Madelaine m. leninger theory of cultural care diversity and

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Read Chapter 22 in Alligood (2022). 

Describe some difficulties you have experienced with patients you think are related to cultural differences.  

Read Chapter 22 in Alligood (2022).

Describe some difficulties you have experienced with patients you think are related to cultural differences. 

What strategies can you use to support cultural sensitivity in your practice? 

How has Leininger’s theoretical perspective influenced professional nursing practice? 

Reference your posts in APA format and be sure to answer all questions posed in narrative form. Please use Rubic

Reference

Alligood, M.R. (2022). Nursing theorists and their work (10th ed.).  Elsevier.

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Total Points: 100

22
Vadeleine M. Leininger:

Theory

Or Culture Care Diversity
and

Universality Madeleine M. Leininger
(1927-2012)

Marilyn R. McFarland*

are is the essence of nursing and a distinct,
dominant, central

and unijying focus.

Madeleine Leininger (Leininger
&McFarland, 2002, p. 192)

CREDENTIALS AND BACKGROUND
nursing at this university’ Vith the Therapeutic
n Psychiatri Nursing Center at their hospital. In 1960, she

bte one oi
OF THE THEORIST

g ent
was pub-

in Nursing, which
lished in 11 languages (Hofling & Leininger, 19601

the first basic psychiatric irsing texts with Hofli

tled Basic Psychiatric Concepts
Madeleine M. Leininger, the founder of transcultural

nurs-

ing and a leader in transcultural nursing
and human care

theory, was the first professional nurse with graduate preP-
aration in nursing to hold a PhD in

cultural and social

anthropology. She was born in Sutton, Nebraska, begin-

ning her nursing career after graduation from
St. Anth0

ny’s School of Nursing in Denver, Colorado,
and the U.s.

Army Nurse Corps with a diploma in nursing.
In 1950, she

earned a bachelor’s degree in biological science from
Bene-

dictine College in Atchison, Kansas, with a minor in phi-

losophy and humanistic studies. She then served
as an

instructor, staff nurse, and head nurse on a medical-surgi

cal unit and opened a new psychiatric unit while
director

of the nursing service at St. Joseph’s Hospital
in Omaha,

Nebraska.

While working at a child guldance honme in the .

staf
1950s in Cincinnati, Leininger discovered that ths
lacked understanding ot cultural factors influencia ng the behavior of children. Among these children of diverse cul
tural backgrounds. she observed difterences in responses
to care and psychiatric treatments that deeplycon concerned

her. Psychoanalytical theories and therapy strategies d
not seem to reach children who were from diverse cultund

backgrounds. She became inereasingly concerned that her
nursing decisions and actions, and those of other staf, did
not appear to help these clhildren. .eininger posed ques.

tions to herself and the st.afl about cultural differences

among children and therapy outcomes. She found few staf
members who were interested or knowledgeable abou

cultural factors in the diagnosis and Ireatment of clients. A
short time later, Margaret Mead became a visiting proles

sor in the Department of Psychiatry, University of Cincin
nati, and Leininger discussed with Mead the potental

interrelationships between nursing and anthropol0gy

During the 1950s and 1960s, Leininger (1970, 1978) tden
tihed common areas of theory interests and researcn u

between the disciplines of nursing and anthropolog), w

aided her in formulating
transcultural nursing concep

theory, principles, and practices. As a doctoral
student, Le

In 1954, Leininger obtained her master’s degree in psy-

chiatric nursing from the Catholic University of
America

in Washington, DC, and was then employed by the College

of Health at the University of Cincinnati, Ohio, where she

developed the first masters-level clinical specialist pro-

gram in child psychiatric nursing.
She initiated and

directed the first graduate nursing program in psychiatric

*This chapter is dedicated in memory of Dr. Madeleine Leininger.

Dr. Madeleine Leininger on a visit to Madonna University, Livonia,

MI, circa 1999. Source: The Madeleine M. Leininger Collection on
Human Caring and Transcultural Nursing, ARC-008, Photo 03, Ar-
chives of Caring in Nursing, Florida Atlantic University, Boca Raton.

fasc

nger studied many cultures. She found anthropolog
terest to

nating and believed it was an area that should
be Or Inc

334

adeleine M. Leininger: Theory of Culture Care Diversity and Universaity
CHA

ER 22 Made 335

on the iadsup people ot the astern nternational Society tor lluman Caring in 1978 0 hely
nirses toeus on the study ot human care plhenea
Leininger. 1988a, 19ssh, 199), She was the tiust tull tine
president ot the American Association ot Colleges ot Nins

ng and one of the tirst members ot the American Acaley
ot Nursing in 1975.

New Gunnea:

living alone with these ndige

th vears, she undertook an ethno
She

to
tUsCNÍ

on
the (

irsing study in the villages (leininger

hserved the unique teatures of the cl

lber ot nmarked
ditterences between 1West.

in tern cultures
related to caring. health, and

i es. Fron her in-depth
study and tirst

the iadsup. she continued to

einger’s book, Nursing and Anthropologr: Tvo
Worlhis

to Blend (1970), laid the toundation for developing the fiell
of transculural ursing. the culture care theory, and eu
turally based health care. Her next book, Tanseultra
s: Concepts, Theories. and Practice (1978), icdentilied
major concepts. theoretical ideas. and practices in transe
tural nursing and was the first detinitive publication on

transcultural ursing. During tlhe next o0 years. Leininger
established, explicated. and used the culture care theory lo
study many eultures in the United States and worldwide.
She developed the ethnonursing research method to lit an
to be used with the theory and to qualitatively discover the

insider or emie view of cultures (1cininger. 1991: 1cininger
&Metarland, 2002, 2006: Mctarland & Wehbe Alamah.
2015b, 201isb). lhe ethnonursing research method was the

frst open inquiry research method designed tor nurse

researchers to study and discover culture care phenomena

from the perspective of human science philosophy an
through the lens of qualitative analysis (Leininger, 1978.
1985a. 1991, 1995; Leininger & Meliarland. 2002, 2000;
Mclarland &Wehbe-Alamah, 2015b, 2018b).

ricnces with

er
theory

ot
culture

are
theory)

and the.

re care diversity and universality

ethnonursing researeh method

1978
1991. 1995 Her esearrh

and theory have
ditferences i

ursing

ents
understand cultural

ealth, and illness. Sh was the major

iet to
endOUrAge

Nnim ients and taculty to0
education nd practice. Her

Ndder to

Tute nursins

interest in developiung
the tield ot transeul

a human care
tocus sustained her tor

arsing with

than six decades.

in transeultural nursing was ottered in

the l’niversity
ot Color. where leininger had

amointed Protessor
ot Nursing and Anthropology.

he
turst

course
in

itiatei the
Commi on Nursing and Anthropology

the American AnthropologUal
Association in 1968

ed as its chair tor
several vears (Leininger, 1991,

Leininger also
initated and served as the director of

st Nurse
Scientist Program (PhD) in the United

s when.
in 1969, she was appointed Dean and Profes-

T o Nursing and
Lecturer in Anthropology at the Uni-

NiY of Washington, Seattle,
where she remained until

There she established the first academic nursing

nartment on comparative nursing care systems to sup-

urt master’s and doctoral programs in transcultural
nurs-

ng She initiated several transcultural nursing courses and
nentored the first nurses in a PhD program with a tocus

m transcultural nursing. Under her leadership, the Uni-

Ersity of Washington was recognized in 1973 as the out-
Sanding public institutional school of nursing in the
nited States.

ln 1981, Leininger was appointed Protessor ot Nursing

and Adjunct Protessor of Anthropology and Director of
Transcultural Nursing and also Director ot the Center tor

Health Research at Wayne State University in Detroit until
her seni retirement in 1995. Dr. Leininger developed sev-
eral transcultural nursing courses and seminars tocused on

caring and qualitative research methods tor baccalaureate,
master’s, doctoral, and postdoctoral nursing and nonnurs-

ing students. She also mentored many
students and nurses

in transecultural nursing tield research and continued these

endeavors at various universities in the United States and

worldwide. In 1989, Leininger launehed the Journal of

Transcultural Nursing, serving as its tirst cditor until her In 1974, Leininger was appointed Dean and Professor ot
ursing at the College of Nursing and Adjunct Professor of
Athropology at the University of Utah in Salt Lake City.

S institution, she initiated the first master’s and doc-
rograms in transcultural nursing and established the
Octoral program offerings at this institution (Leini-

retirement.

