Introduction
This paper is an analysis and critique of a published nursing philosophy and theory by the nurse theorist Madeleine Leininger. The analysis is based on Leininger’s publications about her theory starting in the mid-1950’s with her major contribution stemming from her second book, Transcultural Nursing: Concepts, Theories, Research, and Practice in 1978. The model used to analyze this theory is the Chinn and Kramer model. This model was developed by Peggy Chinn and Maenoa Kramer in 1983. The model utilizes a two-step process to evaluate theories called theory description and critical reflection. Theory description consists of purpose, concepts, definitions, relationships, structure, and assumptions. Critical reflection analyzes the purpose of the theory utilizing a series of questions. (McEwen & Willis, 2010, p. 95) This model will be used to critique one of the oldest theories in nursing.
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Purpose
Transcultural Nursing Theory discovers and explains the culturally based care factors that influence health, well-being, illness, and death of each individual or community. The purpose and goal of the transcultural nursing theory is to provide culturally congruent, safe, and meaningful care to clients of diverse or similar cultures. (Leininger, 2002, p. 190) Leininger has established a theory that studies cultures to understand their differences and similarities. Cultural competence is important within the nursing profession due to the differences in each individual’s perception of illness and wellness. Congruency between culture and health care is essential to the well-being of each individual and community. An individual’s health beliefs and practices are linked by his/her culture. The culture care theory focuses on cultural beliefs and practices when determining a plan of care. It continues with the belief that nurses need to consider that not all cultures are similar, and there are variations within each culture. Each individual or community should be treated differently from the rest and that personal uniqueness should always be considered. This belief stems from Leininger’s personal belief in “God’s creative and caring ways.” (Leininger, 2002, p. 190)
Concepts & Definitions
Transcultural theory uses the concepts of culture, race, and ethnicity to understand human behavior. When providing culturally competent care nurses should understand the meaning of these terms. Leininger also focuses on a few other concepts such as cultural competence, cultural awareness, and acculturation. Leininger’s theory focuses on numerous concepts, but these were selected based on the importance of nurses integrating the most basic concepts of transcultural nursing into their well-established knowledge base. “Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or distress. With increased mobilization of people across geographical and national borders, multicultural trends are emerging in many countries.” (Ayonrinde, 2003, p. 233) Culture is defined as a set of beliefs, values, and assumptions about life that are widely held among a group of people and that are transmitted across generations. (Leininger & McFarland, 2002, p. 47) Burchum (2002) defines culture as a learned world view…”shared by a population or group and transmitted socially that influences values, beliefs, customs, and behaviors, and is reflected in the language, dress, food, materials, and social institutions of a group” (Burchum, 2002, p. 7)
All cultures are not alike, and all individuals within a culture are not alike. Each person should be viewed as a unique human being with differences that are respected. Individuals may be of the same race, but of different cultures. Race is defined as a social classification that relies on physical markers such as skin color to identify group membership. (Leininger & McFarland, 2002, p. 75) Many nurses overlook cultural differences of individuals due to their similar racial characteristics. Race is considered one of the identifying characteristics of a culture, and this identifying characteristic represents an ethnicity. Ethnicity is defined as a cultural membership that is based on individuals sharing similar cultural patterns that, over time, create a common history that is resistant to change. (Leininger & McFarland, 2002, p. 75)
Cultural competence is an important factor in nursing. Culturally competent care is provided not only to individuals of racial or ethnic minority groups, but also to groups that vary by age, religion, socioeconomic status or sexual orientation. Cultural competence is defined as a combination of culturally congruent behaviors, practice attitudes, and policies that allow nurses to work effectively in cross cultural situations. (Leininger & McFarland, 2002, p. 78) Religious and cultural knowledge is important in the healthcare profession. It is also important that health care professionals assess their own beliefs and ask themselves how those beliefs may affect the care given to clients. The awareness of your own beliefs is called, cultural awareness, and is defined as self-awareness of one’s own cultural background, biases, and differences. (Burchum, 2002) Not only must nurses be aware of their own beliefs, but also must be willing to learn and understand an individual’s beliefs. The process of learning a new culture is acculturation. Adapting to a new culture requires changes in each nurse’s practices.
