This document discusses how Leininger's Theory of Culture Care Diversity and Universality and humor therapy can be combined to improve outcomes for home health patients. It provides an overview of Leininger's theory, which focuses on preserving, accommodating, and restructuring a patient's cultural care based on their beliefs, values, and practices. It also describes humor therapy, its advantages of reducing stress and pain, and the need to ensure humor is culturally appropriate. The document presents a case study of a 72-year-old Irish-American man with leg ulcers who enjoyed British comedy and agreed to have humor therapy added to his wound care. His clinician incorporated humor therapy by playing comedy movies to distract from pain during treatment

1. 552 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Home health clinicians provide care for a culturally diverse
patient population. According to Leininger’s Theory of
Culture Care Diversity and Universality (2010), caring is a
universal phenomenon that varies based on a patient’s
cultural beliefs, values, and practices. Humor
therapy promotes spontaneous therapeutic pa-
tient laughter. Assisting patients and families
to maintain or regain their health or well-being
and to deal with disabilities, dying, or other
human conditions in culturally congruent and
humorous ways may be beneficial. The pur-
pose of this article is to discuss how Leininger’s
Theory of Culture Care Diversity and Universality (Leininger
& McFarland, 2006) and humor therapy can be combined to
achieve better outcomes for home health patients. A case study
of how this was applied to a first-generation Irish-American home
health patient is included.
Allillustrations©KathleenD.Schwartz
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2. vol. 28 • no. 9 • October 2010 Home Healthcare Nurse 553
Kathleen D. Schwartz, BSN, RN, and Jana C. Saunders, PhD, RN, CNS
Leininger developed the idea of integrating ap-
propriate cultural patient practices with patient
care interventions to improve satisfaction among
patients and healthcare outcomes. The clinician
can effectively use these concepts to guide judg-
ments, decisions, and actions to plan a culturally
congruent patient humor therapy intervention
for home health patients.
Humor Therapy
Humor therapy creates positive and hopeful atti-
tudes and positive light-hearted communication
between patients and clinicians. The Associa-
tion of Applied and Therapeutic Humor (AATH)
(2010) defines humor therapy as:
Any intervention that promotes health and
wellness by stimulating a playful discov-
ery, expression, and/or appreciation of the
Theory
Leininger’s theory has been used for over three
decades to develop creative approaches to en-
sure that patient’s care and cultural needs are
met in a meaningful and helpful manner. Leini-
nger and McFarland (2006) identified three major
theory concepts:
1. Culture care preservation and/or
maintenance—professional acts that help
cultures maintain care beliefs and values
2. Culture care accommodation and/or
negotiation—provider care actions that
help cultures adapt to or negotiate with
others for culturally congruent care
3. Culture care repatterning and/or
restructuring—professional actions and
mutual decisions that help people modify
their lives for better healthcare practices.
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3. 554 Home Healthcare Nurse www.homehealthcarenurseonline.com
absurdity or incongruity of
life’s situations. The interven-
tion may enhance health or
be used as a complementary
treatment of illness to facilitate
healing or coping, whether
physical, emotional, cogni-
tive, social, or spiritual. (p. 1)
The American Cancer Society
(2010) endorses humor therapy
for the “relief of physical or
emotional pain and stress and
as a complementary method to
promote health and cope with
illness” (para 1). The common
concepts associated with humor
therapy in literature are as fol-
lows:
• The healing power of humor
• Laughter is the best medi-
cine
• Laughter is a diversionary
tactic
• Humor therapy strengthens
the bond between patient
and clinician
• Laughter is a coping
strategy
Clinicians who integrate
humor with patient treatment
regimens create a positive at-
mosphere by promoting an im-
proved healing environment. Laughter acts as
a positive respite from the negative emotional
effects associated with illness. Coping with ill-
ness, injury, or end-of-life issues can be difficult.
Adding humor improves a patient’s ability to
express negative emotions in a more positive
manner.
