22
Vadeleine M. Leininger:

Theory

Or Culture Care Diversity
and

Universality Madeleine M. Leininger
(1927-2012)

Marilyn R. McFarland*

are is the essence of nursing and a distinct,
dominant, central

and unijying focus.

Madeleine Leininger (Leininger
&McFarland, 2002, p. 192)

CREDENTIALS AND BACKGROUND
nursing at this university’ Vith the Therapeutic
n Psychiatri Nursing Center at their hospital. In 1960, she

bte one oi
OF THE THEORIST

g ent
was pub-

in Nursing, which
lished in 11 languages (Hofling & Leininger, 19601

the first basic psychiatric irsing texts with Hofli

tled Basic Psychiatric Concepts
Madeleine M. Leininger, the founder of transcultural

nurs-

ing and a leader in transcultural nursing
and human care

theory, was the first professional nurse with graduate preP-
aration in nursing to hold a PhD in

cultural and social

anthropology. She was born in Sutton, Nebraska, begin-

ning her nursing career after graduation from
St. Anth0

ny’s School of Nursing in Denver, Colorado,
and the U.s.

Army Nurse Corps with a diploma in nursing.
In 1950, she

earned a bachelor’s degree in biological science from
Bene-

dictine College in Atchison, Kansas, with a minor in phi-

losophy and humanistic studies. She then served
as an

instructor, staff nurse, and head nurse on a medical-surgi

cal unit and opened a new psychiatric unit while
director

of the nursing service at St. Joseph’s Hospital
in Omaha,

Nebraska.

While working at a child guldance honme in the .

staf
1950s in Cincinnati, Leininger discovered that ths
lacked understanding ot cultural factors influencia ng the behavior of children. Among these children of diverse cul
tural backgrounds. she observed difterences in responses
to care and psychiatric treatments that deeplycon concerned

her. Psychoanalytical theories and therapy strategies d
not seem to reach children who were from diverse cultund

backgrounds. She became inereasingly concerned that her
nursing decisions and actions, and those of other staf, did
not appear to help these clhildren. .eininger posed ques.

tions to herself and the st.afl about cultural differences

among children and therapy outcomes. She found few staf
members who were interested or knowledgeable abou

cultural factors in the diagnosis and Ireatment of clients. A
short time later, Margaret Mead became a visiting proles

sor in the Department of Psychiatry, University of Cincin
nati, and Leininger discussed with Mead the potental

interrelationships between nursing and anthropol0gy

During the 1950s and 1960s, Leininger (1970, 1978) tden
tihed common areas of theory interests and researcn u

between the disciplines of nursing and anthropolog), w

aided her in formulating
transcultural nursing concep

theory, principles, and practices. As a doctoral
student, Le

In 1954, Leininger obtained her master’s degree in psy-

chiatric nursing from the Catholic University of
America

in Washington, DC, and was then employed by the College

of Health at the University of Cincinnati, Ohio, where she

developed the first masters-level clinical specialist pro-

gram in child psychiatric nursing.
She initiated and

directed the first graduate nursing program in psychiatric

*This chapter is dedicated in memory of Dr. Madeleine Leininger.

Dr. Madeleine Leininger on a visit to Madonna University, Livonia,

MI, circa 1999. Source: The Madeleine M. Leininger Collection on
Human Caring and Transcultural Nursing, ARC-008, Photo 03, Ar-
chives of Caring in Nursing, Florida Atlantic University, Boca Raton.

fasc

nger studied many cultures. She found anthropolog
terest to

nating and believed it was an area that should
be Or Inc

334

adeleine M. Leininger: Theory of Culture Care Diversity and Universaity
CHA

ER 22 Made 335

on the iadsup people ot the astern nternational Society tor lluman Caring in 1978 0 hely
nirses toeus on the study ot human care plhenea
Leininger. 1988a, 19ssh, 199), She was the tiust tull tine
president ot the American Association ot Colleges ot Nins

ng and one of the tirst members ot the American Acaley
ot Nursing in 1975.

