Professional Documents
Culture Documents
____________________________________________________________
A Research Output on Transcultural Nursing and Globalization of
Health Care and the Different Theoretical Perspectives of
Transcultural Nursing
__________________________________________________
Submitted to:
Erika Jane B. Yap, RN, MAN
Professor
Submitted by:
Peter A. Orlino, RN
Student
beliefs, and needs respected, understood, and appropriately used within any caring or curing
process, and so this necessitates that nurses are educated about culture and care phenomena. The
ultimate goal of transcultural nursing is to provide culturally congruent and competent care.
(Leininger, pp. 5-6).
B. Historical Development of Transcultural Nursing
Dr. Madeleine M. Leininger was the founder and leader of this new, specific cognitive
specialty in nursing. The first professional nurse with graduate preparation to complete a
doctorate in anthropology, Leininger took the culture construct from anthropology and care
from nursing and reformulated these two dominant constructs into culture care. Her pioneering
work began with her theory of cultural care diversity and universality, refined by 1975 with the
conceptual sunrise model. She divides the evolution of transcultural nursing into three eras:
1. Establishment of the field (19551975)
2. Program and research expansion (19751983)
3. Establishment of transcultural nursing worldwide (1983 to the present)
At the start in the mid-1950s, no cultural knowledgebase existed to guide nursing
decisions and actions to understand cultural behaviors as a way of providing therapeutic care.
Leininger wrote the first books in this field and coined the terms, transcultural nursing and
culturally congruent care. Leininger developed and taught the first university course in
transcultural nursing in 1966 at the University of Colorado. Programs and tracks in transcultural
nursing for masters and doctoral preparation were launched shortly after, in the early 1970s. In
recognition of her leadership, Leininger was honored as a Living Legend of the American
Academy of Nursing in 1998.
Today, transcultural nursing theory continues to expand and refine itself. Recent
educational and theoretical approaches in the field include the transcultural assessment model,
the model of heritage consistency, the model for cultural competence, the health care services
model, and advocacy for the application of transcultural nursing in clinical and community
contexts as well as a transcultural nursing assessment guide (Murphy).
C. Global Factors that have significantly influenced the need for Transcultural Nursing
Leininger (1995) cites eight factors that influence her to establish transcultural nursing.
1. There was a marked increase in people within and between countries worldwide.
Transcultural nursing is needed because of the growing diversity that characterizes our
national and global populations.
2. There has been a rise in multicultural identities, with people expecting their cultural
beliefs, values, and lifeways to be understood and respected by nurses and other
healthcare providers.
3. The increased use of healthcare technology sometimes conflicts with cultural values of
clients, such as Amish prohibitions against using certain apnea monitors, IV pumps, and
other such health care technologic devices in the home.
4. Worldwide, there are cultural conflicts, clashes, and violence that have an impact health
care as more cultures interact with one another.
5. There was an increase in the number of people traveling and working in many different
parts of the world.
6. There was an increase in legal suits resulting from cultural conflict, negligence,
ignorance, and imposition of health care practices.
7. There has been a rise in feminism and gender issues, with new demands on health care
systems to meet the needs of women and children.
8. There has been an increase demand for community and culturally based health care
services in diverse environmental contexts (Andrews, Margaret M and Joyceen S Boyle).
decisions. Culture and care together are predicted to be powerful theoretical constructs essential
to human health, wellbeing, and survival. In-depth knowledge of the specific culture care values,
beliefs, and lifeways of human beings within lifes experiences is held as important to unlock a
wealth of new knowledge for nursing and health practices.
Basic Theoretical Differences
Philosophically and professionally many questions about culture, care, and nursing have
been raised. In the past, many nurses viewed care linguistically as an important word to use in
teaching and practice, but very few could provide substantive knowledge or explain care within a
culture. It was then clearly evident that within nursing a troubling knowledge deficiency existed
for obtaining authentic, scientific, and accurate data about cultures and their care meanings,
expressions, and beneficial outcomes (Leininger, 1985). The theorist found care and culture had
been limitedly studied in nursing yet she predicted they would guide nursing in powerful ways.
