The ever increasing multicultural world we live in today makes us see cultural competency as a really fundamental element in health care. A main feature of culture is its power to bring people together. Studying the concept of culture can lead to exceptional health care since it will establish a close bond between the patient and the health care professional.
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The cultural beliefs that a community may have will shape their own behaviors all along and, therefore, it will make it possible for medical treatment to be effected when culture becomes an obstacle. Being knowledgeable and sensitive to the social, structural, physiological, and cultural factors that affect health could make a difference in diagnosis, preventive care, or the overall health outcome. Nurses play an important role in patient care, and disease prevention.
Madeleine Leininger a pioneer in transcultural nursing has played an important role in educating nursing for the past 35 years. Her theory focus on changing patterns on the health care practices that will bring the efforts on strong nurse-patient relationship. To achieve harmony in health care, Leninger’s model depicts health is both universal and diverse; therefore nurses must be knowledgeable about the specific culture in which nursing is practiced. Health is cataloged as ‘Universal’ across cultures but it is distinct from each culture on the beliefs, values, and practices. Thus, the concept of health is the same for every culture but it is diverse on the manners that specific cultural approaches to care.
Theory Study of Madeleine M. Leininger
Leninger focused patient care from a cultural perspective. She describes nursing as a humanistic and scientific discipline as whole that focuses on human care and culturally meaningful ways to help patients achieve health. Nursing observation and decision are guided in her theory by Culturally congruent decisions that “are tailor-made to fit with the individual, group or institutional cultural values, beliefs and life ways in order to provide or support meaningful, beneficial and satisfying health care or well being services” (George, 2002).
Nursing is an expression of compassion reflected in the care and respect of individuals in society. Madeleine M. Leininger developed her theory from her strong discipline and concern with understanding people and their cultural backgrounds to excel on patient care. Madeleine M. Leininger was born in Nebraska in 1925. Nurse pioneer graduated from Saint Anthony’s School of Nursing in 1948. She continued her education in Mount Saint Scholastica College, where she obtained her bachelor’s degree. Afterwards, in 1954 she acquired a master degree in science from The Catholic University of America and in 1965 a PhD in cultural and social anthropology from the University of Washington DC (George, 2002).
In 1950, Leninger during time she worked as clinical nurse in a child guidance home with disturbed children experienced what she describes as a cultural shock. She noticed the recurrent behavioral differences among children, what made her realized these differences had a cultural base. After, continuous observation she concluded that these missing links have a factor base in cultural knowledge and understanding. In the 1960’s with her observation and educational background; she developed the terms trans-cultural nursing, ethno-nursing and cross-cultural nursing (George, 2002).
Leninger keep building her theory of transcultural nursing on the foundation of her observation and how people from each culture can perceive their nursing care and experiences differently according to their health beliefs and practices. Based on Leninger’s theory of transcultural nursing, the care nurses provide on their patients is derived and shaped from the cultural context in which it is to be provided.
Leininger defined in 1978 transcultural as:
“a substantive care of study and practice focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different culture with the goals of providing culture-specific and universal nursing care practices in promotion health or wellbeing or to help people to face unfavorable human conditions, illness or death in culturally meaningful ways ” (George, 2002).
Leininger defined in 1979 ethonursing as: “the study of nursing care beliefs, values and practices as cognitively perceived and known by a designated culture through theirs direct experience beliefs, and values system” (George, 2002).
The theory of Culture Care emphasizes that cultural awareness it is fundamental to develop an excellent discipline in the profession of nurses. Culture is an important aspect to understand society. Leininger studied how individuals of each culture interpret nursing care practices in different ways. Her studies help her construct the concept of trans-cultural theory. In 1991, she stated, “human care is central to nursing as a discipline and as a profession.” With this statement, nursing care was a profound fact that knowledge and care are an important aspect in nursing care practices. She also developed another important cultural concept in her theory that relies on the fact that every culture has both health care practices; she defines one of the practices as the specific culture of the individual and the other as prevailing patterns which are common across cultures. From these concepts are born the terms of Universality and Diversity (George, 2002).
