alligood 8th edition_Neat

382 UNIT IV Nursing Theories

MAJOR CONCEPTS & DEFINITIONS
Here, the major concepts and definitions from the (3) change and difference; (4) time span; and
most current Transitions Theory—the middle- (5) critical points and events. Meleis , Sawyer, Im,
range theory of transition suggested by Meleis, and colleagues (2000) asserted that these properties
Sawyer, Im, and colleagues (2000)—are presented. of transition experience are not fundamentally dis-
Some concepts are defined in greater detail based connected, but are interrelated as a complex process.
on the transition framework by Schumacher and Awareness is defined as “perception, knowledge,
Meleis (1994). and recognition of a transition experience,” and
Major concepts of the middle-range theory of tran- level of awareness is frequently reflected in “the
sition include: (1) types and patterns of transitions; degree of congruency between what is known about
(2) properties of transition experiences; (3) transition processes and responses and what constitutes an
conditions (facilitators and inhibitors); (4) patterns of expected set of responses and perceptions of indi-
response (or process indicators and outcome indica- viduals undergoing similar transitions”(Meleis,
tors); and (5) nursing therapeutics. Sawyer, Im, et al., 2000). While asserting that a
person in transition may be somewhat aware of
Types and Patterns of Transitions the changes that they are experiencing, Chick and
Types of transitions include developmental, health and Meleis (1986) posited that a person’s unawareness of
illness, situational, and organizational. Developmental change could mean that the person may not have
transition includes birth, adolescence, menopause, began his or her transition yet; Meleis, Sawyer, Im,
aging (or senescence), and death. Health and illness and associates (2000) later proposed that this lack of
transitions include recovery process, hospital dis- awareness does not necessarily mean that the transi-
charge, and diagnosis of chronic illness (Meleis & tion has not begun.
Trangenstein, 1994). Organizational transitions refer Engagement is another property of transition
to changing environmental conditions that affect suggested by Meleis, Sawyer, Im, and colleagues
the lives of clients, as well as workers within them (2000). Engagement refers to “the degree to which a
(Schumacher & Meleis, 1994). person demonstrates involvement in the process
Patterns of transitions include multiplicity and inherent in the transition.” The level of awareness is
complexity (Meleis, Sawyer, Im, et al., 2000). Many considered to influence the level of engagement;
people experience multiple transitions simultane- there is no engagement without awareness. Meleis
ously rather than experiencing a single transition, and colleagues (2000) suggested that the level of
which cannot be easily distinguished from the con- engagement of a person who has this awareness of
texts of their daily lives. Indeed, Meleis, Sawyer, Im, changes is different from that of a person who does
and colleagues (2000) noted that each of the studies not have this awareness.
that were the basis for the theoretical development Changes and differences are a property of transi-
involved people who simultaneously experienced a tions (Meleis, Sawyer, Im, et al., 2000). Changes that
minimum of two types of transitions, which could a person experiences in her or his identities, roles,
not be disconnected or mutually exclusive. Thus, relationships, abilities, and behaviors are supposed
they suggested considering if the transitions happen to bring a sense of movement or direction to inter-
sequentially or simultaneously, the degree of overlap nal as well as external processes (Schumacher &
among the transitions, and the essence of the asso- Meleis, 1994). Meleis and associates (2000) asserted
ciations between the separate events that initiate that all transitions associate changes, although not
transitions for a person. all changes are associated with transitions. They
then suggested that to comprehend a transition
Properties of Transition Experiences completely, it is essential to disclose and explain the
Properties of the transition experience include meanings and influences of the changes and the
five subconcepts: (1) awareness; (2) engagement; scopes of the changes (e.g., “nature, temporality,

CHAPTER 20 Afaf Ibrahim Meleis 383

MAJOR CONCEPTS & DEFINITIONS—cont’d
perceived importance or severity, personal, familial, transition, and that facilitate or hinder progress to-
and societal norms and expectations”). Differences ward achieving a healthy transition” (Schumacher
are also suggested as a property of transitions. Meleis & Meleis, 1994). Transition conditions include
and associates (2000) believed that challenging differ- personal, community, or societal factors that may
ences could be demonstrated by unsatisfied or atypi- expedite or bar the processes and outcomes of
cal expectations, feeling dissimilar, being realized healthy transitions.
as dissimilar, or viewing the world and others in Personal conditions include meanings, cultural
dissimilar ways, and they suggested that nurses would beliefs and attitudes, socioeconomic status, prepa-
need to recognize “a client’s level of comfort and mas- ration, and knowledge. Meleis , Sawyer, Im, and
tery in dealing with changes and differences.” colleagues (2000) considered that the meanings
Time span is also a property of transitions—all tran- attached to some events accelerating a transition
sitions may be characterized as flowing and moving and to the transition process itself would expedite
over time (Meleis , Sawyer, Im, et al., 2000). Based on or bar healthy transitions. Cultural beliefs and
the assertion by Bridges (1980, 1991), in the middle- attitudes such as stigma associated with a transi-
range theory of transition, transition is defined as tion experience (e.g., Chinese stigmatization of
“a span of time with an identifiable starting point, cancer) would influence the transition experience.
extending from the first signs of anticipation, percep- Socioeconomic status could influence people’s
tion, or demonstration of change; moving through a transition experiences. Anticipatory preparation
period of instability, confusion, and distress; to an or lack of preparation could facilitate or inhibit
eventual “ending” with a new beginning or period of people’s transition experiences. Community condi-
stability.” However, Meleis, Sawyer, Im, and colleagues tions (e.g., community resources) or societal condi-
(2000) also noted that it would be problematic or infea- tions (e.g., marginalization of immigrants in the
sible, and possibly even prejudicial, to frame the time host country) could be facilitators or inhibitors
span of some transition experiences. for transitions. Compared with personal transi-
Critical points and events are the final property of tion conditions, the subconcepts of community
transitions suggested by Meleis, Sawyer, Im, and asso- conditions and societal conditions tend to be
ciates (2000). Critical points and events are defined as underdeveloped.
“markers such as birth, death, the cessation of men-
struation, or the diagnosis of an illness.” Meleis and Patterns of Response or Process and Outcome
colleagues (2000) also acknowledge that specific Indicators
marker events might not be evident for some transi- Indicators of healthy transitions in the framework
tions, although transitions usually have critical points by Schumacher and Meleis (1994) were replaced by
and events. Critical points and events are usually patterns of response in the middle-range theory of
linked to intensifying awareness of changes or dissimi- transitions. Patterns of response are conceptualized
larities or to a more exertive engagement in the transi- as process indicatorsand outcome indicators. These
tion process. Also, Transitions Theory conceptualizes process indicatorsand outcome indicators character-
that final critical points are differentiated by a sense of ize healthy responses. Process indicators that direct
counterpoise in new schedules, competence, lifestyles, clients into health or toward vulnerability and risk
and self-care behaviors, and that the duration of uncer- make nurses conduct early assessment and interven-
tainty is characterized by variations, consecutive tion to expedite healthy outcomes. Also, outcome
changes, and interruptions in existence. indicators may be used to check if a transition is
a healthy one or not, but Meleis, Sawyer, Im, and
Transition Conditions associates (2000) warned that outcome indicators
Transition conditions are “those circumstances could be associated with irrelevant events in people’s
that influence the way a person moves through a lives if they are appraised early in a transition

Continued

384 UNIT IV Nursing Theories

MAJOR CONCEPTS & DEFINITIONS—cont’d
process. The process indicators suggested by Meleis Nursing Therapeutics
and colleagues (2000) include “feeling connected, Schumacher and Meleis (1994) conceptualized
interacting, being situated, and developing confi- nursing therapeutics as “three measures that are
dence and coping.” “The need to feel and stay con- widely applicable to therapeutic intervention dur-
nected” is a process indicator of a healthy transition; ing transitions.” First, they proposed assessment
if immigrants add new contacts to their old contacts of readiness as a nursing therapeutic. Assessment
with their family members and friends, they are of readiness needs to be interdisciplinary efforts
usually in a healthy transition. Through interac- and based on a full understanding of the client; it
tions, the meaning attached to the transition and the requires assessment of each of the transition condi-
behaviors caused by the transition can be disclosed, tions in order to generate a personal sketch of client
analyzed, and understood, which usually results in a readiness, and to allow clinicians and researchers
healthy transition. Location and being situated in to determine diverse patterns of the transition
terms of time, space, and relationships are usually experience. Second, the preparation for transition
important in most transitions; these indicate is suggested as a nursing therapeutic. The prepara-
whether the person is turned in the direction of a tion of transition includes education as the main
healthy transition. The extent of increased confi- modality for generating the best condition to
dence that people in transition are experiencing is be ready for a transition. Third, role supplementa-
another important process indicator of a healthy tion was proposed as a nursing therapeutic. Role
transition. The outcome indicators suggested by supplementation was suggested by Meleis (1975)
Meleis, Sawyer, Im, and colleagues (2000) include and used by several researchers (Brackley, 1992;
mastery and fluid integrative identities. “A healthy Dracup, Meleis, Clark, Clyburn, Shields, & Staley,
completion of a transition” can be decided by the 1985; Gaffney, 1992; Meleis & Swendsen, 1978). Yet,
extent of mastery of the skills and behaviors that in the middle-range theory of transitions, there is
people in transition show to manage their new situ- no further development of the concept of nursing
ations or environments. Identity reformulation can therapeutics.
also represent a healthy completion of a transition.




Use of Empirical Evidence 1997), the aging transition (Schumacher, Jones, &
In the development of the transition framework by Meleis, 1999), African-American women’s transition to
Schumacher and Meleis (1994), a systematic extensive motherhood (Sawyer, 1997), and adult medical-surgical
literature review of more than 300 articles related to patients’ perceptions of their readiness for hospital dis-
transitions provided empirical evidence of the con- charge (Weiss, Piacentine, Lokken, et al., 2007).
ceptualization and theorizing. Then, as mentioned Development of the middle-range theory of tran-
earlier in the chapter, the transition framework was sition builds on empirical evidence from five re-
tested in a number of studies to describe immigrants’ search studies for conceptualization and theorizing
transitions (Meleis, Lipson, & Dallafar, 1998), wom- (Sawyer, 1997; Im, 1997; Messias, Gilliss, Sparacino,
en’s experiences with rheumatoid arthritis (Shaul, et al., 1995; Messias, 1997; Schumacher, 1994). These
1997), recovery from cardiac surgery (Shih, Meleis, studies were conducted among culturally diverse
Yu, et al., 1998), development of the family caregiving groups of people in transition, including African-
role for chemotherapy patients (Schumacher, 1995), American mothers, Korean immigrant midlife
Korean immigrant low-income women in meno- women, parents of children diagnosed with con-
pausal transition (Im, 1997; Im & Meleis, 2000, 2001; genital heart defects, Brazilian women immigrating
Im, Meleis, & Lee, 1999), early memory loss for to the United States, and family caregivers of per-
patients in Sweden (Robinson, Ekman, Meleis, et al., sons receiving chemotherapy for cancer. Empirical

CHAPTER 20 Afaf Ibrahim Meleis 385

findings of these five studies provided the theoretical Person
basis for the concepts of the middle-range theory of • Transitions involve a process of movement and
transition, and the concepts and their relationships changes in fundamental life patterns, which are
were developed and formulated based on a collab- manifested in all individuals.
orative process of dialogue, constant comparison of • Transitions cause changes in identities, roles,
findings across the five studies, and analysis of find- relationships, abilities, and patterns of behavior.
ings. For example, one of the personal conditions, • The daily lives of clients, environments, and
meanings, was proposed based on the findings from interactions are shaped by the nature, condi-
two studies (Im, 1997; Sawyer, 1997). According to tions, meanings, and processes of their transition
Meleis Sawyer, Im, and colleagues (2000), although experiences.
Korean immigrant midlife women had ambivalent
feelings toward menopause in Im’s study, menopause Health
itself did not have special meaning attached to it. Im • Transitions are complex and multidimensional. Tran-
found that most participants did not connect any sitions have patterns of multiplicity and complexity.
special health/illness problems/concerns they were • All transitions are characterized by flow and move-
having to their menopausal transitions. Rather, ment over time.
women went through their menopause without • Change and difference are not interchangeable,
perceiving any health/illness problems/concerns, nor are they synonymous with transition.
which means that “no special meaning” might have
facilitated the women’s menopausal transition. Yet, Environment
Sawyer’s study reported that African-American • Vulnerability is related to transition experiences,
women related intense enjoyment of their roles interactions, and environmental conditions that
as mothers and described motherhood in terms of expose individuals to potential damage, problematic
being responsible, protecting, supporting, and or extended recovery, or delayed or unhealthy coping.
needed. Thus, Meleis, Sawyer, Im, and colleagues
(2000) proposed meanings as a personal transition
condition because, in both studies, neutral and posi- Theoretical Assertions
tive meanings might have facilitated menopause Theoretical assertions in Transitions Theory were
and motherhood. The middle-range theory of tran- inferred in the early works of Meleis. This includes
sition has been used in studies to develop situation- her work on role supplementation, the transition
specific theories (Im, 2006; Im, 2010; Im & Meleis, framework by Schumacher and Meleis (1994), and
1999b; Schumacher, Jones, & Meleis 1999) and to the middle-range theory of transitions by Meleis,
test the theory in a study of relatives’ experience of a Sawyer, Im, and colleagues (2000). Following are the
move to a nursing home (Davies, 2005). theoretical assertions made in the theoretical works:
• Developmental, health and illness, and organiza-
tional transitions are central to nursing practice.
Major Assumptions • Patterns of transition include (a) whether the client
Based on Meleis’ former works on role supplementation, is experiencing a single transition or multiple transi-
the transition framework by Schumacher and Meleis tions; (b) whether multiple transitions are sequential
(1994), and the middle-range theory of transitions by or simultaneous; (c) the extent of overlap among
Meleis, Sawyer, Im, and colleagues (2000), the following transitions; and (d) the nature of the relationship
assumptions of Transitions Theory may be inferred. between the different events that are triggering tran-
sitions for a client.
Nursing • Properties of transition experience are interrelated
• Nurses are the primary caregivers of clients and parts of a complex process.
their families who are undergoing transitions. • The level of awareness influences the level of en-
• Transitions both result in change and are the result gagement, in which engagement may not happen
of change. without awareness.

