6 hours. 2.5 to 3 page paper from questions

,F

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Hnm*mBui***srxffi ffi ry dEfr*GGttffiilrsrutr

mfmrul1x

Hrrrt ttVtl'tttg-,.{.Ldr'r.qt*

i*?re'duting thx Yk**rtst $East**w rf the Tho*rY

App{itt}lm*t cf t}re Tita*rY $rlatn*.mry

Fruttite IxerrP'{ur Sn{Prrare t

Introducing the Theorist ilfadel*inr r\'1. l*rnnrger ( 1925-2012) fcunded

the *qrrlCwide lie1d citra-qsculm:al nursrng, th't

I ntern atio aa1'l'ran scuitural .\* urs in g Socier,v, and the Jounal of Ttatts*ltwrat "\?rurrrg' .Dr. Leininger abtair:eC her i"rltial nursing e'J-

ucation at St. ilrth*ny Sclmcl of }-ursing !n Denrer, Cololado. She ea:ned her underqrad-

uate deglee from Mt' St. Scholastic College in ,{-tc1uson, Kansas; hcr master's deqree in p*'- chiatric and mental heahh nursing liorn the

Carhohc Unltersin'o: Amcricai and he: Phl) in :ocial and cultural anthmpolag,,-- at &e Uai- versiw +f Washington (Bo1'le Ei Glitrenberg lli-nrichs, 2013), Dr. Lrininger:en'e,l as dean at thr Unlversities of Washington and Utah, rvhere she helped inititte md &rect the fust doctoral prograrns in nursing and licilitated the del'elopnrnt of mast*r's degree programs

ir. nursing at,\r::crtcan and overseas instrtu- tions. Recognized as a Living Legtnd b1'the Ameritan rtcadcn.iy of Nu sing and a dlstin-

su-i:hed fe11o'w bl'the i\ustralian !{oval College

of Nursinq, shc sen'ed as a prolissor emcrita ia the College nf Nursing at \lrayre Statc Uni-

versio and adiunct proi'essor at r}re Unlversiry

ofNebraska Ctllege oi\ursing' 1)r' Leiainger passed at'av rt her home i;r Omaha, .r-e'*raska, at the age cl87 on August 10, t012.

In rhe span ofhu prolilic career, Iladelaine Leir.inqer publishtd 35 hooks' rurorc approil-

rnatelv 3,00{l 'articles (scme ol rthich wert ner,er published), and qave more that 5,000 nrcsentations or nublic 1:rnrres tirroughout the

Linired Strtes a-qd abrcad, in adCiti*n to con-

tribudng to flumerous bo,:ks and I'ideos llJor'le'

E+ Glittenberg Ilinr.lchs, 2013). Some ot her

11'gll-i(fltwrr books lnciude Euit Psltlsintrit

'r'riri:. r", 1. :;:r'

303

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304 !rr .L'.r:r 1' 'Oraxd Ta:tries obm& Cart ar Cari*4

Con*pts in Nursing (Leininger 6e' llofung' 1960j; C,ering,' Att Zssentini Human Nud

{i98lil Clare; The Essm* {Nursi*gand He*lrh- (19fi,1); Care Di sutrtj atd {)us in Clininl an Caxtmunig N*rsiilg {1983); Ethkai axd Marai

Dim*siais dCm t199}d); a*d Cultxre Carc Dittrsi4 ani Utitttx*litl A Tbeary tiNursittg i199ia, i0064). ^V#rsing artd intArepclapi: Tv;a

l*Zrftk to 8&rd i1970) 'rvas the 6rst book to

bring together nursing and anthropolo*"'lhe lirrr booi. on transc';.1tural nursing u'as Trrrns-

uitura! NwsittX: Co*itp!s, Tbeari*s. and Pratliits

{i978, 1995,2002). llerbook Qildlitdtiu Rt' st:xth fuIetbods in.Vlrirg i1985, 1998) rvas tire fust published qualitative research methods

booh in nursing. ln 1981], l)r' Leininger iburded th,t Jaur*tt! tf Trensttbar*l Ntsing, the iirst trsnsculru.rsl nursing .iournal in the *'o11d.

J)r. Lerninger conducted the first fie1d stucly oi the Cadsup Akuna of rhe l-astern l lignlands of tre'w Cuine* in rhe eadv 1960s

"ri**rr, ou to studY rnore th'ln culttres' She

developed the fust nursing rescarch mcthod called e/tra,rrttrsjrlg, use d b-v scholars in ntusing

and other disci.plines She lnitiated the idea or

rvor1,lv,'ide cenifitatitn of nurses prepa:ed in transtularral nursing.

"loda;-, Basic (uader-

gracluate) and Adranced igraduetei ctrdfira-

iinr,, "r"

availahle through the'I'mr,stultural Nursing Socieq.

Overyiew of'the Theory One of Dr, Leiningu's ffcst .igflifi.tnt and ulique contributions rvas the delelopment of hzr etlN*u art ditersi4 arsi tttiztmali!1'tlse ' 6ry, dso kaor.'n ls tl:e culture care thcon' lC("I), t'hich she int:oCuced in the carly 1960s to proriide cultulally congn:eat and con:petent care (Leininger' 199lb. 1995, 200641 }lcl'arland, 20i0). She beiieted that trersctltural nursing cue cculd protide mean-

ingful, theraneutlc health and healing out-

comes. .'Xs she develaped the theolv, she idtnrJied rra rscu-irural n:rsrng corlcccrs, prin-

ciples, theories, and research-based knowiedge

to p.ride, chailenge, and explai-n mirsing prac-

tircs. Ihis *as a s:gr.:fica:rt ir:novation in nLlrs-

ing and has heloed open the door in new

scientsc and iru:nar-stlc diraensirrns of t-aring

fo: nccrolc oi divrric anJ sir:ilrr lulture'' 'ih" ih*urr- ol.ull'rre care di'ersi'rv and ur':'

-;ersalitl rra: ieq-rloped to estabiish a substar:uve

knottoCge bast to g,ride nurses L'r disrovery and

use ol tri"stu-ltural nursrng pracrices' Iluring

the oost-World Wa; trl ;ieriod, Dr' Leininger ,.ahled nurses n'ouid need raosculnual knos'l-

cduc and practiccr :o runctio:' it':th pcollt :t' diu.rr. .ult t"t noddrride lLerninqcr' I970' 1978]. Many'ntw immiqraflts and refugees

rver" crrmin! trr the Unrted States, ar:d tle rarld ms lrecoming r-nore multic':1tur:I

I-eininger held that cadcg far people of

**y .*Lir.u **s a critico-l and essential need' 1,ei;urses rnd other health proiesslonals urrt not pr.p*.*d to meet tl'js glab*1 challen,qe' Instead, nursinq and medicine were iocused on

using new rntdic*l tethnoLogies and ueatment

,egirnetr. 'lle1* concentratcd on biomedical

srid,r' of d;seascs and s1'r:rptoms. Shifting to

a ranscultur*l FersFertile was a n:;rjor but

criticallv netded changc. this part ol the chapter Ftesents an

ove*'ieq' oitbe iheon' of culture rare diversirv

rnd uniltrsitlit-1', along rvtth irs purposc, go'rls'

assumptions, theoretical tenets, Preditted hunchcs, related general features' and nev'est

features. 'lhe next part ofthe chapter discusses

applications of the knot{edge in cliniral and

communin'senings' Fo: a m*re in-deptl: dis-

russian of the theorist's PersPeitiYds, L:onsult

the prlmarpliterature on the thcorv (Leicingsr,

1970, 1981, L9E9a, 1989b, 1990a, i990b, 1991a, 1995, 1997a, i998, J001, 2006a; -Nlr!'arlaad, 201Si

Fsd:ors Leadi?tg t0 the Theary

L)r. Leininger's maior mot.ivation lor rhe de-

velopn:ent of tit CC'l rvas the desile t* dis- rurer u*know'n or little-kaorvn knolvlcdge abcut culturm and thtir core lalues, beliefs, and needs. 'lhe idea for the CC'f car"le to her rthile shc was a clinical chrld nurse sFe-

cialist in a child 6uidanee honre in a large Slidv'esrern citv (Lcininger, 1970, 1991:, 1995, 2006r). ! ron: her ibcused obsersations

and dai1.r- nursing cxperience s t'irh the chil dren in the hame, :he bernn.ie arrare that thev rtert fiom manl' cultulcs, diife:ing in

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Csm,ren 1T . Maaldtiat Lthtiager's Ttsary ef Ca**re fja*Diorro4 ard Uxiwur'rry 305

their behaviors, nct:ds, responses, and care er-

Dectxtions. ln the home 'rerr roungsters u'ho it.re Angla American, :\liican r\merican' .Jervish i\merican, :\ppdachian, rnd

manv

other lultures' 'I'htir parents responded to them diflerently, anC their expectations c':

cgre and &catnrent modes uere diflerent 'I'he

realiry was a shwk to Leiningcr because sh*

l,r-as nol prepaled ta care tbr thildren of di-

versc cultures. Liker,l'ise' nu.rses, phvsicians,

social lvorkers, and herlth proiessionals in the

sridarcc \cntc rvetc also not prep'r:ed to ,,,rprnJ ro iuch cu]rural ciiiicrenccs'

it ,ctn b.crtte evrdert that she r-cedeJ cultural lcqou"ledge to be ireipful to the chil-

dren. llel pEychiatric aad general nursing rarc krrowledge and experiences lvere inade-

quate. Shc decidcJ to pursue doctoral in':dt'

in anrh:opologv, \{rhilc in the ar:th'ropol':gr- doctoral ptogirnl, she discovered a rvealth of pot.nri.-11r1 trlurble kncrvledge that would

bL: hclpiul iiun". a::ur:lnq pcrspccrrve' 'fo .*t* ior ch:ldren oI d:ver:e cultures and link such knor,,*edge into nursin6 knorvledge an,J practite 'ras a mrior challenqc' lt rrtrs

