Introduction

Filipino nurses are highly in demand all over the globe. It was cited by the World Health Organization (WHO) as the largest exporter of Registered Nurses to foreign countries. You can find them in almost all parts of the world with most concentration in the U.S., Europe, Canada, Middle East, Australia, Africa, South America and other Asian countries with an estimated total of about 250,000 worldwide. This is because they are known to be highly-competent, hardworking, flexible and patient-oriented professionals. This is a bitter-sweet success for Filipino nurses because working abroad means financial stability and better standard of living. However, working in other countries as nurses is not totally a glamorous job. They have to withstand racial discrimination, unfair labor practices, adopting to different cultures and being away from their beloved family in exchange for that.

For the past decade, emigration of Filipino nurses has notably increased. But aside from the higher pay offered by jobs abroad, exodus of Filipino nurses from the Philippines was also influenced by a variety of factors. These include but not limited to the fragile economy, high unemployment rate, massive contractualization, unregulated nurse-patient ratio and very low salaries and wages. Thanks to the nurses still working in the Philippines, the healthcare system is still functioning.

The massive exit of well-experienced Filipino Nurses from the Philippines resulted not only in the deterioration of the nursing care services in the clinical setting but also of the quality of education in the academe. If this trend goes unchecked, it could lead to the so called “brain drain.”

Other countries like the U.S. recognize that nurses cater to culture-diversified clients thereby an effort to train and prepare their nurses to this challenge has been initiated and maintained. Sending exchange nursing students to other countries like the Philippines is becoming popular nowadays. Continuing education and seminars on transcultural care are also a common practice.

In order to keep Filipino Nurses at pace, transcultural nursing should be adopted openly. Madeleine Leininger’s Culture Care will be a good addition to Filipino nurses’ skills and knowledge in the delivery of healthcare services worldwide. It advocates the utilization of intercultural communication and the need for appropriate culture-sensitive care. Mastery of Leininger’s Theory can help Filipino nurses become more effective and stay globally competitive.

In the future however, some offshore nurses are still hoping that there will come a time that working abroad would only be just an option and not a necessity to have a decent and respectable life. Whether this will ever happen, we play a big role in the realization of that outcome.

Who is Madeleine Leininger?

“Transcultural nursing with a caring focus must become the dominant focus of all areas of nursing. It is the holistic and most complete and creative way to help people.”

Doctor Madeleine Leininger was born in Sutton, Nebraska, USA on July 13, 1925. Since childhood, she has lived on a farm with two brothers and two sisters. She graduated from Sutton High School. In deciding which course to choose in college, she credits her aunt who suffered from congenital heart disease who encouraged her to enter the field of nursing.

She entered the cadet Nurse Corps and a diploma program at St. Anthony’s School of Nursing in Denver, Colorado, USA along with her sister in 1945. She went on to receive a BS degree in Biological Science minor in Philosophy and Humanistic Studies from Mount St. Scholastica College (now known as Benedictine College) in Atchison, Kansas, USA.

Throughout her career, Dr. Leininger has been a pioneer and leader in promoting quality nursing care through transcultural understanding. She developed her theory of Culture Care Diversity and Universality, one of the earliest nursing theories, and coined the term “Culturally Congruent Care” as the goal of this theory.
Dr. Leininger is a nationally and internationally known educator, author, theorist, administrator researcher, consultant, and public speaker. She has been a distinguished visiting professor and scholar at approximately 70 universities in the United States, Canada, and overseas. Her areas of expertise are Transcultural Nursing, Comparative Human Care, Qualitative Research Methods, Cultural Care Theory, Culture of Nursing and Health Fields, Anthropology and the future of nursing.

Leininger's Works

• Opened a Psychiatric Nursing service and educational program at Creighton University in Omaha, NE in 1950.
• Served as Associate Professor of Nursing and Director of the Graduate Program in Psychiatric Nursing at the University of Cincinnati from 195s4 to 1960. She initiated during this time the first graduate program in Psychiatric Nursing at the University and also the first clinical specialist program in Child Psychiatry Nursing in the USA.
• In 1960, she co-authored one of the first psychiatric texts, Basic Psychiatric Nursing Concepts, which was published in eleven languages and used worldwide.
• She was appointed Professor of Nursing in Anthropology at the University of Colorado in 1966 - the first joint appointment of a professor of nursing and a second discipline in the United States.
• In 1966, Dr. Leninger developed the first course in Transcultural Nursing while a professor at the University of Colorado.
• From 1969 to 1973, she was Dean, Professor of Nursing and Lecturer in Anthropology at the University of Washington, School of Nursing.
• She established the first master’s and doctoral programs in Transcultural Nursing at the University of Utah in 1974.
• She founded the Transcultural Nursing Society in 1974 and the International Association of Human Care in 1978, and served as first full-president of the American Association of Colleges of Nursing.
• From 1974 to 1980, Dr. Leininger served as Dean, Professor of Nursing, and Adjunct Professor of Anthropology at the University of Utah College Of Nursing.
• In 1981, she began her tenure as Professor of Nursing at Wayne State University as Professor of Nursing and Director of the Center for Health Research at the College of Nursing, as well as Adjunct Professor of Anthropology in the College of Liberal Arts.
• Established and served as first editor of the Journal of Transcultural Nursing from 1989 to 1995.
• Since 1983, the Leininger Transcultural Nursing Awards have recognized outstanding leaders in Transcultural Nursing. The awards address the imperative to make Transcultural Nursing known as a discipline worldwide.
• Leininger’s greatest contribution to the Nursing Profession was her works on the Theory of Culture and Care. Her recognition of the need for the development of strategies in nursing which will integrate different cultures, patterns and life ways, and her experiences as psychiatric clinical nurse specialist led her to study further and come-up with what we have right now as the Transcultural Nursing theory.
• She retired as Professor Emeritus from Wayne State University on June 1, 1995.