386 UNIT IV Nursing Theories

• Humans’ perceptions of and meanings attached to Indeed, studies have indicated that Transitions Theory
health and illness situations are influenced by and could be applied to nursing practice with diverse groups
in turn influence the conditions under which a of people, including geriatric populations, psychiatric
transition occurs. populations, maternal populations, family caregivers,
• Healthy transition is characterized by both process menopausal women, Alzheimer patients, immigrant
and outcome indicators. women, and people with chronic illness, among others
• Negotiating successful transitions depends on the (Aroian & Prater, 1988; Brackley, 1992; Im, 1997; Kaas
development of an effective relationship between & Rousseau, 1983; Schumacher, Dodd, & Paul, 1993;
the nurse and the client (nursing therapeutic). This Shaul, 1997). Transitions Theory could provide direc-
relationship is a highly reciprocal process that tion for nursing practice with people in various types of
affects both the client and the nurse. transitions by providing a comprehensive perspective
on the nature and type of transitions, transition condi-
tions, and process and outcome indicators of patterns of
Logical Form response to transitions. Also, Transitions Theory leads
Transitions Theory was formulated and theorized to development of nursing therapeutics that are congru-
through induction using existing research litera- ent with the unique experience of clients and their
ture and findings. It was initially developed as a families in transition, thus promoting healthy responses
central concept of nursing and later as a middle- to transition.
range theory. Transitions Theory was formulated
with the goal of integrating what is known about Education
transition experiences across different types of Transitions Theory is used widely in graduate educa-
transitions with nursing therapeutics for people in tion and undergraduate education throughout the
transition. The theory provides a framework for world (Meleis, personal communication, December
understanding the results of previous transitions 29, 2007). There is a growing international interest
research more clearly and for proposing concepts in integrating Transitions Theory into nursing cur-
for further study. ricula across countries (Meleis, personal communi-
cation, January 2008). Transitions Theory was used
as a curriculum framework in a number of places,
Acceptance by the Nursing Community including the University of Connecticut and Clayton
Over recent decades, transitions have emerged as a State University in Morrow, Georgia, where Transi-
central concept of nursing phenomenon, and Transi- tions Theory has been used in their education pro-
tions Theory has been widely used throughout the grams for the past 15 years (www.clayton.edu).
world. Transitions Theory was translated and used In response to an increasing learning need of gradu-
extensively in Sweden, Taiwan, South Korea, Portugal, ate students, Meleis taught an independent graduate
Spain, and Singapore. elective course on transitions and health at the
University of California, San Francisco. At University
Practice of Pennsylvania, a center called Transitions and
Transitions Theory provides a comprehensive perspec- Health, directed by Mary Naylor, was established in
tive on transition experience while considering the 2007 with a $5 million dollar endowment for support
contexts within which people are experiencing a transi- and Transitions Theory as its theoretical basis.
tion. Because of its comprehensiveness, applicability,
and affinity with health, Transitions Theory has been Research
applied to many human phenomena of interest and Internationally, a number of researchers have used
concern to nurses, such as illness, recovery, birth, death, Transitions Theory in their studies as a theoretical
and loss, as well as immigration. Transitions Theory basis for research. Meleis’ research program is natu-
is useful in explaining health/illness transitions such rally based on Transitions Theory, and other research-
as the recovery process, hospital discharge, and diagno- ers have tested the empirical precision of Transitions
sis of chronic disease (Meleis & Trangenstein, 1994). Theory through their studies (Davies, 2005; Weiss,

CHAPTER 20 Afaf Ibrahim Meleis 387

Piacentine, Lokken, et al., 2007). As mentioned ear- applicable in nursing practice. Transitions Theory
lier in the chapter, Transitions Theory was often used tends to be generalizable to people in transitions.
as a parent theory for situation-specific theories When diverse types of transitions are considered,
(Im & Meleis, 1999a; Im, 2006; Schumacher, Jones, & Transitions Theory is relevant for any population in
Meleis, 1999). A number of doctoral students, includ- transition, depending on the type of transition the
ing Shellye Vardaman at the University of Texas at population is experiencing. The research used to
Tyler, have used Transitions Theory in their doctoral derive Transitions Theory was based on the participa-
dissertations. tion of different gender and ethnic groups in various
settings. This makes Transitions Theory more easily
generalizable than theories developed for research
Further Development with specific client populations.
Transitions Theory was an emerging framework that
could be further developed, tested, and refined, Accessibility
reflecting Meleis’ philosophical position on theory Transitions Theory has been tested and supported by
development as cyclic, dynamic, and evolving. Transi- Meleis and others as a framework for explaining the
tions Theory continues to be refined and tested to transition experiences of diverse groups of popula-
explain the major concepts and relationships among tions in different types of transitions. Transitions
diverse groups of populations in various types of tran- Theory continues to evolve through planned pro-
sition. Because sufficient empirical support by a num- grams of research, and continuous empirical research
ber of studies using Transitions Theory exists, future studies will further refine the theory. The develop-
studies will aim at intervention studies to test Transi- ment of situation-specific theories derived from Tran-
tions Theory–based interventions, through which sitions Theory will further reduce its distance from
Transitions Theory gains power to direct nursing the empirical world as well.
practice. Also, as Meleis (2007) envisioned, situation-
specific theories continue to be developed based on Importance
Transitions Theory. Transitions Theory with a focus on people in diverse
types of transitions provides a comprehensive and
Critique evolving guide for all health-related disciplines. Health-
related disciplines always deal with a type of transition,
Clarity whether single or multiple. Especially with an increas-
The conceptual definitions of Transitions Theory are ing need for culturally competent health care for
clear and provide a comprehensive understanding of diverse groups of health care clients, Transitions Theory
the complexity of transitions. The relationships among provides a more appropriate theoretical fit for current
the major concepts are clearly depicted in a visually health care. The inherent consideration of diversities
simple diagram (see Figure 20–1). The variables are of health care clients and its basis in research among
independent of each other, yet the interactive effects diverse groups contribute to its importance.
among the variables are clearly depicted by arrows.
Simplicity Summary
Transitions Theory is simple and clear to understand. Current health care systems are frequently character-
The major concepts are logically linked, and the rela- ized by changes, diversities, and complexities. Transi-
tionships are obvious in their theoretical assertions. tions Theory, which evolved from research studies
among diverse groups of people in various types of
Generality transitions, could adequately direct nursing practice,
Transitions Theory is a middle-range theory in scope. education, and practice in the current health care
Middle-range theories have more limited scope and system. Meleis made her theoretical journey from the
less abstraction than grand theories, and they address 1960s, and her journey continues. Transitions Theory
specific phenomena or concepts, which make them continues to develop through a number of studies

388 UNIT IV Nursing Theories

based on the theory and the many colleagues Meleis
has mentored. Her visionary leadership throughout modest whenever you approach her. Sue is very
the world influences nursing practice, education, and quiet and never complains about any symptoms
research. or pain. However, on several occasions, you
think that Sue is in serious pain, when consider-
ing her facial expressions and sweating forehead.
CASE STUDY You think that Sue’s English skills may not allow
her to adequately communicate with health care
Sue Kim, 49 years of age, emigrated from South providers. Also, you find that Sue does not have
Korea to the United States 6 years ago. Her family many visitors—only her husband and two chil-
came to the United States to educate their chil- dren. You frequently find Sue praying while lis-
dren and moved in with family members in Los tening to some religious songs. You also find her
Angeles. Sue and her husband graduated from a sobbing silently. About 2 weeks are left until Sue
top-ranked university in South Korea, and her finishes chemotherapy. You think that you
husband also had a master’s degree in business. should do something for Sue so she will not suf-
However, their English skills were not adequate fer through pain and symptoms that could be
for them to get jobs in the United States. Instead, easily controlled with existing pain-management
they opened a Korean grocery store with the strategies. Now, you begin some preliminary
money that they brought from South Korea, and planning.
they managed to settle down in Los Angeles, ​ 1.​ Describe your assessment of the transition(s)
where a number of Koreans are living. They have Sue is experiencing. What are the types and
two children: Mina, a 25-year-old daughter who patterns of the transition(s)? What properties
is now the manager of a local shop, and Yujun, a of transitions can you identify from her case?
21-year-old son who is a college student. Both ​ 2.​ What personal, community, and societal tran-
children were born in South Korea and moved to sition conditions may have influenced Sue’s
the United States with Sue. The children had a experience? What are the cultural meanings
hard time, especially Mina, who came to the attached to cancer, cancer pain, and symptoms
United States in her senior year of high school. accompanying chemotherapy, in this situation?
However, the children finally adapted to their What are Sue’s cultural attitudes toward cancer
new environment. Now, Mina is living alone in a and cancer patients? What factors may facili-
one-bedroom apartment near downtown, and tate or inhibit her transition(s)?
Yujun is living in a university dormitory. The ​ 3.​ Consider the patterns of response that Sue
Kim’s are a religious family and attend their com- is showing. What are the indicators of healthy
munity’s Protestant church regularly. They are transition(s)? What are the indicators of
involved in many church activities. unhealthy transition(s)?
Sue and her husband have been too busy to ​ 4.​ Reflect on how Transitions Theory helped
have regular annual checkups for the past 6 years. your assessment and nursing care for Sue.
About 1 year ago, Sue began to have serious indi- ​ 5.​ If you were Sue’s nurse, what would be your
gestion, nausea, vomiting, and upper abdominal first action/interaction with her? Describe a
pain; she took some over-the-counter medicine plan of nursing care for Sue.
and tried to tolerate the pain. Last month, her
symptoms became more serious; she visited a
local clinic and was referred to a larger hospital.
Recently, she was diagnosed with stomach cancer
after a series of diagnostic tests and had surgery;
she now is undergoing chemotherapy.
You are the nurse who is taking care of Sue
during this hospitalization. Sue is very polite and

CHAPTER 20 Afaf Ibrahim Meleis 389

CRITICAL THINKING ACTIVITIES
​ 1.​ Consider a transition you are personally engaged you are experiencing. List influences such as cul-
in now. Identify characteristics of the transition tural beliefs and attitudes, socioeconomic status,
as defined in Transitions Theory that you have and level of your preparation that impact your
observed. Does consideration of this specific tran- approach to the transition.
sition make you more aware of other transitions ​ 4.​ Review your responses to the transition, and look
you are experiencing? for patterns in the responses. Ask five friends or
​2.​ Analyze the changes that you are experiencing due family members of different ages or ethnicity to
to the specific transition. Consider how your level describe their responses to the transition. Com-
of awareness of these changes influences your pare the descriptions given by those individuals
transition experience. Think about how long the with yours.
transition has been and what have been the land- ​ 5.​ Consider the outcomes of the personal transition
mark events and critical points of the transition. in question 1. What would facilitate successful
​ 3.​ Analyze personal, community, and societal condi- outcomes to the transition? What might inhibit
tions that may have influenced the transition that successful outcomes?

POINTS FOR FURTHER STUDY

n Meleis, A. I. (2011). Theoretical Nursing: Development the University of Pennsylvania at:http://www.
and Progress (5th ed.). Philadelphia: Lippincott. nursing.upenn.edu/dean/transitions/
n To respond to researchers’ increasing interest in
Transitions Theory, a website was established at


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Nursing Scholarship, 26(3), 177–180. women’s work: Policy implications. Nursing Outlook,
Meleis, A. I., & Im, E. (1999). Transcending marginalization 45, 258–264.
in knowledge development. Nursing Inquiry, 6(2), 94–102. Nelson, M., Proctor, S., Regev, H., Barnes, D., Sawyer, L.,
Meleis, A. I., & Im, E. O. (2002). Grandmothers and women’s Messias, D., Yoder, L., & Meleis, A. I. (1996). The Cairo
health: From fragmentation to coherence. Health Care for action plan: A challenge to nursing. Image: Journal of
Women International, 23(2), 207–224. Nursing Scholarship, 28(1), 75–80.
Meleis, A. I., & Lindgren, T. (2001). Show me a woman Neves Arruda, E. N., Larson P. J., & Meleis A. I. (1992).
who does not work! Journal of Nursing. Third Quarter, Comfort: Immigrant Hispanic patients’ views. Cancer
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Meleis, A. I., & Lipson, J. (2003). Cross-cultural health Sawyer, L., Regev, H., Proctor, S., Nelson, M., Messias, D.,
and strategies to lead development of nursing prac- Barnes, D., Meleis, A. I. (1995). Matching vs. cultural
tice. In J. Daly, S. Speedy, & D. Jackson (Eds.), Nurs- competence in research: a methodological note. Research
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and health among five Middle Eastern immigrant century action steps. Journal of Transcultural Nursing,
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in Brazil. Research in Nursing and Health, 19, 53–62. racial groups. Western Journal of Nursing Research,
Meleis, A. I., & Stevens, P. E. (1992). Women in clerical 14(6), 754–774.
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& Health, 18(1), 23–40. as a basis for culturally relevant holistic care: Ethnicity
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impoverished Brazilian women: Health implications of Holistic Nursing Practice, 6(3), 49–58.
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11(3), 296–323.

21

CHAP TER



















Nola J. Pender
1941 to present


Health Promotion Model


Teresa J. Sakraida


“Middle range theories that have been tested in research provide evidence for
evidence-based practice, thus facilitating translation of research into practice”
(Pender, personal communication, April 2008).



