receiving palliative care. However, the holistic / holistic care included in the definition of palliative care by the World Health Organization (WHO)[4] does not conflict with the use of humor in its application areas, as it includes respect for the sick individual and self-sharing. Thus, the individual experienced in the last stages of life can share moments of laughter with other individuals. In addition, when humor is used as an approach in nursing interventions in palliative care, there will be an increase in the quality of life for the patient and their relatives. In a study conducted with palliative care patients in hospice and palliative care units, 76% of the participants stated that they valued humor. Majority of them stated that they found humor-based communication with doctors (76%) and nurses (88%) and appropriated.[31] In another study examining the interactions of nurses and patients in nursing homes and hospice, humor was found in 85% of 132 interactions observed. While patients in 70% of these interactions were the initiators of humor, it was determined that nurses were the initiators in only 18% of these interactions.[32] Steinhauser et al.[33] In their studies on 340 seriously ill patients, 93% of the participants stated that they agreed that a sense of humor is important in the end-of-life period. Pinna et al.[34] say that humor is not well researched in oncological treatment and care services despite its positive effect. The shortcoming in nursing research in this field to date is that almost all researchers ignore the humor theories in the psychology literature. In addition, despite the deficiency in this field, this does not prevent some commentators from the interpretation that humor will not bring any benefit to nursing interventions.[35] Every situation in which humor is applied should be examined individually and depending on the situation. Especially, nurses in nursing practices who want to use humor in palliative care should observe the situations in which laughing is not appropriate, in other words, the limits of humor are reached (Table 3). Humor continues to be an important factor during illness in individuals who play an important role in their pre-illness lives. Table 3. Situations where it is recommended to avoid the use of humor[34]

social and mental problems, to reduce / prevent the individual's suffering and to improve the quality of life of the patient and his family by evaluating and treating them. [4] Palliative care should be transferred to the practice of appropriate model approaches systematically as much as possible.
Humor is one such approach. Considering the direct relationship between palliative care and death, the humor approach may not seem appropriate at first glance in nursing practices. Palliative care offered to individuals and their relatives who experience the terminal period bring the difficulty of coping with existential crises. It is important that patients and their relatives are supported in all treatment and care services that the individual methods they use to cope with their situation are respected. This includes humor too. In addition, there are studies revealing the physiological, psychological and social benefits of humor on patients in palliative care. [5,6] For example, Becker [7] emphasizes the positive effect that the use of humor in nursing interventions in palliative care relaxes the sick individuals and helps them to communicate with them better, especially as it facilitates speech in themes that are almost taboo to talk like "death". In this article, the role of humor in nursing interventions offered to patients in these areas and how it can be carried to practice are discussed.

Definition of Humors
Humor, defined as laughter, [8] is a style of expression that can look at reality from a different point of view, make you smile while questioning, make you think while making you smile, and draw attention to different points while making you think. [9] In another definition, it is described as the ability of a person to laugh at herself/himself and what happened, without taking the things completely negative in order to cope with the difficulties of daily life and the misfortunes that these difficulties bring. [10] Since the dawn of humanity, humor has been considered a part of communication and healthcare in every culture. This is supported by proverbs or idioms in cultures. For example, with us 'a laugh is worth a kilo of chops '; Laughter is the expression of health in Germans, while laughter is a good blood maker in Italians. In India, it is said that the best doctor lives inside the individual and laughs. In China, laughing for a minute extends an individual's life by an hour. [11] In Table 1, each of the theories about humor explains one aspect of humor. Each theory, related to cultural, philosophical, anthropological, biological, and instinct, is briefly summarized here.

