Nursing Theory alligood 8th edition

382 UNIT IV  Nursing Theories

MAJOR CONCEPTS & DEFINITIONS (3) change and difference; (4) time span; and
Here, the major concepts and definitions from the (5) critical points and events. Meleis , Sawyer, Im,
most current Transitions Theory—the middle- and colleagues (2000) asserted that these properties
range theory of transition suggested by Meleis, of transition experience are not fundamentally dis-
Sawyer, Im, and colleagues (2000)—are presented. connected, but are interrelated as a complex process.
Some concepts are defined in greater detail based
on the transition framework by Schumacher and Awareness is defined as “perception, knowledge,
Meleis (1994). and recognition of a transition experience,” and
level of awareness is frequently reflected in “the
Major concepts of the middle-range theory of tran- degree of congruency between what is known about
sition include: (1) types and patterns of transitions; processes and responses and what constitutes an
(2) properties of transition experiences; (3) transition expected set of responses and perceptions of indi-
conditions (facilitators and inhibitors); (4) patterns of viduals undergoing similar transitions”(Meleis,
response (or process indicators and outcome indica- Sawyer, Im, et al., 2000). While asserting that a
tors); and (5) nursing therapeutics. person in transition may be somewhat aware of
the changes that they are experiencing, Chick and
Types and Patterns of Transitions Meleis (1986) posited that a person’s unawareness of
Types of transitions include developmental, health and change could mean that the person may not have
illness, situational, and organizational. Developmental began his or her transition yet; Meleis, Sawyer, Im,
transition includes birth, adolescence, menopause, and associates (2000) later proposed that this lack of
aging (or senescence), and death. Health and illness awareness does not necessarily mean that the transi-
transitions include recovery process, hospital dis- tion has not begun.
charge, and diagnosis of chronic illness (Meleis &
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
inherent in the transition.” The level of awareness is
Patterns of transitions include multiplicity and considered to influence the level of engagement;
complexity (Meleis, Sawyer, Im, et al., 2000). Many there is no engagement without awareness. Meleis
people experience multiple transitions simultane- and colleagues (2000) suggested that the level of
ously rather than experiencing a single transition, engagement of a person who has this awareness of
which cannot be easily distinguished from the con- changes is different from that of a person who does
texts of their daily lives. Indeed, Meleis, Sawyer, Im, not have this awareness.
and colleagues (2000) noted that each of the studies
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
dissimilar ways, and they suggested that nurses would Personal conditions include meanings, cultural
need to recognize “a client’s level of comfort and mas- beliefs and attitudes, socioeconomic status, prepa-
tery in dealing with changes and differences.” ration, and knowledge. Meleis , Sawyer, Im, and
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-
tion conditions, the subconcepts of community
Critical points and events are the final property of conditions and societal conditions tend to be
transitions suggested by Meleis, Sawyer, Im, and asso- underdeveloped.
ciates (2000). Critical points and events are defined as
“markers such as birth, death, the cessation of men- Patterns of Response or Process and Outcome
struation, or the diagnosis of an illness.” Meleis and Indicators
colleagues (2000) also acknowledge that specific Indicators of healthy transitions in the framework
marker events might not be evident for some transi- by Schumacher and Meleis (1994) were replaced by
tions, although transitions usually have critical points patterns of response in the middle-range theory of
and events. Critical points and events are usually transitions. Patterns of response are conceptualized
linked to intensifying awareness of changes or dissimi- as process indicatorsand outcome indicators. These
larities or to a more exertive engagement in the transi- process indicatorsand outcome indicators character-
tion process. Also, Transitions Theory conceptualizes ize healthy responses. Process indicators that direct
that final critical points are differentiated by a sense of clients into health or toward vulnerability and risk
counterpoise in new schedules, competence, lifestyles, make nurses conduct early assessment and interven-
and self-care behaviors, and that the duration of uncer- tion to expedite healthy outcomes. Also, outcome
tainty is characterized by variations, consecutive indicators may be used to check if a transition is
changes, and interruptions in existence. a healthy one or not, but Meleis, Sawyer, Im, and
associates (2000) warned that outcome indicators
Transition Conditions could be associated with irrelevant events in people’s
Transition conditions are “those circumstances lives if they are appraised early in a transition
that influence the way a person moves through a

