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Cultural Healthcare
Madeleine Leininger’s Culture Care Diversity and Universality Theory
Kathie O’Dell
Concordia University
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Introduction
Madeleine Leininger was born in 1925 in Sutton, Nebraska. She graduated from a Diploma
Nursing program at St. Anthony’s School of Nursing in Denver, Colorado, and then went on to
receive a Bachelor’s of biological science with a minor philosophy in Atchison, Kansas. She
worked as an instructor, staff nurse, and head nurse in medical surgical unit, until she opened a
new psychiatric unit and was the director of nursing at St. Joseph’s Hospital in Omaha, NE. Her
background in child psychology helped her to realize that there was a lack of understanding
among staff related to cultural factors. She noted differences in responses to treatment from
children who had different cultural backgrounds. She return to school to study these
differences and received a doctorate from the University of Washington, and began teaching
the first ever course of transcultural nursing at the University of Colorado in 1966. Leininger’s
theory is a product of 40 years of research, during which she studied 54 cultures and identified
172 care constructs for the use by nursing professionals (Zoucha and Husted, 2000).
Madeleine Leininger’s Culture Care Diversity and Universality Theory is an area of study and
practice that focuses on values, beliefs, and practices of individuals or groups that promote
health and well-being. Culture is those behavior patterns that are socially acquired and
transmitted by means of such symbols as customs, techniques, beliefs, institutions, and
material objects (Zoucha and Husted, 2000). Cultural congruence and cultural imposition
concepts were also described by Leininger. Cultural imposition is when a nurse imposes her
own beliefs and values upon another culture because she believes it to be more superior to the
patients. Cultural congruence is the care that is provided to the patient that is beneficial,
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satisfying, and meaningful. Leininger’s goal was to make the patient the subject of care
focusing on whom that person really is and how do they live, think, and feel.
Analysis
Madeleine Leininger did not start off in the nursing profession. She was a third grade
school teacher in an elementary school in Nebraska. She however had a desire to continue that
human caring to another level. During World War II she began her nursing career. She
continued her nursing education obtaining a bachelor of science, master of science in
psychiatric nursing, and was employed at the University of Cincinnati where she met Dr.
Margaret Mead a visiting professor. Madeleine worked as a child guidance nurse where she
began to observe the children of diverse cultural backgrounds responded differently to care
and psychiatric treatments (Ray, 2012). After sharing her observation with Dr. Mead, she
began examining the interrelationships between nursing and anthropology. She returned then
to the classroom to pursue a doctorate of philosophy in anthropology focusing on cultural,
social, and psychological content. During her doctorate study she went to New Guinea and
studied the indigenous people of Gadsup. While studying the caring phenomena with the
Gadsup people she could see the need for cultural care as a discipline of nursing study.
There are three modalities that guide nursing judgments, decision, and actions according to
Leininger. Masters (2012) states these as “cultural care preservation and /or maintenance,
cultural care accommodation and/or negotiation, and cultural care repatterning or
restructuring”. Leininger describes the patient as a person who is a human being, family,
group, community or even and institution. These persons could be a product of an event like
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those who experienced the destruction of the twin towers or be part of an isolated community
like the Amish. They are defined by their social interactions in physical, ecological,
sociopolitical, and cultural settings. There can be social boundaries that affect a particular
patient for example, comforting touch, the French patient see it as a social norm where as a
China patient sees it as a social taboo. Each cultural group outlines health as a state of
wellbeing that is culturally defined, valued, and practiced. Nursing these individuals or groups
must be congruent with their cultural values, beliefs, and life ways. Identifying these with a
patient and their families will help initiate care that is supporting and patient centered.
There are thirteen major assumptions that support Leininger’s theory of cultural care
diversity and university. She begins with care being the essence of nursing, and then she
reveals that cultural based care is essential for well-being, health, growth, and survival. Thirdly
she states that culturally based care is a holistic means to guide a nurse’s decisions and actions,
with then the next step being transcultural care with a central purpose of serving individuals,
groups, communities, societies, and institutions. On the fifth assumption this statement
appears, there can be no curing without caring, but caring can exist without curing. Varying
concepts, meanings, expressions, patterns, processes, and structural forms of care make up
number six, and the seventh is that every human culture has generic care knowledge and
practices. By the eighth assumption we are acknowledging that care values, beliefs, and
practices are influenced by worldview, language, philosophy, religion, kinship, social, political,
legal, educational, economic, technological, environmental context of cultures. So now we
know that for care to beneficial, healthy, and satisfying it needs to be culturally based. The
tenth assumption is finding out knowing and using that knowledge for culturally congruent care
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that is appropriate and safe. Worldwide culture care can differ and have similarities, and in the
twelfth assumption cultural conflicts and impositions, stresses, reflect a lack of cultural care
knowledge. Finally the thirteenth is the ethnonursing qualitative research method provides an
important means to discover the diverse culture care data (Masters, 2012).
We as a society continue to migrate and evolve, our cultural differences are also changing
and as nurses our knowledge is challenged, seeking information becomes essential. Internet
and social media are a new element to cultural understanding and plays a role in the new
generation of patients. As nurses we need to consider many different aspects of our patients
and their histories. Learning the history of the area that you work in is beneficial, but keeping
up on current events and trends is crucial. Acquiring a skill in asking the right question can be a
good tool to learn. Some individuals will not be able to share their needs, learning how to ask
the right questions and learning our patient’s cultural diversity will be an art worth learning.
