CREDENTIALS AND BACKGROUND OF THE THEORIST

Madeleine M. Leininger is the founder of transcultural nursing and a leader in transcultural nursing and human care theory. She is the first professional nurse with graduate preparation in nursing to hold a PhD in cultural and social anthropology. She was born in Sutton, Nebraska, and began her nursing career after graduating from the diploma program at St. Anthony’s School of Nursing in Denver, Colorado. She was in the U.S. Army Nurse Corps while pursuing the basic nursing program. In 1950, she obtained a bachelor’s degree in biological science from Benedictine College in Atchison, Kansas, with a minor in philosophy and humanistic studies. After graduation, she served as an instructor, staff nurse, and head nurse on a medical-surgical unit and opened a new psychiatric unit while director of the nursing service at St. Joseph’s Hospital in Omaha, Nebraska. During this time, she pursued advanced study in nursing, nursing administration, teaching and curriculum in nursing, and tests and measurements at Creighton University in Omaha, Nebraska (Leininger, 1995c, 1996b).

In 1954, Leininger obtained a master’s degree in psychiatric nursing from Catholic University of America in Washington, D.C. She was then employed at the College of Health at the University of Cincinnati, Ohio, where she began the first master’s level clinical specialist program in child psychiatric nursing in the world. She also initiated and directed the first graduate nursing program in psychiatric nursing at the University of Cincinnati and the Therapeutic Psychiatric Nursing Center at the University Hospital (Cincinnati). During this time, she wrote one of the first basic psychiatric nursing texts with Hofling entitled Basic Psychiatric Concepts in Nursing, which was published in 1960 in 11 languages and was used worldwide (Hofling & Leininger, 1960).

While working at a child guidance home in the mid-1950s in Cincinnati, Leininger discovered that the staff lacked understanding of cultural factors influencing the behavior of children. Among these children of diverse cultural backgrounds, she observed differences in responses to care and psychiatric treatments that deeply concerned her. Psychoanalytical theories and therapy strategies did not seem to reach children who were of different cultural backgrounds and needs. She became increasingly concerned that her nursing decisions and actions, and those of other staff, did not appear to help these children adequately. Leininger posed many questions to herself and the staff about cultural differences among children and therapy outcomes. She found few staff members who were interested or knowledgeable about cultural factors in the diagnosis and treatment of clients. A short time later, Margaret Mead became a visiting professor in the Department of Psychiatry, University of Cincinnati, and Leininger discussed with Mead the potential interrelationships between nursing and anthropology. Although she did not get any direct help, encouragement, or solutions from Mead, Leininger decided to pursue her interests with focused doctoral study on cultural, social, and psychological anthropology at the University of Washington, Seattle.

As a doctoral student, Leininger studied many cultures. She found anthropology fascinating and believed it was an area that should be of interest to all nurses. She focused on the Gadsup people of the Eastern Highlands of New Guinea, where she lived alone with the indigenous people for nearly 2 years and undertook an ethnographical and ethnonursing study of two villages (Leininger, 1995c, 1996b). Not only was she able to observe unique features of the culture, she also observed a number of marked differences between Western and non-Western cultures related to caring health and well-being practices. From her in-depth study and first-hand experiences with the Gadsup, she continued to develop her Culture Care Theory of Diversity and Universality (Culture Care Theory) and the ethnonursing method (Leininger, 1978, 1981, 1991b, 1995c). Her research and theory have helped nursing students understand cultural differences in human care, health, and illness. She has been the major nurse leader to encourage many students and faculty to pursue graduate education and practice. Her enthusiasm and interest in developing this field of transcultural nursing with a human care focus have sustained her for more than 5 decades.