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, &
Meleis, 1999), African-American women’s transition to
In the development of the transition framework by motherhood (Sawyer, 1997), and adult medical-surgical
Schumacher and Meleis (1994), a systematic extensive patients’ perceptions of their readiness for hospital dis-
literature review of more than 300 articles related to charge (Weiss, Piacentine, Lokken, et al., 2007).
transitions provided empirical evidence of the con-
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

findings of these five studies provided the theoretical CHAPTER 20  Afaf Ibrahim Meleis 385
basis for the concepts of the middle-range theory of
transition, and the concepts and their relationships Person
were developed and formulated based on a collab- • Transitions involve a process of movement and
orative process of dialogue, constant comparison of
findings across the five studies, and analysis of find- changes in fundamental life patterns, which are
ings. For example, one of the personal conditions, manifested in all individuals.
meanings, was proposed based on the findings from • Transitions cause changes in identities, roles,
two studies (Im, 1997; Sawyer, 1997). According to relationships, abilities, and patterns of behavior.
Meleis Sawyer, Im, and colleagues (2000), although • The daily lives of clients, environments, and
Korean immigrant midlife women had ambivalent interactions are shaped by the nature, condi-
feelings toward menopause in Im’s study, menopause tions, meanings, and processes of their transition
itself did not have special meaning attached to it. Im experiences.
found that most participants did not connect any Health
special health/illness problems/concerns they were • Transitions are complex and multidimensional. Tran-
having to their menopausal transitions. Rather, sitions have patterns of multiplicity and complexity.
women went through their menopause without • All transitions are characterized by flow and move-
perceiving any health/illness problems/concerns, ment over time.
which means that “no special meaning” might have • Change and difference are not interchangeable,
facilitated the women’s menopausal transition. Yet, nor are they synonymous with transition.
Sawyer’s study reported that African-American Environment
women related intense enjoyment of their roles • Vulnerability is related to transition experiences,
as mothers and described motherhood in terms of interactions, and environmental conditions that
being responsible, protecting, supporting, and expose individuals to potential damage, problematic
needed. Thus, Meleis, Sawyer, Im, and colleagues or extended recovery, or delayed or unhealthy coping.
(2000) proposed meanings as a personal transition
condition because, in both studies, neutral and posi- Theoretical Assertions
tive meanings might have facilitated menopause
and motherhood. The middle-range theory of tran- Theoretical assertions in Transitions Theory were
sition has been used in studies to develop situation- inferred in the early works of Meleis. This includes
specific theories (Im, 2006; Im, 2010; Im & Meleis, her work on role supplementation, the transition
1999b; Schumacher, Jones, & Meleis 1999) and to framework by Schumacher and Meleis (1994), and
test the theory in a study of relatives’ experience of a the middle-range theory of transitions by Meleis,
move to a nursing home (Davies, 2005). Sawyer, Im, and colleagues (2000). Following are the
theoretical assertions made in the theoretical works:
Major Assumptions • Developmental, health and illness, and organiza-

Based on Meleis’ former works on role supplementation, tional transitions are central to nursing practice.
the transition framework by Schumacher and Meleis • Patterns of transition include (a) whether the client
(1994), and the middle-range theory of transitions by
Meleis, Sawyer, Im, and colleagues (2000), the following is experiencing a single transition or multiple transi-
assumptions of Transitions Theory may be inferred. tions; (b) whether multiple transitions are sequential
Nursing or simultaneous; (c) the extent of overlap among
• Nurses are the primary caregivers of clients and transitions; and (d) the nature of the relationship
between the different events that are triggering tran-
their families who are undergoing transitions. sitions for a client.
• Transitions both result in change and are the result • Properties of transition experience are interrelated
parts of a complex process.
of change. • The level of awareness influences the level of en-
gagement, in which engagement may not happen
without awareness.

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

Piacentine, Lokken, et al., 2007). As mentioned ear- CHAPTER 20  Afaf Ibrahim Meleis 387
lier in the chapter, Transitions Theory was often used
as a parent theory for situation-specific theories applicable in nursing practice. Transitions Theory
(Im & Meleis, 1999a; Im, 2006; Schumacher, Jones, & tends to be generalizable to people in transitions.
Meleis, 1999). A number of doctoral students, includ- When diverse types of transitions are considered,
ing Shellye Vardaman at the University of Texas at Transitions Theory is relevant for any population in
Tyler, have used Transitions Theory in their doctoral transition, depending on the type of transition the
dissertations. population is experiencing. The research used to
derive Transitions Theory was based on the participa-
Further Development tion of different gender and ethnic groups in various
settings. This makes Transitions Theory more easily
Transitions Theory was an emerging framework that generalizable than theories developed for research
could be further developed, tested, and refined, with specific client populations.
reflecting Meleis’ philosophical position on theory Accessibility
development as cyclic, dynamic, and evolving. Transi- Transitions Theory has been tested and supported by
tions Theory continues to be refined and tested to Meleis and others as a framework for explaining the
explain the major concepts and relationships among transition experiences of diverse groups of popula-
diverse groups of populations in various types of tran- tions in different types of transitions. Transitions
sition. Because sufficient empirical support by a num- Theory continues to evolve through planned pro-
ber of studies using Transitions Theory exists, future grams of research, and continuous empirical research
studies will aim at intervention studies to test Transi- studies will further refine the theory. The develop-
tions Theory–based interventions, through which ment of situation-specific theories derived from Tran-
Transitions Theory gains power to direct nursing sitions Theory will further reduce its distance from
practice. Also, as Meleis (2007) envisioned, situation- the empirical world as well.
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-
Clarity related disciplines always deal with a type of transition,
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.
The major concepts are logically linked, and the rela- Current health care systems are frequently character-
tionships are obvious in their theoretical assertions. ized by changes, diversities, and complexities. Transi-
Generality tions Theory, which evolved from research studies
Transitions Theory is a middle-range theory in scope. among diverse groups of people in various types of
Middle-range theories have more limited scope and transitions, could adequately direct nursing practice,
less abstraction than grand theories, and they address education, and practice in the current health care
specific phenomena or concepts, which make them system. Meleis made her theoretical journey from the
1960s, and her journey continues. Transitions Theory
continues to develop through a number of studies