Leininger wrote or edited more than
30 books in her

lifetime and published more than 200 articles and 45 book

chapters plus numerous tilms, videos, 1DVDs,
and research

reports focused on
transcultural nursing; human care and

health phenomena; the tuture of nursing: and
related topics

relevant to nursing and anthropology. During
her career,

Dr. Leininger served on eight editorial
boards and refereed

several publications and was actively
involved with the

Transcultural Nursing Scholars Group and
the development

of and contributions to her
own website (www.madeleine

-leininger.com). She has remained
known as one of the

oter Substantive courses focused specifically on transcul-
nger, 1978). These prog ograms were the first in the world to

974, nger founded the 1ational Transcultural
Nursing and remained an active leader in the orga-

R ng She also initiated and was director of a new
nfacilitation office at the University of Utah. In

nroughout her lifetime. She also established the zation

theory, research rch, onsultatio
UNIT IV Theories

andGrandTheories

and care writings,

nost crcative, productive,
innovative,

and
futuristic

research-based nscultural nursing
content

and ideas
to

honors for
her lifetime professional

plishments, including

include an
LHD from

Kansas; a
PhD from the University of

ege

a DS from
the University of Indiana.

many aNards and and academicand
dynamic

addresses. She received

authors in nursing who provided
new

and
substantive

several hono
Benedictine

N degrees ha

College in Achisn advance nursing as a discipline and a professi1On.
n addition to theory development

and transculurd

nursing. Leininger had many lifelong
areas of interest

and

CpertisC, including comparative
cducation and adminis

ration; nursing theorics; politics;
ethical dilemmas or

rsing and health
care; qualitative research

methods; the

uture ol nursing and
health care; and nursing leadership

As a certihed transcultural nurse
and rescarcher,

Leininger

studied 15 individual and unique cultures;
mentored or

superised approximately 200
master’s and doctoral

stud-

es focused on transcultural nursing.
human caring/care,

and related areas worldwide: and
consulted with many

opio, Finlads a
Indianapolis. In 197% aue and sigpi And and 1995, she was gnized for her he American Asse

of Nursing as its first all-time president.i
the Russell Sage standing Leadership

Anthropology So ciety, fellow

iation of C
eininger r

cant
contribution to the

recevetin 19 and was a fellow in the American Acaderard of
iursing, a fellow of the

American

Society for Applied Anthropology, and a fellow o
e Royal

College of Nursing in Australia. Other affliatliationsGamma, and Scandinavian College of
Sweden. She

served as a

included Sigma Theta Tau; Delta Kappa

Caring Science he in Stockhrrescarchers and institutions, especially
those using her

culture carc theorv. Her culture care theory is
used world-

Wide and continues to grow in relevance
and importance

Tor the discover of culture care phenomena
about diverse

cultures.

distinguished visiting scholar
lecturer at 85

universities in the United

World.wide and was a VISiting professor at n
and

overseas
w

Wayne State Univer.universities. While at
the Board of Regents Distinguished aculty
Distinguished Research Award

in Teaching, and
the Outstanding Graduate

tor Award. In 1996,
Madonna

igan, honored
her with its dedication of the I

Collection and a special Leininger Reading Ra
outstanding contributions to nursing and the

ences and humanities. Leininger was honored as
Legend of the American Academy of Nursing in 1998

Dr. Leininger’s last works on the culture care the heory
were publications in peer-reviewed professional Durnals.
She co authored an interview for Nursing Science O

terly (Clarke et al., 2009) in which she discussed the hit

sity, she eceived
Leiningcr lectured to anthropologists,

physicians, social

workers. pharmacists, and educators, and
conducted research

with colleagues. She remained active in
two disciplines and

contributed to nursing and anthropology
at national and inter-

national transcultural conferences and association meetings.

Award, the the Presidents Excelence
aculty Men- iversity in Livonia, Mich.

ger Book
ing Room for her

Leininger worked to persuade nursing educators
and practi-

ioners to integrate transcultural nursing
and culture-specific

care cocepts based on research findings into nursing
curri-

cula and clinical practices as critical for
the future of all

aspects of nursing. Across seven decades
of the discipline,

numerous nurses with doctoral degrees and many master’s

and baccalaureate students have become certified in
transcul-

SOcial sc

tural nursing. using Leininger’s culture care theory through-
out their work (Leininger, 1991, 1995; Leininger& McFarland,
2002. 2006; McFarland & Wehbe-Alamah, 2015a, 2018b).

Leininger established transcultural nursing
courses and

programs to educate, conduct, and
facilitate research about

transcultural nursing and health phenomena. As
interest in

transcultural nursing and health care grew, Leininger (M.
R.

McFarland, personal communication, 1996) delivered key-

note addresses annually and conducted workshops and
consultations both nationally and internationally through-
out her career. Her academic vitae included nearly 600
conferences, keynote addresses, workshops, and consultant
services in the United States, Canada, Europe, Pacific Island
nations, Asia, Africa, Australia, and the Nordic countries.

Educational and service organizations continued to request
her consultation on transcultural nursing, humanistic car

ing, ethnonursing research, the culture care theory, and
futuristic trends in health care worldwide.

Dr. Leininger gained international recognition in nurs-
ing and related fields through her transcultural nursing

tory and future of transcultural care, the irsing

profession, and global health care. In 2015, she te

about her retrospective comparative study conducted in
2011 about three Western and one non-Western culture

(Old Order Amish Americans, Anglo Americans, Meai
can Americans, and the Gadsup of the Eastern Highlands

of New Guinea) to obtain in-depth knowledge abou
father protective care beliefs and practices with the god

to use that knowledge to provide culturally congruent

care (Leininger, 2015). She reported on culture care deci-
sion and action modes of similar and diverse care findings

discussed with the informant fathers as potential ways
they might integrate their cultural values and care prac

tices to help their sons. Leininger then began
work on d

new culture care construct, collaborative care, which sik

Co-presented with Marilyn McFarland via a keynotevu

eocast at the 37th Annual Conference of
Transculturi

Nursing Society in October 2011.

Aoleine M. Leininger: Iheory of Culture Care Diversity and Un
cHAPTER22 Ma

CH

nger died peacefully on August 10,
e Leininger.

ohraska. She continued to work until

337

002, 2006; McFarland & Wehbe- Alamah, 2015a, 2018D)
ninger predicted that for nursing to be meaningful ana
Terevant to clients and other nurses in the world, transcu
al nursing knowledge and competencies would be impe
Ve to guide all nursing care decisions and actions To

Cective and successful health outcomes (Leininger, 199

1996 Leininger & McFarland, 2002, 2006; McFarland

maha, Nebra

Ilaborating with colleagues on eoreher
strbons lo seve eral projects

and publications in
ongoing

legacy is her work
prog-

on the
einingers

re diversity and universal and in the

nursing that will continue to
transcultural

of culhurec

yiet those

roughouther,

m she
has mentored taught, and influ- m ijine of

accomplished career.
& Wehbe-Alamah, 2015c, 2018b).

inger (2002a) distinguished between transcultural
g and cross-cultural nursing, The former refers to

nurses prepared in transcultural nursing who are prepareuand committed to develop knowledge and practice n
ranscultural nursing, whereas cross-cultural nursing rerers
O nurses who use applied or medical anthropological con-
Cepts instead of developing transcultural nursing theory
and research-based practices (Leininger, 1995; Leininger &
McFarland, 2002, 2006; McFarland & Wehbe-Alamah,
2015a, 2018b). She also identified international nursing
and transcultural nursing as different. International nurs-
ng occurs when nurses travel to or have nursing practice
or service-learning experiences in other nations or coun-
tries; however, transcultural nursing involves multiple cul-
tures and has comparative theoretical and practice base
foci (McFarland & Wehbe-Alamah, 2015, 2018). Leininger
described the transcultural nurse generalist (now known
as certified transcultural nurse-basic or CTN-B), as a nurse
prepared at the baccalaureate level who is able to apply
transcultural nursing concepts, principles, and practices
that are generated by transcultural nurse specialists (Leini-
nger, 1991, 1995; Leininger & McFarland, 2002, 2006;
McFarland & Wehbe-Alamah, 2015, 2018). The transcul
tural nurse specialist (now referred to as a certified trans-

cultural nurse-advanced or CTN-A) is prepared in graduate
programs and receives in-depth preparation and mentor-
ship in transcultural nursing knowledge and practice. The
CTN-A has acquired competency skills through post bac-

calaureate education by having acquired research-based
knowledge about selected cultures in sufficient depth to
provide high-quality, safe, and effective transcultural nurs-
ing care (McFarland & Wehbe-Alamah, 2015, 2018). The
transcultural CTN-A therefore serves as an expert practi-
tioner, teacher, researcher, and consultant with respect to
select cultures. The CTN-A specialist values and uses nurs-
ing theory to develop and advance knowledge within the
discipline of transcultural nursing, the field Leininger pre-
dicted must be the focus of all nursing education and prac-
tice (Leininger, 1991, 1995; Leininger & McFarland, 2002,

TICAL
SOURCES FOR THEORY

EORETICAL

ENTELOPMEN

aer’s
theory

was derived from the disciplinesof

ology and. 2002, 2006; Mckarland & Wehbe-Ala-
and nursing

Leininger, 1991, 1995; Leini-

2015a,
20186).

She described

nursing focused on the comparative studv

fdiverse cultures
and subcultures worldwide

atiyolog

transcultural nursing as

nhaior

area

of r

e to their caring values, expressions, and health sth respect te
and patterns

of. behavior.
e of the theory is to discover human care

ness beliets a

he purpose

.and universalities in relation to worldview, cul-
d ial structure dimensions, and then to discover

turally congruent care for people of to providecultur

frent
or similar cultures

to maintain or regain their

ing or
health or to face death (Leininger, 1991,

t-being

e:
Leininger

& McFarlan 2002, 2006; McFarland &
Alamah, 2015a, :018b). The goal of the theory is to

oVe and to bvide culturally congruent care to people

is beneficial and will ft with and be useful to the client,

mt: or cultural group (Leininger, 1991, 1995; Leininger
afarland, 2002, 2006; McFarland & Wehbe-Alamah,
.2018). Transcultural nursing goes beyond an aware-
state to one of using culture care nursing knowledge

ractice culturally congruent and responsible care

McFarland&Wehbe-Alamah, 2015c, 2018b).

