Leininger’s Culture Care Theory

Continuing Education Article Madeleine Leininger’s Culture Care Theory: The Theory of Culture Care Diversity and Universality Jean Nelson, PhD, RN University of Missouri-St. Louis School of Nursing Program Goal To establish a knowledge base in culture care theory that will promote the administration of culturally competent nursing care for individuals, families, groups, and communities. Objectives Upon completion of the program the participant will: • Identify core concepts in Leininger’s culture care theory. • Explain basic elements and relationships portrayed in the sunrise model. • Describe basic steps in the ethnonursing research method and its importance in developing the theory base for transcultural nursing, • Apply principles of culture care theory to specific nursing care situations. Content Outline I. Overview of culture care theory A, Historical development B. Explanation of the sunrise model C. Assumptive premises of the theory D, Orientational definitions II. Ethnonursing research A, Basic elements of the ethnonursing method B, Research enablers and assessment guides C, Recurrent culture care constructs identified in ethnonursing studies III. Nursing care situations for analysis and application of culture care theory rv. Resources for future theory development and application The theory of culture care diversity and universality evolved through a synthesis of two central concepts: caring and culture. Leininger (1991a, 1995, 2002a) wrote that a personal conviction regarding caring as the essence of nursing developed during her early experiences as a nursing student and as a hospital staff nurse in the 1940s, an era in which compassionate care giving was taught by example in an environment devoid of the distractions associated with today’s complex healthcare technologies. In a later experience in the mid-1950s, employed as a psychiatric nurse specialist caring for children from diverse ethnic backgrounds, Leininger discovered that inadequate knowledge of cultural factors represented a missing link in her ability to provide care. She wrote that, “I experienced culture shock and I felt helpless to assist children who so clearly expressed different cultural patterns and ways they wanted care” (1991a, p. 14). The impact of this experience eventually led Leininger to pursue a doctoral degree in anthropology and to begin synthesizing the concepts of caring and culture (Leininger, 1970). Leininger’s Culture Care Theory

The new concept of culture care became the basis of a nursing theory (Leininger, 1978) directed toward provision of culturally sensitive care. Building on her knowledge of ethnography, the qualitative research method used in anthropology, Leininger (1985b) developed ethnonursing methodology as a tool for exploring transcultural nursing phenomena. On the basis offindingsfrom multiple ethnonursing studies Leininger (1991a, 1995) concluded that caring in some form was universally present in all of the cultures studied but that the specific manifestations and practices of caring were very different. As a result, her theory came to be called the theory of culture care diversity and universality or simply culture care theory. International Journal for Human Caring Leininger also developed the sunrise model to visually portray interacting elements of the theory (2002b, p. 80). The upper level of the sunrise model resembles a rising sun with rays representing the cultural and social structure dimensions of a culture care worldview.

The rays are also the basic elements of a cultural assessment. Convergence of the rays into a central core suggests that these interacting elements influence the unique care expressions and practices of individuals, families, groups, communities, and institutions.

The middle level of the sunrise model portrays nursing care as a circle, overlapped by two other circles representing generic (indigenous or emic) and professional (outsider or etic) care systems. The model suggests that decisions about and actions pertaining to nursing care should be based on integrated knowledge of generic and professional care systems.

The lower level of the sunrise model depicts three types of nursing strategies: culture care preservation, which emphasizes support of indigenous care practices; culture care accommodation, which involves synthesis of indigenous and professional care practices; and culture care repatteming, which means implementation of professional care with respect for indigenous beliefs and values. Deliberate planning and implementation of nursing strategies based on cultural assessment leads to the desired outcome of culturally congruent nursing care. Bidirectional arrows in all parts of the model are identified as influencers, suggesting that all components influence or are influenced by the others. In this respect, the sunrise model stands in sharp contrast to unidirectional, quantitative models. Leininger’s writings (1991a, 1995, 2002a) have consistently identified 13 assumptive premises as fundamental tenets of her theory. These include strong statements Madeleine Leininger^s Culture Care Theory about care/caring as the essence of nursing; the need for nurses to understand cultural differences as well as commonalities in beliefs, values, and practices of caring, and to use this knowledge in the provision of culturally based nursing care; and the need for ongoing qualitative research to develop and expand the knowledge base for culturally congruent care. In addition, Leininger has stated (1991a, 1995) and revised (2002b) definitions of key concepts that are central to the culture care theory. Concepts included in the revised list (2002b, pp. 83-84) include human care/caring, culture, culture care, culture care diversity, culture care universality, worldview, cultural and structural dimensions, environmental context, ethnohistory, emic, etic, health, transcultural nursing, culture care preservation and/or maintenance, culture care accommodation and/or negotiation, culture care repatteming and/or restructuring, and culturally competent nursing care. Leininger’s Culture Care Theory

