Chapter 22
Madeleine M. Leininger was a pioneering nurse, anthropologist, and educator who founded the field of transcultural nursing and developed the culture care theory. Here is an overview of her credentials and background:
Early Education and Career:
Born: Sutton, Nebraska.
Nursing Training: She began her nursing career with a diploma from St. Anthony’s School of Nursing in Denver, Colorado, and served in the U.S. Army Nurse Corps.
Bachelor’s Degree: She earned a B.S. in biological science from Benedictine College in Atchison, Kansas, with a minor in philosophy and humanistic studies in 1950.
Master’s Degree: She obtained a Master’s degree in psychiatric nursing from the Catholic University of America in Washington, D.C., in 1954.
Professional Experience and Contributions:
Leininger worked as an instructor, staff nurse, and head nurse in various hospitals. Notably, she became the director of nursing services at St. Joseph’s Hospital in Omaha, Nebraska, where she initiated a psychiatric unit.
She developed the first master's-level clinical specialist program in child psychiatric nursing at the University of Cincinnati, Ohio.
In the 1960s, Leininger co-authored Basic Psychiatric Concepts in Nursing, one of the first psychiatric nursing texts that was translated into 11 languages.
Development of Transcultural Nursing:
Leininger became deeply interested in cultural factors affecting healthcare when she noticed cultural differences among children in psychiatric care at a Cincinnati child guidance home. Her experiences led her to focus on cultural influences in care, particularly in the treatment of children from diverse backgrounds.
She spent nearly two years living with the Gadsup people in New Guinea, conducting ethnographic research that laid the foundation for her transcultural nursing theory.
Leininger introduced transcultural nursing as a field, defining it as a specialty that focuses on understanding how different cultures perceive care, health, and well-being.
Academic and Institutional Contributions:
In 1966, Leininger developed the first transcultural nursing course at the University of Colorado and became a leader in promoting anthropology within nursing education.
She held positions as a professor and dean at various institutions, including the University of Washington and the University of Utah, where she developed the world’s first doctoral programs in transcultural nursing.
In 1974, she founded the International Transcultural Nursing Society and the International Society for Human Caring, which focused on the study of human care phenomena and transcultural nursing.
Theory and Research:
Leininger is best known for her Culture Care Theory, which emphasizes the need to understand and respect cultural diversity in nursing practice. She developed ethnonursing research methods to study cultural care phenomena from the emic, or insider’s, perspective.
Her groundbreaking work in ethnonursing research continues to influence qualitative nursing research, encouraging a culturally sensitive approach to care.
Leininger published over 30 books and more than 200 articles on transcultural nursing, human care, and health.
Recognition and Legacy:
Leininger was widely recognized for her contributions, receiving numerous awards, honorary degrees, and fellowships in nursing and anthropology.
She was a Living Legend of the American Academy of Nursing and received the Russell Sage Outstanding Leadership Award in 1995.
Her work on the culture care theory remains influential worldwide, inspiring nurses and healthcare professionals to integrate culturally relevant practices into patient care.
Later Years and Death:
Leininger continued to be active in transcultural nursing until her passing in 2012. Even after her death, her contributions to the field continue to shape nursing education, research, and practice.
Her dedication to improving culturally congruent care and her long-lasting impact on transcultural nursing solidified her as a key figure in the field of nursing.
Notes on Leininger’s Theory of Culture Care Diversity and Universality for Theory Development
1. Theoretical Sources for Theory Development
Leininger’s Background and Influences
Leininger’s theory emerged from anthropology and nursing (Leininger, 1991, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018b).
The theory of transcultural nursing focuses on the comparative study of diverse cultures, their caring values, health beliefs, and patterns of behavior.
Purpose and Goals of Leininger’s Theory
Discover human care diversities and universalities related to cultural and social dimensions.
Culturally congruent care is central to improving health outcomes and maintaining well-being.
Theory development goal: To provide care that is beneficial, fits client needs, and respects their cultural values (Leininger, 1991, 1995).
Transcultural nursing moves beyond awareness to culturally responsible care (McFarland & Wehbe-Alamah, 2015c, 2018b).
Cultural Diversity in Nursing
Nurses are encouraged to understand cultural care knowledge as essential in improving nursing education and practice (Leininger, 1991).
Nursing practice must be culturally grounded, with an emphasis on adapting care to diverse cultural contexts (Leininger & McFarland, 2002, 2006).
Transcultural nursing knowledge is critical for guiding nursing decisions and achieving successful health outcomes globally (Leininger, 1991, 1995, 1996).