World War II brought a complete change into the nursing field. During war time 1939-1945, there was a reemergence of new nurses as the government developed programs to entice women into the nursing profession. The US Cadet Nurses Corps from 1943 to 1948 aim in the recruitment of nurses. Many women were offered books, tuition, housing, and stipends if they decided to embark in a nursing career and assist during war. From this point on, we can appreciate how in the nursing discipline became important cultural knowledge. More than 59,000 American Nurses served during war. Nurses worked close to the front lines and served under fire in field hospitals and during evacuations. They also served on hospital trains, ships, and as flight nurses on medical transport (Bellafaire, 1998).
Army nurses experience on the field gave them self-confidence and the desires to grow professionally. When they returned to the United States, many opportunities to pursue career and further education were given to nurses. War World II forever changed the nursing profession, as society was ready to accept nurses as professionals in the medical field and as members of the health care system (Bellafaire, 1998).
During war, nursing was acknowledge as profession and as result nursing studies began to grow. Also, educational programs were not as limit as before. Before war nursing programs were not available in every university, the first nursing masters programs was offered by Yale University in 1923 and the first doctoral program was offered by the University of Columbia in 1929. After war ended, a research trend in nursing began to sprout. In 1950’s the American Association (ANA) begun a 5-year study on nursing functions and activities. The study developed functions, standards and set the qualifications for professional nurses in 1959 (Burns & Grove, 2005).
After the war ended, the baby boomers era stated during 1946 to 1964 more than 75 million babies were born. Health care was needed for the emergent population. The demand for nurses increased and many women nurses decided to get married and stay home with their family leading to a shortage of nurses. Also, during the 1960’s government created Medicare and Medicaid increasing the possibilities of people receiving health care leading to the overall demand of nurses in the United States (Bellafaire, 1998).
The high demand for nurses created the need of developing studies that determined the most effective educational preparation for registered nurses. These studies were conducted during the 1950s and the 1960s by Mildred Montag, a nurse educator who developed and evaluated a 2-year associate degree. In 1953, an Institute for Research and Service in nursing was created at Columbia University; the program was aimed to provide research and learning experiences in doctoral students. Later in 1957, The Walter Reed Army Institute of Research established a department of nursing research. This was the first nursing entity that carried out clinical research (Burns & Grove, 2005).
Between 1950’s and 1960’s we can find numerous clinical studies that focused on the quality of care and how nurses can developed a criteria to measure nurse-patient intervention success. During this time nurses were acknowledge as part of the health care system and the increasing demand of nurses created advance study programs for professionals leading to more clinical research and encouraging nurses to find ways to improve patient care (Burns & Grove, 2005).
Leninger’s theory of Cultural Care, Diversity and Universality, can be apply to everyone as a group or individual since we all form part of a cultural group. The theory can help recognized when a nurse can experience a cultural shock and how can correctly approached cultural differences to deliver the best care. This theory requires critical thinking from the nurse as involves collecting and using data to support overall decisions on patient care (George, 2002).
This theory is universal and can be found in any place where nursing care is delivered. Leninger’s theory has been study by many other researchers who have used the theory as a guide and today is the frame of many nursing organizations. Not only on research and organizations Cultural Care theory has been spread, the education of nurses around the world has also been impacted with Leninger’s framework (George, 2002).
Dr. Leninger is considered an international scholar and worldwide founder and pioneering of the field of transcultural nursing. Leninger has spread her word in over 220 articles and 28 books around the world. Among her most important works we can include; the significance of culture in nursing (1967), Nursing and anthropology: two worlds to blend (1970), and Transcultural nursing concepts, theories, research and practice (1978) (Akram, 2001).