The definitions are orientational, meaning broad enough to facilitate discovery of meanings in a qualitative paradigm, in comparison to operational definitions that facilitate quantitative measurement. Leininger made it very clear that her theory had been generated inductively in a mode of naturalistic inquiry and that she developed ethnonursing as a specific qualitative research method for theory development (1985a, 1985b, 1991b, 2002b).

Data collection in ethnonursing research is accomplished through participant observation and interviews with informants. Participant observation means being involved in the activities of a cultural group while simultaneously observing and making mental notes. The observations are subsequently documented in great detail in a field joumal. Informants are individuals who are willing and able to communicate cultural information to a researcher. Interviews are typically taped and then transcribed verbatim. The analysis of data in ethnonursing has four phases: 1. Collecting, describing, and documenting raw data. 2. Identification and categorization of descriptors and components. 3. Pattem and contextual analysis. 4. Major themes, research findings, theoretical formulations, and recommendations (2002b, p. 95). While quantitative researchers typically use measurement tools or instruments, Leininger consistently advocated that ethnonursing researchers need other devices to help them “tease out data bearing on culture care, health, and related nursing phenomena” and accordingly has developed five “enablers” (2002b, p. 89): • Leininger’s sunrise model (2002b, p. 80)—A comprehensive guide for ethnonursing research and a pictorial depiction of the theory of culture care diversity and universality, • Leininger’s ObservationParticipation-Refiection (OPR) Enabler (2002b, p,90)—Developed to help the researcher move gradually from an observer/active listener role, to roles with increasing levels of participation and eventually to a role involving primarily reflection and reconfirmation of findings with informants. • Leininger’s Stranger-to-TmstedFriend Enabler (2002b, p. 91)— Developed to assist the researcher or nurse clinician in self-assessment as he/she attempts to establish a trusting relationship with informants or clients. The presence of “trusted friend indicators” suggests that a favorable relationship has been established and that cultural data collected are authentic and credible. • Leininger’s Acculturation Health Care Assessment Enabler (2002c, p. 141)

—A guide for evaluating the degree of an informant’s orientation toward traditional or nontraditional beliefs, values, and practices • Domain of Inquiry (DOI) Enabler— A statement developed by the individual ethnonurse researcher, indicating the specific focus of study within the broader domain of culture care and health. In a review of research conducted by expert transcultural nurses in about 100 Westem and non-Westem cultures over a period of 5 decades, McFarland (2002) identified “recurrent and dominant universal culture care constructs” (p. 107) and listed these in rank order: 1. Respect for/about 2. Concem for/about 3. Attention to (details)/in anticipation of 4. Helping/assisting or facilitative acts 5. Active listening 6. Presence (being physically there)

7. Understanding (beliefs, values, lifeways, environmental context) 8. Connectedness 9. Protection (gender related) 10. Touching 11. Comfort measures McFarland (2002, p. 111) also noted the existence of a culture care theory group (CCTG), an on-line discussion group open to all nurses interested in newfindingsrelevant to Leininger’s theory. The site listed for potential members to contact is webmaster@tens.org. While full-scale research on the culture care theory is based on the sunrise model, Leininger also developed an altemative Short Culturological Assessment Guide (2002c, p. 129) useful in situations where time constraints and other limitations make it impractical for the nurse to do an in-depth assessment. Briefly summarized, the Short Culturological Assessment hasfivesteps or phases: 1. Recording observations. 2. Listening to/learning from the client about cultural values, beliefs, and practices. 3. Identifying and documenting recurrent pattems and narratives with client meanings. 4. Synthesizing expressed themes and pattems of care. 5. Developing a culturally based plan of care. The following anecdotes, all based on the author’s own professional experiences, describe situations in which the integration of generic and professional care practices represented a challenge for the nurse. The reader is encouraged to use the culture care theory as a basis for evaluating the nurses’ actions in each case. Case 1: Mrs. S was an elderly retired nurse of German-American descent. She grew up in a mral community with a strong German heritage where the value of cleanliness was especially emphasized and, as a nursing student in the 1940s, she was taught the importance of the bed bath as the epitome of good nursing care.