2. Key Concepts: Transcultural Nursing vs. Cross-Cultural Nursing
Transcultural Nursing: Focuses on nurses developing transcultural nursing knowledge and theory for diverse care practices (Leininger, 1995; Leininger & McFarland, 2002).
Cross-Cultural Nursing: Refers to the use of applied anthropology or medical anthropology concepts instead of theory-based transcultural practices (Leininger, 2002a).
International Nursing: Involves nursing practice across different nations, while transcultural nursing focuses on comparative theoretical approaches to diverse cultures (McFarland & Wehbe-Alamah, 2015, 2018).
Roles in Transcultural Nursing:
Certified Transcultural Nurse-Basic (CTN-B): Baccalaureate-prepared nurse applying transcultural nursing concepts.
Certified Transcultural Nurse-Advanced (CTN-A): Graduate-level nurse specializing in transcultural nursing with in-depth knowledge (Leininger, 1991, 1995; Leininger & McFarland, 2002).
3. Theory Characteristics and Features
Holistic Approach:
Leininger’s theory focuses on human life and existence, integrating social structure, worldview, culture, environmental context, language, and both folk and professional care patterns.
The theory combines emic (insider) and etic (outsider) perspectives to provide culturally congruent care (Leininger, 1991, 1995).
Inductive and Deductive Nature:
The theory allows both inductive and deductive reasoning and is grounded in emic knowledge from cultural groups.
Leininger (1991) emphasized ethnonursing to study care practices directly from cultural participants (insiders) instead of external viewpoints (etic) of researchers.
Unique Focus:
The theory uniquely integrates cultural dimensions and their effects on care, health, and well-being (Leininger, 1996).
It stands out by focusing on both diverse and universal aspects of care that exist across cultures (Leininger, 1991, 1995).
Goal of Theory:
To discover both the diversity and universality of care to improve health, maintain well-being, and help individuals face challenges such as illness and death (Leininger, 1991, 1995).
4. Empirical Evidence and Qualitative Methods
Ethnonursing Method:
Developed in the 1960s to discover cultural care beliefs, practices, and values (Leininger, 1991).
Focuses on the emic (insider) knowledge of cultural groups through direct observation and interviews to understand their unique healthcare practices (Leininger, 1995).
Significance of Care Knowledge:
Leininger highlighted that care is central to nursing and critical for human survival, health, and healing (Leininger, 1988b, 1991).
By understanding cultural care practices, nurses can provide more effective and culturally congruent care.
Cultural Congruence:
Cultural congruence is essential for enhancing client satisfaction and healthcare outcomes, as culturally-based care is directly linked to effective healing (Leininger, 1991, 1995).
Understanding cultural values, beliefs, and social factors helps nurses offer personalized care aligned with the client’s worldview (Leininger, 1991).
5. Challenges and Barriers
Cultural Challenges in Nursing:
Cultural blindness, cultural shock, cultural imposition, and ethnocentrism can reduce the quality of care for culturally diverse clients (Leininger, 1991, 1995).
These barriers highlight the need for nurses to be aware of and address cultural biases and ensure care is rooted in culturally congruent practices.
Cultural Sensitivity and Diagnosis:
Inadequate cultural knowledge in nursing diagnoses and medical practices can lead to poor health outcomes (Leininger, 1991).
Culturally-based nursing diagnoses are essential for improving the accuracy and relevance of patient care (Leininger, 1995).
6. Conclusion
Leininger’s Culture Care Theory stands as one of the most influential theories in nursing, promoting the discovery of culture-specific knowledge about care. It highlights the importance of understanding diverse cultural perspectives and integrating these insights into nursing practice to ensure the delivery of culturally congruent care that aligns with the beliefs, values, and lifeways of diverse populations. The use of ethnonursing and other qualitative research methods has allowed for the systematic study of cultural care practices, enriching nursing theory and practice in a multicultural world.
These notes encapsulate the key points regarding the development, application, and challenges of Leininger's Culture Care Theory, which is foundational for culturally responsive nursing practice.
MAJOR CONCEPTS AND DEFINITIONS IN CULTURE CARE THEORY
Care and Caring
Care: An abstract and manifest phenomenon involving assistive, supportive, enabling, and facilitating actions toward self or others.
Caring: Actions, attitudes, or practices aimed at assisting others in healing and achieving well-being. It includes both generic/folk care and professional care, which influence the health and well-being of diverse cultures (McFarland & Wehbe-Alamah, 2015c).
Generic Care
Refers to learned and transmitted lay, indigenous, or traditional knowledge and practices used to assist, support, enable, or facilitate care for individuals with health needs, often aimed at improving well-being, managing illness, or addressing death (McFarland & Wehbe-Alamah, 2015c).
