MADELEINE LEININGER

Culture Care Theory ofDiversity and Universality

By Molly Bach-Bullen

Who is Madeleine Leininger?

Madeleine Leininger, a nurse scientist and anthropologist, has developed the Cultural Care Diversity and Universality theory over the past three decades.  She developed this theory in response to her growing conviction that culture dictates the way that individuals should receive care, based on the different ways that cultures meet their basic needs and respond to human interaction (Leininger, 1991).

Transcultural Nursing

According to her theory "Cultural care involves those facets of culture that deal with individual and group health and well being, including efforts to improve upon the human condition or to deal with illness, handicaps, or death"  (Frisch & Frisch, 1998). 

Leininger (1991) theorized that every culture had access to some form of folk or indigenous health care system and that some, but not all, had access to a professional health care system.

She saw the urgent need for transcultural nursing in the mid 1950's.  She also felt that transcultural nursing was an essential nursing and healthcare need worldwide. 

Transcultural Nursing

Transcultural nursing was defined as "a humanistic and scientific area of formal study and practice in nursing which is focused upon differences and similarities among cultures with respect to human care, health, and illness based upon the people's cultural values, beliefs, and practices, and to use this knowledge to provide cultural specific or culturally congruent nursing care to people"  (Fernandez, 1997-2001). 

Essentially, transcultural nursing has focused on understanding cultures and their specific care needs and how to provide care that fits their lifeways rather than assuming professional nurses always know what is best for them (Leininger, 1998).Essentially, transcultural nursing has focused on

understanding cultures and their specific care needs and how to provide care that fits their life-ways rather than assuming professional nurses always know what is best for them (Leininger, 1998).

Throughout history, America has been called a

melting pot-a place that draws people from all cultures to

live and thrive together. What most cultures

hope, however, is that in that pot, they are able to

maintain the flavors that make them so unique.

Sunrise Enabler

Leininger developed the Sunrise Enabler in the 1970’s to depict the essential components of the theory.

The upper half of the circle depicts components of the social structure and worldview factors that influence care and health through language, *ethnohistory and environmental context.

These factors influence the folk, professional and nursing systems (middle part of model).

Together, the two halves form a sun, which represents the universe that nurses must consider to appreciate human care and health.

*Ethnohistory refers to the sequence of facts, events, or developments over time as known, witnessed, or documented about a designated people of a culture.

Sunrise Model

Leininger has formulated several theoretical assumptions and orientational definitions to guide nurses in their discovery of culture care phenomena.

The assumptions and definitions are derived from the theoretical conceptualizations and philosophical positions of the Culture Care Theory, and they are used as guides to systematic study of the theory.

Theoretical Assumptions

care (caring) is essential to curing and healing, for there can be no curing without caring

every human culture has lay (generic, folk or indigenous) care knowledge and practices and usually some professional care knowledge and practices, which vary trans-culturally

culture care values, beliefs, and practices are influenced by and tend to be embedded in the worldview, language, philosophy, religion (and spirituality), kinship, social, political, legal, educational, economic, technological ethnohistorical, and environmental contexts of cultures

a client who experiences nursing care that fails to be reasonably congruent with his/her beliefs, values, and caring life-ways will show signs of cultural conflict, noncompliance, stress and ethical or moral concern

the qualitative paradigm provides ways of knowing and discovering the epistemic and ontological dimensions of human care transculturally

When establishing transcultural nursing more then four decades ago, Leininger (1998) held that "Care is the heart of nursing; Care is power; Care is essential to healing (or well-being); Care is curing; and Care is (or should be) the central and dominant focus of nursing and transcultural  nursing decisions and actions". 

Health Beliefs & Practices

When healthcare personnel work with the patient's beliefs, rather than against them, the outcomes are usually more successful, measured not only in patient satisfaction but also in ease for the medical team in managing the patient and family

Be aware that beliefs may influence the way a patient responds to health, illness and death

Communication and understanding lead to improved diagnoses and treatment plans, and the improved patient satisfaction leads to greater compliance with those plans.

Cultural awareness is an integral part of today's multicultural society. It is beneficial for the nursing staff and medical residents

to be aware of the aspects of different cultures.

Leininger has paved the way for the education of nurses, like Marilyn McFarland, interested in addressing the cultural needs of their patients as a way of providing them with comprehensive health care. McFarland, who co-wrote her book with Leininger, feels that cultural care should be a concern of all nurses. "It's very important for nurses to really find out about people's traditions, life ways and beliefs about health care, so they can honor them and combine them with professional care," she said.

The ethnonursing study by McFarland that covered 2 years starting in the late 1980’s compared Anglo-American and African-American groups living in a residence home for the elderly.

Did you know that 12.9% of the population in the US is African-American? And 14% in MI?

