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What is This?
One of the most exciting and important de- Since the early 1960s, nursing has been in
velopments in the history of nursing has been - an era of theory construction, refinement, and
the development of nursing theories to estab- systematic examination. Questions, such as
lish a sound basis for-the discipline of nursing the following, have been asked. What charac-
and to guide nursing practice. During the past terizes the essential nature and essence of
four decades, a cadre of nurse theorists has nursing? What constitutes the essential na-
been active focusing on the systematic study ture of nursing knowledge? What is different
of the nature and critical elements that char- about nursing knowledge compared with that
acterize the discipline of nursing. As a conse- of other health disciplines? These questions
quence, a number of different theories with and related ones have been central to the ad-
diverse conceptualizations of nursing have vancement of nursing as a discipline and
been developed and continue to be examined. profession.
Nursing theories have markedly stimulated As one of the early nurse theorists who be-
the intellectual, clinical, and research per- gan to develop the theory of cultural care di-
spectives of nurses requiring them to think versity and universality in the 1950s, the au-
anew about the nature and meaning of nurs- thor was interested in the nature of nursing
ing as a discipline and profession. This move- and how nursing differed from medicine in its
ment has led to critical positions and debates knowledge base and practice. The idea for the
among scholars of nursing about the core ele- theory began while studying the role of the
ments and epistemological bases of nursing clinical specialist in child psychiatric nursing
knowledge. It also encouraged nurses to shift in 1954 and while documenting the ways that
from the medical paradigm to a nursing para- care and nursing practice could accurately de-
digm. scribe and reflect nursing knowledge. The au-
thor firmly held to the position that care is the
Key Words: Cultural Care Theory. Leininger, Sunrise essence of nursing and the central, domi-
Model
nant, and unifying feature of nursing. Care
Received April 12, 1988 was viewed as a powerful means to help clients
Accepted May 30, 1988 recover from illnesses or unfavorable human
*
Wayne State University, Detroit, MI. life conditions (Leininger, 1978). Through in-
tense observation, it soon became clear to the
author that children of different cultural back-
grounds had different expectations and re-
152
of a Theory
were no other professional nurses with grad-
uate preparation in anthropology. Anthropol- Before a theory can be understood, the the-
ogy was not a part of nursing curricula nor orist’s views in general must be known. Cur-
part of the thinking of nurse theorists and rently, the literature abounds with ideas from
educators in those early days. This reality led nurse theorists who have been educated to
the author to doctoral preparation in anthro- view a theory as &dquo;a set of interrelated concepts,
pology in order to develop the theory in a definitions, propositions or hypotheses with
knowledgeable way. The need for the new field specified and measurable relationships to pre-
of transcultural nursing to prepare nurses to dict and control phenomena under study&dquo;
function in a multicultural world became (Polit and Hungler, 1983, p. 101). This tradi-
clear. As the first nurse anthropologist with tional definition of a theory (and its variants)
doctoral preparation in cultural anthropology, is derived from the elements and criteria used
the author developed knowledge and research in a quantitative paradigm. The theory re-
for the new field of transcultural nursing with quires rigid operational definitions of specified
a focus on cultural care theory (Leininger, relationships among a priori variables that can
1970, 1978). It took time and in-depth study be controlled, measured, and verified in pre-
to link culture and care into a meaningful cise ways. This perspective of theory is only
relationship. The theory of cultural care diver- one way to view theory and it can seriously
sity and universality was difficult to formulate limit the discovery of phenomena that are un-
because there was so much to understand known, vaguely known, or that cannot be es-
about different cultures in the world and nurs- tablished as operationally defined variables
ing’s perspectives of cultural phenomena. At prior to a research investigation. The author
the same time, the need arose to develop was committed to discovery of the epistemo-
courses and programs in transcultural nursing logical sources of nursing knowledge related
so that the theory could be appropriately used. to cultural care with its inherent meanings
There were few nurses interested in anthro- and characteristics as the goal of the theory.