Leininger's Accomplishments

• Received a Master of Science in Nursing Degree, with a minor in Psychiatric Mental Health Health Nursing and Psychology at the Catholic University of America in Washington, DC on 1954.
• To learn more about the influences of cultural factors in nursing as well as the potential of integrating the fields of Nursing and Anthropology, she embarked upon a doctoral program in Cultural and Social Anthropology at the University of Washington in Seattle. In 1965, she became the first professional nurse to have earned a Ph.D in Anthropology.
• Under her leadership, the University of Washington was recognized as the Outstanding Public Institutional School of Nursing in the United States.
• She won the prestigious President’s Award for Excellence in Teaching in 1981. Also, she was awarded The Board of Governor’s Distinguished Faculty Award, and the Gershenson’s Research Fellowship Award.
• As of 1995, she has written 25 books, published over 200 articles and book chapters, produced numerous audio and video recording, and developed a software program.
• She has also given over 850 public lectures around the world.

Introduction to the Theory of Culture Care, Diversity, and Universality

Nurses are in constant interaction with different clients from all walks of life. Regardless of their age, status or condition, we are bound to provide them with the utmost care they deserve. It is a pledge that we made, and one that we have lived by. However, sustaining the care we provide in ensuring that they maintain their well-being is an issue.

Health education and maintenance plays a major role in healthcare and one that is highly participated by nurses. Taking into account our client’s differences in their beliefs, values and practices is tantamount to the success of health promotion. It is with this premise that a sensitivity and knowledge on cultural differences takes the stage.

Madeleine Leininger was the first to identify the impact of culture in relation to nursing. She spent years understanding and developing their connection and how one can influence the other. In this regard, she studied anthropology and utilized it in nursing. The combination of the two brought about her Theory of Cultural Diversity and Universality.

In here, she defined Transcultural Nursing as a subjective area of study and practice focused on comparative cultural care (caring) values, beliefs and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people face unfavourable human conditions, illness or death in culturally meaningful ways (Barnum, 1998). Moreover, it goes beyond an awareness state to that of culture care nursing knowledge to practice culturally congruent and responsible care (Tomey, 1998).

Cultural Diversity and Universality is therefore the highlight of Leininger’s theory. Cultural Diversity is defined as variations in each culture. In acknowledging these differences, the nurse is able to avoid stereotyping and assume that all clients will respond to nursing care in the same manner. Culture Universality on the other hand, pertains to the similarities. Both these concepts lead to the goal of the theory and that is, “to discover similarities and differences about care and its impact on the health and well-being of groups” (Leininger, 1995)

Internalizing the concepts on culture diversity and universality gives rise to culture-specific and culturally congruent care. The former refers to the identification the client’s care practices brought about by their culture and utilizing them to plan and apply nursing care. This in turn would bring about nursing care that “fit the specific care needs and life ways” of the client (Leininger, 1995). The latter, speaks about “cognitively based assistive, supportive, facilitative, or enabling acts or decisions in order for the nurse to provide meaningful, beneficial, satisfying care that leads to health and well-being” (Leininger, 1995). This, according to Leininger, is the central idea and goal of the Theory of Cultural Care.

The Sunrise-Enabler Model

Effective care is the ultimate task of nurses. We are the members of the health team who have direct patient/client interaction and therefore it is through our knowledge & understanding of the values, customs, beliefs & practices our patients’ culture that we can provide effective care. A better way of understanding the factors that influence a person’s perception of well-being is the sunrise enabler of Madeleine Leininger. Leininger’s model of cultural care can be viewed as a rising sun. When using this model, the nurse can begin anywhere depending on the focus of nursing assessment. The model reflects influences of one’s worldview on cultural and structure dimensions. The cultural and social structure dimensions include technological, religious, philosophic, kinship, social, value and lifeway, political, legal, economic, and educational factors. Each of these identified systems affects health. These cultural and social structure dimensions in turn influences environment and language, wherein emphasis should be placed since this is where the patient/client find themselves such as home conditions, access to particular types of food and family access to transport. Environment and language influence the involved health systems – the folk, professional and nursing systems. The folk health system includes the traditional beliefs and practices on health care while the professional health systems are those practices we learned cognitively through formal professional schools of learning. The combination of the folk health system and the professional health system meets the biological, psychosocial, and cultural health needs of the patient/client.

These factors influence the patterns and expressions of caring in relation to the health of individuals, families, groups, and communities. To be able to make sound nursing care decisions and actions, these factors should be assessed properly and always be taken into consideration.

To achieve culture congruent care, nursing actions are to be planned in one of three modes: culture care preservation/maintenance, culture care accommodation/negotiation, or culture care repatterning/restructuring.

A research project on health and social practices regarding dengue in 2008 on three countries in Southeast Asia could be used as an example on how Leininger’s sunrise enabler can be applied on the community level. Some of the cultural and social factors that were assessed are as follows:

Cultural and Social Structure Dimensions
Technological	lack of awareness of first aid remedies and safety procedures on dengue prevention at home
Religious	community people view dengue as a bad omen
Kinship and Social	women are always the caregivers, thus more women are prone to psychological burden of caring for the sick member of the family
Cultural Values	health is of lesser priority; more priority is given to basic needs such as food
Political and legal	lack of policy programs by the local government regarding dengue prevention practices
Economic	more males acquire dengue since most of them are night shift and farms/plantation workers
Educational	low level of education is noted. Most are secondary level graduates, knowledge and comprehension on proper health practices on dengue prevention is low

Proper assessment of the cultural and social structure dimensions will lead to good planning and intervention, leading to a sustainable health care delivery to individual, families, or communities.