In developing the theory, it became apparent to Leininger that the Theory of Culture Care would
be very different from other existing ideas or emerging nursing theories in several respects. First,
the central domain of the theory was focused on the close interrelationships between culture and
care. Second, the terms theories and models are often used in the same way but are different.
Theories should predict and lead to discovery of unknown or vaguely known truths or
interrelated phenomena, whereas models are mainly pictorial diagrams of some idea and are not
theories as they usually fail to show predictive relationships. There are different kinds of theories
used by different disciplines to generate knowledge; however, all theories (including the Culture
Care Theory) have as their primary goal to discover new phenomena or explicate vaguely known
knowledge (Leininger 1991a/b). Third, the Culture Care Theory is open to the discovery of new
ideas that were vague or largely unknown but with bearing on peoples culture care phenomena
related to their health and wellbeing. Leiningers theory focuses on culture care as a broad yet
central domain of inquiry with multiple factors or influencers on care and culture. Fourth, the
theorist values an open discovery and naturalistic process to explore different aspects of care and
culture in natural or familiar living contexts and in unknown environments. Fifth, Leininger has
developed a new and unknown research method different from ethnography, namely the
ethnonursing method, to systematically and rigorously discover the domain of inquiry (DOI) of
culture care. The ethnonursing method is designed as an open, natural, and qualitative inquiry
mode seeking informants ideas, perspectives, and knowledge, and did not control, reduce, or
manipulate culture and care as with quantitative methods.
The Culture Care Theory focuses on obtaining indepth knowledge of care and culture
constructs from key and general informants related to health, wellbeing, dying, or disabilities.
Leiningers theory differs markedly from other nursing theories as it does not rely upon the four
metaparadigm concepts to explain nursing of persons, environment, health and nursing. These
four concepts were too restrictive for open discovery about culture and care. Another major and
unique difference in Leiningers theory in comparison with other nursing ideas are the three
action modalities or decision modes necessary for providing culturally congruent nursing care.
These three theoretically predicted action and decision modalities of the culture care theory were
defined as follows (Leininger, 1991a/b; Leininger & McFarland, 2002).
1. Culture care preservation and-or maintenance referred to those assistive, supporting,
facilitative, or enabling professional acts or decisions that help cultures to retain, preserve
or maintain beneficial care beliefs and values or to face handicaps and death.
2. Culture care accommodation and-or negotiation referred to those
assistive,
contrasting care knowledge and are held as invaluable insights for nurses in caring for cultures.
The reader will find that the frequently used phrase nursing interventions is seldom used in the
Culture Care Theory or in transcultural nursing because it often refers to cultural imposition
practices which may be offensive or in conflict with the clients lifeways. Cultural imposition
practices are often destructive, ethnocentric, offensive, and lead to cultural pain and conflicts
(Leininger, 1991a/b, 1995).
Other Central Constructs in the Culture Care Theory
1. Care refers to both an abstract and-or a concrete phenomenon. Leininger has defined care
as those assistive, supportive, and enabling experiences or ideas towards others with
evident or anticipated needs to ameliorate or improve a human condition or lifeway
(Leininger, 1988a/b/c, 1991a/b, 1995a; Leininger & McFarland, 2002). Caring refers to
actions, attitudes and practices to assist or help others toward healing and wellbeing
(Leininger, 1988a/b/c, 1991a/b, 1995a; Leininger & McFarland, 2002). Care as a major
construct of the theory includes both folk and professional care which are a major part of
the theory and have been predicted to influence and explain the health or wellbeing of
diverse cultures.
2. Culture as the other major construct central to the theory of Culture Care has been
equally as important as care; therefore it is not an adverb or adjective modifier to care.
