Leininger’s Culture Care Theory of Nursing

Around the world Madeline Leininger is considered the founder of the theory of Culture Care Diversity and Universality and also for the discovery of the research method known as “enthonursing” or “transcultural nursing”. She was the first nurse to theorize about human care from a worldview rather than the usual medical view. She is a creative, innovative, and visionary editor and author of 22 books, 265 articles, and 40 chapters focused on transcultural nursing and human care phenomena (Cohen). Leininger is a United States-born anthropologist in which she incorporated her knowledge and expertise in anthropology to her practice in nursing to create an idea that would greatly influence the way in which nurses cared for their clients as well as develop a sense of self-awareness.

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In 1948, Leininger first received a diploma from St. Anthony’s Hospital School of Nursing in Denver, Colorado which qualified her as a registered nurse. She quickly moved on to receive a bachelor’s degree in biological science and soon thereafter earned master’s degree in psychiatric nursing. Finally, she was the first nurse in history to study at a doctorate level and receive a PhD in cultural and social anthropology. She applied her roots in anthropology to provide nursing with a way to study caring while taking into account people’s culture, beliefs, patterns, and values to provide culturally sensitive and congruent care to every patient (McCance, McKenna, Boore).

By the 1950’s, Leininger began to formulate writings on nursing practice with a primary focus on caring and transcultural awareness (Cohen). In the late 1980’s, Leininger’s writings on her theory of transcultural nursing and cultural care were published in her Journal of Transcultural Nursing in which Leininger defined caring as “the essence and central domain of nursing practice”(Cohen). The intention of this publication was to share scholarly work among nurses and others with an interest to incorporate transcultural nursing knowledge into their scope of practice. Her published theory states that “caring is the central and unifying domain for the body of knowledge and practices in nursing” (Leininger). Globally, she is considered one of nursing’s most prolific writers. Leininger’s theory of transcultural care is significant and unique in the fact that it is the sole theory that focuses on cooperative care that takes into consideration all cultures around the world (Cohen). It is predicted by the U.S. Census Bureau, that by 2042, no single racial-ethnic group will hold a majority population position, and more than half of Americans will be members of a minority group (Varcarolis 2010). In a time when the world is growing smaller and our society is encompassing and adopting more and more diverse cultures, it is imperative that nurses are competent in the ability to give culturally congruent care to patients in all healthcare settings.

According to an article on global leadership in transcultural practice, education, and research by Margaret Andrews, Leininger has identified three key historical phases in the process of her development of the transcultural theory of nursing, according to one of her articles called The Evolution of Transcultural nursing with Breakthroughs to Discipline Status (2007). These phases serve to outline the development of transcultural nursing. During the first phase (1955-1975): Establishing the Field of Transcultural Nursing, Leininger acknowledged the relationships between nursing and anthropology, but kept a focus on nursing and the benefits of having a theory (Andrews). During the second phase (1975-1983): Program and Research Expansion for Transcultural Nursing, increasing amounts of nurses became interested in the valuable contribution of transcultural nursing around the world. And lastly the third phase (1983-present): Establishing Transcultural Nursing Worldwide, is the period during which transcultural nursing’s global agenda is the primary focus.

It all began when Leininger was working as a psychiatric clinical nurse specialist in a child guidance home in the 1950’s when she experienced the unfamiliar feeling of “culture shock”. While at the guidance home she worked with children of various cultural backgrounds. She began to notice a lack of understanding amongst herself and the staff about how the children’s cultural backgrounds where influencing their behavior. From this, she came to the conclusion that caring is the central unit to nursing and being culturally competent is vital in order to deliver care to patients. She then began to develop strategies that would help the staff to incorporate congruent care to children with diverse cultures, patterns, and ways of life by developing a “worldview” and incorporating it into their technique.

