MADELEINE LEININGER

INTRODUCTION

• Madeleine Leininger is considered as the founder of the

theory of transcultural nursing.
• Her theory has now developed as a discipline in nursing.
• Evolution of her theory can be understood from her books:
• Culture Care Diversity and Universality (1991)
• Transcultural Nursing (1995)
• Transcultural Nursing (2002)
• Transcultural nursing theory is also known as Culture Care
theory.
• Theoretical framework is depicted in her model called the
Sunrise Model (1997).
 ABOUT THE THEORIST

• One of the first nursing theorist and

transcultural global nursing consultant.
• MSN - Catholic University in Washington
DC.
• PhD in anthropology - University of
Washington.
• She developed the concept of transcultural
nursing and the ethnonursing research
model.
 DEFINITIONS

• Transcultural Nursing
• Transcultural nursing is a comparative study of cultures to
understand similarities (culture universal) and difference
(culture-specific) across human groups (Leininger, 1991).
• Culture
• Set of values, beliefs and traditions, that are held by a specific
group of people and handed down from generation to
generation.
• Culture is also beliefs, habits, likes, dislikes, customs and
rituals learn from one’s family.
• Culture is the learned, shared and transmitted values, beliefs,
norms and life way practices of a particular group that guide
thinking, decisions, and actions in patterned ways.
• Culture is learned by each generation through both formal
and informal life experiences.
• Language is primary through means of transmitting
culture.
• The practices of particular culture often arise because of
the group's social and physical environment.
• Culture practice and beliefs are adapted over time but they
mainly remain constant as long as they satisfy needs.
• Religion
• Is a set of belief in a divine or super human power (or
powers) to be obeyed and worshipped as the creator and
ruler of the universe.
• Ethnic
• refers to a group of people who share a common and
distinctive culture and who are members of a specific
group.
• Ethnicity
• a consciousness of belonging to a group.
• Cultural Identify
• the sense of being part of an ethnic group or culture
• Culture-universals
• commonalities of values, norms of behavior, and life
patterns that are similar among different cultures.
• Culture-specifies
• values, beliefs, and patterns of behavior that tend to be unique
to a designate culture.
• Material culture
• refers to objects (dress, art, religious arti1acts)
• Non-material culture
• refers to beliefs customs, languages, social institutions.
• Subculture
• composed of people who have a distinct identity but are
related to a larger cultural group.
• Bicultural
• a person who crosses two cultures, lifestyles, and sets of
values.
• Diversity
• refers to the fact or state of being different. Diversity can occur
between cultures and within a cultural group.
• Acculturation
• People of a minority group tend to assume the attitudes, values,
beliefs, find practices of the dominant society resulting in a
blended cultural pattern.
• Cultural shock
• the state of being disoriented or unable to respond to a different
cultural environment because of its sudden strangeness,
unfamiliarity, and incompatibility to the stranger's perceptions
and expectations at is differentiated from others by symbolic
markers (cultures, biology, territory, religion).
• Ethnic groups
• share a common social and cultural heritage that is passed
on to successive generations.,
• Ethnic identity
• refers to a subjective perspective of the person's heritage
and to a sense of belonging to a group that is
distinguishable from other groups.
• Race
• the classification of people according to shared biologic
characteristics, genetic markers, or features. Not all people
of the same race have the same culture.
• Cultural awareness
• It is an in-depth self-examination of one's own background,
recognizing biases and prejudices and assumptions about
other people.
• Culturally congruent care
• Care that fits the people's valued life patterns and set of
meanings -which is generated from the people
themselves, rather than based on predetermined criteria.
• Culturally competent care
• is the ability of the practitioner to bridge cultural gaps in
caring, work with cultural differences and enable clients
and families to achieve meaningful and supportive caring.
• Nursing Decisions
• Leininger (1991) identified three nursing
decision and action modes to achieve
culturally congruent care.
• Cultural preservation or maintenance.
• Cultural care accommodation or negotiation.
• Cultural care repatterning or restructuring.
•  
• Culture care Preservation/ Maintenance- caring skilled actions
and decisions that a peole of certain culture retain important
values so they can keep up their well-being.