The theorist conceptualized culture care as a synthesized and closely linked phenomena
with interrelated ideas. Both culture and care require rigorous and full study with
attention to their embedded and constituted relationship to each other as a human care
phenomenon. Leininger has defined culture as the learned, shared, and transmitted
values, beliefs, norms, and lifeways of a particular culture that guides thinking, decisions,
and actions in patterned ways and often intergenerationally (Leininger, 1991a/b; 1997a).
Anthropologically, culture is usually viewed as a broad and most comprehensive means
to know, explain, and predict people lifeways over time and in different geographic
locations. Culture phenomena distinguish human beings from nonhumans but is more
than social interaction and symbols, more than ethnicity or social relationships. Culture
can be viewed as the blueprint for guiding human actions and decisions and includes
material and nonmaterial features of any group or individual.
3. The constructs emic and etic care are another major part of the theory. The theorist
wanted to identify differences and similarities among and between cultures. It is desirable
to know what is universal [or common] and what is different [diversities] among cultures
with respect to care. The term emic refers to the local, indigenous, or insiders cultural
knowledge and view of specific phenomena; whereas, etic refers to the outsiders or
strangers views and often health professional views and institutional knowledge of
phenomena (Leininger, 1991a/b).
4. Cultural and Social Structure Factors are another major feature of the theory. Social
structure phenomena provide broad, comprehensive, and special factors influencing care
expressions and meanings. Social structure factors of clients include religion
(spirituality); kinship (social ties); politics; legal issues; education; economics;
technology; political factors; philosophy of life; and cultural beliefs, and values with
gender and class differences. The theorist has predicted that these diverse factors must be
understood as they directly or indirectly influence health and wellbeing.
5. Ethnohistory is another construct of the theory that comes from anthropology; the theorist
has reconceptualized its meaning within a nursing perspective. The theorist defines
ethnohistory as the past facts, events, instances, and experiences of human beings,
groups, cultures, and institutions that occur over time in particular contexts that help
explain past and current lifeways about culture care influencers of health and wellbeing
or the death of people (Leininger 1991a/b; Leininger & McFarland, 2002).
6. Environmental context refers to the totality of an event, situation, or particular
experiences that gives meaning to peoples expressions, interpretations, and social
interactions within particular physical, ecological, spiritual, sociopolitical, technologic
factors in cultural settings (Leininger 1989, 1991a/b; Leininger & McFarland, 2002).
7. Worldview refers to the way people tend to look out upon their world or their universe to
form a picture or value stance about life or the world around them (Leininger 1991a/b;
Leininger & McFarland, 2002). Worldview provides a broad perspective of ones
orientation to life, people, or group that influence care or caring responses and decisions.
Worldview guides ones decisions and actions especially related to health and wellbeing
as well as care actions.
8. Culture Care Preservation and-or Maintenance, Culture Care Accommodation and-or
Negotiation, and Culture Care Repatterning and-or Restructuring have been defined
earlier.
9. Culturally Congruent Care refers to culturally based care knowledge, acts and decisions
used in sensitive and knowledgeable ways to appropriately and meaningfully fit the
cultural values, beliefs, and lifeways of clients for their health and wellbeing, or to
prevent illness, disabilities, or death (Leininger, 1963, 1973b, 1991a/b, 1995; Leininger &
McFarland, 2002). To provide culturally congruent and safe care has been the major goal
of the Culture Care Theory.
10. Care Diversity refers to the differences or variabilities among human beings with respect
to culture care meanings, patterns, values, lifeways, symbols or other features related to
providing beneficial care to clients of a designated culture (Leininger, 1995, 1997a;
Leininger & McFarland, 2002).
11. Culture Care Universality refers to the commonly shared or similar culture care
phenomena features of human beings or a group with recurrent meanings, patterns,
values, lifeways, or symbols that serve as a guide for care givers to provide assistive,
supportive, facilitative, or enabling people care for healthy outcomes (Leininger, 1995).
Care Theory:
1. Culture care expressions, meaning, patterns, and practices are diverse and yet there are
shared commonalities and some universal attributes.