During the 1950s and 1960s, Leininger (1970, 1978) identified several common areas of knowledge and theoretical research interests between nursing and anthropology, formulating transcultural nursing concepts, theory, principles, and practices. The book, Nursing and Anthropology: Two Worlds to Blend (1970), laid the foundation for developing the field of transcultural nursing, the Culture Care Theory, and culturally based healthcare. Her next book, Transcultural Nursing: Concepts, Theories, and Practice (1978), identified major concepts, theoretical ideas, and practices in transcultural nursing and was the first definitive publication on transcultural nursing. During the past 50 years, Leininger has established, explicated, and used the Culture Care Theory to study many cultures within the United States and worldwide. She developed the ethnonursing qualitative research method to fit the theory and to discover the insider or emic view of cultures (Leininger, 1991b, 1995c). The ethnonursing research method was the first nursing research method developed for nurses to examine complex care and cultural phenomena. During the past 5 decades, approximately 50 nurses with doctoral degrees and many master’s and baccalaureate students have been prepared in transcultural nursing and have used Leininger’s Culture Care Theory (Leininger, 1990a, 1991b; Leininger & McFarland, 2002a; Leininger & Watson, 1990).

The first course in transcultural nursing was offered in 1966 at the University of Colorado, where Leininger was a professor of nursing and anthropology. This marked the first joint appointment in the United States of a professor of nursing with another discipline. Leininger also initiated and served as the director of the first nurse scientist program (PhD) in the United States. In 1969, she was appointed Dean and Professor of Nursing and Lecturer in Anthropology at the University of Washington, Seattle. There she established the first academic nursing department on comparative nursing care systems to support master’s and doctoral programs in transcultural nursing. Under her leadership, the Research Facilitation Office was established in 1968 and 1969. She initiated several transcultural nursing courses and guided the first nurses in a special PhD program in transcultural nursing. She initiated the Committee on Nursing and Anthropology with the American Anthropological Association in 1968.

In 1974, Leininger was appointed Dean and Professor of Nursing at the College of Nursing and Adjunct Professor of Anthropology at the University of Utah in Salt Lake City. At this institution, she initiated the first master’s and doctoral programs in transcultural nursing and established the first doctoral program offerings at this institution (Leininger, 1978). These programs were the first in the world to offer substantive courses focused specifically on transcultural nursing. She also initiated and was director of a new research facilitation office at the University of Utah.

In 1981, Leininger was recruited to Wayne State University in Detroit, where she was Professor of Nursing and Adjunct Professor of Anthropology and Director of Transcultural Nursing Offerings until her semi-retirement in 1995. She was also Director of the Center for Health Research at this university for 5 years. While at Wayne State, she again developed several courses and seminars in transcultural nursing, caring, and qualitative research methods for baccalaureate, master’s, doctoral, and postdoctoral nursing and non-nursing students. In addition to directing the transcultural course offerings at Wayne State University, Dr. Leininger taught and mentored many students and nurses in field research in transcultural nursing. One of the first nurse leaders to use qualitative research methods during the early 1960s, she has continued to teach these methods at various universities within the United States and worldwide. To date, she has studied 14 cultures and continues to consult for many research projects and institutions, especially those that are using her Culture Care Theory.

With growing interest in transcultural nursing and health care, Leininger (personal communication, 1996) has delivered keynote addresses annually and has conducted workshops and consultations both nationally and internationally since 1965. Her academic vitae includes nearly 600 conferences, keynote addresses, workshops, and services as a consultant in the United States, Canada, Europe, Pacific Island nations, Asia, Africa, Australia, and the Nordic countries. Educational and service organizations continue to request her consultation on transcultural nursing, humanistic caring, ethnonursing research, the Culture Care Theory, and futuristic trends in health care worldwide.

As the first professional nurse to complete a doctoral degree in anthropology and to initiate several master’s and doctoral nursing educational programs, Leininger has many areas of expertise and interests. She has studied 14 major cultures in depth and has had experience with many other diverse cultures. In addition to transcultural nursing with care as a central focus, her areas of interest are comparative education and administration, nursing theories, politics, ethical dilemmas of nursing and health care, qualitative research methods, the future of nursing and health care, and nursing leadership. Her Culture Care Theory is now used worldwide and is growing in relevance and importance in the discovery of data from diverse cultures.