New Gunnea:

living alone with these ndige

th vears, she undertook an ethno
She

to
tUsCNÍ

on
the (

irsing study in the villages (leininger

hserved the unique teatures of the cl

lber ot nmarked
ditterences between 1West.

in tern cultures
related to caring. health, and

i es. Fron her in-depth
study and tirst

the iadsup. she continued to

einger’s book, Nursing and Anthropologr: Tvo
Worlhis

to Blend (1970), laid the toundation for developing the fiell
of transculural ursing. the culture care theory, and eu
turally based health care. Her next book, Tanseultra
s: Concepts, Theories. and Practice (1978), icdentilied
major concepts. theoretical ideas. and practices in transe
tural nursing and was the first detinitive publication on

transcultural ursing. During tlhe next o0 years. Leininger
established, explicated. and used the culture care theory lo
study many eultures in the United States and worldwide.
She developed the ethnonursing research method to lit an
to be used with the theory and to qualitatively discover the

insider or emie view of cultures (1cininger. 1991: 1cininger
&Metarland, 2002, 2006: Mctarland & Wehbe Alamah.
2015b, 201isb). lhe ethnonursing research method was the

frst open inquiry research method designed tor nurse

researchers to study and discover culture care phenomena

from the perspective of human science philosophy an
through the lens of qualitative analysis (Leininger, 1978.
1985a. 1991, 1995; Leininger & Meliarland. 2002, 2000;
Mclarland &Wehbe-Alamah, 2015b, 2018b).

ricnces with

er
theory

ot
culture

are
theory)

and the.

re care diversity and universality

ethnonursing researeh method

1978
1991. 1995 Her esearrh

and theory have
ditferences i

ursing

ents
understand cultural

ealth, and illness. Sh was the major

iet to
endOUrAge

Nnim ients and taculty to0
education nd practice. Her

Ndder to

Tute nursins

interest in developiung
the tield ot transeul

a human care
tocus sustained her tor

arsing with

than six decades.

in transeultural nursing was ottered in

the l’niversity
ot Color. where leininger had

amointed Protessor
ot Nursing and Anthropology.

he
turst

course
in

itiatei the
Commi on Nursing and Anthropology

the American AnthropologUal
Association in 1968

ed as its chair tor
several vears (Leininger, 1991,

Leininger also
initated and served as the director of

st Nurse
Scientist Program (PhD) in the United

s when.
in 1969, she was appointed Dean and Profes-

T o Nursing and
Lecturer in Anthropology at the Uni-

NiY of Washington, Seattle,
where she remained until

There she established the first academic nursing

nartment on comparative nursing care systems to sup-

urt master’s and doctoral programs in transcultural
nurs-

ng She initiated several transcultural nursing courses and
nentored the first nurses in a PhD program with a tocus

m transcultural nursing. Under her leadership, the Uni-

Ersity of Washington was recognized in 1973 as the out-
Sanding public institutional school of nursing in the
nited States.

ln 1981, Leininger was appointed Protessor ot Nursing

and Adjunct Protessor of Anthropology and Director of
Transcultural Nursing and also Director ot the Center tor

Health Research at Wayne State University in Detroit until
her seni retirement in 1995. Dr. Leininger developed sev-
eral transcultural nursing courses and seminars tocused on

caring and qualitative research methods tor baccalaureate,
master’s, doctoral, and postdoctoral nursing and nonnurs-

ing students. She also mentored many
students and nurses

in transecultural nursing tield research and continued these

endeavors at various universities in the United States and

worldwide. In 1989, Leininger launehed the Journal of

Transcultural Nursing, serving as its tirst cditor until her In 1974, Leininger was appointed Dean and Professor ot
ursing at the College of Nursing and Adjunct Professor of
Athropology at the University of Utah in Salt Lake City.

S institution, she initiated the first master’s and doc-
rograms in transcultural nursing and established the
Octoral program offerings at this institution (Leini-

retirement.