2. The worldview, multiple social structure factors, ethnohistory, environmental context,
language, and generic and professional care are critical influencers of cultural care
patterns to predict health, well-being, illness, healing, and ways people face disabilities
and death.
3. Generic emic [folk] and professional etic health factors in different environmental
contexts greatly influence health and illness outcomes.
4. From an analysis of the above influencers, three major actions and decision guides can
lead to providing ways to give culturally congruent, safe, and meaningful health care to
cultures. The three culturally based action and decision modes are: a) culture care
preservation and /or maintenance; b) culture care accommodation, negotiation; and, c)
culture care repatterning and-or restructuring. Decision and action modes based on
culture care are key factors to arrive at congruent and meaningful care. Individual, family,
group or community factors are assessed and responded to in a dynamic and participatory
nurse client relationship (Leininger 1991a/b, 1993b, 2002; Leininger & McFarland,
2002).
Theoretical Assumptions:
1. Care is the essence and the central dominant, distinct, and unifying focus of nursing.
2. Humanistic and scientific care is essential for human growth, wellbeing, health, survival, and
to face death and disabilities.
3. Care (caring) is essential to curing or healing for there can be no curing without caring. (This
assumption was held to have profound relevance worldwide.)
4. Culture care is the synthesis of two major constructs which guides the researcher to discover,
explain, and account for health, wellbeing, care expressions, and other human conditions.
5. Culture care expressions, meanings, patterns, processes and structural forms are diverse but
some commonalities (universals) exist among and between cultures.
6. Culture care values, beliefs, and practices are influenced by and embedded in the worldview,
social structure factors (e.g. religion, philosophy of life, kinship, politics, economics, education,
technology, and cultural values) and the ethnohistorical and environmental contexts.
7. Every culture has generic [lay, folk, naturalistic; mainly emic] and usually some professional
[etic] care to be discovered and used for culturally congruent care practice.
8. Culturally congruent and therapeutic care occurs when culture care values, beliefs,
expressions, and patterns are explicitly known and used appropriately, sensitively, and
meaningfully with people of diverse or similar cultures.
9. Leiningers three theoretical modes of care offer new, creative, and different therapeutic ways
to help people of diverse cultures.
10. Qualitative research paradigmatic methods offer important means to discover largely
embedded, covert, epistemic, and ontological culture care knowledge and practices.
11. Transcultural nursing is a discipline with a body of knowledge and practices to attain and
maintain the goal of culturally congruent care for health and wellbeing.
The Purnell Model for Cultural Competence comprises of 12 culture domains. In the figure
below:
Unconsciously competent
Automatically providing culturally congruent care to clients of diverse cultures
12 Cultural Domains
It is not intended for domains to stand alone, rather, they affect one another.
1. Overview/heritage
Concepts related to country of origin, current residence, and the effects of the topography of
the country of origin and current residence, economics, politics, reasons for emigration,
educational status, and occupations.
2. Communication
Concepts related to the dominant language and dialects; contextual use of the language;
paralanguage variations such as voice volume, tone, and intonations; and the willingness to share
thoughts and feelings. Nonverbal communications such as the use of eye contact, facial
expressions, touch, body language, spatial distancing practices, and acceptable greetings;
temporality in terms of past, present, or future worldview orientation; clock versus social time;
and the use of names are important concepts.
3. Family roles and organization
Concepts related to the head of the household and gender roles; family roles, priorities, and
developmental tasks of children and adolescents; child-rearing practices; and roles of the ages
and extended family members. Social status and views toward alternative lifestyles such as
single parenting, sexual orientation, child-less marriages, and divorce are also included in the
domain.
4. Workforce issues
Concepts
related
to
autonomy, acculturation,
assimilation,
gender
roles,
communication styles, individualism, and health care practices from the country of origin.
5. Bicultural ecology
ethnic
Includes variations in ethnic and racial origins such as skin coloration and physical
differences in body stature; genetic, heredity, endemic, and topographical diseases; and
differences in how the body metabolizes drugs.