388 UNIT IV  Nursing Theories modest whenever you approach her. Sue is very
based on the theory and the many colleagues Meleis quiet and never complains about any symptoms
has mentored. Her visionary leadership throughout or pain. However, on several occasions, you
the world influences nursing practice, education, and think that Sue is in serious pain, when consider-
research. ing her facial expressions and sweating forehead.
You think that Sue’s English skills may not allow
CASE STUDY 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
two children: Mina, a 25-year-old daughter who Sue is experiencing. What are the types and
is now the manager of a local shop, and Yujun, a patterns of the transition(s)? What properties
21-year-old son who is a college student. Both of transitions can you identify from her case?
children were born in South Korea and moved to 2. What personal, community, and societal tran-
the United States with Sue. The children had a sition conditions may have influenced Sue’s
hard time, especially Mina, who came to the experience? What are the cultural meanings
United States in her senior year of high school. attached to cancer, cancer pain, and symptoms
However, the children finally adapted to their accompanying chemotherapy, in this situation?
new environment. Now, Mina is living alone in a What are Sue’s cultural attitudes toward cancer
one-bedroom apartment near downtown, and and cancer patients? What factors may facili-
Yujun is living in a university dormitory. The tate or inhibit her transition(s)?
Kim’s are a religious family and attend their com- 3 . Consider the patterns of response that Sue
munity’s Protestant church regularly. They are is showing. What are the indicators of healthy
involved in many church activities. transition(s)? What are the indicators of
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 you are experiencing. List influences such as cul-
tural beliefs and attitudes, socioeconomic status,
1 . Consider a transition you are personally engaged and level of your preparation that impact your
in now. Identify characteristics of the transition approach to the transition.
as defined in Transitions Theory that you have 4 . Review your responses to the transition, and look
observed. Does consideration of this specific tran- for patterns in the responses. Ask five friends or
sition make you more aware of other transitions family members of different ages or ethnicity to
you are experiencing? describe their responses to the transition. Com-
pare the descriptions given by those individuals
2. Analyze the changes that you are experiencing due with yours.
to the specific transition. Consider how your level 5. Consider the outcomes of the personal transition
of awareness of these changes influences your in question 1. What would facilitate successful
transition experience. Think about how long the outcomes to the transition? What might inhibit
transition has been and what have been the land- successful outcomes?
mark events and critical points of the transition.

3 . Analyze personal, community, and societal condi-
tions that may have influenced the transition that

POINTS FOR FURTHER STUDY the University of Pennsylvania at:http://www.
nursing.upenn.edu/dean/transitions/
n Meleis, A. I. (2011). Theoretical Nursing: Development
and Progress (5th ed.). Philadelphia: Lippincott.

n To respond to researchers’ increasing interest in
Transitions Theory, a website was established at

