Madeleine Leininger’s Culture Care Theory focused on the concept of care that is essential and important in nursing. This makes the nurse’s function unique to other disciplines. Care best describes nursing because it is how nurse’s show their compassion and concern to the patient. Thus knowing the patient’s unique cultural attributes and at the same time assimi
lating it within the nursing proce
ss will surely render a culturally congruent care.
She didn’t emphasize on the usual nursing metaparadigm that most nursing theorists utilize such as person, environment and health, though she briefly described each.
The concept of person is culture-dependent especially in non-Western countries where they refer it collectively like family, communities, institutions which they value more than individual entities. Knowing that each culture differentiates the meaning of a person makes it limited to explain in nursing. Next will be the concept of health, since a lot of disciplines already used and defined the term, it is no longer distinct to nursing. Lastly, the concept of environment is important to nursing but it is also not unique to nursing. Thus she used environmental context instead of environment alone because using so includes the events with implications and meanings in a particular setting.
Madeleine Leininger’s theory has been at the forefront of modern day nursing practice. The framework of this theory serves a guideline for professional nurses to provide a holistic approach to caring. The concepts that she introduced paved the way in considering a broader aspect of healthcare service and not merely concentrating on the physiological aspect of human well being.
The concept of Cultural Care Preservation or Maintenance deals on the nursing care aspect with the goal of helping in the preservation or maintenance of favorable health and caring lifestyle. This entails that in maintaining homeostasis, the nurse or the healthcare provider must be sensitive in the idiosyncrasies and uniqueness of the patient. Paying special attention to cultural beliefs and traditions will aid in a more efficient facilitation of caring for the individual.
Another concept introduced by Leininger is about Cultural Care Accommodation or Negotiation. The guiding principle of this concept is based on the realization that in providing quality care, the nurse must be able to adapt or negotiate with the client by taking into account the particular culture the client belongs to. The nurse must recognize that in order to be effective, he must take into account the possible differences of the client’s beliefs from his own. By acknowledging this fact, the nurse will not come across too strong and will not appear as imposing. Striking a balance between what is the universally accepted balance and the traditions and customs of a particular client is the aim of this theory. Accepting the differences and managing to reach into a compromise can eventually lead to a more sustainable healthcare plan for the client because encroachment on beliefs is minimized.
There is also the notion on Cultural Care Restructuring or Repatterning. It dwells on idea that people are capable of modifying their lifestyles to accommodate new healthcare ways or patterns. It further expounds that individuals have the capacity to change and are open to try new practices as long as they think that the results are culturally meaningful and satisfying. For the nursing practice, the repatterning aspect of this model is a useful tool in trying to “bend” or flex some of the stringent beliefs or habits of the client by including them in their own healthcare plan. This further implies that considering the cultural background of an individual does not necessarily mean being certain practices are better left alone. In actuality, the model guides the nurse on how to be culturally sensitive and try to find creative ways of persuasion without being drastic and radical.
The Sunrise Model has a very significant contribution in terms of specific and individualized nursing care. The recognition, that each individual should be treated as a unique entity, with different social and cultural background, provides an impetus to improve the nursing profession.
Understanding culture care diversity and universality theory helps nurses to be culturally competent who can work effectively across cultures. They can consciously address the fact that culture affects nurse-client exchanges; with compassion and clarity, ask each client what their cultural practices and preference are; incorporate the client’s personal, social, environmental, and cultural needs/beliefs into the plan of care wherever possible; and respect and appreciate cultural diversity, and strive to increase knowledge and sensitivity associated with this essential nursing concern. Putting these things in to consideration is important because of the following:
the world is constantly changing and it will be more diverse in the future. Our clients, patients and even other people that we work with came from diverse background and experiences.
in order to provide optimum or best care to our client we must practice cultural competency
being culturally competent and valuing diversity will help us be more sensitive to those we are caring for.
NURSING ACTIONS
COMPONENTS OF THE THEORY
1. The nurse uses participation, observation and interviews within the culture
To discover the worldview of the member or members of the culture, the cultural and social dimensions considering the cultural values and the lifeways such as technological, religious, philosophical, kinship and social, political and legal, economic, and educational factors, and the influence of language, the ethnohistory, and the environmental context.
2. The nurse analyzes the information gathered
To discover patterns and themes related to health and well-being based on the factors from the model.