Leininger stated that, over time, there would be a new
nd of nursing practice that reflects diverse nursing prac-

is that are culturally defined, grounded, and specific to
lide nursing care provided to individuals, families, groups,

ad institutions. She contended that because culture and
e knowledge are the broadest and most holistic means to

cptualize and understand people, they are central and
mperative to nursing education and practice (ILeininger,
91, 1995; Leininger & McFarland, 2002, 2006; McFarland
Nehbe-Alamah, 2015c, 2018b). In addition, she stated
anscutural nursing had become one of the most impor
a1, relevant, and highly promising areas of formal study,
5arch, and practice because people live in a multicultural

UI(Leininger, 1988a, 1995; Leininger & McFarland,

2006; McFarland & Wehbe-Alamah, 2015, 2018).
Leininger (1996) promoted a new and different theory

from traditional nursing theories that defined theory as logi-
cally interrelated concepts and hypothetical propositions to
be tested for the purpose of explaining or predicting an event,

338 UNIT IV Theories and Grand Theories
tory, and the evironmental

ehomenon, or situation. Instead. Lcininger
defined theory

as the s’stematic and creative discovery ol knowlcdge
about

a domain of interest inmportant to understand
or account for

SOmc unknown phenomenon. She belicved nursing
theory

must lake into accoun creative discovery
about individuals,

1amilics, and groups,
and their caring. values, cxpressions,

belicts, and act ions or practices
based on their cultural life-

71 to providc eltective, satislfying,
and culturally congruent

care (1 cininger. 1991.
1995; Icininger & McFarland,

2002,

O6: Allarland & Wehbe- Alamah, 2015a,
2018b).

I cininger (199) developed
her theory of culture care

divcrsitv and universality bascd on the belief that people
of

dilerent culures can intorm and are capable of guiding

protessionals to receive the kind of carc they desire or need
trom others C1lture is the pattcrned and valued lifeways of

people that intlucnce thcir decisions and actions; therefore,

the theor is directed toward nurses to discoverand
docu-

ment the world of the clicnt and to use their emic (insider)
icpoints, knowledge. and practices with appropriate etic

(outsidcr). as bases for making cullurally congruent profes-
sional care actions and decisions (Leininger, 1991, 1995).

The culture care theory can be both inductive and

deductive and is derived from both emic and etic knowl-

Contex abstract and practice dimensione
that can

Tho he theay Ch tematically to achieve culturally congruent be exanine
2015a,c, 2018b). It is the onlv
focused on culture and care of

three theory-based culture care

acceptable care comes (McFarland & w it is possib
care becaus

derived fro

Wehhe in nur
ethnonUrsi

heoare
ou

or

peoAiyerse and
what is

se

culluremodes ol deciiactions that are rectly applicable in clinical reaching beneficial
and satisfactory lifeways
ultimately discover care-what is
sally related to care and
parative focus to discover different

nursing care practices

document,
through he

generic an

(Leininger,

Leining

to support
of the

pracliceebeng, e thcory
health-and has an

integrate or contrastin with specific care based carin nursings co
ory with the onursing method has ramalconstructs iep

nes

na
beneficial care

tease out in-depth infor

information. Thus, these enablers
tural health care assessments.

eration of new knowledge in nursing:

nant emic data and
healh

he enablers
first reason

ment, and s-
the human

reason 1S to

construct or

sed
also be u

. The theory can
at culturally congruent, neaningful, and t

uide he d health care t
edge and th-

ferent cultu

(Leininger, 1

McFarland &
knowledge i

promote the

or disability,

over time (Le

USE OF EMPIRICAL EVIDENCE

hat care
For more than six deca Leininger held

dominant, distinc
cdge (1991. p. 33). Leininger (1991) encouraged nurses and
others to obtain grounded emic knowledge fronm the pe0-

ple or ulture because such knowledge is more
credible.

The theory is ncither a middle-range nor macro theory but

must be viewed holistically with specific domains of inter-

cst. Leininger bclieved the terms middle range
and macroo

to be outdated in theory development and usage (Leini-

nger. 1991, 1995; Leininger & McFarland,
2002, 2006;

McFarland & Wehbe-Alamah, 2015, 2018). Indeed, the
culture eare theory is the broadest holistic nursing theory,
because it takes into account the totality and holistic per-

spective of human life and existence
over time, including

the social structure factors, worldview, cultural history and
values. environmental context (Leininger, 1988b), language

expressions, and folk (generic) and professional
care pat-

terns. These are some of the most critical and essential

essence of nursing and the

ve, and ing feature of nursing (Leininger, 1970, 1988b.nger& McFarland, 2002, 2006; McFarland Nehbe that care is comnpleoften embedded in social structure and other
2015, 2018). She stated

fession needs

holistic cultuz

ture (Leininger, 1991; Leininger & McFarland
held that diferent forms, expressions, and Dat
were diverse, whereas Some were universal ( s f
Leininger & Mckarland, 2002, 2006). Leinino

meanings of a

1991, 1995;

land & Weht

1995) found

asp

often embedd

quali
1990; Leininger & McFarland, 2002, 2006) usei

care.
ethnomethods, especially ethnonursing, to study

:ople-tr.
methods are directed toward discovering the Dennl.
views, beliefs, and patterned liteways of cultural

this knowleds

their practice

therapeutic w-

or help people
& McFarland,

2015a, 2018b)
meaning of ca

health care of

9

bases for the discovery of care knowledge that, as the

essence of nursing, can lead to the health and well-being of
clients and guide therapeutic nursing practices.

According to Leininger (2002b), the theory of culture care

diversity and universality has several distinct features, differ-
ent from those of other nursing theories. It is the only theory

that is focused explicitly on discovering holistic and compre-
hensive culture care, and it is a theory that can be used across

Western and non-Western cultures because of its inclusion of

multiple holistic factors universally found in cultures. It is the
only theory focused on discovering comprehensive factors
influencing human care such as worldview, social structure
factors, language, generic and professional care, eth1nohis-

families, and individuals. During the 1960s, Leiningerd
oped the ethnonursing method tO study transcultural
ing phenomena specifically and systematically. This m

focuses on the discovery of care beliets, values, and pra.
as cognitively or subjectively known by the people oi
ture through their local emic people-centered lang
experiences, beliefs, and values about actual or pute
nursing phenomena such as care, health, and environne

factors (Leininger, 1991, 1995; Leininger & MecFarie
2002, 2006; McFarland & Wehbe-Alamah, 2015, 20
Although nursing has used the words care and carig
more than a century, their definitions and usage have te

vague, having been used as clichés without speciht nke
ings to the culture of the client or nurse (Leininge,
1988b). With the transcultural culture care theory

dicted, and c=

(Leininger, 199

as one of the

phenomenon C

and patterns n

used to ensuree i

guide to transc

used to guide
(Leininger 1991

McFarland &

studied several
graduate and gt

loine M. Leininger: Iheory of Culture Care Diversity and Universality
CHAPTER22 339

cd on emic sider views) beliefs,
ethe to the discovery of people-based

ve research methods. She extensively explicated Care
COnstructs throughout many cultures in which cach cu ulture
ad different meanings, cultural experiences, an verse and similar care values, beliefs, patterns, and expr
SOns by their people (Leininger 1991, 1995; Leininger McFarland, 2002, 2006: McFarland & Wehbe-Alama
2015a, 2018b). New culture care knowledge continues
Cscovered by transcultural nurses in the development OT
Cuture-specific care practices with diverse and similar cu

no getcdircctly from the people and are not
tsider vicws) beliefs and practices

mportant purpose of the theory is to

S dala come.

predict, and explain systematically

nal care of cultures being studied

fcher: An mporlant

(nt. kno

eld dala i

and universal about the whal is diverse
to be

detailed and culturally
owledge and practi should distinguish

studying
the lture care theory is that the

sa) held that nnger 199)

time, Lcininger (1991) believed both diverse and
universal features of care and health would be documented as
the essence of nursing knowledge and practice.

