Madelaine M. Leninger theory of cultural care diversity and universality; charpter 22
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MadeleineM.Leininger22.pdf
22 Vadeleine M. Leininger:
Theory
Or Culture Care Diversity and
Universality Madeleine M. Leininger (1927-2012)
Marilyn R. McFarland*
are is the essence of nursing and a distinct, dominant, central
and unijying focus.
Madeleine Leininger (Leininger &McFarland, 2002, p. 192)
CREDENTIALS AND BACKGROUND nursing at this university' Vith the Therapeutic n Psychiatri Nursing Center at their hospital. In 1960, she
bte one oi OF THE THEORIST
g ent was pub-
in Nursing, which lished in 11 languages (Hofling & Leininger, 19601
the first basic psychiatric irsing texts with Hofli
tled Basic Psychiatric Concepts Madeleine M. Leininger, the founder of transcultural
nurs-
ing and a leader in transcultural nursing and human care
theory, was the first professional nurse with graduate preP- aration in nursing to hold a PhD in
cultural and social
anthropology. She was born in Sutton, Nebraska, begin-
ning her nursing career after graduation from St. Anth0
ny's School of Nursing in Denver, Colorado, and the U.s.
Army Nurse Corps with a diploma in nursing. In 1950, she
earned a bachelor's degree in biological science from Bene-
dictine College in Atchison, Kansas, with a minor in phi-
losophy and humanistic studies. She then served as an
instructor, staff nurse, and head nurse on a medical-surgi
cal unit and opened a new psychiatric unit while director
of the nursing service at St. Joseph's Hospital in Omaha,
Nebraska.
While working at a child guldance honme in the .
staf 1950s in Cincinnati, Leininger discovered that ths lacked understanding ot cultural factors influencia ng the behavior of children. Among these children of diverse cul tural backgrounds. she observed difterences in responses to care and psychiatric treatments that deeplycon concerned
her. Psychoanalytical theories and therapy strategies d not seem to reach children who were from diverse cultund
backgrounds. She became inereasingly concerned that her nursing decisions and actions, and those of other staf, did not appear to help these clhildren. .eininger posed ques.
tions to herself and the st.afl about cultural differences
among children and therapy outcomes. She found few staf members who were interested or knowledgeable abou
cultural factors in the diagnosis and Ireatment of clients. A short time later, Margaret Mead became a visiting proles
sor in the Department of Psychiatry, University of Cincin nati, and Leininger discussed with Mead the potental
interrelationships between nursing and anthropol0gy
During the 1950s and 1960s, Leininger (1970, 1978) tden tihed common areas of theory interests and researcn u
between the disciplines of nursing and anthropolog), w
aided her in formulating transcultural nursing concep
theory, principles, and practices. As a doctoral student, Le
In 1954, Leininger obtained her master's degree in psy-
chiatric nursing from the Catholic University of America
in Washington, DC, and was then employed by the College
of Health at the University of Cincinnati, Ohio, where she
developed the first masters-level clinical specialist pro-
gram in child psychiatric nursing. She initiated and
directed the first graduate nursing program in psychiatric
*This chapter is dedicated in memory of Dr. Madeleine Leininger.
Dr. Madeleine Leininger on a visit to Madonna University, Livonia,
MI, circa 1999. Source: The Madeleine M. Leininger Collection on Human Caring and Transcultural Nursing, ARC-008, Photo 03, Ar- chives of Caring in Nursing, Florida Atlantic University, Boca Raton.
fasc
nger studied many cultures. She found anthropolog terest to
nating and believed it was an area that should be Or Inc
334
adeleine M. Leininger: Theory of Culture Care Diversity and Universaity CHA
ER 22 Made 335
on the iadsup people ot the astern nternational Society tor lluman Caring in 1978 0 hely nirses toeus on the study ot human care plhenea Leininger. 1988a, 19ssh, 199), She was the tiust tull tine president ot the American Association ot Colleges ot Nins
ng and one of the tirst members ot the American Acaley ot Nursing in 1975.
New Gunnea:
living alone with these ndige
th vears, she undertook an ethno She
to tUsCNÍ
on the (
irsing study in the villages (leininger
hserved the unique teatures of the cl
lber ot nmarked ditterences between 1West.
in tern cultures related to caring. health, and
i es. Fron her in-depth study and tirst
the iadsup. she continued to
einger's book, Nursing and Anthropologr: Tvo Worlhis
to Blend (1970), laid the toundation for developing the fiell of transculural ursing. the culture care theory, and eu turally based health care. Her next book, Tanseultra s: Concepts, Theories. and Practice (1978), icdentilied major concepts. theoretical ideas. and practices in transe tural nursing and was the first detinitive publication on
transcultural ursing. During tlhe next o0 years. Leininger established, explicated. and used the culture care theory lo study many eultures in the United States and worldwide. She developed the ethnonursing research method to lit an to be used with the theory and to qualitatively discover the
insider or emie view of cultures (1cininger. 1991: 1cininger &Metarland, 2002, 2006: Mctarland & Wehbe Alamah. 2015b, 201isb). lhe ethnonursing research method was the
frst open inquiry research method designed tor nurse
researchers to study and discover culture care phenomena
from the perspective of human science philosophy an through the lens of qualitative analysis (Leininger, 1978. 1985a. 1991, 1995; Leininger & Meliarland. 2002, 2000; Mclarland &Wehbe-Alamah, 2015b, 2018b).
ricnces with
er theory
ot culture
are theory)
and the.
re care diversity and universality
ethnonursing researeh method
1978 1991. 1995 Her esearrh
and theory have ditferences i
ursing
ents understand cultural
ealth, and illness. Sh was the major
iet to endOUrAge
Nnim ients and taculty to0 education nd practice. Her
Ndder to
Tute nursins
interest in developiung the tield ot transeul
a human care tocus sustained her tor
arsing with
than six decades.
in transeultural nursing was ottered in
the l'niversity ot Color. where leininger had
amointed Protessor ot Nursing and Anthropology.
he turst
course in
itiatei the Commi on Nursing and Anthropology
the American AnthropologUal Association in 1968
ed as its chair tor several vears (Leininger, 1991,
Leininger also initated and served as the director of
st Nurse Scientist Program (PhD) in the United
s when. in 1969, she was appointed Dean and Profes-
T o Nursing and Lecturer in Anthropology at the Uni-
NiY of Washington, Seattle, where she remained until
There she established the first academic nursing
nartment on comparative nursing care systems to sup-
urt master's and doctoral programs in transcultural nurs-
ng She initiated several transcultural nursing courses and nentored the first nurses in a PhD program with a tocus
m transcultural nursing. Under her leadership, the Uni-
Ersity of Washington was recognized in 1973 as the out- Sanding public institutional school of nursing in the nited States.
ln 1981, Leininger was appointed Protessor ot Nursing
and Adjunct Protessor of Anthropology and Director of Transcultural Nursing and also Director ot the Center tor
Health Research at Wayne State University in Detroit until her seni retirement in 1995. Dr. Leininger developed sev- eral transcultural nursing courses and seminars tocused on
caring and qualitative research methods tor baccalaureate, master's, doctoral, and postdoctoral nursing and nonnurs-
ing students. She also mentored many students and nurses
in transecultural nursing tield research and continued these
endeavors at various universities in the United States and
worldwide. In 1989, Leininger launehed the Journal of
Transcultural Nursing, serving as its tirst cditor until her In 1974, Leininger was appointed Dean and Professor ot ursing at the College of Nursing and Adjunct Professor of Athropology at the University of Utah in Salt Lake City.
S institution, she initiated the first master's and doc- rograms in transcultural nursing and established the Octoral program offerings at this institution (Leini-
retirement.
