This paper will outline Madeleine Leininger’s prominent theory, its origins, and its purpose. The discipline of transcultural nursing, its distinctive language, ethnonursing research method, and Sunrise Enabler tool will also be explored. These components equipped nurses to provide patients with individualized, appropriate care; this led to improved health outcomes. Finally, the effect of Madeleine Leininger’s contributions to nursing will be examined. Her idea of congruent care was the catalyst for a multitude of federal legislation making culture a requisite, legal consideration and convinced society of the benefits of cultural diversity.
Madeleine Leininger: Bridging the Cultural Divide through Care The hallmark of a true profession is the ability to demonstrate its unique body of knowledge (Mensik, Martin, Scott, & Horton, 2011).
Madeleine Leininger’s transcultural nursing discipline and its revolutionary companion theory meets this threshold. Counted as “the most significant breakthrough in nursing…in the 20th century,” she forever changed how nurses thought and spoke about healthcare (Leininger, 2002, p. 190). This paper will present a high-level overview of Madeleine Leininger’s contributions to nursing and their influence, as well as reveal the author’s connection to the theorist.
The Theory of Culture Care Diversity and Universality (hereinafter “Culture Care Theory”), Madeleine Leininger’s seminal work, was conceptualized in the mid-1950s and sought to describe, explain, and predict nursing similarities and differences in relation to care and its role in human culture (Leininger, 2001).
To provide significant and effective care, the theorist reasonsed, a nurse had to know what various cultures valued about wellness, health, illness, etc.
and use this understanding to guide their nursing tasks (Clarke, McFarland, Andrews & Leininger, 2009).
The theory grew out of the theorist’s observations during her tenure as a staff nurse in the mid-1940s (Leininger, 2001). Numerous patients emphasized the “nursing care” given and remarked how instrumental it was to their recovery from illness (Leininger, 2001, pp. 8, 13). This struck Leininger as curious, since the activities traditionally associated with providing care were just expected at this point in the development of nursing (Leininger, 2001). The concept of care was certainly never taught, critically explored, or given much credence (Leininger, 2001). Based on the encouraging patient feedback received, care became an integral component of the theorist’s nursing practice (Leininger, 2001). Her patients’ health flourished (Leininger, 2001). Leininger deduced that outstanding caregiving alone was not enough to facilitate positive health outcomes while working on an adolescent psychiatric ward in the mid-1950s (Leininger & McFarland, 2002).
Her clinical floor was a mini-United Nations, with patients from a variety of cultural backgrounds (Leininger & McFarland, 2002). The children responded differently to her care efforts and, after a period of time, she realized their behavior followed distinct cultural patterns (Leininger & McFarland, 2002). For example, the Russian, Lithuanian, German, and Slovenian children would never admit to being in pain, though they had very obvious injuries or signs of discomfort (Leininger & McFarland, 2002). The Jewish and Italian children, in contrast, always cried fervently, at even the slightest needle prick, without solace (Leininger & McFarland, 2002). Her customary pain interventions were useless and obviously needed to be changed, but she was not sure how (Leininger & McFarland, 2002).
The theorist experienced “culture shock” (a concept she introduced into common vernacular) and was concerned at being ill-equipped to respond to her patients’ specific needs even though she had obtained her master’s in nursing (Leininger & McFarland, 2002). There was no research literature available to help make sense of the incidents witnessed, and her colleagues were of limited help (Leininger & McFarland, 2002). After discussing her concerns with the renowned cultural anthropologist and provocateur Margaret Mead, Leininger obtained a Ph.D. in anthropology (Clarke, et al., 2009); she was the first nurse to do so (Leininger & McFarland, 2002).
The theorist performed field studies in non-Western cultures for several years afterwards to hone her new skill-set (Leininger & McFarland, 2002). Having remedied her cultural ignorance, Leininger formalized the Culture Care Theory, establishing the new discipline of transcultural nursing (Leininger & McFarland, 2002). Her goal was to provide knowledgeable care in an increasingly multicultural world (Leininger & McFarland, 2002).