Leininger wrote or edited more than
30 books in her

lifetime and published more than 200 articles and 45 book

chapters plus numerous tilms, videos, 1DVDs,
and research

reports focused on
transcultural nursing; human care and

health phenomena; the tuture of nursing: and
related topics

relevant to nursing and anthropology. During
her career,

Dr. Leininger served on eight editorial
boards and refereed

several publications and was actively
involved with the

Transcultural Nursing Scholars Group and
the development

of and contributions to her
own website (www.madeleine

-leininger.com). She has remained
known as one of the

oter Substantive courses focused specifically on transcul-
nger, 1978). These prog ograms were the first in the world to

974, nger founded the 1ational Transcultural
Nursing and remained an active leader in the orga-

R ng She also initiated and was director of a new
nfacilitation office at the University of Utah. In

nroughout her lifetime. She also established the zation

theory, research rch, onsultatio
UNIT IV Theories

andGrandTheories

and care writings,

nost crcative, productive,
innovative,

and
futuristic

research-based nscultural nursing
content

and ideas
to

honors for
her lifetime professional

plishments, including

include an
LHD from

Kansas; a
PhD from the University of

ege

a DS from
the University of Indiana.

many aNards and and academicand
dynamic

addresses. She received

authors in nursing who provided
new

and
substantive

several hono
Benedictine

N degrees ha

College in Achisn advance nursing as a discipline and a professi1On.
n addition to theory development

and transculurd

nursing. Leininger had many lifelong
areas of interest

and

CpertisC, including comparative
cducation and adminis

ration; nursing theorics; politics;
ethical dilemmas or

rsing and health
care; qualitative research

methods; the

uture ol nursing and
health care; and nursing leadership

As a certihed transcultural nurse
and rescarcher,

Leininger

studied 15 individual and unique cultures;
mentored or

superised approximately 200
master’s and doctoral

stud-

es focused on transcultural nursing.
human caring/care,

and related areas worldwide: and
consulted with many

opio, Finlads a
Indianapolis. In 197% aue and sigpi And and 1995, she was gnized for her he American Asse

of Nursing as its first all-time president.i
the Russell Sage standing Leadership

Anthropology So ciety, fellow

iation of C
eininger r

cant
contribution to the

recevetin 19 and was a fellow in the American Acaderard of
iursing, a fellow of the

American

Society for Applied Anthropology, and a fellow o
e Royal

College of Nursing in Australia. Other affliatliationsGamma, and Scandinavian College of
Sweden. She

served as a

included Sigma Theta Tau; Delta Kappa

Caring Science he in Stockhrrescarchers and institutions, especially
those using her

culture carc theorv. Her culture care theory is
used world-

Wide and continues to grow in relevance
and importance

Tor the discover of culture care phenomena
about diverse

cultures.

distinguished visiting scholar
lecturer at 85

universities in the United

World.wide and was a VISiting professor at n
and

overseas
w

Wayne State Univer.universities. While at
the Board of Regents Distinguished aculty
Distinguished Research Award

in Teaching, and
the Outstanding Graduate

tor Award. In 1996,
Madonna

igan, honored
her with its dedication of the I

Collection and a special Leininger Reading Ra
outstanding contributions to nursing and the

ences and humanities. Leininger was honored as
Legend of the American Academy of Nursing in 1998

Dr. Leininger’s last works on the culture care the heory
were publications in peer-reviewed professional Durnals.
She co authored an interview for Nursing Science O

terly (Clarke et al., 2009) in which she discussed the hit

sity, she eceived
Leiningcr lectured to anthropologists,

physicians, social

workers. pharmacists, and educators, and
conducted research

with colleagues. She remained active in
two disciplines and

contributed to nursing and anthropology
at national and inter-

national transcultural conferences and association meetings.