Professional Care
Refers to formal, learned knowledge and practices from educational institutions, typically taught to nurses and healthcare professionals, aimed at assisting, supporting, enabling, or facilitating others' health and well-being (McFarland & Wehbe-Alamah, 2015c).
Culture
Culture refers to the learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guide decision-making and actions. It is an essential aspect of care and must be considered in providing care that is aligned with cultural values (McFarland, 2018b).
Culture Care
The synthesis of the constructs of care and culture, guiding the researcher to understand health, well-being, and care expressions in various cultural contexts (McFarland & Wehbe-Alamah, 2015c).
Culturally Congruent Care
Refers to care that aligns with the cultural values, beliefs, and lifeways of clients, delivered in a meaningful, sensitive, and creative way to improve health outcomes or address illness, disabilities, or death (McFarland & Wehbe-Alamah, 2015c).
Culture Care Diversity
The differences in cultural care beliefs, practices, values, and symbols among various human groups, affecting the provision of beneficial care in diverse cultural settings (McFarland & Wehbe-Alamah, 2015c).
Culture Care Universality
The common cultural care phenomena shared across human groups that provide recurrent patterns, values, and symbols, guiding caregivers in offering care that promotes healthy outcomes (McFarland & Wehbe-Alamah, 2015c).
Worldview
Refers to the way individuals perceive and interpret their world, which influences their actions, decisions, and responses to health and well-being. It shapes their approach to care (McFarland & Wehbe-Alamah, 2015c).
Cultural and Social Structure Dimensions
The dynamic, interrelated features of culture, including technology, religion, kinship, values, beliefs, politics, economics, education, language, environment, and ethnohistory. These factors structure the culture and influence health and well-being (McFarland & Wehbe-Alamah, 2015a).
Environmental Context
The totality of an event, situation, or experience, including geophysical, ecological, spiritual, sociopolitical, and technological factors, which give meaning to people's expressions, interactions, and health-related decisions (McFarland & Wehbe-Alamah, 2015c).
Ethnohistory
The history of past events and experiences of people, groups, or cultures that influence their lifeways and cultural care beliefs. It provides context to understand health and well-being, especially in relation to illness or death (McFarland & Wehbe-Alamah, 2015c).
Emic
Refers to the insider or local cultural knowledge and perspectives regarding specific phenomena, often used by members of the culture (McFarland & Wehbe-Alamah, 2015c).
Etic
Refers to the outsider or institutional knowledge and perspectives regarding cultural phenomena, often used by health professionals or researchers (McFarland & Wehbe-Alamah, 2015c).
Health
A state of well-being that is culturally defined and practiced, reflecting the ability of individuals or groups to perform daily activities in ways that align with their cultural values and practices (Leininger, 1991; McFarland & Wehbe-Alamah, 2015c).
Culture Care Preservation and/or Maintenance
Refers to professional actions and decisions that help individuals or groups maintain their cultural care practices, beliefs, and values to preserve their well-being or recover from illness or death (McFarland & Wehbe-Alamah, 2015c).
Culture Care Accommodation and/or Negotiation
Professional actions that help individuals or groups adapt to or negotiate care practices with others for culturally congruent, effective, and safe care, promoting meaningful health outcomes (McFarland & Wehbe-Alamah, 2015c).
Culture Care Repatterning and/or Restructuring
Professional actions that help clients modify or reorder their cultural care practices to promote beneficial healthcare patterns and outcomes (McFarland & Wehbe-Alamah, 2015c).
These concepts form the foundational understanding of the Culture Care Theory, guiding nurses and healthcare professionals to provide care that is culturally sensitive, appropriate, and effective.
Notes on Major Assumptions and Theoretical Assertions of Leininger's Theory of Culture Care Diversity and Universality
MAJOR ASSUMPTIONS:
The theory emphasizes both the universality and diversity of care, acknowledging common human experiences as well as cultural variability. Key assumptions include:
Care is Central to Nursing: Care is the essence of nursing, serving as a central, unifying, and distinct focus of the profession.
Humanistic and Scientific Care: Both humanistic and scientific aspects of care are essential for human growth, well-being, health, survival, and coping with death or disabilities.
Caring and Healing: Caring is essential for healing and curing; there can be no healing without caring. This assumption holds profound global relevance.
Culture Care as a Synthesis: Culture care is a combination of culture and care, guiding the discovery and explanation of health, well-being, and human conditions.
Diversity and Commonality in Culture Care: Culture care expressions are diverse but share commonalities across cultures.
Influence of Worldview and Social Factors: Culture care values and practices are influenced by worldview and social structures (e.g., religion, politics, kinship, economics, education, etc.).
