Madeleine Leininger

1. Madeleine Leininger PhD, LHD, DS, CTN, RN, FAAN, FRCNA Theory of Culture Care Diversity & Universality Janet Deregnier, James Harrington & Jane Schunn Ferris State University

2. Madeleine Leininger is the founder of the transcultural nursing movement. The practice of transcultural nursing addresses the cultural dynamics that influence the nurse-client relationship. Because of its focus on this specific aspect of nursing, a theory was needed to study and explain outcomes of this type of care. Leininger developed the Theory of Culture Care: Diversity and Universality with the goal to provide holistic care. The following presentation outlines the life and work of nursing theorist Dr. Madeleine Leininger. She has been chosen by this group because it is our unanimous belief that her theory illustrates a truly holistic approach, one that values the patient’s cultural background as one of the most important determining factors influencing care. We believe that she best represents the spirit of nursing, where we recognize the patient as a human individual rather than just a carrier of pathology.

3. Jerry Johnson, Sutton Life Magazine December 2009 Madeleine Leininger was born on July 13th, 1925 in the small town of Sutton Nebraska. She grew up on a farm near the city with her two brothers and two sisters. Upon graduation from Sutton High School Madeleine decided that she was going to attend college but she was unsure on which course to choose. She has always credited her aunt, who suffered from congenital heart disease, as the person who encouraged her to enter the field of nursing. (Clarke, 2009)

4. Madeleineentered 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.(Clarke, 2009)

5. Madeleine Leininger began studying cultural differences in the perceptions of care in 1954 after working with children while doing psychiatric nursing. She observed children with varied cultural backgrounds and saw how they reacted differently to nursing interventions. This led her to doctoral work in 1959 in cultural anthropology.

6. Papua New Guinea Town and Country Travel Magazine Spring 2008 Following a trip to New Guinea in the 1960’s Dr Leininger’s eyes were opened to the need for nurses to understand their patients’ culture and background in order to provide care. She had seen that nursing care and practice needed to accurately reflect nursing knowledge and also saw cultural considerations as being absent from nursing theory.

7. Appointed dean of the University of Washington, School of Nursing in 1969, she began developing what would later become her Theory of Culture Care Diversity & Universality and created a program based on the concept of transcultural nursing at the School in 1974. “I took the deanship position at the University of Washington School of Nursing to give leadership to this new field and moved ahead with my ideas.” (Clark, 2009) “There is no one person or philosophic school of thought, or ideology per se that directly influenced my thinking. I developed the theory by working on the potential interrelationships of culture and care though creative thinking, and by philosophizing from my past professional nursing experiences and anthropological insights.” (Reynolds, 1993)

8. Leininger’s Sunrise “Enabler” Along with the development of her theory Dr Leininger also developed the Sunrise Enablermodel. This assessment model uses holistic well being as a base with rays extending outward representing the many social and cultural influences on individuals, families, groups, communities and institutions. (Chitty, 2007)

9. Leininger’s Sunrise Model depicts the dimensions of Culture Care Diversity and Universality and is useful across many healthcare systems. • The cultural and social structure dimensions include technological, religious, philosophic, kinship, social, value and life-way, political, legal, economic, and educational factors. These factors influence the patterns and expressions of caring in relation to the health of individuals, families, groups, and communities. • The involved health systems include folk systems, nursing, and other professional systems. • To achieve culture congruent care, nursing actions must be planned in one of the following modes: • Culture care preservation/maintenance • Culture care accommodation/negotiation • Culture care re-patterning/restructuring. (Chitty, 2007)

10. The concepts of Dr. Leininger’s Theory In response to the question: How does your theory rely upon the four nursing paradigms of person, environment, health, and nursing, Dr Leininger replied: “The four nursing paradigms are too restrictive for open discovery about culture and care”. (Clarke, 2009) The following page outlines the major concepts and definitions that make up this theory. Contrary to the above statement made by Dr Leininger, the paradigms of person, environment, health, and nursing can be found among these concepts and definitions.