Pender was born August 16, 1941, in Lansing,
Credentials and Background Michigan. She was the only child of parents who ad-
of the Theorist vocated education for women. Family encouragement
Nola J. Pender’s first encounter with professional to become a registered nurse led her to the School
nursing occurred at 7 years of age, when she observed of Nursing at West Suburban Hospital in Oak Park,
the nursing care given to her hospitalized aunt. “The Illinois. This school was chosen for its ties with
experience of watching the nurses caring for my aunt Wheaton College and its strong Christian foundation.
in her illness created in me a fascination with the She received her nursing diploma in 1962 and began
work of nursing,” noted Pender (Pender, personal working on a medical-surgical unit and subsequently
communication, May 6, 2004). This experience and in a pediatric unit in a Michigan hospital (Pender,
her subsequent education instilled in her a desire to personal communication, May 6, 2004).
care for others and influenced her belief that the goal In 1964, Pender completed her baccalaureate in
of nursing was to help people care for themselves. nursing at Michigan State University. She credits
Pender contributes to nursing knowledge of health Helen Penhale, assistant to the dean, who streamlined
promotion through her research, teaching, presenta- her program for fostering her options for further edu-
tions, and writings. cation. As was common in the 1960s, Pender changed


Previous author: Lucy Anne Tillett. The author wishes to express appreciation to Nola J. Pender for reviewing the chapter.

396

CHAPTER 21 Nola J. Pender 397

her major from nursing as she pursued her graduate was funded by the National Institutes of Health.
degrees. She earned a master’s degree in human Susan Walker, Karen Sechrist, and Marilyn Frank-
growth and development at Michigan State University Stromborg tested the validity of the HPM (Pender,
in 1965. “The M.A. in growth and development influ- Walker, Sechrist, & Stromborg, 1988). The research
enced my interest in health over the human life span. team developed the Health Promoting Lifestyle Pro-
This background contributed to the formation of a file, an instrument used to study the health-promoting
research program for children and adolescents,” stated behavior of working adults, older adults, patients un-
Pender. She completed her PhD in psychology and dergoing cardiac rehabilitation, and ambulatory pa-
education in 1969 at Northwestern University. Pender’s tients with cancer (Pender, Murdaugh, & Parsons,
(1970) dissertation research investigated develop- 2002). Results from these studies supported the HPM
mental changes in encoding processes of short-term (Pender, personal communication, July 19, 2000).
memory in children. She credits Dr. James Hall, doc- Subsequently, more than 40 studies tested the predic-
toral program advisor, with “introducing me to con- tive capability of the model for health-promoting
siderations of how people think and how a person’s lifestyle, exercise, nutrition practices, use of hearing
thoughts motivate behavior.” Several years later, she protection, and avoidance of exposure to environmen-
completed master’s-level work in community health tal tobacco smoke (Pender, 1996; Pender, Murdaugh,
nursing at Rush University (Pender, personal com- & Parsons, 2002).
munication, May 6, 2004). Pender provided leadership in the development of
After earning her PhD, Pender notes a shift in her nursing research in the United States. Her support of
thinking toward defining the goal of nursing care as the National Center for Nursing Research in the
the optimal health of the individual. A series of con- National Institutes of Health was instrumental to its
versations with Dr. Beverly McElmurry at Northern formation. She has promoted scholarly activity in nurs-
Illinois University and reading High-Level Wellness by ing through involvement with Sigma Theta Tau Inter-
Halpert Dunn (1961) inspired expanded notions of national, as president of the Midwest Nursing Research
health and nursing. Her marriage to Albert Pender, Society from 1985 to 1987, and as chairperson of the
an Associate Professor of business and economics Cabinet on Nursing Research of the American Nurses
who has collaborated with his wife in writing about Association. She has served as a Trustee of the Midwest
the economics of health care, and the birth of a son Nursing Research Society since 2009 (http://nursing.
and a daughter provided increased personal motiva- umich.edu/faculty-staff/nola-j-pender). Inducted as a
tion to learn more about optimizing human health. fellow of the American Academy of Nursing in 1981,
In 1975, Pender published “A Conceptual Model she served as President of the Academy from 1991
for Preventive Health Behavior,” as a basis for study- until 1993. In 1998, she was appointed to a 4-year term
ing how individuals made decisions about their own on the U.S. Preventive Services Task Force, an indepen-
health care in a nursing context. This article identified dent panel charged to evaluate scientific evidence and
factors that were found in earlier research to influence to make age-specific and risk-specific recommenda-
decision making and actions of individuals in pre- tions for clinical preventive services (http://nursing.
venting disease. Pender’s original Health Promotion umich.edu/faculty-staff/nola-j-pender).
Model (HPM) was presented in the first edition of her As a leader in nursing education, Dr. Pender
text, Health Promotion in Nursing Practice, which was guided many students and mentored others. Over her
published in 1982. Based on subsequent research, the 40 years as an educator, she facilitated the learning of
HPM was revised and presented in a second edition baccalaureate, masters, and PhD students. She has
in 1987 and in a third edition in 1996. The fourth mentored a number of postdoctoral fellows. In 1998,
edition of Health Promotion in Nursing Practice was the University of Michigan School of Nursing hon-
co-authored by Pender, Carolyn L. Murdaugh (PhD), ored Pender with the Mae Edna Doyle Award for ex-
and Mary Ann Parsons (PhD) and published in 2002, cellence in teaching. She is a Distinguished Professor
and a fifth edition was published in 2006. at Loyola University of Chicago School of Nursing.
In 1988, Pender and colleagues conducted a A recipient of many awards and honors, Dr. Pender
study at Northern Illinois University, DeKalb, which has served as a distinguished scholar at a number of

398 UNIT IV Nursing Theories

universities. She received an honorary doctorate from is now available in the Japanese and Korean languages
Widener University in 1992. In 1988, she received the (Pender, 1997a, 1997b). Dr. Pender continues influ-
Distinguished Research Award from the Midwest Nurs- encing the nursing profession by providing leadership
ing Research Society for her contributions to research as a consultant to research centers and providing early
and research leadership, and in 1997 she received the scholar consultation (http://nursing.umich.edu/faculty-
American Psychological Association Award for out- staff/nola-j-pender). As a nationally and internation-
standing contributions to nursing and health psychol- ally known leader, Pender speaks at conferences and
ogy. Her widely used text, Health Promotion in Nursing seminars. She collaborates with the editor of the
Practice (Pender, Murdaugh, & Parsons, 2002), was the American Journal of Health Promotion, advocating for
American Nurses Association Book of the Year for con- legislation to fund health promotion research (Pender,
tributions to community health nursing (http://nursing. personal communication, May 6, 2004).
umich.edu/faculty-staff/nola-j-pender). Pender’s future plans include travel to offer consul-
Pender was Associate Dean for Research at the tation and her speaking opportunities. She engages in
University of Michigan School of Nursing from 1990 some graduate teaching, including courses on theories
to 2001. In this position, she facilitated external fund- of nursing and scientific writing as a Distinguished
ing of faculty research, supported emerging centers of Professor at Loyola University in Chicago (Pender,
research excellence in the School of Nursing, promoted personal communication, February 27, 2008). She
interdisciplinary research, supported translating re- continues active mentoring through e-mail exchanges
search into science-based practice, and linked nursing with scholars beginning research programs (Pender,
research to formulation of health policy (http://nurs- personal communication, May 6, 2004).
ing.umich.edu/faculty-staff/nola-j-pender). A child and
adolescent health behavior research center initiated at
the University of Michigan in 1991 represents Pender’s Theoretical Sources
efforts to build a large interdisciplinary research team Pender’s background in nursing, human develop-
to study and influence the health-promoting behaviors ment, experimental psychology, and education led
of individuals by understanding how these behaviors her to use a holistic nursing perspective, social psy-
are established in youth (Pender, personal communica- chology, and learning theory as foundations for the
tion, May 24, 2000). Her program of research includes HPM. The HPM (Figure 21–1) integrates several con-
two major foci: 1.) Understanding how self-efficacy structs. Central to the HPM is the social learning
effects the exertion and affective (activity-related theory of Albert Bandura (1977), which postulates
affect) responses of adolescent girls to the physical the importance of cognitive processes in the changing
activity challenge; and, 2.) Developing an interactive of behavior. Social learning theory, now titled social
computer program as an intervention to increase cognitive theory, includes the following self-beliefs:
physical activity among adolescent girls. The Design self-attribution, self-evaluation, and self-efficacy. Self-
of a Computer Based Physical Activity Counseling efficacy is a central construct of the HPM (Pender,
Intervention for Adolescent Girls was a research pro- 1996; Pender, Murdaugh, & Parsons, 2002). The ex-
gram led by Dr. Lorraine Robbins (Robbins, Gretebeck, pectancy value model of human motivation described
Kazanis, & Pender, 2006). by Feather (1982) proposes that behavior is rational
Pender has published numerous articles on exer- and economical and was important to the model’s
cise, behavior change, and relaxation training as as- development.
pects of health promotion and has served on editorial The HPM is similar in construction to the health
boards and as an editor for journals and books. belief model (Becker, 1974), which explains disease
Pender is recognized as a scholar, presenter, and con- prevention behavior; but the HPM differs from the
sultant on health promotion. She has consulted with health belief model in that it does not include fear or
nurse scientists in Japan, Korea, Mexico, Thailand, threat as a source of motivation for health behavior.
the Dominican Republic, Jamaica, England, New The HPM expands to encompass behaviors for en-
Zealand, and Chile (N. Pender, curriculum vitae hancing health and applies across the life span
2000; Pender, Murdaugh, & Parsons, 2006). Her book (Pender, 1996; Pender, Murdaugh, & Parsons, 2002).

CHAPTER 21 Nola J. Pender 399

MAJOR CONCEPTS & DEFINITIONS
The major concepts and definitions presented are Perceived Self-Efficacy
found in the revised HPM (Pender et al, 2006). The Perceived self-efficacy is judgment of personal capa-
following are individual characteristics and experi- bility to organize and execute a health-promoting
ences that affect subsequent health actions (Pender, behavior. Perceived self-efficacy influences perceived
curriculum vitae, 2000). barriers to action, so higher efficacy results in low-

Prior Related Behavior ered perceptions of barriers to the performance of
the behavior.
Frequency of the same or similar behavior in the
past. Direct and indirect effects on the likelihood of Activity-Related Affect
engaging in health-promoting behaviors. An activity-related affect describes subjective posi-
tive or negative feelings that occur before, during,
Personal Factors and following behavior based on the stimulus prop-
Categorized as biological, psychological, and socio- erties of the behavior itself. Activity-related affect
cultural. These factors are predictive of a given be- influences perceived self-efficacy, which means the
havior and are shaped by the nature of the target more positive the subjective feeling, the greater is
behavior being considered. the feeling of efficacy. In turn, increased feelings of
efficacy can generate further positive affect.
Personal Biological Factors
Included in these factors are variables such as age, Interpersonal Influences
gender, body mass index, pubertal status, meno- These influences are cognitions concerning behav-
pausal status, aerobic capacity, strength, agility, and iors, beliefs, or attitudes of others. Interpersonal
balance. influences include norms (expectations of signifi-
cant others), social support (instrumental and emo-
Personal Psychological Factors tional encouragement), and modeling (vicarious
These factors include variables such as self-esteem, learning through observing others engaged in a
self-motivation, personal competence, perceived particular behavior). Primary sources of interper-
health status, and definition of health. sonal influences are families, peers, and health care
providers.
Personal Sociocultural Factors
Factors such as race, ethnicity, acculturation, educa- Situational Influences
tion, and socioeconomic status are included. Situational influences are personal perceptions and
The following are behavioral-specific cognitions cognitions of any given situation or context that can
and affects that are considered of major motiva- facilitate or impede behavior. They include percep-
tional significance; these variables are modifiable tions of available options, demand characteristics,
through nursing actions (Pender, 1996). and aesthetic features of the environment in which
given health-promoting behavior is proposed to
Perceived Benefits of Action take place. Situational influences may have direct or
Perceived benefits of action are anticipated positive indirect influences on health behavior.
outcomes that will result from health behavior. The following are immediate antecedents of
behavior or behavioral outcomes. A behavioral event
Perceived Barriers to Action is initiated by a commitment to action unless there
Perceived barriers to action are anticipated, imag- is a competing demand that cannot be avoided, or a
ined, or real blocks and personal costs of undertak- competing preference that cannot be resisted (Pender,
ing a given behavior. personal communication, July 19, 2000).
Continued

400 UNIT IV Nursing Theories

MAJOR CONCEPTS & DEFINITIONS—cont’d
Commitment to a Plan of Action exert relatively high control, such as choice of ice
This commitment describes the concept of intention cream or an apple for a snack.
and identification of a planned strategy that leads to
implementation of health behavior. Health-Promoting Behavior
A health-promoting behavior is an end point or
Immediate Competing Demands action outcome that is directed toward attaining
and Preferences positive health outcomes such as optimal well-
Competing demands are alternative behaviors over being, personal fulfillment, and productive living.
which individuals have low control, because there Examples of health-promoting behavior are eating a
are environmental contingencies such as work or healthy diet, exercising regularly, managing stress,
family care responsibilities. Competing preferences gaining adequate rest and spiritual growth, and
are alternative behaviors over which individuals building positive relationships.



COGNITIVE-PERCEPTUAL MODIFYING FACTORS PARTICIPATION IN
FACTORS HEALTH-PROMOTING BEHAVIOR




Importance of health Demographic characteristics



Perceived control of health Biological characteristics




Perceived self-efficacy Interpersonal influences



Definition of health Situational factors Likelihood of engaging in
health-promoting behaviors


Perceived health status Behavioral factors
Cues to action


Perceived benefits of
health-promoting behaviors



Perceived barriers to
health-promoting behaviors


FIGURE 21-1 Health Promotion Model. (From Pender, N. J. [1987]. Health promotion in nursing practice
[2nd ed., p. 58]. New York: Appleton & Lange. Copyright Pearson Education, Upper Saddle River, NJ.)