Relationships & Structure
The relationship and structure between the concepts in the culture care theory is presented in Leininger’s sunrise model. (Figure 1) This model is viewed as rising sun and should be utilized as an available tool for nurses to use when conducting cultural assessments. This model interconnects Leininger’s concepts and forms a structure that is usable in practice. This model provides a systematic way to identify the beliefs, values, meanings, and behaviors of people. The dimensions of the model include technological, religious, philosophic, kinship, social, values and lifeway, political, legal, economic, and educational factors. These factors influence the environment and language, which affects the overall health of the individual. Individuals who may not feel understood may delay seeking care or may withhold key information. Environment and language affect the overall health system which consists of the folk and professional health system. The folk health system consists of the traditional beliefs, while the professional health system consists of our learned knowledge such as organized school and evidenced-based practice. The combination of these systems creates the nursing profession which allows us to meet the cultural, spiritual, and physical needs of each individual. These factors help nurses understand the client and recognize what is unique about the client. This model helps each nurse avoid stereotyping an individual into a culture based on the minimal factors of race or ethnicity. (Leininger, 2002, p. 191)
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The last dimension of the model helps nurses establish culturally congruent care through the utilization of three concepts: culture care preservation/maintenance, culture care accommodation/negotiation, or culture care repatterning/restructuring. Cultural preservation means that the nurse supports and facilitates cultural interventions. (Burchum, 2002) Cultural interventions may include the use of acupuncture or acupressure for relief before utilizing standard practices/interventions. Cultural accommodation requires the nurse to support and facilitate cultural practices, such as the burial of placentas, as long as these practices are found not to be harmful to individuals or the surrounding community. (Burchum, 2002) Cultural repatterning requires the nurse to work one-on-one with an individual or community to the help them restructure, change, or modify their cultural practice. (Burchum, 2002) Cultural repatterning should only be used when the practice is found to harmful to an individual or community. All of these factors and concepts guide the nurse towards their ultimate goal of providing culturally competent care. These factors and goals allow the nurse to fulfill the individual’s need of having holistic and comprehensive culturally based care.
Assumptions
There are a number of theoretical premises for the cultural care theory. Leininger (2002) highlighted five important assumptions. The first is “Care is the essence of nursing and a distinct, dominant, central, and unifying focus.” (Leininger, 2002, p. 192) Nurses provide care with sensitivity and compassion. Cultural care theory requires nurses to provide that same care, but based on the cultural uniqueness of each individual. The second is “Culturally based care (caring) is essential for well-being health, growth, survival, and in facing handicaps or death.” (Leininger, 2002, p. 192) Non-culturally competent care may increase the cost of health care and decrease the opportunity for positive health outcomes. The third is “Culturally based care is the most comprehensive, holistic, and particularistic means to know, explain, interpret, and predict beneficial congruent care practices.” (Leininger, 2002, p. 192) Culturally competent nursing care is designed for a specific client, reflects the individual’s beliefs and values, and is provided with sensitivity. The fourth is “Culturally based caring is essential to curing and healing, as there can be no curing without caring, although caring can occur without curing.” (Leininger, 2002, p. 192) Therefore, there is an increased need to recognize the impact of culture on health care and to learn about the culture of the individuals to whom your provide care. The last assumption is “Culture care concepts, meanings, expressions, patterns, processes, an d structural forms vary transculturally, with diversities (differences) and some universalities (commonalities).” (Leininger, 2002, p. 192) Nurses should be aware of cultural beliefs, cultural behaviors, and cultural differences and should avoid the temptation of premature generalizations. Following these assumptions of the cultural care theory allows nurses to be less judgmental and more accepting of cultures which promote holistic care for all cultures.
Critical Reflection
Culture Care Theory has played a significant role in nursing practice. The theory is highlights numerous concepts in which Leininger clearly defines and consistently utilizes in numerous publishings. The concepts in Leininger’s theory are the gold standard for transcultural nursing and are mentioned in the majority of literature regarding culturally based care. The theory is complex with a number of concepts and interrelationships. The complexity is important as it develops a meaningful and comprehensive view of cultural and holistic based care. Leininger’s theory has a high level of generality due to its ability broad to be applied to all cultures, ethnicities, and races. The key to Leininger’s theory is communication, and even crosses languages and establishes how to eliminate language barriers, through the use of interpreters. The theory consistently approaches culturally based care by requiring the nurse to use cultural knowledge as well as specific skills when deciding nursing interventions and practices. The theory continues to be consistent in requiring the same approach by requiring the nurse to perform a cultural assessment. The assessment provides an understanding of an individual health perception which guides culturally appropriate interventions. Culture care theory is widely accessible as it is the major and most significant contributor to transcultural nursing. (Ayonrinde, 2003) Cultural care theory played and will continue to play a significant role in nursing practice, research and education. Healthy People 2020 goal is to eliminate health disparities among different populations based upon numerous factors. Nurses are the key in moving forward with eliminating these disparities. Today’s environment is multicultural and the emphasis on providing culturally competent care has increased. The Culture Care theory is well established and “it has been the most significant breakthrough in nursing and the health fields in the 20th century and will be in greater demand in the 21st century.” (Leininger, 2002, p. 190)
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