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Continuing Education Article
Madeleine Leininger’s Culture Care Theory:
The Theory of Culture Care Diversity
and Universality
Jean Nelson, PhD, RN
University of Missouri-St. Louis
School of Nursing
Program Goal
To establish a knowledge base in culture
care theory that will promote the administration of culturally competent nursing care
for individuals, families, groups, and communities.
Upon completion of the program the
participant will:
• Identify core concepts in
Leininger’s culture care theory.
• Explain basic elements and relationships portrayed in the sunrise
• Describe basic steps in the ethnonursing research method and its
importance in developing the theory
base for transcultural nursing,
• Apply principles of culture care theory to specific nursing care situations.
Content Outline
I. Overview of culture care theory
A, Historical development
B. Explanation of the sunrise
C. Assumptive premises of the
D, Orientational definitions
II. Ethnonursing research
A, Basic elements of the ethnonursing method
B, Research enablers and assessment guides
C, Recurrent culture care constructs identified in ethnonursing studies
III. Nursing care situations for analysis and application of culture care
rv. Resources for future theory development and application
The theory of culture care diversity and
universality evolved through a synthesis of
two central concepts: caring and culture.
Leininger (1991a, 1995, 2002a) wrote that a
personal conviction regarding caring as the
essence of nursing developed during her
early experiences as a nursing student and
as a hospital staff nurse in the 1940s, an era
in which compassionate care giving was
taught by example in an environment devoid of the distractions associated with
today’s complex healthcare technologies. In
a later experience in the mid-1950s, employed as a psychiatric nurse specialist caring for children from diverse ethnic
backgrounds, Leininger discovered that inadequate knowledge of cultural factors represented a missing link in her ability to
provide care. She wrote that, “I experienced
culture shock and I felt helpless to assist
children who so clearly expressed different
cultural patterns and ways they wanted
care” (1991a, p. 14). The impact of this experience eventually led Leininger to pursue
a doctoral degree in anthropology and to
begin synthesizing the concepts of caring
and culture (Leininger, 1970). The new concept of culture care became the basis of a
nursing theory (Leininger, 1978) directed
toward provision of culturally sensitive
Building on her knowledge of ethnography, the qualitative research method used in
anthropology, Leininger (1985b) developed
ethnonursing methodology as a tool for exploring transcultural nursing phenomena.
On the basis offindingsfrom multiple ethnonursing studies Leininger (1991a, 1995)
concluded that caring in some form was
universally present in all of the cultures
studied but that the specific manifestations
and practices of caring were very different.
As a result, her theory came to be called the
theory of culture care diversity and universality or simply culture care theory.
International Journal for Human Caring
Leininger also developed the sunrise model
to visually portray interacting elements of
the theory (2002b, p. 80).
The upper level of the sunrise model resembles a rising sun with rays representing
the cultural and social structure dimensions
of a culture care worldview. The rays are
also the basic elements of a cultural assessment. Convergence of the rays into a central
core suggests that these interacting elements influence the unique care expressions
and practices of individuals, families,
groups, communities, and institutions. The
middle level of the sunrise model portrays
nursing care as a circle, overlapped by two
other circles representing generic (indigenous or emic) and professional (outsider or
etic) care systems. The model suggests that
decisions about and actions pertaining to
nursing care should be based on integrated
knowledge of generic and professional care
systems. The lower level of the sunrise
model depicts three types of nursing strategies: culture care preservation, which emphasizes support of indigenous care
practices; culture care accommodation,
which involves synthesis of indigenous and
professional care practices; and culture care
repatteming, which means implementation
of professional care with respect for indigenous beliefs and values. Deliberate planning
and implementation of nursing strategies
based on cultural assessment leads to the
desired outcome of culturally congruent
nursing care. Bidirectional arrows in all
parts of the model are identified as influencers, suggesting that all components influence or are influenced by the others. In
this respect, the sunrise model stands in
sharp contrast to unidirectional, quantitative
Leininger’s writings (1991a, 1995,
2002a) have consistently identified 13 assumptive premises as fundamental tenets of
her theory. These include strong statements
Madeleine Leininger^s Culture Care Theory
about care/caring as the essence of nursing;
the need for nurses to understand cultural
differences as well as commonalities in beliefs, values, and practices of caring, and to
use this knowledge in the provision of culturally based nursing care; and the need for
ongoing qualitative research to develop and
expand the knowledge base for culturally
congruent care. In addition, Leininger has
stated (1991a, 1995) and revised (2002b)
definitions of key concepts that are central
to the culture care theory. Concepts included in the revised list (2002b, pp. 83-84)
include human care/caring, culture, culture
care, culture care diversity, culture care universality, worldview, cultural and structural
dimensions, environmental context, ethnohistory, emic, etic, health, transcultural
nursing, culture care preservation and/or
maintenance, culture care accommodation
and/or negotiation, culture care repatteming
and/or restructuring, and culturally competent nursing care. The definitions are orientational, meaning broad enough to facilitate
discovery of meanings in a qualitative paradigm, in comparison to operational definitions that facilitate quantitative
Leininger made it very clear that her
theory had been generated inductively in a
mode of naturalistic inquiry and that she developed ethnonursing as a specific qualitative research method for theory
development (1985a, 1985b, 1991b,
2002b). Data collection in ethnonursing research is accomplished through participant
observation and interviews with informants.