Leininger stated that the goal of the culture care theory
1S to provide culturally congruent care (Leininger, 1991,1995; Leininger & McFarland, 2002, 2006; McFarland&
Wehbe-Alamah, 2015a, 2018b). She believed that nurses1must work toward explicating care meanings so that cul ture carc, values, beliefs, and lifeways can serve as accurate
and reliable bases for co participatively making cultureSpecific care decisions and actions as well as to identity
universal or common features about care (Leininger, 1994,McFarland & Wehbe-Alamah, 2015a, 2018b). She main-
tained that nurses could not separate worldviews, soCial
structure factors, and cultural beliefs (lay/folk/generic and
professional) from health, wellness, illness, or care when
Working with cultures because these factors are closely
linked and interrelated (Leininger, 1994; McFarland &
Wehbe-Alamah, 2015a, 2018b). Social structure factors,
such as religion, politics, culture, economics, and kinship,
are significant forces affecting care and influencing illness
patterns and well-being. She also emphasized the impor-
tance of discovering generic (folk/lay, local, and indige-
nous) care beliefs, values, and expressions held by cultures
and comparing them with professional care practices
(Leininger, 1991, 1995; Leininger & McFarland, 2002, 2006;
McFarland & Wehbe-Alamah, 2015a, 2018b).

yninger (1988a)

utions
from those of other disciplines. The

,/

nas0N
Or

stud

re

as been crilical to the growth, develop-

val of
hunman beings fron the beginning of

1988b). The second ies (Leininger, 1988a,

and fully understand cultural knowl-

es of carcgivers
and care recipients in dif-

i survi

humman sfpecics

d the
rolcs

ol
carcgivers

an

s
to

provide culturally congruent care
Leininger &McFarland, 2002, 2006;

1991, 1995;

.1Wehbe-Alamah, 2015a, 2018b). Third,

. ulun

care rland & Wehbe-Alamal

Jiscovered and
can be used as essential to

the
healing

and well-
to cnsure the survival of human cultures

-being ofcl to face death

tbility. or to

et, 1991, 1995). Fourth, the nursing pro-

cds to
sy’stematically study care lrom a broad and

Itural
perspective

to discover the expressions and

of care,
health, illness, and yell-being (Leininger,

1Wehbe-Alamah, 2015a, 2018b). Leininger (1991,
1005;

Leininger
& McFarland, 2002, 2006; McFar-

:1
edded in cultural lifeways and values. However,

help
peoplelface death (Leininger, 1991,

d that care was largely an elusive phenomenon

knowledge
serves as a sound

aractice for culturally congruent care and specific

basis tor nurses to guide

rapeut

apntic wavs to maintain health, prevent illness, heal,

1995; Leininger
arland, 2002, 2006; McFarland & Wehbe-Alamah,

2018b). A central thesis of the theory is that if the

ning of care can be fully grasped, the well-being or
lth care of individuals, families, and groups can be pre-

d, and culturally congruent care can be provided

minger, 1991, 1994, 1995). Leininger (1991) viewed care
E One of the most powerful constructs and the central
henomenon of nursing. However, such care constructs

d patterns must be fully documented, understood, and

ed to ensure that culturally based knowledge is the major
uide to transcultural nursing decisions and actions and is
sed to guide culturally congruent nursing practices
eininger 1991, 1995; Leininger & McFarland, 2002, 2006;
McYarland & Wehbe-Alamah, 2015a, 2018b). Leininger tudied several cultures in-depth, including with under-
Taduate and graduate students and faculty using qualita-

Leininger found that cultural blindness, cultural shock,
cultural imposition, and ethnocentrism by nurses continued
to greatly reduce the quality of care offered to clients from
diverse cultures (Leininger, 1991, 1995; Leininger & McFar-
land, 2002, 2006; McFarland & Wehbe-Alamah, 2015a,
2018b). Moreover, nursing diagnoses and medical diagnoses that are not culturally based and known create serious prob-lems for cultures that lead to unfavorable and sometimes
serious outcomes (Leininger, 1995, 1996; Leininger &
McFarland, 2002, 2006; McFarland 8& Wehbe-Alamah,
2015a, 2018b). Providing culturally congruent care enhances
client satisfaction about the care they have received; it is a
powerful healing force in the provision of quality health
care. Quality care is what clients want most when they seek
care from nurses, and it can be provided only when cultur-
ally derived and congruent care is known and used.

340 UNIT IV Theories
and Grand

Theories

lifeways of values, beliefs, and
nts for

ther
hean

MAJOR CONCEPTS
AND DEFINITIONS

well-being, or to prevent or face ilness, d for

saoitie,t The provision of culturally conCr the major goal of the Culture
Wehbe-Alamah, 2015c, p. 14).

Care and Caring

and sate
care h

With expressions of assistive
supportive,

enabling, and

acilitatina wavs
toward or about self or

others.”Caring

reters to actions. attitudes,
or practices

to assist
others

oward healing and well-being

Care refers to the
abstract and

manifest phenomenon

Care Theory iMo

Care as a major con Culture Care Diversity

“Culture care diversity refers to the
yariadilitiesa

human beings related to providing beneticial cat

ences in ulture care beliefs,

symbols, lifeways, symbols, and

struct of the theory
includes generic/tolk

care and pro-

meanings, atternstessional care which
are major parts

of the theory
that

other
ani well-he ng of dverse

cultures Mc Farland & Wehbe

Alamah 2015c pn 101

have heeon predicted
to influence

and explain the
health

teatures a
clients from a designated culture” McFarand &lek Cata Alamah, 2015c, p. 14). Generic care
Culture Care Universality

Culture care universality refers to Con ndioenous
traditional or local folk lemic)

knowledge and

prartices to provide
assistance, supportive, enabling,

and

faclitative acts fo or toward others
with evident or an

iCInated health needs
in order to improve wellbeing

or to

heir with dying or other human
conditions” (McFarland &

Wehhe Aiamah, 2015c, p
14)

Generic care refers to the
learned and

transmitted lay.

or similar Cultural care phenomena feat

ings or groups with recurrent meanina

symbols, or liteways that serve as a c

to provide assistive, supportive facilitati
people care for healthy outcomes” (MeEa

Alamah, 2015c, p. 15

hura nOs, pattens, ag
Uide for Careri

e, or anat

rarland 2 le
Professional care

Worldview Professional nursing
care refers to formal and explicit cog

ogk o
“Worldview refers to the way people tend to le

form a picture or valus
ohtanec peneraly through

educational institutions lusually

nongenernc that are taught
to nurses and others to provide

a5515tive sunportive enabling, or
tacilitative acts for or to

anothe ndividua or group in order to improve their health,

prevent linesses. or to help with dying
or other human con-

ditions (MoFarland & Wehbe-Alamah, 2015c, p. 14).

veh learned professional
care knowledge and practices

their wold or universe to
about life or the world around them em. Worldview

ofDinea broad perspective a0out ones orientation to to life.
ple, or groups that infiuence care or carina

esponsaand guides one’s decisions or actions, especiall
to matters of health or well-being (McFarland 2 e

enta Alamah, 2015c, p. 15)
Culture

Cultural and Social Structure Dimensions
The “cultural and social structure dimensions lr

tors] refer to the dynamic, holistic, and interrelated
terns of structured features of a culture (or subculte

that include but are not limited to technology factors,

gious and philosophical factors; kinship and social facus
cultural values, beliefs, and lifeways, poltical and eg

Culture reters to learned, shared, and
transmitted val-

Jes beliets, norms. and lifeways
of a paticular culture

tha’ guide thinking.
decisions, and actions in patterned

wavs Culture is eaually as important as care;
is not an ad-

vert o’ adiective to care. Leininger conceptualized culture

care as synthesized and closely linked phenomena
with

interrelated ideas” (McFarland, 2018b, p. 46).

factors; economic factors; and educational factors as we

as environmental context, language, and ethnohistor

(McFarland & Wehbe-Alamah, 2015a, p. 75).

Culture Care
Culture care reters to the synthesis of the two major

constructs Icare and culturel that guide the researcher to

discover explain, and account for health, well-being, care

expressions, and other human conditions (McFarland &

Wehbe-Alamah, 2015c, p 13)

Environmental Context

“Environmental cotext refers to the totalityof an eler

Culturaliy Congruent Care
Culturally congruent care refers to culturally based care

knowiedge, acts, and decisions used in sensitive, cre-
ative, and mearingtul ways to apPpropriately fit the cultural

Situation, or particular experience that givesmeanings

people’s expressions, interpretations,
and social nes

tions within particular geophysical, ecological, spinas

SOCiopolitical, and technologic factors
in specineu

settings” (McFarland &Wehbe-Alamah,
20150, p. i

Va

.Ineory of Culture Care Diversity and Universay

HAPTER 22

CONCEPTS &DEFINITIONScont’d 341

eto the sequence of past facts
or experiences of human be

MAMOR CO

whstory
molis.

shistoryrete,

fs staces,
wes, or

Iduais or groups that enables them to perform tne
ives (McFarland & Wehbe-Alamah, 2015C, P.

ngs
stitutions Over time in particular
lain past and current lifeways about

daily

Culture Care Preservation and/or Maintenane Culture care preservation and/or

15).

e ce mnuencers

sabultyor d

affecting the health and well-be-
(McFarland & Wehbe-/s

thal

nep

expla

death of people”
to those assistive, suppor

maintenance refers
essional actions and decisions that help people o

portive, facilitative, or
20150 p. 15).

fers
to

loca, indigenous, or the insider cul-

par

are beliefs and values for their well-being, to recover Tro
ul

ness, or to deal with handicaps or dying (McFarland o

enabling pro
ucuiar culture to retain, preserve, or maintain medig

and nd views about specitic phenomena” Wehbe-Alamah, 2015c, p. 16). KDO/eOGe
&Wehbe-Alamah, 2015c, p. 14). Culture Care Accommodation and/or Negotiation uture care accommodation and/or negotiation re-ers to those assistive, accommodating, facilitative, o enabing creative professional care actions and decisiois nat help people of a designated culture (or subculture) to adapt to or negotiate with others for culturally congruent, safe, effective care for meaningful, and beneficial nedi Outcomes (McFarland & Wehbe-Alamah, 2015c, p. 16).

he outsider or stranger (otten health pro
ro-

or institutional / system|knowledge and

about cultural phenomena” (McFarland
tic

1elers

0
the

toetea values

1ehbe-Alamah, 2
2015c, p. 14).

valued, and practiced that reflects the ability

ninger
1991, p. 48;

McFarland & Wehbe-Alamah

5 p.
11); a

state of restorativ well-being that is cul-

.a state of well-being that is culturally
Herlth

th refers Culture Care Repatterning and/or Restructuring Culture care repatterning and/or restructuring refers
to the assistive, supportive facilitative, or enabling pro
fessional actions and decisions that help clients reorder,
change, or modify their lifeways for beneficial healthcare

of
to pertorm their daily role activities

ssed, beneticial, and patterned lifewaysuals
or

groups
to

o

lturally

expressed,

ben

valued, and practiced by indi
pdterns, practices, or outcomes (McFarland & Wehbe-
Alamah, 2015c, p. 16).

a
Constituted,

detined,
valis

IAJOR ASSUMPTIONS Culture care is the synthesis of two major constructs
(culture and care) that guide the researcher to discover,
explain, and account for health, well-being, care expres-
sions, and other human conditions.

