LEININGER'S THEORY OF CULTURE CARE

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N207 AY 2011 - 2012

GROUP C







INTRODUCTION

Donnabelle Allauigan and Ericka Sarmiento

In an ever-changing world, society tends to become increasingly diverse, in terms of behaviors, values beliefs and norms. With constant internal and environmental stimuli, such behaviors, values, beliefs and norms develop overtime which creates a mark in the mind of every individual, and is observed through social practices, religious structures and artistic expression. The end result of such change is what we recognize now as culture.  Culture directs an individual’s thinking, doing and being.  Within the context of nursing practice, cultural backgrounds can influence views on health and well-being and illness, which in turn might have an effect on their perceptions on healthcare and healthcare outcomes. Due to the recurrent concerns regarding the challenges encountered in the care for culturally diverse patients, transcultural care has become an important aspect of health care. Nowadays the goal of the medical system is to provide optimal and holistic care for all patients, to be culturally competent is an ingredient in order to accomplish quality care and health outcomes. The need for clinicians to become more sensitive to cultural differences and gain an understanding of transcultural concepts has been repeatedly stressed by Leininger (1988) and is the aim of this piece of writing.

Our group hails from diverse locations and is working in different parts of not only the Philippines, but also of the world. With different upbringings and different customs that we grew up with and encounter on a daily basis as nurses, we chose Madeleine Leininger, who was a pioneer in her time, as our nursing theorist.

When Madeleine Leininger’s name was suggested, the majority immediately agreed on her because of the concept that she has developed; the Theory of Culture Care. Culture Care or Transcultural Nursing deals with nursing and the culture of the clients. And as we are nurses who are working in various nursing fields, in different locations, the group saw how it can be adapted to our profession. Seeking further knowledge on it and how it applies to our specialization, will enhance each individual further as efficient nurses.

The concept is also applicable not only to our work but also to us, students of Masters of Arts in Nursing, because we are currently adapting to a new culture with a different study environment, having interactions with people in various locations by various forms of media. This concept would not only be applied in the work setting but also in our education.

With this, our group encourages you to read through our study and we hope that you will be able to understand and appreciate its contents. We feel confident that after going through our output, you will come to conclude that nursing transcends all cultures, providing care for every race and nation.


BIOGRAPHY OF LEININGER
DENNIS N. MUÑOZ

            The Transcultural Nursing Society, founded in 1974, “...continues to serve as an important annual forum to bring nurses together worldwide with common and diverse interests to improve care to people of diverse and similar cultures. Members are active in consultation, teaching, research, direct care and in policy-making in national and transnational arenas” (TCN Website, www.tcns.org). Dr. Leininger, credited with saying, “Caring is the essence of nursing,” established the Caring Conferences in 1978 as a forum for nurse scholars interested in advancing caring knowledge to gather for formal presentations, informal dialogue, and to evolve research related to caring sciences. This once small group has evolved into the International Association for Human Caring (IAHC).
            

All this began in the 1950’s, when Madeleine Leininger became fascinated with anthropology, finding many concepts she believed were pertinent to nursing. She became the first professional nurse to receive a PhD in cultural and social anthropology, and her vision of the “blending” of two fields, nursing and anthropology, led to her “Culture Care Diversity and Universality: A Worldwide Theory of Nursing.” As the mother of transcultural nursing and founder of the Transcultural Nursing Society, she has advanced transcultural nursing through education, research, administration, and practice. Dr. Leininger has been in demand for over 35 years as a consultant and speaker on issues relate to transcultural nursing and human caring in education and research, and continues such engagements to the present.


EDUCATION, PROFESSION AND PROFESSORIAL WORKS OF
DR. MADELEINE M. LEININGER
(In time line presentation)

DR. MADELEINE M. LEININGER was born in Sutton, Nebraska on July 13, 1925, lived on a farm with four brothers and sisters, and graduated from Sutton High School. Her desire to pursue a career in nursing was due to her inspiration and experience with her aunt who suffered from congenital heart disease.

Dr. Leininger is a nationally and internationally known educator, author, theorist, administrator, researcher, consultant, and public speaker. She has been a distinguished visiting professor and scholar at approximately 70 universities in the United States, Canada, and overseas. As of 1995, she has written 25 books, published over 200 articles and book chapters, produced numerous audio and video recordings, and developed a software program. She has also given over 850 keynote and public lectures in US and around the world. Her areas of expertise are transcultural nursing, comparative human care, qualitative research methods, cultural care theory, culture of nursing and health fields, anthropology, and the future of nursing.  Dr. Leininger’s professional career is recognized as an educator and academic administrator (1956-1995), writer (1961-1995), lecturer (1965-1995), consultant (1971-1992), and leader in the field of transcultural nursing (1966-1995).

1945
The post depression Period, Madeleine and her sister entered the Cadet Nurse Corps (a federally-funded program to increase the numbers of nurses being trained to meet anticipated needs during World War II ) and a diploma program at St. Anthony’s School of Nursing in Denver, Coloradao. They were the only persons entering the nursing profession within several nearby counties.
1950
Madeleine Leininger went on to receive a Bachelor of Science degree in Biological Science, with a minor in Philosophy and Humanistic Studies, from Benedictine College (formerly Mount St. Scholastica College) in Atchison, Kasas
1950
Dr. Leininger opened a psychiatric nursing service and educational program at Creighton University in Omaha, Nebraska.

Ø  She earned the equivalent of a BSN through her studies in biological sciences, nursing administration, teaching and curriculum  during 1951-1954.
Ø  While working in a child guidance home, Leininger experienced what she describes as a cultural shock when she realized that recurrent behavioral patterns in children appeared to have a cultural basis. She identified a lack of cultural and care knowledge as the missing link to nursing understands of the many variations required in patient care to support compliance, healing, and wellness (George, 2002). the beginnings (in the 1950s) of a new construct and phenomenon called transcultural nursing.
1954
She received a Master of Science in Nursing degree, with a minor in Psychiatric Mental Health Nursing and Psychology, at The Catholic University of America in Washington, DC.
1954
to
1960
She moved on to serve as Associate Professor of Nursing (1954-1959) and Director of the Graduate Program in Psychiatric Nursing at the University of Cincinnati.

Ø  She also studied in this university, pursuing further graduate studies in curriculum, social sciences and nursing (1955-58)

There she began the first graduate program in psychiatric nursing at the University, as well as the first clinical specialist program in child psychiatric nursing in the country. During this time she also co-authored one of the first psychiatric nursing texts, Basic Psychiatric Nursing Concepts (1960), which has been published in eleven languages and used worldwide.

Ø  Early in her career, Leininger observed that traditional psychiatric interventions did not adequately address the needs and behaviors of children of differing cultural backgrounds.
Ø   While at the University of Cincinnati, she discussed her concerns regarding the influence of cultural factors in nursing care, as well as the potential of integrating the fields of nursing and anthropology, with visiting professor Margaret Mead.
1960
She pursued doctoral studies beginning in 1960; during this time she was awarded a National League of Nursing Fellowship for fieldwork in the Eastern Highlands of New Guinea, where she studied the convergence and divergence of human behavior in two Gadsup villages.

Ø  Dr. Leininger was the first in the 1960s to coin the concept "culturally congruent care" which was the goal of the Theory of Culture Care, and today the concept is being used globally.
1965
Leininger embarked upon a doctoral program in Cultural and Social Anthropology at the University of Washington in Seattle and became the first professional nurse to earn a Ph.D. in anthropology.
1966
Dr. Leininger was appointed Professor of Nursing and Anthropology at the University of Colorado– the first joint appointment of a professor of nursing and a second discipline in the United States.
1969
to
1974.
She was Dean, Professor of Nursing, and Lecturer in Anthropology at the University of
Washington, School of Nursing.