Research on cultural diverse care has been detail in studies from many other researchers including; American Gypsies (Bodnar & Leininger, 1992, 1995); Anglo and African American elders in long-term care (McFarland, 1997); Culture and Pain (Villarruel, 1995); the Gadsup of New Guinea (Leninger, 1991, 1995); Muscogee Creek Indians (Wing & Thompson, 1996); Old Order Amish (Wenger, 1991, 1995); etc (George, 2002).
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Some organizations found today that share Leninger’s values and beliefs are; Cultural Diversity a non-profit organization dedicated to increase cultural awareness among nurses and propose solutions when problems of bias conflict arise. The organization is run by Victor Fernandez RN BSN and Kathy Fernandez RN BSN. The organization is aim to promote workshops, guest speaker appearances focused to teach student nurses increase awareness of cultural diversity they also offer a web-based center that promotes interactive teaching and learning content about transcultural nursing (Fernandez, V. & Fernandez, K. 2008).
Another non-profit organization is Transcultural nursing society, their mission is to “enhance the quality of culturally congruent, competent, and equitable care that results in improved health and well being for people worldwide” (Leininger, 2010). This organization based their beliefs on Leninger’s work and theory.
Madeleine Leininger has provided transcultural knowledge across the world. Her theory has been used widely spread across nursing and other fields. As cities get multi-culturally populated, nurses need to identify and understand patient’s health status and illness to better assist and educate patient on their illness and condition. The future of transcultural care will continue growing in the research field to advance, reform, adapt, and serve population with diverse cultures. As Dr. Leininger stated nurses have to be educated and be ready for the future because culturally congruent care it is an fundamental in the nursing practice for the future of many cosmopolitan cities (Leininger, Madeleine and McFarland, 2002).
Leininger’s Sunrise Model established the interrelationship between Universality and Culture Care Diversity. The Sunrise Model centers its attention to individuals or groups with different socio-cultural backgrounds. The theory of culture care diversity and universality rises from a transcultural point of view in human care. “It provides a holistic rather than a fragment view of people.” (George, 2002) This Model extends to everyone that belongs to a culture and/or subculture. In addition, the model is relevant to any cultural situation. As a nurse, is important to recognize patient’s cultural identifier. In additions, is vital to assess patient care perception to provide a standing medical management and maximizes the outcome nurse-patient relation. Leininger has educated us for the past 35-years in transcultural nursing. The vast majority of nursing schools around the world and medical institutions have educated their students in patient perceptions and cultural identifiers like knowledge, behaviors, actions, and values, which play an important role in providing a safe therapeutic care (Akram, 2001).
Nurses that are specialized in different nursing fields report consistent use of Leininger’s theory; since, the well being of individuals and/or groups of diverse cultures are affected in a positive manner. In addition, nurses consider Leininger’s theory as an important tool to view human holistic care in a way that promotes well being. This holistic view utilizes specific assessment tools for an extensive selection of research problems used by many researchers. Some of the nursing researchers that have utilized Leininger framework include; Orque, Boyle & Andrews, Dobson, Ginger & Davidhizar. They have explored and investigate culture and its relationship to care (Leininger, 2010).
Leininger defined Nursing as:
“a learned humanistic and scientific profession and discipline focused on human care phenomena and caring actives in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their health or well-being in culturally meaningful and beneficial way, or to help individuals face handicaps or death” (George, 2002).
Leininger defined the profession of nursing as “a societal mandate to server people.” (George, 2002) Also, defined nursing as a discipline, “nursing discipline is expected to discover, develop, and use knowledge distinctive to nursing’s focus on human care and caring” (George, 2002). She stated that nurses need more transcultural education and awareness to reduced cultural stress and possible disagreement between nurse and patient. Three nursing actions have been recommended from Leininger. “These are culture care preservation/maintenance, culture care accommodation/negotiation, and culture care re-patterning /restructuring” (George, 2002).
