Positive Psychological Measure: Constructing and
Evaluating the Reliability and Validity of a Chinese
Humor Scale Applicable to Professional Nursing
Chia-Jung Hsieh · Yu-Ling Hsiao* · Shwu-Jiuan Liu** · Chueh Chang***ABSTRACT: The nursing profession has generally accepted humor as beneficial to health care. As nursing has always emphasized holistic care and the importance of individual needs, the profession values the ability of humor to positively affect all aspects of a patient’s well being. The purposes of this study were to develop a “Chinese Humor Scale (CHS)” for the nursing profession and then test its reliability and validity. The 405 individuals selected for participation in this study included nursing on-the-job students from a medical university and professional nurses practicing at four hospitals in north Taiwan. Researchers developed a list of 57 key humor measures which were filled out and returned by study participants. An evaluation of results using Cronbach’s alpha coefficients demonstrated good consistency (a = .93) for the developed CHS. Intercorrelations amongst the four sub-scales were generally quite low, indicating each sub-scale measures dimensions relatively distinct from one another (r = .24~.48, both p’s < .001). The CHS was tested using item analysis. The scale was constructed in accordance with exploratory factor analysis (EFA) (K.M.O. = .92). Thirty CHS items, categorized under the four indices of “humorous creativity”, “tendency to laugh”, “perceptivity to humor”, and “humorous attitude”, were found to explain 55.42% of total variances. The CHS was found to provide good validity using a content validity index (CVI) developed by five experts. The results of this study provide encouraging evidence for the construct validity and reliability of the proposed humor scale and support its application by nursing educators and clinicians to further test and assess concepts related to humor. Further research is needed to explore more fully the implications of humor in nursing.
Key Words: humor, exploratory factor analysis, construct validity, positive psychological measure.
Introduction
The nursing profession has generally recognized the importance of humor in the provision of health care. As nursing emphasizes holistic care and the importance of indi-vidual needs, humor’s ability to affect positively all aspects of a patients’ well being is widely recognized. The US fed-eral-level National Institute of Health (NIH) provides infor-mation about and sponsors research in alternative treatment therapies. With its concern for both science and nature, mind and body, and wholeness and individuality, alternative medi-cine naturally encompasses humor therapy.
Therapeutic humor leverages the power of smiles and laughter to help heal. Many nurses and home health care workers already appreciate the value of smiles and laughter in addressing the physical needs of patients under their care. Laughter appears to alter chemical balances in the brain and may help boost immune system effectiveness. Psychoneuroimmunology, an important area of scientific research today, is exploring the brain’s natural ability to affect the body’s ability to heal (National center for comple-mentary and alternative medicine, 2005).
Psychologists have long shown interest in studying the effects of humor on individuals (Martin, 1998) and, since the RN, MSN, Instructor, School of Nursing, Taipei Medical University & Doctoral Candidate, Institute of Health Policy and Management, National Taiwan University; *RN, MSN, Instructor, School of Nursing, Taipei Medical University; **RN, PhD, Professor & Director, Graduate Institute of Nursing; ***PhD, Associate Professor, Institute of Health Policy and Management, National Taiwan University. Received: January 17, 2005 Revised: August 1, 2005 Accepted: August 22, 2005
Address correspondence to: Shwu-Jiuan Liu, No. 250, Wushing St., Taipei 11031, Taiwan, ROC. Tel: 886(2)2736-1661 ext. 6324; Fax: 886(2)2377-2842; E-mail: chuan@tmu.edu.tw
early 1980s, much of humor-related research has focused on the potentially beneficial effects of humor on physical, psychosocial health and well-being (Lefcourt, 2001; Martin, 2001). Current interest in “positive psychology”, which focuses on adaptive strengths, such as optimism, faith and courage, will likely continue expanding studies of humor-related traits (Seligman & Csikszentmihalyi, 2000). As humor is grounded in positive individual traits and cultural background, application of a positive psychology perspec-tive may offer a methodology through which to deliver more comprehensive health care tailored to the needs of individ-ual patients (Huebner & Gilman, 2003). However, despite international interest, research on humor-related issues in health care have been rarely studied within the Taiwan nursing specialty (Liu, 2004). Measurements developed in Taiwan that focused on defining humor in school-aged children (Chen, 2003; Ho & Lin, 2000; Hsu, 2002) are not appropriate for studies of adults or for use in nursing stud-ies. Our objective in this study is to develop a humor mea-surement tool of practical use to clinical nursing. As such, subjects of our research were practicing nurses. The devel-oped Chinese Humor Scale (CHS) was tested by item anal-ysis and in accordance with exploratory factor analanal-ysis (EFA) steps.