Ø  In 1973, under her leadership, the University of Washington was recognized as the outstanding public institutional school of nursing in the United States.
1974
to
1980
Dr. Leininger served as Dean, Professor of Nursing, Adjunct Professor of Anthropology, and Director of the Center for Nursing Research and of the Doctoral and Transcultural Nursing Programs at the University of Utah College of Nursing

Ø  She was the first full-time President of the American Association of Colleges of Nursing and one of the first members of the American Academy of Nursing in 1975.
1981
to
1995
She began her tenure at Wayne State University as Professor of Nursing and Director of the Center for Health Research at the College of Nursing, as well as Adjunct Professor of Anthropology in the College of Liberal Arts and Director of the Transcultural Nursing Program
Ø  While at Wayne State, Dr. Leininger won numerous awards, including the prestigious President’s Award for Excellence in Teaching, the Board of Governors’ Distinguished Faculty Award, and the Gershenson’s Research Fellowship Award.
Ø  She was presented with the Women in Science Award from California State University, in addition to many other honors and awards she received throughout her career, 1990
Ø  She also established the Journal of Transcultural Nursing and served as editor from 1989-1995.
Ø  She initiated and promoted worldwide certification of transcultural nurses (CTN) for client safety and knowledgeable care for people of diverse cultures.
June 1, 1995
Dr. Leininger retired as professor emeritus from Wayne State University
At present
 Dr. Leininger’s titles include:
1.       Professor Emeritus of Nursing, Wayne State University College of Nursing;
2.       Adjunct Clinical Professor at University of Nebraska College of Nursing;
3.       Fellow of the American Academy of Nursing;
4.       Distinguished Fellow of the Royal College of Nursing (Australia).
5.       She was honored as a Living Legend by the American Academy of Nursing (1998),
6.       Holds honorary degrees from Benedictine College (LHD, 1975),
7.       University of Indianapolis (DS, 1990),
8.       University of Kuopio, Finland (PhDNSc, 1991).


 
THEORY DEVELOPMENT AND HISTORICAL BACKGROUND
Donnabelle Allauigan

           Leininger’s theory of Cultural Care is a product of devoted consciousness of an ever changing world, wherein individual is at play with society and their environment. It is not a borrowed theory but it an outcome of independent work with the goal of improving care given to meet different health care needs of diverse cultures. The core of the theory was derived from all her experiences in hospital, clinic and in the community setting. World War II became the nest wherein the theory developed; it was during this period that many immigrants and refugees from diverse cultures were moving to the United States and to other places worldwide. With direct observations and interactions with clients of diverse cultures, with variety of health conditions, she became conscious that recovery from illnesses and or maintaining health and wellbeing was greatly affected by how health care was provided to them. The major event that led to the development of her theory happened in the early 1950’s where she worked as a clinical specialist caring for mildly disturbed children of diverse cultural backgrounds. During her exposure it became evident to her that nurses and other health professionals failed to appreciate the important role of culture in healing, caring process and in mental treatment practices. An attempt to use other health care models and other ideas popular during that period was made but was placed in vain due to inadequacy of their methods to address her clients’ needs. She then concluded that understanding and responding appropriately and therapeutically to clients of different cultures was a critical need that warranted further study and research. In order to have a full understanding of different cultures she decided to pursue an academic doctoral program in anthropology.  Resistance was met during the conceptualization of bringing together culture and care together, primarily due to lack of studies to back her up and lack of interest from nurses and other health practitioners. However the need became more and more apparent as she went on with her study and in due course, after five decades study and research, the theory has been established as a major, relevant and dominant theory in nursing.


PHILOSOPHICAL ROOTS
By Farrah Sayo

The philosophical roots of the theory are from the theorist’s extensive and diverse nursing experiences, anthropological insights, life experiences, values, and creative thinking.  Her firm belief in God’s creative and caring ways has always been important to her. Preparation in philosophy, religion, education, nursing, anthropology, biological sciences, and related areas influenced her holistic and comprehensive view of humans. And as the first graduate professional nurse to pursue a PhD in anthropology with the desire to advance nursing theory, she saw great potential for developing relationships between nursing and anthropology and expanding the prevalent mind-body medical and nursing views. Comparative care meanings, expressions, symbols, and practices of different cultures were powerful new ways to practice nursing. Theorizing about the culture and care relationships as a new discipline focus was intellectually exciting to her. Interestingly, anthropologists had not studied care in health and illness when she began the theory in the 1950s.  In developing the theory, a major hurdle for nurses was to discover culture care meanings, practices, and factors influencing care by religion, politics, economics, worldview, environment, cultural values, history, language, gender, and others. Hence, the sunrise model was developed.   If nurses use the model with the theory, they will discover factors related to cultural stresses, pain, racial biases, and even destructive acts as nontherapeutic to clients. One can also reduce and prevent violence in the workplace, anger, and noncompliance with data findings from the model when used with the three prescribed modes of action: a. Cultural preservation or maintenance b. Cultural care accommodation or negotiation c. Cultural care repatterning or restructuring. And because nurses are the largest group of health care providers, a significant difference in quality care and preventing legal suits can occur. The sunrise model used in conjunction with the theory is a powerful means for new knowledge and practices in health care contexts.

INFLUENCES ON THE THEORY
Gayzell A. de Jesus

Dr. Madeleine Leininger was especially candid when asked about her influences in formulating the Culture Care Theory.  She said that there was no one person or philosophic school of thought or ideology per se that directly influenced her thinking.  Dr. Leininger used creative thinking and her experiences as a nurse-anthropologist in working on the interrealationships between culture and care.  Her philosophical interest and conceptual orientation of the Culture Care Theory were derived primarily from holistic nursing and anthropological perspective of human beings living in different places and circumstances.

She formulated a derived theory from the discipline of anthropology and conceptualized it in a new and unique way relevant to nursing.  She defined transcultural nursing as “a major area of nursing which focuses upon a comparative study and analysis of different cultures and subcultures in the world with respect to their caring behavior; nursing care; and health-illness values, beliefs, and patterns of behavior with the goal of developing a scientific and humanistic body of knowledge in order to provide culture specific and culture-universal nursing care practices.”

She developed the theory “based upon the belief that cultures can determine most of the care they desire or need from professional caregivers.”  Culture Care theory is directed toward consumers of care to get their viewpoints, world views, knowledge and practices as bases for sound professional actions and decisions.  It is comprehensive and holistic because it takes into account social structure, world view, values, environment, language expressions, and folk-professional systems to discover nursing knowledge.

Theory Definitions and Specifics of The Theory of Culture Care




Enrique Luis Nuguid  


Dr. Leininger said that Illness and wellness are shaped by a various factors including perception and coping skills, as well as the social level of the patient. She also stressed that  cultural competence is an important component of nursing and that religious and cultural knowledge is an important ingredient in health care. She stressed that value of  culture is  influential in all spheres of human life. It also defines health, illness, and the search for relief from disease or distress. Health concepts held by many cultural groups  may result in people choosing not to seek modern medical treatment procedures and that health care providers 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 they likely to be encountered. Most cases of illness have multiple causalities and may require several different approaches to diagnosis, treatment, and cure including folk and western medical interventions. According to her studies, the use of traditional or alternate models of health care delivery is widely varied and may come into conflict with western models of health care practice that is why being a-depth with different cultures guide the behavior into acceptable ways for the people in a specific group since culture originates and develops within the social structure through inter personal interactions. Effective intercultural communication must take place so that nurse can successfully provide care for a client of a different cultural or ethnic to background.

DANICA MAE BARASI

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 creatively developed the Theory of Culture Care: Diversity and Universality with the goal to provide culturally congruent wholistic care. Some scholars might place this theory in the middle range classification. Leininger holds that it is not a grand theory because it has particular dimensions to assess for a total picture. It is a wholistic and comprehensive approach, which has led to broader nursing practice applications than is traditionally expected with a middle-range, reductionist approach. (Personal communication with Penny Glynn on September 12, 2003). Leininger’s theory is to provide care measures that are in harmony with an individual or group’s cultural beliefs, practices, and values. In the 1960’s she coined the term culturally congruent care, which is the primary goal of transcultural nursing practice. Culturally congruent care is possible when the following occurs within the nurse-client relationship (Leininger, 1981): Together the nurse and the client creatively design a new or different care lifestyle for the health or well-being of the client. This mode requires the use of both generic and professional knowledge and ways to fit such diverse ideas into nursing care actions and goals. Care knowledge and skill are often repatterned for the best interest of the clients…Thus all care modalities require coparticipation of the nurse and clients (consumers) working together to identify, plan, implement, and evaluate each caring mode for culturally congruent nursing care. These modes can stimulate nurses to design nursing actions and decisions using new knowlwdge and culturally based ways to provide meaningful and satisfying holistic care to individuals, groups or institutions.