"rr.nti"I to incotnorate ncrl' cultura] knolvl-

edqe that ,u"ai beyand the traditional nhvs:cal an.l ernotional nceds o: clierts L.in,ng., *'r, ic:cerned about rvhether such lca;ning rvor:ld be possibie, given nursing's

traditional norrns and orientation to*'ard medica.i kroi,ltedge

;\t that tlrne, she questioned what rnade nursing a distinct rnd legrtimate prolissir:n' She declared in the nid-1950s that care is (or

sheruld bri the essence and cenral domain 11' nursing. 1}o*'ever, atcordin.q to Leini::ger, rnanv nurtes resisred th.is ider because thel'

thought care tzs unlmpoftant, tm feminine, t"o iuft, and t<io vague and that it *'ould never explairi nursisg and be accepted

'n,r

r:redirine (Leininger, 1970, 1977, f981' 1984i' \onctheless, Leininger firmly helC to the tlaim and began to teach, srud,t, and *'rite about ca-rrl as the essence of nursiftg, iis unique

and dominanr attribute ileiniager, 1970, 198i, 1988, 1?9ia,2ffi6al' Ir*m both anduo- pol,rqicd atd nursir:g perspectlves, she hrld i1r*t .rr" and cari*g wert basic and essentirl human needs for huma-n growth, developrnent"

and sun'ival (Leininger, 1977- 1?81,2006*)'

Ser argued thtr u'hat hur-rans need is :rulnan

carj.ng'to sun'i,r'e tio:n birth to old age, when

ill oi'we}l. Nevertheiess, rare needed to be specific and appropriate io cultures'

ller next step in the theotr lvas to ton- ceptualize selected t'-rltural lersper:rircs-and

transcultural nursing eoncepts derivcd from

anthro F olo fy-' She dere 1o ped as su mp tioc s

-<ri .ultt-rr.

"*r*-io est,lbhsh a kno*'ledge base for

the nerv ield of ranscu'lrurai nursing' Sr-nthe- s:zing or interl'acing tulture carl into nursing ,*"s i real challtnge. (Leininqer, i976' 1'78, 1?90a, 1990b, 199ia, 20064). tindings iiom

the the,rry could provide the knowledge to car*-

ibr peopie of t{:f}c:ent cultures" "lhc idea *i

proiiding carc was largeiv taken:br granted or

arrun ad-to he understood b-v nur;es, '-Lents' and the public {Leininger, 1?81, i984)' Yet the meanieg ol"care" iiom the perspectile of

different ou-it n*, *ut unlslollrt to nulses aud did not appear in the Lterature beibre the es-

tablishmeot ofLeininger's theory in tht rarly 1?60s. Care kno*tedge had t+ be discotered

s'it1-. culturcs. Lcininger (1981. 1988, 1990a' 1?91a,

1995) maintair:led that befare her rvork, thme

were no theories explicltly lbcused on care and

culrure in nursing environmelts, let alone rcserrch studie, ro *plica:c care meanings and plienarnena ln nursing. Theoretical and practical mcanings ol rare n relatjon to ,p..ili. .r.,1tr."u had not been sl:died, espe- ci alh,' iror:r a ccalparetive cultural perspectivl'

Leininger saw thc urgtnt need to develop a

rvhole nes' bcd-r' ci' culrurallv trased care knolr'ledge to suFF'otr tr.nscultural nursing rare. Shitting nurses' -.hrnking and attltudes liorn rnedical svrnFtorlls, diseasts, snd rreat- roents to that of knor','rng rultures and caring

values and catterns rras a majar task' lJut nursing necded an aPProFriare theorr' ta diucovsr cate, and Leininger htld that her the- orv lvas "ihe cnly theory foculed on deveiop-

inq neu' kno*'ledge ibr the discipliae +f trrnscultural nut"ing" (Ltininger, 2S06a, p. 7.\

Iissential featuses of the CC'I and the rth- nolursing reseilrch rnethcd rtere developed andrior reri:ited throughout Leinirrger's l-lte

ileininger, 2tl06a, 20 1 1),

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306 5rr t.-rr 1I' Crattl Theilis ehtri C'rr'sr (]flritr{

Ratianale ibr Trons cu ltural Nursirg' Signs andNeel 'lhe sati,rnale lbr thange in nursing in A:rl*ica

and elser,there (Leininger, 1'70, i978, t98'1'

1989*, 19?0a, 1995) x:s based on the I'ollowing

obsen'adons:

L'Ihere rvere globrl nigations and inttrac-

tions of people l'r*m vim.ra11y eleiy plact in

the luorld due to modern electronics, Eans-

oortatio*. and communica*ian''lh*se peo-

rle nceded scnsi:tlt ar.d appropriatc tarc'

2, jIh*r"

,r"r. s:g:rs ci cuhunl stresses anJ cr:ltural conflicts as nu:$ts tried to rare

f,tr clients lrom diverse \{estern and

non-\\"estertr cultures.

3, 'lhe.re rvere culnual indicaions ol <an- surncr itars artd resistance tn heaith pcrsonr:tl rs thel' uscd r-crr technolcgics

",rd :,.rt*.rrt modes tl'.rt did not 5t thtir

clients' I'alues a-nd l-ifewaYs.

4,'Ihere rve;e signs that some c[ens from

differtnt cu]tules r ere anqry, frustrated, .qrrd ralsunderstood b1' health personnel

ou'ing to ignorancc of ti-ie clients' tultural

belicfs, ralucs. and *Puctatrons,

5. 'lhere rvert srgns of;:risdiagnosis eld mis-

treat$ent of clients iiom diverse tulures because health ptrsonnel did not under-

stsnd the culrure ci the c[ent' 6,'lhere rr-ere signs that nurses, physician-<,

aad other professionai health personnel

rvere bccon-.ing quitc frustra;cd in lallng

f'or clients Jlor:r uniamiliar tulr'rres Cul-

turc cilre facto.rs lvere largell' misunder-

sioad ol neglected. /,'1here ra'rre siqns that consumers ol dif-

lircnt cultures, rvhether in the horne, Lospital, or clinir, t-ere heing trcated in

*'avs that did not satisfi'then: rnd this

irfiuelced thtir retovery' 8.'Ihere rrere rnanY signs of intercultural

confllcts and culrur:l pain among staff

that Ied to ttnsions, 9.'1he.re *"ere very few'health per:orinel of

dir-erse cultures tarlng tbr dients'

I S. Nurses *'e:e berglnning to 'w'ork in 1'oreign

countries in the military or as srissionar-

ies, and the.Y were har'lng gre ar difi;u1ty understanding atd providhg appropriate

No palt of this book may be reproduced or transmitted

caring for clitnts of d-rverse ruirurcs' '1he-r

rcma"laited 'Jrat they did not understand

the iroples' nceds,,ia1ues, a-ad iifervavs"

rtithaugh antluopclogists were clearlv et-

perts aboui cr,:ltures, rnar:-r'did not knofi'1vhat

i<i do rvith paticnrs' nor *'ere the;* interested

in rrurses'work' in nursing as a profession, or

in rhe studv oi human care phenornena in the

earlr 1950s. -\'lost anthroPologists in thcst

"*1i'd"v. were tar nrore interesttd in medrcal

dismses, archreological findings, and in phvs-

ical and psvthologiial problerns oiculture l'or

th.** ,"ruonu ,r'rJ *"tr others, it sas tlearlr evident in the 1960s that people +f dillertnt cultures wert. not recei.ving rare tongmet:r wii'r

their cultural belieis and values (Leiniogt:r'

1?78, 1995i. I\iurses ald other health proi'es-

sionals u;gent\ needed transcultlral knowl- edge a*d skills to work efrcierdy n'ir} pecple of diverse cultures,

Leininger thcreible toak a leadership rcle

in the n*v lield she called #aarrzf urul nxrting'

She rlelired t;anscrrlrural nursing as an arca ct

studl' and prscti.ce i'ocused on lulr:ral ca:e (caring) valuer, bcliefs, and praitices of'partit-

ulrr cJtures. llhe goal rvas m provide cr'ilture- specilic and tcngruent rare to ptople oldivelse

culrurcs {Lerningrr, i97S, 1984, 1995,20064J' 'Ihe cenrral purpcse of trar:scultural nursing rvas [o use research-based knorvledge to he]p

nurser &scover iare raluas and practices and

use this knolt-ledge ia sa:e, responsibie, and n:eallngfi.r1 w*.vs to care for people ofdiJlerent

cultures.'fcday the CC'f hss led to a l'ealth ofresesrrh-bascd knowledge to guide nulses

eld olher l^.te1th orotLssionals rn rhc carc oi clients. tamili*s, and communities ol diJlerenr

cuhures or subcultures'

lifajar Tbe aretkal Tensts In developiag the theorl-- of rulrure cart direr- siq, md unlversalitl, Leininger identiied sev-

eral predictil'r: tec€ts or premises as essential fot nurses znd crhers to us*.

