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JOURNAL OF TRANSCULTURAL NURSING / JULY 2002Leininger / CULTURE CARE THEORY

Culture Care Theory: A Major Contribution to Advance Transcultural Nursing Knowledge and Practices

MADELEINE LEININGER, PhD, LHD, DS, CTN, FAAN, FRCNA

This article is focused on the major features of the Culture Care Diversity and Universality theory as a central contrib- uting theory to advance transcultural nursing knowledge and to use the findings in teaching, research, practice, and consul- tation. It remains one of the oldest, most holistic, and most comprehensive theories to generate knowledge of diverse and similar cultures worldwide. The theory has been a powerful means to discover largely unknown knowledge in nursing and the health fields. It provides a new mode to assure culturally competent, safe, and congruent transcultural nursing care. The purpose, goal, assumptive premises, ethnonursing research method, criteria, and some findings are highlighted.

This article is focused on the 2001 Pittsburgh Precon- ference theme “Major Contributions of Book Authors to Transcultural Nursing Knowledge and Practices.” As the founder of the discipline and author of 28 books and 220 pub- lished articles, I hold that my Culture Care Diversity and Uni- versality theory has made a significant contribution to estab- lish and advance transcultural nursing research knowledge and practice since the mid-1950s. This article is a brief synop- sis of culture care theory with its unique features and major contributions to support transcultural nursing as a discipline and practice field.

In establishing this new discipline, different lines of think- ing and practice were essential. It necessitated futuristic vision, risk taking, commitment, patience, and leadership to challenge many traditional nursing ideas and practices. Unquestionably new knowledge and practices were essential for nurses to function in a rapidly changing multicultural

world. Substantive theory-based research knowledge was greatly needed with a global and comparative focus to care for people of diverse cultures. Culturally based care knowledge was the major missing area in nursing in the mid-20th century and still is in some places in the world. I coined the construct of culturally congruent care, which is the central goal of the theory.

In my first two books,Nursing and Anthropology(1970) and Transcultural Nursing: Concepts, Theories, Research, and Practice(1978), the nature, rationale, need, and theoreti- cal base were given to establish transcultural nursing. Nurses needed in-depth knowledge of cultures with an anthropologi- cal view and in-depth, culturally based care phenomena. I held that care was the essence of nursing and had meaning within cultural contexts. Care was not fully known and valued in nursing, and so it was a challenge to get nurses interested in the Culture Care theory in the 1950s and 1960s as the medical mind-body treatments and symptoms held nurses’ interests and practices (Leininger, 1991). Moreover, many nurses believed care was “too soft, feminine, and nonscientific” and “culture was irrelevant and unnecessary.” With my persis- tence and enthusiasm for the theory, some nurses began to support the idea.

In 1991, the theory bookCulture Care Diversity and Uni- versalitytook hold and was a great breakthrough in caring for the culturally different. This book has been the primary and definitive resource to discover largely unknown and limitedly valued culture care knowledge and practical uses in client care. My second edition ofTranscultural Nursing(1995) con- tributed a wealth of new research-based knowledge on 30 Western and non-Western cultures, plus refinements in research methods, teaching, clinical practices, and adminis- tration. The third edition ofTranscultural Nursingby Leininger and McFarland (2002) provides theory-based research and practice by transcultural nurse scholars in many

Journal of Transcultural Nursing,Vol. 13 No. 3, July 2002 189-192 © 2002 Sage Publications

cultures and is the most definitive, authoritative, and compre- hensive transcultural nursing book available.

The Culture Care theory has been well established today and is used by many nurses worldwide. In fact, many nurse leaders hold that “it has been the most significant break- through in nursing and the health fields in the 20th century and will be in greater demand in the 21st century” (Leininger, 1997). With the horrible and tragic events of September 11, 2001, the need for understanding of transcultural violence, terrorism, hatred, and killing of innocent people has increased. Indeed, in 1950, I predicted that such violence would occur unless transcultural care knowledge was used worldwide to prevent such destructive human acts.

Today, the theory is known for its broad, holistic yet culture-specific focus to discover meaningful care to diverse cultures. The theory had provided a body of theory-based research knowledge for the growing discipline and practice of transcultural nursing. It provides some entirely new teaching content and ways to care for immigrants and refugees of many different and neglected cultures. This knowledge is gradually transforming health systems and changing nursing practices into relevant new ways of functioning. Research findings from the theory, however, far exceed their full uses in nursing and health services. Nurses prepared in using the theory find it is meaningful and rewarding to use because of the holistic and yet culture-specific care practices (Leininger, 1995; Leininger & McFarland, 2002). More and more often, other nurse theorists are now including culture and care in their nursing theories or using concepts of the theory because of its importance today.