Hospitalized many times in the course of a chronic illness, she found that her nurses wanted to increase her self-care skills and to that end placed her in a chair in the bathroom with instructions to bathe at the sink. Mrs. S 2006, Vol. 10, No. 4 Madeleine Leininger^s Culture Care Theory found this awkward, embarrassing, and an ineffective way to get clean. She longed for an old-fashioned nurse who would give her a bed bath, soak her feet, and rub her back with lotion. Case 2: Mr, B, an African-American client on a psychiatric ward, had long hair styled in traditional dreadlocks. He told his primary nurse that he was a Rastafarian, that his locks were important to him because they helped him conimunicate with God, and that he was upset because someone had cut one of his locks off without his knowledge or permission. The nurse inspected the client’s head and noted that one of the locks had apparently been cut off. Based on his statement that he was upset because the dreadlocks helped him communicate with God, the nurse charted that Mr. B was experiencing delusions. Case 3: Mr, T was a VietnameseAmerican client hospitalized on a psychiatric unit with bipolar affective disorder. He responded well to medications and, as his discharge day approached, he told his nurse that he planned to continue taking his medications as ordered and to keep his appointments for follow-up care at the psychiatric clinic. Then he added: You know, this probably sounds crazy but in my home country people believe that illness can be caused by sins committed in a previous life, A person with this kind of sickness wouldn’t go to a hospital – he would go to a Buddhist temple and pray for forgiveness. And the funny thing is, when people say these prayers in the temple they get better. The nurse told the treatment team that the client apparently did not understand the biological basis of mental illness and needed more teaching on this topic before he could be discharged. Case 4: Miss K, an English-American and practicing Christian Scientist, was hospitalized on a medical-stirgical floor with a seriously infected spider bite. Surgical incision and drainage of the abscess left a huge open cavity that required repacking with wet-to-dry dressings every 4 hours. As the nurse prepared to do the first post-operative dressing change, she informed the padent that the procedure would be painful and that she would administer medication first as ordered by the doctor. The patient replied, ‘Thank you, but I don’t feel pain and I don’t want any medication,” Although puzzled by the patient’s statement, the nurse deferred giving an analgesic and proceeded with the dressing change while continuing to observe for non-verbal indicators of pain. She was surprised to note that the patient appeared very relaxed during the procedure, actually joking with the nurse and engaging in other casual conversation. Leininger’s Culture Care Theory