Advantages
There are multiple advantages of humor ther-
apy. Humor therapy is safe, risk-free, and an
inexpensive way to create a positive patient
and clinician interaction. Humor therapy in-
terventions designed specifically for the needs
of a patient may change a painful, unpleasant
treatment regimen into a less painful, more tol-
erable experience. Humor and laughter reduce
negative feelings that hamper
the healing process. Patients
unable to verbalize feelings of
fear, anger, or sadness may be
able to laugh or cry, thereby
unleashing the fear, anger, or
sadness associated with illness.
Disadvantages
A disadvantage of humor ther-
apy is that it may be considered
offensive or distracting to a pa-
tient during extremely stress-
ful times. Therefore, humor
therapists must consider an
individual’s cultural perception
of humor and be sensitive to
laugh with, not at, the patient
and remember “what is con-
sidered funny, is very much
influenced by a person’s bio-
physical, psychological, socio-
cultural, and spiritual states of
being” (Pasquali, 1990, p. 31).
In addition, a humor therapist
should take particular care
when using humor and laughter
with patients who are acutely
paranoid, critically ill, or termi-
nally ill to ensure it is not mis-
interpreted (MacDonald, 2004).
Wojciechowski (2007) recom-
mends that clinicians also listen
for a patient’s attitude, voice
tension level, inflections, and
personal facts that help them better understand
a patient’s world—including “boundaries” for
appropriate humor.
Practitioners
Humor therapists are not board certified or
licensed therapists. Informal hands-on humor
skills training programs are available to help
develop a basic foundation for using humor as
a healing and coping tool (LaughterRemedy.
org, 2010). The AATH is an organization of
networking professional individuals interested
in the practical application of humor in their
work. The most important qualification of a
humor therapist is the desire to bring the heal-
ing power of laughter to other people. Humor
therapists spread laughter with a spirit of
Humor therapy is
safe, risk free, and
an inexpensive way
to create a positive
patient and clinician
interaction. Humor
therapy interventions
designed specifically
for the needs of a
patient may change
a painful, unpleasant
treatment regimen
into a less painful,
more tolerable
experience.
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4. vol. 28 • no. 9 • October 2010 Home Healthcare Nurse 555
Mr. Murphy, is diagnosed with multiple infected
bilateral lower extremity stasis ulcers second-
ary to severe peripheral vascular disease. He
requires a clinician to perform every-other-day
wound care and compression wrapping to his
lower extremities. Mr. Murphy tells the clinician
he remembers reading a newspaper story about
her clowning travels to China and Tibet with
the famous doctor, Patch Adams, MD. The clini-
cian confirms the story and asks Mr. Murphy
whether he would allow her to add clowning
and humor therapy to his wound care treatment
regimen. Mr. Murphy eagerly agrees saying, “An
Irishman can do with a bit of humor now and
then.”
Mr. Murphy’s peripheral circulation im-
proves when he sits in a recliner elevating his
compression wrapped legs. Due to being chair
bound, he watches television to ease boredom.
The clinician performs a cultural/humor as-
sessment and finds Mr. Murphy enjoys British
comedy movies (Table 1). Mr. Murphy is an
educated man and enjoys the humor of sat-
ire. He does not drink alcohol due to a prior
playfulness in an effort to bring a sense of well-
being to patients. Providing patient care with
a spirit of humor using magic tricks, juggling,
music, comedy movies, or gags promote the
healing power of humor.
Ethical Considerations
The clinician should use moral, principled judg-
ment when applying Leininger’s Theory of Cul-
ture Care Diversity and Universality and humor
therapy to patient practices. Humor should al-
ways be free of gender, race, political, and reli-
gious bias so the patient will not be inadvertently
offended. Humor therapists have adopted no offi-
cial code of conduct or ethical guidelines, but are
self-regulated by an unwritten moral obligation.