Generic and Professional Care: Every culture has both generic (folk) and professional (etic) care that should be identified for culturally congruent practices.
Culturally Congruent Care: Effective, therapeutic care occurs when cultural values, beliefs, and expressions are understood and used in a culturally sensitive, appropriate way.
Leininger’s Modes of Care: Leininger proposed three theoretical modes of care (preservation, accommodation, and repatterning) to guide culturally congruent practices.
Ethnonursing Research: The ethnonursing research method is crucial for discovering cultural care knowledge and practices, providing a means to study culturally diverse health care experiences.
Transcultural Nursing as a Discipline: Transcultural nursing is a distinct discipline with a body of knowledge aimed at achieving culturally congruent care for health and well-being.
THEORETICAL ASSERTIONS:
These are foundational beliefs that guide the application and development of the culture care theory:
Cultural Diversity and Commonality: Culture care expressions, meanings, and practices vary, but there are universal attributes shared across cultures.
Influence of Social and Cultural Factors: The worldview and multiple social structures (e.g., religion, kinship, economics, education, technology, etc.) are critical influences on culture care patterns and impact health outcomes.
Generic and Professional Care: Emic (folk) and etic (professional) health factors influence health and illness outcomes significantly.
Three Major Modes of Care: Leininger identifies three modes (preservation, accommodation, repatterning) that help in delivering culturally congruent care:
Culture Care Preservation: Maintaining cultural practices.
Culture Care Accommodation/Negotiation: Adapting care practices to accommodate cultural differences.
Culture Care Repatterning/Restructuring: Modifying care practices for better health outcomes while respecting cultural values.
These modes are essential to offering safe, meaningful, and culturally acceptable care, with each mode being applied based on the unique needs of individuals, families, or communities.
LOGICAL FORM:
Leininger's theory is grounded in both anthropology and nursing, with a focus on understanding culture care through qualitative methods, primarily ethnonursing.
Ethnonursing Research Method: Data is collected through observation and participation to understand cultural care values, beliefs, and practices from the informants' perspective. This is vital for discovering culturally relevant care practices.
Qualitative Research Focus: Leininger emphasized qualitative methods over quantitative methods for studying culture and care, as they provide in-depth, context-sensitive insights into cultural behaviors and care needs. Quantitative methods are less effective in transcultural nursing research.
The Sunrise Enabler:
The Sunrise Enabler (created by Leininger) is a key tool in the culture care theory that illustrates the key components affecting culture care practices.
Upper Half: Depicts the worldview and various social and cultural structure factors (e.g., religion, economics, education, kinship, etc.), all of which influence culture care.
Middle Section: Describes folk, professional, and integrated care practices. Nurses bridge the gap between generic (folk) and professional care.
Lower Half: Represents cultural patterns and health outcomes, underscoring the need for culturally congruent nursing decisions and actions.
The Full Sun: Symbolizes the integration of all factors (worldview, social structures, cultural factors) that nurses need to consider for holistic care and health promotion.
Enablers for Ethnonursing Research:
Leininger developed several enablers to support ethnonursing research:
Observation-Participation-Reflection Enabler: Facilitates the researcher’s involvement with informants in their natural context, allowing for natural, unbiased data collection.
Stranger-to-Trusted Friend Enabler: Encourages researchers to build trust with informants, which is vital for collecting credible, in-depth data.
Domain of Inquiry Enabler: Guides researchers to focus specifically on culture care and health phenomena, aligning the study with theoretical tenets.
Semi-Structured Inquiry Guide: A tool with open-ended questions to explore cultural worldviews, social structures, and health-related domains.
Acculturation Health Assessment Enabler: Helps assess how much an individual or group has integrated traditional or nontraditional cultural values into their lives, impacting care practices.
Summary:
Leininger’s theory of culture care diversity and universality provides a comprehensive framework for understanding and delivering culturally congruent care. It emphasizes the importance of both universal and culturally unique care practices, guided by the understanding of social and cultural factors. The ethnonursing research method plays a critical role in discovering culturally relevant care practices and informing nursing interventions. Leininger's Sunrise Enabler and associated tools offer a structured approach to studying culture care and ensuring that care decisions align with the cultural needs of individuals and communities.
Notes on Acceptance by the Nursing Community (Leininger & McFarland, 2002, 2006)
1. Factors Affecting the Reluctance to Recognize Transcultural Nursing:
Lack of Anthropology Education (1950s): Nurses were not educated in anthropology, which limited their understanding of transcultural concepts, models, and theories.
Client Reluctance to Demand Cultural Recognition: Clients often did not press healthcare providers to meet their cultural needs, hindering the recognition of cultural factors in healthcare.