Award, the the Presidents Excelence
aculty Men- iversity in Livonia, Mich.

ger Book
ing Room for her

Leininger worked to persuade nursing educators
and practi-

ioners to integrate transcultural nursing
and culture-specific

care cocepts based on research findings into nursing
curri-

cula and clinical practices as critical for
the future of all

aspects of nursing. Across seven decades
of the discipline,

numerous nurses with doctoral degrees and many master’s

and baccalaureate students have become certified in
transcul-

SOcial sc

tural nursing. using Leininger’s culture care theory through-
out their work (Leininger, 1991, 1995; Leininger& McFarland,
2002. 2006; McFarland & Wehbe-Alamah, 2015a, 2018b).

Leininger established transcultural nursing
courses and

programs to educate, conduct, and
facilitate research about

transcultural nursing and health phenomena. As
interest in

transcultural nursing and health care grew, Leininger (M.
R.

McFarland, personal communication, 1996) delivered key-

note addresses annually and conducted workshops and
consultations both nationally and internationally through-
out her career. Her academic vitae included nearly 600
conferences, keynote addresses, workshops, and consultant
services in the United States, Canada, Europe, Pacific Island
nations, Asia, Africa, Australia, and the Nordic countries.

Educational and service organizations continued to request
her consultation on transcultural nursing, humanistic car

ing, ethnonursing research, the culture care theory, and
futuristic trends in health care worldwide.

Dr. Leininger gained international recognition in nurs-
ing and related fields through her transcultural nursing

tory and future of transcultural care, the irsing

profession, and global health care. In 2015, she te

about her retrospective comparative study conducted in
2011 about three Western and one non-Western culture

(Old Order Amish Americans, Anglo Americans, Meai
can Americans, and the Gadsup of the Eastern Highlands

of New Guinea) to obtain in-depth knowledge abou
father protective care beliefs and practices with the god

to use that knowledge to provide culturally congruent

care (Leininger, 2015). She reported on culture care deci-
sion and action modes of similar and diverse care findings

discussed with the informant fathers as potential ways
they might integrate their cultural values and care prac

tices to help their sons. Leininger then began
work on d

new culture care construct, collaborative care, which sik

Co-presented with Marilyn McFarland via a keynotevu

eocast at the 37th Annual Conference of
Transculturi

Nursing Society in October 2011.

Aoleine M. Leininger: Iheory of Culture Care Diversity and Un
cHAPTER22 Ma

CH

nger died peacefully on August 10,
e Leininger.

ohraska. She continued to work until

337

002, 2006; McFarland & Wehbe- Alamah, 2015a, 2018D)
ninger predicted that for nursing to be meaningful ana
Terevant to clients and other nurses in the world, transcu
al nursing knowledge and competencies would be impe
Ve to guide all nursing care decisions and actions To

Cective and successful health outcomes (Leininger, 199

1996 Leininger & McFarland, 2002, 2006; McFarland

maha, Nebra

Ilaborating with colleagues on eoreher
strbons lo seve eral projects

and publications in
ongoing

legacy is her work
prog-

on the
einingers

re diversity and universal and in the

nursing that will continue to
transcultural

of culhurec

yiet those

roughouther,

m she
has mentored taught, and influ- m ijine of

accomplished career.
& Wehbe-Alamah, 2015c, 2018b).

inger (2002a) distinguished between transcultural
g and cross-cultural nursing, The former refers to

nurses prepared in transcultural nursing who are prepareuand committed to develop knowledge and practice n
ranscultural nursing, whereas cross-cultural nursing rerers
O nurses who use applied or medical anthropological con-
Cepts instead of developing transcultural nursing theory
and research-based practices (Leininger, 1995; Leininger &
McFarland, 2002, 2006; McFarland & Wehbe-Alamah,
2015a, 2018b). She also identified international nursing
and transcultural nursing as different. International nurs-
ng occurs when nurses travel to or have nursing practice
or service-learning experiences in other nations or coun-
tries; however, transcultural nursing involves multiple cul-
tures and has comparative theoretical and practice base
foci (McFarland & Wehbe-Alamah, 2015, 2018). Leininger
described the transcultural nurse generalist (now known
as certified transcultural nurse-basic or CTN-B), as a nurse
prepared at the baccalaureate level who is able to apply
transcultural nursing concepts, principles, and practices
that are generated by transcultural nurse specialists (Leini-
nger, 1991, 1995; Leininger & McFarland, 2002, 2006;
McFarland & Wehbe-Alamah, 2015, 2018). The transcul
tural nurse specialist (now referred to as a certified trans-