The humor therapy intervention is carried out in
a safe manner, posing no physical or psychologi-
cal harm to the patient. For instance, in the case
study presented below, Mr. Murphy had control
of the humor therapy intervention by choosing
which movie to watch during the wound treat-
ment regimen.
Integration of Theory and Therapy
Case Presentation
The home health patient is a 72-year-old first-
generation Irish-American male. The patient,
Table 1. Home Health Patients:
Cultural and Humor Assessment
1. What is your ethnicity?
2. Describe your cultural beliefs.
3. Discuss any negative connotations
that you think may be related to your
ethnicity.
4. Do you enjoy comedy and/or humor?
If so, how?
5. What are your favorite humorous
movies?
6. Is laughter a positive experience
for you?
7. Would you be willing to participate in
a home health humor intervention?
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5. 556 Home Healthcare Nurse www.homehealthcarenurseonline.com
Humor Therapy in the Care
Planning Process
Physical Assessment:
• Experiences pain and discomfort during
wound care for multiple bilateral stasis
ulcers.
Culture/Humor Assessment:
• The cultural/humor assessment indicates
patient is proud of his traditional Irish-
American heritage and enjoys British com-
edy and humor and especially movies. He
believes laughter helped him through the
“rough times” in his life and is very eager
to participate in a home health humor
intervention.
• The home health clinician may use the ques-
tions provided in Table 1 to perform a pa-
tient cultural/humor assessment.
Nursing Diagnoses:
An appropriate applicable North American
Nursing Diagnosis Association [NANDA] (2007—
2008) diagnosis related to the case presentation
patient is:
• Risk of acute pain and discomfort related to
wound treatment regimen.
history of alcoholic tendencies; therefore, any
Irish drinking connotations will be avoided. Mr.
Murphy has acculturated as an American but is
still very loyal to his Irish heritage and beliefs.
The clinician requests the patient have a Brit-
ish comedy movie ready to watch during the
next scheduled home visit. The clinician will
evaluate Mr. Murphy’s reaction to a culturally
sensitive humor intervention and interpret its
influence on tolerating the wound treatment
regimen.
On the second home visit, Mr. Murphy has
a copy of his favorite movie, Monty Python and
the Holy Grail, ready for viewing. Before begin-
ning wound care, the clinician explains the pur-
pose of using the comedy movie. Mr. Murphy
watches the movie while the clinician performs
the wound treatment regimen. Mr. Murphy is
pleasantly involved in the action of the movie
and experiences episodes of spontaneous laugh-
ter. The movie acts as a positive diversionary
tactic and an effective intervention for improv-
ing the patient’s ability to cope with the painful
wound care treatment regimen. The addition of
a humorous intervention encourages laughter,
thereby creating a positive environment for heal-
ing and improving a patient’s well-being. The
relationship between Leininger’s culture care
theory and humor therapy creates a balance for
an appropriate cultural and humorous patient
care intervention.
The goal of patient care is to promote positive patient
care outcomes and improve patient satisfaction.
Clinicians may want to consider using Leininger’s
Theory of Culture Care Diversity and Universality
to integrate culturally appropriate humor therapy
interventions with patient care. Knowledge of the
patient’s level of illness and cultural background
are important factors to consider in planning an
appropriate humor therapy intervention. Laughter is
infectious, highly contagious, and should be
eagerly, caringly, and routinely spread by all.
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

6. vol. 28 • no. 9 • October 2010 Home Healthcare Nurse 557
at Texas Tech University Health Sciences Center—
Anita Thigpen Perry School of Nursing in Lubbock,
TX. She enjoys spreading laughter, joy, and cheer
as a therapeutic clown and nurse with her patients
in rural Far West Texas and on her humanitarian
medical mission travels throughout the world. She
is also an artist and created all of the original
watercolor and colored pencil illustrations for this
article (kathleen.d.schwartz@ttuhsc.edu).