3. The nurse considers the care indicated according to the data
To discover generic (folk) care, nursing care and professional systems of care indicated according to the data.
4. The nurse develops a plan of care based on the data and presents it to the patient
To plan for culture care preservation or maintenance, accommodation or negotiation, repatterning or restructuring.
5. The nurse observes the outcome of culturally congruent care
To promote health and well- being
Care is the very heart of nursing. Nurses provide holistic care to patients in several ways but this should be culturally sensitive in order to be effective and to promote patient satisfaction. Nowadays, nurses are challenged by the complexities of a multicultural environment wherein they are faced with patients from diverse cultural backgrounds.
Through Leininger's Theory, nurses are able to open their minds to the concept of culturally congruent care which is the primary goal of transcultural nursing practice. Transcultural nursing has been defined as a substantive 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 to face unfavorable human conditions, illness, or death in culturally meaningful ways. Thus, culture plays a vital role in person’s view of health and how he will react on it.
It is crucial for a nurse to study his feelings, beliefs, and views in life before he may understand the client’s feelings, beliefs and perceptions in their cultural context. In this way, any conflicts, stresses and noncompliance will be avoided in a nurse-client relationship. A thorough understanding and research about the client’s cultural background will help in providing quality and culturally congruent care. That type of care can possibly happen when the nurse and client will create together a new lifestyle that acknowledges the client’s practices, values and beliefs. In this way, the client actively participates in the nursing process and the nurse serves as patient advocate, leading to effective care and fast patient recovery.
As diversity from race, ethnicity, disability, sexual orientation, age, gender, social economic background, religion, and geographic may exist between the nurse and the patients, being conscious and respectful is important. We must understand the impact of the care provided to them. Effective communication will help in providing cultural responsive services, such as developing cultural awareness, having cultural knowledge, and practicing cultural skills are also useful in proving the best possible care to our clients.
Nurses who understand and value the practice of culturally competent care are able to arrive at positive changes in healthcare practices for clients of specific cultures. Sharing a cultural identity requires knowledge of transcultural nursing concepts and principles, along with an awareness of current research findings. Culturally competent nursing care can only occur when client beliefs and values are thoroughly incorporated into nursing care plans. Caring is the core of nursing. Culturally competent nursing guides the nurse to provide optimal holistic, culturally based care. These practices also help the client to care for himself and others within a familiar, supportive, and meaningful cultural context.
Continuous improvement and expansion of appropriate modern technologies and other nursing and general science knowledge are integrated into practice. Nurses nowadays are faced daily with unprecedented cultural diversity. Commitment to learning and practicing culturally competent care offers great satisfaction. This culturally congruent care will be an edge for nurses who practice it and a way of building a strong foundation in a nurse-client relationship.
Anywhere in the world, care is a basic and essential part of every therapeutic regimen, especially nursing care. But this care varies to different people because of individual differences or similarities between culture, beliefs, values, morals, and so on. Thus, it is really important that nurses must provide culturally relevant care to better serve the needs of the patient and at the same time promote faster recovery. Because of this arising concern, Filipino nurses around the world adapted Madeleine Leininger’s theory called Culture Care Diversity and Universality. This will now guide the nurses’ actions and decisions which will either preserve, accommodate or re-pattern the culture so as to provide culturally congruent nursing care, wherever he or she may be.
The following are anecdotes from different nurses from around the world, starting locally, in the Philippines.
As a nurse in a hospital setting, Jovy Joy Macrohon found herself at constant interaction with patients of different cultures, beliefs, attitudes, and morals. This is where she really appreciates Leininger’s theory, wherein she was able to adjust typical care in order to best address the care that the patient deserves. In her exposure in the Intensive Care Unit, she was able to handle a 50 year old French woman, conscious and coherent, who doesn’t speak English and speaks only French. She shared, “I was really puzzled during that time on how to render the care to this patient because I was not able to communicate with her verbally. Although there were available list of basic words, still it was not enough to communicate with her smoothly and understand each other. So what we did was to read a brief cultural background of the patient, employ non-verbal communication along with the basic words and allowed her family to visit and translate some of the needs and wants of the patient.”