Functions and Effects of Humor in Palliative Care
The possible effects of humor in palliative care services can be classified as social and psychological. Here, it is recommended to pay attention to the following points while being used in practice as an auxiliary factor that initiates communication. These are; • Communication with the patient should be clear. • The nurse should evaluate every aspect of the situation that humor will use. • The right time for humor should be chosen. • The patient's humor should be carefully evaluated.
• Counter reactions should be appropriate. Sense of Humor is described as a kind of seeing the world with flexibility, fun and funny filter and interacting from this perspective. [12] There are situations where these perspectives are both positive and negative. The positive side of humor is preferred while moving to nursing practice. Dark humor can be used as a protective mechanism when used in highly stressful environments. [13] Martin et al. [14] mentions four styles of humor (Table 2). Bischofberger [15] lists the emotional and cognitive effects of humor as follows: • Humor helps to integrate health problems into life. • Humor is an expression of honesty. With the humorous The individual makes humor about the misfortune, failure, and poor quality of others Platon theory to show that he is superior to others. It is an expression of a certain degree Ancient Greek of aggression. The theory contains a certain amount of sarcasm, cynicism, and irony. Inconsistency The inconsistency theory is based on the assumption that sudden inconsistencies Theory and oddities will entertain people and ultimately make people laugh. 18 th Century Emmanuel Kant Game Theory The theory states that humor contains a fun element. it considers humor as a form Max Eastman, 1936 of interpersonal communication in which a spontaneous and well-thought moment is characterized.

The Relaxation
The theory of relaxation is based on the assumption that in situations such as anxiety, Sigmund Freud, 1905 Theory tension and anger discharged for any reason, people will be relieved as a result of the use of humor and that this relaxation will cause laughter.

Social Theory
This theory supports that humor has a socially interconnected component. Avnev Siv, 1984 This situation is noticed by enhancing the feeling of solidarity and harmony within a group. "you can trust me" message, personality and illness are more easily accepted.
• Humor is part of the inner harmony of the individual.
• Humor helps change perspective in the face of any chronic illness. • Humor can reduce negative stress. • Humor can distract by reducing inner restlessness. • Humor can help regain control in anxiety situations. Humor can affect our spiritual life and understanding of illness in a variety of ways. An effective sense of humor can be a supportive element and also a protective factor for difficult moments in life. [16] Understanding the humor approach, psychological and social function will increase the quality of nursing interventions in palliative care units.

Social Function of Humor
Humor in sociology is considered as a formative social-relationship. There are various tasks such as humor, holding the group together, approving or disapproving of behavior in the situation. Humor functions as a social unifier according to social theories. It strengthens the feelings of solidarity and harmony in the group. The use of humor is important in terms of the social functionality of humor, especially in groups working in services where issues such as dying, death and mourning are experienced intensely. Because individuals working in these fields find it difficult to find the methods they will use to deal with the pain and grief of others due to their daily exposure. If a space is created for humor in the teams working in the services where such issues are intense, psycho-hygiene will contribute to the success of the group. Robinson [17] finds that humor positively supports cohesion in the group by reducing the tension and stress at work in nurses. In this sense, humor has a preventive function against the development of a possible burnout syndrome. Müller [18] states in her study that nurses working in institutions where palliative care units are provided see humor as the second important factor in dealing with death. On the other hand, Aulber [19] states that tumor pain seen in palliative patients is generally associated with anxiety. The experienced pain is often interpreted by the patient's relatives as the progression of the disease. However, pain should be perceived as a phenomenon that has a social, psychological, cultural and spiritual dimension as well as a physical condition. Here, factors such as withdrawal, isolation, economic concerns, reactions of patients' relatives to pain, stigma and patient expectations are effective on the individual. The feature of humor to distract attention and initiate communication, and to ensure the continuation of contact with life in individuals facing death, the use of palliative care in planned nursing interventions will reveal its social functionality clearly supportive. In Conclusion, according to the palliative care approach, death is a part of life. Patient humor in palliative care can functionally bridge between death and life in a social context.

The Psychological Function of Humor
An approach or a sense of humor is often used in expressions as a personality trait. Nevo et al. [20] reported that humor includes motivational, cognitive, emotional, social and behavioral components. From a psychological point of view, humor encourages people to look from a different perspective by relieving tension in the environment and interpersonal contact by reducing timidity. According to Zimmer, [21] humor has a healing effect, initiating and reconciling communication in interpersonal relationships. Humor is a good resource to cope with stress in daily life, as it activates the resources in the individual. Also, humor can quickly find "resources and new perspectives." [22] Humor ist the importance of in coping with stress. For example, in palliative care, cancer patients see themselves as a burden for their relatives and feel guilty about it. However, the reason that led to this situation; It is the perception that the patient has failed to the outside because the symptoms and pain he experiences make his life difficult. [23] Since a possible Table 2. Humor styles [14]

Humor styles Definition
Spontaneous humor It is used to Show better the individual in a way that does not harm others. Individuals who use this type of humor turn to humor to deal with the difficulties in their daily lives. Usually displays a positive attitude. Most individuals in this group have a realistic perspective and use humor to regulate their own emotions.