Ethnohistory
·   Under Leninger's theory, the enthohistory of a patient is also important when evaluating adequate care. Under Leninger's theory, ethnohistory refers to "to the past events and experiences of individuals or groups, which explain human lifeways within particular cultural contexts over short or long periods.” For example, a person who may have been a member of an African tribe that does not traditionally believe in or trust medical professionals will require a nurse who is especially careful and slow to introduce medical treatments.
Other Concepts
·        Leninger’s theory also states that its cannot only be applied to the nurse-client relationship but also includes care for families, groups, communities, cultures and institutions. Her theory would be especially important in situations in which a nurse may be enlisted in the Army or a member of the Peace Corps, where there will be cultural as well as religious divides, and it would be of the utmost importance for the nurse to be able to address the differences provide care accordingly.

METAPARADIGM IN NURSING
Flor Kenneth Alobin

Madeleine Leininger focused on care as an integral aspect of nursing. Unlike other nursing theorists, she did not emphasized on basic concepts of person, nursing, health and environment.

Instead, she formulated the following descriptions of these:

PERSON:  refers to an individual human caring and cultural being as well as a family, group, a social institution, or a culture.

Human beings are best explained in her assumptions. Humans are thus believed to be caring and capable of being concerned about the desires, welfares, and continued existence of others. Human care is collective, that is, seen in all cultures.

Humans have endured within cultures and through place and time because they have been able to care for infants, children, and the elderly in a variety of ways and in many different environments. Thus, humans are universally- caring beings who survive in a diversity of cultures through their ability to provide the universality of care in a variety of ways according to differing cultures, needs, and settings.

Leininger (1991) also indicates that nursing, as a caring science should focus ahead of traditional nurse-patient interactions to include “families, groups, communities, total cultures, institutions,” as well as worldwide health institutions and ways to expand international nursing care policies and practices.


ENVIRONMENT: refers to the physical or ecological environment and a context in which individuals and cultural groups live

Instead of ‘environment’ Leininger uses the concept ‘environmental context’, which includes events with meanings and interpretations given to them in particular physical, ecological, sociopolitical and/or cultural settings.

Her description of culture centers on a particular group (society) and the patterning of actions, thoughts, and decisions that occurs as the result of “learned, shared, and transmitted values, beliefs, norms and lifeways.” This learning, sharing, transmitting, and patterning take place within a group of people who function in an identifiable setting or environment. Therefore, although Leininger does not use the specific terms of society or environment, the concept of culture is closedly related to society/environment, and is a central matter of her theory.

HEALTH: encompasses a broad spectrum of conditions, including well-being, illness, disability, and handicap

                Madeleine Leininger discussed about components of health, specifically:
§  health systems
§  health care practices
§  changing health patterns
§  health promotions
§  health maintenance

Health is a key concept in transcultural nursing. Because of the weight on the need for nurses to have knowledge that is specific to the culture in which nursing is being practiced, it is acknowledged that health is seen as being universal across cultures but distinct within each culture in a way that represents the beliefs, values, and practices of the particular culture. Thus, health is both universal and diverse.

NURSING: a discipline and profession of transcultural human care. It is a learned humanistic and scientific profession and discipline that focuses on phenomena and activities of human care in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well-being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death

First, Leininger considers nursing a discipline and a profession, and the term ‘nursing’ thus cannot explain the phenomenon of nursing. Instead, care has the greatest epistemic and onto logic explanatory power to explain nursing. Leininger (1995a) views ‘caring’ as the verb counterpart to the noun ‘care’ and refers it to a feeling of compassion, interest and concern for people (Leininger 1970, Morse et al. 1990, Reynolds 1995, McCance et al. 1997). When Leininger’s definition of care is compared to other transcultural scholars’ definitions, it appears that her view of care is wider than, for example, that of Orque et al. (1983), who describe care as goal-oriented nursing activities, in which the nurses recognise the patients’ ethnic and cultural features and integrate them into the nursing process. 

Leininger showed her concern to nurses who do not have sufficient preparation for a transcultural perspective. For that reason, they will not be able to value nor practice such viewpoint to the fullest extent possible.

She gave three types of nursing actions that are culturally-based and thus consistent with the needs and values of the clients. These are:

1.       Cultural care preservation/maintenance
2.       Cultural care accommodation/negotiation
3.       Cultural care repatterning/restructuring

            These three modes of action can lead to the deliverance of nursing care that best fits with the client’s culture and thus reduce cultural stress and chance for conflict between the client and the caregiver.





MAJOR AND UNIQUE FEATURES OF THE THEORY
Fatima Angelica Herrera

Culture care theory, a great breakthrough in caring for the culturally different, has major, unique, and contributing features that can be listed at the onset before presenting the theory itself. These are the following:

1.              The theory which was launched in the mid-1950s remains one of the oldest theories in the field of nursing.
2.               It is the only theory that focused unambiguously on the close interrelationships of culture and care on a person's well-being, health, illness, and death.
3.                 Culture Care theory is the only theory that focused on comparative culture care.
4.    Being the most holistic and multidimensional theory, it discovered specific and multifaceted culturally based care meanings and practices.
5.     It is the first nursing theory to focus on discovering global cultural care diversities/differences and care universalities/commonalties.
6.       With a method called ethnonursing, it is the first nursing theory with a distinctively designed research method to fit the theory.
7.                 In order to deliver culturally congruent care, the theory has both abstract and practical features in addition to three action modes.
8.                 It is the first nursing theory that focused on generic (emic) and professional (etic) culture care, social structure factors, worldview-related data, and ethnohistory in various environmental contexts.

Originating from the theorist’s extensive and diverse nursing experiences, anthropological insights, life experiences, values, and creative thinking, these are unique contributions related to study and use of the theory which can be powerful means for new knowledge and practices in health care contexts.


PURPOSE AND GOAL OF THE THEORY
Fatima Angelica Herrera

To discover and elucidate diverse and universal culturally based care factors that influence an individual's or group's health, well-being, illness, or death is the principal purpose of the theory. Its goal is to use research findings to provide culturally congruent, competent, safe, and meaningful care to clients of different or similar cultures. The three modes for congruent care, decisions, and actions proposed in the theory are expected to lead to wellness, prevent illness or to face death.



THE SUNRISE MODEL
DENNIS N. MUÑOZ
       Theory’s Purpose & Goal
ü  The model is not the theory per se but depicts factors influencing care.
       These factors needed to be included for culturally
           competent care. Hence, the Sunrise Model was created  (Leininger, 1997).
      culture care meanings
      practices
      factors influencing care:
-religion, politics, economics, worldview, environment,   cultural values, history,   language, gender, and others.
       To discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups.

Purpose & Goal:
To use research findings to provide culturally congruent, safe, and meaningful care to clients of diverse or similar cultures

Literature of the Sunrise Model, Explained (excerpt from Parker, 2001)

            The Sunrise Model (Figure 1) was developed to give a holistic and comprehensive conceptual picture of the major factors held as important to the Theory of Culture Care Diversity and Universality (Leininger, 1995, 1997a). The model is a conceptual visual guide depicting multiple factors predicted to influence culturally congruent care with people of different cultures. The model essentially serves as a cognitive guide for the researcher to visualize and reflect on different factors predicted to influence culturally based care in the discovery process.


             The Sunrise Model has also been used as a valuable guide for doing culturalogical health-care assessment of clients’ health needs. As the researcher uses the model, the different factors depicted in the model are kept in mind in relation to discovering culture care phenomena. Gender and sexual orientation, race, class factors, biomedical condition, and the extent of acculturation are all an integral part of the model and theory.


          The factors tend to be embedded in social structure, worldview, and other dimensions identified in the Sunrise Model and are usually not quickly identifiable. Hence, they are not isolated variables but are lodged in their natural and meaningful cultural context, yet are important discovery areas within the theory.

          According to the researcher’s interests and skills, one can begin the discovery at any place in the model except with the three modes of action and decisions, which are studied last or after drawing upon data collected in the upper part of the model. All factors in the model need to be studied to obtain comprehensive or holistic data in order to arrive at an accurate picture of culturally based care. Some researchers may want to start with generic and professional care, whereas others may begin with the worldview and social structure dimensions.

          There is flexibility in the discovery process to fit the informant’s interest and level of comfort as well as the researcher’s goals, domains of inquiry, and research skills. Because three modes of action and decision (in the lower part of the model) are studied and formulated with informants after the researcher has obtained data in the upper part of the model, the nursing actions or decisions become evident.