REFERENCES rehabilitation: effect on patient compliance. Patient
Education and Counseling, 6(4), 169–177.
Aroian, K., & Prater, M., (1988). Transitions entry groups: Gaffney, K. F. (1992). Nurse practice-model for maternal
easing new patients’ adjustment to psychiatric hospi- role sufficiency. Advances in Nursing Sciences, 15(2),
talization. Hospital and Community Psychiatry, 39, 76–84.
312–313. Im, E. O. (1997). Negligence and ignorance of menopause
within gender multiple transition context: Low income
Brackley, M. H. (1992). A role supplementation group Korean immigrant women. Unpublished doctoral dis-
pilot study: a nursing therapy for potential parental sertation, University of California, San Francisco.
caregivers. Clinical Nurse Specialist, 6(1), 14–19. Im, E. O. (2005). Development of situation-specific theories:
An integrative approach. Advances in Nursing Science,
Bridges, W. (1980). Transitions. Reading, (MA): Addison- 28(2), 137–151.
Wesley. Im, E. O. (2006). A situation-specific theory of Caucasian
cancer patients’ pain experience. Advances in Nursing
Bridges, W. (1991). Managing transition: Making the most Science, 29(3), 232–244.
of change. Menlo Park, (CA): Addison Wesley. Im, E. O. (2010). A situation-specific theory of Asian
immigrant women’s menopausal symptom experience
Chick, N., & Meleis, A. I. (1986). Transitions: a nursing in the United States. Advances in Nursing Science,
concern. In: Chin P. L. (Ed.), Nursing Research Method- 33(2), 143–157.
ology: Issues and Implantation. Gainsburg, MD: Aspen. Im, E. O. (2011). Transitions theory: A trajectory of theo-
retical development in nursing. Nursing Outlook, 59(5),
Davies, S. (2005). Meleis’s theory of nursing transitions 278–285.
and relatives’ experiences of nursing home entry. Im, E. O., & Meleis, A. I. (1999a). Situation-specific theories:
Journal of Advanced Nursing, 52(6), 658–671. Philosophical roots, properties, and approach. Advances
in Nursing Science, 22(2), 11–24.
Dracup, K., & Meleis, A. I. (1982). Compliance: an interac-
tionist approach. Nursing Research, 31, 31–36.

Dracup, K., Meleis, A. T., Baker, K., & Edlefsen, P. (1985).
Family-focused cardiac rehabilitation: a role supple-
mentation program for cardiac patients and spouses.
Nursing Clinics of North America, 19(1), 113–124.

Dracup, K., Meleis, A. I., Clark, S., Clyburn, A., Shields,
L., & Staley, M. (1985). Group counseling in cardiac