• Culture care Accomodation/ Negotiation- supporting, facilitative

oe enabling specialized actions and decisions to help people of
designated culture to adapt to others for a beneficiary or
satisfying health outcomes.

• Culture care Restructuring/ Repatterning- Assistive, sustaining,

facilitative, or enabling professional actions that helps client
greatly change their lifeways fro new, different and
beneficial healthcare patterns.
 MAJOR CONCEPTS [Leininger
(1991)]
• Illness and wellness are shaped by a various
factors including perception and coping skills, as
well as the social level of the patient.

• Cultural competence is an important component

of nursing.

• Culture influences all spheres of human life. It

defines health, illness, and the search for relief
from disease or distress.
 MAJOR CONCEPTS [Leininger
(1991)]
• Religious and Cultural knowledge is an important
ingredient in health care.

• The health concepts held by many

cultural groups  may result in people choosing not to
seek modern medical treatment procedures.

• Health care provider need to be flexible in the design

of programs, policies, and services to meet the needs
and concerns of the culturally diverse population,
groups that are likely to be encountered.
 APPLICATION TO NURSING

• To develop understanding, respect and

appreciation for the individuality and diversity of
patients beliefs, values, spirituality and culture
regarding illness, its meaning, cause, treatment,
and outcome.

• To encourage in developing and maintaining a

program of physical, emotional and spiritual self-
care introduce therapies such as ayurveda and
pancha karma.
 HEALTH PRACTICES IN
DIFFERENT CULTURES
• Use of Protective Objects
• Protective objects can be worn or carried or hung in the
home- charms worn on a string or chain around the neck,
wrist, or waist to protect the wearer from the evil eye or evil
spirits.

• Use of Substances .
• It is believed that certain food substances can be ingested
to prevent illness.
• E.g. eating raw garlic or onion to prevent illness or wear
them on the body or hang them in the home.
HEALTH PRACTICES IN
DIFFERENT CULTURES
 HEALTH PRACTICES IN
DIFFERENT CULTURES
• Religious Practices
• Burning of candles, rituals of redemption etc..

• Traditional Remedies
• The use of folk or traditional medicine is seen among
people from all walks of life and cultural ethnic back
ground.

• Healers
• Within a given community, specific people are known to
have the power to heal.
RELIGIOUS PRACTICES
TRADITIONAL REMEDIES
/HEALERS
 HEALTH PRACTICES IN
DIFFERENT CULTURES
• Immigration
• Immigrant groups have their own cultural attitudes ranging
beliefs and practices regarding these areas.

• Gender Roles
• In many cultures, the male is dominant figure and often
they take decisions related to health practices and
treatment. In some other cultures females are dominant.
• In some cultures, women are discriminated in providing
proper treatment for illness.
GENDER ROLES
 HEALTH PRACTICES IN
DIFFERENT CULTURES
• Economic Factors
• Factors such as unemployment, underemployment,
homelessness, lack of health insurance poverty prevent
people from entering the health care system.

• Time orientation
• It is varies for different cultures groups.

• Personal Space
• Respect the client's personal space when performing
nursing procedures.
• The nurse should also welcome visiting members of the
family and extended family.
 HEALTH PRACTICES IN
DIFFERENT CULTURES

• Beliefs about mental health

• Mental illnesses are caused by a lack of harmony
of emotions or by evil spirits.

• Problems in this life are most likely related to

transgressions committed in a past life.
SUNRISE MODEL
 NURSING PROCESS AND ROLE
OF NURSE

• Determine the client's cultural heritage and language skills.

• Determine if any of his health beliefs relate to the cause of
the illness or to the problem.

• Collect information that any home remedies the person is

taking to treat the symptoms.

• Nurses should evaluate their attitudes toward ethnic

nursing care.

• Self-evaluation helps the nurse to become more

comfortable when providing care to clients from diverse
backgrounds
 NURSING PROCESS AND ROLE
OF NURSE

• Understand the influence of culture, race &ethnicity on the

development of social emotional relationship, child rearing
practices & attitude toward health.

