Establishing a strong theory of practice often requires consideration of theories from a multitude of disciplines, folding the strengths of each theoretical perspective into a cohesive whole (Barnum, 1998; Leininger, 1988). Madeleine Leininger's theory of care and nursing is a prime example of how knowledge taken from one field can synergistically benefit another (Leininger, 1988). In her early clinical practices, Leininger recognized the influence that various cultural orientations could have on nursing practice and the construction of nursing knowledge (Leininger, 1988). In the early 1960s, Leininger worked with the Gadsup people of New Guinea (Leininger, 1988). Her experiences there helped her research and formulate a theory on ethnonursing (Leininger, 1988). Through the construction and evolution of an elegant medley of theory and knowledge from the fields of nursing and anthropology, Leininger realized it was possible to significantly enrich approaches to patient care (Leininger, 1988).
Definitions Related to Theory
Any discussion of theory can quickly become esoteric and vague without a clear understanding of the terms related to theory and the interpretable definitions of the main elements and constructs of the particular theory undergoing review (Tomey & Alligood, 1998). This section on definitions which are related to theory are intended to guide the reader past the fundamental structure of theory to the important and interesting aspects of Leininger's theory of care and nursing (Leininger, 1988). Leininger defined culturally competent care as "those appropriate actions or decisions related to: (1) Culture care preservation or maintenance; (2) culture care accommodation or negotiation; (3) culture care repatterning or restructuring which fit with or are specifically tailored to meet the clients' needs in order to improve or maintain their health and/or well-being or to face death or disabilities" (Leininger, 1997).
Theory. This refers to an abstract generalization that provides a rational, systematic explanation or prediction about the relation among certain phenomena (Highfield, 2010).
Paradigm. This term refers to a worldview or a particular shared set of beliefs, values, concepts, and theories that is typically held by a group, and often a professional group; notably, the term distinguishes those elements that are true for a scientific discipline at during one particular period of time. In other words, a scientific paradigm is a "universally recognized scientific achievements that, for a time, provide model problems and solutions for a community of researchers" (Kuhn, 1996),
Concept. This refers to an abstraction based on certain common attributes or behaviors (Highfield, 2010).
Proposition. This term refers to a statement of the relationship between concepts (Highfield, 2010).
Conceptual model or framework. This refers to an assembly of interrelated concept based on a rational scheme structured according to the relevance of the concepts to an overarching theme (Highfield, 2010).
Nursing. "Those functions…which help people cope with difficulties in daily living which are associated with their actual or potential health or illness problems or the treatment thereof which require a substantial amount of scientific knowledge or technical skill" (California Nurse Practice Act, n.d.)
Ethnonursing. This refers to a qualitative, inductive nursing research method used to describe, explain, and interpret the worldview, meanings, symbols, and life experiences of the informants (subject-participants) in an ethnographic (naturalistic, in situ) study (Highfield, 2010).
Leininger's model expresses a unique and particular paradigm that makes certain assumptions regarding the meanings of terms. These metaparadigm concepts are defined below:
Care. This term does not refer to health, specifically, as the construct health is used in many disciplines and is not distinct to nursing. This term "refers to abstract and concrete phenomena related to assisting, supporting or enabling experiences or behaviors toward or for others with evident or anticipated to ameliorate or improve a human condition or lifeway" ("Cultural Diversity," n.d.).
Caring. This term does not refer to nursing, per se, but it does provide the highest explanation for nursing. This term "refers to actions and activities directed toward assisting, supporting, or enabling another individual or group with evident or anticipated needs to ameliorate or improve a human condition or lifeway, or to face death" ("Cultural Diversity," n.d.).
Culture. This term refers to the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guides their thinking, decisions and actions in patterned ways" ("Cultural Diversity," n.d.).
Cultural care. This term "refers to the subjectively and objectively learned and transmitted values, beliefs and patterned lifeways that assist, support, facilitate, or enable another individual or group to maintain their well-being, health, to improve their human condition and lifeway, or to deal with illness, handicaps, or death" ("Cultural Diversity," n.d.).