Clinical Application ofTheory to Practice

McFarland’s culturally congruent care findings were as follows:

Anglo-American and African-American elderly expect culture care & preservation & maintenance of their lifelong generic or folk care patterns

Doing for other residents rather than having a self-care focus was a major care maintenance value for both cultures & was a dominant finding

Protective care was more important to African-American than Anglo-American elders, but nursing staff provided protective care and practiced culture care accommodation for both groups of elders

In addition:

Faith or spirituality can play a major role in the life & death of African-Americans

A dying African-American patient or family member may request the presence of a spiritual leader at the bedside

Many African-Americans & their friends may have a desire to mourn together at the death of a loved one

A reason some are resistant to completing written advanced directives is historical mistreatment, and mistrust of the medical system

AmishHealth Care

BeliefsAnd

Practices

Leininger’s Culture Care Theory of Diversity can be applied to the distinct Amish civilization

The Amish believe all life is given and taken by God and their beliefs tell them to accept God's will as it is.

The Amish prefer to give birth at home and to die at home. The elderly believe in rationing care near the end of life because they do not want to waste the community's/church's money.

Disability is generally feared more than death.  If treatment is refused by the Amish patient, be sure to thoroughly educate him/her if disability from his/her illness is a potential possibility.

Amish couples are usually not deterred from having more children when they have a child with a heredity defect.  A child with disabilities is referred to as a special child and is accepted as God's will.

Amish Health Care Beliefs and Practices

Continued…

The Amish do not forbid the use of modern medical care.  If deemed necessary, they can have surgical procedures, dental work, anesthesia and blood transfusions.

Organ transplants are permitted with the exception of heart transplants (the heart is the soul of the body).

They usually do not have health insurance as it is a "worldly product" and may show a lack of faith in God.

Most Amish need to have church (bishop, community) permission to be hospitalized, as it is the community who will come together to help pay the costs. The Amish generally do not like to be seen by a health care provider who is in the "learning process".  The Amish believe if they are going to pay out-of-pocket for their care, they want to be seen by an experienced practicing provider.

Speak to both the husband and wife regarding health care decisions; they consider themselves as partners in family life.

Evaluation Methods

The transcultural nursing theory is researchable, and qualitative research has been the primary paradigm to discover largely unknown phenomena of care and health in diverse cultures.

This qualitative approach differs from the traditional quantitative research method, which renders measurement the goal of research.

The accuracy of grounded data is leading to high credibility, confirmability and a wealth of empirical data.

Transcultural nursing knowledge that has been established over the past decade had had a great impact on nursing

Making Quality Cultural

Care Universa

l

Initiatives have been created to address cultural differences in all health care arenas. The term "cultural competence" is now used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to describe the strategies used by health care providers to accommodate cultural differences while also providing quality health care to an increasingly diverse population. JCAHO policies have been made to encourage cultural competency in all health care institutions.

As a premier theory in nursing, culture care is greatly valued worldwide

Nurses who use the theory and method frequently communicate how valuable and important it is to discover culturally based ways to know and practice nursing and health care

Practicing nurses now have holistic, culturally based research findings for use in caring for clients of diverse and similar cultures or subcultures in different countries

Nurses often express that this theory and method are the only ones that it makes sense to use in nursing

In Conclusion…

Unquestionably, it is the theory of today and tomorrow and one which will grow in use in the future in our

growing and increasingly multicultural world

ReferencesAndrews, J.D. (2005). African Americans. Cultural, Ethnic, and Religious Reference Manual for Health Care Providers. (3rd edition). Winston-Salem, NC.: JAMARDA Resources, Inc. Retrieved March 16, 2009, from http://www.med.umich.edu/multicultural/ccp/mhg.htm.

Fernandez, V. RN & Fernandez, K.  RN. (1997-2001). Transcultural Nursing: Basic Concepts & Case Studies. Retrieved March 16, 2009, from http://www.geocities.com/ninquiry2002/madeleineleininger.html.

Frisch, N.C. & Frisch L.E. (1998). Psychiatric Mental Health Nursing. Toronto: Delmar Publishers. Retrieved March 18, 2009, from http://www.geocities.com/ninquiry2002/madeleineleininger.html.

Lee, D. (2005). Our Amish Neighbors: Providing Culturally Competent Care Multicultural Health Series. Videotape and handout available from the UMHS, PMCH, Cultural Competency Division. Retrieved March 16, 2009, from http://www.med.umich.edu/multicultural/ccp/mhg.htm.

Leininger, M.M. (1991). Culture Care Diversity & Universality: A theory of Nursing. New York: National League for Nursing Press. Retrieved March 16, 2009, from

http://www.geocities.com/ninquiry2002/madeleineleininger.html.

Tomey, A., & Alligood, M.(2006). Nursing Theorists and Their Work (6th ed). St. Louis, Missouri: Mosby.