390 UNIT IV  Nursing Theories Meleis, A. I., & Trangenstein, P. A. (1994). Facilitating
Im, E., & Meleis, A. I. (1999b). A situation-specific theory transitions: re-definition of the nursing mission.
Nursing Outlook, 42, 255–259.
of Korean immigrant women’s menopausal transition.
Journal of Nursing Scholarship, 31(4), 333–338. Messias, D. K. H. (1997). Narratives of transnational migra-
Im, E., & Meleis, A. I. (2000). Meanings of menopause: tion, work, and health: the lived experiences of Brazilian
low-income Korean immigrant women. Western Journal women in the United States.Unpublished doctoral
of Nursing Research, 22(1), 84–102. dissertation, University of California, San Francisco.
Im, E., & Meleis, A. I. (2001). Women’s work and symptoms
during midlife: Korean immigrant women. Women and Messias, D. K. H., Gilliss, C. L., Sparacino, P. S. A., Tong,
Health, 33(1/2), 83–103. E. M., & Foote, D. (1995). Stories of transition: Parents
Im, E., Meleis, A. I., & Lee, K. (1999). Symptom experience recall the diagnosis of congenital heart defects. Family
of low-income Korean immigrant women during meno- Systems Medicine, 3(3/4), 367–377.
pausal transition. Women and Health, 29(2), 53–67.
Jones, P. S., Zhang, X. E., & Meleis, A. I. (1978). Transform- Robinson, P. R., Ekman, S. L., Meleis, A. I., Wahlund, L. O.,
ing vulnerability. Western Journal of Nursing Research, & Winbald, B. (1997). Suffering in silence: the experience
25(7), 835–853. of early memory loss. Health Care in Later Life, 2(2),
Kaas, M. J., & Rousseau, G. K. (1983). Geriatric sexual confor- 107–120.
mity: assessment and intervention. Clinical Gerontologist,
2(1), 31–44. Sawyer, L. (1997). Effects of racism on the transition to moth-
Kelley, L. S., Lakin, J. A. (1988). Role supplementation as a erhood for African-American women.Unpublished doc-
nursing intervention for Alzheimer’s disease: a case toral dissertation, University of California, San Francisco.
study. Public Health Nursing, 5(3), 146–152.
Meleis, A. I. (1975). Role insufficiency and role supple- Schumacher, K. L. (1994). Shifting patterns of self-care and
mentation: A conceptual framework. Nursing Research, caregiving during chemotherapy. Unpublished doctoral
24, 264–271. dissertation, University of California, San Francisco.
Meleis, A. I. (1985). Theoretical Nursing: Development and
Progress (1st Ed). Philadelphia: Lippincott. Schumacher, K. L. (1995). Family caregiver role acquisition:
Meleis, A. I. (1991). Theoretical Nursing: Development and role-making through situated interaction. Scholarly
Progress (2nd Ed). Philadelphia: Lippincott. Inquiry for Nursing Practice, 9, 211–271.
Meleis, A. I. (1997). Theoretical Nursing: Development and
Progress (3rd Ed). Philadelphia: Lippincott. Schumacher, K. L., Dodd, M. J., & Paul, S. M. (1993).
Meleis, A. I. (2007). Theoretical Nursing: Development and The stress process in family caregivers of persons
Progress (4th Ed). Philadelphia: Lippincott. receiving chemotherapy. Research in Nursing &
Meleis, A. I. (2011). Theoretical Nursing: Development and Health,16, 395–404.
Progress (5th Ed). Philadelphia: Lippincott.
Meleis, A. I. (2010). Transitions theory: middle-range and Schumacher, K. L., Jones, P. S., & Meleis, A. I. (1999). Helping
situation-specific theories in nursing research and practice. elderly persons in transition: a framework for research
New York: Springer. and practice. In L. Swanson & T. Tripp Reimer (Eds.),
Meleis, A. I., Birch, E. L., & Wachter, S. M. (Eds.) (2011). Advances in Gerontological nursing: Life transitions in the
Women’s health and the world’s cities. Philadelphia: older adult (vol 3, pp. 1–26). New York: Springer.
University of Pennsylvania Press.
Meleis, A. I., Lipson, J., & Dallafar, A. (1998). The reluctant Schumacher, K. L., & Meleis, A. I. (1994). Transitions: a
immigrant: immigration experiences among Middle central concept in nursing. Image: Journal of Nursing
Eastern groups in Northern California. In Baxter, D. & Scholarship, 26(2), 119–127.
Krulfeld, R. (Eds.), Selected papers on refugees and im-
migrants, Vol. 5 (pp. 214–230). American Anthropologi- Shaul, M. P. (1997). Transition in chronic illness: rheuma-
cal Association, Arlington, (VA). toid arthritis in women. Rehabilitation Nursing, 22,
Meleis, A. I., Sawyer, L. M., Im, E.O, Hilfinger Messias 199–205.
D.K., & Schumacher, K. (2000). Experiencing transi-
tions: an emerging middle range theory. Advances in Shih, F. J., Meleis, A. I., Yu, P. J., Hu, W. Y., Lou, M. F., &
Nursing Science, 23(1), 12–28. Huang, G. S. (1998). Taiwanese patients’ concerns and
Meleis, A. I., & Swendsen, L. (1978). Role supplementation: coping strategies: transitions to cardiac surgery. Heart
an empirical test of a nursing intervention. Nursing and Lung, 27(2): 82–98.
Research, 27, 11–18.
Walker, L. O., & Avant, K. C. (1995). Strategies for theory
construction in nursing (3rd ed.). Norwalk, (CT): Appleton
& Lange.

Walker, L. O., & Avant, K. C. (2005). Strategies for theory
construction in nursing (4th ed.). Norwalk, (CT): Appleton
& Lange.

Weiss, M. E., Piacentine, L. B., Lokken, L., Ancona, J., Archer, J.,
Gresser, S., et al. (2007). Perceived readiness for hospital
discharge in adult medical-surgical patients. Clinical Nurse
Specialist, 21(1), 31–42.

