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研究生:黃聖媖
研究生(外文):Sheng-ying Huang
論文名稱:醫老溝通之笑聲研究-笑聲對病人參與量之影響
論文名稱(外文):Laughter in Doctor-Elderly Patient Communication- Effects on Patient Participation
指導教授:蔡美慧蔡美慧引用關係
指導教授(外文):Mei-hui Tsai
學位類別:碩士
校院名稱:國立成功大學
系所名稱:外國語文學系碩博士班
學門:人文學門
學類:外國語文學類
論文種類:學術論文
論文出版年:2008
畢業學年度:96
語文別:英文
論文頁數:98
中文關鍵詞:面子互動情境情境寒暄語開場後階段開場階段笑聲醫老溝通病人參與量社會關係話題
外文關鍵詞:patient participationfaceinteractional contextpost-opening stagesocio-relational topicssituational greetingopening stagelaughterdoctor-elderly patient communication
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笑聲為一種互動機制,是人與人溝通中重要的一環。互動雙方對於當下互動過程需要一定的敏感度與專注力才會有笑聲出現,當互動雙方建立背景並達到共同理解,笑聲便出現(Coser, 1959)。在互動中笑聲能夠調整人與人間的距離,人可以藉由笑聲拉近彼此距離、表達善意和分享喜悅,也可以藉笑聲面對難堪或是尷尬敏感的時刻。笑聲的多重功能使得笑聲在溝通過程中佔有重要地位。醫病互動是攸關生死且嚴肅的,笑聲在這樣的互動情境下便成為良好的潤滑劑(Chafe,2001)。尤其當醫病間面臨尷尬或是不可抗力的困難時,適當的笑聲有助於安撫病人情緒並給予支持(Francis,Monahan, & Berger, 1999)。過去研究者專注於探討笑聲的功能(Baker et al., 1997; Partington, 2006; Stewart, 1995)、類型(Beck, 1997;Sayre, 2001)或笑聲在互動中的出現結構(Glenn, 2003; Haakana, 2001; Osvaldsson,2004)。然而這些研究都忽略笑聲對於當下互動所帶來的即時影響。笑聲的出現是否會改變互動雙方後續的互動?有笑聲與無笑聲的互動,是否造成其它不同之互動效果?

本文研究重心便在於觀察笑聲對於醫病互動所造成之影響。參與者包含18位醫師(平均年齡33歲)和55位病人(平均年齡74歲),這55個問診互動皆為初診,錄影語料來源為南部某教學醫院。笑聲界定為一般人能夠聽到的聲音,並依據其本能判斷為笑聲(Bachorowski, Smoski and Owren, 2001)。本文從宏觀與微觀檢視笑聲的影響。在宏觀中,我將問診全程分為開場階段(Opening stage)與開場後階段(Post-opening stage),此兩階段的分野為醫師所使用的第ㄧ個醫療相關問題(例如“a li kin-a-jit si an-na? / What’s your problem today?”),試比較開場與開場後笑聲的數量與出現時間點。結果顯示(1) 若開場階段有笑聲者,其開場後階段笑聲數量多出7.8個笑聲(開場有笑聲者,開場後笑聲出現平均為18.9個;開場無笑聲者,開場後笑聲出現平均為11.1個)。(2) 開場有笑聲者,其開場後的第ㄧ個笑聲較早出現(開場有笑聲者,開場後第ㄧ個笑聲出現時間點為主訴後的第140秒; 開場無笑聲者,開場後第ㄧ個笑聲為第250秒)。由此結果發現開場笑聲的出現有助於後續階段笑聲的出現,也加速開場後階段笑聲的出現。因此,本文作者可以推論開場笑聲的出現代表互動雙方皆對互動當下達到共同理解,問診嚴肅感藉由笑聲去除之後,醫病雙方便延續開場之輕鬆愉快之互動框架(framing),也因此,開場後笑聲出現更多也更容易。

