CULTURE CARE THEORY OF DIVERSITY AND UNIVERSALITY

BY MADELEINE LEININGER

(July 13, 1925 - Present)

Major Concepts and Definitions

Human Care and Caring- The concept of human care and caring refers to the

abstract and manifest phenomena with expressions of assistive, supportive, enabling and facilitating ways to help self or others with evident or anticipated needs to improve health, a human condition, or a lifeway, or to face disabilities or dying.

Culture- Culture refers to patterned lifeways, values, beliefs, norms,

symbols, and practices of individuals, groups, or institutions that are learned, shared, and usually transmitted from one generation to another.

Culture Care- Culture care refers to the synthesized and culturally

constituted assistive, supportive, enabling or facilitative caring acts toward self or others focused on evident or anticipated needs for the client’s health or well-being, or to face disabilities, death, or other human conditions.

Culture Care Diversity- Culture care diversity refers to cultural variability or

differences in care beliefs, meanings, patterns, values, symbols, and lifeways within and between cultures and human beings.

Culture Care Universality- Culture care Universality refers to commonalities or similar

culturally based care meanings (“truths”), patterns, values, symbols, and lifeways reflecting care as a universal humanity.

Worldview- Worldview refers to the way an individual or group looks

out on and understands the world about them as a value, stance, picture, or perspective about life and the world.

Cultural and Social Structure Dimensions- Cultural and social structure dimensions refer to the

dynamic, holistic, and interrelated patterns of structured features of a culture (or subculture), including religion (or spirituality), kinship (social), political characteristics (legal), economics, education, technology, cultural values, philosophy, history, and language.

Environmental Context- Environmental context refers to the totality of an

environment (physical, geographic, and sociocultural), situation, or event with related experiences that give

interpretative meanings to guide human expressions and decisions with reference to a particular environment or situation.

Ethnohistory- Ethnohistory refers to the sequence of facts, events, or

developments over time as known, witnessed, or documented about a designated people of a culture.

Emic- Emic refers to the local, indigenous, or insider’s views and

values about a phenomenon.

Etic- Etic refers to the outsider’s or more universal views and

values about a phenomenon.

Health- Health refers to a state of well-being or restorative state

that is culturally constituted, defined, valued, and practiced by individuals or groups that enables them to function in their daily lives.

Transcultural Nursing- Transcultural nursing refers to a formal area of humanistic

and scientific knowledge and practices focused on holistic culture care (caring) phenomena and competencies to assist individuals or group to maintain or regain their health (or well-being) and to deal with disabilities, dying, or other human conditions in culturally congruent and beneficial ways.

Culture Care Preservation or Maintenance- Culture care preservation or maintenance refers to those

assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a particular culture to retain or maintain meaningful care values and lifeways for their well-being, to recover from illness, or to deal with handicaps or dying.

Culture Care Accommodation or Negotiation- Culture care accommodation or negotiation refers to those

assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a designated culture (or subculture) to adapt to or to negotiate with

others for meaningful, beneficial, and congruent health outcomes.

Culture Care Repatterning or Restructuring- Culture care repatterning or restructuring refers to the

assistive, supportive facilitative, or enabling professional actions and decisions that help clients reorder, change, or modify their lifeways for new, different, and beneficial health outcomes.

Culturally Competent Nursing Care- Culturally competent nursing care refers to the explicit use

of culturally based care and health knowledge in sensitive, creative and meaningful ways to fit the general lifeways and needs of individuals or groups for beneficial and meaningful health and well-being or to face illness, disabilities, or death.

Major Assumptions

Major assumptions to support Leininger’s Culture Care Theory of Diversity and Universality follow. The definitions were derived from Leininger’s definitive works on the theory.

1. Care is the essence of nursing and a distinct, dominant, central, and unifying focus.

2. Culturally based care (caring) is essential for well-being, health, growth and survival, and to face handicaps or death.

3. Culturally based care is the most comprehensive and holistic means to know, explain, interpret, and predict nursing care phenomena and to guide nursing decisions and actions.

