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Cultural Healthcare

Madeleine Leininger’s Culture Care Diversity and Universality Theory

Kathie O’Dell

Concordia University


Madeleine Leininger was born in 1925 in Sutton, Nebraska. She graduated from a Diploma

Nursing program at St. Anthony’s School of Nursing in Denver, Colorado, and then went on to

receive a Bachelor’s of biological science with a minor philosophy in Atchison, Kansas. She

worked as an instructor, staff nurse, and head nurse in medical surgical unit, until she opened a

new psychiatric unit and was the director of nursing at St. Joseph’s Hospital in Omaha, NE. Her

background in child psychology helped her to realize that there was a lack of understanding

among staff related to cultural factors. She noted differences in responses to treatment from

children who had different cultural backgrounds. She return to school to study these

differences and received a doctorate from the University of Washington, and began teaching

the first ever course of transcultural nursing at the University of Colorado in 1966. Leininger’s

theory is a product of 40 years of research, during which she studied 54 cultures and identified

172 care constructs for the use by nursing professionals (Zoucha and Husted, 2000).

Madeleine Leininger’s Culture Care Diversity and Universality Theory is an area of study and

practice that focuses on values, beliefs, and practices of individuals or groups that promote

health and well-being. Culture is those behavior patterns that are socially acquired and

transmitted by means of such symbols as customs, techniques, beliefs, institutions, and

material objects (Zoucha and Husted, 2000). Cultural congruence and cultural imposition

concepts were also described by Leininger. Cultural imposition is when a nurse imposes her

own beliefs and values upon another culture because she believes it to be more superior to the

patients. Cultural congruence is the care that is provided to the patient that is beneficial,

satisfying, and meaningful. Leininger’s goal was to make the patient the subject of care

focusing on whom that person really is and how do they live, think, and feel.


Madeleine Leininger did not start off in the nursing profession. She was a third grade

school teacher in an elementary school in Nebraska. She however had a desire to continue that

human caring to another level. During World War II she began her nursing career. She

continued her nursing education obtaining a bachelor of science, master of science in

psychiatric nursing, and was employed at the University of Cincinnati where she met Dr.

Margaret Mead a visiting professor. Madeleine worked as a child guidance nurse where she

began to observe the children of diverse cultural backgrounds responded differently to care

and psychiatric treatments (Ray, 2012). After sharing her observation with Dr. Mead, she

began examining the interrelationships between nursing and anthropology. She returned then

to the classroom to pursue a doctorate of philosophy in anthropology focusing on cultural,

social, and psychological content. During her doctorate study she went to New Guinea and

studied the indigenous people of Gadsup. While studying the caring phenomena with the

Gadsup people she could see the need for cultural care as a discipline of nursing study.

There are three modalities that guide nursing judgments, decision, and actions according to

Leininger. Masters (2012) states these as “cultural care preservation and /or maintenance,

cultural care accommodation and/or negotiation, and cultural care repatterning or

restructuring”. Leininger describes the patient as a person who is a human being, family,

group, community or even and institution. These persons could be a product of an event like

those who experienced the destruction of the twin towers or be part of an isolated community

like the Amish. They are defined by their social interactions in physical, ecological,

sociopolitical, and cultural settings. There can be social boundaries that affect a particular

patient for example, comforting touch, the French patient see it as a social norm where as a

China patient sees it as a social taboo. Each cultural group outlines health as a state of

wellbeing that is culturally defined, valued, and practiced. Nursing these individuals or groups

must be congruent with their cultural values, beliefs, and life ways. Identifying these with a

patient and their families will help initiate care that is supporting and patient centered.

There are thirteen major assumptions that support Leininger’s theory of cultural care

diversity and university. She begins with care being the essence of nursing, and then she

reveals that cultural based care is essential for well-being, health, growth, and survival. Thirdly

she states that culturally based care is a holistic means to guide a nurse’s decisions and actions,

with then the next step being transcultural care with a central purpose of serving individuals,

groups, communities, societies, and institutions. On the fifth assumption this statement

appears, there can be no curing without caring, but caring can exist without curing. Varying

concepts, meanings, expressions, patterns, processes, and structural forms of care make up

number six, and the seventh is that every human culture has generic care knowledge and

practices. By the eighth assumption we are acknowledging that care values, beliefs, and

practices are influenced by worldview, language, philosophy, religion, kinship, social, political,

legal, educational, economic, technological, environmental context of cultures. So now we

know that for care to beneficial, healthy, and satisfying it needs to be culturally based. The

tenth assumption is finding out knowing and using that knowledge for culturally congruent care

that is appropriate and safe. Worldwide culture care can differ and have similarities, and in the

twelfth assumption cultural conflicts and impositions, stresses, reflect a lack of cultural care

knowledge. Finally the thirteenth is the ethnonursing qualitative research method provides an

important means to discover the diverse culture care data (Masters, 2012).

We as a society continue to migrate and evolve, our cultural differences are also changing

and as nurses our knowledge is challenged, seeking information becomes essential. Internet

and social media are a new element to cultural understanding and plays a role in the new

generation of patients. As nurses we need to consider many different aspects of our patients

and their histories. Learning the history of the area that you work in is beneficial, but keeping

up on current events and trends is crucial. Acquiring a skill in asking the right question can be a

good tool to learn. Some individuals will not be able to share their needs, learning how to ask

the right questions and learning our patient’s cultural diversity will be an art worth learning.