CHAPTER 21 Nola J. Pender 401

model identifies concepts relevant to health-promoting
Use of Empirical Evidence behaviors and facilitates the generation of testable
The HPM, as depicted in Figure 21–1, served as a hypotheses (Pender, Murdaugh, & Parsons, 2002).
framework for research aimed at predicting overall The HPM provides a paradigm for the develop-
health-promoting lifestyles and specific behaviors ment of instruments. The Health Promoting Life-
such as exercise and use of hearing protection (Pender, style Profile and the Exercise Benefits-Barriers Scale
1987). Pender and colleagues conducted a program (EBBS) are two examples.* These instruments
of research funded by the National Institute of Nurs- serve to test the model and support further model
ing Research to evaluate the HPM in the following development.
populations: (1) working adults, (2) older commu- The purpose of the Health Promotion Lifestyle
nity-dwelling adults, (3) ambulatory patients with Profile instrument is to measure health-promoting
cancer, and (4) patients undergoing cardiac rehabili- lifestyle (Pender, 1996). The Health Promotion Life-
tation. These studies tested the validity of the HPM style Profile II (HPLP-II), is a revision of the original
(Pender, personal communication, May 24, 2000). A instrument for research. The 52-item, four-point,
†
summary of findings from earlier studies is included Likert-style instrument has six subscales: (1) health
in the 1996 edition of Health Promotion in Nursing responsibility, (2) physical activity, (3) nutrition,
Practice (Pender, 1996). Studies further testing the (4) interpersonal relations, (5) spiritual growth, and
model are discussed in the fifth edition of Health (6) stress management. The mean can be derived for
Promotion in Nursing Practice (Pender, Murdaugh, & each subscale, or a total mean signifying overall health-
Parsons, 2006). The fifth edition includes an emphasis promoting lifestyle (Walker, Sechrist, & Pender, 1987).
on the HPM as applied to diverse and vulnerable The instrument provides assessment of a health-
populations and addresses evidence-based practice. promoting lifestyle of individuals and is used clinically
The rationale for revision of the HPM stemmed by nurses for patient support and education.
from the research. The process of refining the HPM, The HPM identifies cognitive and perceptual
as published in 1987, led to several changes in the factors as major determinants of health-promoting
model (see Figure 21–1) (Pender, 1996). First, im- behavior. The EBBS measures the cognitive and
portance of health, perceived control of health, and perceptual factors of perceived benefits and perceived
cues for action were deleted. Second, definition of barriers to exercise (Sechrist, Walker, & Pender,
health, perceived health status, and demographic 1987). The 43-item, four-point, Likert-styled instru-
and biological characteristics were repositioned as ment consists of a 29-item benefits scale and a 14-item
personal factors in the 1996 revision of the HPM barriers scale that may be scored separately or as a
(Pender, 1996) and the fourth edition of Health Pro- whole. The higher the overall score on the 43-item
motion in Nursing Practice (Pender, Murdaugh, & instrument, the more positively the individual per-
Parsons, 2002) (Figure 21–2). Third, the revised ceives the benefits to exercise in relation to barriers to
HPM (see Figure 21–2) added three new variables exercise (Sechrist, Walker, & Pender, 1987). The EBBS
that influenced the individual to engage in health- is useful clinically for evaluating exercise perceptions.
promoting behaviors (Pender, 1996):
• Activity-related affect
• Commitment to a plan of action Major Assumptions
• Immediate competing demand and preferences The assumptions reflect the behavioral science
The revised HPM focuses on 10 categories of deter- perspective and emphasize the active role of the
minants of health-promoting behavior. The revised patient in managing health behaviors by modifying




*The EBBS can be obtained from the Health Promotion Research Program, Social Science Research Institute, Northern Illinois
University, DeKalb, IL 60115.
† The HPLP-II can be obtained through the faculty-staff profile for Dr. Susan Noble Walker, EdD, RN, at the College of Nursing,
University of Nebraska Medical Center. http://www.unmc.edu/nursing/Health_Promoting_Lifestyle_Profile_II.htm

402 UNIT IV Nursing Theories

INDIVIDUAL BEHAVIOR-SPECIFIC BEHAVIORAL
CHARACTERISTICS COGNITIONS OUTCOME
AND EXPERIENCES AND AFFECT

Perceived
benefits
of action


Perceived
barriers
to action
Prior Immediate competing
demands
related (low control)
behavior and preferences
Perceived (high control)
self-efficacy



Activity-related
affect
Personal
factors: Commitment Health-
biological, to a promoting
psychological, Interpersonal plan of action behavior
sociocultural influences
(family, peers,
providers), norms,
support, models




Situational
influences:
options,
demand characteristics,
aesthetics

FIGURE 21-2 Revised Health Promotion Model. (From Pender, N. J., Murdaugh, C. L., & Parsons,
M. A. [2002]. Health promotion in nursing practice [4th ed., p. 60]. Upper Saddle River, (NJ): Prentice-
Hall. Copyright Pearson Education, Upper Saddle River, NJ.)




the environmental context. In the third edition of 2. Persons have the capacity for reflective self-
her book, Health Promotion in Nursing Practice, awareness, including assessment of their own
Pender (1996) stated the major assumptions of the competencies.
HPM that address person, environment, and health 3. Persons value growth in directions viewed as posi-
as follows: tive and attempt to achieve a personally acceptable
1. Persons seek to create conditions of living through balance between change and stability.
which they can express their unique human health 4. Individuals seek to actively regulate their own
potential. behavior.

CHAPTER 21 Nola J. Pender 403

5. Individuals in all their biopsychosocial complexity 8. Persons are more likely to commit to and engage
interact with the environment, progressively trans- in health-promoting behaviors when significant
forming the environment and being transformed others model the behavior, expect the behavior
over time. to occur, and provide assistance and support to
6. Health professionals constitute a part of the inter- enable the behavior.
personal environment, which exerts influence on 9. Families, peers, and health care providers are
persons throughout their life spans. important sources of interpersonal influences
7. Self-initiated reconfiguration of person-environment that can increase or decrease commitment to and
interactive patterns is essential to behavioral change engagement in health-promoting behavior.
(pp. 54–55). 10. Situational influences in the external environ-
ment can increase or decrease commitment to or
participation in health-promoting behavior.
Theoretical Assertions 11. The greater the commitment to a specific plan of
The model depicts the multifaceted natures of persons action, the more likely health-promoting behav-
interacting with the environment as they pursue health. iors are to be maintained over time.
The HPM has a competence- or approach-oriented 12. Commitment to a plan of action is less likely to
focus (Pender, 1996). Health promotion is motivated result in the desired behavior when competing
by the desire to enhance well-being and to actualize demands over which persons have little control
human potential (Pender, 1996). In her first book, require immediate attention.
Health Promotion in Nursing Practice, Pender (1982) 13. Commitment to a plan of action is less likely to
asserts that complex biopsychosocial processes moti- result in the desired behavior when other actions
vate individuals to engage in behaviors directed toward are more attractive and thus preferred over the
the enhancement of health. Fourteen theoretical asser- target behavior.
tions derived from the model appear in the fourth edi- 14. Persons can modify cognitions, affect, and the
tion of the book, Health Promotion in Nursing Practice interpersonal and physical environments to cre-
(Pender, Murdaugh, & Parsons, 2002): ate incentives for health actions (pp. 63–64).
1. Prior behavior and inherited and acquired charac-
teristics influence beliefs, affect, and enactment of
health-promoting behavior. Logical Form
2. Persons commit to engaging in behaviors from The HPM was formulated through induction by use
which they anticipate deriving personally valued of existing research to form a pattern of knowledge
benefits. about health behavior. The HPM is a conceptual
3. Perceived barriers can constrain the commitment model from which middle-range theories may be de-
to action, the mediator of behavior, and the actual veloped. It was formulated with the goal of integrat-
behavior. ing what is known about health-promoting behavior
4. Perceived competence or self-efficacy to execute a to generate questions for further testing. This model
given behavior increases the likelihood of com- illustrates how a framework of previous research fits
mitment to action and actual performance of be- together, and how concepts can be manipulated for
havior. further study.
5. Greater perceived self-efficacy results in fewer per-
ceived barriers to specific health behavior. Acceptance by the Nursing Community
6. Positive affect toward a behavior results in greater
perceived self-efficacy, which, in turn, can result in Practice
increased positive affect. Wellness as a nursing specialty has grown in promi-
7. When positive emotions or affect is associated nence, and current state-of-the-art clinical practice
with a behavior, the probability of commitment includes health promotion education. Nursing profes-
and action is increased. sionals find the HPM relevant, as it applies across the

404 UNIT IV Nursing Theories

life span and is useful in a variety of settings (Pender, its application to include global health-promotion
1996; Pender, Murdaugh, & Parsons, 2002). The model strategies.
applies the formation of community partnerships
with its consideration of the environmental context
and extends to global health promotion (Pender, Further Development
Murdaugh, & Parsons, 2010). The model continues to be refined and tested for its
Clinical interest in health behaviors represents a power to explain the relationships among factors be-
philosophical shift that emphasizes quality of lives lieved to influence changes in a wide array of health
alongside the saving of lives. In addition, there are behaviors. Sufficient empirical support for model
financial, human, and environmental burdens upon variables now exists for some behaviors to warrant
society when individuals do not engage in preven- design and conduct of intervention studies to test
tion and health promotion. The HPM contributes a model-based nursing interventions. Lusk and col-
nursing solution to health policy and health care leagues (Lusk, Hong, Ronis, et al., 1999; Lusk, Kwee,
reform by providing a means for understanding Ronis, & Eakin, 1999) used important predictors of
how consumers can be motivated to attain personal construction workers’ use of hearing protection from
health. the HPM (self-efficacy, barriers, interpersonal influ-
ences, and situational influences) to develop an inter-
Education active, video-based program to increase use. This
The HPM is used widely in graduate education large, multiple-site study found that the intervention
and increasingly in undergraduate nursing education increased the use of worker hearing protection by
in the United States (Pender, personal communi- 20% compared with the group without intervention—
cation, May 24, 2000). In the past, health promotion a statistically significant improvement from baseline
was placed behind illness care, because clinical edu- (Lusk, Hong, Ronis, et al., 1999). Additional interven-
cation was conducted primarily in acute care settings tion studies represent the next step in the use of the
(Pender, Baraukas, Hayman, et al., 1992). Increas- model to build nursing science.
ingly, the HPM is incorporated in nursing curricula
as an aspect of health assessment, community health Critique
nursing, and wellness-focused courses (N. Pender,
personal communication, May 24, 2000). Growing Clarity
international efforts across a number of countries are The conceptual definitions provide clarity and lead to
working to integrate the HPM into nursing curricula greater understanding of the complexity of health
(Pender, personal communication, May 6, 2004; Pender, behavior phenomena. Visual diagrams illustrate the
Murdaugh, & Parsons, 2002). relationships clearly (see Fig. 21–2).
Research Simplicity
The HPM is a tool for research. Pender’s research The HPM is easy to understand. The factors in
agenda and that of other researchers have tested each set are linked logically and the relationships are
and report the empirical precision of the model. The clarified in the theoretical assertions. The sets of
Health Promoting Lifestyle Profile, derived from the factors, which are direct or indirect influences, are
model, serves as the operational definition for health- clear in visual diagrams that display their associa-
promoting behaviors. Drawing upon the HPLP, the tions. Factors are seen as independent, but the sets
Adolescent Lifestyle Profile demonstrates the adapt- have an interactive effect that results in action.
ability of the HPM to the life span (Hendricks,
Murdaugh, & Pender, 2006). The HPM model has Generality
applications emphasizing the importance for the The model is middle range in scope. It is highly
assessment of factors believed to influence health generalizable to adult populations. The research used
behavior changes. Further research is indicated to to derive the model was based on male, female, young,
examine the environmental context and expand old, well, and ill samples. The research agenda includes

CHAPTER 21 Nola J. Pender 405

application in a variety of settings. A research program
tested the applicability of the model to children 10 to CASE STUDY
16 years of age (Robbins, Gretebeck, Kazanis, & Thomas, a 26-year-old graduate student of Cuban
Pender, 2006). Cultural and diversity considerations descent, comes to the college health clinic to dis-
support model testing in diverse populations. cuss his perceived weight problem. He tells you
that he wants a more business-like look and wants
Accessibility to have more energy. He says that he is tired of
Pender and others have supported the model through having his belly fall over his belt. In your physical
empirical testing as a framework for explaining health assessment, you find that Thomas is 5 feet 11inches,
promotion. The Health Promoting Lifestyle Profile weighs 260 pounds, and has mild hypertension
is an instrument used to assess health-promoting (132/90 mm Hg). His mother has a history of dia-
behaviors (Pender, Murdaugh, & Parsons, 2006). The betes mellitus, and he tells you that high blood
model continues to evolve through planned pro- pressure runs in the family. His 64-year-old father
grams of research. Continued empirical research, had a heart attack 1 year ago. His electrocardio-
especially intervention studies, further refine the gram demonstrates normal sinus rhythm. He does
model. Research foci continue upon evidence-based not smoke. He says that his stress level is high,
and effective health promotion strategies that serve because he is working on his master’s thesis.
the individual within the context of the community Thomas leaves to have some screening blood work
(Pender, Murdaugh, & Parsons, 2010). and makes an appointment to see you next week.
You begin some preliminary planning. Analysis of
Importance this case study follows to illustrate the use of the
Pender identified health promotion as a goal for the HBM in action with Thomas:
twenty-first century, just as disease prevention was a 1. What online state-of-the-science resources
task of the twentieth century. The model describes the would you use to help you in planning disease
interaction between the nurse and the consumer prevention and health promotion?
while considering the role of environment in health n The Agency for Healthcare Research and
promotion (Pender, Murdaugh, & Parsons, 2010). Quality provides a “Guide to Clinical Pre-
Pender responded to the political, social, and per- ventive Services,” which lists the latest
sonal environment of her time to clarify nursing’s role available recommendations on preventive
in delivering health promotion services to persons of interventions: screening tests, counseling,
all ages. The model fosters thinking about future op- immunizations, and medication regimens
portunities and influences the use of technological for more than 80 conditions. Age-specific
advances such as the electronic health record as a periodic screenings based on gender and
means to achieve prevention and health promotion individual risk factors are available from
(Pender, Murdaugh, & Parsons, 2010). the website (http://www.ahrq.gov/clinic/
uspstfix.htm). The consumer section offers

Summary downloadable files for your personal digital
assistant as another resource.
The movement to greater responsibility and account- n Go to http://www.ahrq.gov/research/
ability for successful personal health practices re- obesity.htm. Look under the Screening and
quires the support of the nursing profession through treatment.
development of evidence-based practice. The HPM n Healthy People 2020 includes a comprehen-
evolved from a substantive research program and sive set of disease prevention and health
continues to provide direction for better health prac- promotion objectives developed to improve
tices. The model guides further research in various the health of all people in the United States
populations. Dr. Pender’s visionary leadership contin- during the first decade of the twenty-first
ues to influence health promotion–related education, century (http://www.healthypeople.gov).
research, and policy.