          The researcher involves informants in the discussion to arrive at appropriate actions, decisions, or plans. Throughout this discovery process, the researcher holds his or her own epic views, resuppositions, and biases in abeyance, so that the informants’ cultural ideas will come forth, because they, rather than the researcher’s views, are important and are the reason for the study. Transcultural nurses are taught, guided, and mentored in ways to withhold and deal with their biases and prejudices through formal courses and clinical experiences in transcultural nursing.



ORIENTATIONAL DEFINITIONS
Amor Auro-Llenas

Leininger develop new terms and definition which are important and to facilitate easier understanding ( although such key terms are crucial to understanding) but are essential to understanding Leininger's Theory.
  1. CARE - is to render/ help others with the present or incoming needs to facilitate improvement in either human health conditions or even facing death.
  2.  CARING - service, or an act of rendering/ giving care
  3. CULTURE - is the people’s various ways of adaptation in their everyday life.
  4. CULTURAL CARE - is an individual's, group or community's different adaptation or learning, acquired and being used to improve and face their everyday way of life, sickness, health and even facing death
  5. CULTURAL CARE DIVERSITY - is the people’s  own understanding in delivering care that are recognized within or in other circle of community.
  6. CULTURAL CARE UNIVERSALITY - simple/ ordinary care with almost the same perception or concepts that are seen in many cultures.
  7. NURSING - is one branch in health profession that is directed  to client in scope of care. 
  8. WORLD VIEW - is how the people perceived the world or universe in making their personal understanding of what life is all about.
  9. CULTURAL & SOCIAL STRUCTURAL DIMENSION - the people/ person's activity in daily living  and the influences of their culture, traditions, beliefs, how their political views helps, education and even new technologies, primitive history that affects cultural responses of people within cultural context.
  10. HEALTH - is a condition of an individual that is culturally recognized and given importance.
  11. CULTURAL CARE PRESERVATION & MAINTENANCE - rendering care and giving importance to peoples' culture, belief and respecting their values and practices regarding health care status and scope of health care understanding.
  12.  CULTURAL ACCOMODATION & NEGOTIATION - offering other alternative ways of rendering health care that is acceptable to people and community for a better result that is  shared by the health care provider and health care receiver.


ASSUMPTIVE PREMISES
Edcel Lyra M. Reyes
  
The assumptive premises serve as the philosophical basis which supports the Culture Care: Diversity and Universality Theory.  These assumptions gave meaning, clarity, and an in-depth understanding to the focus of the theory which will help us to achieve a culturally congruent and competent nursing care.
  1. Care is the essence and central focus of nursing, but the processes, structure and forms of caring varies among culture.
  2. Caring is essential for health and well-being, healing, human birth, growth, development, survival, and also for facing illness or death.
  3. Culture care is a broad holistic perspective, which covers the biophysical, psychological, social, cultural, and environmental concepts to guide nursing care practices.
  4. Nursing’s central purpose is to serve human beings in health, illness, and if dying.
  5. There can be no curing without caring but there can be caring without curing.
  6. Care behaviors, goals and functions have different and similar aspects among all cultures of the world, depending on their social structure, world view and cultural values.
  7.  Every human culture has folk practices, professional knowledge, and professional care systems that vary. The nurse must identify and address these factors consciously with each client in order to provide holistic and culturally congruent care.
  8. Cultural care values, beliefs, and practices are influenced by worldview and language, as well as technological, religious, social, cultural, political, economic and educational factors.
  9. Only when cultural care values, expressions, or patterns are known and used appropriately and knowingly by the nurse providing care, culturally beneficial nursing care can be achieved.
  10.  Stress, cultural conflicts, non-compliance and ethical concerns will be evident in clients who fail to experience nursing care congruent to their cultural beliefs and values.


ACCEPTANCE BY THE NURSING COMMUNITY
Gayzell A. de Jesus

A.   Practice

Nurses are now gradually realizing the importance of cultural nursing and the need to understand cultures, especially Filipino nurses who are working overseas. Nursing is in a new phase of health emphasis where there is an increased display of cultural identity, accompanied by increased demands for culture specific care and general health services.  I believe that Filipino nurses are much in demand for being culturally open and caring regardless of their clients’ cultural orientation.  The world is strongly multicultural and that we, as health personnel are anticipated to respond to our clients’ diverse cultural needs.

B.   Education

The relationship between nursing and culture gained recognition by being added to the Nursing curriculum in the mid-1970s but there were very few nurse educators adequately prepared and qualified to teach courses on culture and nursing.  This gave rise to the first doctoral program in transcultural nursing in 1977 at the University of Utah.   Despite the encouraging outcomes, using care as the central theme in nursing curriculum needs further research on validation of its usefulness and effectiveness.

C.   Research

Basic and advanced research studies are being done and tested by nurses globally.  There is a heightened interest on the part of consumers who are funding to continue research in transcultural nursing care. Nurse anthropologists and other nurses have contributed to international and regional/local workshops, conferences and instructional programs on transcultural nursing.  Researches in the field of transcultural nursing is expected to enhance theoretical development and will continue to identify culture-specific and universal care constructs.

Due to the upturned needs for international understanding and nursing care, it is reasonable to predict that transcultural nurse specialists will be tomorrow’s leaders in education, research and service programs.


NURSING PROCESS AND ROLE OF NURSE
Enrique Luis Nuguid and Farrah Sayo

§  The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills.
§  The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem.
§  The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms.
§  Nurses should evaluate their attitudes toward ethnic nursing care.
§  The process of self-evaluation can help the nurse become more comfortable when providing care to clients from diverse backgrounds
§  Nurses have a responsibility to understand the influence of culture, race &ethnicity on the development of social emotional relationship child rearing practices &attitude toward health.
§  A child's self concepts evolves from ideas about his or her social roles
§  Important sub culture influences on children include ethnicity social class, occupation school peers and mass culture
§  Socioeconomic influences play major role in ability to seek opportunity for health promotion for wellness
§  Religious practices greatly influence health promotion belief in families.
§  Many ethnic and cultural groups in country retain the cultural heritage of their original culture.
§  How culture influences behaviors, attitudes, and values depends on many factors and thus is not the same for different members of a cultural group.
§  The nurse should have an understanding of the general characteristics of the major ethnic groups, but should always individualize care rather than generalize about all clients in these groups.
§  Before assessing the cultural background of a client, nurses should assess how they are influenced by their own culture.
§  The nursing diagnosis for clients should include potential problems in their interaction with the health care system and problems involving the effects of culture.
§  The planning and implementation of nursing interventions should be adapted as much as possible to the client's cultural background.
§  Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds.
§  The client’s educational level and language skills should be considered when planning teaching activities.
§  Discussing cultural questions related to care with the client and family during the planning stage helps the nurse understand how cultural variables are related to the client's health beliefs and practices, so that interventions can be individualized for the client.
§  Evaluation continues throughout the nursing process and should include feedback from the client and family.
§  Self-evaluation by the nurse is crucial as he or she increases skills for interaction.    

PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR NURSES

Knowing the patient's cultural background  would help the nurse to heighten his or her awareness with his own beliefs, values, morals and prejudices. This would also foster understanding, respect and appreciation for the individuality and diversity of patients beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome.  It will also strengthen  the nurses' commitment to relationship-centered nursing that emphasizes care of the suffering person rather than attention simply more to the pathophysiology of disease, and recognizes the essentiality of the nurse as a dynamic component of that relationship.


STRENGTHS AND LIMITATIONS OF THE CULTURE CARE THEORY
Diane Hilario

Strengths:       
·         Leininger’s Transcultural Nursing Theory or Culture Care Diversity and Universality focused on the concept of culture in providing nursing care to our patients. It aids the nurse to be culture sensitive. Nurses should be conscious on different culture that necessitates them to respond to the needs of the patient who has different cultural values.
·         Compare to other theories which primarily focus on people, health, environment and nursing, for Leininger she highlight on care as core of nursing. However the assumption of it is base from culture data. For her, in order to fathom care, we should also understand the concept of culture.