Social humor
It is used to improve the relationship with both ourselves and others. People who use this kind of humor like to tell jokes or funnies. The goal is often to relax and create a pleasant atmosphere in difficult situations. For them, humor functions as a social operator. Social humor is often used in a non-hostile way. In addition, such individuals do not take themselves too seriously.

Offensive humor
Used to be little other people around them. This can be accompanied by sarcastic and biting, as well as sexist and racist features. These people prefer impulsive jokes without thinking they can hurt others. Sometimes they threaten, harass or intimidate others, using offensive humor. Self-humiliating humor This style of humor is used to gain acceptance by doing or saying funny things that involve and misrepresent yourself. People who use this kind of humor are insecure, they want to fool themselves by letting others make fun of them.
communication problem will cause the patient to withdraw and isolate herself, it is obvious that it will be beneficial for the nurse to use approaches such as humor to relax communication. Good communication is an important step in determining the patient's needs and supporting the patient. Freud, [24] for example, assumes that humor is one of several methods an individual uses to prevent the painful.
Some studies [25] on humor are examined. Their psychological components can be listed as follows; • Humor Creation/Humor production; describes an individual's ability to create a state of humor like a comedian or by joke telling.
• Humor Appreciation; the ability of the individual to perceive, appreciate and interpret humor stimuli and situations.
• Humor coping; is the individual's use of humor in stressful and tense situations. [26] According to Dean and Major, [27] the value of humor in palliative care lies not in its capacity to change reality, but in promoting emotional and psychological changes that facilitate humane investigation of disease for both healthcare professionals and patients. Humor also helps healthcare providers reduce the stress caused by end-of-life care. [28] Considering all these reasons, it can be said that there is a good reason for the use of humor in palliative care services in our country.