406 UNIT IV Nursing Theories

n The U.S. Department of Health and Human limited time for physical activity, possibly
Services website contains information using eating as a coping mechanism. (Addi-
about safety and wellness and more (http:// tional assessment is indicated to validate
www.hhs.gov). Look under the category of barriers.)
prevention. 4. List some alternatives in the behavior change
2. What were some of the emotional and behav- plan that you will discuss with Thomas at your
ioral cues provided that suggest Thomas is next meeting. In general, discuss diet, physical
ready for a weight loss management plan? activity, and stress management.
n Thomas demonstrated self-direction, because n Complete a behavioral contract as a com-
he came to the clinic on his own. mitment to a plan of action. In the plan,
n He told you that he wants a more business- establish a long-term weight loss goal and
like look and wants to have more energy. short-term progress goals.
n He stated that he is tired of having his belly n Review kinds of foods he enjoys, while
fall over his belt. assessing dietary concerns, if any.
n He stated that his stress level is high. n Discuss ways to increase physical activity
3. In establishing a behavior change plan with and which of the activities he intends to
Thomas, what are some interpersonal facilita- carry out, and establish a calendar.
tors and potential barriers to change? n Provide a referral to the campus physical
n Facilitators: Self-direction, motivation by activity trainer.
family medical history, desire for change. n Discuss stress management.
n Potential barriers: Graduate students may n Establish follow-up.
have limited financial resources; stress level n Schedule weight checks every week.
is high, and Thomas may view self with n Begin reward-reinforcement planning.


CRITICAL THINKING ACTIVITIES
1. Choose one health-promoting behavior in which 3. Consider your own philosophy of health and
you personally could but don’t engage. Identify prepare your description of wellness. Is absence
factors, as defined in the HPM, which contribute of disease more prominent than positive, active
to your decision not to participate. Include statements of health?
immediate competing alternatives. 4. Anticipate the health-promoting behaviors im-
2. Analyze factors that contribute to your participa- portant at various stages of development across
tion in a health-promoting activity and place each the life span. What health promotion topics do
factor under the appropriate label from the HPM. you include in your practice?

POINTS FOR FURTHER STUDY
n Nola J. Pender, Faculty-Staff profile, University at the Nursing Conference, October 16–17,
of Michigan School of Nursing. Retrieved from Memphis, TN. Available through University of
http://nursing.umich.edu/faculty-staff/nola-j- Tennessee, Memphis, School of Nursing.
pender n Pender, N. J. (1989, May). Expressing health
n Pender, N. J. (2008). Portraits of Excellence: The through beliefs and actions (Videotape). Recorded
Nurse Theorists, Vol. 2. Athens, Ohio: Fitne, Inc. live at Discovery Inter-national, Inc.’s Nurse Theo-
n Pender, N. J. (1986, Oct.). Enhancing wellness rist Conference, May 11–12, Pittsburgh. Available
through nursing research (Videotape). Recorded through Meetings Internationale, Louisville, KY.

CHAPTER 21 Nola J. Pender 407

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New York: Appleton-Century-Crofts. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006).
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tion. In H. Werley & J. Fitzpatrick (Eds.), Annual review semantic differential, and acoustical dimensions as
of nursing research (pp. 83–105). New York: Springer. encoding categories in short-term memory (Doctoral
Pender, N. J. (1985). Self modification. In G. Bulechek & dissertation, Northwestern University). Dissertation
J. McCloskey (Eds.), Interventions: Treatments for nurs- Abstracts International, A, 30(10), 4283.
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strategies. In B. Logan & C. Dawkins (Eds.), Family- Adeyemi, A. A., Jarad, F., Pender, N., & Higham, S. M. (2007).
centered nursing in the community (pp. 295–334). Assessing the efficacy of denture cleaners with quantitative
Menlo Park, (CA): Addison-Wesley. light-induced fluorescence (qlf). European Journal of
Pender, N. J. (1987). Health and health promotion: The Prosthodontics & Restorative Dentistry, 15(4), 165–170.
conceptual dilemmas. In M. E. Duffy & N. J. Pender Garcia, A. W., Broda, M. A., Frenn, M., Coviak, C.,
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of proceedings of a wingspread conference (pp. 7–23). opmental differences in exercise beliefs among youth
Indianapolis: Sigma Theta Tau International. and prediction of their exercise behavior [Japanese
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culturally diverse populations: Can we meet the chal- barriers, and commitment to a plan for exercise among
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22

CHAP TER



















Madeleine M. Leininger
1925 to 2012


Culture Care Theory of Diversity

and Universality


Marilyn R. McFarland



“Care is the essence of nursing and a distinct, dominant, central and unifying focus”
(Madeleine Leininger, 2002e, p. 192).




instructor, staff nurse, and head nurse on a medical-
Credentials and Background surgical unit and opened a psychiatric unit while
of the Theorist director of nursing service at St. Joseph’s Hospital in
Madeleine M. Leininger is the founder of transcultural Omaha. During this time, she pursued advanced
nursing and a leader in transcultural nursing and hu- study in nursing at Creighton University in Omaha,
man care theory. She was the first professional nurse Nebraska (Leininger, 1995c, 1996b).
with graduate preparation in nursing to hold a PhD in In 1954, Leininger obtained a master’s degree in
cultural and social anthropology. Leininger was born psychiatric nursing from Catholic University of
in Sutton, Nebraska, and began her nursing career after America in Washington, D.C. She became employed
graduating from the diploma program at St. Anthony’s at the University of Cincinnati College of Health,
School of Nursing in Denver where she was also in the where she began the first master’s-level clinical spe-
U.S. Army Nurse Corps. In 1950, she obtained a bach- cialist program in child psychiatric nursing. She
elor’s degree in biological science from Benedictine initiated the first graduate nursing program in
College in Atchison, Kansas, with a minor in philoso- psychiatric nursing at the University of Cincinnati
phy and humanistic studies. After graduation, she was and a Therapeutic Psychiatric Nursing Center at the


Photo credit: Kathleen Leininger, Shiner, TX

417

418 UNIT IV Nursing Theories

University Hospital in Cincinnati. During this time, between nursing and anthropology, formulating
she wrote a basic psychiatric nursing text with Hofling transcultural nursing concepts, theory, principles,
entitled Basic Psychiatric Concepts in Nursing, which and practices. Her book, Nursing and Anthropology:
was published in 1960 and in 11 languages (Hofling & Two Worlds to Blend(1970), laid the foundation for
Leininger, 1960). developing transcultural nursing, the Culture Care
While in Cincinnati, Leininger discovered that the Theory, and culturally based health care. Her second
staff lacked understanding of cultural factors influenc- book, Transcultural Nursing: Concepts, Theories, and
ing the behavior of children. Among these children of Practice (1978), identified major concepts, theoretical
diverse cultural backgrounds, she observed differences ideas, and practices in transcultural nursing, the
in responses to care and psychiatric treatments that first definitive publication on transcultural nursing.
deeply concerned her. She became increasingly con- Leininger established, explicated, and used the Cul-
cerned that her nursing decisions and actions, and ture Care Theory to study many cultures in the United
those of other staff, did not appear to help these chil- States and worldwide. She developed the ethnonursing
dren adequately. Leininger posed many questions to qualitative research method to fit the theory and
herself and the staff about cultural differences among to discover the insider or emic view of cultures
children and therapy outcomes and observed that few (Leininger, 1991b, 1995c). The ethnonursing research
staff members were knowledgeable about cultural fac- method was the first nursing research method devel-
tors in the diagnosis and treatment of clients. Margaret oped for nurses to examine complex care and cultural
Mead became a visiting professor at the University of phenomena. Over 50 nurses with doctoral degrees
Cincinnati Department of Psychiatry, and Leininger and many master’s and baccalaureate students have
discussed potential interrelationships between nursing been prepared in transcultural nursing and have used
and anthropology with Mead. Although not encour- Leininger’s Culture Care Theory (Leininger, 1990a,
aged by Mead, Leininger decided to pursue doctoral 1991b; Leininger & McFarland, 2002a; Leininger &
study focused on cultural, social, and psychological Watson, 1990).
anthropology at University of Washington, Seattle. The first transcultural nursing course was offered at
As a doctoral student, Leininger studied many cul- the University of Colorado in 1966, where Leininger
tures. She found anthropology fascinating and believed was professor of nursing and anthropology (the first
it should be of interest to all nurses. She focused on the joint appointment of a professor of nursing in the
Gadsup people of the Eastern Highlands of New Guinea, United States) and where she initiated and directed
where she lived with the indigenous people for 2 years the nurse scientist program (PhD). In 1969, she was
and undertook an ethnographical and ethnonursing appointed Dean and Professor of Nursing and Lecturer
study of two villages (Leininger, 1995c, 1996b). Not only in Anthropology at the University of Washington,
was she able to observe unique features of the culture, Seattle, where she established an academic nursing
she also observed a number of marked cultural differ- department for master’s and doctoral programs in
ences related to caring health and well-being practices. transcultural nursing. She initiated several transcul-
From her in-depth study and first-hand experiences tural nursing courses and guided the first nurses in a
with the Gadsup, she developed her Culture Care The- PhD program in transcultural nursing. She initiated
ory of Diversity and Universality (Culture Care The- the Committee on Nursing and Anthropology with the
ory) and the ethnonursing method (Leininger, 1978, American Anthropological Association in 1968.
1981, 1991b, 1995c). Leininger’s research and theory In 1974, Leininger was appointed Dean and Profes-
have helped nursing students understand cultural differ- sor of Nursing at the College of Nursing and Adjunct
ences in human care, health, and illness. She has been Professor of Anthropology at the University of Utah in
a major nurse leader encouraging many students and Salt Lake City. There she initiated master’s and doctoral
faculty to pursue graduate education and practice. Her programs in transcultural nursing (Leininger, 1978).
enthusiasm in developing transcultural nursing with a These programs were the first to offer substantive
human care focus sustained her for over 5 decades. courses focused specifically on transcultural nursing. In
Leininger (1970, 1978) identified several common 1981, Leininger was recruited to Wayne State University
areas of knowledge and theoretical research interests in Detroit, where she was Professor of Nursing, Adjunct

CHAPTER 22 Madeleine M. Leininger 419

Professor of Anthropology, and Director of Transcul- active in consulting, writing, and lecturing. Her goal is
tural Nursing Offerings until her semi-retirement in to establish transcultural nursing institutes to educate
1995. She directed the Center for Health Research and facilitate research on transcultural nursing and
there for 5 years. While at Wayne State University, she health phenomena.
developed courses and seminars in transcultural Leininger has written or edited more than 30 books
nursing, caring, and qualitative research methods for listed in the bibliography of this chapter along with
baccalaureate, master’s, doctoral, and postdoctoral more than 200 articles and 45 book chapters. She has
nursing students and for non-nursing students. been featured in numerous films, videos, DVDs, and
Dr. Leininger taught and mentored students and research reports focused on transcultural nursing,
nurses in field research in transcultural nursing. One human care and health phenomena, the future of nurs-
of the first nurse leaders to use qualitative research ing, and topics relevant in nursing and anthropology.
methods in the 1960s, she taught these methods at She served on eight editorial boards and refereed
various universities in the United States and world- publications, and is involved with the Transcultural
wide. Leininger studied 14 cultures and continues to Nursing Scholars Group and her website (www.made-
consult for research projects and institutions that are leine-leininger.com). She is one of the most creative,
using her Culture Care Theory. productive, innovative, and futuristic authors in nurs-
Leininger’s academic vitae includes nearly 600 con- ing, providing new and substantive research-based
ferences, keynote addresses, workshops, and services transcultural nursing content to advance nursing as a
as a consultant in the United States, Canada, Europe, discipline and a profession.
Pacific Island nations, Asia, Africa, Australia, and the Leininger has received many awards and honors for
Nordic countries. Educational and service organiza- her lifetime professional and academic accomplishments.
tions requested consultation on transcultural nursing, She is in Who’s Who of American Women, Who’s Who in
humanistic caring, ethnonursing research, Culture Health Care, Who’s Who in Community Leaders, Who’s
Care Theory, and trends in health care worldwide. Who of Women in Education, International Who’s Who
In addition to transcultural nursing with care as a in Community Service, Who’s Who in International
central focus, Leininger’s interests include comparative Women, and other such listings. Her name appears
education and administration, nursing theories, poli- on the National Register of Prominent Americans and
tics, ethical dilemmas of nursing and health care, quali- International Notables, International Women, and the
tative research, future nursing and health care, and National Register of Prominent Community Leaders.
nursing leadership. Her Culture Care Theory is used She has received honorary degrees, including the LHD
worldwide and is growing in relevance with the discov- from Benedictine College in Atchison, Kansas; a PhD
ery of knowledge from diverse cultures. Leininger initi- from University of Kuopio, Finland; and a DS from the
ated the National Transcultural Nursing Society in 1974 University of Indiana, Indianapolis. In 1976 and 1995,
and established the National Research Care Conference Leininger was recognized for her significant contribu-
in 1978 for nurses to study human care phenomena tions to the American Association of Colleges of Nurs-
(Leininger, 1981, 1984a, 1988a, 1990a, 1991b; Leininger ing as its first full-time president. She received the
& Watson, 1990). She initiated the Journal of Transcul- Russell Sage Outstanding Leadership Award in 1995
tural Nursing in 1989 and was editor until 1995. and is designated as a Fellow of the American Academy
Leininger worked enthusiastically to persuade nurs- of Nursing and the Society for Applied Anthropology.
ing educators and practitioners to incorporate trans- Her affiliations include Sigma Theta Tau International,
cultural nursing and culture-specific care concepts into Delta Kappa Gamma, and the Scandinavian College of
nursing curricula and clinical practices for all aspects Caring Science in Stockholm, Sweden. She was a distin-
of nursing (Leininger, 1991b, 1995c; Leininger & guished visiting scholar and lecturer at 85 universities
McFarland, 2002a; Leininger & Watson, 1990). She in the United States and worldwide and was a visiting
remained active in two disciplines and continued to professor at universities in Sweden, Wales, Japan, China,
contribute to nursing and anthropology at national and Australia, Finland, New Zealand, and the Philippines.
international conferences and meetings. Dr. Leininger While at Wayne State University, Leininger received the
resides in Omaha, Nebraska, and is semi-retired but Board of Regents’ Distinguished Faculty Award, the