4. Trancultural nursing is a humanistic and scientific care discipline and profession with the central purpose to serve individuals, groups, communities, societies, and institutions.

5. Culturally based caring is essential to curing and healing, for there can be no curing without caring, but caring can exist without curing.

6. Culture care concepts, meanings, expressions, patterns, processes, and structural forms of care vary transculturally with diversities (differences) and some universalities (commonalities).

7. Every Human culture has generic (lay, folk, or indigenous) care knowledge and practices and usually professional care knowledge and practices, which vary transculturally and individually.

8. 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 context of cultures.

9. Beneficial, healthy, and satisfying culturally based care influences the health and well-being of individuals, families, groups, and communities within their environmental contexts.

10. Culturally congruent and beneficial nursing care can occur only when care values, expressions, or patterns are known and used explicitly for appropriate, safe, and meaningful care.

11. Culture care differences and similarities exist between professional and client-generic care in human cultures worldwide.

12. Cultural conflicts, cultural impositions practices, cultural stresses, and cultural pain reflect the lack of culture care knowledge to provide culturally congruent, responsible, safe, and sensitive care.

13. The ethnonursing qualitative research method provides an important means to accurately discover and interpret emic and etic embedded, complex, and diverse culture care data.

The universality of care reveals the common nature of human beings and humanity, whereas diversity of care reveals the variability and selected, unique features of human beings.

Theoretical Assertions

Tenets are the position one holds or are givens that the theorist uses with a theory. In developing the theory, the following four major tenets were conceptualized and formulated with the Theory of Culture Care:

1. Culture care expressions, meaning, patterns, and practices are diverse, and yet there are shared commonalities and some universal attributes.

2. The worldview consists of multiple social structure factors, such as religion, economics, cultural values, ethnohistory, environmental context, language, and generic and professional care, that are critical influencers of cultural care patterns to predict health, well-being, illness, healing, and ways people face disabilities and death.

3. Generic emic (folk) and professional etic care in different environmental contexts can greatly influence health and illness outcomes.

4. From an analysis of the previously listed influencers, three major actions and decision guides were predicted to provide ways to give culturally congruent, safe, and meaningful health care to cultures. The three culturally based action and

decision modes were the following: (1) culture care preservation or maintenance, (2) culture care accommodation or negotiation, and (3) culture care repatterning or restructuring. Decision and action modes based on culture care were predicted as key factors to arrive at congruent, safe, and meaningful care.

In conceptualizing the theory, the first major and central theoretical Tenet was, “care diversities (differences) and universalities (commonalities) existed among and between cultures in the world”. However, Leininger asserted that culture care meanings and uses had to be discovered to establish a body of transcultural knowledge. A second major theoretical tenet was “[that the] worldview, social structure factors such as religion, economics, education, technology, politics, kinship (social), ethnohistory, environment, language, and generic and professional care factors would greatly influence culture care meanings, expressions, and patterns in different cultures”.

Leininger has maintained that these factors needed to be documented in order to provide meaningful and satisfying care to people and are predicted to be powerful influencers on culturally based care. These factors also needed to be discovered directly from the informants as influencing factors related to health, well-being, illness, and death. The third major theoretical tenet was, “both generic (emic) and professional (etic) care needs to be taught, researched, and brought together into care practices for satisfying care for clients which lead to their health and wellbeing”.

The fourth majot theoretical tenet was the conceptualization of the “three major care actions and decisions, to arrive at culturally congruent care for the general health and wellbeing of clients, or to help them face death or disabilities”. These modes are culture care preservation or maintenance; culture care accommodation, negotiation; and culture care repatterning or restructuring. The researcher draws upon findings from the social structure, generic and professional practices, and other influencing factors while studying culturally based care for individuals, families, and groups. These factors would need to be studied, assessed and responded to in a dynamic and participatory nurse-client relationship.

