The practice of nursing in today’s multicultural societies calls for nurses to identify and meet the cultural needs of diverse groups of people; to understand the social and cultural reality of the client, family, and community; to develop expertise in the implementation of culturally acceptable strategies for the provision of nursing care, and to identify and use appropriate resources for health teaching that is acceptable to the client. Undeniably, this cultural diversity necessitates that the care provided be compatible with the needs of the culturally diverse population.
Madeleine Leininger is recognized worldwide as the founder of transcultural nursing, her theory is known as the Theory of Culture Care. Culture Care or Transcultural Nursing deals with nursing and the culture of the clients (Leininger, 1997). In order to provide culturally sensitive, individualized, and holistic care, nurses and other health care professionals must embrace Madeleine Leininger’s Transcultural Nursing Theory, which promotes cultural sensitivity in the provision of care to a culturally diverse group of patients (Leininger, 1997).
Overview of the Theory of Culture Care
Madeleine Leininger realized in the mid-1950s that care and culture were the two major and significant nursing phenomena that had not been formally and systematically studied. She then began to investigate these phenomena in order to advance nursing science knowledge from a global transcultural nursing perspective. Reflecting on her educational and practice experiences, it became evident to Leininger that care and culture were invisible and unknown phenomena that had obviously been ignored as essential knowledge and skills to advance nursing as a discipline and profession (Leininger, 1997).
Her awareness of these major deficits in nursing enabled her to foresee the need for a body of humanistic and scientific knowledge with concomitant skills she called transcultural nursing, as essential to help nurses care for people of diverse culture in the world (Leininger, 1997). Further, Leininger foresaw growing evidence that nurses needed transcultural nursing knowledge to function in a rapidly changing multicultural world. She was concerned about how nurses could care for people of different cultures without been formally prepared in nursing education which necessitated research-based knowledge.
The major features along with the ethno nursing research designed to fit the theory has been used to ascertain a lot of new cultural care data (Leininger, 1997). Description of the Theory: Goal, Underlying Assumptions Transcultural nursing addresses the cultural dynamics that influence the nurse–client relationship. Leininger developed the Theory of Culture Care: Diversity and Universality with the goal to provide culturally congruent holistic care intended to contribute to the health or wellbeing of people, or to help them face disabilities, dying or death (Leininger, 1997).
In other words, the goal of Leiningers theory is to provide care measures that are in harmony with an individual or group’s cultural beliefs, practices, and values. Several specific assumptions are incorporated in the Leininger’s theory that supports its premises. These assumptions add depth, clarity and meaning to the general focus of the theory. One of the key assumptions is that care is an integral component and the essence of nursing. In addition, theory assumes that caring is fundamental for well-being and health, survival, growth, healing, as well as facing death or illness (Chiarella & Lau, 2008).
Another significant assumption is that the central purpose of nursing is providing service to human beings in illness, if dying, and in health. The well-being of clients enhanced by healthy, beneficial, and satisfying cultural based nursing is another assumption held by the theory. The influence of language, worldview, as well as spiritual, religious, political, environment, social, economical, educational, and technological factors is also an assumption.
The final assumption is the fact that nursing care that is culturally beneficial can only be provided when the nurse providing the care has knowledge of cultural care expressions, patterns, and values (Kardong-Edgreen & Campinha-Bacote, 2008). The concepts of Person, Environment, Health and Nursing Unlike other nursing theorists, Leininger did not put emphasis on basic concepts of person, environment, health, and nursing, which are usual nursing metaparadigms that most nursing theorists utilize. Leiningers theory instead, emphasized different metaparadigms.
