Madeleine Leininger: Transcultural Nursing Theory

Two patients with the same diagnosis can need very different care, and a lot of that difference is culture: what they eat, who decides, what healing means to them, how they show pain. Leininger built an entire nursing discipline around that fact. Her Transcultural Nursing Theory (Culture Care Theory) says care only works when it fits the patient's cultural values, and she gave nurses a framework for making it fit.

Biography of Madeleine Leininger

Madeleine Leininger (July 13, 1925 – August 10, 2012) was an educator, author, theorist, administrator, researcher, consultant, and public speaker who created the concept of transcultural nursing. She was a Certified Transcultural Nurse, a Fellow of the Royal College of Nursing in Australia, and a Fellow of the American Academy of Nursing.

Early Life and Education

Leininger was born in Sutton, Nebraska, raised on a farm with her four brothers and sisters, and graduated from Sutton High School. She joined the U.S. Army Nursing Corps while in a basic nursing program; an aunt with congenital heart disease pointed her toward nursing.

In 1945 she and her sister entered the Cadet Nurse Corps, the federally funded program built to grow the nursing workforce for World War II. She earned a nursing diploma from St. Anthony's Hospital School of Nursing, then undergraduate degrees at Mount St. Scholastica College and Creighton University. At Creighton in Omaha, Nebraska she opened a psychiatric nursing service and educational program and earned the equivalent of a BSN through studies in biological sciences, nursing administration, teaching, and curriculum during 1951-1954. She took a Master of Science in Nursing from the Catholic University of America in 1954. In 1965 she entered a doctoral program in Cultural and Social Anthropology at the University of Washington in Seattle and became the first professional nurse to earn a Ph.D. in anthropology.

Career and Appointments

The theory started with a problem she could not explain. Working in a child guidance home in the 1950s, Leininger hit what she called culture shock when she saw that children's recurrent behavior patterns had a cultural basis. She named the missing link: nurses lacked cultural and care knowledge.

In 1954 she became Associate Professor of Nursing and Director of the Graduate Program in Psychiatric Nursing at the University of Cincinnati, continuing her own graduate study in curriculum, social sciences, and nursing. In the 1960s she coined "culturally congruent care," the goal of Culture Care Theory and now a global term. She was appointed Professor of Nursing and Anthropology at the University of Colorado, the first joint nursing-and-second-discipline appointment in the United States.

A trip to New Guinea in the 1960s sharpened the point: nurses need to understand a patient's culture to care for them. Some call her the "Margaret Mead of nursing." She was named Dean of the University of Washington School of Nursing in 1969 and served until 1974; under her, the school was recognized in 1973 as the outstanding public institutional school of nursing in the United States, and she founded the transcultural nursing program there in 1974. From 1974 to 1980 she served as Dean, Professor of Nursing, Adjunct Professor of Anthropology, and Director of the Center for Nursing Research and the Doctoral and Transcultural Nursing Programs at the University of Utah College of Nursing.

She was the first full-time President of the American Association of Colleges of Nursing and one of the first members of the American Academy of Nursing in 1975. Her career runs as educator and administrator from 1956 to 1995, writer from 1961 to 1995, lecturer from 1965 to 1995, consultant from 1971 to 1992, and transcultural nursing leader from 1966 to 1995. She was Professor Emeritus of Nursing at Wayne State University and adjunct faculty at the University of Nebraska Medical Center in Omaha, retiring from the former in 1995.

Her certifications read LL (Living Legend), Ph.D. (Doctor of Philosophy), LHD (Doctor of Human Sciences), DS (Doctor of Science), CTN (Certified Transcultural Nurse), RN (Registered Nurse), FAAN (Fellow American Academy of Nursing), and FRCNA (Fellow of the Royal College of Nursing in Australia).

Works

Leininger wrote and edited 27 books and founded the Journal of Transcultural Nursing to support the Transcultural Nursing Society's research, which she started in 1974. She published over 200 articles and book chapters, produced audio and video recordings, developed a software program, and gave over 850 keynote and public lectures in the US and worldwide. She served as editor of the Journal of Transcultural Nursing from 1989 to 1995, and she built and promoted the worldwide transcultural nurse certification (CTN) for client safety and knowledgeable care across diverse cultures.