Leininger wrote or edited more than 30 books in her
lifetime and published more than 200 articles and 45 book
chapters plus numerous tilms, videos, 1DVDs, and research
reports focused on transcultural nursing; human care and
health phenomena; the tuture of nursing: and related topics
relevant to nursing and anthropology. During her career,
Dr. Leininger served on eight editorial boards and refereed
several publications and was actively involved with the
Transcultural Nursing Scholars Group and the development
of and contributions to her own website (www.madeleine
-leininger.com). She has remained known as one of the
oter Substantive courses focused specifically on transcul- nger, 1978). These prog ograms were the first in the world to
974, nger founded the 1ational Transcultural Nursing and remained an active leader in the orga-
R ng She also initiated and was director of a new nfacilitation office at the University of Utah. In
nroughout her lifetime. She also established the zation
theory, research rch, onsultatio UNIT IV Theories
andGrandTheories
and care writings,
nost crcative, productive, innovative,
and futuristic
research-based nscultural nursing content
and ideas to
honors for her lifetime professional
plishments, including
include an LHD from
Kansas; a PhD from the University of
ege
a DS from the University of Indiana.
many aNards and and academicand dynamic
addresses. She received
authors in nursing who provided new
and substantive
several hono Benedictine
N degrees ha
College in Achisn advance nursing as a discipline and a professi1On. n addition to theory development
and transculurd
nursing. Leininger had many lifelong areas of interest
and
CpertisC, including comparative cducation and adminis
ration; nursing theorics; politics; ethical dilemmas or
rsing and health care; qualitative research
methods; the
uture ol nursing and health care; and nursing leadership
As a certihed transcultural nurse and rescarcher,
Leininger
studied 15 individual and unique cultures; mentored or
superised approximately 200 master's and doctoral
stud-
es focused on transcultural nursing. human caring/care,
and related areas worldwide: and consulted with many
opio, Finlads a Indianapolis. In 197% aue and sigpi And and 1995, she was gnized for her he American Asse
of Nursing as its first all-time president.i the Russell Sage standing Leadership
Anthropology So ciety, fellow
iation of C eininger r
cant contribution to the
recevetin 19 and was a fellow in the American Acaderard of iursing, a fellow of the
American
Society for Applied Anthropology, and a fellow o e Royal
College of Nursing in Australia. Other affliatliationsGamma, and Scandinavian College of Sweden. She
served as a
included Sigma Theta Tau; Delta Kappa
Caring Science he in Stockhrrescarchers and institutions, especially those using her
culture carc theorv. Her culture care theory is used world-
Wide and continues to grow in relevance and importance
Tor the discover of culture care phenomena about diverse
cultures.
distinguished visiting scholar lecturer at 85
universities in the United
World.wide and was a VISiting professor at n and
overseas w
Wayne State Univer.universities. While at the Board of Regents Distinguished aculty Distinguished Research Award
in Teaching, and the Outstanding Graduate
tor Award. In 1996, Madonna
igan, honored her with its dedication of the I
Collection and a special Leininger Reading Ra outstanding contributions to nursing and the
ences and humanities. Leininger was honored as Legend of the American Academy of Nursing in 1998
Dr. Leininger's last works on the culture care the heory were publications in peer-reviewed professional Durnals. She co authored an interview for Nursing Science O
terly (Clarke et al., 2009) in which she discussed the hit
sity, she eceived Leiningcr lectured to anthropologists,
physicians, social
workers. pharmacists, and educators, and conducted research
with colleagues. She remained active in two disciplines and
contributed to nursing and anthropology at national and inter-
national transcultural conferences and association meetings.
Award, the the Presidents Excelence aculty Men- iversity in Livonia, Mich.
ger Book ing Room for her
Leininger worked to persuade nursing educators and practi-
ioners to integrate transcultural nursing and culture-specific
care cocepts based on research findings into nursing curri-
cula and clinical practices as critical for the future of all
aspects of nursing. Across seven decades of the discipline,
numerous nurses with doctoral degrees and many master's
and baccalaureate students have become certified in transcul-
SOcial sc
tural nursing. using Leininger's culture care theory through- out their work (Leininger, 1991, 1995; Leininger& McFarland, 2002. 2006; McFarland & Wehbe-Alamah, 2015a, 2018b).
Leininger established transcultural nursing courses and
programs to educate, conduct, and facilitate research about
transcultural nursing and health phenomena. As interest in
transcultural nursing and health care grew, Leininger (M. R.
McFarland, personal communication, 1996) delivered key-
note addresses annually and conducted workshops and consultations both nationally and internationally through- out her career. Her academic vitae included nearly 600 conferences, keynote addresses, workshops, and consultant services in the United States, Canada, Europe, Pacific Island nations, Asia, Africa, Australia, and the Nordic countries.
Educational and service organizations continued to request her consultation on transcultural nursing, humanistic car
ing, ethnonursing research, the culture care theory, and futuristic trends in health care worldwide.
Dr. Leininger gained international recognition in nurs- ing and related fields through her transcultural nursing
tory and future of transcultural care, the irsing
profession, and global health care. In 2015, she te
about her retrospective comparative study conducted in 2011 about three Western and one non-Western culture
(Old Order Amish Americans, Anglo Americans, Meai can Americans, and the Gadsup of the Eastern Highlands
of New Guinea) to obtain in-depth knowledge abou father protective care beliefs and practices with the god
to use that knowledge to provide culturally congruent
care (Leininger, 2015). She reported on culture care deci- sion and action modes of similar and diverse care findings
discussed with the informant fathers as potential ways they might integrate their cultural values and care prac
tices to help their sons. Leininger then began work on d
new culture care construct, collaborative care, which sik
Co-presented with Marilyn McFarland via a keynotevu
eocast at the 37th Annual Conference of Transculturi
Nursing Society in October 2011.
Aoleine M. Leininger: Iheory of Culture Care Diversity and Un cHAPTER22 Ma
CH
nger died peacefully on August 10, e Leininger.
ohraska. She continued to work until
337
002, 2006; McFarland & Wehbe- Alamah, 2015a, 2018D) ninger predicted that for nursing to be meaningful ana Terevant to clients and other nurses in the world, transcu al nursing knowledge and competencies would be impe Ve to guide all nursing care decisions and actions To
Cective and successful health outcomes (Leininger, 199
1996 Leininger & McFarland, 2002, 2006; McFarland
maha, Nebra
Ilaborating with colleagues on eoreher strbons lo seve eral projects
and publications in ongoing
legacy is her work prog-
on the einingers
re diversity and universal and in the
nursing that will continue to transcultural
of culhurec
yiet those
roughouther,
m she has mentored taught, and influ- m ijine of
accomplished career. & Wehbe-Alamah, 2015c, 2018b).
inger (2002a) distinguished between transcultural g and cross-cultural nursing, The former refers to
nurses prepared in transcultural nursing who are prepareuand committed to develop knowledge and practice n ranscultural nursing, whereas cross-cultural nursing rerers O nurses who use applied or medical anthropological con- Cepts instead of developing transcultural nursing theory and research-based practices (Leininger, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018b). She also identified international nursing and transcultural nursing as different. International nurs- ng occurs when nurses travel to or have nursing practice or service-learning experiences in other nations or coun- tries; however, transcultural nursing involves multiple cul- tures and has comparative theoretical and practice base foci (McFarland & Wehbe-Alamah, 2015, 2018). Leininger described the transcultural nurse generalist (now known as certified transcultural nurse-basic or CTN-B), as a nurse prepared at the baccalaureate level who is able to apply transcultural nursing concepts, principles, and practices that are generated by transcultural nurse specialists (Leini- nger, 1991, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015, 2018). The transcul tural nurse specialist (now referred to as a certified trans-
cultural nurse-advanced or CTN-A) is prepared in graduate programs and receives in-depth preparation and mentor- ship in transcultural nursing knowledge and practice. The CTN-A has acquired competency skills through post bac-
calaureate education by having acquired research-based knowledge about selected cultures in sufficient depth to provide high-quality, safe, and effective transcultural nurs- ing care (McFarland & Wehbe-Alamah, 2015, 2018). The transcultural CTN-A therefore serves as an expert practi- tioner, teacher, researcher, and consultant with respect to select cultures. The CTN-A specialist values and uses nurs- ing theory to develop and advance knowledge within the discipline of transcultural nursing, the field Leininger pre- dicted must be the focus of all nursing education and prac- tice (Leininger, 1991, 1995; Leininger & McFarland, 2002,
TICAL SOURCES FOR THEORY
EORETICAL
ENTELOPMEN
aer's theory
was derived from the disciplinesof
ology and. 2002, 2006; Mckarland & Wehbe-Ala- and nursing
Leininger, 1991, 1995; Leini-
2015a, 20186).
She described
nursing focused on the comparative studv
fdiverse cultures and subcultures worldwide
atiyolog
transcultural nursing as
nhaior
area
of r
e to their caring values, expressions, and health sth respect te and patterns
of. behavior. e of the theory is to discover human care
ness beliets a
he purpose
.and universalities in relation to worldview, cul- d ial structure dimensions, and then to discover
turally congruent care for people of to providecultur
frent or similar cultures
to maintain or regain their
ing or health or to face death (Leininger, 1991,
t-being
e: Leininger
& McFarlan 2002, 2006; McFarland & Alamah, 2015a, :018b). The goal of the theory is to
oVe and to bvide culturally congruent care to people
is beneficial and will ft with and be useful to the client,
mt: or cultural group (Leininger, 1991, 1995; Leininger afarland, 2002, 2006; McFarland & Wehbe-Alamah, .2018). Transcultural nursing goes beyond an aware- state to one of using culture care nursing knowledge
ractice culturally congruent and responsible care
McFarland&Wehbe-Alamah, 2015c, 2018b).