r\ plinciprl tenet u'as thrt r1-il-ers.ities and sim- ilarirics (or comrnonriiries) in culrnre care cx-

pressions, meanings, pltlelns, and practices

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CH,r.r"rrk 17 . Jl",adeldfue lalnirguri T*wqy af, Caltwr C*e llivrri+ *fld Unims/4 3fl7

rvauld be ibund rvithin c''lltures' 'lhis tt'net rhallenges fturses to discover this knowiedge

so that n,:rses could use cultural data t* pro- vide therapeutic our.ofiss. lt rvas pr*dict*d thcm vv'oid bc a golci mine ol kno*'ledge il flu.rses rYers patient *-nd persistent to distomr

care valucs and Pafterns within cultures, a Ji- mension chat nad b*en rnissing lion: tradi- tional nursing. Ltininger rnaintained that humaa t-reings are bnrn, live, and die *rth rheir stecGc cuhural values and belleti, as vreltr as

with their historital and enr.ironmental con-

tert, and that {aje is inporralt tbr therr sur- vilal and rvell-bei*g. Leininger predicted tirat

dircolering tthlch eiements of care lt'ere cul-

rurrl1y ,r:ir.rsal and rshich tqrrc dillirent u,ouli drasticalll' revolutionize lursing and uId:nately tran siorm heal',h-tare svste::rs and

practi.es (L*ininger, 1978, 1990a, 1990b, 1991a,2006a,i.

r\nother major tcnei of the theon lras ihat rvorldvi*v and social siruf,ture iattors-:uch as techoalo6' reiigioa {including sr:irltualiry' and ph.rlosophl'), kinshiP {l'smlly ties), r-u1mr*1

values, beliefs, and liferval;s, political and 1ega1

factors, economic and educatianal iictors, as rvell ar eihllclistolr, lang':agc expressions' envi.ronrnental tontxt, afld gcn+ric a-nd pro- fessional care-infl uente rvrvs indil'idu'lls, ihnllies, groups, an#or ccmrnunlties tonsider and deal s'ith he.rlth, rcli-being, rllness, heal- inq, disabilities, anC death (Leinlnger, 1995,

2ilO6a).'lhis brord and multiiaceted vierr pro-

vides a holitric pe$pe.ti.Ye ibr understanding peoplc and grasping their rvorld aad environ-

meat s,ithin a historicd contexi l)atl liom this irtlistic research -based kno'*'1edge gulde s

nurses in caring for th* health and r*e11-beiog oi *re individual or to rrelp disa.bifld *r dving clients :'ssm drfere[t cuiturff . Socia] stmcttral factors inlluencing care ofpeopie liom diffler- ert culn:res provide nnv lnslghts for culturall-v (cnqflrrlt car-e. Slster,atic sfudy bv nurss .rc- u."..h"r, rather than supenicial kncwledgt ol culture is required to provide culru-rlll-v con- gruf,nt ca-re, 'lhese fact':rs, it:gether B'ith thc

histon oic';ltures *nd ktowledge oftheir en- vironnrental factorcr wst€ discovered to creste

tlre theory and to bring lbrth nerv inslghts a-nd

nerr kncrwi*dge. 'lhere data disclose lvals that

clients can stay weil and prevent ill"nesses' In- deed, to meer the theorv's goai of making de-

cisions ttlct provide cuirurally congruent caret

holistic culru*] Lnowledge must be discolrered (Lrininger, 1991.a, 2006a).

Discol'€ring rulrural crrc knorvJedge rt- quircs cntcring rhc cultural lvorld ro obscn'c,

Jisren, ar.d lalidatc idcas, 'i'ranscultural nursing

is an immersion experience, not a "dip in a-ld

dip out" ntperleoce. No longer can nurses relv

only on iisgrr,ents of medica-l and psychologi--

ral kno*'ledge, Nurscs mrist become alvale ot

the social :tructrre. cultural histor.v, 1:rnguage use , and the crrl:r,lnment in which pe oFle Lve

to uldsrstand cultural care expressions' 'fhus'

nr.lrses need to understand the phiiosophr- of

transcultural *ursing, tl:e culture t*-re theorl',

end wals to discoue.r culture knc*'1edqe. Tra'n-

sr:ultural nursing ccurses and Eroqrarns are

csseniiai to provide the nccessa4' ins truction --l ^.--i^.i--dlru rrrtlr(urrr!5,

.rlnorher malor and preditted terret oithe the- or;.: is that dl{ferences and rimilarities exist

betvceen the practices ,:i nr"* Icinds ol ci,e: professional (etic) a.nd generic (emir, tradi- tional, indigenous, or "ib1k"l Leininger, 1?91a,

2006a; .N'{cFarland, 2010)''Ihese diferences

influer:te the health, i11ness, and well-beng of cLients. lilucidating these difierenccs identii' q.lps in care, inxppropriate care' and also ben-

efir-ia.l care. Such findings influence the recov-

en' (healingJ, health, and rrell-being of clienrs

ol dillbrent culrures. Xlarked dillcrenccs be- t*een plenerit and professlonal care ideas end

acrions iead to sericus clienr-nurse coniicts, por€ndf,l illnesses, ar:d even death (Leildager,

1978, ir95). Such ditl'erences musl be identi- {ied ard resolved.

Leininger i.d*ntilied three t'a1t to attain and ma.intain rrrlturally coegrueat care {Leir:inger, 1991a, 20054; iMc!-srlrnd, 2010). 'Ihe tl-'ree m,:dalities postulated are (1i cu-ltr:e cart presen'atj.oa and.ror r,:ainteaance, ti2) rultue ."r* r..o*rnodrtior.r andlar negoriadon, and

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308 Si r t -i:r 1: " Grpnd th*ries ebtfi Cift or Cstin{

i3) culrure carr restruclurir:g a*dlor repaftern-

ing (Leininger, 199ia, 1995, 2006a)' these

thl*. mod*, iu*t" r'erv diiterent from traditional nu:sing prar'ices, loutines, or inten'ention!' 'liiey aie lbcused Dn rlrf,1ts to us€ iheorfliical dxta

crsativeil to f'aciLitrte ccngruent care tc ht clients' particuh: c':ltural needs.'L'o arrive at

culturalll'aPPr$PriatL care, the nursc has to

draw on lrcsh cub,:re ean: researth and disco'j-

ered ii-oorviedge froni the people alone rvith

ther:retica.l daia finCings. 'Ihe care is tailored

to client needs. L*ininger believtd tirat rou-

tine inten'enlicns l+'ould not ahval's be appro- priare arJ iould leal to L'ulturai irnposition' t"nsions. and cor:fllcts. -\ursti nceJ to shiti iiorn relting on routile intenentions *nd frorn ibursing oa slmptoms to emplo,r'ilg rartr

practices d.r:r'.d fron the cller.ts' cuirure ar'd iiom the rneon', 'lhcl' necd to usr holistic care knor.4edge ftorn '.he theorr as opp*:ed to relying soleiy on rnedical data. i\'lost ir':Por-

,rr.t ni'rli, tirey need to use borh generic and professional care lindings. 'lhis u'as a nerv ih"U*rtg* but a rervarding cne t'or the' nurse and the client ilthoughr:iull-v donc, as it ibsters

nurse-client coilaboration. Examples of the

u:e of the three modalities can be lound in

several pubiished rources (l-tir:inge:, 1995, 19?9, 2002r }lc!'rrland et a1., 2011i \Vehbe- tUamah, ?008a, 20il) and re presented in rhe next part ofthis chaPter.

Use ol Lelninger's theory has Ied to the dis-

col'ery oi new k-inds ol tran;cultural nursing knowledge. Cultur*l1y baserJ ca;e catr lreYenl illnes: and mai.ntain t'rellness. .\tethods for heiping ireoplt throughout tire Life crrle, iiorn

tirth tc death. havs been discoverd. Cultural pafierns oi caling acd health rnrintenance slong with er-nironrneatal xnd historical ilactors

,o* !*poarrnt, )lost important, ihe u:e ci Lelninger's thcoqt has helpcd unrover signlfi-

cant culrural differences and sirnilarities,

,rs: Paryo|e, af the'Ihmry

cultural and care lactors iniluencing hurnaas

in heahh, sickness, aad dying and to therebv

advarce ar.d improte nurs.ing lrucdces' the theory's goal rs to discover gencric

ifi,lkl xr.d prot'c5sicnal care behcfs, eicressions, and practires ihtt could be hcorporated into collaboratite rlans oicarr de:igned to provide

culrurallt aFproFriate, sate, beneiiclJ, and

saris+'lng crre to people of diverse nr similar

.ulnri"s, to Fronrore their healrh and w*il- being, and to assist them ir: facirq dearh or

disabilldcs. 'lhus. the ultimaie and primar.r-

soi.l oirhe rheon'is to provide culrurallv con- gru.nt ."r* that i: tailor-madc ibr the Li'ewat's and ralues ofpcople (Lcin-:rger, 1991r' 1995,

20il6a; l\'trclar1and, .\ilxer, Wehbt-Alanah, 6r

Burke, 2012)'

Leininger postulated sn'eral theoretical assumpdons, or basic belieis, designed to as- sist rescarchers exploring \'Yestern and non-

\,Vestrrn c,.:-ltures (Lelninger, 1970, i977, 1981, 1984, 19!1a, 1?9tu,20064):

I. Cr.re is the essence and the cenrral dominant, dlstinct, and uni$ing focus

^d.,,,.;.cvr.rgrJ.r.F,

2. I lumanistic and scientific cate are esscn-

tia.l for human gro*th, rveil-being, health, su*'lva], and to f'ace death and disabilities'

3. Carc (caring] is cssentlal to flr:ng or healing, tbr *c.re can be nc curing t'ith- out caring. flhis assumptioa '*'as hcld to haye p:nt'ound relevance rrorldwide')

4. Culture csre is the sl'nihesis of tw'c najor constructs that guide the reserrclier to

disc*'er, explaln, and 3c{ouni f.rr health,

*ell-bcing, care expressions, and other hurnan condltions.