Literature Review
Key concepts and cultural differences
Traditional Chinese concepts of humor were aptly described by poet Quyuan, who, in his work the Ninth Chapter, described humor as deep, remote and silent. Merriam-Webster Collegiate Dictionary (2005) defines humor as “a normal functioning bodily semi-fluid or fluid (as the blood or lymph). Merriam-Webster describes humor as “that quality which appeals to a sense of the ludicrous or absurdly incongruous, the mental faculty of discovering, expressing, or appreciating the ludicrous or absurdly incon-gruous, something that is or is designed to be comical or amusing. Humor is a state of mind, formerly believed to determine a person’s physical and mental qualities.” (Com-pact Oxford English Dictionary, 2005). Humor is spread throughout every culture on earth (Howe, 2002). Tradi-tionally, humor is used in a rather latent and suppressed man-ner in Chinese culture. In a cross-cultural comparison that compared with Chinese and American students, Chinese jokes tended to contain relatively greater aggressive content and relatively less sexual content (Nevo, Nevo, & Yin, 2001).
The benefits of humor in nursing education
Humor can be an effective tool for nurse educators to teach course content, hold students’ attention, relieve anxi-ety, establish rapport with students, and make learning fun. When combined with other teaching methods, humor can enhance student learning. The use of humor to stimulate mental processes and control fear and anxiety helps students retain the content they have been taught (Ulloth, 2002).
An extensive study of the social functions of humor (Marie, 2002) found that humor can increase group morale and cohesiveness. Humor has been an integral part of human communication for much of recorded history. Hellenistic philosophers Socrates and Plato were known for their sophisticated humor (Ulloth, 2002). During medieval times, a balance of the four body fluids, known as the humors, was considered necessary to the maintenance of good health. Humor has continued as a topic of interest in various fields (Ulloth, 2003).
The benefits of humor in clinical nursing work Investigations into the relationships between humor and health have increased significantly in recent decades and, today, the results of numerous studies support the idea that laughter and good humor have important and positive roles to play in cardiac rehabilitation, pain perception and discomfort threshold, coping and stress, and immune response (Godfrey, 2004; Paivi & Arja, 2001).
Care provider attitudes can influence patient response to treatment. Attributions of low worth and self-blame, stigma, negative patient behavior, and clinician incompetence can make patients feel unwanted. Many of patients can be hospi-talized for years, and they may be present as angry, hopeless, and helpless. By adopting humor as a focus of patient treat-ment, we understand humor to be a process involving a stimu-lus-humor, i.e., an emotional response of mirth or amusement, usually resulting in such auto-response behavior as smiling, grinning, giggling or laughing (Ulloth, 2002).
The measurement of humor in research development The concept of humor has evolved from it being a fluid in the body to its modern position as a multifaceted concept, characterized by divergent and overlapping theo-ries (Ulloth, 2003). Freud (1960) sparked the psychoanalytical phase of humor research, which included theories of supe-riority and disparagement as means by which forbidden impulses are expressed through one person or group “puts down” another person or group as inferior. In both theories,
humor can be appropriate or inappropriate. Appropriate humor fits the situation; is emotionally uplifting; offends no one; creates a positive, supporting atmosphere; and is relevant to the topic discussed. On the other hand, inappro-priate humor does not fit the situation; can be hurtful, dis-paraging, and offensive; and employs profane or sexual language (Blumenfeld & Alpern, 1994).