BIBLIOGRAPHY CHAPTER 20  Afaf Ibrahim Meleis 391

Primary Sources Advances in Gerontological nursing: Life transitions in the
Books older adult (vol 3, pp. 1–26). New York: Springer.
Meleis, A. I. (2007). Theoretical Nursing: Development and Dissertations
Almendarez, B. L. (2007). Mexican American elders and
Progress (4th Ed). Philadelphia: Lippincott. nursing home transition.Unpublished doctoral disser-
tation, University of Texas Health Science Center at
Book Chapters San Antonio, TX.
Brooten, D., & Naylor, M. D. (1999). Transitional Environ- Batty, M. L. E. (1999). Pattern identification and expanding
consciousness during the transition of “low-risk” pregnancy.
ments. In A. S. Hinshaw, S. L. Feetham, & J. Shaver (Eds), A study embodying Newman’s health as expanding con-
Handbook of clinical nursing research (pp. 641–654). sciousness. Unpublished doctoral dissertation, University
Thousand Oaks (CA): Sage. of New Brunswick, Canada.
Chick, N., & Meleis, A. I. (1986). Transitions: a nursing Fowles, E. R. (1994). The relationship between prenatal
concern. In P. L. Chinn (Ed.), Nursing research method- maternal attachment, postpartum depressive symptoms,
ology (pp. 237–257). Boulder, (CO): Aspen. and maternal role attainment. Loyola University of
Lipson, J. G., & Meleis, A. I. (1999). Research with immi- Chicago, Chicago, IL.
grants and refugees. In A. S. Hinshaw, S. L. Feetham, & Im, E. O. (1997). Negligence and ignorance of menopause
J. Shaver (Eds), Handbook of clinical nursing research within gender multiple transition context: Low income
(pp. 87–106). Thousand Oaks (CA): Sage. Korean immigrant women. Unpublished doctoral dis-
Meleis, A. I. (1997). On transitions and knowledge develop- sertation, University of California, San Francisco.
ment. Nursing Beyond Art and Science (Annotated Ed.). Kelly, C. (1997). Restructuring public health nursing: experi-
Japan: Japan Academy of Nursing Science. ences in Northern California. Unpublished doctoral dis-
Meleis, A. I. (1998). Research on role supplementation. In sertation, University of California, San Francisco.
J. J. Fitzpatrick (Ed), Encyclopedia of nursing research. Lenz, B. K. (2002). Correlates of tobacco use and non-use
New Jersey: Springer. among college students at a large university: Application
Meleis, A. I., Lipson, J., & Dallafar, A. (1998). The reluctant of a transition framework. Unpublished doctoral disser-
immigrant: immigration experiences among Middle tation, University of Minnesota.
Eastern groups in Northern California. In D., Baxter & McMillan, E. S. (2002). Education to practice questionnaire:
Krulfeld, R. (Eds.), Selected papers on refugees and A content analysis. Unpublished doctoral dissertation,
immigrants, vol. V (pp. 214–230). American Anthropo- Wilmington College Division of Nursing, Delaware.
logical Association, Arlington, VA. Missal, B. E. (2003). The Gulf Arb woman’s transition to moth-
Meleis, A. I., Lipson, J. G., Muecke, M., & Smith, G. (1998). erhood. Unpublished doctoral dissertation, University of
Immigrant women and their health: an olive paper.India- Minnesota.
napolis: Sigma Theta Tau International. O’Brien-Barry, P. (2003). The contribution of sex-role
Meleis, A. I., & Schumacher, K. L. (1998). Transitions and orientation and role commitment to interrole conflict
health. In J. J. Fitzpatrick (Ed.), Encyclopedia of nursing in working first-time mothers at 6 to 9 months post-
research (pp. 570–571). New Jersey: Springer. partum. Unpublished doctoral dissertation, New York
Meleis, A. I., & Swendsen, L. (1977). Does nursing interven- University.
tion make a difference? A test of the ROSP. Communicating Sawyer, L. (1997). Effects of racism on the transition to mother-
Nursing Research: Nursing Research Priorities: Choice or hood for African-American women. Unpublished doctoral
Chance (vol. 8, 308–324). Boulder, (CO): Western Inter- dissertation, University of California, San Francisco.
state Commission for Higher Education. Vardaman, S. (2011). Lived experiences of transitions in
Meleis, A. I., Swendsen, L., & Jones, D. (1980). Preventive international nursing students. Unpublished doctoral
role supplementation: a grounded conceptual framework. dissertation, University of Texas, Tyler.
In M.H. Miller & B. Flynn (Eds.), Current perspectives Journal Articles
in nursing: Social issues and trends (vol. 2, pp. 3–14). Aroian, K., Prater, M. (1988). Transitions entry groups: eas-
St. Louis: Mosby. ing new patients’ adjustment to psychiatric hospitaliza-
Schumacher, K. L., Jones, P. S., & Meleis, A. I. (1998). tion. Hospital and Community Psychiatry, 39, 312–313.
The elderly in transition: need and issues of care. Brackley, M. H. (1992). A role supplementation group pi-
In L. Swanson & T. Tripp Reimer, Advances in geron- lot study: a nursing therapy for potential parental care-
tological nursing. New York: Springer. givers. Clinical Nurse Specialist, 6(1), 14–19.
Schumacher, K. L., Jones, P.S., & Meleis, A. I. (1999). Helping
elderly persons in transition: a framework for research
and practice. In L. Swanson & T. Tripp Reimer (Eds.),