Leininger stated that, over time, there would be a new nd of nursing practice that reflects diverse nursing prac-
is that are culturally defined, grounded, and specific to lide nursing care provided to individuals, families, groups,
ad institutions. She contended that because culture and e knowledge are the broadest and most holistic means to
cptualize and understand people, they are central and mperative to nursing education and practice (ILeininger, 91, 1995; Leininger & McFarland, 2002, 2006; McFarland Nehbe-Alamah, 2015c, 2018b). In addition, she stated anscutural nursing had become one of the most impor a1, relevant, and highly promising areas of formal study, 5arch, and practice because people live in a multicultural
UI(Leininger, 1988a, 1995; Leininger & McFarland,
2006; McFarland & Wehbe-Alamah, 2015, 2018). Leininger (1996) promoted a new and different theory
from traditional nursing theories that defined theory as logi- cally interrelated concepts and hypothetical propositions to be tested for the purpose of explaining or predicting an event,
338 UNIT IV Theories and Grand Theories tory, and the evironmental
ehomenon, or situation. Instead. Lcininger defined theory
as the s'stematic and creative discovery ol knowlcdge about
a domain of interest inmportant to understand or account for
SOmc unknown phenomenon. She belicved nursing theory
must lake into accoun creative discovery about individuals,
1amilics, and groups, and their caring. values, cxpressions,
belicts, and act ions or practices based on their cultural life-
71 to providc eltective, satislfying, and culturally congruent
care (1 cininger. 1991. 1995; Icininger & McFarland,
2002,
O6: Allarland & Wehbe- Alamah, 2015a, 2018b).
I cininger (199) developed her theory of culture care
divcrsitv and universality bascd on the belief that people of
dilerent culures can intorm and are capable of guiding
protessionals to receive the kind of carc they desire or need trom others C1lture is the pattcrned and valued lifeways of
people that intlucnce thcir decisions and actions; therefore,
the theor is directed toward nurses to discoverand docu-
ment the world of the clicnt and to use their emic (insider) icpoints, knowledge. and practices with appropriate etic
(outsidcr). as bases for making cullurally congruent profes- sional care actions and decisions (Leininger, 1991, 1995).
The culture care theory can be both inductive and
deductive and is derived from both emic and etic knowl-
Contex abstract and practice dimensione that can
Tho he theay Ch tematically to achieve culturally congruent be exanine 2015a,c, 2018b). It is the onlv focused on culture and care of
three theory-based culture care
acceptable care comes (McFarland & w it is possib care becaus
derived fro
Wehhe in nur ethnonUrsi
heoare ou
or
peoAiyerse and what is
se
culluremodes ol deciiactions that are rectly applicable in clinical reaching beneficial and satisfactory lifeways ultimately discover care-what is sally related to care and parative focus to discover different
nursing care practices
document, through he
generic an
(Leininger,
Leining
to support of the
pracliceebeng, e thcory health-and has an
integrate or contrastin with specific care based carin nursings co ory with the onursing method has ramalconstructs iep
nes
na beneficial care
tease out in-depth infor
information. Thus, these enablers tural health care assessments.
eration of new knowledge in nursing:
nant emic data and healh
he enablers first reason
ment, and s- the human
reason 1S to
construct or
sed also be u
. The theory can at culturally congruent, neaningful, and t
uide he d health care t edge and th-
ferent cultu
(Leininger, 1
McFarland & knowledge i
promote the
or disability,
over time (Le
USE OF EMPIRICAL EVIDENCE
hat care For more than six deca Leininger held
dominant, distinc cdge (1991. p. 33). Leininger (1991) encouraged nurses and others to obtain grounded emic knowledge fronm the pe0-
ple or ulture because such knowledge is more credible.
The theory is ncither a middle-range nor macro theory but
must be viewed holistically with specific domains of inter-
cst. Leininger bclieved the terms middle range and macroo
to be outdated in theory development and usage (Leini-
nger. 1991, 1995; Leininger & McFarland, 2002, 2006;
McFarland & Wehbe-Alamah, 2015, 2018). Indeed, the culture eare theory is the broadest holistic nursing theory, because it takes into account the totality and holistic per-
spective of human life and existence over time, including
the social structure factors, worldview, cultural history and values. environmental context (Leininger, 1988b), language
expressions, and folk (generic) and professional care pat-
terns. These are some of the most critical and essential
essence of nursing and the
ve, and ing feature of nursing (Leininger, 1970, 1988b.nger& McFarland, 2002, 2006; McFarland Nehbe that care is comnpleoften embedded in social structure and other 2015, 2018). She stated
fession needs
holistic cultuz
ture (Leininger, 1991; Leininger & McFarland held that diferent forms, expressions, and Dat were diverse, whereas Some were universal ( s f Leininger & Mckarland, 2002, 2006). Leinino
meanings of a
1991, 1995;
land & Weht
1995) found
asp
often embedd
quali 1990; Leininger & McFarland, 2002, 2006) usei
care. ethnomethods, especially ethnonursing, to study
:ople-tr. methods are directed toward discovering the Dennl. views, beliefs, and patterned liteways of cultural
this knowleds
their practice
therapeutic w-
or help people & McFarland,
2015a, 2018b) meaning of ca
health care of
9
bases for the discovery of care knowledge that, as the
essence of nursing, can lead to the health and well-being of clients and guide therapeutic nursing practices.
According to Leininger (2002b), the theory of culture care
diversity and universality has several distinct features, differ- ent from those of other nursing theories. It is the only theory
that is focused explicitly on discovering holistic and compre- hensive culture care, and it is a theory that can be used across
Western and non-Western cultures because of its inclusion of
multiple holistic factors universally found in cultures. It is the only theory focused on discovering comprehensive factors influencing human care such as worldview, social structure factors, language, generic and professional care, eth1nohis-
families, and individuals. During the 1960s, Leiningerd oped the ethnonursing method tO study transcultural ing phenomena specifically and systematically. This m
focuses on the discovery of care beliets, values, and pra. as cognitively or subjectively known by the people oi ture through their local emic people-centered lang experiences, beliefs, and values about actual or pute nursing phenomena such as care, health, and environne
factors (Leininger, 1991, 1995; Leininger & MecFarie 2002, 2006; McFarland & Wehbe-Alamah, 2015, 20 Although nursing has used the words care and carig more than a century, their definitions and usage have te
vague, having been used as clichés without speciht nke ings to the culture of the client or nurse (Leininge, 1988b). With the transcultural culture care theory
dicted, and c=
(Leininger, 199
as one of the
phenomenon C
and patterns n
used to ensuree i
guide to transc
used to guide (Leininger 1991
McFarland &
studied several graduate and gt
loine M. Leininger: Iheory of Culture Care Diversity and Universality CHAPTER22 339
cd on emic sider views) beliefs, ethe to the discovery of people-based
ve research methods. She extensively explicated Care COnstructs throughout many cultures in which cach cu ulture ad different meanings, cultural experiences, an verse and similar care values, beliefs, patterns, and expr SOns by their people (Leininger 1991, 1995; Leininger McFarland, 2002, 2006: McFarland & Wehbe-Alama 2015a, 2018b). New culture care knowledge continues Cscovered by transcultural nurses in the development OT Cuture-specific care practices with diverse and similar cu
no getcdircctly from the people and are not tsider vicws) beliefs and practices
mportant purpose of the theory is to
S dala come.
predict, and explain systematically
nal care of cultures being studied
fcher: An mporlant
(nt. kno
eld dala i
and universal about the whal is diverse to be
detailed and culturally owledge and practi should distinguish
studying the lture care theory is that the
sa) held that nnger 199)
time, Lcininger (1991) believed both diverse and universal features of care and health would be documented as the essence of nursing knowledge and practice.
Leininger stated that the goal of the culture care theory 1S to provide culturally congruent care (Leininger, 1991,1995; Leininger & McFarland, 2002, 2006; McFarland& Wehbe-Alamah, 2015a, 2018b). She believed that nurses1must work toward explicating care meanings so that cul ture carc, values, beliefs, and lifeways can serve as accurate and reliable bases for co participatively making cultureSpecific care decisions and actions as well as to identity universal or common features about care (Leininger, 1994,McFarland & Wehbe-Alamah, 2015a, 2018b). She main- tained that nurses could not separate worldviews, soCial structure factors, and cultural beliefs (lay/folk/generic and professional) from health, wellness, illness, or care when Working with cultures because these factors are closely linked and interrelated (Leininger, 1994; McFarland & Wehbe-Alamah, 2015a, 2018b). Social structure factors, such as religion, politics, culture, economics, and kinship, are significant forces affecting care and influencing illness patterns and well-being. She also emphasized the impor- tance of discovering generic (folk/lay, local, and indige- nous) care beliefs, values, and expressions held by cultures and comparing them with professional care practices (Leininger, 1991, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018b).