The theory’s main purpose was to “discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups” (Leininger, 2002, p. 190). It stressed the use of “research findings to provide culturally congruent, safe, and meaningful care to those of diverse or similar backgrounds” (Leininger, 2002, p. 190). Theory Application Tools. The theorist did not want to espouse platitudes; she wanted her discipline to empower nurses and promote their autonomy (Leininger, 2002). To this end, she outlined thirteen assumptive beliefs to explain the focus of the theory and guide nurses in their practice (Leininger, 2001). Several key beliefs are outlined below:
These assumptions formed the crux of transcultural nursing and what it was intended to do. Leininger also designed three theoretical modalities to guide culturally-based nursing decisions and actions (Leininger, 2001). The first modality, “cultural care preservation and/or maintenance,” referred to generic/folk behaviors and practices that encouraged wellness and did not need to be changed when planning nursing care (Leininger, 2001, p. 41; Literature review, n.d.).
The next modality, “cultural care accomodation and/or negotiation,” involved nursing care activities which help patients of diverse cultures adapt or negotiate professional care activities (Leininger, 2001, p. 41). It encouraged the nurse to integrate generic/folk behaviors and practices when planning care to encourage healthy outcomes (Leininger, 2001). Under this modality, for example, a nurse would allow a patient to hang a healing amulet above their bed in the hospital because they believed in it and it calmed them (Literature review, n.d.). The final modality that nurses could utlize was “culture care repatterning and restructuring” (Leininger, 2001, pp. 41-42).
This modality involved activities which assist with the extensive modification, change, or repattering of a patient’s unhealthy behavior while remaining aligned with their cultural values and beliefs (Literature review, n.d.). This was the most difficult of all the modalities to employ because the nurse must know a great deal about the patient’s culture to have an optimal outcome (Leininger, 2001). As with any plan of care, the nurse had to discuss their choices with the patient and obtain their agreement (Leininger, 2001).
Since the introduction of Florence Nightengale’s Environmental Theory, nursing frameworks had traditionally focused on four metaparadigms: person, environment, health, and nursing (Dayer-Berenson, 2011). However, the Culture Care Theory broke with convention and selected care and culture as its foundational concepts (Leininger, 2001). Leininger found the standard four metaparadigms limited in scope and unsuitable for use in new discipline (Leininger, 2001). For instance, the theorist could not believe nursing’s pundits still refused to acknowledge the indispensible role of care, though they had obviously witnessed its successful impact on health (Leininger, 2001). She also considered the current trend of trying to explain nursing phenomenon with more nursing phenomenon a logical fallacy akin to answering a question with another question (Leininger, 2001).
Further, Leininger pointed out that the Western concept of person would be problematic in transcultural nursing because many cultures focused on the family or an institution, rather than the individual (Leininger, 2001). While Leininger thought environment was important, she opted not to use it as a pillar of her theory because it was not unique to nursing or provocative enough to garner scarce research funding (Leininger, 2001). She discounted the use of health for a similar rationale, citing its commonness and the plethora of existing research (Leininger, 2001). Leininger apsired to enlighten, not emulate (Leininger, 2001).
Other nursing theorists and researchers tried to shoe horn themselves into existing medical models as a means of gaining legitimacy, prestige, and funding (Fawcett, 2002). Leininger, conversely, sought to distinguish her theory from the disease-focused philosophies of the period by not seeking input from other disciplines; it functioned independently (Leininger, 2001). Always seeking to demonstrate the skill and intellect of nurses, Leininger authored a series of definitions to provide clinicians with their own distinct language and, thus, avoid the incongruous use of medical terminology when practicing transcultural nursing (Leininger & McFarland, 2002). Several of the theory’s key explanations are highlighted below:
Leininger’s theory generated little interest when it was introduced in the 1950s (Leininger, 2002). Nurses’ practices had begun to shift to include more administration of medication and assistance with complex medical treatments (Leininger, 2001). Additionally, they tried to emulate physicians by wearing stethoscopes, focusing on curative measures, and being very precise in their tasks (Leininger, 2001). Nurses, during this era, were medicine’s faithful “shot givers” (Leininger & McFarland, 2002, p. 76). Needless to say, this mindset was nurtured by physicians, who wanted nurses to remain on the periphery of healthcare, subservient to them (Fawcett, 2002).
Nurses, in Leininger’s opinion, willingly relinquished their power and diminished their professional value by becoming so immersed in physicians’ procedures (Leininger, 2001). With nurses so intent on obtaining medical validation, it was no surprise they found the Culture Care Theory “soft,” “fuzzy,” and “too feminine” (Fawcett, 2002, p. 133; Leininger, 2002, p. 75). The theorist jokingly recalled thinking, “Nurses have no time to learn about care and cultures, as they must keep to medical tasks!” (Fawcett, 2002, p. 113). Patient care was not a priority (Fawcett, 2002).