Another instance was when Jovy was handling a 20 year old female Filipino-Chinese patient with the diagnosis of Dengue. Her Dengue was already near critical and she really needs to follow everything what the doctor ordered. Jovy said that “Since Chinese people are open to herbal medicines, she agreed to drink the Tawa-tawa extract prescribed by the physician. Another thing that I noticed from her is that she was really compliant and valued the advice of her elders. Her grandmother gave her Chinese medicines to take, aside from the indicated therapeutic regimen. Chinese medicine was also believed by these people because of their strong belief that it is very effective and better that the western medications. This seemed not to be a problem because the doctor was also open to the cultural aspects of the patient, as long as it doesn’t cause any harm on her.”
Through these experiences, Jovy learned that it is really important to consider and respect the patient’s culture, values and beliefs because it promotes better patient compliance to therapeutic regimen. Moreover, they feel at ease and confident of the care rendered as they undergo healing and recovery.
Joicee Almoneda read in Ruth Benedict’s Patterns of Culture (1961) that “The life history of the individual is first and foremost an accommodation to the patterns and standards traditionally handed down in his community. From the moment of his birth, the customs into which he is born shape his experience and behavior. By the time he can talk, he is the little creature of his culture and by the time he is grown and able to take part in its activities, its habits are his habits, its beliefs his beliefs, its impossibilities his impossibilities.” Considering this and applying Leininger’s theory, Joicee believes that an ability to work in a multi-environment is a must in every nurse, catering to the different needs of patients with different backgrounds.
“Every day I encounter individuals from different nationalities mainly because of the hospital’s location. We’re located at the city of Olongapo and we are so near to SBMA. Aside from that our hospital has affiliation with an international company. We are expected to cater Americans, British, Australians and Koreans because the city has been known to be occupied with immigrants. In this case, I must possess a culturally-sensitive knowledge and skill in order to provide a culturally congruent care to all my patients together with acknowledgement of their own preferences. In our department, which is the Emergency Room, we use HIMS as part of our computer system for registration of clients as outpatient. Nationality is one of the information to be filled up. I had encountered a foreign national one time and I asked if he was an American or British. He was thankful for asking his nationality in that manner. He answered it and he said he is a British. He told us that some Filipinos think that whites are all Americans not recognizing that there may be Australians or even British. It is quite sad and this maybe a simple scenario but it is evident that dominance over a specific race still exists.” Joicee believed that this is a reality that nurses should face.
Another experience Joicee had was when she encountered a Korean patient. He was not familiar yet with the English language and it was very difficult to converse with him. Joicee tried to do some sign language and talk in English just like how the patient does it. He had a mini translator and she assisted him during his admission. Joicee added “I was just surprised when I was doing the IV insertion. He was expecting that I will do it on his arm not on his hand. He told me that it is their practice in South Korea. I was really surprised about it and I just explained the rationale of choosing the peripheral veins. I apologized for what I did because I did not ask his preference. This experience helped me a lot for being culturally sensitive to my patient’s preference. After accomplishing the doctor’s orders, I endorsed him to the ward NOD accordingly. I just noticed that some of our nurses are not considering the patient’s choice of food. I had to go to our private station to clarify some matters and he told me that he does not like the food served to him.”
Working in an International hospital, Joicee belives that nurses must provide quality care with utmost sensitivity to what the patient want and need. Patient satisfaction will be one of the grounds for gauging the hospital’s commitment to achieve its mission; wherein in Joicee’s case is “To fully satisfy our patients with compassion, care and competency.”
Applying Leininger’s theory, Johanna Camille Divino imbued that every patient needs an individualized and unique nursing care. With this, communication plays an important role for the nurse to be able to effectively deliver nursing care. Johanna shared, “In the institution where I currently work as a staff nurse at the emergency department, our vision is ‘to become a world class hospital of everyone’s choice’. To be able to keep up with this vision, the hospital does not only cater to Filipinos but also to other nationalities all over the world. I once encountered a Filipino patient with stage IV cancer and is already comatose and the heart rate in the cardiac monitor already showed ventricular fibrillation and the patient was already gasping for air. The family still wants the conservative measures to be done to the patient and does not want defibrillation and intubation. Explanation of the consequences was done and their final decision was respected.”
Another case Johanna handled was a Japanese patient who does not know how to speak English. It was really hard to discuss modes of treatment and diagnostic tests to that patient. Luckily, Johanna has in her institution a Japanese translator that made it easy for the whole health care team to communicate with the patient and the family.