First, she considers nursing as both a discipline and a profession. The term ‘nursing’ according to her, cannot explain the phenomenon of nursing. Instead, ‘care’ has the greatest explanatory power to explain nursing. Leininger (1995) views ‘caring’ as the verb counterpart to the noun care and refers it to a feeling of compassion, interest and concern for people. When Leininger’s definition of care is compared to other transcultural scholars’ definitions, it appears that her view of care is wider than, for example, that of Orque et al. 1983), who depicted care as goal-oriented nursing activities, in which nurses recognize the patients’ ethnic and cultural features and integrate them into the nursing process as cited in (Giger, Davidhizar, Purnell, Harden, Phillips, & Strickland, 2007). Second, the nursing profession uses the term ‘person’ in a way that is limiting and binding, as the concept of ‘person’ does not exist in every culture. Further, Leininger (1997) argues that nurses occasionally use ‘person’ to refer to families, groups, and communities, although each of these concepts is different in meaning from the term ‘person’.
Third, the concept of ‘health’ is not distinct to nursing as many disciplines use the term (Leininger 1997). Fourth, instead of environment, Leininger uses the concept ‘environmental context’, which includes events with meanings and interpretations given to them in particular physical, ecological, sociopolitical and/or cultural settings (Leininger, 1997. ) Leininger’s Culture Care Theory focuses on the concept of care that is essential and important in nursing. Care’ best describes nursing because it is how nurse’s show their compassion and concern for the patient. Thus, knowing the patient’s unique cultural attributes and, at the same time assimilating it within the nursing process, will surely render culturally congruent care. Reason for Selecting Madeleine Leininger’s Theory The ever-growing number of patients from various cultural backgrounds creates a major challenge for nurses to provide individualized and holistic care based on each patient’s cultural needs.
This requires nurses to understand cultural differences in healthcare values, beliefs, and customs. Transcultural knowledge is important for nurses to acquire in order for them to become sensitive to the needs of patients from various cultures especially as societies become increasingly global and complex. Since nurses have the most intimate contact with patients and are responsible for formulating care plans that help meet the individual needs of patients, it is a necessity for them to understand, appreciate, and respond to the patients’ cultural preferences.
The most effective way to accomplish this is for nurses to increase their awareness of cultural differences and become knowledgeable about the cultural preferences of patients under their care. Further, Leininger (1997, P. 38) refers to culture as “the lifeway of an individual or a group with reference to values, beliefs, norms, patterns, and practices”. With the advent of holistic nursing care, knowledge of transcultural nursing plays a significant part in addressing the specific cultural need of a patient.
This knowledge can facilitate better communication, resulting in an effective and trustworthy patient-nurse relationship. Strengths of the Theory Canadian society is quickly becoming increasingly multicultural, making transcultural nursing a vital constituent of nursing care and, in turn, mandating that nurses are culturally competent in their daily practice. Culturally competent nurses have knowledge of other cultural ways and are skilled in identifying particular cultural patterns.
This allows for an individualized care plan to be formulated, in order to meet the established healthcare goals for the patient (Maier-Lorentz, 2008). In addition, nursing practice involves providing care that is holistic. Holistic care means planning care to meet patients’ individual needs and cultures. In order to provide holistic care, nurses must account for cultural differences in their care plans because care plans are formulated based on individual needs. Having knowledge of the patient’s cultural perspectives enables the nurse to provide more effective and appropriate care.
For example, understanding one’s religious or cultural beliefs may be a deciding factor against the administration of a blood transfusion for a patient who is a Jehovah’s Witness since these individuals are forbidden to receive this treatment (Maier-Lorentz, 2008). It is clear that having specific knowledge of each patient’s culture ensures holistic and cultural competence in nursing care. Gap of the Theory Nurses are taught that veracity and fidelity are ethical principles that guide their interactions with their patients and their families.
However, in the Cameroonian culture, it is the family’s role to protect the patient from the anxiety and the stress associated with the knowledge of impending death. Cameroonians are especially protective and they believe it is their responsibility to protect friends and relatives who are mourning a close family member. In fact there is a protocol in place that Cameroonians need to follow before notifying family members of their deceased love one. This protocol requires us to ensure that there is enough support available before the bad news is revealed.
A friend of mine collapsed in the doctor’s office 7 years ago after been told during her prenatal visit that her 6 months old fetus had no heartbeat, meaning that the fetus was dead. She was told directly, with no husband, no friend or other family member there to support her emotionally. Not only that, she was sent home and was expected to come back two days later for a D&C. Her doctor was compassionate, but could not ease of her fear. This experience was so devastating that the couple decided to move back to Cameroon. Canadian nurses may encounter an ethical conflict when caring for patients from diverse origins.