Participant observation means being involved in the activities of a cultural group
while simultaneously observing and making
mental notes. The observations are subsequently documented in great detail in a field
joumal. Informants are individuals who are
willing and able to communicate cultural
information to a researcher. Interviews are
typically taped and then transcribed verbatim. The analysis of data in ethnonursing
has four phases:
1. Collecting, describing, and documenting raw data.
2. Identification and categorization of
descriptors and components.
3. Pattem and contextual analysis.
4. Major themes, research findings,
theoretical formulations, and recommendations (2002b, p. 95).
While quantitative researchers typically
use measurement tools or instruments,
Leininger consistently advocated that ethnonursing researchers need other devices to
help them “tease out data bearing on culture
care, health, and related nursing phenomena” and accordingly has developed five
“enablers” (2002b, p. 89):
• Leininger’s sunrise model (2002b,
p. 80)—A comprehensive guide for
ethnonursing research and a pictorial depiction of the theory of culture
care diversity and universality,
• Leininger’s ObservationParticipation-Refiection (OPR)
Enabler (2002b, p,90)—Developed
to help the researcher move gradually from an observer/active listener
role, to roles with increasing levels
of participation and eventually to a
role involving primarily reflection
and reconfirmation of findings with
• Leininger’s Stranger-to-TmstedFriend Enabler (2002b, p. 91)—
Developed to assist the researcher
or nurse clinician in self-assessment
as he/she attempts to establish a
trusting relationship with informants or clients. The presence of
“trusted friend indicators” suggests
that a favorable relationship has
been established and that cultural
data collected are authentic and
• Leininger’s Acculturation Health
Care Assessment Enabler (2002c, p.
141)—A guide for evaluating the
degree of an informant’s orientation
toward traditional or nontraditional
beliefs, values, and practices
• Domain of Inquiry (DOI) Enabler—
A statement developed by the individual ethnonurse researcher,
indicating the specific focus of
study within the broader domain of
culture care and health.
In a review of research conducted by expert transcultural nurses in about 100
Westem and non-Westem cultures over a
period of 5 decades, McFarland (2002)
identified “recurrent and dominant universal
culture care constructs” (p. 107) and listed
these in rank order:
1. Respect for/about
2. Concem for/about
3. Attention to (details)/in anticipation of
4. Helping/assisting or facilitative acts
5. Active listening
6. Presence (being physically there)
7. Understanding (beliefs, values, lifeways, environmental context)
8. Connectedness
9. Protection (gender related)
10. Touching
11. Comfort measures
McFarland (2002, p. 111) also noted the
existence of a culture care theory group
(CCTG), an on-line discussion group open
to all nurses interested in newfindingsrelevant to Leininger’s theory. The site listed for
potential members to contact is
While full-scale research on the culture
care theory is based on the sunrise model,
Leininger also developed an altemative
Short Culturological Assessment Guide
(2002c, p. 129) useful in situations where
time constraints and other limitations make
it impractical for the nurse to do an in-depth
assessment. Briefly summarized, the Short
Culturological Assessment hasfivesteps or
1. Recording observations.
2. Listening to/learning from the
client about cultural values, beliefs,
and practices.
3. Identifying and documenting recurrent pattems and narratives with
client meanings.
4. Synthesizing expressed themes and
pattems of care.
5. Developing a culturally based plan
of care.