In the early 1960’s, as a part of her doctoral studies in cultural anthropology at the University of Washington, Leininger decided to reside with the people of New Guinea, in which no one had any familiarity, in order to further study this new idea of culturally based interventions (Cohen). She established herself in Gadsup, New Guinea for two years in which she opened her eyes to the values, world views, and beliefs about the health and illness of the villages and how they were crucial in delivering appropriate healthcare. When Leininger arrived in Gadsup she was baffled at how completely different their world was from the one she left behind and she knew that the unfamiliarity would pose a tremendous challenge to her studies. However, Leininger’s eagerness to study the meaning of healthcare to these people and how it influenced their wellbeing lead her to adapt and provide specific care that would be beneficial to people and families who were ill. Leininger believed that culture was universal framework to how people solve their problems. The experiences she encountered during her visit in Gadsup sprung the idea that beliefs about health and healthcare are imbedded in the values of the person or persons receiving the care and the understanding of these values and beliefs are critical for interventions to be successful in allowing the patient to heal and be cured. “Transcultural nursing with a focus on caring must become the dominant focus of all areas of nursing. It is holistic and the most complete and creative way to help people” (Leininger, 1981:5). A key factor that she derived from her experience was her newly discovered research method that she referred to as ethnonursing. The central idea of the enthnonurisng research method was to establish a naturalistic and largely emic method to study phenomena especially related to her culture care diversity and universality theory (Leininger & McFarland). The terms Emic and Etic are used widely by anthropologists to refer to the way in which observations are viewed. The term “etic” refers to the behavior or belief of the observer of the culture. The term “emic” refers to the view from the person within the culture and this view is has largest influence on Leininger’s studies considering that her work was centered on the patient’s views in order to meet and understand concepts that were indigenous to them. Leininger applied ethnonursing for “the study and analysis of the local or indigenous people’s viewpoints, beliefs, and practices about nursing care phenomena and the processes of designated cultures.” She formulated this concept to take into account that nurses do not usually have the time to study the entity of people’s lifeways and interests, but that care is more geared toward the health patterns and phenomena.

In an article written by McCance, McKenna, and Boore, a practical application of Leininger’s theory was conducted by Barry & Kronk in 1993. The purposed of this study was to gain knowledge of the culture of a group of Guatemalan refugees who fled to the United States due to political unrest, extreme poverty, and persecution. The refugees’ major barrier to congruent care was the language barrier that disabled the caregivers to provide culturally congruent care due to being unable to communicate the refugee’s cultural preferences. The knowledge that needed to be acquired of their culture included concept of health, health care beliefs, caring behaviors, and barriers to health care. In order to acquire these concepts the health care providers used methods of data collection such as observing, interviewing, life history, photography, and participating with the people in their own environment. When using these methods, Barry & Kronk, were able to gather findings of the refugees such a kinship and social factors, educational factors, religious and political factors, traditional factors, belief factors, economic factors, and previous health care factors. When applying Leininger’s transcultural care theory and diagnostic tools, Barry & Kronk were able to provide a number of recommendations for the refugees in order to provide care. This study also conveys another concept that is unique to Leininger’s theory in which the focus of caring may transcend the individual and focus on families, society, or communities as a client (Cohen 1992). Sometimes, culturally competent care cannot be focused on the person as central to nursing because in many cultures, such as those of Eastern or Indigenous cultures, the term “person” or “self” does not linguistically exist (Cohen 1992). In these cultures it is not uncommon to see that the concept of a client’s health illness is due to a lack balance or harmony within their community or tribe.

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Madeleine Leininger’s culture care theory suggested three modes in which to facilitate nursing actions, judgments, and interventions to meet the heathcare needs of their patients in a culturally sensitive and congruent manner. The three modes of care were: preservation/maintenance, accommodation/negotiation, and repatterning/restructuring. Cultural preservation or maintenance refers to nursing care interventions that help clients of particular cultures to retain and preserve cultural care values when providing healthcare. Cultural care accommodation or negotiation refers to creative and innovative nursing actions that help people of different cultures adapt or negotiate with others in order to attain a goal of optimal health outcomes suitable to the client’s culture whether it be an individual, a family, or a community. Cultural care repatterning or restructuring refers to the therapeutic actions taken by the culturally competent nurse that enable the client to modify personal health behavior to achieve beneficial outcomes while respecting the cultural values of the client . These assumptions are the philosophical basis in which Leininger has used to add meaning, depth, and clarity to the overall focus of culturally competent care.

Visual aid to her theory: sunrise

“It is amazing what some women and men dare to do with their ideas in many places in the world. Creative thinking and actions are what the world needs most. Transcultural nursing has been an example of these attributes. While taking new actions may be troublesome to some people, yet new actions and new ideas can lead to a wealth of new knowledge and new ways to serve people. Transcultural nurses have taken such actions and are transforming nursing and health care in many places in the world” (Leininger).