SOME MAJOR AND UNIQUE FEATURES OF THE THEORY

Before presenting a brief on the culture care theory, some major, unique, and contributing features can be listed at the outset. First, the theory remains one of the oldest theories in nursing as it was launched in the mid-1950s. Second, it is the only theory explicitly focused on the close interrelationships of culture and care on well-being, health, illness, and death. Third, it is the only theory focused on comparative culture care. Fourth, it is the most holistic and multidimensional the- ory to discover specific and multifaceted culturally based care meanings and practices. Fifth, it is the first nursing focused on discovering global cultural care diversities (differences) and care universalities (commonalties). Sixth, it is the first nurs- ing theory with a specifically designed research method (ethnonursing) to fit the theory. Seventh, it has both abstract and practical features in addition to three action modes for delivering culturally congruent care. Finally, it is the first the- ory focused ongeneric(emic) andprofessional(etic) culture care, data related to worldview, social structure factors, and

ethnohistory in diverse environmental contexts. These are unique contributions related to study and use of the theory.

Major Philosophical Roots of the Theory

The philosophical roots of the theory are from the theo- rist’s extensive and diverse nursing experiences, anthropolog- ical insights, life experiences, values, and creative thinking. My firm belief in God’s creative and caring ways has always been important to me. Preparation in philosophy, religion, education, nursing, anthropology, biological sciences, and related areas influenced my holistic and comprehensive view of humans. And as the first graduate professional nurse to pursue a PhD in anthropology with the desire to advance nurs- ing theory, I saw great potential for developing relationships between nursing and anthropology and expanding the preva- lent mind-body medical and nursing views. Comparative care meanings, expressions, symbols, and practices of different cultures were powerful new ways to practice nursing. Theo- rizing about the culture and care relationships as a new disci- pline focus was intellectually exciting to me. Interestingly, anthropologists had not studied care in health and illness when I began the theory in the 1950s.

In developing the theory, a major hurdle for nurses was to discover culture care meanings, practices, and factors influ- encing care by religion, politics, economics, worldview, environment, cultural values, history, language, gender, and others. These factors needed to be included for culturally competent care. Hence, the Sunrise Model (see Figure 1) was created (Leininger, 1997). The model isnot the theory per se but depicts factors influencing care.

If nurses use the model with the theory, they will discover factors related to cultural stresses, pain, racial biases, and even destructive acts as nontherapeutic to clients. One can also reduce and prevent violence in the workplace, anger, and noncompliance with data findings from the model when used with the three prescribed modes of action (Leininger, 1991, 1997, 2002). And because nurses are the largest group of health care providers, a significant difference in quality care and preventing legal suits can occur. The model used in con- junction with the theory is a powerful means for new knowl- edge and practices in health care contexts.

PURPOSE AND GOAL OF THE THEORY

The central purposeof the theory is to discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of indi- viduals or groups. Thepurposeandgoalof the theory is to use research findings to provide culturally congruent, safe, and meaningful care to clients of diverse or similar cultures. The three modes for congruent care, decisions, and actions pro- posed in the theory are predicted to lead to health and well- being, or to face illness and death.

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Definition of Terms

Due to space limitations, the definition of terms can be studied in other sources, which are cited in the reference list at the end of this article.

ASSUMPTIVE PREMISES OF THE THEORY

Due to restricted space, only a few theoretical premises (or “givens”) are presented as examples, with others found in author’s theory references (Leininger, 1991, 1997).

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FIGURE 1. Leininger’s Sunrise Model to Depict Dimensions of the Theory of Culture Care Diversity and Universality.

1. Care is the essence of nursing and a distinct, dominant, cen- tral, and unifying focus.

2. Culturally based care (caring) is essential for well-being, health, growth, survival, and in facing handicaps or death.

3. Culturally based care is the most comprehensive, holistic, and particularistic means to know, explain, interpret, and predict beneficial congruent care practices.

4. Culturally based caring is essential to curing and healing, as there can be no curing without caring, although caring can oc- cur without curing.

5. Culture care concepts, meanings, expressions, patterns, pro- cesses, and structural forms vary transculturally, with diversi- ties (differences) and some universalities (commonalties).