• Collect informationabout the socioeconomic status of the

family and its influence on their health promotion and
wellness.

• Identifiy the religious practices of the family and their

influence on health promotion belief in families.
JEAN WATSON
 Introduction

• Theorist - Jean Watson was born in West Virginia, US

• Educated: BSN, University of Colorado, 1964, MS, University of
Colorado, 1966, PhD, University of Colorado, 1973
• Distinguished Professor of Nursing and Chair in Caring Science at
the University of Colorado Health Sciences Center.
• Fellow of the American Academy of Nursing.
• Dean of Nursing at the University Health Sciences Center and
President of the National League for Nursing
• Undergraduate and graduate degrees in nursing and psychiatric-
mental health nursing and PhD in educational psychology and
counseling.
• Six (6) Honorary Doctoral Degrees.
• Research has been in the area of human caring and loss.
• In 1988, her theory was published in “nursing: human science and
human care”.
 The seven assumptions

• Caring can be effectively demonstrated and practiced only

interpersonally.
• Caring consists of carative factors that result in the satisfaction
of certain human needs.
• Effective caring promotes health and individual or family
growth.
• Caring responses accept person not only as he or she is now
but as what he or she may become.
• A caring environment is one that offers the development of
potential while allowing the person to choose the best action
for himself or herself at a given point in time.
• Caring is more “ healthogenic” than is curing. A science of
caring is complementary to the science of curing.
• The practice of caring is central to nursing.
 The ten primary carative factors

• The formation of a humanistic- altruistic system of values.

• The installation of faith-hope.
• The cultivation of sensitivity to one’s self and to others.
• The development of a helping-trust relationship
• The promotion and acceptance of the expression of
positive and negative feelings.
• The systematic use of the scientific problem-solving
method for decision making
• The promotion of interpersonal teaching-learning.
• The provision for a supportive, protective and /or corrective
mental, physical, socio-cultural and spiritual environment.
• Assistance with the gratification of human needs.
• The allowance for existential-phenomenological forces.
• 1. The formation of a humanistic-
altruistic system of values.
• Begins developmentally at an early age with values shared
with the parents.
• Mediated through ones own life experiences, the learning
one gains and exposure to the humanities.
• Is perceived as necessary to the nurse’s own maturation
which then promotes altruistic behavior towards others.
• 2. Faith-hope
• Is essential to both the carative and the curative
processes.

• When modern science has nothing further to offer

the person, the nurse can continue to use faith-
hope to provide a sense of well-being through
beliefs which are meaningful to the individual.
• 3. Cultivation of sensitivity to one’s self
and to others
• Explores the need of the nurse to begin to feel an emotion as it
presents itself.
• Development of one’s own feeling is needed to interact
genuinely and sensitively with others.
• Striving to become sensitive, makes the nurse more authentic,
which encourages self-growth and self-actualization, in both
the nurse and those with whom the nurse interacts.

• The nurses promote health and higher level functioning only

when they form person to person relationship.
• 4. Establishing a helping-trust
relationship
• Strongest tool is the mode of communication, which
establishes rapport and caring.

• Characteristics needed to in the helping-trust relationship

are:
• Congruence
• Empathy
• Warmth
• Communication includes verbal, nonverbal and listening in
a manner which connotes empathetic understanding.
• 5. The expression of feelings, both
positive and negative
• “Feelings alter thoughts and behavior, and they
need to be considered and allowed for in a caring
relationship”.

• Awareness of the feelings helps to understand the

behavior it engenders.
• 6. The systematic use of the scientific
problem-solving method for decision
making
• The scientific problem- solving method is the only method
that allows for control and prediction, and that permits self-
correction.

• The science of caring should not be always neutral and

objective.
• 7.  Promotion of interpersonal
teaching-learning
• The caring nurse must focus on the learning
process as much as the teaching process.