cultural nurse-advanced or CTN-A) is prepared in graduate
programs and receives in-depth preparation and mentor-
ship in transcultural nursing knowledge and practice. The
CTN-A has acquired competency skills through post bac-

calaureate education by having acquired research-based
knowledge about selected cultures in sufficient depth to
provide high-quality, safe, and effective transcultural nurs-
ing care (McFarland & Wehbe-Alamah, 2015, 2018). The
transcultural CTN-A therefore serves as an expert practi-
tioner, teacher, researcher, and consultant with respect to
select cultures. The CTN-A specialist values and uses nurs-
ing theory to develop and advance knowledge within the
discipline of transcultural nursing, the field Leininger pre-
dicted must be the focus of all nursing education and prac-
tice (Leininger, 1991, 1995; Leininger & McFarland, 2002,

TICAL
SOURCES FOR THEORY

EORETICAL

ENTELOPMEN

aer’s
theory

was derived from the disciplinesof

ology and. 2002, 2006; Mckarland & Wehbe-Ala-
and nursing

Leininger, 1991, 1995; Leini-

2015a,
20186).

She described

nursing focused on the comparative studv

fdiverse cultures
and subcultures worldwide

atiyolog

transcultural nursing as

nhaior

area

of r

e to their caring values, expressions, and health sth respect te
and patterns

of. behavior.
e of the theory is to discover human care

ness beliets a

he purpose

.and universalities in relation to worldview, cul-
d ial structure dimensions, and then to discover

turally congruent care for people of to providecultur

frent
or similar cultures

to maintain or regain their

ing or
health or to face death (Leininger, 1991,

t-being

e:
Leininger

& McFarlan 2002, 2006; McFarland &
Alamah, 2015a, :018b). The goal of the theory is to

oVe and to bvide culturally congruent care to people

is beneficial and will ft with and be useful to the client,

mt: or cultural group (Leininger, 1991, 1995; Leininger
afarland, 2002, 2006; McFarland & Wehbe-Alamah,
.2018). Transcultural nursing goes beyond an aware-
state to one of using culture care nursing knowledge

ractice culturally congruent and responsible care

McFarland&Wehbe-Alamah, 2015c, 2018b).

Leininger stated that, over time, there would be a new
nd of nursing practice that reflects diverse nursing prac-

is that are culturally defined, grounded, and specific to
lide nursing care provided to individuals, families, groups,

ad institutions. She contended that because culture and
e knowledge are the broadest and most holistic means to

cptualize and understand people, they are central and
mperative to nursing education and practice (ILeininger,
91, 1995; Leininger & McFarland, 2002, 2006; McFarland
Nehbe-Alamah, 2015c, 2018b). In addition, she stated
anscutural nursing had become one of the most impor
a1, relevant, and highly promising areas of formal study,
5arch, and practice because people live in a multicultural

UI(Leininger, 1988a, 1995; Leininger & McFarland,

2006; McFarland & Wehbe-Alamah, 2015, 2018).
Leininger (1996) promoted a new and different theory

from traditional nursing theories that defined theory as logi-
cally interrelated concepts and hypothetical propositions to
be tested for the purpose of explaining or predicting an event,

338 UNIT IV Theories and Grand Theories
tory, and the evironmental

ehomenon, or situation. Instead. Lcininger
defined theory

as the s’stematic and creative discovery ol knowlcdge
about

a domain of interest inmportant to understand
or account for

SOmc unknown phenomenon. She belicved nursing
theory

must lake into accoun creative discovery
about individuals,

1amilics, and groups,
and their caring. values, cxpressions,

belicts, and act ions or practices
based on their cultural life-

71 to providc eltective, satislfying,
and culturally congruent

care (1 cininger. 1991.
1995; Icininger & McFarland,

2002,

O6: Allarland & Wehbe- Alamah, 2015a,
2018b).