Four major tenets were formulated to systematically examine the theory with the researcher’s stated domain of inquiry (DOI) and the ethnonursing method. An example of a DOI would be “the study of care meanings, values, and expressions of Mexican rural families with cancer.” Every word in this DOI is studied in-depth using the four theory ten- ets, which are (a) culturally based care has diversities (differ- ences or variabilities) and some universal (common) features; (b) worldview, cultural, and social structure factors and others in the Sunrise Model influence care outcomes related to cul- turally congruent care; (c) genericemic(lay, folk, or indige- nous) practices and professionaleticnursing practices influ- ence care practice outcomes; (d) the three predicted theoreti- cal modes for transcultural care actions and decisions are, namely, culture care preservation and/or maintenance, cul- ture care accommodation and/or negotiation, and culture care repatterning and/or restructuring to provide culturally con- gruent and beneficial care. Besides the Sunrise Model, other ethnonursing enablers are used to rigorously examine the the- ory tenets.

THE ETHNONURSING RESEARCH METHOD, ENABLERS, AND QUALITATIVE CRITERIA

The ethnonursing research method was specifically designed by the theorist to provide in-depth study of the domain of inquiry. Covert and embedded care and culture data could be teased out with the enablers. Although other nurse theorists were borrowing quantitative methods and tools, I found that these modes failed to tap rich and meaning- ful emic and etic data and that cultural care beliefs and lifeways could not be manipulated and measured meaning- fully. The five enablers that I developed are, as follows: (a) Sunrise Model Enabler, (b) Stranger to Trusted Friend Enabler, (c) the Observation, Participation, and Reflection Enabler, (d) the Researcher’s Domain of Inquiry (DOI) Enabler, and (e) the Acculturation Enabler (Leininger, 1991, pp. 139-142; Leininger, 1997, pp. 38, 45-47). The concept of enablers was new in the 1960s but most valuable in teasing out vague ideas.

Because the Sunrise Model Enabler is so frequently requested by nurses for health care assessments, a brief sum-

mary on its use is offered. One usually begins with a focus on an individual or small group and wherever one wishes and is comfortable with the model. Some nurses begin with a focus on generic and professional care, whereas others start at the top of the model with worldview, spiritual, family, political, and other areas. What is most crucial is listening with a very open mind to the informant, learning from them, and not imposing your ideas. One checks and rechecks ideas for accu- racy as one uses the enablers with informants.

The Observation-Participation Reflection Enabler is very important in obtaining holistic, specific, and accurate data. All data from the top and middle of the Sunrise Model are reflected on with the three modes of decisions and actions to arrive at culturally congruent care (bottom part of model). All data collected is thoughtfully examined with the author’s six qualitative criteria: credibility, confirmability, meaning-in- context, recurrent patterning, saturation, and transferability (Leininger, 1995, 1997). Specific evidence that these criteria are met is essential to substantiate or refute the domain of inquiry and the theory.

In sum, the Culture Care theory has been a major and sig- nificant contribution to establish and maintain the discipline of transcultural nursing discipline over the past five decades. The holistic and particularistic features and the ethnonursing method have led to a new body of knowledge about culture and care phenomena. Today, nurses are becoming sensitive to and knowledgeable about cultural differences and similarities in people’s care. A wealth of rich research findings, however, has yet to be woven into practice, education, and administra- tion. Transcultural knowledge is also being used by other dis- ciplines today. Many users of the theory find it most meaning- ful and timely as our world becomes increasingly global and complex, requiring realistic and sensitive understanding of people.

REFERENCES

Leininger, M. (1978).Transcultural nursing. Thorofare, NJ: Slack. (Reprinted in 1994 by Greyden Press, Columbus, OH)

Leininger, M. (1991).Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press (redistributed by Jones and Bartlett Publishers, Inc., New York, 2001).

Leininger, M. (1994).Nursing and anthropology: Two worlds to blend. New York: John Wiley. (Reprinted in 1994 by Greyden Press, Columbus, OH)

Leininger, M. (1995).Transcultural nursing: Concepts, theories, research, and practice. Columbus, OH: McGraw-Hill College Custom Series.

Leininger, M. (1997). Overview and reflection of the theory of culture care and the ethnonursing research method.Journal of Transcultural Nursing, 8(2), 32-51.

Leininger, M., & McFarland, M. (2002).Transcultural nursing: Concepts, theories, research, and practice(3rd ed.). New York: McGraw-Hill.

Madeleine Leininger is a self-employed transcultural global nursing consultant, lecturer, and author. She received her PhD in an- thropology from the University of Washington, and her MSN from Catholic University in Washington DC. Research interests include transcultural nursing care, comparative human care, cultural con- texts, cultures of nursing and health professions, and clinical use of Culture Care findings.

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