在微觀中,本文分析重點專注於開場笑聲對於開場本身的影響,試比較開場笑聲與病人發言量間的關係。Tsai(2005)指出醫師使用情境寒暄語(situational greeting,像是“li ma-king e lang hioo?/Wooh! You are from Ma-king City?”)相較於制式寒暄語(general greeting,像是“li ho/ How are you?”) 能引發病人較多發言(51.7音節vs. 4.2音節),有鑑於寒暄語對病人發言量之影響,本文也試比較開場笑聲、醫師寒暄語與病人發言量三者間的關係。結果顯示(3) 開場笑聲之有無與病人平均發言量呈正比(有開場笑聲者,開場病人平均發言量為52.5音節;開場無笑聲者,開場病人平均發言量為5.9音節)。(4) 使用情境寒暄語並有笑聲出現的開場有較多的病人平均發言量(開場使用情境寒暄語並有笑聲者,開場中病人平均發言量為61.1音節;無笑聲者,開場中病人平均發言量為 6.8音節)。本文結果顯示開場笑聲的出現有助於病人的發言,若醫師使用情境寒暄語並有引發病人笑聲,此情境下能引發最多的病人發言量。據此,我們推論情境寒暄語與笑聲對於病人的發言有正面的影響。當醫師用情境寒暄語關心病人,病人發言較多,笑聲出現的機率也相對提高,在交互影響之下,醫師能搜集到較多來自病人的第ㄧ手資訊。

除了量化分析,本文亦採質化分析,觀察笑聲經常出現的互動情境,分析並歸納笑聲出現前的言談互動。結果顯示(5) 在下列敏感話題與活動中笑聲經常伴隨出現,像是問及病人已亡親友、過去生子觀念等文化相關話題或有關病人生活習慣等話題,另外像是糾正錯誤訊息與對他人言論看法以笑聲回應等活動。這些話題與活動的共同特色便是互動雙方的面子需求。笑聲成為弱化醫師與病人面子威脅的最有效的機制。綜合以上量化與質化分析結果,我們可以發現笑聲對問診互動產生實質影響,開場笑聲的影響不僅是對於開場本身也包含後續互動。因此,本文建議醫師使用情境寒暄語作為開場模式,如此可以引發較多病人發言,也有助於開場與開場後笑聲的出現,同時笑聲也可以作為醫師處理敏感或困難問題時的有效溝通方式。
Laughter is regarded as an interactional device in conversations and it is an important element in human communication. When interactants have a mutual understanding of the situation at hand laughter occurs (Coser, 1959). People can laugh to shorten the distance, express friendliness and also express joy. People can also
laugh to deal with awkward or sensitive moments. Doctor-patient interactions are usually regarded as serious contexts and laughter is the best lubricant (Chafe, 2001),
especially when encountering embarrassing moments and uncontrollable problems (Francis, Monahan, & Berger, 1999). Researchers devoted to analyzing the functions
(Baker et al., 1997; Partington, 2006; Stewart, 1995), the types (Beck, 1997; Sayre,2001), or the interactive organization of laughter (Glenn, 2003; Haakana, 2001;
Osvaldsson, 2004). Despite this abundant research, few of them inspect how laughter affects the doctor-patient interaction. Thus, the current research examines the effect of laughter on doctor-patient interaction in both quantitative and qualitative approaches.

The participants in the research include 18 physicians (an average of 33 years old) and 55 elderly patients (an average of 74 years old) on the patients’ first visit to a teaching hospital in southern Taiwan. The identification of laughter is based on the intuition of an “ordinary person” to identify “audible sound” that can be “regarded as laughter” in an interaction (Bachorowski, Smoski and Owren, 2001, p.1582). I separated each consultation into opening and post-opening stages and the doctor’s first medical related question (such as “a li kin-a-jit si an-na? / What’s your problem today?”) is
used as the boundary of the two stages.
The present study applied both macro and micro analyses of the effect of laughter on the doctor-patient interaction. In the macro analysis, I observed the effect of opening stage laughter on the amount and timing of the post-opening stage laughter. (1) Within consultations with opening stage laughter, the instances of post-opening
stage laughter (18.9 instances) were more than those without opening stage laughter (11.1 instances). (2) The first post-opening stage laughter accelerated when opening
stage laughter occurred (140 seconds when with laughter versus 250 seconds when without laughter). One explanation for the increased instances of laughter and accelerated timing of laughter is that the occurrence of opening stage laughter mitigates the seriousness of medical consultations and sets a lighter and joyful framing of the interactions at hand. Thus, the post-opening stage laughter occurs more often and earlier.