Humor has been studied most frequently using a quanti-tative approach. Clinically oriented research has explored humor chiefly as adjunct to other primary treatments and therefore offers little guidance regarding methods by which to evoke therapeutically desirable laughter (Minden, 2002). Sense of humor may be conceptualized in various ways: as a cognitive ability (e.g., ability to create, understand, reproduce, and remember jokes; Feingold & Mazzella, 1993); as an aesthetic response (e.g., humor appreciation, enjoyment of particular types of humorous material; Ruch & Hehl, 1998); as an habitual behavior pattern (e.g., tendency to laugh frequently, to tell jokes and amuse others, to laugh at others’ jokes; Craik, Lampert, & Nelson, 1996); as an emo-tion-related temperament trait (e.g., habitual cheerfulness; Ruch & Kohler, 1998); as an attitude (e.g., bemused outlook on the world, positive attitude toward humor; Svebak, 1996); as a coping strategy or defense mechanism (e.g., tendency to maintain a humorous perspective in the face of adversity; Lefcourt & Martin, 1986); and as a social sharing of emotion (Meisiek & Yao, 2005). However, there is not necessarily a strong correlation between these diverse components of sense of humor, nor are these necessarily instructive regarding which component (or components) are most relevant to pro-fessional nursing. These measures purportedly assess such aspects of humor as the degree to which individuals smile and laugh in a wide variety of situations and utilize humor in a multidimensional sense (Thorson & Powell, 1993). The use and perception of humor depends on multiple contextual complexities and situational dimensions of power.
Thus, despite the widespread view that a sense of humor is an important component of healthy psychological function-ing, humor measures commonly employed in self-reportfunction-ing, at best, show only weak and inconsistent relation to various indicators of psychological, physical, and social well-being. One possible reason for these generally weak findings to data may be that such measures generally do not explicitly distin-guish between the potentially adaptive function of humor and uses of humor that may be less conducive and possibly even detrimental to well-being. The multidimensional sense of humor scale (MSHS), for example, is designed to assess the
degree to which people engage in smiling and laughter, as well as notice, enjoy, create, and express humor (Thorson & Powell, 1993). The humor styles questionnaire (HSQ) assesses four dimensions (self-enhancing, affiliative, aggres-sive, and self-defeating) related to individual differences in humor use (Martin, Puhlik-Doris, Larsen, Gray, & Weir, 2003). The multidimensional sense of humor scale (Chinese version) consists of six subscales, namely “humor compre-hension”, “humor creation”, “use of humor in social con-texts”, ”humor coping”, “the attitude toward humor”, and “the tendency of laugh” (Chen, 2003). Based on findings and recommendations published in the literature (Chen, 2003; Ho & Lin, 2000; Hsu, 2002; Liu, 2004; Thorson & Powell, 1993), we develop and conduct an initial validation of a Chinese ver-sion multidimenver-sional measure in nursing in this paper.
Methods
Definition
Operationalizing humor as laughter has been revealed to facilitate physical health and mental functions, which assesses multiple dimensions related to individual differ-ences in use of humor.
Sampling
This study was designed as a cross-sectional survey. The survey sample comprised 425 subjects, including nursing on-the-job students from a medical university and profes-sional nurses employed at four hospitals in northern Taiwan (including hospitals in both urban and rural districts) Despite data sampling from different units, they all were the nurses at hospitals. The two groups were homoscedasticity. Subject participation in this study was voluntary. To assure complete confidentiality, all answer sheets were anonymous.