420 UNIT IV Nursing Theories

Distinguished Research Award, the President’s Excel- successful outcomes (Leininger, 1991b, 1995c, 1996a,
lence in Teaching, and the Outstanding Graduate 1996b; Leininger & McFarland, 2002a, 2006).
Faculty Mentor Award. In 1996, Madonna University, Leininger (2002a) distinguishes between transcul-
Livonia, Michigan, honored her with the dedication of tural nursing and cross-cultural nursing. The former
the Leininger Book Collection and a Leininger Read- refers to nurses prepared in transcultural nursing who
ing Room for her outstanding contributions to nurs- are committed to develop knowledge and practice in
ing and the social sciences and humanities. transcultural nursing, whereas cross-cultural nursing
refers to nurses who apply anthropological concepts
(Leininger, 1995c; Leininger & McFarland, 2002a).
Theoretical Sources She specifies international nursing and transcultural
Leininger’s theory is derived from the disciplines of nursing as follows: international nursing focuses on
anthropology and nursing (Leininger, 1991b, 1995c; nurses functioning between two cultures; and, trans-
Leininger & McFarland, 2002b, 2006). She defined cultural nursing focuses on several cultures with a
transcultural nursing as a major area of nursing comparative theoretical and practice base (Leininger,
focused on the comparative study and analysis of 1995c; Leininger & McFarland, 2002a).
diverse cultures and subcultures in the world with Leininger describes the transcultural nurse gener-
respect to their caring values, expressions, health- alist as a nurse prepared at the baccalaureate level who
illness beliefs, and patterns of behavior. is able to apply transcultural nursing concepts, prin-
The purpose of the theory was to discover human ciples, and practices generated by transcultural nurse
care diversities and universalities in relation to world- specialists (Leininger, 1989a, 1989b, 1991c, 1995c;
view, social structure, and other dimensions cited, and Leininger & McFarland, 2002a). The transcultural
then to discover ways to provide culturally congruent nurse specialist prepared in graduate programs receives
care to people of different or similar cultures in order to in-depth preparation and mentorship in transcultural
maintain or regain their well-being or health, or to face nursing knowledge and practice. This specialist has
death in a culturally appropriate way (Leininger, 1985b, acquired competency skills through postbaccalaureate
1988b, 1988c, 1988d; as cited in 1991b). The goal of the education. “This specialist has studied selected cultures
theory is to improve and provide culturally congruent in sufficient depth (values, beliefs, and lifeways) and
care to people—care that is beneficial and useful to the is highly knowledgeable and theoretically based about
client, family, or culture group (Leininger, 1991b). care, health, and environmental factors related to
Transcultural nursing goes beyond an awareness transcultural nursing perspectives” (Leininger, 1984b,
state to that of using Culture Care nursing knowledge p. 252). The transcultural nurse specialist is an expert
to practice culturally congruent and responsible care field practitioner, teacher, researcher, and consultant
(Leininger, 1991b, 1995c). Leininger has stated that with respect to select cultures. This individual values
there will be nursing practice that reflects nursing and uses nursing theory to develop and advance
practices that are culturally defined, grounded, and knowledge within the discipline of transcultural nurs-
specific to guide nursing care provided to individuals, ing (1995c, 2001).
families, groups, and institutions. She contends that Leininger (1996b) holds and promotes a new and
because culture and care knowledge are the most different type of theory. She defines theory as the sys-
holistic means to conceptualize and understand tematic and creative discovery of knowledge about a
people, they are central to and imperative to nursing domain of interest or a phenomenon that is important
education and practice (Leininger, 1991b, 1995c; to understand or to account for some unknown phe-
Leininger & McFarland, 2002a, 2006). She states that nomenon. She believes nursing theory should take into
transcultural nursing is one of the most important, account creative discovery about individuals, families,
relevant, and highly promising areas of formal study, and groups, and their caring, values, expressions,
research, and practice because we live in a multicul- beliefs, and actions or practices based on their cultural
tural world (Leininger, 1984a, 1988a, 1995c; Leininger lifeways to provide effective, satisfying, and culturally
& McFarland, 2002a, 2006). She predicts cultural nurs- congruent care. If nursing practices fail to recognize
ing knowledge and competencies will be imperative to the cultural aspects of human needs, there will be evi-
guide all nursing decisions and actions for effective and dence of dissatisfaction with nursing services, which

CHAPTER 22 Madeleine M. Leininger 421

limits healing and well-being (Leininger, 1991b, 1995a, knowledge (1991b). The theory is neither a middle-
1995c; Leininger & McFarland, 2002a, 2006). range nor macro theory but is best viewed broadly with
Leininger (1991b) developed her Theory of Cul- specific domains of interest (1991b, 1995c; Leininger
ture Care Diversity and Universality, based on the & McFarland, 2002a, 2006). According to Leininger
belief that people of different cultures can inform and (2002c), the Theory of Culture Care Diversity and
are capable of guiding professionals to receive the Universality has several distinct features. It is focused
kind of care they desire or need from others. Culture explicitly on discovering holistic and comprehensive
is the patterned and valued lifeways of people that Culture Care, and it can be used in Western and non-
influence their decisions and actions; therefore, the Western cultures because of multiple holistic factors
theory is directed toward nurses to discover and found universally. It is purposed to discover compre-
document the world of the client and to use their emic hensive factors influencing human care such as world-
viewpoints, knowledge, and practices with appropri- view, social structure factors, language, generic and
ate etic (professional knowledge) as bases for making professional care, ethnohistory, and the environmental
culturally congruent professional care actions and context. It has three theoretical practice modalities
decisions (Leininger, 1991b, 1995c). Culture Care is a to arrive at culturally congruent care decisions and
broad nursing theory because it takes into account actions to support well-being, health, and satisfactory
the holistic perspective of human life and existence lifeways for people. The theory is designed to ulti-
over time, including the social structure factors, mately discover care—what is diverse and what is
worldview, cultural history and values, environmental universally related to care and health—and has a com-
context (Leininger, 1981), language expressions, and parative focus to identify different or contrasting trans-
folk (generic) and professional patterns viewed in cultural nursing care practices with specific care
terms of culture. These are some of the essential bases constructs. The ethnonursing method has enablers
for discovery of grounded care knowledge, which is designed to tease out in-depth informant emic data
the essence of nursing leading to the well-being of that can be used for cultural health care assessments.
clients and therapeutic nursing practice. The theory may generate new knowledge in nursing
The Culture Care Theory is inductive and deduc- and health care for culturally congruent, safe, and
tive, derived from emic (insider) and etic (outsider) responsible care.





MAJOR CONCEPTS & DEFINITIONS
Leininger developed terms relevant to the theory. or institutions that are learned, shared, and usually
The major terms are defined here, and one can access transmitted from one generation to another.
the full theory from her works (Leininger, 1991b,
1995c; Leininger & McFarland, 2002a, 2006). Culture Care
Culture Care refers to the synthesized and culturally
Human Care and Caring constituted assistive, supportive, enabling, or facili-
The concept of human care and caring refers to the tative caring acts toward self or others focused on
abstract and manifest phenomena with expressions evident or anticipated needs for the client’s health
of assistive, supportive, enabling, and facilitating or well-being, or to face disabilities, death, or other
ways to help self or others with evident or antici- human conditions.
pated needs to improve health, a human condition,
or lifeways, or to face disabilities or dying. Culture Care Diversity
Culture Care diversity refers to cultural variability or
Culture differences in care beliefs, meanings, patterns, values,
Culture refers to patterned lifeways, values, beliefs, symbols, and lifeways within and between cultures
norms, symbols, and practices of individuals, groups, and human beings.
Continued

422 UNIT IV Nursing Theories

MAJOR CONCEPTS & DEFINITIONS—cont’d
Culture Care Universality and practiced by individuals or groups and that
Culture Care universality refers to commonalities or enables them to function in their daily lives.
similar culturally based care meanings (“truths”), Transcultural Nursing
patterns, values, symbols, and lifeways reflecting
care as a universal humanity. Transcultural nursing refers to a formal area of
humanistic and scientific knowledge and practices
Worldview focused on holistic Culture Care (caring) phe-
Worldview refers to the way an individual or a group nomena and competencies to assist individuals or
looks out on and understands the world about them groups to maintain or regain their health (or well-
as a value, stance, picture, or perspective about life being) and to deal with disabilities, dying, or other
and the world. human conditions in culturally congruent and
beneficial ways.
Cultural and Social Structure Dimensions Culture Care Preservation or Maintenance
Cultural and social structure dimensions refer to the
dynamic, holistic, and interrelated patterns of struc- Culture Care preservation or maintenance refers to
tured features of a culture (or subculture), including those assistive, supportive, facilitative, or enabling
religion (or spirituality), kinship (social), political professional actions and decisions that help people
characteristics (legal), economics, education, technol- of a particular culture to retain or maintain mean-
ogy, cultural values, philosophy, history, and language. ingful care values and lifeways for their well-being,
to recover from illness, or to deal with handicaps or
Environmental Context dying.
Environmental context refers to the totality of an envi- Culture Care Accommodation or Negotiation
ronment (physical, geographic, and sociocultural),
situation, or event with related experiences that give Culture Care accommodation or negotiation refers to
interpretative meanings to guide human expressions those assistive, supportive, facilitative, or enabling
and decisions with reference to a particular environ- professional actions and decisions that help people
ment or situation. of a designated culture (or subculture) to adapt to or
to negotiate with others for meaningful, beneficial,
Ethnohistory and congruent health outcomes.
Ethnohistory refers to the sequence of facts, events, Culture Care Repatterning or Restructuring
or developments over time as known, witnessed, or
documented about a designated people of a culture. Culture Care repatterning or restructuring refers to
the assistive, supportive, facilitative, or enabling
Emic professional actions and decisions that help clients
Emic refers to local, indigenous, or the insider’s reorder, change, or modify their lifeways for new,
views and values about a phenomenon. different, and beneficial health outcomes.

Etic Culturally Competent Nursing Care
Etic refers to the outsider’s or more universal views Culturally competent nursing care refers to the explicit
and values about a phenomenon. use of culturally based care and health knowledge in
sensitive, creative, and meaningful ways to fit the
Health general lifeways and needs of individuals or groups
Health refers to a state of well-being or a restorative for beneficial and meaningful health and well being,
state that is culturally constituted, defined, valued, or to face illness, disabilities, or death.

CHAPTER 22 Madeleine M. Leininger 423

theory is that the construct of care has been critical
Use of Empirical Evidence to human growth, development, and survival for
For more than 6 decades, Leininger has held that care human beings from the beginning of the human spe-
is the essence of nursing and the dominant, distinctive, cies (Leininger, 1981, 1984a). The second reason is to
and unifying feature of nursing (1970, 1981, 1988a, explicate and fully understand cultural knowledge
1991b; Leininger & McFarland, 2002a, 2006). She has and the roles of caregivers and care recipients in dif-
found that care is complex, elusive, and embedded in ferent cultures to provide culturally congruent care
social structure and other aspects of culture (1991b; (Leininger, 1991b, 1995c, 2002a, 2002b, 2002c). Third,
Leininger & McFarland, 2006). She holds that different care knowledge is discovered and can be used as
forms, expressions, and patterns of care are diverse, essential to promote the healing and well-being
and some are universal (Leininger, 1991b; Leininger & of clients, to face death, or to ensure the survival of
McFarland, 2002a, 2006). Leininger (1985a, 1990b) human cultures over time (Leininger, 1981, 1984a,
favors qualitative ethnomethods, especially ethnonurs- 1991b). Fourth, the nursing profession needs to sys-
ing, to study care. These methods are directed toward tematically study care from a broad and holistic cul-
discovering the people-truths, views, beliefs, and pat- tural perspective to discover the expressions and
terned lifeways of people. During the 1960s, Leininger meanings of care, health, illness, and well-being as
developed the ethnonursing method to study transcul- nursing knowledge (Leininger, 1991b, 1995c, 2002a,
tural nursing phenomena specifically and systemati- 2002b, 2002c). Leininger (1991b, 1995c, 2002a, 2002b,
cally. The method focuses on the classification of care 2002c) finds that care is largely an elusive phenome-
beliefs, values, and practices as cognitively or subjec- non often embedded in cultural lifeways and values.
tively known by a designated culture (or cultural repre- However, this knowledge is a sound basis for nurses
sentatives) through their local emic people-centered to guide their practice for culturally congruent care
language, experiences, beliefs, and value systems about and specific therapeutic ways to maintain health, pre-
actual or potential nursing phenomena such as care, vent illness, heal, or help people face death (Leininger,
health, and environmental factors (Leininger, 1991b, 1994). A central thesis of the theory is that if the
1995c; Leininger & McFarland, 2002a, 2006). Although meaning of care can be fully grasped, the well-being
nursing has used the words careand caringfor more or health care of individuals, families, and groups can
than a century, the definitions and usage have been be predicted, and culturally congruent care can be
vague and used as clichés without specific meanings to provided (Leininger, 1991b). Leininger (1991b) views
the culture of the client or nurse (Leininger, 1981, care as one of the most powerful constructs and the
1984a). “Indeed, the concepts about caring have been central phenomenon of nursing. However, such care
some of the least understood and studied of all human constructs and patterns must be fully documented,
knowledge and research areas within and outside of understood, and used to ensure that culturally based
nursing” (Leininger, 1978, p. 33). care becomes the major guide to transcultural nurs-
With the transcultural care theory and ethnonurs- ing therapy and is used to explain or predict nursing
ing method based on emic (insider views) beliefs, a practices (Leininger, 1991b).
person gets close to the discovery of people-based To date, Leininger has studied several cultures in
care, because data come directly from people rather depth and has studied many cultures with undergradu-
than the etic (outsider views) beliefs and practices of ate and graduate students and faculty using qualitative
the researcher. An important purpose of the theory is research methods. She has explicated care constructs
to document, know, predict, and explain systemati- throughout cultures in which each culture has different
cally through field data what is diverse and universal meanings, cultural experiences, and uses by people of
about generic and professional care of the cultures diverse and similar cultures (Leininger, 1991b, 1995c;
being studied (Leininger, 1991b). Leininger & McFarland, 2002a, 2006). New knowledge
Leininger (1984a, 1988a) holds that detailed and continues to be discovered by transcultural nurses in
culturally based caring knowledge and practices the development of transcultural care practices with
should distinguish nursing’s contributions from those diverse and similar cultures. In time, Leininger (1991b)
of other disciplines. The first reason for studying care contends, diverse and universal features of care and