With these, Johanna realized that nurses are indeed flexible. They can easily adjust to the culture of their client as well as to their work place. They adapt to the situations given to them but at the same time maintaining their own identity and culture they grew up with. “I can say that I am proud and happy to be a nurse! Reaching out a helping hand to others even if they have different beliefs and values as what I have is such a fulfilling job. Understanding and respect is the key to our success as a professional and in delivering of effective nursing care,” Johanna added.
From the Philippines, let’s now travel the world through the words of offshore nurses. Maria Helen Villacorte went to Abu Dhabi full of hope and uncertainties. She admitted that she was scared of so many things like thinking if she could cope well with her new work, adjusting for another period with new colleagues and environment, and most of all approaching a new patient population. “I know for a fact that I will be dealing with Arab world knowing nothing except for a single phrase ‘Asalam malaycum’. Most of my ‘kababayans’ here said they have had ‘culture shock’ when they came here. It was really true. Arab people and their culture is significantly different. I still remember those days of staff orientation when they emphasized about Arab culture and when they gave me a small booklet of basic Arabic translation,” stated Maria. She was very grateful when she landed in Pediatric ICU as she was thinking that she do not need to learn Arabic as most of the patients in ICU is very sick and intubated. “I was absolutely wrong as I realized I cannot escape from reality when I had my first encounter with the parents. Thank God, I was saved by a translator. I have learned that it is very important to know at least the basic Arabic words as parent’s language per se and their culture is greatly influenced in dealing and treating a sick child. The role of cultural factors in nursing practice is highly significant,” she added.
Maria believes that Madeleine Leininger’s culture care theory is very related and applicable in the overall nature of her work in Abu Dhabi. It is powerful yet practical. It’s philosophy focuses on generating knowledge about the care of people from different cultures. Leininger’s model is unique because it suggests that the nurse assess the patient’s need and determine intervention according to their culture and lifestyles. “I have learned that different cultural factors greatly influence patient’s illness and wellness and how they maintain their health but most of all I have learned not to forget to respect each individual patient,” Maria affirmed. Every human culture has folk remedies, professional knowledge, and professional care practices that vary. The nurse must identify and address these factors consciously with each client in order to provide holistic and culturally congruent care.
Michelle Sioson stated that in their hospital, she and her co-workers are facing a lot of difficulties in dealing with cultural differences. Their mission and vision is “to lead in one way”, but in order to deliver and make this happen, each hospital employee must acknowledge each other’s differences. Filipinos are one of the leading populations as health care workers in Michelle’s institution and speaking as one of them, “I never had difficulty in finding myself to know how the work goes with my colleagues inside our unit. However, the first problem I faced is language barrier with the Arab patient. Although English is our mode of communication, most Arabs don’t know how to speak other languages than Arabic. The consequence to this is miscommunication leading to unsatisfied client. Secondly, learning about their culture, Arab people are so dwell in their religious way that tend to interfere health care delivery. So in order to intervene, we need to learn about their culture’s dos and don’ts. Lastly, as healthcare facilities are growing imminently, health care personnel are so in demand in proportion to increasing ill and well patient population. The hospitals are recruiting nurses in different countries. Because of this we also face many problems in nurse’s communications.”
This year, Michelle’s workplace launches a new project of cultural diversity as part of magnet accreditation. As one of the special interest group in the unit to promote Cultural Diversity, they have adapted the Leininger’s Cultural Care Diversity and Universality Model. “We used transcultural nursing to serve as a guide on how to embrace the uniqueness of every individual in our institution. Learning more about the skills, knowledge, and attitudes that make up cultural diversity awareness has the potential to transform the interaction between nurse and patient. Acquiring on patient’s cultural beliefs, values and attitudes is an integral part of providing total health care. Therefore understanding cultural diversity and applying delivery of culturally competent care is essential to the provision of effective and safe care for our patient population leading to better patient satisfaction,” she added.