Nursing Paradigm of the Theory

1. Human BeingsHuman beings are best represented in her assumptions.

Humans are believed to be caring and to be capable of being concerned about the needs, well-being and survival of others. Human care is universal, that is, seen in all cultures. Humans

have survived within cultures and through place and time because they have been able to care for infants, children and the elderly in a variety of ways and in many different environments. Thus, humans are universally caring beings who survive in a diversity of cultures through their ability to provide the universality of care in a variety of ways according to differing cultures, needs and settings.

2. HealthLeininger define health as “a state of well-being that is

culturally defined, valued, and practiced and which reflects the ability of individuals (or groups) to perform their daily role activities in culturally expressed, beneficial and patterned lifeways”. It is an important concept in transcultural nursing because the emphasis is on the need for the nurses to have knowledge that is specific to the culture in which nursing is being practiced. It is presumed that health that health is viewed as being universal across cultures but defined within each culture in a manner that reflects the beliefs, values and practices of that particular culture. Thus health is both universal and diverse.

3. Society/ EnvironmentAre not terms that are defined by Leininger, she speaks

instead of worldview, social structure and environmental context. Although Leininger does not use the specific terms of society or environment, the concept of culture is closely related to society or environment and is a central theme of her theory.

Limitations of the Theory

Some limitations, as identified by Leininger (1991), include the limited number of graduate nurses who are academically prepared to conduct the investigations needed to provide transcultural nursing care. An associated concern is that too few nursing programs include courses and planned learning experiences that provide a knowledge base for transcultural nursing practice. While there has been some increase in the number of nurses prepared in transcultural nursing, it is important to note the danger of cultural biases and cultural imposition occurring with nurses’ personal cultural values. There is also a need for research funds to support continued study of caring practices—both those that are universal and those that are particular to a culture. Leininger identifies that the three greatest continuing needs are for education of nurses to practice transcultural nursing, to use the existing findings from transcultural nursing research and to continue research to develop

new knowledge and reaffirm credible findings in a continually changing world.

It is interesting to note that, in spite of Leininger’s emphasis on the importance of avoiding cultural imposition and cultural shock, Domenig (1999) expresses concern that Leininger does not make interaction the main object of her theory and that nurses need to be encouraged to analyze their own cultural backgrounds. It would be difficult to identify how Leininger could have put greater emphasis on the importance of these aspects.

In some of her writings, Leininger is not consistent in her terminology. For example, in Transcultural Nursing (1979), she refers to ethnocultural care constructs and then to ethnonursing care constructs. In her theory presentation she refers to these same constructs as major cultural care constructs. Since the constructs are listed it is relatively easy to be aware that these terms all refer to the same constructs. However, the reader’s mental energy could be conserved for understanding the theory and model if the terminology were more consistent.

The complexity of the Sunrise Model can be viewed as both a strength and a limitation. The complexity is a strength in that it emphasizes the importance of the inclusion of anthropological and cultural concepts in nursing education and practice. On the other hand, the complexity can lead to misinterpretation or rejection, both of which are limitations.

Application of Theory of a Case Study

Sample schematic diagram of a study:“Arab Muslim Nurses’ Experiences Of The Meaning of Caring”

Leininger’s Short Culturalogic Assessment Guide

Phase I : Record observations of what you see, hear or experience with clients (includes dress and appearance, body condition

features, language, mannerisms and general behaviour, attitudes and cultural features).

Phase II : Listen to and learn from the client about cultural values, beliefs, and daily (nightly) practices related to care and health in the client’s environmental context. Give attention to generic (home or folk) practices and professional nursing practices.

Phase III : Identify and document recurrent client patterns and narratives (stories) with client meanings of what has been seen, heard or experienced.

Phase IV : Synthesize themes and patterns of care derived from the information obtained in phases I, II and III.

Phase V : Develop a culturally based client-nurse care plan as a coparticipation for decisions and actions for cultural congruent care.

Bibliography

1. Nursing Theories and Their Work (6th edition)by Ann Marriner Tomey and Martha Raile Alligood

2. Nursing Theories: The Base for Professional Nursing Practice (Fifth Edition)by Julia B. George, RN, PHD

3. http://ses.library.usyd.edu.au/bitstream/2123/3764/1/sr_lovering_2008_thesis.pdf