Leininger (1996) stated in an interview “today, in a typical urban hospital, many nurses care
for patients from as many as 20 different cultures. The diversity among cultures will continue
to increase”. We as nurses need to consider our patient population and what cultures we
have in our area. Not growing up in the area that you serve may have some challenges when
you are learning patient backgrounds or histories. You may not know that they are of an ethnic
decent that refuses to bath daily or that direct eye contact is considered being dominating to
that patient. To be culturally congruent you would need to do some research of your area or
that particular patient. We are living in society that is mobile. Having quick resources is
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essential. Interpreters or access to phones that provide that service can mean the difference in
patient care and outcomes.
Malinowski and Stamler (2002) describes using the ethnonurse method and identified that
“Philippine nurses value patients' physical comfort as an important aspect of nursing care.
Securing comfort for their patients is a means of developing relationships”. This would be an
expected part of nursing practice in the Philippines. Identifying patient needs and background
is part of the nursing process of obtaining health history information. We as nurses need to
ask is there any cultural practices you would like us to observe while you are in the hospital.
The patient may not be able to list these at the time but by learning likes and dislikes is helpful
in providing for their needs. This patient likes the room warm or needs to eat fish on Fridays is
an example of following cultural practices.
Discussion
In our short time we have seen current events that have changed our world leading to
population changes. We see foreign refugees seeking sanctuary from their oppressors or illegal
immigrants seeking jobs. Each comes with their own stories, fears, and experiences. Seeking
health care alone can be a stressful experience as not all countries have health care facilities
like the United States. Sometimes just getting past the language barrier can be a struggle. As
nurses we need to be prepared to care for these challenges. Having interpreters or access to
multilingual teaching sheets and admission paper work is essential. Keeping an open mind
about cultures that practice things we are not use to like circumcisions on females, or family
dynamics where you can only talk to the patient’s husband. Not all practices are healthy.
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Understanding some biological backgrounds can be as helpful as well, for instance there is a
higher prevalence of hypertension and sickle cell anemia in black people. Working in
healthcare you begin to see several interesting cultural practices and prevalence. Taking all
those experiences and expanding on them will assist you with adjusting to a new cultural
practice that you haven’t seen before. Don’t ever assume because an individual maybe Native
American they practice all the cultural aspects of that background. Rajan (1995) states “one
must develop an awareness of different cultures while keeping in mind individual differences”.
You will not know this unless you ask.
There is also a need to keep current on the new trends that are happening in your area or in
the world. One current trend of piercing different parts of your body may cause some
embarrassment when prepping a patient for surgery. Working in outpatient surgery you can
see this frequently. By accepting this trend and being prepared for it makes the patient more
comfortable about receiving nursing care and health care in general. Our outpatient services
have learned to have a cup with a lid ready at bedside, for the keeping of the appliance, until
surgery is over. However we do make a point to have them have a designated person to
replace the appliance when they return from surgery. We do incorporate in the discharge
teaching with the patient about caring for such areas, watching for infection, and when to seek
medical care as to promote a healthy lifestyle.
We are also caring for a large older population that grew up in the 1930’s and 40’s these are
post war veterans and have a lot to share but also come with interesting health promotion
ideas. We were surprised by a request while caring for a gentleman who said he needed to
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eat 1 small piece of garlic each day to stave off respiratory infections. He was given garlic every
morning with his breakfast. This was important to him and in doing so he felt comfortable in
taking his other medication from us and respected the teaching we gave to him.
Doing a thorough health assessment is critical to patient care. Knowing what is important to
this patient and how they have cared for themselves in the past may alter or add to their plan
of care while in the health care setting. Rajan (1995) states, “the person is a cultural being who
cannot be viewed apart from his or her cultural background”. It is important to add in your
health policy for admission this statement: Are there any cultural practices you would like us to
observe while you are in the hospital?
Conclusion
Madeleine Leininger’s Culture Care Diversity and Universality Theory was a long term goal
for her. She worked 30 years to fulfill an obvious need for patient and human care that was
culturally congruent. Through her observations we are able to conduct incisive medical
histories that include the diverse backgrounds that our patients generate from. With this
background knowledge our healthcare systems can treat patients with the values, beliefs, and
practices that are their own, promoting well-being in meaningful ways. As our patients evolve
so do their cultural experiences, it could be an event, childhood upbringing, a community they
live in, or a country they have come from. All of these experiences have an influence on their
daily needs and beliefs and this in turn governs the health care they seek and the expectations
of the nursing care they receive.
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Reference List
Leininger, M. (1996) Transcultural nursing: essential for excellence interview Madeleine
Leininger. (1996). Nursing, 26(1), 76
Masters, K. (2012). Nursing Theories: a framework for professional practice. (pp. 213) Sadbury,
MA: Jones and Bartlett Learning
Malinowski, A., & Stamler, L. (2002). Comfort: exploration of the concept in nursing. Journal Of
Advanced Nursing, 39(6), 599-606. doi:10.1046/j.1365-2648.2002.02329.x
Rajan, M. (1995). Transcultural nursing: a perspective derived from Jean-Paul Sartre. Journal Of
Advanced Nursing, 22(3), 450-455. doi:10.1046/j.1365-2648.1995.22030450.x
Ray, M. (2012). Remembering Madeleine M. Leininger, PhD, LHD, DS, RN, CTN, FAAN, FRCNA,
1925-2012. International Journal For Human Caring, 16(4), 6-8.
Zoucha, R., & Husted, G. (2000). The ethical dimensions of delivering culturally congruent
nursing and health care. Issues In Mental Health Nursing, 21(3), 325-340.
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