pology in those days; nurses were deeply in- The concept of care had not been studied from
volved in medical tasks and the physical and different cultural viewpoints, and thus an
technical needs of clients. Gradually, tran- open approach was essential to discover the
scultural nursing and cultural care made unknown attributes of care from a compara-
sense to some nurses. The author’s firm con- tive cultural perspective. A qualitative ap-
viction about the importance of transcultural proach was imperative to identify, describe,
nursing led her to prepare a cohort of nurses and account for unknown aspects of cultural
to try the ideas espoused in the theory. care. Indeed, there was a critical need for the-
As nurses became prepared in transcultural ories that would lead to the discovery of the
nursing, the theory became meaningful to people’s emic (local or insider’s) views of the
more practicing nurses. Transcultural nurses meanings, symbols, patterns, and expressions
and others began using the cultural care the- of cultural care and nursing from a wholistic
ory with enthusiasm. Likewise, nursing stu- perspective. The open ethnographic or anthro-
dents’ began to use the theory in the clinical pological qualitative approach was selected to
153
discovery of care as a concept in nursing was is the essence of nursing and provides dis-
a
stifled until the use of the qualitative. ap- tinctconcept to describe, explain, and predict
proach, with the research methods of ethnog- nursing (Leininger, 1984, 1988b). Care should
raphy and phenomenology, became known to be central to nursing paradigms or metapara-
nurses (Leininger, 1985a). In addition, some digms and supported by the concepts of health
nurses devalue the concept of care because and environmental contexts. The author re-
they have not studied it in depth as a theory jects the idea that nursing and person explain
and as a phenomenon to be explained in its nursing, for one cannot explain nor predict the
own right (Leininger, 1986; Deers, 1988). same phenomenon one is studying. Nursing is
Some nurse leaders cannot envision care as a the phenomenon to be explained. Moreover,
theoretical concept in its own right as a phe- person, per se, is not sufficient to explain
nomenon to be studied, but rather see it as a nursing as it fails to account for groups, fam-
concrete action or practice (Lundh, Soder, & ilies, social institutions, and cultures. Nursing
Waerness, 1988). is not only concerned with person as an indi-
This leads to the author’s definition of the- vidual concept but includes groups, collectivi-
ory as sets of interrelated knowledge with ties, and institutions. It is ironic that some
meanings and experiences that describe, ex- nurses fail to recognize care in the metapara-
plain, predict, or account for some phenome- digms of nursing, or as the crucial dimension
non (or domain of inquiry) through an open, to explain and predict as a theoretical phenom-
creative, and naturalistic discovery process. enon. Only a few theorists, such as Watson
This perspective is critical to discover, account (1985) and Orem (1980) focus on care as im-
for, confirm, and explain unknown or vaguely portant or central to nursing, a phenomenon
known phenomena. It is essential to the de- to be explained and predicted. However, in the
velopment of nursing knowledge to document past decade, more nurses are beginning to fo-
and describe new insights and possibilities not cus on care and there are more research stud-
yet known or explicated. The use of inductive ies, publications, and writings specifically on
strategies to get to people (emic) truths, reali- the care phenomenon than at any time in the
ties, and other life-death knowledge about hu- past history of nursing. For example, before
man conditions is essential. The theory of cul- the 1970s, there were less than 30 nursing
tural care diversity and universality is con- articles, very few research studies, and vir-
gruent with methods that support the tually no books specifically directed to the
discovery of &dquo;people truths&dquo; in human living study of the care phenomenon per se, whereas
contexts rather than methods that follow the in 1987, there were more than 500 nursing
researcher’s preconceived views. The theory articles and 28 books by nurses addressing
can guide researchers to discover naturalistic care research, theory, and clinical findings in
inquiry patterns and expressions of cultural the United States (Leininger, in press).
care within diverse environmental contexts The author’s conceptualization of the theory
and social structures. of cultural care was derived from anthropology
Watson’s (1985) definition of theory lends with new formulations made within nursing
support to the author’s. She states that &dquo;a care perspectives. Her philosophy of nursing,
154
155
prove a human condition and lifeway or to The sunrise model was developed and re-
face death. fined over the past three decades to provide a
6. Cultural care universality refers to com-
mon, similar, or uniform meanings, pat-
gestaltic view of the major and interrelated
terns, values, or symbols of care that are components of the theory. The model (Fig. 1)
is not the theory per se but a conceptual pic-
culturally derived by humans for their well- ture to depict the components of the theory to
being or to improve a human condition and
lifeway or to face death. study how these components influence the
7. World view refers to the way people tend care and health status of individuals, families,
to look upon the world or universe to form groups, and sociocultural institutions. It is a
156
wholistic conceptualization to help the re- ponents of the theory. The researcher is free
searcher systematically study the theory’s di- to start the discovery process according to per-
verse components, such as world view, social sonal interest regarding care. The nature, pat-
structure factors, cultural values and beliefs, terns, meanings, and characteristics of care
and folk and professional health systems, and can be systematically investigated. The model
how these components interface with each should not be used from a casual, linear, or
other in a gestaltic perspective. Thus, the re- positivistic perspective, but rather with the
searcher is able to see the whole conceptual goal to discover the essence, meanings, and
picture of the theoretical components. patterned expressions of generic and profes-
As the researcher uses the model, one can sional care. Because this base of care knowl-
focus on specific areas, such as the individual, edge is still relatively unknown, the author
family, group, or institution and study care supports qualitative ethnomethods to obtain
phenomena in relation to the different com- grounded knowledge derived from key and
157
158
159
160