Leininger (1996) stated in an interview “today, in a typical urban hospital, many nurses care

for patients from as many as 20 different cultures. The diversity among cultures will continue

to increase”. We as nurses need to consider our patient population and what cultures we

have in our area. Not growing up in the area that you serve may have some challenges when

you are learning patient backgrounds or histories. You may not know that they are of an ethnic

decent that refuses to bath daily or that direct eye contact is considered being dominating to

that patient. To be culturally congruent you would need to do some research of your area or

that particular patient. We are living in society that is mobile. Having quick resources is

essential. Interpreters or access to phones that provide that service can mean the difference in

patient care and outcomes.

Malinowski and Stamler (2002) describes using the ethnonurse method and identified that

“Philippine nurses value patients' physical comfort as an important aspect of nursing care.

Securing comfort for their patients is a means of developing relationships”. This would be an

expected part of nursing practice in the Philippines. Identifying patient needs and background

is part of the nursing process of obtaining health history information. We as nurses need to

ask is there any cultural practices you would like us to observe while you are in the hospital.

The patient may not be able to list these at the time but by learning likes and dislikes is helpful

in providing for their needs. This patient likes the room warm or needs to eat fish on Fridays is

an example of following cultural practices.


In our short time we have seen current events that have changed our world leading to

population changes. We see foreign refugees seeking sanctuary from their oppressors or illegal

immigrants seeking jobs. Each comes with their own stories, fears, and experiences. Seeking

health care alone can be a stressful experience as not all countries have health care facilities

like the United States. Sometimes just getting past the language barrier can be a struggle. As

nurses we need to be prepared to care for these challenges. Having interpreters or access to

multilingual teaching sheets and admission paper work is essential. Keeping an open mind

about cultures that practice things we are not use to like circumcisions on females, or family

dynamics where you can only talk to the patient’s husband. Not all practices are healthy.

Understanding some biological backgrounds can be as helpful as well, for instance there is a

higher prevalence of hypertension and sickle cell anemia in black people. Working in

healthcare you begin to see several interesting cultural practices and prevalence. Taking all

those experiences and expanding on them will assist you with adjusting to a new cultural

practice that you haven’t seen before. Don’t ever assume because an individual maybe Native

American they practice all the cultural aspects of that background. Rajan (1995) states “one

must develop an awareness of different cultures while keeping in mind individual differences”.

You will not know this unless you ask.

There is also a need to keep current on the new trends that are happening in your area or in

the world. One current trend of piercing different parts of your body may cause some

embarrassment when prepping a patient for surgery. Working in outpatient surgery you can

see this frequently. By accepting this trend and being prepared for it makes the patient more

comfortable about receiving nursing care and health care in general. Our outpatient services

have learned to have a cup with a lid ready at bedside, for the keeping of the appliance, until

surgery is over. However we do make a point to have them have a designated person to

replace the appliance when they return from surgery. We do incorporate in the discharge

teaching with the patient about caring for such areas, watching for infection, and when to seek

medical care as to promote a healthy lifestyle.

We are also caring for a large older population that grew up in the 1930’s and 40’s these are

post war veterans and have a lot to share but also come with interesting health promotion

ideas. We were surprised by a request while caring for a gentleman who said he needed to

eat 1 small piece of garlic each day to stave off respiratory infections. He was given garlic every

morning with his breakfast. This was important to him and in doing so he felt comfortable in

taking his other medication from us and respected the teaching we gave to him.

Doing a thorough health assessment is critical to patient care. Knowing what is important to

this patient and how they have cared for themselves in the past may alter or add to their plan

of care while in the health care setting. Rajan (1995) states, “the person is a cultural being who

cannot be viewed apart from his or her cultural background”. It is important to add in your

health policy for admission this statement: Are there any cultural practices you would like us to

observe while you are in the hospital?


Madeleine Leininger’s Culture Care Diversity and Universality Theory was a long term goal

for her. She worked 30 years to fulfill an obvious need for patient and human care that was

culturally congruent. Through her observations we are able to conduct incisive medical

histories that include the diverse backgrounds that our patients generate from. With this

background knowledge our healthcare systems can treat patients with the values, beliefs, and

practices that are their own, promoting well-being in meaningful ways. As our patients evolve

so do their cultural experiences, it could be an event, childhood upbringing, a community they

live in, or a country they have come from. All of these experiences have an influence on their

daily needs and beliefs and this in turn governs the health care they seek and the expectations

of the nursing care they receive.


Reference List

Leininger, M. (1996) Transcultural nursing: essential for excellence interview Madeleine

Leininger. (1996). Nursing, 26(1), 76

Masters, K. (2012). Nursing Theories: a framework for professional practice. (pp. 213) Sadbury,

MA: Jones and Bartlett Learning

Malinowski, A., & Stamler, L. (2002). Comfort: exploration of the concept in nursing. Journal Of

Advanced Nursing, 39(6), 599-606. doi:10.1046/j.1365-2648.2002.02329.x

Rajan, M. (1995). Transcultural nursing: a perspective derived from Jean-Paul Sartre. Journal Of

Advanced Nursing, 22(3), 450-455. doi:10.1046/j.1365-2648.1995.22030450.x

Ray, M. (2012). Remembering Madeleine M. Leininger, PhD, LHD, DS, RN, CTN, FAAN, FRCNA,

1925-2012. International Journal For Human Caring, 16(4), 6-8.

Zoucha, R., & Husted, G. (2000). The ethical dimensions of delivering culturally congruent

nursing and health care. Issues In Mental Health Nursing, 21(3), 325-340.