424 UNIT IV Nursing Theories

health will be documented as the essence of nursing 4. Transcultural nursing is a humanistic and scien-
knowledge and practice. tific care discipline and profession with the central
Leininger believes that nurses must work toward purpose to serve individuals, groups, communi-
explicating care use and meanings so that culture care, ties, societies, and institutions.
values, beliefs, and lifeways can provide accurate and 5. Culturally based caring is essential to curing and
reliable bases for planning and effectively implementing healing, for there can be no curing without caring,
culture-specific care and for identifying any universal or but caring can exist without curing.
common features about care. She maintains that nurses 6. Culture Care concepts, meanings, expressions,
cannot separate worldviews, social structures, and cul- patterns, processes, and structural forms of care
tural beliefs (folk and professional) from health, well- vary transculturally with diversities (differences)
ness, illness, or care when working with cultures, and some universalities (commonalities).
because these factors are closely linked. Social structure
factors such as religion, politics, culture, economics, Person
and kinship are significant forces affecting care and 7. Every human culture has generic (i.e., lay, folk,
influencing illness patterns and well-being. She empha- or indigenous) care knowledge and practices
sizes the importance of discovering generic (folk, local, and usually professional care knowledge and
and indigenous) care from the cultures and comparing practices, which vary transculturally and indi-
it with professional care (Leininger, 1991b). She has vidually.
found that cultural blindness, shock, imposition, and 8. Culture Care values, beliefs, and practices are
ethnocentrism by nurses continue to reduce the quality influenced by and tend to be embedded in the
of care offered to clients of different cultures (Leininger, worldview, language, philosophy, religion (and
1991a, 1994, 1995c; Leininger & McFarland, 2002a, spirituality), kinship, social, political, legal, edu-
2006). She points out that nursing diagnoses and medi- cational, economic, technological, ethnohistori-
cal diagnoses that are not culturally based are known to cal, and environmental context of cultures.
create serious problems for some cultures that lead to
unfavorable outcomes (Leininger, 1990c). Culturally Health
congruent care is a powerful healing force for the qual- 9. Beneficial, healthy, and satisfying culturally based
ity health care that clients seek most when they come care influences the health and well-being of indi-
for care by nurses, and it is realized when culturally viduals, families, groups, and communities within
derived care is known and used. their environmental contexts.
10. Culturally congruent and beneficial nursing care
can occur only when care values, expressions, or
Major Assumptions patterns are known and used explicitly for appro-
Major assumptions of Leininger’s Culture Care The- priate, safe, and meaningful care.
ory of Diversity and Universality were derived from 11. Culture Care differences and similarities exist
Leininger’s definitive works on the theory (Leininger, between professional and client-generic care in
1991b; Leininger & McFarland, 2002a, 2006). human cultures worldwide.
Nursing Environment
1. Care is the essence of nursing and a distinct, 12. Cultural conflicts, cultural impositions practices,
dominant, central, and unifying focus. cultural stresses, and cultural pain reflect the lack
2. Culturally based care (caring) is essential for well- of Culture Care knowledge to provide culturally
being, health, growth, and survival, and to face congruent, responsible, safe, and sensitive care.
handicaps or death. 13. The ethnonursing qualitative research method pro-
3. Culturally based care is the most comprehensive vides an important means to accurately discover
and holistic means to know, explain, interpret, and and interpret emic and etic embedded, complex,
predict nursing care phenomena and to guide and diverse Culture Care data (Leininger, 1991b,
nursing decisions and actions. pp. 44–45).

CHAPTER 22 Madeleine M. Leininger 425

The universality of care reveals the common nature studying culturally based care for individuals, fami-
of human beings and humanity, whereas diversity lies, and groups. These factors are studied, assessed,
of care reveals the variability and selected, unique and responded to in a dynamic and participatory
features of human beings. nurse-client relationship (Leininger 1991a, 1991b,
2002b; Leininger & McFarland, 2002a).
Theoretical Assertions
Tenets are the positions one holds or the givens that the Logical Form
theorist uses with a theory. In developing the Culture Leininger’s theory (1995c) is derived from anthropol-
Care Theory, four major tenets were conceptualized ogy and nursing but is reformulated to become trans-
and formulated (Leininger, 2002c, 2006): cultural nursing theory with a human care perspective.
1. Culture Care expressions, meanings, patterns, and She developed the ethnonursing research method and
practices are diverse, and yet there are shared com- has emphasized the importance of studying people
monalities and some universal attributes. from their emic or local knowledge and experiences
2. The worldview consists of multiple social structure and later contrasting them with the etic (outsider)
factors (e.g., religion, economics, cultural values, beliefs and practices. Her book, Qualitative Research
ethnohistory, environmental context, language, Methods in Nursing (Leininger, 1985a) and related pub-
and generic and professional care), which are criti- lications (Leininger, 1990b, 1995c, 2002c; Leininger &
cal influencers of cultural care patterns to predict McFarland, 2006) provide substantive knowledge about
health, well-being, illness, healing, and ways people qualitative methods in nursing.
face disabilities and death. Leininger is skilled in using ethnonursing, ethnog-
3. Generic emic (folk) and professional etic care in raphy, life histories, life stories, photography, and
different environmental contexts can greatly influ- phenomenological methods that provide a holistic
ence health and illness outcomes. approach to study cultural behavior in diverse envi-
4. From an analysis of the previously listed influencers, ronmental contexts. With these qualitative methods,
three major actions and decision guides were pre- the researcher moves with people in their daily living
dicted to provide ways to give culturally congruent, activities to grasp their world. The nurse researcher
safe, and meaningful health care to cultures. The inductively obtains data of documented descriptive
three culturally based action and decision modes and interpretative accounts from informants through
were the following: (1) Culture Care preservation observation and participation explicating care as a
or maintenance, (2) Culture Care accommodation major challenge within the method. The qualitative
or negotiation, and (3) Culture Care repatterning or approach is used to develop basic and substantive
restructuring. Decision and action modes based on grounded data-based knowledge about cultural care
culture care were predicted as key factors to arrive at to guide nurses in their work. Although other meth-
congruent, safe, and meaningful care. ods of research such as hypothesis testing and experi-
Leininger has maintained that documentation mental quantitative methods can be used to study
of these tenets was necessary in order to provide transcultural care, the method of choice depends
meaningful and satisfying care to people, and they are upon the researcher’s purposes, the goals of the study,
predicted to be powerful influencers on culturally and the phenomena to be studied. Creativity and
based care. These factors needed to be discovered experience of the nurse researcher to use different
directly from the informants as influencing factors research methods to discover nursing knowledge are
related to health, well-being, illness, and death. The encouraged. However, Leininger holds that qualita-
modes set forth in the four tenets are Culture Care tive methods are important to establish meanings and
preservation or maintenance; Culture Care accom- accurate cultural knowledge.
modation and negotiation; and Culture Care repat- Leininger developed the Sunrise Enabler (Figure
terning or restructuring. The researcher draws upon 22–1) in the 1970s to depict the essential components
findings from the social structure, generic and profes- of the theory. She has refined the sunrise, and thus the
sional practices, and other influencing factors while evolved enabler is more definitive and valuable to

426 UNIT IV Nursing Theories

CULTURE CARE

Worldview


Cultural & Social Structure Dimensions



Cultural Values,
Kinship & Beliefs & Political &
Social Lifeways Legal
Factors Factors
Environmental Context,
Language & Ethnohistory
Religious & Economic
Philosophical Factors
Factors
Influences



Care Expressions
Technological Patterns & Practices Educational
Factors Factors


Holistic Health/Illness/Death
Focus: Individuals, Families, Groups, Communities or Institutions
in Diverse Health Contexts of

Professional
Generic (Folk) Care–Cure
Care Nursing Care Practices
Practices



Transcultural Care Decisions & Actions



Culture Care Preservation/Maintenance
Culture Care Accommodation/Negotiation
Culture Care Repatterning/Restructuring
Code: (Influencers)
© M. Leininger, 2004
–kl
Culturally Congruent Care for Health, Well-being or Dying
FIGURE 22-1 Leininger’s Sunrise Enabler. (Copyright Madeleine Leininger, 2004. Used by permission.)

CHAPTER 22 Madeleine M. Leininger 427

study the diverse elements or components of the theory, generally used in quantitative studies. These tools are
and to make culturally congruent clinical assessments. often viewed as unnatural and [are] frightening to cul-
Selected information is offered here to introduce the tural informants” (Leininger, 2002c, p. 89).
reader to Leininger’s creative work of evolving theory 1. The observation participation reflection enabler
and Sunrise Enabler over time. The Sunrise Enabler is used to facilitate the researcher in entering and
symbolizes the rising of the sun (care) (Leininger, remaining with informants in their familiar or natu-
1991b, 1995c; Leininger & McFarland, 2002a, 2006). ral context during the study. The researcher gradu-
The upper half of the circle depicts components of the ally moves from the role of observer and listener,
social structure and worldview factors that influence transitioning to that of participant and reflector
care and health through language, ethnohistory, and with the informants. By moving slowly and politely
environmental context. These factors also influence the with permission, the researcher does not disrupt
folk, professional, and nursing system(s), which are the and therefore is able to observe what is naturally
middle part of the model. The two halves together form occurring in the environment or with the people.
a full sun, which represents the universe that nurses 2. With the stranger to trusted friend enabler, the nurse
must consider to appreciate human care and health researcher is able to learn much about oneself and
(Leininger, 1991b, 1995c; Leininger & McFarland, the people and culture being studied. The goal with
2002a, 2006). According to Leininger, nursing acts as this guide is to become a trusted friend as one moves
a bridge between folk (generic) and the professional from distrusted stranger to trusted friend and differ-
system. Three kinds of nursing care and decisions and ent attitudes, behaviors, and expectations can be
actions are predicted in the theory: Culture Care pres- identified. This process is essential for the researcher
ervation or maintenance, Culture Care accommodation to become trusted such that honest, credible, and
or negotiation, and Culture Care repatterning or in-depth data may be discovered from informants.
restructuring (Leininger, 1991b, 1995c; Leininger & 3. The domain of “inquiry enabler” is a process used by
McFarland, 2002a, 2006). nurse researchers in each study to clearly establish
The Sunrise Enabler depicts human beings as in- the researcher’s interest and area of focus. The
separable from their cultural background and social domain of inquiry is a “succinct tailor made state-
structure, worldview, history, and environmental con- ment focused directly and specifically on Culture
text as a basic tenet of Leininger’s theory (Leininger, Care and health phenomena” (Leininger, 2002c,
1991b, 1995c; Leininger & McFarland, 2002a, 2006). p. 92), stating questions or ideas related to the focus
Gender, race, age, and class are embedded in social of the study, its purpose, and goals.
structure factors and are studied. Biological, emo- 4. The acculturation health assessment enabler is an-
tional, and other dimensions are studied from a holis- other important guide used with the method. It is
tic view and are not fragmented or separate. Theory essential when studying cultures to assess the
generation from this model may occur at multiple extent of the informants’ acculturation as to
levels from the micro range (small-scale specific indi- whether they are more “traditionally or nontradi-
viduals) to study groups, families, communities, or tionally oriented in their values, beliefs, and general
large-scale phenomena (several cultures). Leininger lifeways” (Leininger, 2002c, p. 92). This enabler is
has also developed several enablers to facilitate study- used for both cultural assessments and ethnonurs-
ing phenomena using the four phases of qualitative ing research studies.
data analysis. Most importantly, qualitative criteria
are used to analyze the data; they are credibility, con- Acceptance by the Nursing Community
firmability, meaning-in-context, saturation, repat-
terning, and transferability (Leininger, 1995c, 2002c). Practice
Leininger has developed four other enablers to assist Leininger identifies several factors related to the slow-
nurse researchers in their use of the ethnonursing ness of nurses to recognize and value transcultural
method. “Enablers sharply contrast with mechanistic nursing and cultural factors in nursing practices and
devices such as tools, scales, measurement instru- education (Leininger, 1991b; Leininger & McFarland,
ments, and other impersonal objective distancing tools 2006). First, the theory was conceptualized during the