5. Cul:u-rc croc crpreislons, nrc;rir.gs, pf,tterfls, Prn.flsses, and structural iorrns

a-re diverse; bur sorne commanalides (univtrsalities) exist anong and bet'weea cuiiures.

6, Culnrre care valucs, beliei's, and pract.ites

s"re hiluenred by'aad enrbedded in me +'orldr.ierv, social strucrure fectors (t,g., re-

ligion, phllos*phv ot iif*, hinship, politics,

Gaal, and 'Ihis section discussrs some of the majcr as- sumFriDEs, definitions, and purposes of the the,:n,'lF-e thto:v-* ortr:idirrg purpose ii tc discover, d+cument, ana-ltzc, and identiry the

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economics, tducation, techn*lo5-, and

rultura-1 raluss) and the ethnohistorical and

enrir*nfl1ental rontextt. 7, llvery culnrre has gtneric (1a,,*, ibl}', natu-

ralisti,:, n;t:nlr* emic) and usu,rLiv son:e

prolessional (ede) care tc be discovered

and used ibr culrur:1I1'congfllert care pracIces,

E. 'CuJturallu

Lo:flrucni and th.eraptut:'' tart

orcurs u'hen culrure care values, 'oe1ieii,

expressions, and patlPjns are explicidv

knorrn and used applopriateiy, sensitively',

and n-reanin$tlly *'ith people oidiverse or slrrilar cultures.

9. the three modes of care ofier iherapeutic rvrvs tc lielp people of di*rsc cu-ltures"

I 0, QuaLitative research paradigrnfl dc meihods

olier imponant rneans to discover largelv

embeddcd, covtrt, epistemic, and ontolcg-

ical cultule care knoutLedge and practices'

! l.'fran:cultural nursing is a discipline wlth

a bodv uf kno*'ledge a*d pracdces to at-

rain and ndntain the goal cf culrurally rongrrelt tase lcr health rnd rvej-i-beinq (Lcininqcr, 200/ra, PP. 1 8-l 9)

fo encouragSe discotery of qualitadve knolrl- edge, Leininger u:ed orientational (not oper-

ational) definltions for her rheor-1", to a-l1olv the

researther to discern pr*viousl,v unknoll'n phe-

norr.cra or rdcas. Or;enta:ional tcrrts aLIow

dis.'ose!. and are usuallv congruent *'ith the cLlent 1ifewt1n.'lhe,v are irnportant in using the

qrialitative ethnonursing discovery mtthcd, ,ihi.h ir i'octsed on how people understand and *peritnce theirr';orld usiag cultural knorviedge and lilirral: (Leininger, 19S5, 1991a, 199?b, 1997c, 2002, 2006a).'l.hc lbl-

lorving are se.lect eramPles:

1, Cultara,''lhe learned, shared, and transmit-

ted salues, beiiefs, norrns, and lifiwars of a

particular Eloup a\at guides thek rhjnkinS,

decislons, and aciions in patterned t:a1s

and ofren intergereiadonalit (Ltining*r,

20064, p. 13), ?. Carr, lhose rssistive, supportive, a-ad

enabiing -;xperiences or ide*t torvard

*thers t'ith evidtnt cr mticiPated needs to ameliorate or improle a human condidon

or }}'erva;,'. C*.riag reiers to aitions, itti- rudes, md pra:tices to assist or help otFiers torrard healing and *'ell-being (Lelninger,

2006.t, p. l2J. Care is both an rbsttact ind

a toncreta Phenomtnon, 3, Cttlturt *.rrr: SublecivelY and objtctiveiy

iearntd and trrnsraited va1u"t. 6sliei-c, and

patterned liierval:s that assist, suPpsrt,

i".ilrtrr., or eaahle another individual or

flroup to maintairr rveii-treing and health,

t i*p.ut. rheir i:u:rnan conditic'n a-')d ilii:rvry, or to deal *'rth i11ness, handicaps, or desth (Leininger, i991a, P, 47)'

4, Ctltart Ccre Drt'erri{": 'Ihe diJferenrcs or

'r.ariabilitier *nrong human beings u'ith rf;soefi io culfi:re rarc meanings, patterns'

vatrues, liinray's, s1-mtro1s, or other features

related to pror-i&ng beneiir-ie} care !o

cLcnts oi a designated.-ulture (Leialnger,

200i:a, p. 16). 5, C*llure Carc L"r,trsrrs*litt':'"Ihe common],v

shared o: similar culrure care phenornerra

iLarure s *ihunan btings with recurrerrt meanings, patterns, values, lifertra,vs, or

s1'mbo1s tFrat sen'e as a Euidt fbr cuegivers

to prorid e assistil'e, supPa.tive, facilitativt,

or enabLlng peoole care for healthv out-

iomcs (Leirunger.2006a, : 16) 6. I}ar!:xi*nat {etril rare: lbrma1 and exa}icir

cognidvei-v learned protessional care luro*'l-

edge and practices obtained gener*ll1'

rhrciugh educaticnai insdurions''Ihe1' are

taught to nurses and cthels to prulide assis-

dve, sugpcrire, tnabling, or ihcilitatire

acts lbr or to anorher lndiridual or group

in order to i.rnprove their heaith, pr*'ent ilhesses, or to htlp utth dling cr other h.uman cotdltions {Leinlngrr,2006a. p. llJ'

7, Gm*ir (erxa) tmt: 'lhe learned and trans- nrined lav, indigenous, traditinnal, or lccal

ibik kno*'1edge antl practices to provide

assisti'r,c, supportil'el enabling, rnd faciLLta-

ilve acts for or t*rl'rrd others rr'iih efidelt or anticipeteri health needs in order to

irnprove rreJl-being or to help rvith dfing oi *ther human conditior:l {Leininger, 2006a, p. 14).

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310 -st l r ;;: f " Cratd Thttriet abrul Cart or Cairig

S, Calture rdre Plt\t/'i!atiafr a*l/'ar maixlt rsarr,' those assistil'e, supportive, iacilita-

iive, or enabling professionrl acts cr

dcc:sions ihat h.elp culrures to rcrain,

lrcscn'e. or r::entain benefrtial tare be-

ii*ii .nd 'a.lucs

or to rate hanilcaps and

deafi (Leininger,1006a, ::' 8)'

*, Culture ure *i*mmtdatbn attdlat fit1arid' lrr:'lhcse assi:tiw, arcomnrodating, ti- cilitatire, or enabling crcative protider care

ections or decisicns tlat trcilitate adapta- tion to or negotiadon rr-ith others for cul-

turallr, congment. saJ'e. and eflective care

for 'heir health, te11-being, or to deal with

illness or dJing (Leinineer,2006a, p' 8)'

10, Culturr idre repilllerflifig *ailet rt$r*tlar- ilg."IF.osc asiistive, support:r'e, facdita-

tive, or enabling proi'essicnal acdons and

mltua] decisiolLs that help people to re- order, change, rnodi['. or r€EtructuJe ti:eir iilbrtals and instirutions fo: better (or benefici.xl) h*a-lth-care Pafterns, pra'- tires, or cuicofiles {Leinlnger, 2006a,

p. 8). 'lhese safterfls sre muuaLlv cstab-

lished benveen caregil'ers and teceivers'

11, Ethnth:irtry: 'lhe pasr facts, cre nts, in-

stances, and experiences ofhuman Leings, groups, cultures, and institutions thar

occal orer time in pa-rticular contexts

that help expiain past and cjlruent lii'trvals

about culture eare influencers of health

and *'e1l-bei,rg or tlic Ceath of people (Lcrninger. 20i"rt,r, P. i5).

12, Enriranmtnlal taatext:'lb-e rotaliq' cf f,tr event, siruadofi, or Farticular exFcri-

eace that grves r:reaning to people's

expressions, intrrpretations, and rocial

inter*ctions within particular 6eopirlsical' etologrcal, spirirual, socicpolitical, and

technoioglcal iactor: ia specifit culural scttrngs (l,eininqcr, 2il06a' :. 15)'

13, Worldtiru: 'lhe rvav people tend to look out ol thei-r u'orld or the.k uniycrse io form a !:icture cr r.alue srante about life

or rhe wor1d around them {Leinlagel, 2006r, p. 15).

14. Ctiltwa! antl sorial strutturerkLJors: religion (spirin:alitr'); kinship (sacial ties); oolitics; legal issues; educationl ecorrofii.csi tech-

ndog,,'; polltica1 iactors; philosophy of

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liill and cxitural beliei! and ralues rvith gendcr and class dirt'crencr. '.lhe rhcorist

i^s credicted thst *Iese diverse lactors must be understood as they dircctly or

indkect\' iniluence health and rvell-being (Lelning*r, 2006a, P. 14).

15. Culruralli toztgt#r:rrl rarr.' Culturallv based

care knowledge, rcts, and decision: used

in scnsitive and knoil'ledgeable waJ's to

aocropriatclv and mtanrngrull)' ti: rhe .uirursi talu.s, bel-iefi, and lifeu'avs of cLents t'or th*ir health and rre11-being, D{ ro prcvefit illness, disabiljties, or deatl:

{Lelninger, 2006a, P. 15J

The Sunrise Enabler; A ConcePtval Guide to Knawledge Disrcaery

Leininger developed the sunrise enabler (I'is. 17-L) to provide a holistic and con:pr*- h*nsive conreprual picn:re o{'the maior ihctors

influtncing culture care dirersirr and unil'er- s,rli+* (Lelninger, i995, :997b: Ltininger & -\'tci'arhnd, 2002.2006). lhc r.cdel car' bc a

va.luablc visual guide tn elucidadng n:ultiple lictors that ln$uence human care and iii'e*'a-vs

rf diffirent culrures, 'lhe enabler scrl'es as 3 cognitiuc guide tbr tl"e rescrriher to refltct on

diiicrent prcdicted inB.uences on tulturalli'' brsed care.