Culture care expressions, meanings, patterns, processes,

universality
of care reflects the common nature of

nan beings and humanity,
Whereas the diversity of care

the discovered variability and unique features of

-man beings. Major assumptions
of the theory of culture

diversity and universality presented
here were derived

Leiningers definitive works on the theory and subse-

ETt evolutionary changes (Leininger
1991; Leininger &

cFfarland, 2002, 2006; McFarland & Wehbe-Alamah,

and structural forms are diverse, but some commonali-

ties (universalities) exist among and between cultures.
Culture care values, beliefs, and practices are influenced

by and embedded in the worldview, social structure fac-
tors (e.g, religion, philosophy of life, kinship, politics,
economics, education, technology, and cultural values)
and the ethnohistorical and environmental contexts.

15a, 2018b):

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

Humanistic and scientific care is essential for human

growth, well-being, health, survival, and to face death
and disabilities.

Every culture has generic (lay, folk, naturalistic; mainly

emic) and usually some professional (etic) care to be dis-
covered and used for culturally congruent care practices.

Culturally congruent and therapeutic care occurs when

culture care values, beliefs, expressions, and patterns are

explicitly known and used appropriately, sensitively,
and

meaningfully with people of diverse or similar
cultures.

Care (caring) is essential to curing or healing for there
can be no curing without caring (this assumption was

aeld to have profound relevance worldwide).

maj
“[that the] worldvie social ructure

ment, lang
and y

theoretical tenes
UNIT IV

Theories
and

Grand
Theories

cultural
knowledge. A second 342

Leiningers
threc

thcoretical
modes of care

offer new,

creative, and
different

therapeutic
ways

to help
peopie

of diverse cullurcs.

gion,
economics, education, to.

(social), ethnohistory, environme:

care and professional
care factors

culture care meanings, expression

ent cultures”
(Leininger & N

Leininger maintained that kno

actors such technolo8Y politics,
The cthnonursing

rescarch
method and

other qualitative

research
paradigmatic

methods
offer important

means

to
discovcr largely

embedded,
covert,

epistemic,
and

ontological
culture care

knowledge
and practices.

Transcultural nursing
is a discipline

with a body
of

knowledge
and practices

to atlain
and

maintain the goal

of culturally
congruent

care for
health and

well-being.

(l cininger
1991; Leininger

&
McFarland,

2002, 2006;

McFarland & Wehbhe-A lamah,
2015a,

2018b).

would greatly
and patter

cFarland, 2002, p. 781 ng the cu
Social structure

lactors was necessary in order t meaningful and satistying care to people and they would be pOwerful influenc
care. These

factors also on Culturaiy tmasneeded to be
discoNered direnfrom

cultural informan to confirm th
as

beng ina
to health, well-

being. nness, ana
encing factors related

death. The third majoritheoretical tenet was “both(emic) and professional (etic) care
researched, and brought together intsto care ha

satisfying care for clients which leads to their hl

needs enesr
Tencts are the

assertions one
holds or are givens

that the

theorist uses with a theory.
In developing

the culture
care

theor, the following
four major tenets

were conceptual-

i7ed and
formulated by the theorist

(1Leininger & McFar

land. 2002, 2006:
McFarland &

Wehbe-Alamah, 2015,

2018):

THEORETICAL ASSERTIONS

be

acices he well-being” (Leininger, 2002).
The fourth major theoretical tenet

ization of the three major care modes

actions (stated previously) to arrive at

care for the general health and well-beir
help them face death or disabilities (Leinin

nealth a
as the conceptud

of
decisions culturally congrCulture care cxpressions, meaning, patterns,

and prac-

tices are diverse
and yet there are

shared
commonalities

ients, om
McFarla,

researcher or clinician draws upon findin
structure, generic care and

2002, 2006; McFarland & Wehbe-Alamah 2015, 2018).TThe worldview, multiple social
structure factors, ethno-

history, environmental
context, language, and generic

and professional care are
critical influencers of culture

care patterns to predict health, well-being,
illness, heal-

ing. and ways people
face disabilities and death.

Generic emic (folk) and etic (professional)
health fac-

tors in different environmental
contexts greatly influ-

B).The ngs trom the soco

and some universal
attributes.

professional practic
influencing factors to study or provide cultural.do

for individuals, families, and groups. These factoa
be studied, assessed, and responded to in a dun ynamic

ed
and participatory nurse-client relation (Leininger Leininger & McFarland, 2002, 2006; McFarland

Alamah, 2015a,b, 2018b). Wehide From an analysis of the above influencers, three major
decision and action modes (culture care preservation or
maintenance; culture care accommodation or negotia-

tion: and culture care repatterning or restructuring)

were predicted to provide ways to give culturally con-

gruent, safe, and meaningful health care to cultures

(Leininger & McFarland, 2002, 2006; McFarland &
Wehbe-Alamah, 2015a, 2018b).
These decision and action modes were predicted to be

key factors in the provision of culturally congruent, mean-
ingful, and acceptable care for beneficial outcomes. When
using the modes, individual, family, group, or community
factors are assessed and responded to in dynamic and par-
ticipatory nurse-client relationships.

In conceptualizing the theory, the first major and central
theoretical tenet was “care diversities (differences) and uni-
versalities (commonalities) existed among and between
cultures in the world” (Leininger & McFarland, 2002, p. 78). However, Leininger asserted that culture care meanings and uses first had to be discovered to establish a body of trans-

ence health and illness outcomes.

LOGICAL FORM

Leininger derived concepts for her theory of culture c
diversity and universality from both anthropolog

nursing but reconceptualized them into a new set of can
structs that became a transcultural nursing theory with
human care perspective (1991, 1995). She developed th
ethnonursing research method and emphasized the imper
tance of studying people from their emic local knowledge
and experiences and later compares this knowledge with
the etic (outsider) beliefs and practices. Her book, Qualte
tive Research Methods in Nursing (Leininger, 1985a) ani

subsequent publications (Leininger, 1990, 191, 19
Leininger & McFarland, 2002, 2006; McFarland &Wehile
Alamah, 2015a,b, 2018b) continue to provide substanie
knowledge about qualitative methods in nursing.

Leininger was skilled in using ethnonursing, ethnog
life histories, life stories, photography, and phenomenong

nd

Madeleine M. Lein ne M. Leininger: Iheory of Culture Care Diversity and Universaly
CHAPTER22

343

ovide a hol

iverse environmental

the study of cul-
contexts (Leininger,

holistic aPproach tor
es, beliefs, and lifeways; biological factors

(neW ”

hori 15 1eminger&
&McFarland, 2002, 2006; McFarland

With these qualitative
with people in their daily liv-

Poltical and legal factors; economic factors;
cducational factors as well as environmenta Alamah,

h. 2015a, 2018b).

lan-

rd

understandi
their world.

nonursing
research

method the nurse

ge, and ethnohistory (McFarland & Wehbe-Alaman,
018a; Wehbe-Alamah, 2019; Wehbe- Alamah & Mcra

land, 2020).
esearcher.

Atiies toNar

th he ennonursi
nher indtuctivel obt

ta of documented descrip-
These factors also influence culture care expressions

patterns, and thus the folk, professional, and integrared

care practices, which are depicted
in the middle

ection of the Sunrise. The upper and lower halves together
form a full sun, which represents the universal

care co
structs that nurses must consider to appreciate human cau
and health (McFarland & Wehbe-Alamah, 2018a; Wehbe
Alamah, 2019; Wehbe-Alamah & McFarland, 2020). NurSing
acts as a bridge integrating generic (folk) and professional
care (McFarland & Wehbe-Alamah, 2018). Nurses can then

use the three culture care modes of nursing decisions and

actions in practice as predicted in the theory: Culture care

preservation and/or maintenance; culture care accommoda-
tion and-or negotiation; and culture care repatterning and-or
restructuring (McFarland & Wehbe-Alamah, 2015a, 2018b).

The Sunrise Enabler depicts human beings as insepara-

ble from their cultural backgrounds and social structure
factors, worldview, history, and environmental context
(McFarland & Wehbe-Alamah, 2015a, 2018a,b). In the

theory, gender, race, age, and class are embedded in social
structure factors and are studied from a holistic perspec-
tive. Theory generation from ethnonursing studies may
Occur at multiple levels, from small-scale studies with

specific individuals (micro level) to larger studies with

vely obtainsdata.

ve
narratives

tromn informants througl

And intery

he e R McParland,
2002, 2006; McFarland

explicating culture care val- and participation.
ing

research method (Leininger,
w7ti
sing.