Limitations:
·     It can also be the primary cause of error in making clinical decisions like misperception of the outcomes and misperception of the values patients place on to outcomes. (http://nursinglibrary.info/nursing-theories/madeleine-leininger/). Not all the data that will be taken will be accurate and applicable to all clients. We should also consider the uniqueness of individual.
·     If nursing practices fail to recognize culturological aspects of human needs, there will be signs of less efficacious nursing care practices and dissatisfaction with nursing services (Leininger). Does it mean that a sole principle in providing efficient care is the culturally consistent care? It can be an aspect but it doesn’t mean that we will not consider the other important things, because we need to remember that we should also provide holistic care, not only in the concept of culture.
·     This theory doesn’t give any attention to the disease, symptoms etc.
·   There can be a problem in adapting or integrating the culture of the other which can be the cause of cultural shock on the part of the nurses. Studying culture doesn’t mean that we could already relate to them, studying is different from actual experience.
·     The limited applicability of a static culture framework, lack of attention to the structural context in which health care issues arise and must be addressed, and the consequent inappropriateness of many health care strategies based on cultural framework. (Bruni, N. -1988- Australian Journal of Advanced Nursing, 5(3)


CRITIQUE
Elizabeth Anne Resma and Floriza Maco

Transcultural nursing theory is really a broad, holistic, comprehensive perspective of human groups, populations, and species. According to Tomey and Alligood, 2006, this theory continues to generate many domains of inquiry for nurse researchers to pursue for scientific and humanistic knowledge. The theory challenges nurses to seek both universal and diverse culturally based care phenomena by diverse cultures, the culture of nursing, and the cultures of social unsteadiness worldwide. Leininger’s culture care theory is relevant worldwide to help guide nurse researchers in conceptualizing the theory and research approaches and to guide practice.


SIMPLICITY
The applicability of Transcultural Nursing Theory transcends the wide array of human cultures. It is likewise holistic and comprehensive (Tomey & Alligood, 2006) hence paving the way for further analysis of the concept of health as a soceital phenomenon. 

GENERALITY
The emphasis of Transcultural Nursing theory on the qualitative standpoint of care addresses multitudes of patients. The objective of universality in terms of Nursing care duly guided by Leininger’s theory makes it possible to attend to different cases of patients without compromising one’s cultural aspect, in fact because of the insights acquired through the study of cultural backgrounds, cultural-specific care emerged. its due familiarity among the people makes acceptability and integration easier, non-judgmental and therefore, non-threatening. Comparative studies among vast cultures also prove itself highly esteemed in the field of education, practice and research. Thereby, it necessitates further investigation on diverse cultures, heath situations, their commonalities and points of conflict. These studies are highly important not just to judge and state facts towards the masses but ultimately, for health care providers to understand and accommodate beliefs as an indispensable part of human nature. 

EMPIRICAL PRECISION
Transcultural Nursing helps fill in the gaps between folklore and science as it becomes the basis for varied unexplained phenomena. Though mainly subjective in nature due to its qualitative approach, it is still deemed highly credible because constructs based upon specific and widely recognized criteria are initially & duly identified. Its richness in resources by virtue of simple observation to in-depth analysis from informants also made it sustainable in terms of empirical information.

DERIVABLE CONSEQUENCES
With the advent of holistic Nursing care, knowledge of Transcultural Nursing plays a significant part in addressing to specific cultural needs of a patient. This knowledge facilitates better communication thus resulting to an effective and trustworthy patient-nurse relationship. Leininger’s theory further paves the path for multicultural care, a kind of care that is sensitive, empathic and highly practical. The ultimate goal of Nursing through this theory therefore facilitates self-actualization and not just address the curability of an infirmity.

As a premier theory in nursing, culture care is greatly valued worldwide. Other disciplines have found the theory and method very helpful and valuable. Nurses who use the theory and method frequently communicate how valuable and important it is to discover culturally based ways to know and practice nursing and health care. Practicing nurses now have holistic, culturally based research findings for use in caring for clients of diverse and similar cultures or subcultures in different countries. The theory is not difficult to use once the researcher understands it and method and has mentor guidance. Newcomers to the theory and method can benefit from experienced, expert mentors in addition to studying transcultural research conducted using the theory and method. Most importantly, nurses often express that this theory and method are the only ones that it makes sense to use in nursing. They contend it is very natural to nursing and helps one to gain fresh new insights about care, health, and well – being. Unquestionably, it is the theory of today and tomorrow and one which will grow in use in the future in our growing and increasingly multicultural world. The research and theory provide a new pathway to advance the profession of nursing and the body of transcultural knowledge for application in nursing practice, education, research, and clinical consultation worldwide.


Theory findings/ Evaluation/ Analysis
Elizabeth Anne Resma

THEORY FINDINGS
The advent of anthropological study in relation to nursing opened several viewpoints to the universal concept of Health. We came to learn that while health is a universal phenomenon, its definition is in fact not as universal as we thought. Leininger’s theory further proves this assertion as she ventures towards giving holism a new and improved meaning. While previous theories mentioned societal role in passing, we cannot deny that cultural dictates greatly impacts research, education and most especially practice. Man, as a social being will always seek the approval of the society where he/she belongs. This approval becomes dictates and dictates become practices who over time and repeated use become in itself what we now call cultural identity. A fairly common example is that of circumcision. Per medical standpoint, circumcision is a hygienic necessity while for cultural groups such as in the Jewish and Islamic faiths, circumcision is a matter of belief or religion. As filipinos, our diligence in this said practice lies on both reasons as stated above plus the pressure of belongingness. From this simple comparison alone, it is evident that despite the commonality, a certain variance still differs among the subjects. In terms of Nursing, knowledge of variances among pertinent events is crucial. These variances help define the strengths and limitations in the nurse-patient relationship, thereby aggregating a sensitive and highly individualized ambiance for nursing care to take place. Transcultural Nursing does not only aim to correct and enhance societal practice but also towards giving the nurses as sense of understanding and appreciation on the actual environmental occurrences that affects man.


EVALUATION

The general scope of Transcultural Nursing is definitely a large body to explore and deduce upon. It thereby necessitates a thorough background study of a specific culture initially made and duly studied before the actual assessment is acted upon. Health assessment tool may vary a lot per culture and due standardization is deemed challenging as well. The availability of resources for surveys and studies are relatively bounty but subjectivity is a crucial matter to be resolved so as to extract a non-bias and accurate database. It is imperative that while cultural allowances are made, standard nursing practice must still be maintained and constantly met. 

ANALYSIS
Transcultural Nursing ultimately paves a deeper and more systematic communication between the nurse and the patient. It enhances the individuality of each person that problem-oriented approach often tend to neglect. It has a simple premise and yet it is all encompassing. It is applicable to all health-care settings in a broad sense through its cultural understanding and consideration. It is likewise practical and deeply relate-able.

STRATEGIES TO PROMOTE EFFECTIVE CROSS-CULTURAL COMMUNICATION IN THE MULTI-CULTURAL WORKPLACE
Fatima Angelica Herrera

1.          Pronounce names correctly. When in doubt, ask the person for the correct pronunciation.
2.   Use proper titles of respect: "Doctor", "Reverend", "mister". Be sure to ask the person's permission to use his or her first name, or wait until you are given permission to do so.
3.     Be aware of gender sensitivities. If uncertain about the marital status of a woman or her preferred title, it is best to refer to her as Ms. (pronounced mizz).
4.    Be aware of subtle linguistic messages that may convey bias or inequality, for example, referring to a white man as Mister while addressing a Black female by her first name.
5.         Refrain from Anglicing or shortening a person's given name without his or her permission. For example, calling a Russian American "Mike" instead of Mikhael, or shortening the Italian American Maria Rosa to Maria. The same principle applies to the last name or surname.
6.     Call people by their proper names. Avoid slang such as "girl", "boy", "honey", "dear", "guy", "fella", "babe", "chief", "mama", "sweetheart", or similar terms.
7.      Refrain from using slang, pejorative, or derogatory terms when referring to person's ethnic, racial, or religious groups and convey to all staff that this is a work environment in which there is zero tolerance for the use of such language. Violators should be counseled immediately.
8.   Identify people by race, color, gender, and ethnic origin only when necessary and appropriate.
9.     Avoid using words and phrases that may be offensive to others. For example, "culturally deprived" or "culturally disadvantaged" imply inferiority and "non-White" implies that White is the normative standard.
10.    Avoid clichés and platitudes such as "Some of my best friends are Mexicans" or "I went to school with Blacks".
11.      Use language in communication that includes all staff rather than excludes some of them.
12.     Do not expect a staff member to know all other employees of his or her background or to speak for them. They share ethnicity, not necessarily the same experience, friendship, or beliefs.
13.    Communications describing staff should pertain to their job skills, not their color, age, sex, race, or national origin.
14.   Refrain from telling stories or jokes demeaning to certain ethnic, racial, age, or religious groups. Also avoid those pertaining to gender-related issues or persons with physical or mental disabilities. Convey to all staff that there will be zero tolerance for this inappropriate behavior. Violators should be counseled immediately.
15.   Avoid remarks that suggest to staff from diverse backgrounds that they should consider themselves fortunate to be in the organization. Do not compare their employment opportunities and conditions with those people in their country of origin.
16.     Remember that communication problems multiply in telephone communications because important nonverbal cues are lost and accents may be difficult to interpret.
17.  Provide staff with opportunities to explore diversity issues in their workplace, and constructively resolve differences. 