'lhe sunrise enabler can also be used as a r.sluable aid in culzura} and health-care assess-

ment ol clienrs. As thc rcsearil'.cr uscs thc madel the diil'erent iictcrs aiert hirrr or her to find culture care phrnomena, Cender, scxual orle*tation, race. c1ass, and biornedical condi-

tinns are studied as part oi the thtorv. 'Ihese

detern:inanrs tend to be embedded in the worldr.ierl'and social selrlctttre and rake tlme

to r:.cognize, Care values and beliefs als usuallY

lodged inio cnvironmcnt, religion, kinship, and da:1v lite F,iiterrls,

'lhe nurse can begin tht discovelr at aav place in the enatrler ard loLlolv the informant's

ideas and experientes about crre. lfone starts in the upper pan of the enrbler, onc needs to reilect on all aspects dtpicted to otrtain hoiistic

or total tart data, Silrne nurses start ri'ith gerr:it ald prol*ssional tare then lor:k at hr:rv r"i-igb", N.oflomi.s, anri othcr lnfluences affect

theie care rirodes. Onc a1*'a1's moves lvith the

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f,:HA!,r'r:rt1?'Madelrinel*iningxtlhtorTtf1*ltwef,re&iaem$uxdUritwraiiry 311

Cultural Care

Culturai Care Preser'-ationlMaintenance Culture. Care Accommudation,'hregotiation

Cdtt {+ llnilr.rr$s, culture carc Repattcming'Resrructuring

t +

6 rlf . I*hitlSer 2004 -.u

Culturally Congruent Care foi ltealth, l1'ell-being or Dying

I ' ' L.elrritL;lrr's surise crlabltr lo riisqorqr cu.ltut ruc f ;V 'L.irin'qrJtl/-ld7

ini'nrmants', rather than the resercher's, inter- nrocess, &e nr:rse holds h'is or her ol'n' etic cst and story. llexibfir-v in using rhe enablec tiases in check so that tLre int'or':ant's ldeas

prDmotes a tctal or holistic viern lf .rre. will come fr:nh, rather than the researchm's' 'Ihe three transculru.ral clrc decisicns lod 'l"ranscultural nurses a.re ment:.red in rvays to

actions (in tire lor+er part of the figure) are lery r+'i'.hhold theg biases or $'ishes and to enter the importr.at to keep :r mind' Nursi'ng decisions clientt unridviex''

"nd *ctiofls are studied until o!]e ,e*1i,es the 'Ihe nurse begirrs the s:ud,v bl' rrrakng

carr nreded.. "Ihr nurse disroTers rrith thc in- expiicrt a specilic donrair tfixquiry. !'or tr.att- fc,rmant the rppropriate decisions, acrions, or ple, tire rcse 'lrcher may foms on a iiomain ol

il;, f"a .*r*l 'ihrorghout this discovery inquin such ss "cullure care ';f Mtxican

CULTURE CARE

z/\ lnflucrces '\ t V

Care ExPnssions Faltems & Prattittr

t Ilolirdic Health I lllns$ / I)€sth

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312 !r t: t ,rr:. V ' Llrand Th*ties a'icti trt or Caing

.t\rrr(ri.an rnothets csJing lor their lhildrerr i'rr

their home.'' Lverv lvord in the donlain strte-

Erent i* L'r1Pofiant and st',rdie d with the suruise

cnabls and the theory tenets. the nuse ot re-

searcher n:ia,v h.x!€ hunches about the domain

and care, but until all dara hrl'e been studied

rvith the theory teners, she or ht ca-rinoi Fro'!e them. lnfor:nrn15' 1'lqrvpollls' cxpelitncci, and acti,:rs are irl1,1i documeatcd. Generall1,

informants select *fiat the.v hke to lalk xbout limt, and the nursdresearttier r{romrnodates

theb interest cr stcries ahout care. l)uring ir- ,lcfth srdCy oi rht domrrr ol lr,quiry. all zrcas .ithr sunr:se cnlblcr arc ider.tified a-nd ton- furned s'ith the intbrmanrs. 'Ihe inibrrnanrs becorne ritlr'e Px.ttiripants thrcughout thcdis- .o1,cry process in such a u"a1'as to feel comfbrt-

able a-nd rvilling to share the.ir idtas.

The real chal.lengc is to f<rtus tare mean-

in6s, beliei!, r":luer, and ptartices related to

inlorm,rnts'culturas so that subtle and obvi-

ous difi*rences rnd sirnilarities about care are

ide nti:ied among key and gener.ql infurmants' "lhe differeaces anC similariti*s ate imPortant

ro docurnent with rhe theor,"-' If inforn:ants ask abour the researcher's vielr.s, the latter must be ctrehllly and sp*rse\ shared''l-he re-

sea:clre: keeps in rrunti that some inibrmants may s'anr tl please the researcher b1' talkir:g about profcssional n-redicines a:rd treatments'

Prolesiional ideas, hou'ever, oiien cloud ar mask the cl-ient's reil interests and l'iet's' 1t this occu.rs, rhe researchttr must be dert to such tendrncies and ketp the lbcus oa the in-

formant's idtrss arid on ihe dorniin of inquirl studitd. Tire inlbrmani's kno*'1edge is rlwr'vs

kcpt cerrtral to the discovery prccess abuui .ultur. ."t*, heelth, and rte11-being. trfthe re- searcher finds some factors unfarniliar, such

as kinship, etonornics, and p+lidcai aad other

consider*tions depictcd in tle r:r<,'dei, the researcher should listtn attentiYel-t- to ihe informant's ideas. Obtaining insight into thr i.l1'ormarrt's e;:ric (insider's) vitws, belieis, and pnctices is cenual ts str-idvlng the theon'

{Lcrninger, 198-i, 1991a' 1995, 11}9/b; Leininser flc MtFa-r1and, 2002, 2t106).

'lhroughout the sr':dv and use ofthe thecry,

the rneanings, cxpressians, and patterns of

No part of this book may be reproduced or transmitted

culturall.v bascd care are inportant' -lhe

n''rse/

researchcr lisirns rrtentively tp informants' accounts about care and then docun:errts tle idear. What inforrr.ants ko'nv and practice

aboui care or caring in thek culrure is signifi-

ra!!t. lJocurrenting ideas from rhe informents'

emir l'icrvpoint ir essential to aJri\:c xt atcuratil

cultura.lh based carc. Unlinour: iarc nea-rings,

such as tie conc€Fts of protertion, respect, 1ove, and matl'olirer care concepts' need to be

tersed out and explored in depth, as the!'are the ke.yu'ords acd idcas in understanding crre'

Such care meanlngs rnd expressions are nct al-

lvays readiiy' knolvnl inibrrnaats ponder care

meanings and are chcn surprised that nurses are focused on care instead oi medicai s1'n:p- toms. Sanletiroes intbrm;rnrs maYbe relurtant

to share ideas ahout social structuler religion, and economlts or politics, as thev i'ear thfse

idear ma.-v not be xccePted or unCerstood bv

health prrsoar:el. Generic folk or iadige*cus

knorvledge often has rich care data mrd needs

to be exdored. Gcteric care ideas nee d tn be approp:iately integnteC ir.to the threc trar- ri"ttritl moties oi decisians and actions i'or cuhdralll' co[IJr"uent c are outiomcs. Generic

and prot'essional care rre integrated so that tle clients benefit iiom both fipes o{ caru.

'lhe sunrise enabler rsas developed wlth the idea to "iet the sun efliet lhe reseatcher's

rnind' ,qnd discover largeir unkn':*'n care lictors oicultures' Letting the sun "rise anu{ shrne" is importsnt and ct'ers iresh insights abcut care pracrices. A recent metasynthtsis oif4 doctcral dissertations using Leinlnger's CLIT and tht eth:roaursing research method ied to the discoyeri- of lnterpretive and cx- planarory culr,rre care findings, neq' th*oretical

formulaticns, and evldence-based retommen-

dadons to guide nursing practice ([lc]'*riand et a1.,201i).

Newest,ldilition ta tbe Thrlry In the sumnrsr o12011, Dr. Leininqer inrro-

duced rc/ldd'rrditrve t$e Ls a new cale consaF:ct,

r+'hich she ofiered as *re nert phast in the sro-

lutionan'development ci CC'll. She n'rain- tained that diverse cultur&1 values, belieis, expressions, actions, and practices *'rthit a

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Cl{li,f ER 1? . .l&rdelrfue Imnirugrt Ifutoy of Caltwe ilaw]}ivro4r *xd Uxiwro,liy 313

familv, a group, an insiilrition' or nthc.r unit

mal prtscnt wth sltratiot:s in uhith conflitts r:rav arise. She oroposed collaboradve circ e! a

*.L, .. * rrr",*g* t* resoive diifelences end f rovide culntral.l' cor.gruent cere

Lcinir'.ge: ritfine,l the iollaborrtive care

aDEroach as thasc ualues, n:eantngs, expres-

,ion*, .-d acricns by ir-ibrn:ar.ts thst rerrca'l a desire an,l a pla-n to w,:rk rvitl'l cthers in order

ro identih', attain, and maintaln hcaith and *,el1-treing and to resolve conillcts 'I}ris care

r-otrsrruct las been published b;.. Ilclarland and \ilehhe-"\1'rrnah (Mc!'adand & trtrehbe- r'Uanrah,2015).