392 UNIT IV  Nursing Theories

Brown, M. A., & Olshansky, E. F. (1997). From limbo to Kaas, M. J., Rousseau, G. K. (1983). Geriatric sexual confor-
legitimacy: A theoretical model of the transition to the mity: assessment and intervention. Clinical Gerontologist,
primary care nurse practitioner role. Nursing Research, 2(1), 31–44.
46(1), 46–51.
Kelley, L. S., Lakin, J. A. (1988). Role supplementation as a
Clingerman, E. (2007). A situation-specific theory of nursing intervention for Alzheimer’s disease: a case
migration transition for migrant farm worker women. study. Public Health Nursing, 5(3), 146–152.
Research and Theory for Nursing Practice, 21(4), 220–235.
McCain, G. C., & Deatrick, J. A. (1994). The experience of
Davidson, P. M., Dracup, K., Phillips, J., Padilla, G., & high-risk pregnancy. Journal of Obstetric, Gynecologic,
Daly, J. (2007). Maintaining hope in transition. A theo- and Neonatal Nursing, 23(5), 421–427.
retical framework to guide interventions for people
with heart failure. Journal of Cardiovascular Nursing, Meleis, A. I. (1975). Role/insufficiency and role supple-
22(1), 58–64. mentation: a conceptual framework. Nursing Research,
24, 264–271.
Davies, S. (2005). Meleis’s theory of nursing transitions and
relatives’ experiences of nursing home entry. Journal of Meleis, A. I. (1987). Role transition and health. Kango
Advanced Nursing, 52(6), 658–671. Kenkyo: The Japanese Journal of Nursing Research,
20(1), 81, 69–89.
Dracup, K., & Meleis, A. I. (1982). Compliance: an interac-
tionist approach. Nursing Research, 31, 31–36. Meleis, A. I. (1991). Between two cultures: identity, roles,
and health. Health Care For Women International, 12,
Dracup, K., Meleis, A., Baker, K., & Edlefsen, P. (1985). 365–378.
Family-focused cardiac rehabilitation: a role supple-
mentation program for cardiac patients and spouses. Meleis, A. I. (1997). Immigrant transitions and health care:
Nursing Clinics of North America, 19(1), 113–124. an action plan. Nursing Outlook, 45(1), 42.

Dracup, K., Meleis, A. I., Clark, S., Clyburn, A., Shields, L., Meleis, A. I., & Rogers, S. (1987). Women in transition:
& Staley, M. (1985). Group counseling in cardiac reha- being vs. becoming or being and becoming. Health
bilitation: effect on patient compliance. Patient Education Care for Women International, 8, 199–217.
and Counseling, 6(4), 169–177.
Meleis, A. I., Sawyer L., Im, E. O., Hilfinger Messias, D. K.,
Duchscher, J. B. (2008). A process of becoming: The stages of & Schumacher, K. (2000). Experiencing transitions: an
new nursing graduate professional role transition. Journal emerging middle range theory. Advances in Nursing
of Continuing Education in Nursing, 39(10), 441–450. Science, 23(1), 12–28.

Elmberger, E., Bolund, C., & Lutzen, K. (2000). Transform- Meleis, A. I., & Swendsen, L. (1978). Role supplementation:
ing the exhausting to energizing process of being a an empirical test of a nursing intervention. Nursing
good parent in the face of cancer. Health Care for Research, 27, 11–18.
Women International, 21(6), 485–499.
Meleis, A. I., & Trangenstein, P. A. (1994). Facilitating
Gaffney, K. F. (1992). Nurse practice-model for maternal transitions: redefinition of a nursing mission. Nursing
role sufficiency. Advances in Nursing Sciences, 15(2), Outlook, 42(6), 255–259.
76–84.
Meleis, A. I., Birch, E. L., & Wachter, S. M. (Eds) (2011).
Im, E. O. (2006). A situation-specific theory of Caucasian Women’s health and the world’s cities. Philadelphia:
cancer patients’ pain experience. Advances in Nursing University of Pennsylvania Press.
Science, 29(3), 232–244.
Messias, D. K. H. (2002). Transnational health resources,
Im, E. O. (2008). The situation-specific theory of pain practices, and perspectives: Brazilian immigrant women’s
experience for Asian American cancer patients. narratives. Journal of Immigrant Health, 4(4), 183–200.
Advances in Nursing Science, 31(4), 319–331.
Messias, D. K. H., Gilliss, C. L., Sparacino, P. S. A., Tong,
Im, E. O., & Meleis, A. I. (1999). A situation-specific theory E. M., and Foote, D. (1995). Stories of transition:
of Korean immigrant women’s menopausal transition. Parents recall the diagnosis of congenital heart
Journal of Nursing Scholarship, 31(4), 333–338. defect. Family Systems Medicine, 13(3,4), 367–277.

