CLIENT-NURSE-ENVIRONMENT DYNAMICS

Discuss the historical backgrounds of Leiningers Theory of Culture Care and Neumans Systems Model; Discuss the major assumptions of the Theory of Culture Care and the Systems Model Explain the key concepts and propositions relevant to the above theories/models Discuss the strengths and limitations of the above theories/models; and Describe a personal or work that will illustrate the key concepts of Leininger and Neuman models. Some of the previous nursing theories you studied in the previous modules on man as a biological system, a behavioral composite and an organism with stages of development. The other modules discussed nursing theories that highlighted one-to-one client-nurse relationships which depicted persons as interactive beings. Two particular theories, those of Madeleine Leininger and Betty Neuman, considered all these dimensions simultaneously and comprehensively within a cultural and systems perspectives. They viewed the environment as encompassing family, society, culture, healthcare professionals, significant others, as well as the socio-economic and social conditions surrounding the client. Neuman asserted that man is in constant interaction with their environment and that any change occurring in one affects the other. Leininger stated that culture guides a particular groups thinking, decisions and actions in patterned ways

For many years, studies have been conducted along this line with the purpose of helping nurses work more effectively with clients from different cultures. The work of Leininger on human care theory was a result of extensive studies of many cultures, both western and non-western

HISTORICAL BACKGROUND OF LEININGERS THEORY OF CULTURE CARE

How was the theory of Culture Care developed?
In the historical account that you are about to read, you will be amazed at how Madeleine Leininger devoted her career to studying the cultural dimensions of human care and caring. Her theory was developed through insights from personal experiences, extensive readings in anthropology, and in-depth studies of the caring behavior and values of selected cultures.

PERSONAL EXPERIENCES
Leininger first realized the importance of culture care to nursing practice in the mid-1940s. She was then young graduate staff nurse in a large general hospital in the United States. While providing care, she received different remarks and comments from her patients regarding the care that she provided and realized that there were differences in the way patients responded to her care giving practices. She thought that being sensitive to their responses was important to human care. During that time, many nurses like her believed that caring meant spending time with patients and listening to their stories about themselves, their families, work and home life. During the mid-1950s, while working as a psychiatric clinical nurse specialist in a child guidance home, she observed recurrent behavioral differences among children she looked after for. She concluded that these differences in the way they played, ate, slept, and interacted were rooted in their culture. On the other hand, she identified in the staff a lack of knowledge of the childrens cultures as the reason why nurses were unable to respond appropriately to the childrens behavior and expressed needs. This time, she recognized the need to develop nursing strategies that would incorporate different cultures, patterns and life ways. Toward this end, Leininger pursued doctoral studies at the University of Washington, focusing on cultural anthropology. In 1978, Leininger defined Transcultural Nursing as: a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-illness practices, beliefs, and values with the goal to provide meaningful and efficacious nursing services to people according to their cultural values and health-illness context.

LEININGERS THEORY OF CULTURE CARE

Madeleine Leininger introduced the concept that care and health practices have cultural dimensions. Although I cited indigenous cultures as examples, in this modern day and age, nurses encounter different kinds of clients in different health care settings. There may be instances perhaps, that in your interactions with your clients, you found some of them difficult, demanding, or passive. You must have felt exasperated with the way these clients behaved and reacted even to your tender loving care. You must have asked, who really is causing the problem here the client or myself, the caregiver? Am I being aware of the cultural needs of my clients? You, as a nurse, should be especially aware of the cultural aspects of nursing care because you have constant and more direct interactions with clients compared toother members of the health care team.

The term TRANSCULTURAL means across all world cultures. It applies to the evolving knowledge and practices related to this new field of study and practice. According to her, transcultural nursing theory and ethnoscience methods allow one to discover and learn about peoples views and practice of caring. According to her, transcultural nursing theory and ethnoscience methods allow one to discover and learn about peoples views and practice of caring. Ethnomethods use people-centered data sources that focus on emic (insiders views), views, as opposed to the researchers etic (outsiders views). Leininger clarified that her Culture Care Theory was not just an application of anthropological concepts to nursing. She explained that while the roots of culture are discussed mainly in anthropology, and concepts of care are discussed largely in nursing, the theory was developed to discover that will serve mainly the discipline of nursing. In 1978, Leininger defined Transcultural Nursing as: a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-illness practices, beliefs, and values with the goal to provide meaningful and efficacious nursing services to people according to their cultural values and health-illness context. First, there were no nurses who had interest in conceptualizing the actual or potential relationship between anthropology and nursing. Second, after formulating and disseminating some ideas and hunches related to her theory, there were still very few nurses interested in such strange idea in nursing. She realized that nurses realied too heavily on biophysical and psychological explanations with virtually no awareness of how culture could influence nursing and nursing care. Challenged as she was to continue developing her theory, she envisioned helping nurses to discover new knowledge and different perspectives of nursing. Leininger encouraged mane students and faculty to pursue graduate studies in anthropological nursing practice.