Undeterred by the initial chilly reception, Leininger resolved to make the discipline more relevant to nurses (Leininger, 2001). She knew the situation would change gradually over time and utilized the lull to increase the number of transcultural nurses in practice and cultivated the harvest of more cultural data for use in the field (Fawcett, 2002). Transcultural Programs of Study. She developed and taught courses in transcultural nursing (Leininger, 2001). Building upon this momentum, the theorist then established several degree programs of study in transcultural nursing (Leininger, 2001). She steered nurses toward graduate-level courses in anthropology as well, and served as their advisor when several of them continued on to doctoral studies (Leininger, 2001; Leininger & McFarland, 2002). Soon, she had amassed a hardy band of transcultural devotees to assist in her tireless promulgation and support of the discipline (Leininger, 2001).
Ethnonursing Research Method. As her followers began to utilze the theory, Leininger was compelled to develop a natural, inducive, and open research method to help “tease out” complex, covert, elusive cultural data (Leininger & McFarland, 2002, pp. 85, 89). It was called the ethnonursing research method (Leininger & McFarland, 2002). At the time, clinicians utilized research tools and methods borrowed haphazardly from other fields (Leininger & McFarland, 2002). Enablers. The theorist worried that valuable cultural knowledge was lost, concealed, or rendered useless from the improper use of quantitative instruments to perform qualitative research (Leininger & McFarland, 2002). In response, Leininger invented five tools she called enablers to facilitate the mining of cultural data (Leininger & McFarland, 2002). Each enabler was designed to collect a different type of qualitative information (Leininger & McFarland, 2002). The most popular enabler, The Sunrise Enabler to Discover Culture Care, was a conceptual model of the entire theory (Appendix A).
Its purpose was to systematically guide nurses through seven areas of influence to find relevant cultural knowledge and provide a holistic view during the health assessment process (Leininger & McFarland, 2002). Qualitative Criteria. To further support accurate interpretations and credible research findings, Leininger identified six criteria by which qualitative studies, like those performed with her ethnonursing method, could be evaluated (Leininger & McFarland, 2002). The criteria “credibility, confirmability, meaning-in-context, recurrent patterning, saturation, and transferability” received the endorsement of research experts, which led to qualitative data’s acceptance as valid scientific evidence. (Leininger & McFarland, 2002, p. 88) Dedicated Resources. Leininger also established the Transcultural Nursing Society in 1974 as a forum for intelligent discussion among nurses in the discipline, as well as to aid the dissemination of transcultural information (Clarke, et al.). Finally, Leininger launched the Journal of Transcultural Nursing in 1988 to serve as a dedicated publishing source for transcultural nursing research, ensuring the entire nursing profession also had access to her protegés’ useful findings (Clarke, et al.).
After existing in near obscurity for several decades, the Culture Care Theory was thrust into the spotlight in the mid-1980s (Murphy, 2006). Several factors prompted its emergence from the shadows. First, just as Leininger predicted back in 1950, geographic borders shrank and the U.S. became the adopted country of choice for immigrants from all over the world (Leininger, 2002). The healthcare system became innudated with people clinicians did not understand and could not effectively assist (DeRosa & Kochurka, 2006). Desparate to address patients’ needs in a culturally respectful manner, they discovered Leininger’s blueprint for congruent care (DeRosa & Kochurka, 2006).
The federal mandates of the 1990s further catapulted the Culture Care Theory into prominence (Murphy, 2006). The directives were designed to resolve disparities in healthcare and ensure equitable treatment for those from diverse backgrounds (Maier-Lorentz, 2008). This meant that academic programs, clinical settings, and healthcare agencies now had to promote, incorporate, and enforce Leininger’s ideas of cultural competence (Murphy, 2006).
The Culture Care Theory, developed organically from one woman’s insightful observations, has left an indellible mark on not only nurisng, but education, medicine, law, social science, religion, and so forth (Leininger, 2002). It would be far easier to name the areas of society that the theory has not impacted, for that would be a much shorter list. Amazingly, the author also owes Madeleine Leininger a tremendous amount of personal gratitude. While conducting research, the author was stunned to learn that Leininger’s theory was the motivation for her academic scholarship. The theorist’s emphasis on congruent care and its positive influence led to the Health Resources and Services Administration’s (HRSA) campaign to significantly increase the number of culturally competent healthcare professionals in critical shortage areas. The NURSE Corps Scholarship Program, which offers a full tuition grant, monthly stipend, and full-time employment to intellectually outstanding nursing students, was founded to accomplish this objective.