015;

Leninger

&

McFarlas

e-Alanah, 201

developing
basic and substantive data-

ure care to guide nurses in their

2015a,
2018b). The qualitative approach

portant
dge about culture

afknonlea
rath es. Pro, rom

the beginning,
hnonursing has been

primaruly on the.

ral
groups

under

study

though othe

lata directly from the
arily on

the discovery
of dat

ther
methods of research, such as hypoth-

erimental quantitative
methods, can

ral care, the method of choice s tstinga study transcultura

on
the

researche purposes, the goals of the

and
the phenomena

to be studied. Creativity and

ness Of the
nurse researcher

to use diverse
wilingness

of the
nur

methods
to liscover nursing knowledge are

ET

2Ccurate

cultural knowled and that quantitative

Tures
and care. Leininger

also ieved that combining

ed.
However, Leininger

held

Were important
to establish meanings and dis-

that qualitative

generally
were of limited value when studying

ihods

hgqualitative and quantitative
methods in the same

ni obscured the findings
and was a misuse of both

adigms (Leininger, 1991,
1995; Leininger & McFar-

i 2002, 2006; McFarland & WNehbe-Alamah,
2015a,

groups, families, communities, or institutions (macro

level). Leininger also developed several enablers to facili-
tate studying phenomena using the four phases of qualita-
tive data analysis (Leininger & McFarland, 2002, 2006;
McFarland & Wehbe-Alamah, 2015a, 2018b).

8b).
The Sunrise Enabler and a complete overview of the

c2or of cultural care diversity and universality are not

addressed here. Selected ideas are presented to intro-
e the reader to Leininger’s pioneering and creative work
n evolving holistic and comprehensive theory. Leini-

r developed the Sunrise Enabler (Fig. 22.1) in the 1970s
apict the essential components of the theory. The Sun-

vas refined by Leininger in 2006 and subsequently
0ated by McFarland and Wehbe-Alamah in 2015 and

a in 2018a (see Fig. 22.1). It has thus evolved to be a
dehnitive and valuable enabler to comprehensively
and focus studies and with which to make culturally

t care decisions and actions. The upper half of the

e Enabler depicts key theoretical constructs related
eW and cultural and social structure dimensions.

The first phase of data analysis is collecting, describing and
documenting raw data; the second phase is identificatiorn and
categorization of descriptors and components; the third phaseis
pattern and contextual analysis; the fourth phase is mjor
themes, research findings, theoretical formulations, and recom-
mendations (Wehbe-Alamah, 2018b, p. 72). The criteria to
evaluate ethnonursing research findings are “used to challenge
discovered universalities and diversities in relation to the CCT
and the qualitative paradigm and to systematically examine
and discover in-depth care and culture meanings and interpre-

tive findings” (McFarland & Wehbe-Alamah, 2015b, p. 56).
These criteria are credibility; confirmability; meaning-in-
context; saturation; recurrent patternings and transferabil-

ity (McFarland & Wehbe-Alamah, 2015b, p. 56). Leininger

strongly held that quantitative criteria should not be used with
qualitative methods because the former use paradigm-specific
criteria to measure such outcomes (Leininger, 2002, p. 87).

ese dimensions include technole factors; religious and Aosophical factor ors; kinship and social factors; cultural

944 UNII
V Thent les

and Ga
hln

CU TUN CANE

Worllview

GuluralA
tionlal

iiuoturn
Dlnonlon

Cultural Valuos,
Boliefa,

Biologlon
FAotorn

LIfewaya
Politoal

Kinehip

fiocial

nvironmental Contoxt,
Languagn n Eohistory

ogal
aotors6

Faotor

Religlou
spiritual,

Philosophleal
Factors

6onom
Influenos Factors

Care Expresslons,
Pattorns, & Praotioes

ducatlonal
Technological

Factors

Factors
Hollstle Health, Wellbelng,

Dlsabllity,

Ilnoss, Dylng, &
Death

Focus: Individualn,
Famlllon, Groups, Conmunitio1s,

or lnatitutions

In Dlverno Hoalth
Cont0xtn of

Profess ional
Generlc (Folk)

Care

Care Cure

Intogratlvo Caro

Practlcos
Practic0s

Throo Modos of Caro
Doclslons & Actions

Culluro Caro Prosorvatlon and/or
Maintenance

Cullure Care Accommodalion and/or Nogotiation

Culture Caro Ropatterning and/or Restructuring

M.R. McFarland &
H.B. Wohbe-Alamah (2018) Code: (Influoncors)|

Culturally Congruont Caro for
Hollstlc Hoalth, Wollbeing, Disability,

llnoss, Dylng, and Doath

Fig. 22.1 Lemnger’s Suni1S0 Enablor
(1om McI arland, M, and Wohbo- Alamah H. B. 12018|. Tianscultural nursing

concopts, thoonos,
r0seara,

&practice 14th edl Now York, NY: McGraw-Hill Education.) Usod with permission.

M, Leininger:Theory of Culture Care Diversity and
pTER 22 Madeleina

cHAPTER22 M

and Universality
loned several additional enablers t

the ethnonursing

345

pr Enuber:Leininienaif
o ASSCSS ult

inger aiso deve,

st researcher
Observation-

in their use of

on-Participation-Refled

Friend Enabler; the Domain of

09.This enabler correlates closely with the social structur
on Enabler; ors of the culture care theory as depicted in the >unt Enabl Dier (Leininger & McFarland, 2002, 2006; McFarland &

Wehbe-Alamah, 2015a, 2018b).Semi-Structured Inquiry Guide
ulture Care and Health; and the Accul

traditional Lifeways. “Enablers sharply

tiger he Acculturation Health Assessment Enabler for Cul-
ural Patterns in Traditional or Nontraditional Lifeways
Wehbe-Alamah, 2018b, pp. 69-72) is another importaguide used with the ethnonursing method for both cuitura4ssessments and ethnonursing research studies. It is essen al when studying cultures to assess the extent of the infor
mants acculturation, whether they are more or less
traditionally or nontraditionally oriented in their values,

Enabler for Cultural Patterns in
ealth Assessment,

Mna

wrth mechanistic devid

ruments, and other

istic devices such as tools, scales, mea-

er impersonal objective dis-

nt

used in quantitativ studies. These
wed as unnatural (foreign) and (are)

rvation-Partici ticipation-Reflection Enabler

familiaror natural.context during the

eultural informants
(Leininger, 2002, p. 89). beliefs, and general lifeways” (Leininger & McFarland, is 2002, p. 92).

ObSche researcher to enter and remain with
do tacilitate

nandsin their be-Alamah, 2018b, p. 64). The researcher gradu- ACCEPTANCE BY THE NURSING
om the role of observer and listener, transition- COMMUNITY

reflector with the informants. articipant and

slowly and politely with permission, the Practice
nRoNng

atherdoes 1

all occurring in the environment or with the

not disrupt and therefo is able to observe

th the

mh. 2018%, p p. 63), the
nurse researcher is able to learn

nemselves and the people and ulture being

McFarland & Weh Alamah, 2015a, 2018b).
Stranger-to-lrusted Friend Enabler (Wehbe-

Leininger identified several factors associated with the reluc-
tance by nursing to recognize and value transcultural nursing
and cultural factors in nursing practices and education (Leini-
nger, 1991; Leininger & McFarland, 2002, 2006; McFarland 8&
Wehbe-Alamah, 2015, 2018).

about theni

The goal with this guide 1S
to move from distrusted

n become a trusted friend, and thereby able to more

First, the theory was conceptualized during the 1950s
when very few nurses were prepared in anthropology or
had any cultural knowledge to help them understand
transcultural concepts, models, or theories. In those early
days, most nurses did not have much knowledge about the
nature of anthropology and how anthropological knowl-

edge might contribute to human care and health behav-
iors or serve as background knowledge for understanding
nursing phenomena or problems. Second, although peo-
ple had longstanding and inherent cultural needs, many
clients were reluctant to press health care providers to
meet their cultural needs and therefore did not demand

zie observe
cultural attitud behaviors, and expres-

This process is
essential for the researcher so that hon-

dible, and in-depth data may be discovered with the
mants (McFarland & Wehbe-Alamah, 2015, 2018).
Te Domain of Inquiry Enabler is a statement made by

TEsearchers when guided by the culture care theory

ung the ethnonursing method to cdearly focus his or
2 of study (Wehbe-Alamah, 2018b, p. 59). The domain
rses questions or ideas related to the focus of the
t is purpose, and goals related to culture and care and
Sch is a ‘succinct, tailor-made statement focused directly
specihcaly on culture care and health phenomena
nge,2002, p. 92). This domain is carefully worded and
arigorously examined for adherence to theory tenets and
miptions using the six qualitative evaluation criteria
atbe-Alamah, 2018b, p. 52).
LAmnger’s Semi-Structured Inquiry Guide Enabler to

5 Culhure Care and Health (Wehbe-Alamah, 2018b, pp.

was developed by Leininger with open-ended ques-0 a5Sist the nurse to discover and understand the difter-
ensions related to cultural worldview, social structure,
aother domains of inquiry” (Wehbe-Alamah, 2018b,

that their cultural and social needs be recognized or met

(Leininger, 1970, 1978, 1995; Leininger & McFarland,
2002, 2006; Mckarland & Wehbe-Alamah, 2015, 2018).
Third, until the 1990s, transcultural nursing articles sub
mitted for publication were often rejected because journal
editors did not know, value, or understand the relevance
of cultural knowledge or transcultural nursing as essential
to nursing. Fourth, the concept of care was of limited
interest to nurses until the late 1970s, when Leininger

began promoting the importance of nurses studying
human care, obtaining background knowledge in anthro-

pology, and obtaining graduate preparation in transcul-
tural nursing, research, and practice. Fith, Leininger contended

346 UNIT IV Theories and Grand Theories

International Jou Human Caring, Journa of Cultural
Diversity, and

diverse global cultu to guide effective, ingful, and evidence-babased nursing practices.