Rejection in Journals (Pre-1990s): Transcultural nursing articles were frequently rejected by journals because editors did not understand the relevance of cultural knowledge to nursing.
Limited Interest in the Concept of Care (Before 1970s): Nursing care did not emphasize human care or cultural sensitivity until Leininger began promoting transcultural nursing.
Ethnocentric Nursing Practices: Nursing was too focused on Western medicine, limiting the understanding and acceptance of diverse cultural practices.
Slow Adoption of Qualitative Research: Nursing was traditionally dependent on quantitative research methods, which slowed the progress in developing a distinct body of knowledge in transcultural nursing.
2. Development of Transcultural Nursing:
1970s and Beyond: Nurses began to realize the importance of transcultural nursing and human care, as migration and consumer cultural identity increased.
Global Need for Culturally Competent Nursing: With multicultural societies, nurses needed to respond to the cultural needs of diverse populations.
Culture Shock and Conflict: Nurses who move to different regions or countries without transcultural preparation face challenges, and patients experience lower satisfaction when cultural needs are unmet.
Transcultural Nurse Certification: The Transcultural Nursing Society's certification process ensures culturally competent practices.
Growth of Journals: Journals such as the Journal of Transcultural Nursing and the International Journal of Human Caring publish research focused on transcultural nursing practices.
3. Education in Transcultural Nursing:
Initial Focus in 1966: The University of Colorado included culture care in nursing curricula, starting with Leininger’s advocacy for culture-specific care.
Master’s and Doctoral Programs (1977): The University of Utah implemented the first programs focused on transcultural nursing.
Demand for Holistic, Culturally Competent Care: A growing need for nurses educated in transcultural nursing is driven by health costs, diversity, and human rights issues.
Urgent Need for Faculty: There is a critical shortage of qualified faculty to teach transcultural nursing in nursing schools.
Global Impact of Leininger’s Work: Leininger’s calls for transcultural nursing programs have led to increased education efforts worldwide, though there are still shortages in faculty and resources.
4. Transcultural Nursing Research:
Ethnonursing Method: Leininger’s culture care theory is the only one in nursing specifically focused on cultural care, using the ethnonursing research method.
Limited Research Funding: Biomedical and technical research often receive more funding than transcultural nursing, but researchers continue their work despite limited resources.
Influence of Research on Nursing Practice: Transcultural nurses contribute to the development of culturally sensitive practices and share their research at international conferences.
Somali Immigrant Study: An ethnonursing study explored the mental health care beliefs and practices of Somali immigrants, leading to culturally congruent care findings.
5. Application of Culture Care Theory to Advanced Practice Nursing:
Culturally Sensitive Practice: Advanced practice nurses need to integrate emic (insider) and etic (outsider) perspectives to avoid cultural imposition and improve care.
Use of the Sunrise Enabler: This conceptual tool helps nurses visualize the theory’s application in practice and research.
Emphasis on Qualitative Research Methods: Research using qualitative methods and the ethnonursing approach is crucial to discovering new cultural care knowledge.
6. Future Development of Transcultural Nursing:
Global Need for Transcultural Nurses: Leininger predicted that transcultural nursing would be essential for all nurses globally, with the demand for transculturally prepared nurses exceeding the available number.
Need for Further Research and Knowledge Development: The field of transcultural nursing must continue to evolve to meet the needs of an increasingly multicultural world.
Education and Training: All nurses need a basic understanding of cultural diversity, with in-depth knowledge of at least two or three cultures.
Integration into Other Disciplines: Fields such as medicine, pharmacy, and social work have started to incorporate transcultural practices, raising the demand for culturally competent faculty.
7. Critique of the Culture Care Theory:
Clarity: The theory offers a broad, holistic, and comprehensive understanding of care across cultures, applicable in practice and research.
Simplicity: Despite its complexity, the theory is elegant and practical, guiding researchers to discover culturally relevant care knowledge.
Generality: The theory is applicable across various cultures, promoting culture-specific nursing care globally.
Accessibility: The ethnonursing method provides credible and meaningful findings, contributing to evidence-based, culturally congruent care practices.
8. Conclusion:
Importance of the Culture Care Theory: The theory of culture care diversity and universality continues to guide nursing practice and research, shaping nursing’s approach to providing culturally congruent care.
Global Influence: The theory has a significant impact on nursing worldwide, contributing to the development of new nursing knowledge, research methods, and practices that ensure culturally competent care.
These notes provide a comprehensive overview of the key points discussed in Leininger’s work on transcultural nursing, emphasizing the development, education, research, and ongoing evolution of culturally congruent care in the nursing community.