Use of Humor in Palliative Care Practices
Nurses, doctors, therapists, volunteer hospice staff who work with patients and their relatives in the end-of-life period avoid using humor in their daily work and conversations. The dominant opinion is that an individual facing death as a result of an incurable disease has nothing left to laugh. In fact, considering the potential of humor to be useful in situations where it is used positively, making brighter the extremely serious daily life by using a little humor will facilitate palliative care and increase its quality. [29] Humor helps an individual to relax cognitively by affecting their physiological and psychosocial state. Nunes et al. [30] as a result of their studies with 66 nurses who experienced at least one death in palliative care wards, they found that humor can be used in supportive and nursing practices in the process of death and grief. According to the result of the study, nurses stated that they did not see humor alone enough to cope with stress, and they needed problem-focused coping mechanisms.  [4] does not conflict with the use of humor in its application areas, as it includes respect for the sick individual and self-sharing. Thus, the individual experienced in the last stages of life can share moments of laughter with other individuals. In addition, when humor is used as an approach in nursing interventions in palliative care, there will be an increase in the quality of life for the patient and their relatives. In a study conducted with palliative care patients in hospice and palliative care units, 76% of the participants stated that they valued humor. Majority of them stated that they found humor-based communication with doctors (76%) and nurses (88%) and appropriated. [31] In another study examining the interactions of nurses and patients in nursing homes and hospice, humor was found in 85% of 132 interactions observed. While patients in 70% of these interactions were the initiators of humor, it was determined that nurses were the initiators in only 18% of these interactions. [32] Steinhauser et al. [33] In their studies on 340 seriously ill patients, 93% of the participants stated that they agreed that a sense of humor is important in the end-of-life period. Pinna et al. [34] say that humor is not well researched in oncological treatment and care services despite its positive effect. The shortcoming in nursing research in this field to date is that almost all researchers ignore the humor theories in the psychology literature. In addition, despite the deficiency in this field, this does not prevent some commentators from the interpretation that humor will not bring any benefit to nursing interventions. [35] Every situation in which humor is applied should be examined individually and depending on the situation. Especially, nurses in nursing practices who want to use humor in palliative care should observe the situations in which laughing is not appropriate, in other words, the limits of humor are reached (Table 3).
Humor continues to be an important factor during illness in individuals who play an important role in their pre-illness lives.  [6] In other words, people who are cheerful can maintain this mood during illness. However, it should be taken into account that she/he was a cheerful person in the past, and she/he had great difficulty in maintaining their sense of humor during illness. When they get sick, they no longer like to laugh [36] and have changed to the extent that they characterize themselves as different people from the outside. [37] The general recommendation for the "when to use humor" debate is to adapt it to the patient. [34] On the other hand, health professionals who provide palliative care services have positive attitudes and good humor, which will increase the quality of the services provided. [38] It would not be wrong to say that an important principle here is that despite the humor used in nursing practices, the patient feels taken seriously from the other side. This means that the nurse carefully determines whether the use of humor is appropriate or not by evaluating the patient's condition from every aspect in palliative care services. The most important point that facilitates the transfer of humor to the application areas is the detailed anamnesis of the patient. Thus, by using the right amount of humor at the right time, the success rate in nursing services is increased. When using humor, it is important to convey the message that the relationship with the patient is valued in order to give the impression of laughing with the patient rather than laughing at herself/himself. Therefore, the quality of the relationship created is an important component in the use of humor. [13] The purpose of carrying humor to applications; It stems from the need for an approach that increases the quality of the nursing services provided. This does not mean that the nurse should only wait for a sign from the patient to use humor in nursing diagnoses. Humor can be used as an approach in possible nursing diagnoses about the patient, and discussions about humor with patients and colleagues are supported by bringing humor as an approach. Ex. Such as newspaper and magazine articles, comedy movies, medical staff's own experience (funny experiences with children or animals). Thus, the whole team's sense of humor is strengthened. Especially days when humor is encouraged, such as April 1, are particularly suitable for bringing humor to the agenda. Here, defining humor within the team will help team members to perceive humor and carry it to its application areas. [16] Humor journaling is a way to combine spontaneous and planned humor. Anyone who writes funny experiences contributes to the use of humor in the services provided. [13] Here, it is meaningful to have a general knowledge about the situations where humor is used in palliative care units. Pina et al. [34] They summarized the usage and functions of humor in palliative care as shown in Table 4 in their systematic reviews about humor.
Patient's use of humor is invaluable for its capacity to develop the relationship between the patient and her/his family and healthcare professionals as well as professionals. On the other hand, humor has a different effect on building relationships between professionals. Humor normally enhances teamwork. It is effective in the workplace, reduces stress in the workplace and increases job satisfaction. Humor neutralizes hierarchical differences between professionals, generates confidence, aids in acceptance of flaws, and has a preventive effect on stress. [34] For example, nurses working in oncology wards are often faced with emotional stress that can lead to syndromes such as compassion fatigue and burnout. [39] It is recommended that the use of humor approach in possible nursing interventions and among the working team in these fields can positively support the work environment and as a supportive element in coping with the stress that the staff will encounter. [40] Humor can be used as a therapeutic communication tool when used with sensitivity. For example, various communication difficulties, where brain metastases affect a patient's speech or where maxillofacial surgery results in physical speech difficulties, can make communication difficult. In such cases, patients can use humor using non-verbal communication forms such as blinking, eye contact or gestures or hand gestures. Nurses should be sensitive to recognize humor if it is expressed by patients in body language and non-verbal cues. With an increasingly multicultural social profile associated with globalization and Table 4. Situations where humor is used in palliative care [34] Situations related to the patients and their relatives Relational situations Occupational work situations