428 UNIT IV Nursing Theories

1950s, when virtually no nurses were prepared in identity, and demands in culturally based care,
anthropology or cultural knowledge to understand nurses are realizing the need for culturally sensi-
transcultural concepts, models, or theory. In the early tive and competent practices. Most countries and
days, most nurses had little knowledge of anthropol- communities of the world are multicultural to-
ogy and how anthropological knowledge might con- day, and so health personnel are expected to un-
tribute to human care and health behaviors, or serve derstand and respond to clients of diverse and
as background knowledge to understand nursing similar cultures. Immigrants and people from
phenomena or problems. Second, although people unfamiliar cultures expect nurses to respect and
had longstanding and inherent cultural needs, many respond to values, beliefs, lifeways, and needs. No
clients were reluctant to push health personnel longer can nurses practice unicultural nursing.
to meet their cultural needs and therefore did not
demand that their cultural and social needs be recog- As the world becomes more culturally diverse,
nized or met (Leininger, 1970, 1978, 1995c; Leininger nurses need to be prepared to provide culturally compe-
& McFarland, 2002a). Third, transcultural nursing tent care. Some nurses are experiencing culture shock,
articles submitted early for publication were rejected conflict, and clashes as they move from one area to an-
because editors did not know, value, or understand other and from rural to urban communities without
the relevance of cultural knowledge to transcultural transcultural nursing preparation. As cultural conflicts
nursing or as essential to nursing. Fourth, the concept arise, families are less satisfied with nursing and medi-
of care was of limited interest to nurses until the late cal services (Leininger, 1991b). Nurses who travel and
1970s, when Leininger began promoting the impor- seek employment internationally experience cultural
tance of nurses studying human care, obtaining back- stresses; therefore, transcultural nursing education is
ground knowledge in anthropology, and obtaining imperative for all nurses worldwide. Certification of
graduate preparation in transcultural nursing, re- transcultural nurses by the Transcultural Nursing
search, and practice. Fifth, Leininger contends that Society provides a major step toward protecting the
nursing tends to remain too ethnocentric and far too public from unsafe and culturally incompetent nursing
involved in following medicine’s interest and direc- practices (Leininger, 1991a, 2001). Accordingly, more
tions. Sixth, nursing has been slow to make substan- nurses are seeking transcultural certification to protect
tive progress in the development of a distinct body of themselves and their clients. The Journal of Transcul-
knowledge, because many nurse researchers have tural Nursing provides research reports and theoretical
been far too dependent on quantitative research perspectives of more than 100 cultures worldwide to
methods to obtain measurable outcomes rather than guide transcultural nurses in their practices.
qualitative data outcomes. The recent acceptance and
use of qualitative research methods in nursing pro- Education
vides new insights related to nursing and transcul- The inclusion of culture and comparative care in nursing
tural nursing (Leininger, 1991b, 1995c; Leininger & curricula began in 1966 at the University of Colorado,
McFarland, 2002a). There is growing interest in using where Leininger was professor of nursing and anthro-
transcultural nursing knowledge, research, and prac- pology. Awareness of the importance of Culture Care to
tice by nurses worldwide. nursing began gradually during the late 1960s, but very
Nurses are now realizing the importance of trans- few nurse educators were prepared to teach courses
cultural nursing, human care, and qualitative methods. about transcultural nursing. Since the first master’s
Leininger (personal communication, April 2002) has and doctoral programs in transcultural nursing were
stated: approved and implemented in 1977 at the University
of Utah, more nurses have been prepared specifically in
We are entering a new phase of nursing as we transcultural nursing. Today, with a heightened public
value and use transcultural nursing knowledge awareness of health care costs, different cultures, and
with a focus on human caring, health, and illness human rights, there is a greater demand for comprehen-
behaviors. With the migration of many cultural sive, holistic, and transcultural people care to protect
groups and the rise of the consumer cultural and provide quality-based care and to prevent legal suits

CHAPTER 22 Madeleine M. Leininger 429

related to improper care. Leininger’s demand for culture- Leininger & McFarland, 2002a, 2006). Funds to support
specific care based on theoretical insights has been criti- transcultural nursing are limited because biomedical
cal for the discovery of diverse and universal aspects and technical research funds head the priority list.
of care (Leininger, 1995c, 1996a, 1996b; Leininger & Transcultural nurses and other nurses interested in
McFarland, 2002b). A critical need remains for nurses to transcultural nursing research are continuing their
be educated in transcultural nursing in undergraduate research with limited funds. These nurses are leaders in
and graduate programs and for faculty prepared in sharing their research at conferences and instructional
transcultural nursing to teach and guide research in programs related to transcultural nursing. They have
nursing schools within the United States and in other been instrumental in opening doors to transcultural
countries (Leininger, 1995c, 1996b; Tom-Orne, 2002). nursing in many organizations. Transcultural nurses
An increasing number of nursing curricula em- have stimulated other nurses to pursue research and
phasize transcultural nursing and human care. One of discover new knowledge in nursing as reported in the
the early programs to focus on care was presented Journal of Transcultural Nursing.
during the 1970s at Cuesta College in San Luis Obispo, The ethnonursing study by McFarland (1995,
California, where care was developed as a central 2002), covered 2 years in the late 1980s, and compared
theme for an undergraduate program in nursing. Anglo-American and African-American groups living
Course titles included Caring Concepts I & II, Caring in a residence home for the elderly in one large Mid-
of Families, and Professional Self Care (Leininger, western United States city. This in-depth emic and etic
1984a). During the late 1980s, four master’s and culture care investigation revealed significant findings
four doctoral programs in the United States offered and highlighted the importance of using the three
transcultural nursing courses, research experiences, action and decision modes of the theory when caring
and guided field study experiences (Leininger, 1995c). for older adults. The culturally congruent care findings
Leininger received numerous requests to give courses, were as follows:
lectures, and workshops on human care and transcultural • Anglo-American and African-American older adults
nursing in the United States and other countries. The expect Culture Care preservation and maintenance
demand for transcultural nurses exceeded available of their lifelong generic or folk care patterns.
faculty, money, and other resources. As the last cen- • Doing for other residents rather than having a self-
tury ended, Leininger put out a call for schools care focus was a major care maintenance value for
of nursing to offer transcultural programs to meet both cultures and was a dominant finding.
the worldwide demand for many nurses and cultures • Protective care was more important to African-
(Leininger, 1995a, 1995b, 1996b). The programs are American than to Anglo-American older adults,
needed for practice and preparation for certification but nursing staff provided protective care and
of transcultural nurses. There is a need for research practiced Culture Care accommodation for both
and worldwide consultation. There are still inade- groups, such as accompanying them when they
quate research funds to study transcultural nursing desired to go for walks in the surrounding inner-
education and practice. Although the societal de- city neighborhood.
mand for transcultural nurses is evident, educational • African-American nurses practiced culture accom-
preparation remains weak and limited for nurses modation when they linked their emic care with
worldwide. generic care values and practices.
Culture Care maintenance-preservation and Cul-
Research ture Care accommodation-negotiation were new ways
Nurses today are using Leininger’s Culture Care Theory for nurses to provide culturally congruent and safe
worldwide. This nursing theory is focused specifically lifeways care practices for older adults of both cultures.
on Culture Care and with a specific research method Based on the findings, several institutional Culture
(ethnonursing) to examine the theory (Leininger, Care policies were developed to guide professional
1991b, 1995c; Leininger & McFarland, 2002a, 2006). older adult care. Application of the Culture Care
Approximately 100 cultures and subcultures had been Theory to advanced practice nursing has been expli-
studied as of 1995 (Leininger, 1991b, 1995c, 1996a; cated by McFarland and Eipperle (2008) proposing the

430 UNIT IV Nursing Theories

theory as a “ . . . foundational basis for the educational Burk, 2012). The method has been adapted for use in
preparation, primary care contextual practice, and out- retrospective metasynthesis studies as the Metaeth-
comes-focused research endeavors of advanced prac- nonursing Research Method. McFarland, Webhe-
tice nursing” using the three modes of care, the Alamah, Wilson, and Vossos (2011) conducted a
enablers, and the ethnonursing method. The authors retrospective analysis of 24 doctoral dissertations
emphasized integration of culturally congruent or sen- based on the Culture Care Theory, presenting a syn-
sitive care through direct and explicit approaches to be opsis of their findings which were found to be “...both
used by the nurse practitioner, who “ . . . needs to be interpretive and explanatory, and further conceptu-
able to sensitively and competently integrate Culture alized from the themes and patterns of the original
Care into contextual routines, clinical ways, and dissertation studies” and entailed “...new theoretical
approaches to primary care practice through role mod- formulations based on the Culture Care Theory [with
eling, policy making, procedural performance and discovered] recommendations related to nursing
performance evaluation, and the use of the advance practice . . . . [which were] predicted to make a sig-
practice nursing process” (McFarland & Eipperle, nificant contribution to the discipline and practice of
2008). Concepts and methods for integrating emic and nursing as well as the epistemic and ontologic basis
etic care approaches into primary care practice mo- of culture care knowledge and evidence-based best
dalities and the use of the education-research-practice practices” (p. 24).
continuum as the basis for clinical actions and deci- Leininger calls for all professional nurses in the
sions are presented. world to be prepared in transcultural nursing and
demonstrate competencies in transcultural nursing
(Leininger, 1981, 1995c; Leininger & McFarland,
Further Development 2002a, 2006; McFarland & Eipperle, 2008). Trans-
Leininger continues to develop the theory and the cultural nursing must become an integral part of
application of the theory and the ethnonursing education and practice for nurses to be relevant in
research method. The theorist further explicated the the twenty-first century (Mixer, 2011). Currently,
concept of Father Protective Care, which is manifested the demand for prepared transcultural nurses far
differently in Western and non-Western cultures. exceeds the numbers of nurses, faculty, and clinical
Leininger (2011) focused her research “ . . . on the specialists in the world. More transcultural nurse
subtle, hidden, obscure, and diverse expressions and theorists, researchers, and scholars are urgently
examples of father protective care” in Western and needed to continue to develop the body of transcul-
non-Western cultures (p. 1). The construct of Collab- tural knowledge and transform nursing education
orative Care was presented by McFarland (2011) in and practice. By the year 2020, all nurses will need
her keynote address “The Culture Care Theory and a basic knowledge about diverse cultures in the world
Look to the Future for Transcultural Nursing” at the and in-depth knowledge of at least two or three
37th Annual Conference of the International Society cultures (Leininger, 1995c, 1996a). Leininger be-
of Transcultural Nursing in which Dr. Leininger lieves that transcultural nursing research has begun
participated via videotape. The construct of Collab- to lead to some highly promising and different
orative Care refers to those values, meanings, and ways to advance nursing education and practice
expressions by persons that reveal a desire for work- (Leininger & McFarland, 2002a, 2006). All health
ing together in order to attain and preserve health and disciplines, including medicine, pharmacy, and so-
well-being for oneself and others. cial work, are incorporating transcultural health
The Ethnonursing Research Method “can be useful knowledge and practice into their programs of
for research that addresses providing care in other dis- study. This trend is increasing the demand for com-
ciplines including education, administration, physical/ petent faculty in transcultural health care. Leininger
occupational/speech therapy, social work, pharmacy, (1995c) believes that the development of transcul-
medicine, and disciplines in which the meaning of tural institutes is essential to fill the growing need
research findings has implications for human care for transcultural nurses prepared to work with other
and health” (McFarland, Mixer, Webhe-Alamah, & disciplines.

CHAPTER 22 Madeleine M. Leininger 431

Present and future theories and studies in trans- oriented theory that is broad, comprehensive, and
cultural nursing are essential to meet the needs of worldwide in scope. Transcultural nursing theory ad-
culturally diverse people. The Culture Care Theory dresses nursing care from a multicultural worldview
continues to grow worldwide. Both universal and perspective. It is applicable to groups and individuals
diverse care knowledge is extremely important to who have a goal of rendering culture-specific nursing
establish a substantive body of transcultural nursing care. The research has led to a vast amount of expert
knowledge, and to make nursing a transcultural pro- knowledge largely unknown in the past. Aspects of
fession and discipline. Leininger’s theory has gained culture, care, and health are identified because they
worldwide interest and use because it is holistic, rele- have an impact on nursing. More research is needed
vant, and futuristic, and it deals with specific, yet for comparative purposes from both culture-specific
abstract, care knowledge. data and universal care knowledge. More cultural
groups need to be studied and compared to validate
Critique the caring constructs. The theory is most helpful
for the study of any culture and for comparative study
Clarity of several cultures. Findings from the theory are
The Sunrise Enabler (see Figure 22–1) and other en- being used in client care in a variety of health and
ablers mentioned earlier remain invaluable as guides community settings worldwide to transform nursing
to study and practice with people of diverse and simi- education and service. It is valued especially for de-
lar cultural needs. veloping a new and different approach to the tradi-
tional community nursing perspective.
Simplicity
Transcultural nursing theory is a broad, holistic, Accessibility
comprehensive perspective of human groups, popu- The transcultural nursing theory is researchable, and
lations, and species. The broad or generic concepts qualitative research has been the primary approach to
are well organized and defined for study in specific discover largely unknown phenomena of care and
cultures. Leininger’s Culture Care Theory is relevant health in diverse cultures. This qualitative approach
worldwide to guide nurse researchers in the concep- differs from the traditional quantitative research
tualization of research approaches to study culture. method, which renders measurement the goal of
The concepts and constructs related to social struc- research. The ethnonursing research method is ex-
ture, environment, and language are extremely tremely rigorous and linguistically exacting in nature
important and clearly defined for culturally based and outcomes. One hundred thirty-five care con-
knowledge grounded in the people’s world. Multiple structs have been identified, and more are being dis-
key concepts and interrelationships of concepts are covered each day, with a wealth of other transcultural
made explicit, especially to social structure factors. nursing knowledge. An important attribute is the ac-
Understanding the theory requires some basic curacy of grounded data derived with ethno methods
anthropological knowledge as well as considerable or from an emic or people’s viewpoint is leading to
transcultural nursing knowledge, to be used in an high credibility and confirmability, and a wealth of
accurate and scholarly fashion. When the theory has empirical data. Ongoing and future research will lead
been fully conceptualized, Leininger finds that to additional care and health findings and implications
undergraduate and graduate nursing students are for ethnonursing practices and education to fit specific
excited to use the theory and discover how practical, cultures and universal features. The qualitative criteria
relevant, and useful it is in their work. The Sunrise of credibility and confirmability from in-depth studies
Enabler (see Figure 22–1) becomes imprinted on of informants and their contexts are becoming clearly
their minds as a way of knowing. evident. Unequivocally, the body of transcultural
nursing knowledge that has been established over the
Generality past decade has had a great impact on nursing and
The transcultural nursing theory demonstrates the many health care systems (Leininger, 1995c; Leininger
criterion of generality because it is a qualitatively & McFarland 2002a, 2006).