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PERSONAL EXPERIENCES

Amor Auro- Llenas
           
Working in the middle east is quite difficult, especially to someone like me who is a first timer. Years back when i worked at Psychological Medicine Hospital here in Kuwait and was assigned to work in a male ward where I am the only female staff nurse aside from my female headnurse, a jobsite where almost all of my colleague are speaking language that is so much strange and new to me. My fear is overwhelming, thinking how would I face and communicate with all of them, most especially with my client(s) without knowing any single word they have been spoken. However, I console myself, saying that the issue of language barrier will be broken as long as I knew the basic do's and don’ts of their culture, religion, beliefs and traditions, where we learned in transcultural nursing introduced to us by Leininger. It is where I remember the cultural diversity and universality, that as long as I knew how to respect their culture, belief and traditions and giving importance to it,  I will survive and were able to surpass everyday performing my task and duty for my client(s). But since my client(s) are mentally incapacitated I am not excused not to learn the language, so I started to learn even just the basic, simple greetings that my client(s) would understand and appreciate, until the time I was re-assigned to work in Geriatric side where almost all of  my client(s) have a less or worst, without any educational background, knows only their own spoken language and such. In here, I came to realized I have to learn fast and adapt their language and culture to make my desired outcome everyday be successful. Understanding simple language, makes my work more effective, because I was able to empathize with my client(s) complaints. I was able to deliver more effective care, explaining whatever procedure needed to be done, more useful whenever client(s) exhibits aggression and restlessness. Hence, achieving the desired outcome I have for my client(s) are meet satisfactorily.

Diane Jane Hilario

I had been working here at the Kingdom of Saudi Arabia for more than two years. Basically, their way of life is not new to me, because I’d been here several times before I graduated from College. However, I realized that dealing with people from outside work is much easier that dealing with this patient who is totally different from me, from the religion, culture and language. Fundamentally, the first thing I need to know to be able to acquaint with them is learn their language. Although it is not easy, but with determination, in less than a year I was able to understand and speak basic Arabic words which are applicable to me. I remember during my first few days, I heard two patients talking in the waiting area. I thought they are fighting because they’re voice is very loud and I can’t understand the conversation, when I came there, they are like friends who are chatting. Then through constant observation, I realized that is normal for them to talk so loud, as if they are mad.

During my hospital experience in the Philippines, I’m used to the practice that I don’t have to attend to my doctor all the time during the consultation especially if I am busy, but for here, you have to go inside the room with the doctor during the whole consultation period if the patient is female. Because culturally, it is not appropriate for them to stay and talk to opposite sex even though he is a doctor. 

There are also mothers who will tie the body of their newborn baby, so the baby will sleep in one position only when he/she is sleeping. As a nurse, you need to ask them not to tie the baby so tight that might cause fracture, or the baby may not breathe properly.

A lot of experiences I had encountered during my stay here. But as a nurse, I need to work on the barriers that might hinder or compromise on the care I am providing with my patients.

Divina Digap

The Hospital where I'm working incorporates Madeleine Leininger's "Transcultural Nursing" Model of care which focuses human-care(caring) difference and similarities of the beliefs, values and patterned lifeways of cultures to provide culturally congruent, meaningful and beneficial health care to people. One of our practiced is that we have a monthly Survey and audits in each department for clients satisfaction in relation to application of excellent nursing care."For Nursing care to be meaningful and therapeutic, professional knowledge needs to fit the cultural values, beliefs and expectations of the client. If professional knowledge and skills fail to fit the client's values and lifeways, one can anticipate that the client will be uncooperative, noncompliant and dissatisfied with nursing efforts.

Transcultural nursing is challenging but complex and we nurses to study the clients culture values, beliefs and lifeways and then to identify how to incorporate our nursing skills and knowledge to best help the client and usually the family as part of nursing care practiced by giving them a lot of education and reading materials with frequent followup in doing hourly rounding to addressed each concerns.

Culture and care are usually so embedded in each other and closely linked with client's beliefs and practices that they cannot be over looked over neglected in the helping-healing process of transcultural nursing" As Leininger identifies that inorder for transcultural nursing to function successfully, "nurses need to be knowledgeable about their own cultural care heritage and of biases and beliefs and prejudices,to work effectively with clients..and that maintaining an open learning-discovery process about care and culture is imperative" This will enable "culturally congruent and competent care "which should become "an integral part of nurse's thinking and decisions for family and individual care practices". So what we do here are clearly caring for any patients of nationalities dissimilar to their own. Their orientation to the organization, hospital and unit, will have involved intense introduction to caring for cultures other than their own .Our day-to-day nursing practiced requires and demonstrates ongoing "culturally congruent and competent care"

Elizabeth Anne A. Resma

I am a Neonatal Intensive Care Unit Staff Nurse at St. Luke’s Medical Center Global City. True to its location—“Global” City, our hospital mostly caters to foreign patients and their relatives who are living within the vicinity. Initially, upon knowing the ethnicity of a patient, we, nurses tend to deduce previously learned characteristics or preferences of this group. For instance,we have observed from several occasions that people from Guam and Saipan are generally a happy, easy-to-please and friendly bunch while Koreans tend to be self-contained and aloof towards foreigners. From that alone, even upon the introductory phase, we would know what group of people would appreciate a lively chat or a direct-to-the-point approach, either way, knowing one’s cultural background though not generally consistent is still a valuable initial information. We make it a point that despite the categorization, we should still look into the individuality of the person/s we come to deal with. 

At the Neonatal ICU, we are not only responsible for the well-being of our immediate patients but also towards teaching the parents on how to care for their babies in preparation for an imminent discharge. Health teachings and demonstrations are two of the most significant activities that basically defines us as a nurse in our unit. To be able to have a successful outcome, it is a must to establish a trusting relationship in which good communication is the key ingredient. For example, in teaching new parents on how to bathe the baby, it is always best to anchor our health teachings on the parents’ initial beliefs, prior knowledge, cultural/religious considerations and personal preferences. From the data gathered, the nurse should infer which merits to correct or uphold then assess the need to provide additional information in reference with the clinical standards. Through this technique, parents are empowered by their active involvement and in turn, the nurse becomes more sensitive on the subject/s which greatly impacts the patient and the family. It really makes my day, when upon discharge, foreign patients appreciate our efforts to be accommodating and even give a vote of approval towards Filipino nurses in general for our compassionate rendition of care compared when they are hospitalized abroad wherein according to them, nurses tend to be more focused on clerical activities. 

Just in case you are wondering where on earth are we located, you’d see, upon looking into the map, Global City, better known as Bonifacio Global City or The Fort is within Taguig city, Philippines.

Enrique Luis Nuguid

As an  OFW, I have definitely applied the theory of Dr. Madeline Leininger in my own practice as a nurse. As a middle-east based nurse, working in a "Muslim and Arab Country" would mean adapting largely and extensively to their laws, regulations, culture as well as their religion. I have to be equipped with the  proper knowledge as regards to their religion and culture as I deliver my care to my patients or simple living out my everyday life here. The fact that it would protect me from any harm or danger, it could also help me deliver the best possible care to them through proper communication. During my first few days here in Kuwait, I had to know the importance of greeting my patients; asking permission from my female patients before touching them as I do my nursing care and avoiding eye contact to them as much as possible as they may misinterpret it. I also had to learn the basics of their language since some of them don't speak nor understand english. These simple things made a big difference in my work and were essential in building rapport  with my patients thus, the nurse-patient relationship was established and it paved the way for a better quality of care to them. 