• Understanding the person’s perception of the

situation assist the nurse to prepare a cognitive
plan.
• 8. Provision for a supportive, protective and /or
corrective mental, physical, socio-cultural and
spiritual environment
• Watson divides these into eternal and internal variables,
which the nurse manipulates in order to provide support
and protection for the person’s mental and physical well-
being.

• The external and internal environments are

interdependent.

• Nurse must provide comfort, privacy and safety as a part

of this carative factor.
• 9. Assistance with the gratification of human
needs
• It is based on a hierarchy of need similar to that of
the Maslow’s.
• Each need is equally important for quality nursing
care and the promotion of optimal health.

• All the needs deserve to be attended to and

valued.
 Watson’s ordering of needs

• Lower order needs (biophysical needs)

• The need for food and fluid
• The need for elimination
• The need for ventilation

• Lower order needs (psychophysical needs)

• The need for activity-inactivity
• The need for sexuality

• Higher order needs (psychosocial needs)

• The need for achievement
• The need for affiliation
• Higher order need (intrapersonal-interpersonal need)
• The need for self-actualizatio
• 10.  Allowance for existential-phenomenological forces
• Phenomenology is a way of understanding people from the way
things appear to them, from their frame of reference.

• Existential psychology is the study of human existence using

phenomenological analysis.

• This factor helps the nurse to reconcile and mediate the

incongruity of viewing the person holistically while at the same
time attending to the hierarchical ordering of needs.

• Thus the nurse assists the person to find the strength or

courage to confront life or death.
 Watson’s theory and the four
major concepts

• 1.     Human being

• Human being refers to “….. a valued person in

and of him or herself to be cared for, respected,
nurtured, understood and assisted; in general a
philosophical view of a person as a fully functional
integrated self. He, human is viewed as greater
than and different from, the sum of his or her
parts”.
• 2.     Health
• Watson adds the following three elements to WHO
definition of health:
• A high level of overall physical, mental and social
functioning

• A general adaptive-maintenance level of daily

functioning

• The absence of illness (or the presence of efforts

that leads its absence)
• 3.      Environment/society

• According to Watson, caring (and nursing) has

existed in every society.

• A caring attitude is not transmitted from

generation to generation.

• It is transmitted by the culture of  the profession

as a unique way of coping with its environment.
• 4.      Nursing
• “Nursing is concerned with promoting health,
preventing illness, caring for the sick and restoring
health”.
• It focuses on health promotion and treatment of
disease. She believes that holistic health care is
central to the practice of caring in nursing.

• She defines nursing as…..

“a human science of persons and human health-
illness experiences that are mediated by
professional, personal, scientific, esthetic and
 Watson’s theory and nursing
process
• Nursing process contains the same steps as the scientific
research process. They both try to solve a problem. Both
provide a framework for decision making.

• 1.      Assessment
• Involves observation, identification and review of the problem;
use of applicable knowledge in literature.

• Also includes conceptual knowledge for the formulation and

conceptualization of framework.

• Includes the formulation of hypothesis; defining variables that

will be examined in solving the problem.
• 2.      Plan
• It helps to determine how variables would be examined or
measured; includes a conceptual approach or design for
problem solving. It determines what data would be
collected and how on whom.

• 3.      Intervention
• It is the direct action and implementation of the plan.
• It includes the collection of the data.
• 4.      Evaluation
• Analysis of the data as well as the examination of the
effects of interventions based on the data.

• Includes the interpretation of the results, the degree to

which positive outcome has occurred and whether the
result can be generalized.