As a Filipino nurse, Michelle realized that learning cultural differences is important t. “I fought so many times by not letting go my own beliefs and values. This will not work for we need to be flexible in order to survive. I am proud to say that Filipino nurses are always the patient’s request. Nursing is not just a job that could answer our financial needs, as a nurse we should be open in new learning and influence ourselves from other races,” she concluded. Marcelo Tanjusay is a registered nurse in California, USA. A patient in his 50’s was admitted to his telemetry unit for atrial fibrillation. A few hours after admission, the patient approached the nurses’ station and asked which direction is north? Upon learning the directional orientation, he went back to his room. A few moments later, when Marcelo was doing his rounds, he noticed that his door was locked from the inside. This lasted for a couple of minutes and he opened it again. “When I came back the next day, the nurse of the outgoing shift told me that the patient locked his door again and they have to knock several times before he opened it. He was then instructed not to lock the door again. Since that time, he started to become uncooperative and wanted to be left alone. When I started my shift, I decided to talk to him about the issue and explore the rationale behind his actions. At first he was hesitant to tell me but upon showing him genuine concern and empathy, he talked to me openly. He told me that based on their Islamic culture, he has to pray several times a day and he needs privacy when doing it. He emphasized that the above-mentioned practice is very important to him. He also verbalized that he felt offended when he was told not to lock the door again. I explained to him that the reason why we don’t like the door locked is that, it is dangerous during the time of emergency. If something happens to him, we cannot help him immediately especially that he has cardiac problem. After indentifying the problem, we made an agreement. I told him that I will make arrangement to everyone involved in his care not bother him during his time of prayer as long as he will not lock his door again. He readily agreed and he has been a happy camper since then,” Marcelo narrated. This is an application of cultural care preservation or maintenance, as one of Leininger’s models of actions and decisions.
In order to represent everyone, Marc Arman Jay Flores interviewed two nurses who happened to be “balikbayans”.
Professor Rowena Chua of the University of Santo Tomas College of Nursing has worked as a nurse in the USA prior to her academic load. She said that adapting at first was really hard due to the cultural differences and individual prejudices. She would even often hear her patients ask “Aren’t you a bit too young to be a nurse?” Despite all these, Professor Chua still optimally provided nursing care, earning respect not only from her patients but also from her co-workers.
“Leininger’s theory can be applied not only to patients but also to co-workers as well,” she added. Respecting different beliefs and practices should be rendered to everyone, including nurses. Presently, Professor Chua shares her experiences abroad and more to future nurses of the country.
Another nurse who previously worked in the USA is Ms. Grace Doinog, supervisor of the Neurology Ward and Community Center of the University of Santo Tomas Hospital. Like Professor Chua, Ms. Doinog also had difficulties adjusting at first. She said that “it’s hard to adjust especially if racism is present.” Even with these circumstances, she was still able to give excellent nursing service. “Nursing service here and in the US is just the same. The thing that differs is technology,” Ms. Doinog said in terms of comparison. Now that she’s back in the Philippines, she shares her experiences to her subordinates. There’s just one problem though, and according to her “the difference in technology would make it hard to apply these learnings in the local setting.”
So, whether a Filipino nurse is based locally, offshore, or is back from a worldly adventure, equipped with an excellent theoretical background and a flexible clinical experience in applying Madeleine Leininger’s Culture Care Diversity and Universality and more, he or she will be able to survive and live to tell the tale.
Madeleine Leininger’s life is dedicated in bringing the world knowledge about the importance of culture in caring. Having read her history, we can say that all of her hardships are worth it because now, the world recognizes the significance of culture-sensitive care. As Filipinos, we are used to the different cultures that are present in our small country. That’s why the idea of Transcultural Nursing is not unfamiliar to us. We know that many of our countrymen have different needs depending on where they came from. However, as nurses, we still need to understand fully the theory presented by Leininger in order for us to be a globally competent nurse with regards to transcultural care.
The Theory of Cultural Diversity and Universality does not only show the similarities and the differences of each individual but it also opened our eyes that not everyone has the same needs and priorities. For example, patients with similar diseases don’t necessarily mean that they have the same need. Others need to pray during their times of struggles while others want to have fun to relieve their stress. Placing importance on patient’s cultural background is not easy. However, Leininger provided us a way to do so. Her Sunrise Model helps nurses in assessing culture and social related factors of patients. It also serves as a guide as we develop our skills in providing a culture-sensitive care to our patients.
Using Leininger’s Theory of Culture Care and her Sunrise Model as a framework for nursing practice has several benefits.
First, it helped us engaged ourselves in a reflective discourse with Leininger. Consequently, while we try to synthesize and assimilate her points of emphasis, our perceptions are reframed to what constitutes culture from the nurse’s point of view. This kept us more receptive to learning and developing ourselves in the process, for optimum patient outcomes. Culture affects outcome. Our nursing care plan to provide optimum results must reflect our awareness of the differences in people's cultural backgrounds -- just as we are aware of the physical condition of their bodies. By understanding their culture, we can give them the appropriate care that they deserve