Ericka Sarmiento

Working in a review center, I have to deal with different cultures on a daily basis. We have different knowledge-base, different approaches, and different attitudes. I used to have difficulty adapting to the different personalities of the students in our center and usually only attend to those who were pleasant enough to deal with.

After a while I've managed to understand how to handle things and I can say that understanding is a big factor when dealing with other people. When I started to understand how different every person is, that's when I was able to form a working relationship with each student that I deal with. Linking to Leininger's theory, I began to understand that these people came from different backgrounds, having different beliefs and attitudes. Knowing this helped me cope and improved my provision of service to the student in our review center.

Farrah M. Sayo

            Working on a tertiary hospital, I can say I have encountered a considerable number of people in a wide variety of cultures and traditions different from one another.  I had once a Chinese patient who was admitted for massive MI.  She was 70 years old, pure Chinese, and cannot even understand the slightest English word.  When she came in, she was intubated and was so restless that I had to put her on 4 point restraints with the order of the attending physician and her daughter’s consent.  She has an IABP accessed to her left groin and a temporary pacemaker on her right groin.  We had to keep her both legs straight so as not to dislodge the devices that kept her heart working effectively. But since there was already a language barrier, it was very difficult to get her cooperation and keep her calm.  Situation made it even worse because since she was in the ICU, we cannot let her daughter stay on her side as per unit policy and of course for sterility reasons.  Trying to convince her proved to be ineffective since I knew only two or three Chinese words I asked her daughter to translate for me.  Almost an hour passed and still I worry how to keep her still.  She pulled the restraints, bit her ET, and pressed the buzzer repeatedly.  At first, I felt it was all non-purposeful, that she just wants to get down her bed and go away. But then again, I realized that maybe she needed to communicate something.  So I held her hand, stayed a little bit longer than usual and noticed her closed her eyes and slept.  Afterwards, I realized I need to keep my table beside her to let her know she has company.  True enough, when she woke up, she was not rummaging on her bed anymore. To my pity, i released her restraints and gave her the idiot board as she seemed to want to write something.  On the board she wrote Chinese words, which i honestly do not understand, and drew 2 objects that seemed to be a bracelet and a bag.  So I went outside to ask her daughter about it.  Her daughter handed me an old green cloth bag and an emerald bracelet.  She even told me that it was her mom’s favourite and she never takes it off until an ER staff had to remove all the jewellery when she came to our hospital.   When I got back to her, I saw a smile glued to her face for the first time.  She wanted me to place the bag on her side and let her wear the bracelet.  I was hesitant at first, but just to appease her, I let her have them and later on asked my immediate supervisor about it.  I realized that maybe she just needed some security in the place where nobody is Chinese.  Maybe she felt safe and secured with those things close to her. Maybe she was afraid and she just needed a hand to hold in the middle of the deafening sound of the machines in the ICU. For me it was just work, but for her, probably it was an ordeal.  Everything changed the moment I put that green bag on her bed and that bracelet on her wrist.  Before I ended my shift, I waived her goodbye. But she asked me to come to her. She wrote Chinese words again (which i honestly do not have a clue). I pretended to have understood it as a thank you note so I responded with a smile and said, “You are welcome po”. As I removed the board and the pen from her hand, she reached over the pocket of her green bag and handed me a green beaded bracelet, almost same as hers.  It was overwhelming. 


Fatima Angelica Herrera

As I have shared in our UPOU portal during our discussion regarding the uses of theory in relation to our work setting, Leininger’s Cultural Care Diversity and Universality Theory is applicable in my present work. I have been working as an Emergency Room Nurse for about a year and a half now in the largest hospital in Oriental Mindoro. Mindoro, the seventh largest Island in the Philippines, is the home for the eight indigenous groups called Mangyans.  I got the chance to take care of the province’s ethnic groups with tribal names such as Alangan, Bangon, Tau-Buid, Buhid, Hanunuo, Tadyawan, Iraya and Ratagnon, each with its own language, values and customs.

There were various groups engaged in the preservation and promotion of the Mangyan cultural heritage. And in terms of their health, the local government provided them with a separate ward, called Mangyan Wing, located at the highest area of the hospital premises where hospitalization is free of charge. Additional medications are also available in the so-called German Doctors who are dedicated in helping the group.  The families of the Mangyan patients were also included in the diet list.

When I was assigned in Mangyan Wing for about a month, I was able to observe, assess and render care to our indigenous group. Outside the ward, they have a nipa hut where their families get together and chew beetle nuts (preservation and maintenance). “Nganga" or beetle nut chewing is not allowed inside the ward for the reason that we tend to paint the walls repeatedly to cover the orange tint they spit outside the window (negotiation). Instead of foam beds, we built beds made of bamboo for their comfort (repatterning). Although some of them still refuse to take a bath, some of them learned to practice good hygiene. We reward them with soaps and clothes donated by our co-nurses. And because the children’s diagnosis is mostly AGE, we provide health teachings related to proper water and food handling including hand washing and trimming of nails (restructuring). As their sign of gratitude, they give their caregivers Mangyan products like flutes, body ornaments or fruits.

Regardless of communication barriers (we use translators for those who can’t speak Tagalog and of course, nonverbally), this experience helped me grow and mature as a nurse. Leininger's Theory is truly a big help in the proper provision of holistic and culturally-congruent care.

Dennis N. Muñoz

ARMM remains at the bottom from other regions of the country in terms of health conditions of its constituents. Maguindanao is recognized lacking of sophisticated health facilities, manpower and financial support that shall cater the suppose to a more than four (4) millions population of the region. Further, the problems have been aggravated and troubled by the prevailing peace and order situation in the area.


Since July 2008, more than 300 residents of the Municipality of Buluan Maguindanao province, that have been displaced by the on-going war between the Philippine government military and the rebel forces of the Moro Islamic Liberation Front and worst case is, the internal political conflict between two dominant tyrants and lords of power in the region leading to a more troubled health condition of the locality.

Let me first describe the picture of the Filipino-Muslim inhabitants of the locale of Buluan, followed by the health and cultural implications of the muslim practices in the area, as well as theoretical application of Leininger’s theory.

Different inhabitants in Mindanao result in big differences of practices and beliefs. Discrimination is common and this happens everywhere. Despite this, Lumads, Catholic Christians, and Muslims are free to express their beliefs and practices. Lumads have not succumbed to the modern ways of living. Up to this day, they prefer to live in the mountainsides of Mindanao, living the traditional life. Their beliefs can be seen through the ornaments of every woman and the woven dresses they wear. They believe in spirits and gods. There’s a god for land, another for water, another for harvest, to name a few. For them, the mountain is sacred. Death and illness or bad faith is believed to be the god’s way of showing anger. Offering of live animals like pigs and chicken are common during tribal ceremonies for a good harvest, health and protection, and thanksgiving.

Mindanao is one large community of diverse people. Understanding one another regardless of his or her religion or belief is best because we are all children of God, each created unique. Respect, understanding, and appreciation of differences are important.

The Muslims in the locale were truly faithful and religious like Christian, believing in monotheism. The place of worship and meditation is in the mosque. Congregational prayer is traditionally done every Friday. They follow the five pillars of Islam, which requires them to pray five times a day. Another global practice of Islam is the Ramadan, where Muslims abstain from food, drink, and sex. However this practice is not binding to all Muslims; on occasions, pregnant women and old folks Muslims are exempted from doing such religiosity due to some health related reasons and as part of being adherent to the sacred words and writings in the Holy Quran. Idle Fetre is a major Muslim prayer practiced signifying the end of Ramadhan. Idle Adha is prayer and celebration practiced by muslims Hadji (referring to a male) and Hadja (referring to a woman) who went to Holy Land in Mecca.

As a nurse, it is our morale and humane act to understand cultural diversity as to the way Muslims wore clothes especially among women. Indeed, it  has major implications to their practices that women has to wear “malong”  or “abaya”,  a kind of Islamic clothing and the wearing of “hijab”- a fine veil or head dress to cover the hair, cheek and neck of a woman is a must. Therefore, it is important that male or female nurse to be very careful not to reprimand them to remove such clothes unless otherwise it interfere the initiation of care during emergency situations and or for the purpose of maintain sterility and safety.

