Madeliene Leininger Culture Care Theory of Diversity and

Madeliene Leininger Culture Care Theory of Diversity and Universality Shelly Wolfrom, Shanda Christiansen, Shauna Petosky

History • Born in Sutton, Nebraska • Diploma program St. Anthony’s School of Nursing Denver, Colorado • U. S. Army Nurse Corps • Bachelor Degree in Biological Science from Benedictine College in Acthison, Kansas in 1950 • Masters Degree in Psychiatric Nursing from Catholic University of America in Washington D. C.

Evolution of Theory Leininger’s first thoughts of the culture care theory developed while working in a child guidance home for children with psychiatric disorders and diverse cultural backgrounds in the mid 1950 s

“The children were so expressive and persistent in what they wanted or needed, yet I was unable to respond appropriately to them as I did not understand their behavior. Later I came to learn that their behavior and care were culturally constituted and influenced their mental health” (Fawcett, 2002).

As a doctoral student she studied many cultures with a focus on anthropology. She lived with the Gadsup people of the Eastern Highlands, New Guinea for two years studying two villages.

Through the 1950 s and 1960 s Leininger noted several commonalities between nursing and anthropology and began to formulate her theory of transcultural care incorporating nursing concepts, principles, and practices.

• Leininger studied 14 major cultures and has experience with many other cultures. • She has published several books on transcultural nursing. • Her culture care theory is world renown and is increasingly important to the continuation of the study of diversity amongst cultures.

Leininger believes that, “nursing theory must take into account the creative discovery about individuals, families, and groups and their caring values, expressions, beliefs, and actions or practices based on their cultural lifeways to provide effective, satisfying, and culturally congruent care” (Tomey & Alligood, 2006).

Leininger criticizes the four nursing metaparadigm concepts. PERSON The term “person” is too limited and culture bound to explain nursing as the concept of person does not exist in every culture. Leininger argues that nurses use person to refer to families, groups, communities, and collectivities.

Environment Instead of “environment” Leininger uses the environmental context which includes events with meanings and interpretations given to them in particular physical, ecological, sociopolitical, and cultural settings.

Health The concept of “health” is not distinct to nursing as many disciplines use the term.

Nursing Leininger considers nursing a discipline and a profession, and the term “nursing” cannot explain the phenomenon of nursing. Instead care has the greatest power to explain nursing.

Unique Concepts • Culture care theory is the only nursing theory that focuses on culture. • The theory can be used in Western and non-Western cultures because it uses multiple holistic factors within cultures. • The range of study within the model goes from small scale (individuals) to a large scale (cultures).

Unique Concepts The goal of theory is not to change the perspectives or beliefs of the group but to preserve, maintain, accommodate, negotiate, re-pattern, or restructure in order to provide culturally congruent care.

Unique Concepts Leininger’s Sunrise Enabler was developed to illustrate the main criteria of theory. It is used as a tool to understand the worldview, lifeways, and cultural values to make culturally congruent clinical assessments.

The Sunrise Enabler The upper half of the circle represents elements that influence care and health through language, ethno history, and environmental context. The generic or folk, professional, and nursing care systems in the middle of the model are influenced by the components in the upper half of the circle. The two halves form a full sun representing elements nurses need to consider to provide culturally congruent care.

Case Study of the Farm and Midwifery Services to the Amish The farm began as an experimental community in the 1970’s by a group of 300 hippie idealists seeking to exchange society norms for a new social order. The group chose a 1750 acre farm in Tennessee as the best site to begin their experiment in collectivism. When the group left for Tennessee several of the women were pregnant. Eleven babies were born on the bus en-route. Which started the practice of midwifery for some of the women.

The area of Tennessee where the Farm is located also includes a large community of Amish people. The Farm community is very focused on health and well being for their own community, their neighbors including the Amish and the larger world.

Midwifery at the Farm • Developed their own folk primary health care center with a birthing center in a six room house on the Farm. • It is a strong cultural value for the Farm people that childbirth and the care needs of the child birthing family should occur naturally and unimpeded in a home context. • Generic caregivers evolved into lay midwives, and they continue offering child birthing services on the Farm and in the nearby community who chose to give birth at home.

Amish Seeking Care From the Farm Midwives The Farm and the Amish community, maintain some similar core values, beliefs, and life ways. Some commonalities between both groups include: pacifism, protection of the environment, farm as a chosen setting, valuing families, raising and educating children as the primary responsibility of the family, and assuming responsibility for their own healthcare. These common values and life ways facilitated the acceptance of the Farm midwives by the Amish community.

• Acceptance of the Farm midwives by the Amish community was a slow, gradual process. • A local physician who had been accepted in the Amish community took the farm midwives on rounds with him. • Farm midwives began assisting Amish women in home births. • Because of the high birth rate in the Amish community, the demand on the midwives became too great and they proposed that the Amish select two women to be trained as their own folk midwives.

The Amish • Commonly an Amish family may have 10 or more children. Some midwives were observing women having their 18 th or 19 th baby at home. • Before seeking outside (Farm) assistance, the Amish folk midwives would attempt their own homeopathic remedies including herbal therapies. • Using their generic and naturalistic methods first has decreased the need for outside (Farm) assistance. • The Amish care values and beliefs are preserved and maintained by The Farm midwives which accounts for the acceptance by the Amish of midwifery services when their own midwives cannot cope with the situation (Finn, 1995).