In 1974, Leininger initiated the National Transcultural Nursing Society and has been an active leader since its inception. She also established the National Research Care Conference in 1978 to help nurses focus on the study of human care phenomena (Leininger, 1981, 1984a, 1988a, 1990a, 1991b; Leininger & Watson, 1990). She initiated the Journal of Transcultural Nursing in 1989 and served as its editor through 1995.

Dr. Leininger has gained international recognition in nursing and related fields through her transcultural nursing and care writings, theory, research, consultation, courses, and dynamic addresses. She has worked enthusiastically to persuade nursing educators and practitioners to incorporate transcultural nursing and culture-specific care concepts based on research findings into nursing curricula and clinical practices as the new and futuristic direction of all aspects of nursing (Leininger, 1991b, 1995c; Leininger & McFarland, 2002a; Leininger & Watson, 1990). She has found time to give lectures to anthropologists, physicians, social workers, pharmacists, and educators, and to do research with colleagues. She is one of the few nurses who has kept active in two disciplines and has continued to contribute to both nursing and anthropology at national and international transcultural conferences and association meetings. Currently, Dr. Leininger resides in Omaha, Nebraska, and is semi-retired but still active in consulting, writing, and lecturing. Her present interest is to establish transcultural nursing institutes to educate and to conduct and facilitate research on transcultural nursing and health phenomena.

Leininger has written or edited more than 30 books. Some of her books include Nursing and Anthropology: Two Worlds to Blend (1970), Transcultural Nursing: Concepts, Theories, Research, and Practice (Leininger & McFarland, 2002a), Caring: An Essential Human Need (Leininger, 1981), Care: The Essence of Nursing and Health (1984a), Qualitative Research Methods in Nursing (1985a), Ethical and Moral Dimensions of Care: Chapters from Conference on the Ethics and Morality of Caring (1990a), The Caring Imperative in Education (Leininger & Watson, 1990), Culture Care Diversity and Universality: A Theory of Nursing (1991b), and Culture Care Diversity and Universality: A Worldwide Theory of Nursing (Leininger and McFarland, 2006), which are full accounts of her theory with the method. She has published more than 200 articles and 45 book chapters plus numerous films, videos, DVDs, and research reports focused on transcultural nursing, human care and health phenomena, the future of nursing, and related topics relevant in nursing and anthropology. She formerly served on eight editorial boards and refereed several publications, and is actively involved with the Transcultural Nursing Scholars Group and her own website (www.madeleine-leininger.com). She is known as one of the most creative, productive, innovative, and futuristic authors in nursing, always providing new and substantive research-based transcultural nursing content and ideas to advance nursing as a discipline and a profession.

Leininger has received many awards and honors for her lifetime professional and academic accomplishments. She is in Who’s Who of American Women, Who’s Who in Health Care, Who’s Who in Community Leaders, Who’s Who of Women in Education, International Who’s Who in Community Service, Who’s Who in International Women, and other such listings. Her name appears on the National Register of Prominent Americans and International Notables, International Women, and the National Register of Prominent Community Leaders. She has received several honorary degrees, such as an LHD from Benedictine College in Atchison, Kansas, a PhD from the University of Kuopio, Finland, and a DS from the University of Indiana, Indianapolis. In 1976 and 1995, she was recognized for her unique and significant contribution to the American Association of Colleges of Nursing as its first full-time president. Leininger received the Russell Sage Outstanding Leadership Award in 1995. Leininger is a fellow in the American Academy of Nursing, a fellow of the American Anthropology Society, and a fellow of the Society for Applied Anthropology. Other affiliations include Sigma Theta Tau, the national honor society for nursing; Delta Kappa Gamma, the national honor society in education; and the Scandinavian College of Caring Science in Stockholm, Sweden. She has served as a distinguished visiting scholar and lecturer at 85 universities in the United States and worldwide and has been a visiting professor at numerous foreign universities, including schools in Sweden, Wales, Japan, China, Australia, Finland, New Zealand, and the Philippines. While at Wayne State University, she received the Board of Regents’ Distinguished Faculty Award, the Distinguished Research Award, the President’s Excellence in Teaching, and the Outstanding Graduate Faculty Mentor Award. In 1996, Madonna University, Livonia, Michigan, honored her with the dedication of the Leininger Book Collection and a special Leininger Reading Room for her outstanding contributions to nursing and the social sciences and humanities.