Procedure
The study population included a representative sample of clinical nurses and nursing students. Subject participation in this study was voluntary. We developed structured ques-tionnaires to collect data through subjects’ self-report. Vol-unteers who agreed to participate were given an oral expla-nation of the study and its purpose at their place of work or schooling by the research team. The subjects were given another opportunity to decline to participate at the time they received the questionnaire. To assure complete confidential-ity, answer sheets contained no identification numbers and were completely anonymous.
Tool
In developing the Chinese Humor Scale (CHS) for nursing, we employed the construct-based scale construc-tion approach recommended by Jackson (1970), which aims to produce measures that are based in theory with good internal consistency and minimal overlap between measures. The sub-concepts of humor noted most often in the literature include “humor comprehension”, “humor creation”, “use of humor in social contexts”, “humor cop-ing”, “attitudes toward humor”, and “tendency to laugh”. Based on related literature readings, the researchers defined 57 items to use to measure humor (Chen, 2003; Ho & Lin, 2000; Hsu, 2002; Liu, 2004; Thorson & Powell, 1993). Each item was assigned a Likert 4-point response set that ranged from “almost disagree” to “almost agree”, with a higher score demonstrating a higher level of humor for the item measured and a lower score demonstrating a lower level of humor for the item measured.
Another measurement tool, the Perceived Stress Scale (PSS) (Cohen, Kamarck, & Mermelstein, 1983), has proven effective in the assessment of perceived stress. This scale was designed to measure the degree to which situations in one’s life are appraised as stressful. The PSS is a 14-item self-report instrument with a five-point scale (0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, 4 = very often). PSS scores are obtained by reversing scores on the seven positive items and then summing across all 14 items. The items are easy to understand and the response alternatives are simple to grasp. A higher score demonstrates a higher level of per-ceived stress for a measured item. Researchers used the PSS to test CHS discriminability validity.
Data Analysis
Data for this study was collected over a half-year period. Data analysis was done using the statistical soft-ware package SPSS 10.0 for Windows. Item analysis was performed using various statistical methods, including means, standard deviations, and EFA.
Results
The questionnaires of 20 (4.7%) of the 425 subjects who agreed to participate in this study were not used due either to the questionnaire missing more than five responses or to evidence indicating a respondent had not taken the questionnaire seriously. The study accepted 405 question-naires as valid for a response rate of 95.3%.
Demographic Data
The 405 valid subjects in this study were all female (Table 1), between 17 and 55 years of age (mean = 26.89± 6.80 years). Most were unmarried (79.7%) and held a uni-versity degree (56.5%). The main religious affiliation of subjects was Buddhism/Taoism (37.8%). Clinical nurses accounted for 58.0% of the sample, with a mean of 7.15 (SD = 5.54) years at work.
Descriptive Validity for Instruments
This study examined the construct validity of the CHS. Content validity (expert validity) was considered to be supported based on the findings of previous studies and the comments of a panel of five content experts who checked the fundamental design and structure of the test, critiqued CHS relevance, definition, and clarity, and pro-vided suggested revisions to CHS content. According to the suggestions of the experts, seven items were identified as overlapping with others and removed. Item-specific content validity indices (CVI) were calculated, and items Table 1. Demographic Characteristics (n = 405) Variable M SD n % Age 26.89 6.80 £ 20 21-40 ³ 41 43 341 21 10.60 84.20 5.20 Education Graduate school College/University Junior college Senior high school
21 229 122 33 5.20 56.50 30.10 8.10 Religion None Protestant Catholic Buddhist/Taoist Other 215 29 3 153 5 53.10 7.20 0.70 37.80 1.20 Marital Status Unmarried Married Widowed Divorced 322 78 1 4 79.50 19.26 0.25 0.98 Work Status Employed Unemployed 7.15 5.54 170 235 42.00 58.00