According to her, the purpose of the Culture Care Theory is to discover human care similarities (universality) and differences (diversity) in relation to world view, social structure and other dimensions. The goal of the theory is to improve and provide culturally congruent care that is beneficial, fitting, and useful to the client, family or culture group. In conceptualizing the theory, Leininger held this as the central tenet: CARE is the essence of nursing, and its central, dominant and unifying focus. She stated that culture care would provide a distinctive feature by which to know, interpret, and explain nursing as a discipline and profession. Leininger theorized that all cultures of the world had folk, indigenous and naturalistic lay care systems and that some people were exposed to professional health care systems. Folk and professional health care systems greatly influenced individual or group access to quality care in favorable or less favorable ways. She further stated that what was similar or different between folk and professional systems was yet to be discovered. To support her theory, she formulated several assumptive premises, which included: Human caring is a universal phenomena, but the expressions, processes, structural forms, and patterns of caring vary among cultures. Caring acts and processes are essential for human birth, development, growth, survival, and peaceful death. Care has a biophysical, cultural, psychological, social, and environmental dimension, and the concept of cultural provides the broadest means to know and understand care. Nursing is a transcultural phenomenon as nurses interact with clients, staff, and other groups, and requires that nurses identify and use intercultural nurse-client and system data. Care behaviors, goals, and functions vary transcultural because of the social structure, worldview, and cultural values of people from different cultures. Self and other care practices vary in different cultures and in differences folks and professional care systems. The identification of universal and non-universal folk and professional caring behaviors, beliefs, and practices is essential to discover the epistemological and ontological base of nursing care knowledge. Care is largely culturally derived and requires culturally based-knowledge and skills for satisfying and efficacious nursing practices. There can be no curing without caring but there can be caring without curing. (The statement means that curing activities must go with caring activities.

She saw nursing in the 21st century as multicultural because of the global changes that would bring people closer to each other due to changes in social, cultural, political, health care, and technological forces
LEININGER THEORY OF CULTURAL CARE In this section of the lecture, you will have a glimpse of what Leininger wanted to emphasize in her theory. She called her theory Culture Care Diversity and Universality.

As Leininger sais, care is the nurses way of being with and helping people. Caring can be done not only in illness states but also wellness conditions in order to improve the human health condition.)

THE SUNRISE MODEL

Leininger viewed her models as the rising of the sun. The upper half of the circle depicts components of the socio-cultural structure and worldview factors that influence care and health through language and environment. These factors influence folk, professional, and nursing systems which are in the lower half of the model. The nursing subsystem ast as a bridge between folk and professional health systems. Through the three types of nursing care decisions and actions, it is possible to provide culture congruent care that is beneficial, satisfying, and meaningful to people. These nursing decisions and actions are: CULTURE CARE PRESERVATION, CULTURAL CARE ACCOMODATION, AND CULTURAL REPATTERNING. The arrows on the model indicate influences which flow in different areas and across major factors. The factors are closely interrelated to each other, very much like a view of the total functioning of human beings. The dotted lines indicate an open world or an open system of living. Do you find the model helpful in capturing the essential dimensions or components of the theory? Culture care preservation or maintenance to those assistive, supportive, facilitative, or enabling professional actions and decisions that help individuals preserve or maintain favorable health and caring lifeways. A good example is promotion of breastfeeding practices. Another is maintaining the involvement of families/relatives in caring for the client. Cultural care accommodation or negotiation refers to those culturally based assistive, supporting, facilitative, or enabling professional actions and decisions that help people of a particular culture adapt to, or negotiate with others, a beneficial or satisfying health outcome. We can cite as an example the training of hilots or traditional birth attendants on the use of sterile technique in delivering babies. We can also consider nurses action as negotiation when she advises a client about the positive and negative aspects of seeking help from an indigenous spiritual healer. Culture care restructuring or repartterning refers to those assistive, supportive, facilitative, or enabling