yninger (1988a)
utions from those of other disciplines. The
,/
nas0N Or
stud
re
as been crilical to the growth, develop-
val of hunman beings fron the beginning of
1988b). The second ies (Leininger, 1988a,
and fully understand cultural knowl-
es of carcgivers and care recipients in dif-
i survi
humman sfpecics
d the rolcs
ol carcgivers
an
s to
provide culturally congruent care Leininger &McFarland, 2002, 2006;
1991, 1995;
.1Wehbe-Alamah, 2015a, 2018b). Third,
. ulun
care rland & Wehbe-Alamal
Jiscovered and can be used as essential to
the healing
and well- to cnsure the survival of human cultures
-being ofcl to face death
tbility. or to
et, 1991, 1995). Fourth, the nursing pro-
cds to sy'stematically study care lrom a broad and
Itural perspective
to discover the expressions and
of care, health, illness, and yell-being (Leininger,
1Wehbe-Alamah, 2015a, 2018b). Leininger (1991, 1005;
Leininger & McFarland, 2002, 2006; McFar-
:1 edded in cultural lifeways and values. However,
help peoplelface death (Leininger, 1991,
d that care was largely an elusive phenomenon
knowledge serves as a sound
aractice for culturally congruent care and specific
basis tor nurses to guide
rapeut
apntic wavs to maintain health, prevent illness, heal,
1995; Leininger arland, 2002, 2006; McFarland & Wehbe-Alamah,
2018b). A central thesis of the theory is that if the
ning of care can be fully grasped, the well-being or lth care of individuals, families, and groups can be pre-
d, and culturally congruent care can be provided
minger, 1991, 1994, 1995). Leininger (1991) viewed care E One of the most powerful constructs and the central henomenon of nursing. However, such care constructs
d patterns must be fully documented, understood, and
ed to ensure that culturally based knowledge is the major uide to transcultural nursing decisions and actions and is sed to guide culturally congruent nursing practices eininger 1991, 1995; Leininger & McFarland, 2002, 2006; McYarland & Wehbe-Alamah, 2015a, 2018b). Leininger tudied several cultures in-depth, including with under- Taduate and graduate students and faculty using qualita-
Leininger found that cultural blindness, cultural shock, cultural imposition, and ethnocentrism by nurses continued to greatly reduce the quality of care offered to clients from diverse cultures (Leininger, 1991, 1995; Leininger & McFar- land, 2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018b). Moreover, nursing diagnoses and medical diagnoses that are not culturally based and known create serious prob-lems for cultures that lead to unfavorable and sometimes serious outcomes (Leininger, 1995, 1996; Leininger & McFarland, 2002, 2006; McFarland 8& Wehbe-Alamah, 2015a, 2018b). Providing culturally congruent care enhances client satisfaction about the care they have received; it is a powerful healing force in the provision of quality health care. Quality care is what clients want most when they seek care from nurses, and it can be provided only when cultur- ally derived and congruent care is known and used.
340 UNIT IV Theories and Grand
Theories
lifeways of values, beliefs, and nts for
ther hean
MAJOR CONCEPTS AND DEFINITIONS
well-being, or to prevent or face ilness, d for
saoitie,t The provision of culturally conCr the major goal of the Culture Wehbe-Alamah, 2015c, p. 14).
Care and Caring
and sate care h
With expressions of assistive supportive,
enabling, and
acilitatina wavs toward or about self or
others."Caring
reters to actions. attitudes, or practices
to assist others
oward healing and well-being
Care refers to the abstract and
manifest phenomenon
Care Theory iMo
Care as a major con Culture Care Diversity
"Culture care diversity refers to the yariadilitiesa
human beings related to providing beneticial cat
ences in ulture care beliefs,
symbols, lifeways, symbols, and
struct of the theory includes generic/tolk
care and pro-
meanings, atternstessional care which are major parts
of the theory that
other ani well-he ng of dverse
cultures Mc Farland & Wehbe
Alamah 2015c pn 101
have heeon predicted to influence
and explain the health
teatures a clients from a designated culture" McFarand &lek Cata Alamah, 2015c, p. 14). Generic care Culture Care Universality
Culture care universality refers to Con ndioenous traditional or local folk lemic)
knowledge and
prartices to provide assistance, supportive, enabling,
and
faclitative acts fo or toward others with evident or an
iCInated health needs in order to improve wellbeing
or to
heir with dying or other human conditions" (McFarland &
Wehhe Aiamah, 2015c, p 14)
Generic care refers to the learned and
transmitted lay.
or similar Cultural care phenomena feat
ings or groups with recurrent meanina
symbols, or liteways that serve as a c
to provide assistive, supportive facilitati people care for healthy outcomes" (MeEa
Alamah, 2015c, p. 15
hura nOs, pattens, ag Uide for Careri
e, or anat
rarland 2 le Professional care
Worldview Professional nursing care refers to formal and explicit cog
ogk o "Worldview refers to the way people tend to le
form a picture or valus ohtanec peneraly through
educational institutions lusually
nongenernc that are taught to nurses and others to provide
a5515tive sunportive enabling, or tacilitative acts for or to
anothe ndividua or group in order to improve their health,
prevent linesses. or to help with dying or other human con-
ditions (MoFarland & Wehbe-Alamah, 2015c, p. 14).
veh learned professional care knowledge and practices
their wold or universe to about life or the world around them em. Worldview
ofDinea broad perspective a0out ones orientation to to life. ple, or groups that infiuence care or carina
esponsaand guides one's decisions or actions, especiall to matters of health or well-being (McFarland 2 e
enta Alamah, 2015c, p. 15) Culture
Cultural and Social Structure Dimensions The "cultural and social structure dimensions lr
tors] refer to the dynamic, holistic, and interrelated terns of structured features of a culture (or subculte
that include but are not limited to technology factors,
gious and philosophical factors; kinship and social facus cultural values, beliefs, and lifeways, poltical and eg
Culture reters to learned, shared, and transmitted val-
Jes beliets, norms. and lifeways of a paticular culture
tha' guide thinking. decisions, and actions in patterned
wavs Culture is eaually as important as care; is not an ad-
vert o' adiective to care. Leininger conceptualized culture
care as synthesized and closely linked phenomena with
interrelated ideas" (McFarland, 2018b, p. 46).
factors; economic factors; and educational factors as we
as environmental context, language, and ethnohistor
(McFarland & Wehbe-Alamah, 2015a, p. 75).
Culture Care Culture care reters to the synthesis of the two major
constructs Icare and culturel that guide the researcher to
discover explain, and account for health, well-being, care
expressions, and other human conditions (McFarland &
Wehbe-Alamah, 2015c, p 13)
Environmental Context
"Environmental cotext refers to the totalityof an eler
Culturaliy Congruent Care Culturally congruent care refers to culturally based care
knowiedge, acts, and decisions used in sensitive, cre- ative, and mearingtul ways to apPpropriately fit the cultural
Situation, or particular experience that givesmeanings
people's expressions, interpretations, and social nes
tions within particular geophysical, ecological, spinas
SOCiopolitical, and technologic factors in specineu
settings" (McFarland &Wehbe-Alamah, 20150, p. i
Va
.Ineory of Culture Care Diversity and Universay
HAPTER 22
CONCEPTS &DEFINITIONScont'd 341
eto the sequence of past facts or experiences of human be
MAMOR CO
whstory molis.
shistoryrete,
fs staces, wes, or
Iduais or groups that enables them to perform tne ives (McFarland & Wehbe-Alamah, 2015C, P.
ngs stitutions Over time in particular lain past and current lifeways about
daily
Culture Care Preservation and/or Maintenane Culture care preservation and/or
15).
e ce mnuencers
sabultyor d
affecting the health and well-be- (McFarland & Wehbe-/s
thal
nep
expla
death of people" to those assistive, suppor
maintenance refers essional actions and decisions that help people o
portive, facilitative, or 20150 p. 15).
fers to
loca, indigenous, or the insider cul-
par
are beliefs and values for their well-being, to recover Tro ul
ness, or to deal with handicaps or dying (McFarland o
enabling pro ucuiar culture to retain, preserve, or maintain medig
and nd views about specitic phenomena" Wehbe-Alamah, 2015c, p. 16). KDO/eOGe &Wehbe-Alamah, 2015c, p. 14). Culture Care Accommodation and/or Negotiation uture care accommodation and/or negotiation re-ers to those assistive, accommodating, facilitative, o enabing creative professional care actions and decisiois nat help people of a designated culture (or subculture) to adapt to or negotiate with others for culturally congruent, safe, effective care for meaningful, and beneficial nedi Outcomes (McFarland & Wehbe-Alamah, 2015c, p. 16).
he outsider or stranger (otten health pro ro-
or institutional / system|knowledge and
about cultural phenomena" (McFarland tic
1elers
0 the
toetea values
1ehbe-Alamah, 2 2015c, p. 14).
valued, and practiced that reflects the ability
ninger 1991, p. 48;
McFarland & Wehbe-Alamah
5 p. 11); a
state of restorativ well-being that is cul-
.a state of well-being that is culturally Herlth
th refers Culture Care Repatterning and/or Restructuring Culture care repatterning and/or restructuring refers to the assistive, supportive facilitative, or enabling pro fessional actions and decisions that help clients reorder, change, or modify their lifeways for beneficial healthcare
of to pertorm their daily role activities
ssed, beneticial, and patterned lifewaysuals or
groups to
o
lturally
expressed,
ben
valued, and practiced by indi pdterns, practices, or outcomes (McFarland & Wehbe- Alamah, 2015c, p. 16).
a Constituted,
detined, valis
IAJOR ASSUMPTIONS Culture care is the synthesis of two major constructs (culture and care) that guide the researcher to discover, explain, and account for health, well-being, care expres- sions, and other human conditions.