• It may also generate additional hypothesis or may even

lead to the generation of a nursing theory.
PATRICIA BENNER
 Introduction

• Dr Patricia Benner introduced the concept that expert

nurses develop skills and understanding of patient care
over time through a sound educational base as well as a
multitude of experiences.
• She proposed that one could gain knowledge and skills
("knowing how") without ever learning the theory ("knowing
that").
• She further explains that the development of knowledge in
applied disciplines such as medicine and nursing is
composed of the extension of practical knowledge (know
how) through research and the characterization and
understanding of the "know how" of clinical experience.
• She coneptualizes in her writing about nursing skills as
experience is a prerequisite for becoming an expert.
 ABOUT THE THEORIST

• Patricia E. Benner, R.N., Ph.D., FAAN is a Professor

Emerita at the University of California, San Francisco.
• BA in Nursing - Pasadena College/Point Loma College
• MS in Med/Surg nursing from UCSF
• PhD -1982 from UC Berkeley
• 1970s - Research at UCSF and UC Berkeley
• Has taught and done research at UCSF since 1979
• Published 9 books and numerous articles
• Published ‘Novice to Expert Theory’ in 1982
• Received Book of the Year from AJN in 1984,1990,1996,
2000
• Her web address is at: http://www.PatriciaBenner.com
 LEVELS OF NURSING
EXPERIENCE

• She described 5 levels of nursing

experience as;
• Novice
• Advanced beginner
• Competent
• Proficient
• Expert
 Novice
• Beginner with no experience
• Taught general rules to help perform tasks
• Rules are: context-free, independent of specific
cases, and applied universally
• Rule-governed behavior is limited and inflexible
• Ex. “Tell me what I need to do and I’ll do it.”
• Faced in an unfamiliar situation.
• This is where nursing students belong.
 Advanced Beginner
• Demonstrates acceptable performance.
• Has gained prior experience in actual situations to
recognize recurring meaningful components.
• Principles, based on experiences, begin to be
formulated to guide actions.
• Clinical situations are viewed as a challenge of their
abilities.
• Manage their own clients, rely on the help of
superiors.
• Newly graduated students belong.
 Competent
• Typically a nurse with 2-3 years experience on the
job in the same area or in similar day-to-day
situations.
• More aware of long-term goals
• Gains perspective from planning own actions based
on conscious, abstract, and analytical thinking and
helps to achieve greater efficiency and organization
• Considers consistency, predictability and time
management as essential component.
• Shows confidence in performing nursing procedures.
 Proficient
• Perceives and understands  situations as
whole parts.
• More holistic understanding  improves
decision-making.
• Learns from experiences what to expect in
certain situations  and how to modify plans.
 Expert
• No longer relies on principles, rules, or guidelines
to connect situations and determine actions.
• Much more background of experience.
• Has intuitive grasp of clinical situations.
• Performance is now fluid, flexible, and highly-
proficient
• Demonstrates clinical grasp and resouced based
practice.
• Able to see the big picture.
• No longer relies on analytical principle.
 SIGNIFICANCE OF THE
THEORY

• These levels reflect movement from reliance on past

abstract principles to the use of past concrete experience
as paradigms and change in perception of situation as a
complete whole in which certain parts are relevant.

• Each step builds on the previous one as abstract principles

are refined and expanded by experience and the learner
gains clinical expertise.
• This theory changed the profession's understanding of
what it means to be an expert, placing this designation not
on the nurse with the most highly paid or most prestigious
position, but on the nurse who provided "the most
exquisite nursing care.

• It recognized that nursing was poorly served by the

paradigm that called for all of nursing theory to be
developed by researchers and scholars, but rather
introduced the revolutionary notion that the practice itself
could and should inform theory.
 4 METAPARADIGM IN NURSING

• 1. NURSING- ‘ enabling condition of connection and

concern which shows a high level of emotional
involvement in the nurse-client relationship.

• 2. PERSON- stated a self interpreting individual, that is,

the person does not come into the world predefined but
gets define in the course of living a life.
• Person is viewed as participant in common meanings.
• 3. HEALTH- focused on the lived experiences of being
healthy and ill.
• As what can be assessed, while well-being is the human
experience of health or wholeness.
• HEALTH is described as not just the absence of disease
and illness. A person may have a disease and not just
illness because illness is the human experience or loss of
dysfunction, whereas disease is what can be assessed at
the physical ;evel.
• 4. ENVIRONMENT
• Benner used the term” situation” , it suggest social
environment with social definition and meaning.

• Used terms of being situated and situated meaning,

which are defined by the person’s engaged in interaction,
interpretation and understanding of the situation.