professional actions and decisions that help people change or modify their life ways to accommodate new or different health care patterns that are culturally meaningful and satisfying to them. For example, a client who is a chronic smoker can work together with a nurse so that the former will stop smoking for his own health and well-being. Leiningers Sunrise Model guides nurses in discovering knowledge about culture-specific care practices that can be used to improve nursing care. In using this model, you may work either from the top or bottom depending on the scope of your interest or inquiry. You may want to begin exploration by focusing your study on the care of individuals or groups in hospitals or homes (lower part of the Model.) Then you gradually move the exploration upward to include specific culture. Finally, you move on to discover large scale phenomena including the worldview, cultural, and social structural dimensions of several cultures. Let me illustrate this by an example: You may be interested in discovering the caring ways of the Aetas of Zambales in Central Luzon. Specifically, you may want to explore their childbirth practices. Then yo may want to expand your study to include other Filipino indigenous cultures such as the Mangyans of Southern tagalo and the Tinguians of Northern Luzon, or the Subanons and Maranaws od Mindanao because you want to discover similarities and differences in childbirth folk beliefs, practices, and taboos. If you are interested in doing large scale study, then you would look into bigger aspects of life economy or production, social structure and political organization and how these factors influence their health, well-being, and caring practices. From 1960 to 1990, Leininger and other nurse studied 54 cultures in Western and Non-western societies. They were able to identify 172 care constructs with specific meanings, usages, and interpretations which can guide nursing actions and decisions. The studies revealed in general that: 1.Emic culture care knowledge from western and nonWesterm cultures showed more differences than similarities in culture values, usage and meanings, 2.The social structure and worldview of Western and Non-Western cultures strongly influenced care practices leading to health or well-being. 3. Major differences existed between the clients cultural care knowledge (emic viewpoint) and that of professional nurses and other health personnel (etic viewpoint) in hospital contexts, and

4. Culture care differences between the client and health personnel gave rise to conflicts, stresses, noncompliance, and slower client recovery.

Other theories generated by studies conducted by Leininger and several graduate Transcultural students reveal the following: 1. Nursing care decisions or actions that reflect the use of the clients cultural care view values, beliefs, and practices were positively related to clients satisfaction with care received. 3. High dependency of the clients upon technological nursing care activities were closely related to cultural care that reflected decreased personalized care actions. 4. Religion and kinship care factors were more resilient to change than technological factors. 5. Self-care practices were evident in cultures that value individualism and independence; other care practices were evident in cultures that support human interdependence. STRENGTHS AND LIMITATIONS A major strength of Leiningers Theory is the recognition of the importance of culture in providing nursing care. Unlike other nursing theorists who held that person, nursing, health, and environment are the basic concepts in nursing, Leininger focused o care as the central aspect of nursing. She asserted that the use of the term PERSON may be controversial particularly in non-western cultures because the concepts of family or institutions are more important and meaningful to them. She stated that there are disciplines such as the humanities and the sciences which already focus on man or person. She further stated that while the concept of ENVIRONMENT is important in nursing, it is not really unique to the profession. She likewise believed that the concept of HEALTH is not distinct to nursing becaue many disciplines and fields have studied health. The theory is useful and applicable to both individuals and groups of clients because the goal is the same - rendering culture-specific care.

The Sunrise Model can be used as a guide for the study of any culture or for the comparative study of several cultures. While the theory does not provide specific directions for nursing care, it provides guidelines for the gathering of knowledge, and a framework for decision-making that would be great benefit to the client. Leininger did not use the term NURSING INTERVENTION because the she believed that the term communicates some sort of interference or imposition on peoples cultural practices. Even the term NURSING PROBLEMS is not part of her vocabulary for the reason that nursing problems may not necessarily be the peoples problems; or the problems may be viewed differently by people of different cultures.
If the theory can be applied in planned nursing experiences, it can help nurses become culture-sensitive health care professionals. However, as Leininger herself pointed out there are only few nurses who are academically prepared to conduct transcultural investigations, the results of which can contribute to the increasing knowledge about transcultural care. Some critics of Leininger believe that her focus on culture omits other variables such as class and gender differences which can be sources of conflict and stress within a society and among people. Another comment is that culture-specific nursing care may divert attention from the uniqueness of the individual. Wilkins suggested that nurses should use cultural awareness. Sensitivity and a good knowledge base in asking the right questions so they can make a realistic and proper assessment of the needs of each of the individual. SUMMARY The major concepts of Leiningers Theory are culture, culture care, culture care diversity and universality, worldview, social structure, environmental; context, folk health system, professional, culture care, preservation, culture care accommodation, culture care repartterning. These concepts and their interrelationships provide the basis for the sunrise of The Theory. The Sunrise Model presents of focus which move from the cultural and social structure through individuals, families, groups, and institutions in diverse health care systems in which nursing care decisions and actions can involve culture care preservation, accommodation and repartterning. Leininger said that cares are those care patterns, values, and behaviors that are common across cultures. Care diversities are those patterns and processes that

are unique or specific to an individual, family, or cultural group. A basic tenet of Leiningers theory is that human beings are inseparable from their cultural background and the society which they belong.