Culture care expressions, meanings, patterns, processes,
universality of care reflects the common nature of
nan beings and humanity, Whereas the diversity of care
the discovered variability and unique features of
-man beings. Major assumptions of the theory of culture
diversity and universality presented here were derived
Leiningers definitive works on the theory and subse-
ETt evolutionary changes (Leininger 1991; Leininger &
cFfarland, 2002, 2006; McFarland & Wehbe-Alamah,
and structural forms are diverse, but some commonali-
ties (universalities) exist among and between cultures. Culture care values, beliefs, and practices are influenced
by and embedded in the worldview, social structure fac- tors (e.g, religion, philosophy of life, kinship, politics, economics, education, technology, and cultural values) and the ethnohistorical and environmental contexts.
15a, 2018b):
Care is the essence and the central dominant, distinct, and unifying focus of nursing.
Humanistic and scientific care is essential for human
growth, well-being, health, survival, and to face death and disabilities.
Every culture has generic (lay, folk, naturalistic; mainly
emic) and usually some professional (etic) care to be dis- covered and used for culturally congruent care practices.
Culturally congruent and therapeutic care occurs when
culture care values, beliefs, expressions, and patterns are
explicitly known and used appropriately, sensitively, and
meaningfully with people of diverse or similar cultures.
Care (caring) is essential to curing or healing for there can be no curing without caring (this assumption was
aeld to have profound relevance worldwide).
maj "[that the] worldvie social ructure
ment, lang and y
theoretical tenes UNIT IV
Theories and
Grand Theories
cultural knowledge. A second 342
Leiningers threc
thcoretical modes of care
offer new,
creative, and different
therapeutic ways
to help peopie
of diverse cullurcs.
gion, economics, education, to.
(social), ethnohistory, environme:
care and professional care factors
culture care meanings, expression
ent cultures" (Leininger & N
Leininger maintained that kno
actors such technolo8Y politics, The cthnonursing
rescarch method and
other qualitative
research paradigmatic
methods offer important
means
to discovcr largely
embedded, covert,
epistemic, and
ontological culture care
knowledge and practices.
Transcultural nursing is a discipline
with a body of
knowledge and practices
to atlain and
maintain the goal
of culturally congruent
care for health and
well-being.
(l cininger 1991; Leininger
& McFarland,
2002, 2006;
McFarland & Wehbhe-A lamah, 2015a,
2018b).
would greatly and patter
cFarland, 2002, p. 781 ng the cu Social structure
lactors was necessary in order t meaningful and satistying care to people and they would be pOwerful influenc care. These
factors also on Culturaiy tmasneeded to be discoNered direnfrom
cultural informan to confirm th as
beng ina to health, well-
being. nness, ana encing factors related
death. The third majoritheoretical tenet was "both(emic) and professional (etic) care researched, and brought together intsto care ha
satisfying care for clients which leads to their hl
needs enesr Tencts are the
assertions one holds or are givens
that the
theorist uses with a theory. In developing
the culture care
theor, the following four major tenets
were conceptual-
i7ed and formulated by the theorist
(1Leininger & McFar
land. 2002, 2006: McFarland &
Wehbe-Alamah, 2015,
2018):
THEORETICAL ASSERTIONS
be
acices he well-being" (Leininger, 2002). The fourth major theoretical tenet
ization of the three major care modes
actions (stated previously) to arrive at
care for the general health and well-beir help them face death or disabilities (Leinin
nealth a as the conceptud
of decisions culturally congrCulture care cxpressions, meaning, patterns,
and prac-
tices are diverse and yet there are
shared commonalities
ients, om McFarla,
researcher or clinician draws upon findin structure, generic care and
2002, 2006; McFarland & Wehbe-Alamah 2015, 2018).TThe worldview, multiple social structure factors, ethno-
history, environmental context, language, and generic
and professional care are critical influencers of culture
care patterns to predict health, well-being, illness, heal-
ing. and ways people face disabilities and death.
Generic emic (folk) and etic (professional) health fac-
tors in different environmental contexts greatly influ-
B).The ngs trom the soco
and some universal attributes.
professional practic influencing factors to study or provide cultural.do
for individuals, families, and groups. These factoa be studied, assessed, and responded to in a dun ynamic
ed and participatory nurse-client relation (Leininger Leininger & McFarland, 2002, 2006; McFarland
Alamah, 2015a,b, 2018b). Wehide From an analysis of the above influencers, three major decision and action modes (culture care preservation or maintenance; culture care accommodation or negotia-
tion: and culture care repatterning or restructuring)
were predicted to provide ways to give culturally con-
gruent, safe, and meaningful health care to cultures
(Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018b). These decision and action modes were predicted to be
key factors in the provision of culturally congruent, mean- ingful, and acceptable care for beneficial outcomes. When using the modes, individual, family, group, or community factors are assessed and responded to in dynamic and par- ticipatory nurse-client relationships.
In conceptualizing the theory, the first major and central theoretical tenet was "care diversities (differences) and uni- versalities (commonalities) existed among and between cultures in the world" (Leininger & McFarland, 2002, p. 78). However, Leininger asserted that culture care meanings and uses first had to be discovered to establish a body of trans-
ence health and illness outcomes.
LOGICAL FORM
Leininger derived concepts for her theory of culture c diversity and universality from both anthropolog
nursing but reconceptualized them into a new set of can structs that became a transcultural nursing theory with human care perspective (1991, 1995). She developed th ethnonursing research method and emphasized the imper tance of studying people from their emic local knowledge and experiences and later compares this knowledge with the etic (outsider) beliefs and practices. Her book, Qualte tive Research Methods in Nursing (Leininger, 1985a) ani
subsequent publications (Leininger, 1990, 191, 19 Leininger & McFarland, 2002, 2006; McFarland &Wehile Alamah, 2015a,b, 2018b) continue to provide substanie knowledge about qualitative methods in nursing.
Leininger was skilled in using ethnonursing, ethnog life histories, life stories, photography, and phenomenong
nd
Madeleine M. Lein ne M. Leininger: Iheory of Culture Care Diversity and Universaly CHAPTER22
343
ovide a hol
iverse environmental
the study of cul- contexts (Leininger,
holistic aPproach tor es, beliefs, and lifeways; biological factors
(neW "
hori 15 1eminger& &McFarland, 2002, 2006; McFarland
With these qualitative with people in their daily liv-
Poltical and legal factors; economic factors; cducational factors as well as environmenta Alamah,
h. 2015a, 2018b).
lan-
rd
understandi their world.
nonursing research
method the nurse
ge, and ethnohistory (McFarland & Wehbe-Alaman, 018a; Wehbe-Alamah, 2019; Wehbe- Alamah & Mcra
land, 2020). esearcher.
Atiies toNar
th he ennonursi nher indtuctivel obt
ta of documented descrip- These factors also influence culture care expressions
patterns, and thus the folk, professional, and integrared
care practices, which are depicted in the middle
ection of the Sunrise. The upper and lower halves together form a full sun, which represents the universal
care co structs that nurses must consider to appreciate human cau and health (McFarland & Wehbe-Alamah, 2018a; Wehbe Alamah, 2019; Wehbe-Alamah & McFarland, 2020). NurSing acts as a bridge integrating generic (folk) and professional care (McFarland & Wehbe-Alamah, 2018). Nurses can then
use the three culture care modes of nursing decisions and
actions in practice as predicted in the theory: Culture care
preservation and/or maintenance; culture care accommoda- tion and-or negotiation; and culture care repatterning and-or restructuring (McFarland & Wehbe-Alamah, 2015a, 2018b).
The Sunrise Enabler depicts human beings as insepara-
ble from their cultural backgrounds and social structure factors, worldview, history, and environmental context (McFarland & Wehbe-Alamah, 2015a, 2018a,b). In the
theory, gender, race, age, and class are embedded in social structure factors and are studied from a holistic perspec- tive. Theory generation from ethnonursing studies may Occur at multiple levels, from small-scale studies with
specific individuals (micro level) to larger studies with
vely obtainsdata.
ve narratives
tromn informants througl
And intery
he e R McParland, 2002, 2006; McFarland
explicating culture care val- and participation. ing
research method (Leininger, w7ti sing.