They have learned to be truthful to patients in order to give them control. Yet, caring for people from other culture may prevent them from being open and honest about their health problems. It is the requirement that nurses must maintain cultural competency in their care as it is important for nurses to always be aware of cultural differences in health beliefs. But what is the likelihood that nurses would be able to obtain information about all their patients’ cultural perspectives in order to provide care that is culturally congruent with their patients’ views and wishes?
Leininger, (1997) postulates that communicating effectively cross-culturally, depends on the nurse’s ability to gain rapport with the client. Also, that the ability to adapt to different verbal and nonverbal communication styles where the culture of the nurse is different from that of the client, is another important skill needed to avoid misunderstanding and actions that may be unacceptable to the client (Leininger (1991) as cited in(Clarke, Andrews & McFarland, 2009).
Although Leininger’s theory paves the path for culturally congruent care, that is sensitive and empathetic (Leininger, 1997), one is left wondering how nurses can develop knowledge of the general beliefs, values, and health practices of all groups of people of diverse origins, especially when there is a language barrier. I believe that when performing a cultural assessment, learning about the patient’s family structure is crucial. Family is the basic social unit, and it defines how patients from different cultures view health and illness. Further, family can give nurses insight about their patient’s support systems.
Although these factors play a significant role in restoring and maintaining the patients’ health, family is not always present at the point of care. I also suggest that nurses use interpreters effectively to communicate cross-culturally and to elicit accurate information. How Does the Theory Encompass the Nursing Process? A succinct cultural assessment is an effective way to obtain pertinent information about patients’ perspectives on important aspects of their care (Maier-Lorentz, 2008). For example, it is important for nurses to learn which foods are culturally important and acceptable and if there are certain foods that are not tolerated.
Not only do these questions guide nurses in planning care, but they give better insight as to which food are considered healthy and helpful when experiencing an illness. Additionally, a thorough assessment will identify whether the patient subscribes to alternative or traditional medicine. Leininger’s Transcultural Nursing Theory was established on six concepts: Assessment; Communication; Cultural Negotiation and Compromise; Establishing Respect and Rapport; Sensitivity; and Safety (Maier-Lorentz, 2008, pp. 9-42).
These core ingredients of culturally sensitive care can be applied at every step of the nursing process including: assessment, diagnosis, planning, implementation, and evaluation. For example, during an assessment of a patient from a different cultural background, the nurse first must be able to have self-awareness of his or her own values and beliefs so that he or she can be able to focus on the cultural aspects of the patient’s lifestyle and belief.
It is the effectiveness of the assessment that will determine how well the other steps of the nursing process will be accomplished. Any cultural bias or lack of cultural sensitivity during assessment will have a significant impact on the diagnosis, implementation, evaluation of nursing interventions and patient outcomes. It is critical to understand that the provision of culturally sensitive care will not only help a patient during his or her recovery, but it is part of fulfilling a patient’s primary health care needs and health promotion.
Health Promotion and Primary Health Care within the Theory of Culture Care Leininger’s culturally congruent care theory is possible when the following occurs within the nurse-client relationship: “Together the nurse and the client creatively design a new or different care lifestyle for the health or well-being of the client. This mode requires the use of both generic and professional knowledge and ways to fit such diverse ideas into nursing care actions and goals.
Care knowledge and skill are often repatterned for the best interest of the clients…Thus all care modalities require coparticipation of the nurse and clients (consumers) working together to identify, plan, implement, and evaluate each caring mode for culturally congruent nursing care. These modes can stimulate nurses to design nursing actions and decisions using new knowledge and culturally based ways to provide meaningful and satisfying holistic care to individuals, groups or institutions” Leininger, (1991) as cited in (Leininger, 1997).
One of the primary health care principles is to ensure accessibility of health care services, which are socially acceptable, affordable, and which encourages self-reliance to all individuals who require them (World Health Organization, 2012). However, for this to be possible, nurses must create an environment, which is receptive to diverse cultural beliefs in relation to health and lifestyle. It will be unethical and culturally insensitive to ignore a patient’s believe in herbal medicine and other traditional practices during sickness.