In the micro analysis, I inspected the effect of opening stage laughter on the immediate stage by observing the degree of patient participation. Tsai (2005) observed
that doctors’ use of situational greetings (such as “li ma-king e lang hioo?/Wooh! You are from Ma-king City?”) elicited more patient participation than using general
greetings (such as “li ho/ How are you?”). In view of the effect of doctors' greeting expressions on patient participation, I examined the relationship among the
occurrence of opening stage laughter, doctors’ greeting expressions, and patient participation. The patients’ verbal activity can be regarded as an agent of patient
participation and through calculation of the amount of the patients’ verbal activity one can evaluate the patients’ degree of involvement and participation (Ishikawa et al.,2005). (3) The occurrence of opening stage laughter was positively related to the average amount of patient syllables (5.9 syllables when without laughter versus 52.5
syllables when with laughter). (4) In the situational greeting pattern, those with laughter contained a higher amount of patient syllables (61.1 syllables) than those
without laughter (26.8 syllables). The present results prove that doctors’ greeting expressions and the occurrence of opening stage laughter both have a positive effect on the degree of patient participation. When doctors use situational greeting patterns with patients, the patients tend to be more forthcoming and the probability of the occurrence of laughter increases and doctors may gain more first-hand information
from patients.

I also incorporated the qualitative analysis to observe the interactional contexts in which laughter commonly co-occurs. (5) When tackling sensitive topics (death issues,
cultural related issues, medical issues, or health behavior issues) or activities (correction and acknowledgement), laughter usually occurred. The common
characteristic of these topics and activities is that they are the possible contexts of face threat and thus laughter becomes an effective device in mitigating the threats to
doctors and patients. In that, I suggest doctors use situational greeting patterns, which can elicit more patient participation and also increase the possibility of laughter in both opening and post-opening stages, and use laughter as a resource for dealing with sensitive and delicate issues in consultations.
ABSTRACT (Chinese) i
ABSTRACT (English) ii
ACKNOWLEDGEMENTS v
TABLE OF CONTENTS vi
LIST OF TABLES ix
CHAPTER ONE INTRODUCTION 1
Motivation and Background 1
Purposes of the Study 3
Research Questions 6
A Preview of the Following Chapters 7
Definition of Terms 8
Laughter 8
Patient participation 9
Greeting 9
Interactional context 10
CHAPTER TWO LITERATURE REVIEW 11
Laughter and Humor 11
Laughter as an Interactional Device 13
Patient Participation 16
Laughter and Its Functions 17
Cope with the Situation 17
Build Rapport 19
Laughter and Face 21
Laughter in the Medical Settings 23
Opening Stage 25
Greeting 26
CHAPTER THREE METHODOLOGY 30
Data Collection and Participants 30
Coding of Variables 31
Definition and Quantification of Laughter 32
The Opening Stage and the Post-Opening Stage 36
Quantification of Patient Participation 39
Types of Greeting 41
Categorization of Interactional Contexts 42
CHAPTER FOUR RESULTS AND DISCUSSION 44
Results 45
The Occurrence of Opening and Post-Opening Stage
Laughter 45
The Time Taken for the First Post-Opening Stage
Laughter to Occur 46
The Occurrence of Opening Stage Laughter and Patient
Syllables 47
The Occurrence of Opening Stage Laughter, Patient
Syllables, and Greetings 47
The Interactional Contexts for Laughter 49
Discussion 51
Macro-Analysis of the Effect of Laughter 51
Microanalysis of the Effect of Laughter 54
The Interactional Contexts of Laughter 56
Cultural issues 57
Death issues 61
Health behavior issues 65
Medical issues 66
Correction 73
Acknowledgement 79
CHAPTER FIVE CONCLUSION AND IMPLICATIONS 84
Summary of Major Findings 84
Significance of the Study 85
Limitations and Suggestions of Further Studies 87
Research and Pedagogical Implications 89
REFERENCES 91
APPENDICES
Appendix A 96
Appendix B 98
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