015;
Leninger
&
McFarlas
e-Alanah, 201
developing basic and substantive data-
ure care to guide nurses in their
2015a, 2018b). The qualitative approach
portant dge about culture
afknonlea rath es. Pro, rom
the beginning, hnonursing has been
primaruly on the.
ral groups
under
study
though othe
lata directly from the arily on
the discovery of dat
ther methods of research, such as hypoth-
erimental quantitative methods, can
ral care, the method of choice s tstinga study transcultura
on the
researche purposes, the goals of the
and the phenomena
to be studied. Creativity and
ness Of the nurse researcher
to use diverse wilingness
of the nur
methods to liscover nursing knowledge are
ET
2Ccurate
cultural knowled and that quantitative
Tures and care. Leininger
also ieved that combining
ed. However, Leininger
held
Were important to establish meanings and dis-
that qualitative
generally were of limited value when studying
ihods
hgqualitative and quantitative methods in the same
ni obscured the findings and was a misuse of both
adigms (Leininger, 1991, 1995; Leininger & McFar-
i 2002, 2006; McFarland & WNehbe-Alamah, 2015a,
groups, families, communities, or institutions (macro
level). Leininger also developed several enablers to facili- tate studying phenomena using the four phases of qualita- tive data analysis (Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018b).
8b). The Sunrise Enabler and a complete overview of the
c2or of cultural care diversity and universality are not
addressed here. Selected ideas are presented to intro- e the reader to Leininger's pioneering and creative work n evolving holistic and comprehensive theory. Leini-
r developed the Sunrise Enabler (Fig. 22.1) in the 1970s apict the essential components of the theory. The Sun-
vas refined by Leininger in 2006 and subsequently 0ated by McFarland and Wehbe-Alamah in 2015 and
a in 2018a (see Fig. 22.1). It has thus evolved to be a dehnitive and valuable enabler to comprehensively and focus studies and with which to make culturally
t care decisions and actions. The upper half of the
e Enabler depicts key theoretical constructs related eW and cultural and social structure dimensions.
The first phase of data analysis is collecting, describing and documenting raw data; the second phase is identificatiorn and categorization of descriptors and components; the third phaseis pattern and contextual analysis; the fourth phase is mjor themes, research findings, theoretical formulations, and recom- mendations (Wehbe-Alamah, 2018b, p. 72). The criteria to evaluate ethnonursing research findings are "used to challenge discovered universalities and diversities in relation to the CCT and the qualitative paradigm and to systematically examine and discover in-depth care and culture meanings and interpre-
tive findings" (McFarland & Wehbe-Alamah, 2015b, p. 56). These criteria are credibility; confirmability; meaning-in- context; saturation; recurrent patternings and transferabil-
ity (McFarland & Wehbe-Alamah, 2015b, p. 56). Leininger
strongly held that quantitative criteria should not be used with qualitative methods because the former use paradigm-specific criteria to measure such outcomes (Leininger, 2002, p. 87).
ese dimensions include technole factors; religious and Aosophical factor ors; kinship and social factors; cultural
944 UNII V Thent les
and Ga hln
CU TUN CANE
Worllview
GuluralA tionlal
iiuoturn Dlnonlon
Cultural Valuos, Boliefa,
Biologlon FAotorn
LIfewaya Politoal
Kinehip
fiocial
nvironmental Contoxt, Languagn n Eohistory
ogal aotors6
Faotor
Religlou spiritual,
Philosophleal Factors
6onom Influenos Factors
Care Expresslons, Pattorns, & Praotioes
ducatlonal Technological
Factors
Factors Hollstle Health, Wellbelng,
Dlsabllity,
Ilnoss, Dylng, & Death
Focus: Individualn, Famlllon, Groups, Conmunitio1s,
or lnatitutions
In Dlverno Hoalth Cont0xtn of
Profess ional Generlc (Folk)
Care
Care Cure
Intogratlvo Caro
Practlcos Practic0s
Throo Modos of Caro Doclslons & Actions
Culluro Caro Prosorvatlon and/or Maintenance
Cullure Care Accommodalion and/or Nogotiation
Culture Caro Ropatterning and/or Restructuring
M.R. McFarland & H.B. Wohbe-Alamah (2018) Code: (Influoncors)|
Culturally Congruont Caro for Hollstlc Hoalth, Wollbeing, Disability,
llnoss, Dylng, and Doath
Fig. 22.1 Lemnger's Suni1S0 Enablor (1om McI arland, M, and Wohbo- Alamah H. B. 12018|. Tianscultural nursing
concopts, thoonos, r0seara,
&practice 14th edl Now York, NY: McGraw-Hill Education.) Usod with permission.
M, Leininger:Theory of Culture Care Diversity and pTER 22 Madeleina
-
cHAPTER22 M
and Universality loned several additional enablers t
the ethnonursing
345
pr Enuber:Leininienaif o ASSCSS ult
inger aiso deve,
st researcher Observation-
in their use of
on-Participation-Refled
Friend Enabler; the Domain of
09.This enabler correlates closely with the social structur on Enabler; ors of the culture care theory as depicted in the >unt Enabl Dier (Leininger & McFarland, 2002, 2006; McFarland &
Wehbe-Alamah, 2015a, 2018b).Semi-Structured Inquiry Guide ulture Care and Health; and the Accul
traditional Lifeways. "Enablers sharply
tiger he Acculturation Health Assessment Enabler for Cul- ural Patterns in Traditional or Nontraditional Lifeways Wehbe-Alamah, 2018b, pp. 69-72) is another importaguide used with the ethnonursing method for both cuitura4ssessments and ethnonursing research studies. It is essen al when studying cultures to assess the extent of the infor mants acculturation, whether they are more or less traditionally or nontraditionally oriented in their values,
Enabler for Cultural Patterns in ealth Assessment,
Mna
wrth mechanistic devid
ruments, and other
istic devices such as tools, scales, mea-
er impersonal objective dis-
nt
used in quantitativ studies. These wed as unnatural (foreign) and (are)
rvation-Partici ticipation-Reflection Enabler
familiaror natural.context during the
eultural informants (Leininger, 2002, p. 89). beliefs, and general lifeways" (Leininger & McFarland, is 2002, p. 92).
ObSche researcher to enter and remain with do tacilitate
nandsin their be-Alamah, 2018b, p. 64). The researcher gradu- ACCEPTANCE BY THE NURSING om the role of observer and listener, transition- COMMUNITY
reflector with the informants. articipant and
slowly and politely with permission, the Practice nRoNng
atherdoes 1
all occurring in the environment or with the
not disrupt and therefo is able to observe
th the
mh. 2018%, p p. 63), the nurse researcher is able to learn
nemselves and the people and ulture being
McFarland & Weh Alamah, 2015a, 2018b). Stranger-to-lrusted Friend Enabler (Wehbe-
Leininger identified several factors associated with the reluc- tance by nursing to recognize and value transcultural nursing and cultural factors in nursing practices and education (Leini- nger, 1991; Leininger & McFarland, 2002, 2006; McFarland 8& Wehbe-Alamah, 2015, 2018).
about theni
The goal with this guide 1S to move from distrusted
n become a trusted friend, and thereby able to more
First, the theory was conceptualized during the 1950s when very few nurses were prepared in anthropology or had any cultural knowledge to help them understand transcultural concepts, models, or theories. In those early days, most nurses did not have much knowledge about the nature of anthropology and how anthropological knowl-
edge might contribute to human care and health behav- iors or serve as background knowledge for understanding nursing phenomena or problems. Second, although peo- ple had longstanding and inherent cultural needs, many clients were reluctant to press health care providers to meet their cultural needs and therefore did not demand
zie observe cultural attitud behaviors, and expres-
This process is essential for the researcher so that hon-
dible, and in-depth data may be discovered with the mants (McFarland & Wehbe-Alamah, 2015, 2018). Te Domain of Inquiry Enabler is a statement made by
TEsearchers when guided by the culture care theory
ung the ethnonursing method to cdearly focus his or 2 of study (Wehbe-Alamah, 2018b, p. 59). The domain rses questions or ideas related to the focus of the t is purpose, and goals related to culture and care and Sch is a 'succinct, tailor-made statement focused directly specihcaly on culture care and health phenomena nge,2002, p. 92). This domain is carefully worded and arigorously examined for adherence to theory tenets and miptions using the six qualitative evaluation criteria atbe-Alamah, 2018b, p. 52). LAmnger's Semi-Structured Inquiry Guide Enabler to
5 Culhure Care and Health (Wehbe-Alamah, 2018b, pp.
was developed by Leininger with open-ended ques-0 a5Sist the nurse to discover and understand the difter- ensions related to cultural worldview, social structure, aother domains of inquiry" (Wehbe-Alamah, 2018b,
that their cultural and social needs be recognized or met
(Leininger, 1970, 1978, 1995; Leininger & McFarland, 2002, 2006; Mckarland & Wehbe-Alamah, 2015, 2018). Third, until the 1990s, transcultural nursing articles sub mitted for publication were often rejected because journal editors did not know, value, or understand the relevance of cultural knowledge or transcultural nursing as essential to nursing. Fourth, the concept of care was of limited interest to nurses until the late 1970s, when Leininger
began promoting the importance of nurses studying human care, obtaining background knowledge in anthro-
pology, and obtaining graduate preparation in transcul- tural nursing, research, and practice. Fith, Leininger contended
346 UNIT IV Theories and Grand Theories
International Jou Human Caring, Journa of Cultural Diversity, and
diverse global cultu to guide effective, ingful, and evidence-babased nursing practices.