with a CVI of less than three were either revised or deleted. The final version of the scale consisted of 39 items. The psychometric properties of the CHS, including item analy-sis and exploratory factor analyanaly-sis measures, were assessed based on the responses of the 405 participants. Item and factor analyses were used to establish the construct validity of the scale in order to ensure that the CHS could evaluate interactions genuinely and efficiently. Analytical proce-dures consisted of the following. First, comparison the outliner group for examined each item’s discriminability. The small group analysis was done. The subjects of all total score in two to class with two groups, they were lower than 27% score and higher than 73% score, compare with inde-pendent t-test. Items 4, 7, 16, 17, 18, 24, 26, 31, and 44, found to be non-significant (p > .05), were removed - leav-ing 30 items. After item analysis, an EFA of the remainleav-ing 30 items was performed. Running a Kaiser-Meyer-Olkin measure of sampling adequacy and a Bartlett’s sphericity test demonstrated that samples met the factor analysis cri-teria (K.M.O. = .92 andc2= 6072.93, p < .001, respec-tively). Principle components analysis was used to extract common factors. Criteria for extraction factors employed
eigenvalues (> 1), scree plots, and component plots in rotated space. We elected to use the varimax method for our orthogonal rotational analysis. Factor analysis yielded a four-factor instrument with an eigenvalue greater than 1 that explained 55.42% of the variance in the 30 items used in the CHS. Through orthogonal rotation, a factor loading of .5 was selected as the cut-off point to delete items with loading values smaller than .4 that could not be catego-rized. This resulted in a total of 30 items that could be cat-egorized within the four factors, explaining a total vari-ance of 55.42%. The four selected factors included Factor I: “humorous creativity” (incorporating sixteen items, with a variance of 33.34%); Factor II: “tendency to laugh” (incorporating six items, with a variance of 9.58%); Fac-tor III: “perceptivity to humor” (covering four items, with a variance of 6.50%); Factor IV: “humorous attitude” (covering four items, with a variance of 6.00%). Total variance for each factor and the loading of each item are illustrated in Table 2. Correlations between the four of CHQ dimensions were significantly negative in correla-tion with the Perceived Stress Scale (PSS) (r =-.12~.32, both p’s < .05), with the exception of “humorous
creativ-ity” (see Table 3). The research subjunctives were to class low-PSS scores and high-PSS scores, the two group was significantly difference in the dimension of humor percep-tion and laugh tendency (t = 2.40~4.39, both p’s < .05). The CHS discriminability validity was good.
Instrument Descriptive Reliability and
Intercorrelations
Reliability measures with regard to the CHS were assessed using the responses of 405 participants. The inter-nal consistency Cronbach’s alpha reliability coefficient for the total scale was .93 and item-scale correlations fell between .32-.69. Cronbach’s alpha coefficients for each of the four factors ranged from .76 to .94 (Table 2). The gener-ally low intercorrelations among the four sub-scales indicate that these sub-scales measure dimensions relatively distinct from one another. Not surprisingly, all sub-scales were posi-tively correlated (r = .24~.48, both p’s < .001), indicating that an individual who used humor creativity along one dimension was likely to do so along others as well (Table 4).
Discussion
In our development of a CHS for nursing, we employed the construct-based scale construction approach recom-mended by Jackson (1970), which aims to produce theo-retically-based measures with good internal consistency and minimal inter-scale overlap. Internal consistency and reliability are especially important when we were
measuring constructs. The results of this study indicate that the CHS has good reliability in Taiwanese and that it is valid for use with nurses to assess humor. Stevens (1996) stated that the purpose of EFA is to identify the factor structure of a set of variables, and should be considered as a theory-generating procedure. Therefore, it can be used to establish the construct validity of an instrument.