Hopelessness
In personal or complex medical To combat burnout syndrome examination situations In spirituality and existential inquiry Anxiety about medical care Managing the recurring feeling of loss In complicated or complex situations and in need to review To accept reality Preservation of perspective to resolve problems To create a positive environment by shaping what Accepting the truth is experienced In the expression of feelings; as a defense mechanism to face death, fear and anxiety management, stay alive In the acceptance of the end of life by keeping the distance To increase self-esteem and to manage one's own vulnerability Adapting to loss situations To feel the feeling of being in life and to recall happy memories migration, there are a wide variety of words, actions and social norm meanings in any health setting. This may limit the effective use of humor; If a wrong message is sent or received, it can lead to negative consequences such as misunderstanding, upset or violation. Therefore, nurses need to be aware of the obvious and potential differences in the humor and cultural meanings of words and actions. [41] Adamle and Ludwick [42] examined which cues from sick individuals would like to initiate a humorous communication. As a result of the research, it is revealed that the intonation in verbal communication and speech is a significant variable for the recognition of humor by the patient and response to humor. Tanay et al., [41] using observation and one-on-one interview methods in the oncology ward, found that patients use humor to help nurses cope with the stress they face in their clinical practice and to strengthen nurse-patient communication. Patients stated that they perceive nurses who use humor positively. The nurses participating in the study, on the other hand, stated that they carried humor to their practices where more consensus was sought in professional understanding. The interpretation of humor depends on the individual and is influenced by culture, gender, and stress levels. Associating humor with play creates a bond of empathy by bringing both sides closer to each other. However, it should be kept in mind that at times humor and games can conflict with cultural expectations and respect for the dying person. [34,43] Kinsman and Gregory [34] suggest caution when moving to practices, given that the majority of women who practice the nursing profession are women. Especially for some patients, it may not be appropriate for nurses to laugh or joke with them. Otherwise, it may be the case. Clown therapy is considered inappropriate when the patient is asleep, in acute pain, very ill, or cannot understand whether the person has entered their room or why they have arrived. Some nurses say that the use of humor in practice should be arranged according to the signs coming from the patient, others say that nurses should decide on this in their care initiatives. [44] Bischofberger [15,16] offers options for the possibilities of adapting humor according to Pasquali: [45] • Evaluate the level of anxiety: Humor is appropriate when patients have mild or moderate anxiety levels and can reduce it. • Recognizing coping strategies: Humor is an effective and beneficial coping strategy for the patient if it enables the cognitive and emotional state of the patient to perceive and laugh, and helps reduce social distance by giving the patient a new perspective. • Adjusting the humor style: It can be used in practice if the humor style used is able to meet with the patient on a common ground by centering laughing together. AstedtKurki and Isola [46] state that patients find it easier to discuss difficult issues with nurses who have a sense of humor that they can use as a starting point to communicate their concerns. In their observations of patient conversations in a palliative daycare setting, Langley-Evans and Payne [47] emphasize the value of humor in allowing patients to psychologically distance themselves from death while allowing acknowledgment of the severity of the disease. While clinical knowledge contributes to evidence-based research and practice guidelines, superficial information such as knowing when and how to introduce humor is an important source of nursing knowledge. The thing to remember here is that humor will not change the reality of the terminal illness. However, these are not trivial things that should be easily rejected. It eases the experience of the last days and enriches caring relationships.

Conclusion
The use of humor in daily life brings positive social and psychological effects. Nurses can use a group of humor techniques (word games, imitation, surprise, etc.) to serve a specific purpose in palliative care services. For many people, a humorous approach facilitates participation in topics that are taboo to talk about. Humor doesn't change the situation itself. However, the individual who experiences the situation can change her/his attitude towards what is experienced. The application of humor in nursing interventions is associated with the participants' understanding of each other, spiritual preparedness, emotional maturity, and acceptance of mutual humor. The research literature reveals that the prerequisite for providing emotional support to the patient individual is improving the communication of patient experiences in reaching a therapeutic goal in nursing interventions. [48] Here, the participation of the nurse in the communication process for the patient or vice versa is prioritized. Nurses experience difficulties during this process in the delivery of palliative care services. Because most of the patients have reached the end of the disease processes in which a therapeutic relationship is limited. For this reason, it is important to choose the humor that will be used in nursing interventions carefully. There is a need for research on how to manage this limitation.