Awards, Honors, and Death

In 1960 Leininger received a National League of Nursing Fellowship for fieldwork in the Eastern Highlands of New Guinea, studying the convergence and divergence of human behavior in two Gadsup villages. At Wayne State she won the President's Award for Excellence in Teaching, the Board of Governors Distinguished Faculty Award, and the Gershenson Research Fellowship Award. In 1998 she was honored as a Living Legend by the American Academy of Nursing and as a Distinguished Fellow of the Royal College of Nursing in Australia. The Leininger Transcultural Nursing Award, established in 1983 to recognize creative leaders in the field, continues under the Transcultural Nursing Society in her honor.

Leininger died on August 10, 2012, at her home in Omaha, Nebraska, and was buried in Sutton's Calvary Cemetery.

The Transcultural Nursing Theory

Culture Care Theory is about knowing different cultures well enough to give care that actually fits their health-illness practices, beliefs, and values. Its premise: cultures differ in their caring behaviors and in what they hold as health and illness.

Leininger defined transcultural nursing in 1995 as "a substantive area of study and practiced focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different cultures to provide culture-specific and universal nursing care practices in promoting health or well-being or to help people to face unfavorable human conditions, illness, or death in culturally meaningful ways." The theory first appeared in Culture Care Diversity and Universality (1991) but was developed in the 1950s; it was carried further in Transcultural Nursing (1995), and the third edition (2002) lays out the theory-based research and its application.

Major Concepts

Transcultural nursing. A learned branch of nursing focused on the comparative study and analysis of cultures with respect to nursing and health-illness caring practices, beliefs, and values, to deliver meaningful and effective care within the patient's cultural and health-illness context.

Ethnonursing. The study of nursing care beliefs, values, and practices as cognitively perceived and known by a designated culture through their direct experience, beliefs, and value system (Leininger, 1979).

Nursing. A learned humanistic and scientific profession and discipline focused on human care phenomena and activities that assist, support, facilitate, or enable individuals or groups to maintain or regain well-being (or health) in culturally meaningful ways, or to face handicaps or death.

Professional nursing care (caring). Formally and cognitively learned professional care knowledge and practice skills obtained through educational institutions, used to provide assistive, supportive, enabling, or facilitative acts that improve a person's health condition, disability, or lifeway, or work with dying clients.

Culturally congruent (nursing) care. Cognitively based assistive, supportive, facilitative, or enabling acts or decisions tailor-made to fit the individual, group, or institutional cultural values, beliefs, and lifeways, to support meaningful, beneficial, satisfying care or well-being.

Health. A culturally defined, valued, and practiced state of well-being, reflecting the ability to carry out daily role activities in culturally expressed, beneficial, patterned lifeways.

Human beings. Caring and capable of concern for others' needs, well-being, and survival. Leininger held that nursing as a caring science should reach beyond the nurse-patient dyad to families, groups, communities, total cultures, and institutions.

Society and environment. Leininger did not define these; she spoke instead of worldview, social structure, and environmental context.

Worldview. How people look at the world or universe and form a "picture or value stance" about it and their lives.

Cultural and social structure dimensions. The dynamic patterns and features of interrelated structural and organizational factors of a culture (religious, kinship/social, political/legal, economic, educational, technological, cultural values, ethnohistorical), and how they interrelate to influence human behavior across environmental contexts.

Environmental context. The totality of an event, situation, or experience that gives meaning to human expressions, interpretations, and social interactions within physical, ecological, sociopolitical, or cultural settings.

Culture. Learned, shared, and transmitted values, beliefs, norms, and lifeways of a group that guide thinking, decisions, and actions in patterned ways.

Culture care. The subjectively and objectively learned and transmitted values, beliefs, and patterned lifeways that assist, support, facilitate, or enable a person or group to maintain well-being or health, improve their condition or lifeway, or deal with illness, handicaps, or death.

Culture care diversity. The variabilities and differences in meanings, patterns, values, lifeways, or symbols of care within or between groups.

Culture care universality. The common or dominant care meanings, patterns, values, lifeways, or symbols shared across many cultures (Leininger, 1991).

Subconcepts

Generic (folk or lay) care systems. Culturally learned and transmitted indigenous, folk, home-based knowledge and skills used to assist, support, enable, or facilitate care for a person, group, or institution.

Emic. Knowledge from direct experience or from those who have lived it. Generic or folk knowledge.

Professional care systems. Formally taught, learned, and transmitted professional care, health, illness, and wellness knowledge and skills that prevail in professional institutions, usually staffed by multidisciplinary personnel.

Etic. Knowledge describing the professional perspective. Professional care knowledge.