Journal of Transcultural Nursino
at nursing remained too ethnocentric and far to adner ent to following interest and directions of organized vves CTh medicine. Sixth, nursing was slow to make substantive Progress in the development of a distinct body of knowl Cage because many nurse researchers had been far too dependent on using quantitative research methods.
Contemporary acceptance and use of qualitative researchmethods in nursing has continued to grow and evolve and
willcontinue to provide new insights and knowledge related to nursing and transcultural nursing (McFarland & Wehbe-Alamah, 2015a, 2018b).

transculturally focused professional
ally publish research and nal journalstheoretica

internatisy perspectiv e, benef
eical, mea

Education
The inclusion of culture
curricula began in 1966

where Leininger was professor

d comparative

care in nursiat the iversity of
Colora ogy. Nurses’ awareness of the importance of

or of nursing and
anthro

Beginning with the 1970s, nurses began to real1ze the importance of transcultural nursing, hunman care, and
qualitative methods. Leininger stated: culture catrehut very lew

nuy

gradually began during the late 1960s
educators were adequately prepared to teach

coursesthe world’s firs
masters

an

transcultural nursing. After
doctoral programs in transcuultural nursing

We are entering a new phase of nursing as we value
and use transcultural nursing knowledge with a focus
011 human caring, health, and illness behaviors. With
the migration of many cultural groups and the rise
of the consumer cultural identity, and demands in

culturallhy-based care, nurses are realizing the need
for culturally sensitive and competent practices. Most countries and communities of the world are multicul-
tural today, and so health personnel are expected to
understand and respond to clients of diverse and simi-
lar cultures.

and implemented in 1977 at the Univers: were;
nurses have become specifically prepared’
nursing. With the heightened public
care costs, diverse cultures,

temporary society worldwide, there is much e
for comprehensive, holistic, and transcultur- professionals to provide
holistic care. Leininger’s advocacy for culture.c

Utah, mari
nscuhuraess of hedih

scultural health high-quality, comprehe
based on theoretical constructs has been Cris itical f

a

nger, 1991, 1995, 1996; Leininger & McFarland
discovery of diverse and universal aspects of Cars

200
Immigrants and people from unfaniliar cultures

expect nurses to respect and respond to values, beliefs,
lifeways, and needs. No longer can nurses practice uni-
cultural nursing.”

2006; McFarland & Wehbe-Alamah, 2015a, 2018 D186). critical need remains for nurses to be educated in t fransaul. tural nursing in undergraduate, master’s, and doct ctoral pro grams. There is also a need for well-qualified
prepared in transcultural nursing to teach and to mi research in nursing schools within the United States and other countries (McFarland & Wehbe-Alamah, 201
2018b; Mixer, 2015).

Leininger continued to receive numerous requests to tead
courses, give lectures, and conduct workshops on human caz
and transcultural nursing in the United States and oth
countries until her death in 2012. Therefore, Leininger hai
put out a call for schools of nursing to offer transcultural po
grams to meet the worldwide demand for transculunah

prepared nurses in many cultures (Leininger, 1991, 195
These nursing programs remain urgently needed for practie
education, research, administration, consultation, and in te

preparation of transcultural nurses for certification. l:
demand for transcultural nurses far exceeds available tas

culturally prepared nursing faculty, educational fundng
other resources (McFarland & Wehbe-Alamah, 20
20185). Although the societal demand for transclt
nurses is evident, educational preparation remains limic

many nurses worldwide.

facult
(M. R. McFarland, personal

communication, April 2002)

In the 21st century, the world continues to become more
culturally diverse, requiring nurses to prepare themselves to
provide culturally congruent care. Some nurses may experi
ence culture shock, conflict, and clashes as they move from

one location to another or from rural settings to urban

communities without having first had some transcultural
nursing preparation. As cultural conflicts arise, individuals
and families experience less satisfaction with nursing and

medical professional care practices (McFarland & Wehbe-
Alamah, 2015a, 2018b). Nurses who travel and seek
employment globally experience cultural stresses. Transcul-
tural nursing education has thus become imperative for all
nurses worldwide. Transcultural Nurse Certification by the
Transcultural Nursing Society provides a major step toward
ensuring safe and culturally conmpetent nursing practices
(McFarland && Wehbe-Alamah, 2015, 2018). Accordingly,
more nurses seek transcultural certification so as to be able
to provide culturally congruent care for their clients. The

M. Leininger: Iheory of Culture Care Diversity and Universality rER 22 Madeleine
GHAPTER22

347

oW use i
education, and admi

in nursing

Leininger’s culture care theory
Gender differences and roles
Fiders and generational differences

Communication ministration. This
focused specifically on
research method (eth-

care practices (Leini

& McFarland,
2002, 2006; McFar-

Bb). Funds to support

carch, History of past trauma
Importance of respect

Leininger & McEa

Herhbe-Alamah,
2015a

200″es (
(er

mly one

has a specific

ulturesand Culture care maintenance and/or preservation (read
ing the Qur’an); culture care accommodation and/or

negotiation (accepting treatment in addition to religion
ana culture care repatterning and/or restructuring (dis-

Continuing stimulant khat) were new ways for nurses to
provide culturally congruent and safe mental health care

for urban-dwelling Somali immigrants to the United States.

APplication of the culture care theory to advanced practice

nursing has been explicated by several contemporary trans-
cultural authors (Chatham& Mixer, 2020; Eipperle, 2015a,

2018b; Embler et al., 2018; Hascup, 2018; Kelch & Wehbe-

Alamah, 2018; Lee, 2018; Mixer et al., 2015; Wehbe-Alamah,
2018a, Wehbe-Alamah et al, 2020) as necessary for “appro
priate client culture-specific focus and care to prevent cultural

imposition or cultural pain” (Eipperle, 2018, p. 330) using the

three culture care modes, the enablers, and the ethnonursing

method. These authors emphasized integration of culturally
congruent or sensitive care through direct and explicit
approaches to be used by the nurse practitioner. Concepts and

methods for integrating emic and etic care approaches into

primary care practice and use of the education-research-
practice continuum form the basis for clinical care decisions
and actions (Eipperle, 2015a, 2018b).

nt

te
ama

that

Nonetheless,

transcult

unds

elies

Ppo

funds (Strang
& Mixer, 2016). hese

research with students

are

limited
in most:

uhural mu

and

techniCal

research

fund

cultural

ursing
research conduc their

erences
and structional programs

anscultural
nurses and other nurses

ite linited fiund

oaders
in

sharing

their
researc

aN eaaders,

Scu
cultural

nursing

worldwi

ues at conferen lwide and have been
d o lransCultur:

menlal in .

transcultural nursingiin

demands for cultur
opening doors to

zations. Despitesociet

n
sensitive,

and
responsible re, national

zations began
to support transcul-

Ds. Through the persistent

tencies of
transcultural nurse

has been made. Transcul-

Ynational organizat

only
in the

1990s
nterna

acting competen

bstantive progress

inspired many
other nurses to pursue

aiTsingonl

SS SUbSstant

nurseshave inspire

and to o discover
entirely

neW Culture care knowl-

‘nursing

Alamah & McFarland,

(McFarland,
2018a Wehbe-Alamah, 2019;

2020). This knowledge will

hape and
transform

current and future nursing

es (McFarland,
2018a; McFarland & Wehbe-

2015a, 2018b; Wehbe-
Alamah, 2019;

Wehbe-Ala-

amah.

McFarland, 2020).

let al (2014)
conducted an ethnonursing study about

FURTHER DEVELOPMENT

Leininger predicted that all professional nurses in the world
must be prepared in transcultural nursing and must dem-

onstrate competencies in transcultural nursing (Leininger,
1988b, 1995; Leininger & McFarland, 2002, 2006; McFar-
land &Wehbe-Alamah, 2015a, 2018b; Mixer, 2008). Trans-
cultural nursing must become an integral part of education
and practice for nurses to be relevant in the 21st century.