The following anecdotes, all based on
the author’s own professional experiences,
describe situations in which the integration
of generic and professional care practices
represented a challenge for the nurse. The
reader is encouraged to use the culture care
theory as a basis for evaluating the nurses’
actions in each case.
Case 1: Mrs. S was an elderly retired
nurse of German-American descent. She
grew up in a mral community with a strong
German heritage where the value of cleanliness was especially emphasized and, as a
nursing student in the 1940s, she was taught
the importance of the bed bath as the epitome of good nursing care. Hospitalized
many times in the course of a chronic illness, she found that her nurses wanted to increase her self-care skills and to that end
placed her in a chair in the bathroom with
instructions to bathe at the sink. Mrs. S
2006, Vol. 10, No. 4
Madeleine Leininger^s Culture Care Theory
found this awkward, embarrassing, and an
ineffective way to get clean. She longed for
an old-fashioned nurse who would give her
a bed bath, soak her feet, and rub her back
with lotion.
Case 2: Mr, B, an African-American
client on a psychiatric ward, had long hair
styled in traditional dreadlocks. He told his
primary nurse that he was a Rastafarian,
that his locks were important to him because they helped him conimunicate with
God, and that he was upset because someone had cut one of his locks off without his
knowledge or permission. The nurse inspected the client’s head and noted that one
of the locks had apparently been cut off.
Based on his statement that he was upset
because the dreadlocks helped him communicate with God, the nurse charted that Mr.
B was experiencing delusions.
Case 3: Mr, T was a VietnameseAmerican client hospitalized on a psychiatric unit with bipolar affective disorder. He
responded well to medications and, as his
discharge day approached, he told his nurse
that he planned to continue taking his medications as ordered and to keep his appointments for follow-up care at the psychiatric
clinic. Then he added:
You know, this probably sounds
crazy but in my home country people
believe that illness can be caused by
sins committed in a previous life, A
person with this kind of sickness
wouldn’t go to a hospital – he would
go to a Buddhist temple and pray for
forgiveness. And the funny thing is,
when people say these prayers in the
temple they get better.
The nurse told the treatment team that
the client apparently did not understand the
biological basis of mental illness and
needed more teaching on this topic before
he could be discharged.
Case 4: Miss K, an English-American
and practicing Christian Scientist, was hospitalized on a medical-stirgical floor with a
seriously infected spider bite. Surgical incision and drainage of the abscess left a huge
open cavity that required repacking with
wet-to-dry dressings every 4 hours. As the
nurse prepared to do the first post-operative
dressing change, she informed the padent
that the procedure would be painful and that
she would administer medication first as ordered by the doctor. The patient replied,
‘Thank you, but I don’t feel pain and I don’t
want any medication,” Although puzzled by
the patient’s statement, the nurse deferred
giving an analgesic and proceeded with the
dressing change while continuing to observe for non-verbal indicators of pain. She
was surprised to note that the patient appeared very relaxed during the procedure,
actually joking with the nurse and engaging
in other casual conversation. The nurse
completed the dressing change and informed the patient that medication was
available if she needed it later.
Case 5: In a study of two communitybased adult day care centers with predominantly African-American clients (Nelson,
2001,2002) the researcher noted that nurse
managers at the centers were very aware of
kinship; social, spiritual, and cultural beliefs; and practices of importance to clients
and their families. With the assistance of ancillary staff members and volunteers, the
nurse managers were able to use this cultural knowledge to plan and implement
meaningful programs that promoted the development of caring communities in the
Any nurse can apply basic principles of
the culture care theory by being aware and
sensitive to clients’ cultural beliefs, values,
and practices and by incorporating indigenous care practices into the plan of care as
much as possible. Full application of culture
care theory goes beyond culturally sensitive
care, and requires extensive, ongoing ethnonursing research with dissemination and
implementation offindingsand evaluation
of outcomes, A valuable resource is the
Transcultural Nursing Society, established
by Leininger (2002a) in the early 1970s as
the official transcultural nursing organization. In 1989 the society initiated a process
of certifying transcultural nurses and in the
same year the Joumal of Transcultural
Nursing began publication with Leininger
as its first editor, A recent important development is the opening of the Worldwide
Transcultural Nursing Society Office at
Madonna University in Lavonia, Michigan,
in 2001, Leininger’s theory of culture care
diversity and universality has had an enormous impact on nursing practice and the
opportunities for continuing applications in
the 21st century are endless.