Ethnohistory. The past facts, events, and experiences of individuals, groups, and cultures that are people-centered (ethno) and describe, explain, and interpret human lifeways within particular cultural contexts over time.

Care (noun). The abstract and concrete phenomena tied to assisting, supporting, or enabling behaviors toward others with evident or anticipated needs, to improve a human condition or lifeway.

Care (verb). The actions and activities that assist, support, or enable another person or group with evident or anticipated needs, to improve a human condition or lifeway or face death.

Culture shock. What an outsider may feel trying to comprehend or adapt to a different cultural group: discomfort, helplessness, disorientation from the differences in values, beliefs, and practices. It can lead to anger and is reduced by learning the culture before encountering it.

Cultural imposition. The outsider's efforts, subtle and not, to impose their own cultural values, beliefs, and behaviors on a person, family, or group from another culture (Leininger, 1978).

The Sunrise Model

The Sunrise Model pushes nurses to think critically about practice by integrating cultural and social structure dimensions in each context, alongside the biological and psychological aspects of care. The cultural care worldview flows into knowledge about individuals, families, groups, communities, and institutions within diverse health care systems, giving culturally specific meanings about care and health. From there the focus moves to the generic or folk system, professional care systems, and nursing care, comparing the care features of each to identify cultural care universality and diversity. Then come the nursing care decisions and actions, the three modes, where care is actually delivered.

Three Modes of Nursing Care Decisions and Actions

Cultural care preservation or maintenance. Professional actions and decisions that help people of a culture keep the care values that maintain well-being, support recovery, or help them face handicaps or death.

Cultural care accommodation or negotiation. Creative professional actions and decisions that help people of a culture adapt to or negotiate with providers for a beneficial, satisfying health outcome.

Culture care repatterning or restructuring. Professional actions and decisions that help clients reorder or modify their lifeways toward a new, healthier pattern while still respecting their cultural values and beliefs (Leininger, 1991).

Assumptions

Cultures perceive and practice care differently, yet share some commonalities. Care values and practices are shaped by and embedded in a culture's worldview, language, religion, kinship, politics, education, economics, technology, ethnohistory, and environment. Human care is universal across cultures, but caring shows up through diverse expressions and meanings. Cultural care is the broadest holistic means to know, explain, interpret, and predict nursing care phenomena. Every culture has generic or folk care, professional practices vary across cultures, and similarities and differences exist between care-receivers and professional caregivers. Care is the central, unifying focus of nursing: curing and healing cannot happen effectively without care, though care can occur without cure. Care and caring are essential to human survival, growth, health, healing, and dealing with handicaps and death. Nursing as a transcultural discipline serves human beings everywhere, and culturally based care, when beneficial, supports the client's well-being within their environment. Care is culturally congruent only when the nurse knows the client and uses their patterns, expressions, and values appropriately; when care is not at least reasonably congruent with the client's lifeways, the client shows stress, noncompliance, cultural conflict, or ethical and moral concerns.

Analysis

The theory asks the nurse to move clients toward better health practices, and that is hard. Introducing new ideas into another culture can read as intrusive to insiders, and culture, built over generations, resists penetration. Immersing in a culture deeply enough to understand its beliefs is time-consuming and costly, and with unclear financial compensation, many nurses do not lean into this approach. The intrusive nature can also pose a safety risk where practices are highly taboo. The theory's strength is its multicultural focus; its gap is that so much weight lands on culture itself that Leininger does not fully spell out the nurse's functions or how to assist, support, or enable the client toward an improved lifeway.

Strengths and Weakness

The Sunrise Model lays out the interrelationships of Culture Care Diversity and Universality in logical order. The theory is parsimonious, folding the needed concepts together so the model works across many settings, and it is highly generalizable through its level of abstraction. It can be grasped on first contact even though the terminology is not simple. That terminology is also the weakness: the theory and model are not simple in terms.

Bottom Line

Transcultural nursing aims to deliver care congruent with the patient's cultural values, beliefs, and practices. Cultural knowledge changes how a nurse works: it shows how a patient's culture and faith shape their experience of illness, suffering, and death; it builds respect for the diversity in any patient load; it strengthens commitment to whole-person, relationship-based care instead of treating symptoms alone; and it opens the nurse to nontraditional treatments like meditation or anointing. Patients' cultures are integral to who they are and shape how they respond to treatment, so awareness of the differences lets the nurse design culture-specific interventions that move the patient toward health while respecting their background.