Jana C. Saunders, PhD, RN, CNS, is a Pro-
fessor of Undergraduate and Graduate Nursing at
Texas Tech University Health Sciences Center—
Anita Thigpen Perry School of Nursing in Lubbock,
Texas. She has been a certified Adult Psychiatric-
Mental Health Clinical Nurse Specialist for over 20
years who has found that humor can be effective
in helping individuals deal with emotional con-
flicts, stressors, and anxiety in life (jana.saunders@
ttuhsc.edu).
Address for correspondence: Kathleen D. Schwartz
(kathleen.d.schwartz@ttuhsc.edu).
DOI:10.1097/NHH.0b013e3181f2f312
REFERENCES
American Cancer Society.org (2010). Humor therapy.
Retrieved April 1, 2010, from http://www.cancer.org/
docroot/ETO/content/ETO_5_3X_Humor_Therapy.asp
Association for Applied and Therapeutic Humor.
(2010). What is therapeutic humor? Retrieved April 1,
2010, from http://www.aath.org/about.htm
LaughterRemedy.org (2010). Paul McGhee. Retrieved
April 1, 2010, from http://www.humor.ch/mcghee/
mcghee.htm
Leininger, M. L. (2010). Overview of Leininger’s theory
of culture care diversity and universality. Retrieved
April 1, 2010, from http://www.madeleine-leininger.com
Leininger, M. L., & McFarland, M. R. (2006). Culture care
diversity and universality a worldwide nursing theory
(2nd ed.). Sudbury, MA: Jones and Bartlett.
MacDonald, C. M. (2004). A chuckle a day keeps the
doctor away. Journal of Psychosocial Nursing and
Mental Health Services, 42(3), 18-25.
North American Nursing Diagnosis Association. (2007-
2008). About NANDA international. Retrieved April
1, 2010, from http://www.scribd.com/doc/8465961/
NANDA-Nursing-Diagnosis-2008
Pasquali, E. A. (1990). Learning to laugh: Humor as
therapy. Journal of Psychosocial Nursing and Mental
Health Services, 28(3), 31-35.
Wojciechowski, M. (2007, December). Tickling the funny
bone: The use and benefits of humor in health care.
April 1, from http://www.apta.org/AM/Template.
cfm?Section=Archives3&Template=/Customsource/
TaggedPage/PTMagIssue.cfm&Issue=12/01/2007
Expected Outcome:
• The patient will be more comfortable during
the wound care regimen by participating in
a culturally appropriate diversionary humor
therapy intervention.
Plan:
• Encourage patient to choose humorous
movies to watch during wound care.
Evaluation
The clinician observed no overt signs or symp-
toms of pain or discomfort from the patient
during the wound care treatment. The patient
reported the pain and discomfort associated
with wound care and compression wrapping
was greatly reduced. After completing the
wound care treatment, the patient remarked
“You’re finished already, I was so wrapped up
in the movie, and I did not feel a thing!” The
patient’s attention was totally focused on the
movie instead of the treatment regimen and
he experienced episodes of spontaneous laugh-
ter throughout the movie. The humorous movie
successfully acted as a positive diversionary
tactic, distracted the patient from experiencing
the negative effects of wound care, and improved
the patient’s ability to cope with the pain and
discomfort associated with wound care. The
use of Leininger’s theory in combination with
humor therapy proved to be an effective nursing
intervention for the trial case patient.
Home Healthcare Clinician
Implications
The goal of patient care is to promote positive
patient care outcomes and improve patient sat-
isfaction. Clinicians may want to consider using
Leininger’s Theory of Culture Care Diversity and
Universality to integrate culturally appropriate
humor therapy interventions with patient care.
Knowledge of the patient’s level of illness and
cultural background are important factors to
consider in planning an appropriate humor ther-
apy intervention. Laughter is infectious, highly
contagious, and should be eagerly, caringly, and
routinely spread by all.
Kathleen D. Schwartz, BSN, RN, is a graduate
student in the MSN-Nursing Administration Program
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.