The theory of Cultural Care offers a framework for the future study of new changes in culture. The development of this theory over the years has allowed testing the theory in a large number of cultures and researches; as well as potential future cultures can be analyzed under this model. Another strong point is the structure of this theory involves all parts in nursing care, such as the recipients and all health care providers. In the other hand, some limitations to this theory is Leninger’s theory requires nurses academically prepared to provide transcultural nursing care; however there are very few funds for research in this field, and support the further study of these practices. In addition, the sunrise model due to its complexity can be viewed as both; a strength or limitation. Its complexity can depict the importance of cultural behaviors in nursing practices; however, the model’s complexity can also lead to misinterpretation.
LP is a 45 years old Cuban American Male, aerospace engineer at Miami International Airport with no previous medical history. LP was found to be Diabetic type II after a routine medical checkup with his primary physician. The medical assessment indicates that the patient was for the past couple of weeks suffering of increased thirst and frequent urination. Diagnostic demonstrated a sugar fasting of 182 and A1C of 7.2. Dr LD Primary Physician ordered oral hypoglycemic medication metformin, diet, and exercise. However, he was encouraged by the MD to see his nurse educator before going home.
Nurse educator RD White American descendent reviewed the patient’s cultural background to develop a proper approach to teach the patient about his diabetes care. RD gave details to the patient about how to customize an 1800-calorie diet plan based on the most common meals for Cubans, exercise, as well as information of metformin.
RD in a compassioned and interested way explained how some typical foods can still be eaten on a daily bases but controlling the amounts and choice. For instance, for breakfast it is fine to have a hot cup of ‘café con leche’ (coffee and milk) with low fat milk and non-sugar sweeteners, also he could add a small serving of fruit of the size of a fist. For lunch, a small portion of black beans or any other legumes combined with a small portion of a stake or poultry, and for dinner Atlantic salmon fillet or tilapia, broiled with rice keeping a daily regimen of 1800 calories per day.
LP agreed to avoid foods with high concentration of sugars, carbohydrates and to keep food intake controlled to 1800 calories per day. LP verbalized understanding the educational care that was given to him and he stated, “I will be away from the beloved Cuban pastry, many sugary deserts, and sweet drinks and will measure the amount of carbohydrates, starch, fruit, and milk”. In addition, he was also made aware of hypoglycemic and hyperglycemic symptoms. Without losing eye contact from the nurse, he showed with a lot of emphasis of exercise and medication routine and gave multiple examples of hypoglycemic and hyperglycemic symptoms.
After three months of strict exercising, proper diet and insulin administration LP goes back to see his PCP for a follow up. A1C blood work shows a remarkable well controlled blood sugar levels. Patient verbalized to the PCP happily, “This is the product of having such of caring nurse that educate me well, every gesture, word, and care practice nurse passed onto me became a success to control my diabetes”
The case above reflects a nursing situation developed under the Leininger’s culture care theory. The nurse was taking into consideration Leininger ultimate goal of offering harmonious nursing care practice to patients of different cultures. RD nurse educator and professional practitioner were able to make clear and foresee patient well being through proper care meanings, patterns, and processes.
Society has been growing non-stop for the past decades and immigration from different countries has played an important role in the multicultural environment we live in today. Leininger has emphasized how important is to be cultural competent and nurses have to be prepare in transcultural nursing. She stated, “All nurses need to be prepared in transcultural nursing to serve culturally vulnerable populations and to develop professional competencies in transcultural nursing by the year 2015.” (Leininger, Madeleine and McFarland, 2002)
As clinicians, we have seen and been educated under her theory. In addition, we have been exposed to her cultural awareness into our everyday practice. For instance, we take into consideration many cultural aspects that take the human expression to a next level of humanity. As practitioners, we do not see patients as clients, we see human beings that need our support and our goodwill. Her holistic view of care and understanding of individual sickness, health, welfare, and death is an exciting way to value any multicultural society. Furthermore, Leininger’s job of putting together human beings and care into a well-organized theory embraces an important step into patient care.
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