11. Major Concepts and Definitions Care refers to abstract and concrete phenomena related to assisting, supporting or enabling experiences or behaviours toward or for others with evident or anticipated to ameliorate or improve a human condition or lifeway. Caring refers to actions and activities directed toward assisting, supporting, or enabling another individual or group with evident or anticipated needs to ameliorate or improve a human condition or lifeway, or to face death. Culture refers to the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guides their thinking, decisions and actions in patterned ways. Cultural care refers to the subjectively and objectively learned and transmitted values, beliefs and patterned lifeways that assist, support, facilitate, or enable another individual or group to maintain their well-being, health, to improve their human condition and lifeway, or to deal with illness, handicaps, or death. Worldview refers to the way people tend to look out on the world or their universe to form a picture or a value stance about their life or world around them. Cultural and social structure dimensions refers to the dynamic patterns and features of interrelated structural and organizational factors of a particular culture (subculture or society) which includes religious, kinship (social), political (and legal), economic, educational, technologic and cultural values and ethnohistorical factors, and how these factors may be interrelated and function to influence human behavior in different environmental contexts. Environmental context refers to the totality of an event, situation or particular experiences that give meaning to human expressions, interpretations, and social interactions in particular physical, ecological, socio-political and/ or cultural settings. Ethnohistory refers to those past facts, events, instances and experiences of individual, groups, cultures and institutions that are primarily people-centered (ethno) and that describe, explain, and interpret human lifeways within particular cultural contexts and over short or long periods of time. (Andrews, 2003)

12. Major Concepts and Definitions (cont) Generic (folk or lay) care system refer to culturally learned and transmitted, indigenous (or traditional ), folk (home based) knowledge and skills used to provide assistive, supportive, enabling or facilitative acts toward or for another individual, group or institution with evident or anticipated needs to ameliorate or improve a human lifeway or health condition (or well-being) or to deal with handicaps and death situations.Professional care system(s) refers to formally taught, learned and transmitted professional care, health, illness, wellness and related knowledge and practice skills that prevail in professional institutions usually with multidisciplinary personnel to serve consumers.Health refers to a state of well-being that is culturally defined, valued and practiced, and that reflects the ability of individuals (or groups) to perform their daily role activities in culturally expressed, beneficial, and patterned lifeways..Care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death.Cultural care accommodation or negotiation refers to those assistive, supporting, facilitative or enabling creative professional actions and decisions that help people of a designated culture to adapt to, or to negotiate with, others for a beneficial or satisfying health outcome with professional care providers.Cultural care repatterning or restructuring refers to those assistive, supportive, facilitative or enabling professional actions and decisions that help clients reorder, change or greatly modify their lifeways for new, different and beneficial health acre pattern while respecting the client’s cultural values and beliefs and still providing a beneficial, healthier lifeway than before the changes were coestablished with the client.Cultural congruent (nursing) care refers to those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are tailor made to fit the individual, group or institutional cultural values, beliefs and lifeways in order to provide or support meaningful beneficial and satisfying health care or well-being services. (Andrews, 2003)

13. Dr Leininger’s Theory of Culture Care Diversity & Universality can be utilized with individuals, families, groups, communities and institution in diverse health systems (Andrews, 2003, p6). For example in a focus group that was set up to explore issues surrounding breast feeding in African American women the methodology was “guided by Leininger’s theory of culture care diversity and unversality”.(Lewallen, 2010) • Considered a Grand Theory Leininger’s theory is extremely flexibleand widely useful in healthcare roles beyond nursing. Transcultural nursing is based on legitimate and formal study and uses research that is aimed at using cultural beliefs, values, and practices to preserve health and to help treat illness or prepare for death. (Leininger,1999) • Regardless of the healthcare setting this theory and the associated Sunrise Model provide excellent tools which help guide the nurse or other healthcare professional in the provision of care with concern to culture.