THEORETICAL SOURCES

Leininger’s theory is derived from the disciplines of anthropology and nursing (Leininger, 1991b, 1995c; Leininger & McFarland 2002b, 2006). She has defined transcultural nursing as a major area of nursing that focuses on the comparative study and analysis of diverse cultures and subcultures in the world with respect to their caring values, expressions, and health-illness beliefs and patterns of behavior.

The purpose of the theory was to discover human care diversities and universalities in relation to worldview, social structure, and other dimensions cited, and then to discover ways to provide culturally congruent care to people of different or similar cultures in order to maintain or regain their well-being or health, or to face death in a culturally appropriate way (Leininger, 1985b, 1988b, 1988c, 1988d; as cited in 1991b). The goal of the theory is to improve and to provide culturally congruent care to people that is beneficial and will fit with, and will be useful to, the client, family, or culture group healthy lifeways (Leininger, 1991b).

Transcultural nursing goes beyond an awareness state to that of using Culture Care nursing knowledge to practice culturally congruent and responsible care (Leininger, 1991b, 1995c). Leininger has stated that in time, there will be a new kind of nursing practice that reflects different nursing practices that are culturally defined, grounded, and specific to guide nursing care provided to individuals, families, groups, and institutions. She contends that because culture and care knowledge are the broadest and most holistic means to conceptualize and understand people, they are central to and imperative to nursing education and practice (Leininger, 1991b, 1995c; Leininger & McFarland, 2002a, 2006). In addition, she states that transcultural nursing has become one of the most important, relevant, and highly promising areas of formal study, research, and practice because people live in a multicultural world (Leininger, 1984a, 1988a, 1995c; Leininger & McFarland, 2002a, 2006). Leininger predicts that for nursing to be meaningful and relevant to clients and other nurses in the world, transcultural nursing knowledge and competencies will be imperative to guide all nursing decisions and actions for effective and successful outcomes (Leininger, 1991b, 1995c, 1996a, 1996b; Leininger & McFarland, 2002a, 2006).

Leininger (2002a) distinguishes between transcultural nursing and cross-cultural nursing. The former refers to nurses prepared in transcultural nursing who are prepared and committed to develop knowledge and practice in transcultural nursing, whereas cross-cultural nursing refers to nurses who use applied or medical anthropological concepts, with many nurses not committed to developing transcultural nursing theory and research-based practices (Leininger, 1995c; Leininger & McFarland, 2002a). She also identifies that international nursing and transcultural nursing are different. International nursing focuses on nurses functioning between two cultures; however, transcultural nursing focuses on several cultures with a comparative theoretical and practice base (Leininger, 1995c; Leininger & McFarland, 2002a).

Leininger describes the transcultural nurse generalist as a nurse prepared at the baccalaureate level who is able to apply transcultural nursing concepts, principles, and practices that are generated by transcultural nurse specialists (Leininger, 1989a, 1989b, 1991c, 1995c; Leininger & McFarland, 2002a). The transcultural nurse specialist prepared in graduate programs receives in-depth preparation and mentorship in transcultural nursing knowledge and practice. This specialist has acquired competency skills through post baccalaureate education. “This specialist has studied selected cultures in sufficient depth (values, beliefs, and lifeways) and is highly knowledgeable and theoretically based about care, health, and environmental factors related to transcultural nursing perspectives” (Leininger, 1984b, p. 252). The transcultural nurse specialist serves as an expert field practitioner, teacher, researcher, and consultant with respect to select cultures. This individual also values and uses nursing theory to develop and advance knowledge within the discipline of transcultural nursing, the field Leininger (1995c, 2001) predicts must be the focus of all nursing education and practice.