Please refer to the test items and test
form to apply for continuing education units
(CEUs) from the Intemationai Association
for Human Caring,
International Journal for Human Caring
Leininger, M,M, (1970), Nursing andanthropology: Two worlds to blend. New
York: Wiley,
Leininger, M,M, (1978), Transcultural
nursing: Concepts, theories, & practices. New York: Wiley,
Leininger, M,M, (1985a), Nature, rationale,
and importance of qualitative research
methods in nursing. In M,M, Leininger
(Ed,), Qualitative research methods in
nursing (pp. 1-25). Orlando, FL: Grune
& Stratton,
Leininger, M,M, (1985b), Ethnography and
ethnonuursing: Models and modes of
qualitative data analysis. In M,M,
Leininger (Ed,), Qualitative research
methods in nursing (pp. 33-71).
Orlando, FL: Gmne & Stratton.
leininger, M.M, (1991a). The theory of culture care diversity and universality. In
M,M, Leininger (Ed,), Culture care diversity and universality: A theory of
nursing (pp. 5-68). New York: National
League for Nursing,
Leininger, M,M, (1991b), Ethnonursing: A
research method with enablers to study
the theory of culture care. In M.M,
Leininger (Ed), Culture care diversity
and universality: A theory of nursing
(pp, 73-117), New York: National
League for Nursing.
Leininger, M.M, (1995), Overview of
txininger’s culture care theory. In M.M,
Leininger (Ed.), Transcultural nursing:
Concepts, theories, & practices (2nd
ed.) (pp. 93-111). St. Louis, MO:
Leininger, M. (2002a). Transcultural nursing and globalization of health care:
Importance, focus, and historical aspects. In. M. Leininger & M.R.
McFarland (Eds.), Transcultural nursing: Concepts, theories, research &
practice (3rd ed.) (pp, 3-43), New York:
Leininger, M, (2002b), The theory of culture care and the ethnonursing research
method. In M. Leininger & M.R.
McFarland (Eds.), Transcultural nursing: Concepts, theories, research &
practice (3rd ed.) (pp. 71-98). New
York: McGraw-Hill,
Leininger, M, (2002c), Culture care assessments for congruent competency practices. In M, Leininger & M,R.
McFarland (Eds.), Transcultural nurs-
Madeleine Leininger’s Culture Care Theory
ing: Concepts, theories, research &
practice (3rd ed.) (pp. 117-143). New
York: McGraw-Hill.
McFarland, M.R. (2002). Selected research
findings from the culture care theory. In
M. Leininger & M.R, McFarland (Eds.),
Transcultural nursing: Concepts, theories, research & practice (3rd ed.) (pp.
99-116), New York: McGraw-Hill.
Nelson, J. (2001). Factors influencing care
expressions, pattems, and practices in
adult day care. Unpublished doctoral
dissertation, Barnes College of Nursing
and Health Studies, University of
Missouri-St, Louis.
Nelson, J. (2002). Spiritual expressions in
the caring environment of adult day care
centers. ABNF {Association of Black
Nurse Faculty) Joumal, 13(6), 136-139.
Select one best response for each item.
1. Which of the following is a central
idea in Leininger’s theory that distin
guishes it from other caring theories
in nursing?
a. Caring as the essence of nursing
b. Health as expanding conscious
c. Nursing as self-care of another
d. Culture as the missing link in caring
2 Leininger’s early work as a nursing
theorist incorporated concepts from
which other academic discipline?
a. Anthropology
b. Sociology
c. Psychology
d. Philosophy
3. Which research method was developed
by Leininger as a specific tool for
exploring transcultural nursing phe
a. Ethnography
b. Ethnonursing
c. Grounded theory
d. Phenomenology
4. Which of the following elements are
portrayed by the rays of the sun in
Leininger’s sunrise model?
a. Dimensions of a culture care
world view
b. Individual, family, group, and
community systems
c. Person-environment interactions
d. Dimensions of nursing diagnosis
and care
5. Leininger’s theory suggests that deci
sions about and actions pertaining to
nursing care be based on which of the
a. Evidence-based professional nursing
care systems
b. Indigenous care beliefs and prac
tices of patients and families
c. Integration of indigenous and profes
sional care systems
d. Interdiscip …
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