Technological, religious, philosophical, political, legal, and economic factors were discovered to be important social structure factors for these subcultures. Both communities rely on all three systems of healthcare. However, they prefer to receive health care from generic and/or folk caregivers who are part of the community. They resort to the professional health care system only when absolutely necessary.

Technological Factors The Farm • Minimal impact on the environment The Amish • Gasoline engines for woodworking and washing machines • Non-materialism

Religious & Philosophical Factors The Farm • Refer to themselves as “free thinkers” • They hold openness to religious expressions as a strong cultural value • Value life whether human, animal, or plant The Amish • Refer themselves as “Brethern” • Obedience to church and God

Kinship & Social Factors The Farm • Welcoming and inclusive • Strong family values • Community sharing life ways The Amish • Strong family values • Community sharing life ways

Cultural Values, Beliefs, and Life ways The Farm • Vegetarian • Environmental preservation • Pacifistic values and spiritual beliefs The Amish • Dress in plain clothing • Folk practices and God • Large families

Political & Legal The Farm • Environmental health • Lobbied to prevent environmentally destructive industries from moving into the area The Amish • Amish clergyman serve as political and legal advisors

Economic Factors The Farm • Farming • Began as a collectivism and then reorganized into a capitalistic framework • Midwifery services The Amish • The economy is based on barter and cash • Sell handmade goods to the public • Collectivism

Educational Factors The Farm • Education is a strong cultural value • Parents assume ongoing responsibility for the education of their children • Midwifery conferences and educational seminars The Amish • Do not value education past elementary grades

Diverse Health Systems • Generic Care- consists of lay or naturalistic care practices learned at home growing up in a particular cultural context. Any member of a culture can provide generic or lay care. For example the Amish used Saffron tea and/or jello to bind up intestinal bilirubin in jaundiced newborns. • Folk Care- a specialized caregiver who possesses particular skills or training not common to lay members of the culture. • Professional Care- this is based on the modern Western biomedical system. Care providers include physicians, nurses, and physical therapists, etc.

The Sunrise Enabler Nursing mediates between folk (generic) and the professional system. Three kinds of nursing care and interventions are applied in this theory: culture care preservation or maintenance, culture care accommodation or negotiation, and culture care re-patterning or restructuring.

Culturally Congruent Care for Health, Well-being, or Dying

Clinical Practice The cultures that people come from affect their behavior and everything about them. It is easy to have biases and think our way is the only right way when that is all we have ever known.

• Practice culture care maintenance, preservation, accommodation, and negotiation. • This theory can be applied to any practice by considering the patient’s cultural needs and ability to comply when explaining care alternatives. • Assess patients acceptance of goals, planning, and outcomes. • Being attentive to a patients’ desire for healthcare that encompasses preservation of their personal values and beliefs. • Educating oneself about different cultures and being more conscious and aware of the differences • Asking culturally appropriate questions

Patient Assessment • Gather appropriate cultural background and history • Ask appropriate questions related to perceived health care needs • Gathering all this information is a long process that takes time

Education Nurses need to be educated about diverse cultures and ethnicities and maintain an openness to learning about health care practices in diverse cultures. This model can guide and stimulate nurses into a new pathway of knowledge and practice.

A critical need remains for nurses to be educated in transcultural nursing in undergraduate and graduate programs. “There is also a need for well qualified faculty prepared in transcultural nursing to teach and to guide research in nursing schools within the United States and in other countries” (Tomey & Alligood, 2006).

Current Research Status • Qualitative methods have been used to research theory of culture care. • Government funds are limited for qualitative research. Funds are more likely made available for quantitative research. • Despite limited funding, transcultural nurses continue to research theory, and share information at conferences and instructional programs.

Strengths of the Model • One of the oldest theories in nursing. It has been around since the mid 1950 s. • Only theory focused on the close interrelationships of culture and care on wellbeing, health, illness, and death. • Only theory focused on comparative culture care. • Most holistic and multidimensional theory to discover specific and multifaceted culturally based care meanings and practices

Limitations of the Model • One must have basic anthropological knowledge, and moderate transcultural nursing knowledge. • Funds to support transcultural nursing are limited. • Transcultural knowledge has been limitedly used due to organizational structures and educational factors.

The Model Overall This theory is greatly valued worldwide, “nurses often express that this theory and method…is very natural to nursing and helps one to gain fresh new insights about care, health, and well-being” (Tomey & Alligood, 2006).

• Nurses find this theory easy to use and understand. • Can be easily applied to various clinical settings. • This theory will grow in use in our increasingly multicultural world. • Culture specific and congruent care practices are what culturally different clients are seeking today.

• Nursing decisions and actions are guided by preservation and maintenance, accommodation and negotiation, and repatterning or restructuring. • Focus is on health promotion, health maintenance, and prevention within the context of the client’s cultural belief system.

• Selected tools for assessment must be culturally sensitive and include individual focus on the assessment factors depicted in the sunrise model. • Nursing practice will be based on the specific characteristics of the people and environment in which you work.

References Fawcett, J. (2002). The nurse theorists: 21 st century updates-Madeleine Leininger. Nursing Science Quarterly, 15; 131 Finn, J. (1995). Leininger’s model for discoveries at the farm and midwifery services to the amish. Journal of transcultural nursing, 7; 28 Tomey, A. , & Alligood, M. (2006). Nursing Models. In Y. Alexopoulos et al. (Ed. ), Nursing theorists and their work. (pp. 472 -490). St. Louis, MO