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). Present day, our society is adopting more diverse cultures, and nurses need to be proficient in the ability to give culturally congruent care to patients in all healthcare settings. “Understanding Leininger’s Culture Care Theory of Diversity and Universality theory continues to be one of the oldest and broadest concepts to create understanding of varied and related cultures around the globe” (Andrews and Boyle, 2002).
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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”. This theory reverberates throughout many cultures around the world. Leininger was the first nurse to theorize about human care from a world view rather than the usual medical view. She is an innovative, and visionary editor and author of numerous books and has founded the Journal of Transcultural Nursing to support the research of the Transcultural Nursing Society, which she started in 1974. Leininger is a United States-born anthropologist. She incorporated her knowledge and expertise in anthropology to her practice in nursing, thus creating an idea that would greatly influence the way in which nurses care for their clients as well as developing their own awareness as professionals.
Leininger, born in Sutton, Nebraska, received her diploma in nursing in 1948 from St. Anthony’s School of Nursing. She then continued her education and received a MSN in Psychiatric Mental Health Nursing in 1954. Later, she continued even further, and earned a Ph.D. in Cultural and Social Anthropology in 1966. Early in her career she recognized the importance of caring, and made it her focal component in nursing. While working in a child guided home, Leininger realized that a child’s cultural foundation is related to their behavioral patterns. She recognized that the absence of cultural care knowledge of a nurse causes insufficiency of support, compliance, healing, and wellness. From this, she came to the conclusion that caring is the central unit to nursing, and being culturally competent is crucial in order to deliver quality care to patients. Leininger then began to develop strategies that would help nurses to incorporate congruent care in diverse cultures, by developing a “worldview” and integrating it into their technique.
During 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 Gadsup, New Guinea, in order to further study this new idea of culturally based interventions. The unique experiences she encountered during her visit in Gadsup birthed the idea that beliefs about health and healthcare are deeply imbedded in the values of the person receiving the care; and that the understanding of these values and beliefs are critical for the interventions to be successful. “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). A key influence that she derived from her experience was the method that she referred to as ethnonursing. “The central idea of the ethnonursing 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, 2002). The term “emic” refers to the view from the person within the culture; conversely the term “etic” refers to the behavior or belief of the observer of the culture. 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 defined transcultural nursing as, “a substantive area of study and practice focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people to face unfavorable human conditions, illness, or death in culturally meaningful ways” (Sitzman, 2010). In order to understand her theory, Leininger developed tenets and definitions that are essential to her major concepts. They are as follows (Sitzman, 2010):
• “Care is to assist others with real or anticipated needs in an effort to improve a human condition of concern or to face death;
• “Caring is an action or activity directed towards providing care;
• “Culture refers to learned, shared, and transmitted values, beliefs, norms, and lifeway’s of a specific individual or group that guide their thinking, decisions, actions, and patterned ways of living;
• “Cultural care refers to multiple aspects of culture that influence and enable a person or group to improve their human condition or to deal with illness or death;
• “Cultural care diversity refers to the differences in meanings, values, or acceptable modes of care within or between different groups of people;
• “Cultural care universality refers to common care or similar meanings that are evident among many cultures;
• “Nursing is a learned profession with a disciplined focused on care phenomena;
• “Worldview refers to the way people tend to look at the world or universe in creating a personal view of what life is about;
• “Cultural and social structure dimensions include factors related to religion, social structure, political/legal concerns, economics, educational patterns, and the use of technologies, cultural values, and ethnohistory that influence cultural responses of human beings within a cultural context;
• “Health refers to a state of well-being that is culturally defined and valued by a designated culture;
• “Cultural care preservation or maintenance refers to nursing care activities that help people of particular cultures to retain and use core cultural care values related to healthcare concerns or conditions;
• “Cultural care accommodation or negotiation refers to creative nursing actions
that helps people of a particular culture adapt to or negotiate with others in the healthcare community in an effort to attain the shared goal of an optimal health outcome for client(s) of a designated culture;
• “Cultural care repatterning or restructuring refers to therapeutic actions taken
by culturally competent nurse(s) or family. These actions enable or assist a client to modify personal health behaviors towards beneficial outcomes while respecting the client’s cultural values” (p 95).
The major concepts, which follow in accordance with the previously stated tenets and definitions of Leininger’s theory, are as follows (Leininger, 1991):
“Illness and wellness are shaped by a various factors including perception and coping skills, as well as the social level of the patient;
“Cultural competence is an important component of nursing;
“Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or distress;
“Religious and Cultural knowledge is an important ingredient in health care;
“The health concepts held by many cultural groups may result in people choosing not to seek modern medical treatment procedures;
“Health care provider need to be flexible in the design of programs, policies, and services to meet the needs and concerns of the culturally diverse population, groups that are likely to be encountered;
“Most cases of lay illness have multiple causalities and may require several different approaches to diagnosis, treatment, and cure including folk and Western medical interventions;
“The use of traditional or alternate models of health care delivery is widely varied and may come into conflict with Western models of health care practice;
“Culture guides behavior into acceptable ways for the people in a specific group as such culture originates and develops within the social structure through inter personal interactions;
“For a nurse to successfully provide care for a client of a different cultural or ethnic to background, effective intercultural communication must take place” (p 1).
The above stated concepts and definitions require the use of both basic and skilled knowledge to find ways to fit such diverse ideas into reasonable nursing care actions and goals. These tenets can help nurses to design nursing actions that provide meaningful, holistic care to patients.