Carrent Status ofthe Theory

Currentll, the theory ol rulture cr-re ditersiq' md univeaalirycontinues tobe studied md used

in manl rchools of nursing rvithln '']re Unit+d

States and in tther countries, such as L€baroli, jordaa, SauCi rtabia, 'faiwan, Ci-Jna, Japan, and !'inland (l-*ninger & Mcl'arland, 2002, 2006; lVehhc-;\hmal Ec Mclarland; 2012)' lnterdiscipli-naq' health personnel a:e b*cominq

ir:c;easingil' alvare of transnlirural nursing con-

repts thai help them in rhei-r work Serenl dis- ciplines including dentistlr, medicine, social rvlrh and pharrnac.v hare reoorted using th'e culruratll'congruent care theorv or teaching it in

the.ir prug;a:ns {}lc} x1and, .201 1). fh" th.otr- of culrure care rriLi ;emsin cf

globa1 inrerest and srgnificance as nurses and

other heaith-care prclessi+nals cofltlnue tc

e:;plore cultures and their cre needs and prac-

tices'ivorlds'ide, Transtulrural nursing con-

cepts, printiples, theort, and Sndings rnust

becc,me ii:iIy incorporatcd into professionrl areas cf teaching, practice, consultation, and research.. \\tren this occu.rs, one can anticlpate trte transculiural hea-lth Frattires and c+l- corrita nt bene{its' Llnqucstio nablv, tne theorl'

rrill continue tr grow in relevrrrte and use as our worid bccomes more intenselv mulricu-l- tural. Iursts aed crher hcalth proiLssionais art expetted io prc,vide culruraliv f,Dngruent c'1rs r+ people of direrse cultures.

.Ihe theory, alcng

s.ith maty translulrural nursing colceprs. prlac!+lts, and research f,ndings, u'iil conrinue

to prore indispensable.

Applications *f the Theorv 'Ihe p,:rpose ,:f this Part of th* chapter is to

preser:r the implications fbl aursinfl Prartice ot

it . CCt' a.'rd related eihnonutsing reseuch fin&ngs, ,F1any r:ursing theories are rather ab-

s'uact and do not I'otus or how practicing lu:ses eight use tl:e reseerh lindings related tc a theory. 1L:*'ever' rvith the CC1', along r*'rth the ethno[ursiflg met]rod, there is a budt-

in means I'or disccvering and confirming data

with informants in order to rnake Pracricai nursing actitrns s'nd detisions meanindll rnd

culzurallr' congruent {Leioinser, 2002)'l

I-eilrnger purposelirllv aroided uslng the

phrasc nrrring inlm-slicrt because this term ofter, implies to tlients frora dirtbrenl culru:es

that the nr:rse is lmposing his or |rer (etic]

vicws, rth.ich n:41'not be helpiui. Instcad, ttre

term lursing adians and detiiastttvas used, but

als.art with the clients hclpilg to arrive at r,q'hai.ver scilons $r Cecisions r+'ere planned anJ tnrplencntcJ. Lhe lare nodcs fir t:rh thc clje.::ts' or peoples' life'*r-rt aud rre borh ther-

a.peuric anJ satis$iag fbr thtm. '1he nurse iafl

drarv on scientfic and evldence-based nursing'

medical, and other icrou'iedge rvitir each care

rnode. l)ata collected itorn the upper and lo*'er

parts of rie suruise cnabler prol'ide cult'le care Lor"ledge for rhe nurse and +ther rese*"rr-hers

to discorer and cstabLsh usei'ul*'a1s t'r provide

qualin' care ptacticcs, Acttve panicipato.ry i:r-

volvement'cvlth. clirnts is essendrl to arrive at

cularrallv congruent cate lvith one or all oithe th;ee action modes to meet clients' care needs

in rheir particular ewironmental context's' '1he

use ofrhese modes in nursing cart is one ofth'e

[:ost treaiive and reluardirrg teanrres oi tran- scultural and general c.ussing practice rrith clients of dir-erse culrures. [,]sing Lrininger's cart modes in clinical Frractlct sho$s respect to

clients'belieii, values, and expressions ald es-

tabllshes a panncrship bet$een health-care

lFai ddiriond iltirrotios ubour trIe lJ:hmilu*iag ldwrch bluhod p1e*e 1p to banus *ngter cottttt ruilalrk al FA $a*it hrtp:,{davisplus'ildaviacom

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314 Sr., r:ir: \' ' Gratd 1Tesni-' atu$ Cere cr C*titg

prov'ider: and clients ta ensure sai'e, beneitent,

and culturalh'congruent care (l{cl-arland 8r

Eipperle, 2008).'}i is most iupcrranr {and a shlft in ru*ng)

ta irref,:11,v ibcus on the hoiistic &mensiotls,

as depicted in tie sunrise enablcr, to arriw at rherapeutit culture care pracdces. "{'-11

the fac-

tors in the sunrise enablcr must be considered

rc arrive .qt iult'.:railv ccngruent s:art' 'Ihese

lnclude rvorldview; technological, religious'

kinship, political-leg'aI, economrc, and eCuca-

tionrl iactorsi culrural vdues and lileuays; enl'iromte nt al co nre*t, langoage, and et}:no-

listory: and generic (ioll') and professional care pracdces ileiainger, 2002, 2006*l' Llare g"reiat"d irom the CC'l' urll beccrne sal'e, iorrgr,rtn,, me*ningful, and beneficial rc clients only when the nurse in clinical prartice

becomes ful11' alvale of and explicitlr uses knorr,ledge generated ilom ttre theon and eth- nonursing met'hcd, rl'hether irr a communitl',

hon-re, orlnstitutional c ontext.'Ihe C C'I, used with the ethnocurslng raethod, is a pou'erful E-leans J"or exploring ne',+'di:ecdons and prac-

tices i-ri nursinq. trncorsor'ttinq culrurt-speri6c

care irlto dienr tare is essential to ihe pracdre

of proitssional carc rnd to licensure ls reEI\- t*r*d nrrr"r, Culture-speci{ic care is the safe rtre&ns ;o ensure culnrrall-v based holirtic care

that lits rne client's cultur-a ma-ior challenge lbr nur:es *nd ,:ther healdr-crre prcfessionals *'ho practice :r.rd prol'ide ser':rcei ia ali heshh-

care sertings,

The {Jse of Cukare C*te Research Findir"gt (}ver the p*st -q de.ades, Dr. Leininger and odler research colleagues have used the CCI' and the ethnonursing metiod to tbcus on the

care rrieaninqs and cxperiences of 10C culzuses

{Leininger, :002). they discovered 187 care

construrts in Western and non-Western cul-

tures benvetn 1989 and 1998 (Leininger, 1998a, 1998b). Leinitger listed the Li most domlnalt construcls oi carc in priorlt-v ra-'rk- irrg:, with tf ie nosr urrive*al or fiequenth- di-t-

cocered lirst: reiptct forl'1bout. concerrt for/abouE, afiefl tion to (details)iin anticipation

of; helping*assisting or ihcilltaiive acts; sciiYe

helping; pr{:sence {being ph.vsicallv there);

,.rndersianding {heliei!, values, liiertal's, ald cnvironmcntaL)i connectednessl protection (gender reJated)i tcuching; and comibrt meas-

ures {Leininger, 2006b; Stcf'arland' 2002)' 'Ihese care consffucts are the most critical and

ifiportant uqil'ersal or ro11ln]o3 {indiags to consider in nursing praciice, hut care diversi- ties rvill also be ibund and nrust bc considered' 'lhc rvavs in rvh.ch culture care is apaiied and

used ia soetifit culrures rviii refle':t both sir:ri- laritles *nd difierences arnong and rtithin ditTerent cultures.

i\*ct, nl.o erhoon',usitrg smdies art rsielved rvith focus on the {inding:, u'hich have impli- cations for nurring Practice,

C u ltur e C arc af Tradi tiona I Muslims in the Midwestet?t Sfafes

1n 2005, the the*ry'c,irulture care dirqrsitv a-tld

unlversahty and the tthnonursing researth method lvffe used ro guide a study of th* cu-l-

ture crre of tradi.tional Stryian Musiin:s in the

Midrrestern Linit*d Srat*s {Wehbe-iUanra-h, :008b, 201i). 'Ihe domain af inquiry for 'jris etinooursing sruCy rABs the gentrit and the protessional care meanings, beliefs' and prac-

iices ,"14t*d to health and illness oftraditlcnai Srtran .\lus1ims living ia selerel urbrn cotruru-

nlties 1n the -trtidrvestem Unired States. 'Ihe

purpose ofthis Etudl lt?s to discover, d+stribe, a,nd anallze the *ffttt of rvorldvierv, cul::'.ual contsxt, terhnologic*l, religicu:' poi-itical, ed-

ucadonal, and eronomic i.retors on the tradi-

tional Svrian ;\lus)ims' generic and proi'tssionai

care memings, beliefs, cnd praidces"Ihr gcai

rvas to provide practicing nurses and other health-care prol'iders u'ith know'ledge that can

be turned lnto trre actions and decision: that facilitate the prorisiotl al cu1rural1,v congrxsnt care to tradltlonal Syrian Muslims li'.'ing in sl'nilar {ontaxts i\\'ehbe-A1am*h, 2011).