I cininger (199) developed
her theory of culture care

divcrsitv and universality bascd on the belief that people
of

dilerent culures can intorm and are capable of guiding

protessionals to receive the kind of carc they desire or need
trom others C1lture is the pattcrned and valued lifeways of

people that intlucnce thcir decisions and actions; therefore,

the theor is directed toward nurses to discoverand
docu-

ment the world of the clicnt and to use their emic (insider)
icpoints, knowledge. and practices with appropriate etic

(outsidcr). as bases for making cullurally congruent profes-
sional care actions and decisions (Leininger, 1991, 1995).

The culture care theory can be both inductive and

deductive and is derived from both emic and etic knowl-

Contex abstract and practice dimensione
that can

Tho he theay Ch tematically to achieve culturally congruent be exanine
2015a,c, 2018b). It is the onlv
focused on culture and care of

three theory-based culture care

acceptable care comes (McFarland & w it is possib
care becaus

derived fro

Wehhe in nur
ethnonUrsi

heoare
ou

or

peoAiyerse and
what is

se

culluremodes ol deciiactions that are rectly applicable in clinical reaching beneficial
and satisfactory lifeways
ultimately discover care-what is
sally related to care and
parative focus to discover different

nursing care practices

document,
through he

generic an

(Leininger,

Leining

to support
of the

pracliceebeng, e thcory
health-and has an

integrate or contrastin with specific care based carin nursings co
ory with the onursing method has ramalconstructs iep

nes

na
beneficial care

tease out in-depth infor

information. Thus, these enablers
tural health care assessments.

eration of new knowledge in nursing:

nant emic data and
healh

he enablers
first reason

ment, and s-
the human

reason 1S to

construct or

sed
also be u

. The theory can
at culturally congruent, neaningful, and t

uide he d health care t
edge and th-

ferent cultu

(Leininger, 1

McFarland &
knowledge i

promote the

or disability,

over time (Le

USE OF EMPIRICAL EVIDENCE

hat care
For more than six deca Leininger held

dominant, distinc
cdge (1991. p. 33). Leininger (1991) encouraged nurses and
others to obtain grounded emic knowledge fronm the pe0-

ple or ulture because such knowledge is more
credible.

The theory is ncither a middle-range nor macro theory but

must be viewed holistically with specific domains of inter-

cst. Leininger bclieved the terms middle range
and macroo

to be outdated in theory development and usage (Leini-

nger. 1991, 1995; Leininger & McFarland,
2002, 2006;

McFarland & Wehbe-Alamah, 2015, 2018). Indeed, the
culture eare theory is the broadest holistic nursing theory,
because it takes into account the totality and holistic per-

spective of human life and existence
over time, including

the social structure factors, worldview, cultural history and
values. environmental context (Leininger, 1988b), language

expressions, and folk (generic) and professional
care pat-

terns. These are some of the most critical and essential

essence of nursing and the

ve, and ing feature of nursing (Leininger, 1970, 1988b.nger& McFarland, 2002, 2006; McFarland Nehbe that care is comnpleoften embedded in social structure and other
2015, 2018). She stated

fession needs

holistic cultuz

ture (Leininger, 1991; Leininger & McFarland
held that diferent forms, expressions, and Dat
were diverse, whereas Some were universal ( s f
Leininger & Mckarland, 2002, 2006). Leinino

meanings of a

1991, 1995;

land & Weht

1995) found

asp

often embedd

quali
1990; Leininger & McFarland, 2002, 2006) usei

care.
ethnomethods, especially ethnonursing, to study

:ople-tr.
methods are directed toward discovering th