6. High-risk behaviors
Includes the use of tobacco, alcohol and recreational drugs; lack of physical activity; nonuse
of safety measures such as seatbelts and helmets; and high-risk sexual practices.
7. Nutrition
Includes having adequate food; the meaning of food; food choices, rituals, and taboos; and
how food and food substances are used during illness and for health promotion and wellness.
8. Pregnancy and childbearing
Includes fertility practices; methods for birth control; views towards pregnancy; and
prescriptive, restrictive, and taboo practices related to pregnancy, birthing, and postpartum
treatment.
9. Death rituals
Includes how the individual and the culture view death, rituals and behaviors to prepare for
death, and burial practices. Bereavement behaviors are also included in this domain.
10. Spirituality
Includes religious practices and the use of prayer, behaviors that give meaning to life, and
individual sources of strength.
11. Health care practices
Includes the focus of health care such as acute or preventive; traditional, magico-religious,
and biomedical beliefs; individual responsibility for health; self-medication practices; and views
towards mental illness, chronicity, and organ donation and transplantation. Barriers to health care
and ones response to pain and the sick role are included in this domain.
Concepts include the status, use, and perceptions of traditional, magico-religious, and
allopathic biomedical health care providers. In addition, the gender of the health care provider
may have significance. The major focus: is to identify culture care beliefs, values, patterns,
expressions, and meanings related to the clients needs for obtaining or maintaining health or to
face acute or chronic illness, disabilities, or death.
In cultural care assessment the nurse goes beyond assessment of physical, psycho. ,
social, and mental aspects to include or tap the holistic or totality living and functioning
dimensions. Nurses are taught in Trans- cultural nursing to use liberal arts and other broad areas
of knowledge to get a realistic and accurate picture of people and their health needs or concerns
To discover the clients culture care and health patterns and meanings in relation to the
clients worldview, life ways, cultural values, beliefs, practices, context, and social structure
factors.
2.
To obtain holistic culture care information as a sound basis for nursing care decisions and
actions.
3.
To discover specific culture care patterns that can be used to make differential nursing
decisions that fit the clients values and life ways and to discover what professional knowledge
can be helpful to the client.
4.
To identify potential areas of cultural conflicts, clashes, and neglected areas resulting
from emic and etic value differences between clients and professional health personnel
5.
To identify general and specific dominant themes and patterns that need to be known in
cultures, which can be shared and used in clinical, teaching, and research practices.
7.
To identify both similarities and differences among clients in providing quality care.
8.
To use theoretical ideas and research approaches to interpret and explain practices for
congruent care and new areas of Trans- cultural nursing knowledge for discipline users.
The sunrise model serves as a guide to cultural assessment. The major areas for assessment
are the following:
1.
2.
3.
Economic factors.
4.
Educational factors.
5.
Technological views.
6.
7.
TO show a genuine and sincere interest in the client as one listens to and learns to and
The nurse need to remain fully aware of ones own cultural biases and prejudices. If not
To remain an active listener to fit client expectations and create a climate that is trusting
so that the client feels it is safe and beneficial to share ones beliefs and life ways.
Transcultural communication modes
The nurse should understand the many verbal and nonverbal modes of many diverse
cultures. This is an imperative today in this multicultural world. Nurses should speak at least two
languages today. Body language expressions are forms of communication and are culturally
patterned. Kinesics is the term that refers to body movements communication modes, which
include posture, facial expressions (smile or anger), gestures, eye contact, and other body
features.
Proxemics: it refers to the use and perception of interpersonal or personal space in socio cultural
interactions. Finally, within the many areas of Tran cultural communication, a few pointers need
to be given about the use of interpreters to get accurate assessments. The interpreter should know
the clients cultural language and knows the culture. ("Cultural Care Assessment for Congruent
Competency Practices")
Leiningers short culturalogical assessment guide:
Phase 1: Record observation of what you see, hear or experience with clients (includes dress and
appearance, body condition features, language, mannerisms and general behavior, attitudes, and
cultural features).