Findings from thrs grudY retealed that the

worldtiew of traditional S,vrian Muslims is deeph, en:bedded in *re lslamic religion and the lrrian culture. Life is vieweJ as a t€st iiom Cod ald a journcJ'in which one must aftemFl to dc as manv good deeds as possib'le .lcd to behave in a rlghteous wav rvheihfr condllcting

bu:iness, taking c:re ofhouseu'ork, or engaging

Syri*n Llnited

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Ci{d?,r}:n 17 ' i{sdej,r'ze Isizirgv'r 'Ihmry of *tttt*e D*e Diwti* *nd th1ifltrffiSry 3 15

in an1'other regul*r daily acrivig' Kinship *nd

f*r*iLrl r"lrtio.thips are rreasured' Socializine rrlth f*rLily members and friends rre consid- ered in:paitant aspectri ci Strian lilbrva1" Vis-

itltions and telephone ,-onl'ersati*ns as well as

!':ida1' prayer corgregations are rnajor sccial

activities tc,r Sy:ians. ln S1:ian }lusiirn :oriet1,

lhe n.ran ry5rita1!- assurnes the role ol the breadrtinner, whertas rhe rromln takes on other responsibilities, such as managing the

h'.usehold and rrising the thiiCren {Wehbe- ;Uamah,2008b).

Some or the discorered traditional culmrai

beliel's and practlces included^ modesq, gener-

ous hospltalig+, segregation olmen and rvomen

during social evenis surh as r+'eddlng partirs

and dicner indrations, *'cariag oia coar orjr/'' Srrd over tlothes 1'or rvome n '*'hen in public, caring ibr older familv ntembers *'ithin the home seting, as u'e}1 as risiring, pravrng fbr,

and cool:ing for the sick' 'l*orr*al *'ery-da.v ac-

ricns rvere considered h,v manf inlbrmants as

acts ofrvorship. Engagine in rcLlgious pracdccs

such as pravcr and Qr-r'ar: reci:ation or ;nelrr-

orization wlas reported as a source oi phl:ical,

spirirual, eclotional, and mental supFort by

nufilorous lnfotmanis' Religious b'eliefs lvere

deterrnined tc plav an important role in a per-

son's decision-making inl'oit'lng abortion, ster-

ilization, autopsY, orgrn donation, binh conrrol, and other signi{icant health issues

{\'VchLe-rtr1amah, 1008a).

Cxing uus described as being considerate oicther people's irelings and respecting rheir bcliefs, Enpathv, s1'mFathy' sensitivit), un-

seliishness, an*! understanding were other

qua.Itier u:ed to describe caring, Caring can be

expressed b1'checking orr others, being avail-

abie to &em, olfering tF.em he1p, cooking he:dthy ibod, and keeping a clcan bodr- and a

hlgienic envirc*ment. Llring can additionallv

be exempliiied bv rvirhnolding a diagnosis.

o-nC/or prognosis iiom a patient especialll if an impendiirg death w* exp+cted anii b1'bu1r'- ing the dead with 24 hours oltheir passing' Caricg anribures oinu.rses u'err identified as

srniting, responding quicklv to the needs c'f

s:ck patients, loving &e nursir,S profession and

role, and respecting the patient'l culture (trVehbe-;Uanah, 200Sb).

A plethora ai generii cr folk pratticcs were discoi,ered and induded some th'tr art tteneii-

cial to health and c*iers rvith potentrallv harrnful ramiiicarions' One suth example is

the consumption of ra*' liver, which is rich in

iron and is used to treat anerrlia or iron defi-

cierrcl'. Another ex*mpl+ is treating head llce

b1 pouring gasoline over the sc:1p anC massag-

ing !r inro the hu. I'cik practices that arc ben- .irti.1to health inciudtd eating ir moderation, exercising, rrd takltg vitamin C when treating a cold (Weh.bc-:llamah. ]008b).

Such information can be turned into cul- rura11,r' congruent decisious and actions that

ean ltr!paet clitical lrattice tLr*ugn the ap- plication of Lelnir:ger's r-ulrurc care modes'

-{ccordingly, nurses aad other health-care prootders ian prestn'e andlor maintain the cu-1-

iural beliei's, e-xpressioas, aad practices cftra- ditional S1'rian r\luslirns bv respectilg the nttd for rnodestv and seeregation and assigning same-sex health-care providers lvhcnel'er pos-

sible. 'lhe culrural belieland prartice ot visiting

thc sick can be rccommodated bl ensouraging a large uumber of *sitors within the hospital set*ng \tith the negotiadon of having onl1- a fr* oLitott in the parient's roorq at a time 'lhe

harnfirl iblk prartices ofusing gasoline to treat

head lice and consuming ra\f iil'Er to treat ane-

mia can be repattcrned x'nd/or restructllred through eduration eiramifications aad discus-

sion of heahLicr altt'matives

trffiHffiffiffi T :\ i\'iiddlc Ilastern patiert in labor identi&ed as }lrs. Sarah Isiam has iust been adrnitted to the obstetrics iloor. She is acccn:panied bv her husband and is dressed in icqrse cloth-

ing that covers all *fher bodv except ibr irer frc" ,nd hands" She belongs ro the S1uslim

faith and rrears a hcad cover, }1er husband r€quEsts that orlly temale health-eare pror,iders {1lCPs} be assigned to his rviie. 'I'hr turse pruvitles cuituralhl congrutnt care ro fhls familv using Leiuinger's culture tsre

the{}n'.

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316 !r.r: r -irr V ' Crsnd'Ihtcries absul Cttre or Carinq

F$etri*B {k,FW&s jyj* :\cccrding to this theoii--, the worldyieli'

oi everv human beine is aflbcted b,v cu1rural and soci"l sgucrural dirn*lsions, including but

not iimited to culzural va-1ues, beliefs, and liie - rrnys, r-nd kinship, so{ial and reiiglous farrors' 'lhtreibre. proltssional nursing ctre must in-

corsorate an u*.derstanding of these belieis *.j pr*.o."r' rls a resuft, the nurse procecd-s bv conJuctrng a cJlmraf assessmer't to identL+-

irr.oortrnr n*,1. ,nd prohibitions rhat need to

bc add-ressed in the plan ofcare.'1he nurse be*

srns br'*plaining thai she rvould iike to ask

"u"r,rln, io lcrn rbout how to brst care foI

t'h. .1i.nt and her ts.mllv.'lhc cu}'.xal a;sess-

n'reni rereals tht fbllorvicg:

' -Nlcdesn* aad prirarl are important values to.Mrs. and Mr. 1slm and should bc prc-

sen'td $'hcne1'er possibic, according to '-':1- tural and religious teachings. Ihe couple

explains th*t this can be achiered bv assign-

inq san:e-set I lCPs md trv preventing *"1* *dio'id*u-lt {ron', tttering thc Patient's room rvrtl'.out fi:st obt.rinrng pcrrr:ssior' to

do sr..

' Pork-d*riveC products induding gelatin ue prohlbited in lsiam and therei'ore should

be exduded *om diet a-ad medirations' '1he cougle uplains thatJe.lio and geJrtin-

encapsulate-d medications contaia 6elatin and should be ar-cided'

' :! special praycr needs tc be *'hispered b1' the ilthtr in rhc nelvborrls ears aJier birrh- the couple reque-rts thar the ner*'L'orn be har:ded to the father as sooa as possible

aftrr birth to l'aciLitatr this practice.

' tr/isiu.tion hy lirnily members and iiiends is to be *pected fb1lowin6 birth. The couple in-

forms r'cu that they ergfct at least 30 r{sitors'

' Smoking the wattr pip* is a comrnon cuitrra-1 practice and is olten caried in tht

Fresente ofchildren. Itr. Islam smokes the uate.r pi.=e m'lce a dw.

ilaving identilied important culmrql xnd religicus valucs, Prallices' needs, rnd prohibi-

ions, the nurse oroceeds to deveJop .1 culRtr- ai}l' congruent plan of care using Leiringels Cuiture rare modes:

Culturc tare Presewrtion and./or

mrintenance:

' 'lhe nurse includes a note in the electronic health record absut identilied cultural and

reJigious rnlucs, oracdces, needs, rnd pro-

hibitions. 'Ihis r-i1l assisr rvith conrirruitl'of rulturall,v congruent cxre'

" 'Ihe nurse is female; therei'ore shc is able to

cue ibr;\'lrs. ls1am.

' 'Ihe nrirse places a sign at }1rs. Isiam do'or that reads: "No males aliou'ed x"ithour perr.rission-'

.;lhe obstcticrar: rnd a-11 nurs!ng stalfat- tending the birrh sre iniormed tbout the

in:portant prtctlce ofhanding tlc nelryborn to the t'ather *'itlin minutes of blrrh. 'ihe father recltcs the pmlcr in *re babv's tals' 'Ihe nurse attends the bkth and ensures that this happecs.

Culrure care rccornmodation andr'or

negotiation:

. 'Ihe lurte alranqes lbr kitthen stait lo pro- l'lde vegetarlan Je}-lo I'ersus animal-dcrlled

Je)1o.

' 'lhe nurse alranges for mtdicr'tions to tre ordered er dispensed in tablet versus gelcap

lorn:at. ' '1he nurse negotiates t'ith the iar.'rily to

haqe l"isitors coile et different tlmes, *zit in lrdti:rg rocm, aad r-isit il nunrbers ol f or 3 at a time,

Culture care restructuring aftd/or

repitt€rning:

. 'fhe nurse educates the clitnt and her husband sbo':t dangers associated rqith

smoking and secondhaad smoking inhala-

tion implications is;hg nsrtborn. Sh* ad- lises the discontinuation olthis practit'e' (Alternativelt, th.e nurse negotiaies rrith IUr Islart to oalll smoke cutdoors and cur down to onte a day.)