Journal of Transcultural Nursino at nursing remained too ethnocentric and far to adner ent to following interest and directions of organized vves CTh medicine. Sixth, nursing was slow to make substantive Progress in the development of a distinct body of knowl Cage because many nurse researchers had been far too dependent on using quantitative research methods. Contemporary acceptance and use of qualitative researchmethods in nursing has continued to grow and evolve and willcontinue to provide new insights and knowledge related to nursing and transcultural nursing (McFarland & Wehbe-Alamah, 2015a, 2018b).
transculturally focused professional ally publish research and nal journalstheoretica
internatisy perspectiv e, benef eical, mea
Education The inclusion of culture curricula began in 1966
where Leininger was professor
d comparative
care in nursiat the iversity of Colora ogy. Nurses' awareness of the importance of
or of nursing and anthro
Beginning with the 1970s, nurses began to real1ze the importance of transcultural nursing, hunman care, and qualitative methods. Leininger stated: culture catrehut very lew
nuy
gradually began during the late 1960s educators were adequately prepared to teach
coursesthe world's firs masters
an
transcultural nursing. After doctoral programs in transcuultural nursing
We are entering a new phase of nursing as we value and use transcultural nursing knowledge with a focus 011 human caring, health, and illness behaviors. With the migration of many cultural groups and the rise of the consumer cultural identity, and demands in
culturallhy-based care, nurses are realizing the need for culturally sensitive and competent practices. Most countries and communities of the world are multicul- tural today, and so health personnel are expected to understand and respond to clients of diverse and simi- lar cultures.
and implemented in 1977 at the Univers: were; nurses have become specifically prepared' nursing. With the heightened public care costs, diverse cultures,
temporary society worldwide, there is much e for comprehensive, holistic, and transcultur- professionals to provide holistic care. Leininger's advocacy for culture.c
Utah, mari nscuhuraess of hedih
scultural health high-quality, comprehe based on theoretical constructs has been Cris itical f
a
nger, 1991, 1995, 1996; Leininger & McFarland discovery of diverse and universal aspects of Cars
200 Immigrants and people from unfaniliar cultures
expect nurses to respect and respond to values, beliefs, lifeways, and needs. No longer can nurses practice uni- cultural nursing."
2006; McFarland & Wehbe-Alamah, 2015a, 2018 D186). critical need remains for nurses to be educated in t fransaul. tural nursing in undergraduate, master's, and doct ctoral pro grams. There is also a need for well-qualified prepared in transcultural nursing to teach and to mi research in nursing schools within the United States and other countries (McFarland & Wehbe-Alamah, 201 2018b; Mixer, 2015).
Leininger continued to receive numerous requests to tead courses, give lectures, and conduct workshops on human caz and transcultural nursing in the United States and oth countries until her death in 2012. Therefore, Leininger hai put out a call for schools of nursing to offer transcultural po grams to meet the worldwide demand for transculunah
prepared nurses in many cultures (Leininger, 1991, 195 These nursing programs remain urgently needed for practie education, research, administration, consultation, and in te
preparation of transcultural nurses for certification. l: demand for transcultural nurses far exceeds available tas
culturally prepared nursing faculty, educational fundng other resources (McFarland & Wehbe-Alamah, 20 20185). Although the societal demand for transclt nurses is evident, educational preparation remains limic
many nurses worldwide.
facult (M. R. McFarland, personal
communication, April 2002)
In the 21st century, the world continues to become more culturally diverse, requiring nurses to prepare themselves to provide culturally congruent care. Some nurses may experi ence culture shock, conflict, and clashes as they move from
one location to another or from rural settings to urban
communities without having first had some transcultural nursing preparation. As cultural conflicts arise, individuals and families experience less satisfaction with nursing and
medical professional care practices (McFarland & Wehbe- Alamah, 2015a, 2018b). Nurses who travel and seek employment globally experience cultural stresses. Transcul- tural nursing education has thus become imperative for all nurses worldwide. Transcultural Nurse Certification by the Transcultural Nursing Society provides a major step toward ensuring safe and culturally conmpetent nursing practices (McFarland && Wehbe-Alamah, 2015, 2018). Accordingly, more nurses seek transcultural certification so as to be able to provide culturally congruent care for their clients. The
M. Leininger: Iheory of Culture Care Diversity and Universality rER 22 Madeleine GHAPTER22
347
oW use i education, and admi
in nursing
Leininger's culture care theory Gender differences and roles Fiders and generational differences
Communication ministration. This focused specifically on research method (eth-
care practices (Leini
& McFarland, 2002, 2006; McFar-
Bb). Funds to support
carch, History of past trauma Importance of respect
Leininger & McEa
Herhbe-Alamah, 2015a
200"es ( (er
mly one
has a specific
ulturesand Culture care maintenance and/or preservation (read ing the Qur'an); culture care accommodation and/or
negotiation (accepting treatment in addition to religion ana culture care repatterning and/or restructuring (dis-
Continuing stimulant khat) were new ways for nurses to provide culturally congruent and safe mental health care
for urban-dwelling Somali immigrants to the United States.
APplication of the culture care theory to advanced practice
nursing has been explicated by several contemporary trans- cultural authors (Chatham& Mixer, 2020; Eipperle, 2015a,
2018b; Embler et al., 2018; Hascup, 2018; Kelch & Wehbe-
Alamah, 2018; Lee, 2018; Mixer et al., 2015; Wehbe-Alamah, 2018a, Wehbe-Alamah et al, 2020) as necessary for "appro priate client culture-specific focus and care to prevent cultural
imposition or cultural pain" (Eipperle, 2018, p. 330) using the
three culture care modes, the enablers, and the ethnonursing
method. These authors emphasized integration of culturally congruent or sensitive care through direct and explicit approaches to be used by the nurse practitioner. Concepts and
methods for integrating emic and etic care approaches into
primary care practice and use of the education-research- practice continuum form the basis for clinical care decisions and actions (Eipperle, 2015a, 2018b).
nt
te ama
that
Nonetheless,
transcult
unds
elies
Ppo
funds (Strang & Mixer, 2016). hese
research with students
are
limited in most:
uhural mu
and
techniCal
research
fund
cultural
ursing research conduc their
erences and structional programs
anscultural nurses and other nurses
ite linited fiund
oaders in
sharing
their researc
aN eaaders,
Scu cultural
nursing
worldwi
ues at conferen lwide and have been d o lransCultur:
menlal in .
transcultural nursingiin
demands for cultur opening doors to
zations. Despitesociet
n sensitive,
and responsible re, national
zations began to support transcul-
Ds. Through the persistent
tencies of transcultural nurse
has been made. Transcul-
Ynational organizat
only in the
1990s nterna
acting competen
bstantive progress
inspired many other nurses to pursue
aiTsingonl
SS SUbSstant
nurseshave inspire
and to o discover entirely
neW Culture care knowl-
'nursing
Alamah & McFarland,
(McFarland, 2018a Wehbe-Alamah, 2019;
2020). This knowledge will
hape and transform
current and future nursing
es (McFarland, 2018a; McFarland & Wehbe-
2015a, 2018b; Wehbe- Alamah, 2019;
Wehbe-Ala-
amah.
McFarland, 2020).
let al (2014) conducted an ethnonursing study about
FURTHER DEVELOPMENT
Leininger predicted that all professional nurses in the world must be prepared in transcultural nursing and must dem-
onstrate competencies in transcultural nursing (Leininger, 1988b, 1995; Leininger & McFarland, 2002, 2006; McFar- land &Wehbe-Alamah, 2015a, 2018b; Mixer, 2008). Trans- cultural nursing must become an integral part of education and practice for nurses to be relevant in the 21st century.