Phase 2: Listen to learn from the client about cultural values, beliefs, and daily (nightly)
practices related to care and health in the clients environmental context. Give attention to generic
(home or folk) practices and professional nursing practices.
Phase 3: identify and document recurrent client patterns and narratives (stories) with client
meanings of what has been seen, heard or experienced.
Phase 4: Synthesize themes and patterns of care derived from the information obtained in phase
1, 2, 3.
Phase 5: Develop a culturally-based client-nurse care plan as co-participants for decisions and
actions for culturally congruent care.
Caring rituals important to assess:
In doing culture care assessments there are special areas bearing on caring patterns and healing
that provide valuable information.
1.
Eating rituals
2.
3.
4.
Life cycle rituals are especially crucial because they demonstrate patterns of caring for
Consumers of diverse cultures have a right to have Tran cultural care standards used to
protect and respect their generic (folk) values, beliefs, and practices and to have health personnel
incorporate.
2.
Nurses assessing and providing care to diverse culture or subcultures have a moral
Cultural assessment and practices need to demonstrate the use of Tran cultural nursing
concepts, principles, theories, and research findings and competencies to ensure safe, congruent,
and competent practices.
4.
study, understand, and use relevant research-based Transcultural care for safe, beneficial, and
satisfying client or family outcomes.
5.
Providing culturally competent and congruent care should reflect the caregivers ability to
assess and use culture-specific data without biases, prejudices, discrimination, or related negative
outcome
6.
Nurses caring for clients of diverse cultures should seek to provide holistic care that is
comprehensive and takes into account the clients worldview and includes ethno history, religion
(or spiritual), morale/ ethical values, specific cultural care beliefs and values, kinship ties.
7.
learning, flexible attitude and desire to expand their knowledge of diverse cultures and caring life
ways.
8.
Nurses with Transcultural competencies show evidence of being able to use local,
Nurses with Transcultural competencies demonstrate leadership skills to work with other
nurses and interdisciplinary colleagues who need help to provide culturally safe and congruent
client practices, thus preventing cultural imposition, cultural pain offenses, cultural conflicts, and
many other negative and destructive outcomes.
10.
Nurses with Trans cultural competencies are active to defend, uphold, and improve care
to clients of diverse cultures and to share their research findings and competency experiences in
public and professional arenas ("Cultural Care Assessment For Congruent Competency
Practices").
REFERENCES
A. PRINTED BOOK:
Andrews, Margaret M and Joyceen S Boyle. Transcultural Concepts in Nursing Care. 1st ed.,
Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins, 2008.
Giger, Joyce and Ruth Elaine Davidhizar. Transcultural Nursing: Assessment and Intervention.
5th ed. St. Louis, Missouri: Mosby Elsevier, 2008. Print.
Leininger, M., & McFarland, M.R. (2002). Transcultural Nursing: Concepts, theories,
research, & practice (3rd ed.). New York: McGraw Hill Medical Publishing Division.
Leininger, M. Transcultural Nursing: Concept, Theories, And Practices, New York: John
Wiley & Sons, 1978.. 1st ed. Columbus, Ohio: Greyden Press, 1994. Print.
Leininger, M. (Ed.). (1985). Qualitative research methods in nursing. New York: Grune &
Stratton.
Purnell, L. (2002). The Purnell model for cultural competence. Journal of Transcultural Nursing,
13(3), 193-197.
B. JOURNAL ARTICLE:
Leininger, M.M. (1991). Second reflection: Comparative care as central to transcultural nursing.
Journal of Transcultural Nursing, 3(1), 2.
Leininger (in press). The evolution of transcultural nursing with breakthroughs to discipline
status. Journal of Transcultural Nursing.
Murphy, Sharon. "Mapping The Literature Of Transcultural Nursing". Pubmed Central (PMC),
2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463039/.
Pacquiao, Dula. "Ethics And Cultural Diversity- A Framework For Decision Making". 2017,
https://practicalbioethics.org/files/members/documents/Pacquiao_17_3_4.pdf.
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2017,