Llpon discharge, 51r. and }Irs. lslam thank

i*u, ih. nursc, for providing thcm *'ith the best tare they have n'er receired in a \\iestern

health-care setting.

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ortransmitted

wiitrout publisher's prior permission Violators will be prosecuted'

f,rrA:"rr*r 1? . &rclclr ine Leitingx\ Tkcmy af caf,'Jrre cer* Diwtsiry a*d llni|M*liry 3L7

'Ihe purpose of the CC'I and the ethnonurs- i;rg mesod is to dise over culrure care L"lo11'1-

edge and to cot:rbine generic and prol'essional

car. 'Ihe goal is to proride culturallv congru--

ent nursing care uslng the th.ree modes ol nursinq actions anC dtcisions thflt att ilcar- in$rl, -"afe, aad beneiicial to periole oisimiiar ,rJ dir.tt* cuitr:es lvarldwide {Leinlngtr, 1991b, 19r5, 2006a).'Ihe clinical use of the

three major ca.re modes (culrure care preser-

vatiofi and,/or rnxintenance: culturt crre ac-

comrnodation and,/or negoriationl and culture

.i.re reFf,tterring and/or restructuring) tt1' *urses to guide nurslrg iudgments, dccisionr,

and actions is essenrlal in crder to prortde rui- ruraI1y congruent care rhrl is benefrcial, saris- hing. and mean:nftul to the ptocle nurses cen-c. 'lhc srud:es oresented Lcre substantiarc

rhat thc three modes rre care-centered and

are bascd on ihe use of gcneric care (emic)

kncwledge along rvith plrllssional cart (etic)

krou'IeCge obtrir:rd from researth using the CCT along rl'irh the ethronursing method' "lhis chapter has reviewed onlv a small sel*c-

tion oi tl're culture care findings iiorn eth- nonursirg research studies conducted over the

past 5 decxdes. "lhere is a*'esltl ofadditionsl iindings olinterest to Ptatticing nurses *ho care for clirnts cf a1l ages frnm diverse and sirnila-r cuitural groups in manl' di{erent in- sriturional and communirv contexts arc'uad

the *'orld, tr{cre in-dep;h cu}ure care finil* ings, along r+'ith the use oi the three mcdes, can ire iDund tn the Jotntti q!'Tratstullural .\irriag (1?89-2013), in the OttlircJotrual of Cvkrtrai Cow1ttttt* in Nuttitg a*i Healthtart {u*"lr'.OjCC^\II.org) *nd in the qumerous

Itr+yle,J., 6cGtttenbug i iiridrs, j" (2613). Sladeiei*e tr+inisger, PhS, i,!dD, lili. !'S"CA' t-A-An-r A s- mrbnm.J+mal afT*t*l.r*el Mwirg, }41]' 5.

Lxininpt, &1. {1!?0'1 . i'{*itg etd m$rry*lag1: Tw wr!& re &!nnd. Nw Yorlr WihY

Lsisi*ge{, }i, i1+76}. 'Iwo1turuI nursiss Prc#ns s midsg eiulleflEE. 'trbc&**it*x Nw, 515\, &-d.

books and articles lvrittrr: b,r' I)r. -\'ladeleine Leinlnger and resea-rchers using her theorr''

and method. Nruses in clinical practite can reier to researcir studles and doctolal disserta-

tions conceprualiztd u'rthin the CC'I' for rd-

ditlonal detailed nursing iraplicatioas ior clients i'ronr diverse cukures iLeininger & -&lrFarland, 2002; *\{cl'ariand et ai., 2011)'

'Ihe theory ,;i culture care diversig and uni- versaiiqv is one of tire rnost cornprehensive vet

pracdcal theories to advance ranscultural lqd g*nerai nursing knowledge a'itl: concomitant r+.a1-r tb; pra.ticirg nruses to establish or iln-

,ror. .*i* to peopic. Nursing srudentt and practicing nurses have remaineC the strongest

*duo.rt"i olrtre CCT (Leininger, ?002), -Ihe

theory- focuses on a long-neglerted a-rea in nursinq practice-culturr care-that is most relevant to our rnultlcultural world.

the tlreory oi'tulture rare diversiry md uni- versalit,v.is depicred in the sunliie enabler as a

risieg sun. lLs ri:ua-l ntiaPhor is particularh' apt. 'lhe fumre of the CC'll shines brightly in- deed because it is hoiistic and comprehcnsivel and it faciiitates discct'ering tare related to dircrse and similar culturcs, contextB, aad lges

olpeople in lran:iiiar and naturalistic *'a1:.'Ihe theory is usefi:l to nurses and nursing as w'ell

as tc proi'essionals in other d:sciplines sueh as phvsical, ocrupatiooalr and speech thertpl',

nledirine, social *'ork, and pharrnaq" I lealth-

rare pracriioners in other disciplines are beginni.ng to use this ttreorv berause thtv also n""d to b".or:re knot'ledgeable about and sensitive nnd responsible to people of direrse

cult:res rvho need care il-einlnger.3002; illcl'arland, 201 1],

l*inirger, I1. f 9?fl" Cuiag:'ilw esre and moual lomr of amit5, .Vrritgfiam&Fo*ada*im Bgrr, tz\Llt L-!+

Lsi{ir$s, M. {1978}, fffierr}641 e&5ir$- fla,r+},i rAmt, aadfruc*er Nm Ydc lviht'

f*i*ingu, M. {1881}, Cm;g,'dr ara tia! $umaa tud. '.tho:cfw, Hj: $ladc

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L*iflirutr;M: (1988). Crt: Ditouttl onduw in diakd aar! ammairy ouairs. l)ffiir' -t1I: \Yayne Sate UnireEiq Pres-

lxinlnes, Iri, (1989t), "frumulrual nwing QLo red\ (wtrw gtrth rhe 6etd!}.lomsl a[T'tariltwul &ksrhS, ,{{$,33-45.

Lcininfltr, I!1. {1989b). TruorrnorC rNrE }pEcidisu *ig"ncj"*, Jlev Pffrition€s in rusiog' Jmrl a{ Tdntftlrurl! buuffiag, l(1}, a-16'

Leiriltp, ${. {1990e). Trrmulrunl rusing A wwld- wiJe nw*iry t* adrm nusiug krot'lcdgt and rrattie*" trJ. &lcClwiexy Se &{. ilm, {tds'), Cr MJ i6s itr ilmif,g- St. lsua MO: t' V' ils*I'

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LeinlrrEs, &1. {1990d), gr*iird#/Md d#r'rnad *r ar* I3euoir, Silr W*3ee Se{e Uniffiity tsrffi'

l*inin*e, M, {1991E). GdJaB rffi d#Js*' #/#i{e @lirj:,i rI,fdr'4l&ftin6- Nru Yuk iradmal Legut t-e l\using Prcse.

L*inineer, -\'1. (1991b)-'fhc theuy of culturc rue dirtsis md univssaliry. lo -\4. I*irnngs (Ed ), Cu&s{ trrs /r:E#ir} ead ****m/iry::f r*enry o1{ rming {pp. 5-68}' Nw YorL Hatiooa! Lmgue for Nusirrg Fem,

Liinn)s#, xf , (19951- Tmwnntval tnj,g: (hrcfit' tAilt, t*ed:, aadTrwne Colmbul, OI i: McCqs-Hili tntleYP Curtm Suier'

t*inio*er, -V. (1997r). Otmi* and refl*tion of the .leon of culue rx md dre eLhoonudng rwmh oedrcd-,Iamo!{?rmor*we/,i!tr,"trd! *U)' 3?-51'

I*itir:qw, &s. {1997bi" Owrim ol rhe rhmr-r *f cu1- tur; ff rviih rhe $hnonusbg rswch metlud' /axmef gf ?roaw/ruarlnrrrr'ag' S(I)' 3!-53'

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{{dc.), Sslr&rediiffi i4 tl xxi*ncli4: d *tr*Jwdc

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*urL*tr *tth "onh1s*

m rtudy dre Li)€o{y of mlele w. In M. S{. Leiflinger &'Sf I McFsisd

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Lciniats, Il. (20091- lt is tiw to ub6'e*' ry&t ud l*i intc tfu fr,twc Retriwcd on Jarruary 9, ?013 liun tt u ii'Lqnrinr*1?'{m!ng 3ukttr'website at hrrp r//tw,ut*.o4i&'oundrex-hsni

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LeiilnA;, &L ${-. & }k}'arland, M, 1l (Ed+. {2002}' TruEr'vlr#}! nfflin#: c'tr4'B' i'Bd'n4' dildP8{Iia (3rd ed.). Irtrv YaL. IlcGnw-iii.ll'

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-lrcftrI;d, fi{. R. {2002}. Pm lI: Selected reseffi}: fndiqs from the ruire ffi6 *Es{'. In 1l{' M' Leltitgr f*14- IL rllcFriend {Ed*)! ftensailstd/ w*1a11: futttptt, t&6ffi, drlptrdsrd {3rd Bd-,

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Hc$'slm{I\1.11., {rElpprle, M' K' (3ffiS)' Cuitue cm tlrmry: .{ p*pwd pmrtire r}rrory guide ftr oiffi practitionus ia primry tut wttiAgr' Cmtm- jrer,lr rVorot,fJ*aef/r rir Jurrrufm rYmi:tg Itc&rgr" .At{l-?}. 4E-dl,

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Wehb{-Aimah, ! 1., & Mc!'ulud, !1- (20U) T'r Tdwex *{twl apxiext, Podium prmmtation ai tlu 3$rh.jLlrrual CsrI'erema ofthe Tnucultural I'iurog $oricry. Orlando' F'lorida