It is expected that the CHS will be useful for research on humor and psychological well-being to assess forms of humor that may be deleterious to health as well as those that may be beneficial. Interest in the study of humor-related traits is likely to continue in view of current atten-tion to the concept of “positive psychology” (Seligman & Csikszentmihalyi, 2000). Therefore, our development of this measure began by examining past theoretical and clini-cal literature on the relationships between humor and well-being to identify the various functions, forms, or styles of humor that have been described as either adaptive and beneficial or maladaptive and detrimental to human health. The Chinese Humor Scale assesses four dimensions related to the different uses and functions of humor in everyday life. The factors result is nearly identical to the findings of Chen (2003). Chen’s sense of humor survey, designed to explore how sense of humor affects cognitive appraisals that individuals make during periods of stress or emotional difficulties, used a scale that incorporated the six subscales of “humor comprehension”, “humor creation”, “using humor in social contexts”, “humor coping”, “atti-tudes toward humor”, and “the tendency to laugh”. Chen’s Table 4.
Intercorrelations Between the Four CHQ Dimensions (n = 405)
Item Humorous creativity Tendency to laugh Perceptivity to humor Humorous attitude
Humorous creativity 1.00*** Tendency to laugh .23*** 1.00*** Perceptivity to humor .37*** .30*** 1.00*** Humorous attitude .48*** .24*** .27*** 1.00 *** p< .001. Table 3.
The Correlations of the Four CHQ Dimensions With the Perceived Stress Scale (PSS) (n = 405)
Low-PSS High-PSS Item (M ± SD) (M ± SD) g t Humorous creativity 52.28± 7.90 50.86± 8.80 -.09 1.70 Tendency to laugh 16.87± 2.69 15.74± 2.49 -.32*** 4.39*** Perceptivity to humor 12.81± 1.97 12.32± 2.09 -.12* 2.40* Humorous attitude 12.69± 1.73 12.50± 1.97 -.12* 1.06* *p< .05. *** p < .001.
study provided empirical support for the stress-buffering (mediating) effects and the positive enhancement effects of humor.
By assessing each of these aspects of humor, we expect that these scales, taken together, may account for a greater proportion of the variance among variables than do previous self-report humor scaled. This finding agrees with the results of studies done previously by Thorson and Powell (1993) and Chen (2003).
Conclusion and Applications
The strength of this study is its focus on positive ele-ments to measure psychological health. The CHS repre-sents a new approach to assess individual differences in humor because it is the first self-report measure to specifi-cally assess ways in which people use humor in ways that are less desirable and potentially detrimental to psycholog-ical well-being. CHS takes into consideration the previous observations of experts (Martin et al., 2003) that certain forms of humor can be deleterious to psychological health. We developed a nursing CHS as an effective rating scale by which to evaluate the concept of humor as it relates to patient and health care. The CHS for subjects were evalu-ated with Cronbach’sa coefficients. Both the internal con-sistency and stability of the scale were higher than .8, indi-cating that scale reliability is acceptable. The CHS was tested by item analysis and in constructed in accordance with exploratory factor analysis (EFA) steps. The construct validity of the scale was good, as was its discriminability validity. The CHS was constructed around four factors (sub-scales). Overall, the present findings offer encourag-ing evidence in support of CHS construct validity. In addition to the convergent self-report data, correlations observed amongst each of the four CHS subscales and peer ratings of corresponding dimensions provide promising evidence of criterion validity and specificity. Based on the result, we see encouraging evidence in support of both the construct validity and reliability of CHS and believe that the scale can be applied in both nursing education and prac-tice. Futher research is required to explore the psychologi-cal health implications of the use of humor.
Limitations
Because this study employed a cross-sectional research design, we were unable to assess changes in humor over time. For longitudinal designs (i.e., repeated measures) are appro-priate. Also, as this study is limited to female subjects,
find-ings can neither be generalized nor be taken as representa-tive of all nursing fields. More research is needed to explore the applicability of CHS in diverse gender populations.
Acknowledgments
We would like to thank the Taipei Medical University Research Funds for their financial support (TMU92-AE1-B17). We would also like to express our appreciation to all the students and nurses who participated in this study and contributed their valuable opinions.
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