14. A life well spent Dr Leininger is a fellow and distinguished Living Legend of the American Academy of Nursing and the Emeritus Member of the American Association of Colleges of Nursing. She started the Transcultural Nursing Society, is the initiator and Editor of the Journal of Transcultural Nursing, and author/editor of 28 books and over 220 articles. Pictures retrieved from: http://www.madeleine-leininger.com/resources

15. References Andrews, M.M. & Boyle, J.S. (2003). Transcultural concepts in nursing care (4th ed.). Lippincott: Philadelphia. Chitty, K.K. & Black, B.P. (2007) Professional nursing concepts and challenges (5th ed.). Suanders Elsevier: St. Louis. Clarke, P., McFarland, M., Andrews, M., Leininger, M. (2009).Caring: Some reflections on the impact of the Culture Care Theory by McFarland & Andrews and a conversation with Leininger. Nursing, Scientific Quarterly, Vol. 22, No. 1. July 2009 Leininger, M. (1999). What is transcultural nursing and culturally competent care? Journal of Transcultural Nursing,10(1). Lewallen, L. P. and Street, D. J. (2010), Initiating and Sustaining Breastfeeding in African American Women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39: 667–674. doi: 10.1111/j.1552-6909.2010.01196.x Reynolds, C. L. & Leininger, M. (1993). Cultural Care Diversity and Universality Theory. Sage Publications: Newbury Park, Ca Struthers R, & Littlejohn S. (1999). The essence of Native American nursing. Journal of Transcultural Nursing,10(2), 131-5. Dr. Leininger’s recent articles may be found at: http://www.madeleine-leininger.com/resources The Journal of Transcultural Nursing can be found at http://tcn.sagepub.com/Journal of Transcultural Nursing

16. Scholarly Articles Submitted by James Harrington RN: Ethics: Nursing Around the World: Cultural Values and Ethical Conflicts Ludwick, R., Silva, M.C., (August 14, 2000) "Ethics: Nursing Around the World: Cultural Values and Ethical Conflicts" Online Journal of Issues in Nursing Vol. 5 No. 3www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/CulturalValuesandEthicalConflicts.aspx Submitted By Jan deRegnier RN: Initiating and Sustaining Breastfeeding in African American Women Lewallen, L. P. and Street, D. J. (2010), Initiating and Sustaining Breastfeeding in African American Women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39: 667–674. doi: 10.1111/j.1552-6909.2010.01196.x http://tcn.sagepub.com/Journal of Transcultural Nursing Submitted By Jane Schunn RN: Transcultural Nursing: Concepts, theories and practice Leininger, M. (1995). Transcultural Nursing: Concepts, theories and practice (2nd ed.). Columbus, OH: McGraw-Hill Medical Publishing Division

17. Case Study • A 55 year old male Native American male presents to the surgical department for laparoscopic cholesystectomy surgery. • Past medical history- MVA age 20 resulting in fractured left femur • Hypertension • Borderline diabetes • Past smoker (1PPD for 30 years) • Past alcohol use but none now • Mild osteoarthritis involving knees mainly • Surgical history –Repair of fractured femur • Appendectomy age 10 • Family history –Father died age 60 of liver disease • Mother is alive at age 65 • On admission the patient is accompanied by his wife, brother, and 2 children who he requests remain with him during the pre and post-op phases. He wears a medicine bag around his neck and he is very adamant that it is not removed during surgery. The patient frequently confers with his family on aspects of his care. • The family asks to be able to bring the patient food for the post operative time he will be in the hospital. • The patient states he uses herbal medicines and is controlling his blood sugar with diet. • Department policy allows for 1 family member to be present in the room during the patient’s hospital stay. • Post operatively the patient will be on a low fat diet. .