Several ethnic and cultural groups prefer to retain their original culture and heritage even when in foreign countries. This therefore, indicates that a patient of African descent with diabetes would prefer to retain her cultural heritage even when receiving nursing care in Canada. Rather than generalizing care by providing the general diabetic teaching given to all patients, nursing care for patients should be individualized, in such a way that it is in harmony with their cultural beliefs, values, and ideas. Amid the key intervention for patients with diabetes is lifestyle modification.
This may include formulation of a physical exercise plan as well as diet plan. Patients need to work collaboratively with the nurse to come up with a diet plan that includes foods that are culturally acceptable. For instance, there are some cultures where eating of certain foods is forbidden. In such circumstances, the nurse needs to work with the client to identify some of the foods that are culturally acceptable as well as those that are unacceptable. Analysis Generally, there are three modes of nursing decision and action emphasized in Leininger’s theory (Cuella, 2008).
The first action is that of preserving and retaining culture. Accommodation of cultural care is the second mode while the final mode of action is re-patterning and restructuring cultural care. The first mode entails formulation of nursing interventions and decisions that help individuals of a specific culture to preserve important values that may prove beneficial in improving their health and well-being. These values may also help patients to enhance their means of coping with sickness or dying.
The second mode of action is accommodation of culture care which refers to actions that help patients in negotiating with others to improve their health outcomes. In the case of the diabetic patient, this mode of action may involve talking with the patient concerning various ways they can use to integrate physical exercises into their daily schedules. The final mode of actions and decisions is re-patterning of cultural care which entails modification of the client’s lifestyles or formation of new lifestyles that would help in improving their health outcomes.
The changes and modifications that are made should take into account the cultural beliefs and values held by the patient. In the case of the patient with diabetes, this could involve discussions concerning ways of cutting back on sugar and cholesterol-rich foods. Each of the three modes can form a basis for providing nursing care for immigrant individuals diagnosed with diabetes. The nurse needs to keep in mind the fact that the modes of actions described will only be effective when there is collaboration between the nurse and the patient.
The eventual result would be attainment of culturally congruent care (Clarke, Andrews & McFarland, 2009). In the nursing literature, it is argued that an individual’s culture influences how illness events are perceived, and the need for nurses to provide culturally sensitive care is identified (Leininger, 2002). Many research studies have been conducted on the topic of Transcultural Nursing. One of them, by Ayaz, Bilgili, and Akin (2010) found that there were many challenges in preparing students and professionals to offer competent and sensitive cultural nursing care (p. 450).
These challenges are not only faced by students, but also by other health care providers in different settings. Ayaz et al. , (2010) stress the importance for nursing students to possess cultural competency through education and practice (p. 452). Health care institutions should continue to ensure that the learning needs of their professional staff in cultural sensitivity are met through continuing education. In summary, nurses who understand and value the practice of culturally competent care are able to effect positive changes in healthcare practices for clients of designated cultures.
Sharing a cultural identity requires knowledge of transcultural nursing concepts and principles, along with an awareness of current research findings. Culturally competent nursing care can only occur when client beliefs and values are thoughtfully and skillfully incorporated into nursing care plans (Papadopoulos and Omeri, 2008). With ‘care’ as the core of nursing, culturally competent nursing should guide the nurse to provide optimal holistic, culturally based care. Today nurses are faced daily with unprecedented cultural diversity because of the increasing number of immigrants and refugees.
Commitment to learning and practicing culturally competent care offers great satisfaction and many other rewards to those who can provide holistic supportive care to all patients (Leininger 2002). Transcultural Nursing ultimately paves the way for a deeper and more systematic communication between the nurse and the patient. It enhances the individuality of each person that problem-oriented approaches often tend to neglect. It has a simple premise and yet it is all encompassing. It is applicable to all health-care settings in a broad sense through its cultural understanding and consideration (Kardong-Edgreen, 2008).