Leininger (1996b) holds and promotes a new and different theory from traditional theories in nursing, which usually define theory as a set of logically interrelated concepts and hypothetical propositions that can be tested for the purpose of explaining or predicting an event, phenomenon, or situation. Instead, Leininger defines theory as the systematic and creative discovery of knowledge about a domain of interest or a phenomenon that appears important to understand or to account for some unknown phenomenon. She believes that nursing theory must take into account creative discovery about individuals, families, and groups, and their caring, values, expressions, beliefs, and actions or practices based on their cultural lifeways to provide effective, satisfying, and culturally congruent care. If nursing practices fail to recognize the cultural aspects of human needs, there will be signs of less beneficial or efficacious nursing care practices and even evidence of dissatisfaction with nursing services, which limits healing and well-being (Leininger, 1991b, 1995a, 1995c; Leininger & McFarland, 2002a, 2006).

Leininger (1991b) developed her Theory of Culture Care Diversity and Universality, which is based on the belief that people of different cultures can inform and are capable of guiding professionals to receive the kind of care they desire or need from others. Culture is the patterned and valued lifeways of people that influence their decisions and actions; therefore, the theory is directed toward nurses to discover and document the world of the client and to use their emic viewpoints, knowledge, and practices with appropriate etic (professional knowledge), as bases for making culturally congruent professional care actions and decisions (Leininger, 1991b, 1995c). Indeed, Culture Care is the broadest holistic nursing theory, because it takes into account the totality and holistic perspective of human life and existence over time, including the social structure factors, worldview, cultural history and values, environmental context (Leininger, 1981), language expressions, and folk (generic) and professional patterns. These are some of the critical and essential bases for the discovery of grounded care knowledge that as the essence of nursing that can lead to the health and well-being of clients and can guide therapeutic nursing practice. The Culture Care Theory can be inductive and deductive, derived from emic (insider) and etic (outsider) knowledge. However, Leininger encourages obtaining grounded emic knowledge from the people or culture because such knowledge is most credible (1991b).

The theory is neither middle range nor macro theory but must be viewed holistically with specific domains of interest. Leininger believes the terms middle range and macro are outdated in theory development and usage (1991b, 1995c; Leininger & McFarland, 2002a, 2006).

USE OF EMPIRICAL EVIDENCE

For more than 5 decades, Leininger has held that care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing (1970, 1981, 1988a, 1991b; Leininger & McFarland, 2002a, 2006). She states that care is complex, elusive, and often embedded in social structure and other aspects of culture (1991b; Leininger & McFarland, 2006). She holds that different forms, expressions, and patterns of care are diverse, and some are universal (Leininger, 1991b; Leininger & McFarland, 2002a, 2006). Leininger (1985a, 1990b) favors qualitative ethnomethods, especially ethnonursing, to study care. These methods are directed toward discovering the people-truths, views, beliefs, and patterned lifeways of people. During the 1960s, Leininger developed the ethnonursing method to study transcultural nursing phenomena specifically and systematically. This method focuses on the classification of care beliefs, values, and practices as cognitively or subjectively known by a designated culture (or cultural representatives) through their local emic people-centered language, experiences, beliefs, and value systems about actual or potential nursing phenomena such as care, health, and environmental factors (Leininger, 1991b, 1995c; Leininger & McFarland, 2002a, 2006). Although nursing has used the words care and caring for more than a century, the definitions and usage have been vague, and the terms have been used as clichés, without specific meanings to the culture of the client or nurse (Leininger, 1981, 1984a). “Indeed, the concepts about caring have been some of the least understood and studied of all human knowledge and research areas within and outside of nursing” (Leininger, 1978, p. 33). With the transcultural care theory and ethnonursing method based on emic (insider views) beliefs, a person gets close to the discovery of people-based care, because data come directly from the people and are not derived from the etic (outsider views) beliefs and practices of the researcher. An important purpose of the theory is to document, know, predict, and explain systematically through field data what is diverse and universal about generic and professional care of the cultures being studied (Leininger, 1991b).