Because of the theorist’s tenacity and zeal, this future clinician’s ambition to serve the underrepresented was made a debt-free reality. Leininger passed away in August of last year (Ray, 2012). Ironically, the author was awarded her scholarship during this same month. Janet Jones wrote in Leininger’s obituary guest book entry, “She truly was a visionary and her work will continue to be of great significance to many more generations of nurses” (Madeleine M. Leininger, Ph.D., 2012). The author could not agree more with this statement and, in tribute, intends to contribute to Leininger’s legacy of nursing excellence by maintaining a culturally-informed practice, performing research that offers innovative knowledge to the profession, obtaining an advanced degree, and serving as a staunch advocate for the marginalized. Similar to the theorist, the author also pledges to refuse to accept limitations as to what a nurse can accomplish. The author believes Madeleine Leininger would expect no less.
Clarke, P., McFarland, M., Andrews, M., & Leininger, M. (2009). Caring: some reflections on the impact of the culture care theory by McFarland & Andrews and a conversation with Leininger. Nursing Science Quarterly, 22(3), 233-239. doi:10.1177/0894318409337020 Dayer-Berenson, L. (2011). Cultural
competencies for nurses: Impact on health and illness (pp. 9-39). Sudbury, Mass: Jones and Bartlett Publishers. DeRosa, N., & Kochurka, K. (2006). Implement culturally competent healthcare in your workplace. Nursing Management, 37(10), 18-18, 20, 22 passim. Fawcett, J. (2002). Scholarly dialogue. The nurse theorists: 21st-century updates — Madeleine M. Leininger. Nursing Science Quarterly, 15(2), 131-136. Jeffreys, M. R. (2010). Teaching cultural competence in nursing and health care inquiry, action, and innovation (2nd ed.). (pp. 9-10). New York: Springer Publishing Company. Leininger, M. M. (Ed.). (2001). Culture care diversity and universality: A theory of nursing. Boston: Jones and Bartlett Publishers. Leininger, M., & McFarland, M. (2002). Transcultural nursing in the new millennium: Concepts, theories, research & practice (3rd ed.). New York: McGraw-Hill. Leininger, M. (2002). Culture care theory: a major contribution to advance transcultural nursing and practices. Journal Of Transcultural Nursing, 13(3), 189-192. Literature review. (n.d.). Retrieved from http://uir.unisa.ac.za/bitstream/handle/10500/1555/02chapter2.pdf Madeleine M.Leininger, Ph.D. (2012). Retrieved from http://www.heafeyheafey.com/newobituary/display.asp?id=7022 McFarland, M., & Eipperle, M. (2008). Culture care theory: a proposed practice theory guide for nurse practitioners in primary care settings. Contemporary Nurse: A Journal For The Australian Nursing Profession, 28(1-2), 48-63. doi:10.5172/conu.673.28.1-2.48 Maier-Lorentz, M. (2008). Transcultural nursing: its importance in nursing practice. Journal Of Cultural Diversity,15(1), 37-43. Mensik, J. S., Martin, D., Scott, K. A., & Horton, K. (2011). Development of a Professional Nursing Framework: The Journey Toward Nursing Excellence. Journal Of Nursing Administration, 41(6), 259-264. doi:10.1097/NNA.0b013e31821c460a Murphy, S. (2006). Mapping the literature of transcultural nursing. Journal of the Medical Library Association : JMLA, 94(2 Suppl), E143-51. Ray, M. A. (2013). Madeleine M. Leininger, 1925–2012. Qualitative Health Research, 23(1), 142-144. doi:10.1177/1049732312464578 Sagar, P. (2011). Transcultural nursing theory and models: application in nursing education, practice, and administration. New York: Springer Publishing Company. Sitzman, K., & Eichelberger, L. W. (2011). Understanding the work of nurse theorists: a creative beginning (2nd ed.). (pp. 93-98). Sudbury, Mass.: Jones and Bartlett Publishers.
Transcultural Nursing Society. (n.d.). Theories and models. Retrieved from http://tcns.org/Theories.html
Appendix A
Figure. Adapted from Transcultural Nursing Society. (2013). Theories and models. http://tcns.org/Theories.html. Reprinted with permission.
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