The old  Muslim folks are considered the leader, and the source of wisdom, they are the most respected group since their influence to the tradition is so strong and inviolable. They congregate during occasions which require celebration and conventions of the elders, relatives and clans. Some Muslim traditions have health implications and ceremonial practices that have been rooted since immemorial remain a practice even up to modern days. 

To mention the few, here are some of those traditions I encountered during my period of exposure and immersion in a Muslim community of Buluan Maguindanao such as Kalilang- the form of Muslim wedding, Kanduli - a muslim ceremony that may be associated to commemoration of death or burial of their love ones; Sagayan or Bagipat - another traditional religious ceremonials and celebrations  are conducted for the purpose of driving spirits and act of healing for those who are sick, ill and spiritual possession where the officiated by a “Taligamut or the quack doctor”; Mauludin Nabhi – this is a time Prophet Mohammad announced to his followers of faith in Islam where all young Muslims have to baptized, this is called “Antiyak or Tabungawan, as mentioned in their local dialect,” accompanied by circumcision among young males. Therefore, circumcision has its religious significance as part of tradition and for the purpose of health and sanitation.

The traditional health faithful and practitioners remain another challenge on my part as community health nurse and as DR Nurse before. Let me compare Modern day western Medicine man from a traditional practioner and their corresponding designations as traditionalist practioner:

Taligamut” -  A male quack doctor
Walian” – a female midwife or a nurse
Pakayan or Duka” – a Witch who makes love potion, magic spells and witchcrafts
Pagalamatan” – clairvoyant, mystic or fortune teller

Implications of knowing the patients culture as sited from above examples

         Transcultural nursing helps heighten my awareness of ways in which  Muslim- Maguindanaon clients integrate faith and health system to work and take effect the desired action for which they are intend to practice. There are ways or practices which the nurse may perceive as exactly dangerous or may endanger the life of the client if we are to refer the acts from western medicine concept. one might say it is truly stepping beyond the point of the health care system, but it is therefore the initiative and effort of the nurse to identify the strength and limitation of such act provided, it doesn’t interfere or endanger the life of the client in general, so they may continue to evolve do such act.

          I learned to foster understanding, respect and appreciation of such unique individuality and diversity of patient’s beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome. Refer how they integrate the developmental patterns of every individual young muslim is relative to religious reference. Example, Circumcision is patterned with religious celebration Mauludin Nabhi . Sensitivity to practicing midwifery and nursing should also be considered, like the case of the Walian or the traditional birth attendant is also one factor which sometimes cause of “most disagreements of practices in the Rural health unit”, especially woman who gave birth in the far countryside.  What the modern medicine can offer to these traditional birth attendants is to teach them the proper and safe process of handling a baby during labor. Nowadays, traditional birth attendants are encouraged to help the women and assist during delivery at the RHU providing comfort and assistance during post partum.

        To sum up, Identifying religious and cultural difference strengthen my commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply more to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.


Flor Kenneth Alobin


I am presently working in a review center and am connected with the local government unit as a barangay kagawad in our municipality. I find myself working in the company of different types of people- with different beliefs, attitudes and backgrounds, with different ages, demographics and status. I encounter multitudes of personality day in and day out.
 
As the chairman on health and social services, I organized and facilitated our barangay’s health programs such as medical missions, health education and information drives. With health as one of my advocacies, I spearheaded the voluntary blood donation program last February which was participated by our constituents, barangay health workers and volunteers.
 
During the preparation, I was so overwhelmed by the reactions of different sectors in our community. Our volunteer workers who are distributing flyers were approached by a group of Jehovah’s Witnesses who started questioning our activity. A group of mothers were hesitant and were apprehensive regarding blood donation.  There were also other constituents who were so naive and innocent, who presented several myths.
 
I encountered this individual who complained that he would contact a disease, once he donates blood. There were closed-minded individuals. There were pessimists as well.
 
I have this volunteer worker, a member of the Seventh Day Adventist who would not report for the activity because it falls on a Saturday.
 
But despite the differences in opinions, the activity was a success. We educated and imparted people of the importance of blood donation. We presented several scenarios and medical conditions needing blood transfusion during times of emergency, disasters, and epidemics. We also provided an avenue for open-forum and clarification before we started our activity. We respected these differences in background, ideas and beliefs.

Wherever we go, we will encounter scenarios like these. In the different nursing settings, be it in the company, hospitals, communities, and organizations, we encounter differences in cultures. But this doesn’t mean that we need to know each and every culture. However, we need to be sensitive to cultures that are different from our own. We live in a world where people of different cultures are working together. 
By respecting and understanding various cultures, we will be able to succeed together as an organization, as a community, as a family and as an individual in this multi-cultural world.


Gayzell A. de Jesus

It is inevitable to deal with patients from various culture and background since I am serving in a tertiary referral hospital.  As early as our general orientation period, we were briefed on the number and range of the clientele we will be offering our services to, being The National University Hospital.  UP-PGH caters to almost all known medical cases in the Philippines and is open to people from all walks of life.  To be able to adapt to different cultures and ways, we make sure that during our initial interview during admission, we ask for their idiosyncrasies, practices and beliefs and tell them they can still continue those even while admitted.

Working as a nurse in the Rehabilitation Medicine Ward has taught me to be adaptive, patient and understanding.  Sometimes, there is a need to really be in our clients’ shoes to feel, know and understand the things they are going through.  I remember a patient I had.  He was an Aeta with spinal cord injury which he sustained while foraging.  Aside from the fact that he only speaks his dialect, he is not used to wearing slippers, bathing in a bathroom and eating with utensils.  Good thing, the American missionary who brought him to PGH their dialect so we were able to communicate with the client through him.  It posed a challenge for us nurses to make him follow the ward regulations and follow aseptic techniques especially when we were training him for self straight catheterization since he was having urinary dysfunctions.  In the end, we met halfway.  We devised ways for him to learn proper techniques and taught him tips on how he can still do catheterization aseptically even as he goes back to his native.  Resourcefulness and openness were key to meeting our goals for the patient.  We also had a Papua New Guinea native who was admitted for prosthesis training.  At first he was aloof and shy and didn’t talk much.  Since I was his nurse in charge, I sat with him and talked to him.  I found out that he was bothered because people kept looking at him because he had dark skin and is missing a leg.  Although I still had other things to do, I interacted with him and asked him to tell me about his country to establish rapport and gain his trust.  Eventually, he began to open up with other staff and other amputees.  He was discharged happy with his new prosthesis and gave good regards to the services given to him.

At the end of the day, I realize that maybe, care is the universal language.  It transcends different cultures and backgrounds and still has the same message-you care.

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REFERENCES

Books

B. T. Basavanthappa. (2007) Nursing Theories. India

Eufemia Octaviano, RN, RM, MN, EdD and Carl E. Balita, RN, RM, MAN Theoretical Foundations of Nursing: The Philippine Perspective

Jacqueline Fawcett. (1993) Analysis and Evaluation of Nursing Theories

George Julia B. Nursing theories: The base of professional nursing practice 5rd edition. Norwalk, CN: Appleton and Lange; 2002.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing. McGraw-Hill, Medical Pub.

Leininger M. Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Pres; 1991. 

Leininger M.Transcultural nursing: Concepts, theories, research,and practice. Columbus, OH: McGraw-Hill College Custom Series; 1995.

Leininger, M., McFarland,M. 2006. Culture Care Diversity and Universality: A Worldwide Nursing Theory 2nd Illustrated Edition. Jones & Barlette Learning, 2006

Sitzman,K. and  Eichelberger,L. W. (2011). “Understanding The Work Of Nurse Theorists: A Creative Beginning.2nd edition. Jones and Bartlett Publishers, LLC

Tomey, A. & Alligood, M. (2006). Nursing Theorists and their Works. Mosby, Inc.


Journals/Dissertations

Leininger, M. Journal of Transcultural Nursing, Vol. 13 No. 3, July 2002 189-192 (2002). Sage Publication.

Culture Care Theory: A Major Contribution to Advance Transcultural Nursing Knowledge and Practices, Madeleine Leininger, PhD (Journal of Transcultural Nursing, Vol. 13 No. 3, July 2002 

Professional and lay care in the Tanzanian village of Ilembula, A Dissertation by Anitta Juntunen, September 21st, 2001 


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