Leininger (1984a, 1988a) holds that detailed and culturally based caring knowledge and practices should distinguish nursing’s contributions from those of other disciplines. The first reason for studying care theory is that the construct of care has been critical to human growth, development, and survival for human beings from the beginning of the human species (Leininger, 1981, 1984a). The second reason is to explicate and fully understand cultural knowledge and the roles of caregivers and care recipients in different cultures to provide culturally congruent care (Leininger, 1991b, 1995c, 2002a, 2002b, 2002c). Third, care knowledge is discovered and can be used as essential to promote the healing and well-being of clients, to face death, or to ensure the survival of human cultures over time (Leininger, 1981, 1984a, 1991b). Fourth, the nursing profession needs to systematically study care from a broad and holistic cultural perspective to discover the expressions and meanings of care, health, illness, and well-being as nursing knowledge (Leininger, 1991b, 1995c, 2002a, 2002b, 2002c). Leininger (1991b, 1995c, 2002a, 2002b, 2002c) finds that care is largely an elusive phenomenon often embedded in cultural lifeways and values. However, this knowledge is a sound basis for nurses to guide their practice for culturally congruent care and specific therapeutic ways to maintain health, prevent illness, heal, or help people face death (Leininger, 1994). A central thesis of the theory is that if the meaning of care can be fully grasped, the well-being or health care of individuals, families, and groups can be predicted, and culturally congruent care can be provided (Leininger, 1991b). Leininger (1991b) views care as one of the most powerful constructs and the central phenomenon of nursing. However, such care constructs and patterns must be fully documented, understood, and used to ensure that culturally based care becomes the major guide to transcultural nursing therapy and is used to explain or predict nursing practices (Leininger, 1991b).

To date, Leininger has studied several cultures in depth and has studied many cultures with undergraduate and graduate students and faculty using qualitative research methods. She has extensively explicated care constructs throughout many cultures in which each culture has different meanings, cultural experiences, and uses by people of diverse and similar cultures (Leininger, 1991b, 1995c; Leininger & McFarland, 2002a, 2006). A new body of knowledge continues to be discovered by transcultural nurses in the development of transcultural care practices with diverse and similar cultures. In time, Leininger (1991b) believes, both diverse and universal features of care and health will be documented as the essence of nursing knowledge and practice.

Leininger stated that the goal of the care theory is to provide culturally congruent care (1991b, 1995c, 2002a, 2002b, 2002c; Leininger & McFarland, 2006). She believes that nurses must work toward explicating care use and meanings so that culture care, values, beliefs, and lifeways can provide accurate and reliable bases for planning and effectively implementing culture-specific care and for identifying any universal or common features about care. She maintains that nurses cannot separate worldviews, social structures, and cultural beliefs (folk and professional) from health, wellness, illness, or care when working with cultures, because these factors are closely linked. Social structure factors such as religion, politics, culture, economics, and kinship are significant forces affecting care and influencing illness patterns and well-being. She also emphasizes the importance of discovering generic (folk, local, and indigenous) care from the cultures and comparing it with professional care (Leininger, 1991b).

Leininger has found that cultural blindness, shock, imposition, and ethnocentrism by nurses continue to greatly reduce the quality of care offered to clients of different cultures (Leininger, 1991a, 1994, 1995c; Leininger & McFarland, 2002a, 2006). Moreover, nursing diagnoses and medical diagnoses that are not culturally based and known create serious problems for cultures that lead to unfavorable and sometimes serious outcomes (Leininger, 1990c). Culturally congruent care is what makes clients satisfied that they have received good care; it is a powerful healing force for quality health care. Quality care is what clients seek most when they come for services from nurses, and it can be realized only when culturally derived care is known and used.

MAJOR ASSUMPTIONS

Major assumptions to support Leininger’s Culture Care Theory of Diversity and Universality follow. The definitions were derived from Leininger’s definitive works on the theory (Leininger, 1991b; Leininger & McFarland, 2002a, 2006).

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