The nurse completed the dressing change and informed the patient that medication was available if she needed it later. Case 5: In a study of two communitybased adult day care centers with predominantly African-American clients (Nelson, 2001,2002) the researcher noted that nurse managers at the centers were very aware of kinship; social, spiritual, and cultural beliefs; and practices of importance to clients and their families. With the assistance of ancillary staff members and volunteers, the nurse managers were able to use this cultural knowledge to plan and implement meaningful programs that promoted the development of caring communities in the centers. Any nurse can apply basic principles of the culture care theory by being aware and sensitive to clients’ cultural beliefs, values, and practices and by incorporating indigenous care practices into the plan of care as much as possible. Full application of culture care theory goes beyond culturally sensitive care, and requires extensive, ongoing ethnonursing research with dissemination and implementation offindingsand evaluation of outcomes, A valuable resource is the Transcultural Nursing Society, established by Leininger (2002a) in the early 1970s as the official transcultural nursing organization. In 1989 the society initiated a process of certifying transcultural nurses and in the same year the Joumal of Transcultural Nursing began publication with Leininger as its first editor, A recent important development is the opening of the Worldwide Leininger’s Culture Care Theory Transcultural Nursing Society Office at Madonna University in Lavonia, Michigan, in 2001, Leininger’s theory of culture care diversity and universality has had an enormous impact on nursing practice and the opportunities for continuing applications in the 21st century are endless. Please refer to the test items and test form to apply for continuing education units (CEUs) from the Intemationai Association for Human Caring, International Journal for Human Caring References Leininger, M,M, (1970), Nursing andanthropology: Two worlds to blend. New York: Wiley, Leininger, M,M, (1978), Transcultural nursing: Concepts, theories, & practices. New York: Wiley, Leininger, M,M, (1985a), Nature, rationale, and importance of qualitative research methods in nursing. In M,M, Leininger (Ed,), Qualitative research methods in nursing (pp. 1-25). Orlando, FL: Grune & Stratton, Leininger, M,M, (1985b), Ethnography and Leininger’s Culture Care Theory ethnonuursing: Models and modes of qualitative data analysis. In M,M, Leininger (Ed,), Qualitative research methods in nursing (pp. 33-71). Orlando, FL: Gmne & Stratton. leininger, M.M, (1991a). The theory of culture care diversity and universality. In M,M, Leininger (Ed,), Culture care diversity and universality: A theory of nursing (pp. 5-68). New York: National League for Nursing, Leininger, M,M, (1991b), Ethnonursing: A research method with enablers to study the theory of culture care. In M.M, Leininger (Ed), Culture care diversity and universality: A theory of nursing (pp, 73-117), New York: National League for Nursing. Leininger, M.M, (1995), Overview of txininger’s culture care theory. In M.M, Leininger (Ed.), Transcultural nursing: Concepts, theories, & practices (2nd ed.) (pp. 93-111). St. Louis, MO: McGraw-Hill. Leininger, M. (2002a). Transcultural nursing and globalization of health care: Importance, focus, and historical aspects. In. M. Leininger & M.R. McFarland (Eds.), Transcultural nursing: Concepts, theories, research & practice (3rd ed.) (pp, 3-43), New York: McGraw-Hill, Leininger, M, (2002b), The theory of culture care and the ethnonursing research method. In M. Leininger & M.R. McFarland (Eds.), Transcultural nursing: Concepts, theories, research & practice (3rd ed.) (pp. 71-98). New York: McGraw-Hill, Leininger, M, (2002c), Culture care assessments for congruent competency practices. In M, Leininger & M,R. McFarland (Eds.), Transcultural nurs- Madeleine Leininger’s Culture Care Theory ing: Concepts, theories, research & practice (3rd ed.) (pp. 117-143). New York: McGraw-Hill. McFarland, M.R. (2002). Selected research findings from the culture care theory. In M. Leininger & M.R, McFarland (Eds.), Transcultural nursing: Concepts, theories, research & practice (3rd ed.) (pp. 99-116), New York: McGraw-Hill. Nelson, J. (2001). Leininger’s Culture Care Theory

Factors influencing care expressions, pattems, and practices in adult day care. Unpublished doctoral dissertation, Barnes College of Nursing and Health Studies, University of Missouri-St, Louis. Nelson, J. (2002). Spiritual expressions in the caring environment of adult day care centers. ABNF {Association of Black Nurse Faculty) Joumal, 13(6), 136-139. Test Select one best response for each item. 1. Which of the following is a central idea in Leininger’s theory that distin guishes it from other caring theories in nursing? a. Caring as the essence of nursing b. Health as expanding conscious ness c. Nursing as self-care of another self d. Culture as the missing link in caring 2 Leininger’s early work as a nursing theorist incorporated concepts from which other academic discipline? a. Anthropology b. Sociology c. Psychology d. Philosophy 3. Which research method was developed by Leininger as a specific tool for exploring transcultural nursing phe nomena? a. Ethnography b. Ethnonursing c. Grounded theory d. Phenomenology 4. Which of the following elements are portrayed by the rays of the sun in Leininger’s sunrise model? a. Dimensions of a culture care world view b. Individual, family, group, and community systems c. Person-environment interactions d. Dimensions of nursing diagnosis and care 5. Leininger’s theory suggests that deci sions about and actions pertaining to nursing care be based on which of the following? a. Evidence-based professional nursing care systems b. Indigenous care beliefs and prac tices of patients and families c. Integration of indigenous and profes sional care systems d. Interdiscip … Leininger’s Culture Care Theory