18. Just another patient? From the history and physical we can see that this patient suffers from the same pathologies as all humans. It would be easy to treat him and all other patients in the same way regardless of religious or cultural backgrounds. While this type of standardization of treatment would seem appropriate to some, when considering the principles upon which Dr. Leininger’s theory is based this patient will only achieve maximum healing potential by also addressing those things which make him different rather than those that make him the same as others. For that very reason some additional research was done. The following page outlines research found useful when addressing this patients cultural needs as well as his physical needs.

19. Cultural guide used in determining appropriate care for this patient Essence of Native American Nursing • At a 1997 American Indian Nursing Summit held in Polson, Montana a group of native and non-native American Indian nurses gathered to describe the essence of Native American Nursing. Seven themes evolved from this Summit. • Caring-This was the most common theme identified as the essence of Native American nursing and is common to mainstream nursing. “Caring occurs in that special moment between nurse and patient. Native American nurse further identified nurturing, natural, love, partnership, and healing as characteristics of caring. • Respect-respect for elders and others in the world was further defined as honor, never talking down, and honoring traditional medicine. Respect is important and nurses need to earn it. • Connection- Native Americans believe that all things are connected and this is apparent in bringing together the relationship between the nurse and the client for the purpose of health and healing. The nurse shows caring and listens to and focuses on the client. This leads to compassion. • Holism/holistic- The mind, body, and spirit are all components of the whole person and are interdependent. Nurses need to be able to see the whole person and recognize the interconnectedness of spirituality, emotions, thinking, and the physical being. Nurses also must be whole within themselves to pass it on to the client. • Trust-This develops over time and is found in a healing relationship. It involves sharing ideas, sharing ones self, and consistency on the part of the nurse. • Spirituality-Native American see spirituality as a basic element of life. It provides a base and is emphasized in Native American nursing practice. Mainstream and Indian medicine compliment each other but magic and miracles can not be ignored. • Traditions-Traditions include rituals, knowledge and heritage and the connection of these helps with the nursing process. Knowing the past helps to call upon wisdom and strength and honoring traditional medicine is important. (Struthers, 1999) • Struthers R, & Littlejohn S. (1999). The essence of Native American nursing. Journal of Transcultural Nursing,1999 10(2), 131-5.

20. Question for Case study What would you do to care for this patient that supports the use of Dr. Leininger’s theory? How do you think the concepts in Dr.Leininger’s theory supports the Essence of Native American Nursing? What would discharge teaching involve?

21. These are but a few possible answers to the questions on the previous page: Question 1 • Upon entering the room, greet the patient respectfully and acknowledge the family members. • Attempt to arrange for privacy and allow the family to remain with the patient. • Involve the family in the pre and post operative teaching. • Begin to find out what the patient’s plans are for discharge. • Inform the family of the post operative diet restrictions and allow for discussion. • Gain permission from the OR for the patient to be allowed to keep his medicine bag on during surgery.

22. Question 2 • Care and caring are reflected back and forth between Leininger and the Native American themes. • Culture and culture care refer to the Native American culture. • Worldview and Cultural and social structure dimensions takes in traditions ,spirituality , and holism themes expressed by the Native American culture. • Environmental context is the setting and the interactions between the nurse and the patient and family/group and the connections between them and the trust that is built during the time spent together. • Ethnohistory and Generic (folk or lay) care system encompasses traditions and respect. • Health supports holism, caring, trust, and connection. • Care preservation or maintenance, Cultural care accommodation or negotiation,Cultural care repatterning or restructuring, and Cultural congruent (nursing) care are all parts of observing the tradition and recognizing spiritual aspects of Native American culture. Treating the patient with respect and building a trusting relationship are a large part of care.

23. Question 3 Teaching would be centered around the involvement of the family and the traditions of the patient. He is trying to control his diabetes and blood pressure issues using natural or traditional remedies. Encourage the patient to seek medical advice and allow him to be able to incorporate this into his personal philosophy. Educate the patient and family on the results of the lab tests and how it relates to the medical issues. Allow the patient and family to discuss the issues and give time for them to reflect on the new information presented. Remain open and respectful with the patient and the family.

24. Thank you!