Cultural care diversity. This term "refers to the variabilities and/or differences in meanings, patterns, values, lifeways, or symbols of care within or between collectivities that are related to assistive, supportive or enabling human care expressions" ("Cultural Diversity," n.d.).
Person. The use of the word person is taken in this model to extend beyond an individual patient or an individual client to families, groups, and communities (Highfield, 2010).
Environment. This term refers to events that are assigned meanings and interpretations in cultural, ecological, socio-political, or physical settings (Highfield, 2010).
Cultural care diversity and universality theory. Leininger begins with the assumption that there will be differences and similarities or commonalities in approaches to care across cultures (Highfield, 2010). The focus of Leininger's culture care theory is broad, encompassing the care of individuals, families, groups, communities, cultures, and institutions (Highfield, 2010). The underlying theoretical construct of Leininger's work is that care is the essence of nursing and functions as a distinct, central, and unifying force for the practice and the construction of nursing knowledge (Highfield, 2010).
Leininger's work fundamentally refutes four paradigms of nursing (Highfield, 2010). She extended the definition of nursing beyond that of nursing, in and of itself (Highfield, 2010). Doubtless having been influenced by her work in tribal settings, Leininger determined that the notion of person was too limiting in care and nursing and, if it must be used, it should refer to families, groups, and communities at the same time that it referred to individuals -- this primarily because in some cultures, these human classifications are inextricable (Highfield, 2010). Further, Leininger asserted that the word health does not express the essence of nursing as well as the word care does (Highfield, 2010). Moreover, she argued that "There could be no curing without caring but caring can exist without curing" (Leininger, 1991).
Leininger's Sunrise Enabler
Leininger developed a tool called the Sunrise Enabler (See Appendix I) that serves as a conceptual guide or cognitive map that can be used by nurses in order to conduct a systematic study of all the elements and dimensions of the theory of care and nursing (Highfield, 2010). By using the Sunrise Enabler, nurses and care providers can avoid having a focus just on the presenting medical problems, and avoid a fragmented view of the client (Highfield, 2010). Instead, the Sunrise Enabler encourages care providers and nurses to see all the many important variables that affect patients (Highfield, 2010).
Leininger's rationale behind the development of the Sunrise Enabler was that and similarities in the culture of care occur between patients and nurses in all human cultures and societies worldwide (Highfield, 2010). It is possible, according to Leininger, to engage in culturally congruent nursing care when the care values, care expressions, and care patterns of individuals, groups, families, communities, or institutions are known to care providers and used explicitly in appropriate and meaningful ways (Highfield, 2010). Culturally congruent care can be achieved when nursing actions are planned and implemented within three frames: (1) Culture care preservation and maintenance; (2) culture care accommodation and negotiation; and (3) culture care repatterning and restructuring (Highfield, 2010).
The visual representation of the Sunrise Enabler model is structured like a rising sun ("Cultural Diversity," n.d.). The nurse using the Sunrise Enabler can begin virtually anywhere on the diagram to focus the nursing assessment ("Cultural Diversity," n.d.). Different worldviews are represented in the diagram and configured along cultural and structural dimensions ("Cultural Diversity," n.d.). These cultural and structural dimensions include "technological, religious, philosophic, kinship, social, value and lifeway, political, legal, economic, and educational factors ("Cultural Diversity," n.d.). All of these cultural and structural systems have the potential to affect health and the provision of health care ("Cultural Diversity," n.d.). The cultural and structural systems impact the language and symbols used to represent worldviews about health and health care, as well as the environments in which patients and clients live and receive care ("Cultural Diversity," n.d.). Both formal professional health systems and folk health systems are represented in the model, since it is the combination of the two that "meets the biological, psychosocial, and cultural health needs of the patient/client" ("Cultural Diversity," n.d.).
All patients have experiences and concepts of care that stem from lay practices, generic practices, and folklore, all of which pre-date professional nursing care (Suh, 2004). In America, for instance, the broader society consists of many discrete groups that have their own cultural values, identities, and contexts…