Currently, the demand for prepared transcultural nurses far exceeds the numbers of nurses, faculty, and clinical special- ists in the world. Significantly more transcultural nurse theorists, researchers, and scholars are urgently needed to continue to develop a new body of transcultural knowledge and to transform nursing education and practice. All nurses need to have a basic knowledge about diverse cultures in the world and in-depth knowledge of at least two or three cul- tures (McFarland & Wehbe-Alamah, 2015a, 2018b). Leini-
nger believed that transcultural nursing research had already begun to lead to some highly promising and difter- ent ways to advance nursing education and practice (Leini- nger, 1991, 1995; Leininger & McFarland, 2002, 2006;
care eliets and
eriences of Somali immigrants living in
e Midwestern city in the United States. Through in-depth
sTuctured interviews, the researchers sought to discover
mental health care meanings, beliefs,
and practices of the
imali people in their new urban context. The purpose of this
arch was to gain emic and etic culture care knowledge
dissemination to mental health nurses and providers
enable provision of culturally congruent and beneficial
zantal health care for Somali immigrants. Open-ended ques-
ns adapted from Leininger's Semi-structured Interview ikeaided the researchers in conducting the interviews. itnodemographic data were also collected and quantitatively agaed. Leininger's Four Phases of Data Analysis Enabler gided the qualitative data analysis and development of pat-
EIS, categories, and thermes. The culturally congruent care dngs influencing mental health care acceptance included: Significance of religion inbal connectedness, cultural history, and khat (native
fowering herbal plant) usage
348
Ab). It is imporlant ta a
UNIT IV Theories and Grand Theories
Wehbe-Alamah, 2015a, 2018b), I based knowledge
the explicati
McFarland & Wehbe- Alamah, 2015a, 2018b). Health discl-plines including medicine, pharmacy, and social work nave gradually begun to integrate transcultural health knowicage dna practices into their programs of study (Leininger, 995).This trend has thus incrcased the demand for cultur ally competent faculty to teach transcultural health care.
Present and future theories and studies in transcultural nursing will be essential to mect the needs of culturally diverse people. The culture care theory will continue to grow in importance worldwide. Both universal and diverse
care knowledge are extremely important to establish a sub- stantive body of transcultural nursing knowledge, and to
Support nursing as a transcultural profession and disci- pline. Leininger's theory has gained global interest and use because it is holistic, relevant, and futuristic and deals with specific, yet abstract., care knowledge (McFarland & Wehbe- Alamah. 2015, 2018, 2019: Wehbe-Alamah, 2019; Wehbe- Alamah & McFarland. 2020).
and obtain culturally
Srom the worldview. The theory allows fo ple conceptual elationships and
diverse socal.
ture factors that influence care Wehbe-Alamah, 2015, 2018). nd health (Mc
diatar Generality The culture care theory demonstrates ality because it is a qualitatively the criterio broad, comprehensive, and worldwid. enables the nurse to address the Dro
perspective of a multicultural
ide in scope. The the TOvision oi care from Jview. It is
uSeid
theory thd applicable to groups and individuals with the viding culture-specihc nursing care (M Alamah, 2015,2018). The broad constru arland & wa and described for study with specific
ltures. The Dot
culture care research has led to a vast amour knowledge. Many aspects of culture.. care, been and continue to be identified aand h
neatth practice of culturally congruent nursingcare on More reser CRITIQUE OF THE WORK
is needed for comparative tudy of culture-s -speciic and versal care knowledge (McFarland & Wehbe- Ala 2018). More of the worlds cultural groups ied to confirm their care constructs for
Clarity
o be ste
transfer
The culture care theory enables a broad, holistic, compre-hensive perspective of individuals, families, cultures, com- munities, and populations. Nurse researchers and others continue to develop many domains of inquiry using the theory to pursue scientific and humanistic culture care knowledge. Nurses seek both universal and diverse cultur- ally based care phenomena held by diverse cultures. Using the theory requires gaining basic conceptual understand- ings and cultural knowledge. Leininger found that under- graduate and graduate nursing students alike were excited to use the theory and discover how practical, relevant, and useful it can be to their work. As the cognitive map of the theory, the Sunrise Enabler helps nurses to better visualize the theory and thereby understand its application to nurs- ing practice and research.
icarandt discoveries to diverse groups and settings (McF Wehbe-Alamah, 2015, 2018). culture care theory and the eth
continue to be used to provide culturally cons care in a variety of health and community ot i wide as well as to transform nursing education (McFarland & Wehbe-Alamah, 2015, 2018).
Findings from the use of nonursing research me
No
pract
Accessibility been the empirical paradign
Simplicity The theory is truly transcultural and global in scope; it is both intricate, elegant in its simplicity, and applicable to nursing practice. It is used by researchers to guide the dis- covery of transcultural nursing knowledge and qualitative research methods to explicate culture care phenomena. Leininger's culture care theory is relevant worldwide to help guide nurse researchers to conceptualize theoretically based research questions and findings to guide practice (McFarland & Wehbe-Alamah, 2015, 2018). It is holistic and comprehensive in nature with key constructs related to worldview and key cultural and social structure dimen- sions as depicted in the Sunrise Enabler (McFarland &
Qualitative research has discover largely unknown phenomena of care and heal diverse cultures using the culture care theory. Qualiamapproaches differ from traditional quantitative rese methods. The ethnonursing research method, the quai tive method developed by Leininger for use with the the of culture care diversity and universality, uses the crtera credibility, confirmability, meaning-in-context, recure patterning, saturation, and transferability to evaluate t empirical nature of ethnonursing research findings (Mc land & Wehbe-Alamah, 2015, 2018). Using these criter within the ethnonursing research method, 164 care con structs have been confirmed with more continually discovered. The data discovered with the use of the ethnom ursing method and discovered from the emic or peop worldview leads to high credibility and confirmabilityot research findings (McFarland & Wehbe-Alamah, 20 Ongoing and future research is predicted to reveal a
eine M. Leininger: Iheory of Culture Care Diversity and Universality HAPTER22
pTER 22 Madeleir
health findings and implications for
349
ing for culture care knowledge acquisition and applica- tion (McParland & Wehbe-Alamah, 2015, 2018). The nscultural care practices and nurs-
discovered body of trans met the evaluative /
ulhtre
cre and
uivocally lhe
neq
ledge that has ncory 1s highly useful, applicable, and essential to nurs- ng practice, consultation, education, leadership, research, and administration. The concept of care as the primary and central focus of nursing and the basis for building nursing knowledge and its application to practice is essen- tial to advance culturally congruent nursing knowledge
and care practices (Eipperle, 2015, 2018; McFarland & Wehbe-Alamah, 2015, 2018). The social structure factors of the Sunrise Enabler and the three culture care modes or decisions and actions guide the provision of culturally Congruent care. The theory of culture care diversity and
universality supports a sound, culturally, and socially responsible discipline and profession, and it guides nurs- ing practices to meet the care and health needs of a mu-
ticultural world (Wehbe-Alamah et al., 2020).
ecades has had significant infl yl nursine ia O1eT nepast
Hin ing knowledge
ng care practices as well as the
jon of many
health care systems (Leini
ininge & McFarland 2002, 2006:
ional nursing
t1 ana unction
1091, 199; amah, 2015a, 2018b).
nd& Wehbe-Alam.
diversity and versality has lture care
nursing care tor meaningful and
theorr ol culture
outcomes. Provid
are is a vital, necessary, and essen-
emporary nursing (Eipperle,
is central to the domain of nurs-
ture-specific,
fi ial
cient ou
ongruent.
ed goal in
contenm
SUMMARYy
hapte.
the nature, importance, and major features tures. Other disciplines have found the theory and the method
very helpful and valuable. Newcomers to the theory and the
method can benefit from experienced expert mentors, in
addition to studying previous transcultural research con-
ducted using the theory and the method. Most importantly, nurses often express that the theory is very natural to nursing
and helps one to gain fresh new insights about care, health, and well-being. The theory continues to guide the building of
nursing knowledge and discovery of new applications of practice using the three culture care modes of decisions and
actions in an increasingly multicultural and global society (Wehbe-Alamah et al, 2020). Research guided by the theory provides a credible pathway to advance the profession of nursing and the body of transcultural knowledge for applica- tion in nursing practice, consultation, education, leadership, and research worldwide.
.oi culture care diversity and universality were
thThe ethnonursing research method and the
nresented to show the ht between the theory
ers were
hod, Knowledge of both the theory and the
and the
method (with the enablers) leads to credible
a olistic
human care theory in nursing, the culture
thod is neede eded before an nonursing study can be
len, Fully understanding
and using both the the-
meaningful study findings.
greatly valued worldwide. Nurses who use the
an the method frequently communicate how valu-
nd important it is to discover culturally based ways to
and practice nursing and health care. Practicing nurses
hare holistic, culturaly based research findings for use in
E for dlients of diverse and similar cultures or subcul-
CASE STUDY
20-vear-old temale first-year nursing student from main- erd China presented to the university health clinic with
ormpjarnts of persistent but stable upper abdominal pain Sve rad been seen on two occasions by physicians at a
aurgent care center and again in the hospital emer HCy r00m. Her recollections about these visits and the He and treatrment received were unfamiliar and there-
records access and the lateness of the hour. The student
was very distraught because her symptoms mirrored
those of her grandfather who had recently died after suf- fering with gastric cancer for 2 years. As an international student, she lived on campus while her parents remained
in China
Ye unclear. She had no other signs or symptoms. He- TErBl of her rmedical records when seen by the nurse VEAtoner was hindered by lack of interorganizational
As a transcultural nurse, how might you use the three
modes of culture care decisions and actions from the
theory of culture care diversity and universality to provide
culturally congruent care for this young woman?