Currently, the demand for prepared transcultural nurses far
exceeds the numbers of nurses, faculty, and clinical special-
ists in the world. Significantly more transcultural nurse
theorists, researchers, and scholars are urgently needed to
continue to develop a new body of transcultural knowledge
and to transform nursing education and practice. All nurses
need to have a basic knowledge about diverse cultures in the
world and in-depth knowledge of at least two or three cul-
tures (McFarland & Wehbe-Alamah, 2015a, 2018b). Leini-

nger believed that transcultural nursing research had
already begun to lead to some highly promising and difter-
ent ways to advance nursing education and practice (Leini-
nger, 1991, 1995; Leininger & McFarland, 2002, 2006;

care
eliets and

eriences of Somali immigrants living in

e Midwestern city
in the United States. Through in-depth

sTuctured interviews,
the researchers sought to discover

mental health
care meanings, beliefs,

and practices of the

imali people in their
new urban context. The purpose of this

arch was to gain emic
and etic culture care knowledge

dissemination to mental
health nurses and providers

enable provision of culturally congruent and
beneficial

zantal health care for Somali immigrants. Open-ended ques-

ns adapted from Leininger’s Semi-structured Interview
ikeaided the researchers in conducting the interviews.
itnodemographic data were also collected and quantitatively
agaed. Leininger’s Four Phases of Data Analysis Enabler
gided the qualitative data analysis and development of pat-

EIS, categories, and thermes. The culturally congruent care
dngs influencing mental health care acceptance included:
Significance of religion
inbal connectedness, cultural history, and khat (native

fowering herbal plant) usage

348

Ab). It is
imporlant ta a

UNIT IV Theories and Grand Theories

Wehbe-Alamah, 2015a, 2018b), I
based knowledge

the explicati

McFarland & Wehbe- Alamah, 2015a, 2018b). Health discl-plines including medicine, pharmacy, and social work nave
gradually begun to integrate transcultural health knowicage
dna practices into their programs of study (Leininger,
995).This trend has thus incrcased the demand for cultur
ally competent faculty to teach transcultural health care.

Present and future theories and studies in transcultural
nursing will be essential to mect the needs of culturally
diverse people. The culture care theory will continue to
grow in importance worldwide. Both universal and diverse

care knowledge are extremely important to establish a sub-
stantive body of transcultural nursing knowledge, and to

Support nursing as a transcultural profession and disci-
pline. Leininger’s theory has gained global interest and use
because it is holistic, relevant, and futuristic and deals with
specific, yet abstract., care knowledge (McFarland & Wehbe-
Alamah. 2015, 2018, 2019: Wehbe-Alamah, 2019; Wehbe-
Alamah & McFarland. 2020).

and obtain culturally

Srom the worldview. The theory allows fo
ple conceptual elationships and

diverse
socal.

ture factors that influence care
Wehbe-Alamah, 2015, 2018). nd health (Mc

diatar Generality
The culture care theory demonstrates
ality because it is a qualitatively the criterio
broad, comprehensive, and worldwid.
enables the nurse to address the Dro

perspective of a multicultural

ide in
scope. The the TOvision oi care from Jview. It is

uSeid

theory thd
applicable to groups and individuals with the viding culture-specihc nursing care (M
Alamah, 2015,2018). The broad constru arland & wa
and described for study with specific

ltures. The
Dot

culture care research has led to a vast
amour knowledge. Many aspects of culture.. care, been and continue to be identified aand h

neatth practice of culturally congruent nursingcare on More reser
CRITIQUE OF THE WORK

is needed for comparative tudy of culture-s -speciic and versal care knowledge (McFarland & Wehbe- Ala 2018). More of the worlds cultural groups
ied to confirm their care constructs for

Clarity

o be ste

transfer

The culture care theory enables a broad, holistic, compre-hensive perspective of individuals, families, cultures, com-
munities, and populations. Nurse researchers and others
continue to develop many domains of inquiry using the
theory to pursue scientific and humanistic culture care
knowledge. Nurses seek both universal and diverse cultur-
ally based care phenomena held by diverse cultures. Using
the theory requires gaining basic conceptual understand-
ings and cultural knowledge. Leininger found that under-
graduate and graduate nursing students alike were excited
to use the theory and discover how practical, relevant, and
useful it can be to their work. As the cognitive map of the
theory, the Sunrise Enabler helps nurses to better visualize
the theory and thereby understand its application to nurs-
ing practice and research.

icarandt
discoveries to diverse groups and settings (McF Wehbe-Alamah, 2015, 2018).
culture care theory and the eth

continue to be used to provide culturally cons
care in a variety of health and community ot i
wide as well as to transform nursing education
(McFarland & Wehbe-Alamah, 2015, 2018).

Findings from the
use of nonursing research me

No

pract

Accessibility
been the empirical paradign

Simplicity
The theory is truly transcultural and global in scope; it is
both intricate, elegant in its simplicity, and applicable to
nursing practice. It is used by researchers to guide the dis-
covery of transcultural nursing knowledge and qualitative
research methods to explicate culture care phenomena.
Leininger’s culture care theory is relevant worldwide to
help guide nurse researchers to conceptualize theoretically based research questions and findings to guide practice
(McFarland & Wehbe-Alamah, 2015, 2018). It is holistic
and comprehensive in nature with key constructs related to
worldview and key cultural and social structure dimen-
sions as depicted in the Sunrise Enabler (McFarland &

Qualitative research has
discover largely unknown phenomena of care and heal diverse cultures using the culture care theory. Qualiamapproaches differ from traditional quantitative rese methods. The ethnonursing research method, the quai tive method developed by Leininger for use with the the of culture care diversity and universality, uses the crtera
credibility, confirmability, meaning-in-context, recure
patterning, saturation, and transferability to evaluate t
empirical nature of ethnonursing research findings (Mc
land & Wehbe-Alamah, 2015, 2018). Using these criter
within the ethnonursing research method, 164 care con
structs have been confirmed with more continually
discovered. The data discovered with the use of the ethnom
ursing method and discovered from the emic or peop
worldview leads to high credibility and confirmabilityot
research findings (McFarland & Wehbe-Alamah, 20
Ongoing and future research is predicted to reveal a

eine M. Leininger: Iheory of Culture Care Diversity and Universality
HAPTER22

pTER 22 Madeleir

health findings
and implications for

349

ing for culture care knowledge acquisition and applica-
tion (McParland & Wehbe-Alamah, 2015, 2018). The nscultural care practices and nurs-

discovered body of trans
met the evaluative /

ulhtre

cre
and

uivocally lhe

neq

ledge that has
ncory 1s highly useful, applicable, and essential to nurs-
ng practice, consultation, education, leadership, research,
and administration. The concept of care as the primary
and central focus of nursing and the basis for building
nursing knowledge and its application to practice is essen-
tial to advance culturally congruent nursing knowledge

and care practices (Eipperle, 2015, 2018; McFarland &
Wehbe-Alamah, 2015, 2018). The social structure factors
of the Sunrise Enabler and the three culture care modes or
decisions and actions guide the provision of culturally
Congruent care. The theory of culture care diversity and

universality supports a sound, culturally, and socially
responsible discipline and profession, and it guides nurs-
ing practices to meet the care and health needs of a mu-

ticultural world (Wehbe-Alamah et al., 2020).

ecades has had significant infl yl nursine
ia O1eT nepast

Hin ing knowledge

ng care
practices as well as the

jon
of many

health care systems (Leini

ininge
& McFarland 2002, 2006:

ional nursing

t1 ana unction

1091, 199;
amah, 2015a, 2018b).

nd& Wehbe-Alam.

diversity and versality has
lture care

nursing care
tor meaningful and

theorr ol culture

outcomes. Provid

are is a
vital, necessary, and essen-

emporary nursing (Eipperle,

is central
to the domain of nurs-

ture-specific,

fi ial

cient
ou

ongruent.

ed goal
in

contenm

SUMMARYy

hapte.

the nature, importance,
and major features tures. Other disciplines have found the theory and the method

very helpful and valuable. Newcomers to the theory and the

method can benefit from experienced expert mentors, in

addition to studying previous transcultural research con-

ducted using the theory and the method. Most importantly,
nurses often express that the theory is very natural to nursing

and helps one to gain fresh new insights about care, health,
and well-being. The theory continues to guide the building of

nursing knowledge and discovery of new applications of
practice using the three culture care modes of decisions and

actions in an increasingly multicultural and global society
(Wehbe-Alamah et al, 2020). Research guided by the theory
provides a credible pathway to advance the profession of
nursing and the body of transcultural knowledge for applica-
tion in nursing practice, consultation, education, leadership,
and research worldwide.

.oi culture care diversity
and universality were

thThe ethnonursing
research method and the

nresented to show
the ht between the theory

ers were

hod, Knowledge
of both the theory and the

and
the

method (with the enablers) leads to credible

a
olistic

human care theory in nursing, the culture

thod is neede eded before
an nonursing study can be

len, Fully
understanding

and using both the the-

meaningful study findings.

greatly valued
worldwide. Nurses who use the

an the method frequently
communicate how valu-

nd important it
is to discover culturally based ways to

and practice nursing
and health care. Practicing nurses

hare holistic, culturaly
based research findings for use in

E for dlients of
diverse and similar cultures or subcul-

CASE STUDY

20-vear-old temale first-year nursing student from main-
erd China presented to the university health clinic with

ormpjarnts of persistent but stable upper abdominal pain
Sve rad been seen on two occasions by physicians at a

aurgent care center and again in the hospital emer
HCy r00m. Her recollections about these visits and the
He and treatrment received were unfamiliar and there-

records access and the lateness of the hour. The student

was very distraught because her symptoms mirrored

those of her grandfather who had recently died after suf-
fering with gastric cancer for 2 years. As an international
student, she lived on campus while her parents remained

in China

Ye unclear. She had no other signs or symptoms. He-
TErBl of her rmedical records when seen by the nurse
VEAtoner was hindered by lack of interorganizational

As a transcultural nurse, how might you use the three

modes of culture care decisions and actions from the

theory of culture care diversity and universality to provide

culturally congruent care for this young woman?

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