The United States has one of the most diverse populations in the world and there is a widening disparity among quality health care and access within these minority populations. Healthy People 2020 (U.S. Department of Health and Human Services, 2010) has as one of its goals, the elimination of these disparities. This ever-growing patient population creates a major challenge for nurses to provide individualized and holistic care based on each patient’s cultural needs. Bridging basic and skilled nursing care is a prerequisite to culturally congruent care; this is done by using Leininger’s three action modes as a framework in the practice setting along with the nursing process.
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First mode addresses nurses utilizing the skills of maintenance and preservation in providing culturally congruent care to clients. This approach relies heavily on the need for the patient’s norms and values to be recognized as genuine preferences, while still preserving their cultural values by making efforts to incorporate those preferences into the plan of care. “In acknowledging these care values we indicate a level of respect towards our client and we help to build the foundation for a trusting nurse-client relationship” (Srivastava, 2007).
Leininger’s negotiation and accommodation mode can be used by the nurse to promote health, prevent illness, or to cope with illness or death. The trusting nurse-client relationship that was formed from maintenance/preservation gives way for negotiation and compromise to take place, thus allowing for accommodation, which helps the client to adapt and will include options that are new, or have been previously inaccessible, to the nurse or client. The use of interpreters in the hospital enabling different diverse patients to remain informed and active in their care is a great example. When utilizing Leininger’s third mode, re-patterning/reframing, the nurse and the client are seeing and doing things differently, allowing them to establish new possibilities and challenge old assumptions. At this point, the nurse can form mutual decisions with the patient in their plan of care in order to achieve optimal health outcomes; this can be as simple as viewing a situation from another’s eyes to gain a new perspective.
The “Transcultural Nursing Theory”, with its emphasis on cultural sensitivity and cultural congruence, has its limitations. Assuming that knowledge of different cultures will improve care and services, this falls short in accounting for the structural and political aspects of the inequalities of minority ethnic people. If the ability is limited to focusing only on the cultural differences and deficits, this makes the cultural problem the focus and could possibly give rise to ‘victim blaming.’ This bias is based in part of the RN seeing, cultural differences as cultural deficits, reinforcing stereotypes, and perpetuating the power distance between health care professionals and patients. There is a singularity of every client; it should be noted that not all the data taken will be accurate and applicable to all clients. “If nursing practices fail to recognize culturological aspects of human needs, there will signs of less efficacious nursing care practices and dissatisfaction with nursing services” (Leininger, 2002). The former can be an aspect, but nurses should also provide holistic care, not only as it relates to the concept of culture. Also, Leininger’s theory does not give any attention to the disease or symptoms a client may present with. In the end, this can lead to a problem in familiarizing or incorporating the culture of the patient, which may be the cause of culture shock on the part of the nurse. Studying culture does not mean that nurses can relate; studying is different from experience. Nurses must have positive experiences with members of other cultures and learn to sincerely value the contributions all diversities make to our multicultural society a productive one with regards to health care.
There are critics that maintain that this “narrow view” of the theory results in stereotyping. Since Leininger received her doctorate in anthropology, critics see her understanding of culture only relying on customs, folkways, and patterns. “It is important that this process of identifying the characteristics that may be associated with certain cultural groups be done with an extremely open mind and for the nurse to realize that, just like in anything exceptions can be found” (Sitzman, 2010). Nurses must always assess for verification or for exceptions when it comes to patient care.
The foundation for Leininger’s theory is that cultures exhibit both diversity and universality. This can be seen in her ‘Sunrise Model’ (Figure 1, Leininger, 2002) which shows the relationships of culture care, diversity, and universality. She uses this to visualize the different, albeit very closely related dimensions of her Culture Care Theory.
This model is frequently used in practice as “a better way of understanding the factors that influence a person’s perception of well-being” (Leininger, 2002). When using this model, the nurse can begin anywhere, depending on the focus of nursing assessment. The model reflects one’s perspective on cultural and structural dimensions, including technological, religious, kinship, philosophic, social, values and lifeway’s, political, legal, economic and educational factors. The upper half of the model influences care and health through language, ethno history, and environmental context: importance should be placed here because this is where the patient finds themselves. In turn, these factors influence the folk, professional, and nursing systems. The use of folk and professional systems, according to Leininger’s model, meet all the biological, psychosocial, and cultural health needs of the patient.
Leininger found that this model depicts all components of the social structure and worldview factors that influence care and health. The Sunrise Model can be applied to any culture or group in order to explain the cultural care world view and the application of the different systems, and subsystems, in it. The importance of her foundation and theory is extensive because it has served as an archetype for the development of other culturally specific nursing tools. Drawing from basic culture theory, the “Transcultural Nursing Theory” narrows the focus of cultural competence and proficiency to patient care, at the same time encouraging holistic care. It revolves around the comparison, assessment, and analysis of the cultures present in a patient care situation.
Culture Care Diversity and Universality express the ways in which a changing world needs a nursing system that can continue to evolve and accommodate the nuances of specific cultures. Different cultural influences affect one’s perception of caring, which shape the type and manner of nursing care within that population. As such, Leininger offers her theory of care, which not only takes into account the different cultural aspects that shape caring for different cultures, but Leininger, from her nursing and anthropological observations, was able to devise the universal aspects of care that exist in each specific culture. In keeping with this path, the nursing care model has expanded the direction of nursing practice to be more culturally sensitive, while also allowing it to be more unified in terms of a holistic concept of caring. Leininger is perceptive to point out that even nursing has its own cultural diversity between traditional values of caring and evolving ones. She is wise to express how imperative it is that nurses need to become aware of their own diversity and unity within the confines of their own professional culture.
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