Im, E. O., Meleis, A. I., & Lee, K. (1999). Symptom experi- Robinson, P. R., Ekman, S. L., Meleis, A. I., Wahlund, L. O.,
ence of low-income Korean immigrant women during & Winbald, B. (1997). Suffering in silence: the experi-
menopausal transition. Women and Health, 29(2), 53–67. ence of early memory loss. Health Care in Later Life,
2(2), 107–120.
Im, E. O., & Meleis, A. I. (2000). Meanings of menopause:
low-income Korean immigrant women. Western Journal Schumacher, K. L. (1995). Family caregiver role acquisition:
of Nursing Research, 22(1), 84–102. role-making through situated interaction. Scholarly
Inquiry for Nursing Practice, 9, 211–271.
Im, E. O., & Meleis, A. I. (2001). Women’s work and symp-
toms during midlife: Korean immigrant women. Schumacher, K. L. (1996). Reconceptualizing family care-
Women and Health, 33(1/2), 83–103. giving: family-based illness care during chemotherapy.
Research in Nursing & Health, 19, 261–272.

Schumacher, K. L., Dodd, M. J., & Paul, S. M. (1993). The CHAPTER 20  Afaf Ibrahim Meleis 393
stress process in family caregivers of persons receiving
chemotherapy. Research in Nursing & Health, 16, 395–404. Book Chapters
Meleis, A. I., Lipson, J., & Dallafar, A. The reluctant
Schumacher, K. L., & Meleis, A. I. (1994). Transitions: a
central concept in nursing. Image: Journal of Nursing immigrant: immigration experiences among Middle
Scholarship, 26(2), 119–127. Eastern groups in Northern California. In D. Baxter,
& Krulfeld, R. (Eds.), Selected papers on refugees and
Schumacher, K. L., Stewart, B. J., & Archbold, P. G. (1998). immigrants, vol. V, (pp. 214–230). Arlington, (VA):
Conceptualizing and measurement of doing family American Anthropological Association.
caregiving well. Image: Journal of Nursing Scholarship,
30(1): 63–69. Journal Articles
Barnes, D., Eribes, C., Juarbe, T., Nelson, M., Proctor, S.,
Shaul, M. P. (1997). Transition in chronic illness: rheumatoid
arthritis in women. Rehabilitation Nursing, 22, 199–205. Sawyer, L., et al. (1995). Primary health care and
primary care: A confusion of philosophies. Nursing
Shih, F., & Huang, L. H. (1996). Patients’ needs and their Outlook, 43, 7–16.
coping strategies transition to cardiac surgery. Kaohsi- Bernal, P., & Meleis, A. I. (1995). Being a mother and
ung Journal of Medical Sciences, 12(2), 114–127. a “por dia” domestic worker: Companionship and
deprivation. Western Journal of Nursing Research,
Shih, F. J., Meleis, A. I., Yu, P. J., Hu, W. Y., Lou, M. F., & 17(4), 365–382.
Huang, G. S. (1998). Taiwanese patients’ concerns and Bernal, P., & Meleis, A. I. (1995). Self care actions of
coping strategies: transitions to cardiac surgery. Heart Colombian por día domestic workers: On prevention
and Lung, 27(2): 82–98. and care. Women and Health, 22(4), 77–95.
Budman, C. L., Lipson, J. G. & Meleis, A. I. (1992). The
Swendsen, L., Meleis, A. I., & Jones, D. (1978). Role sup- cultural consultant in mental health care: The case of an
plementation for new parents: a role mastery plan. Arab adolescent. American Journal of Orthopsychiatry,
American Journal of Maternal Child Nursing, 3, 84–91. 62(3), 359–370.
Davidson, P., Meleis, A. I., Daly, J., & Douglas, M. (2003).
Watson, N., & Pulliam, L. (2000). Transgenerational health Globalization as we enter the 21st century: Reflections
promotion. Holistic Nursing Practice, 14(4), 1–11. and directions for nursing education, science, research
and clinical practice. Contemporary Nurse, 15(3), 162–174.
Weiss, M. E., Piacentine, L. B., Lokken, L., Ancona, J., Davis, L. H., Dumas, R., Ferketich, S., Flaherty, M. J.,
Archer, J., Gresser, S., et al. (2007). Perceived readi- Isenberg, M., Koerner, J. E., et al. (1992). Culturally
ness for hospital discharge in adult medical-surgical competent health care. Nursing Outlook, 40(6), 277–283.
patients. Clinical Nurse Specialist, 21(1), 31–42. Douglas, M. K., Meleis, A. I., Eribes, C., & Kim, S. (1996).
The work of auxiliary nurses in Mexico: Stressors,
Weiss, M. E., & Lokken, L. (2009). Predictors and out- satisfiers and coping strategies, Journal of International
comes of postpartum mothers’ perceptions of readiness Nursing Studies, 33(5), 495–505.
for discharge after birth. Journal of Obstetric, Gyneco- Douglas, M. K., Meleis, A. I., & Paul, S. M. (1997). Auxiliary
logic, and Neonatal Nursing, 38(4), 406–417. nurses in Mexico: Impact of multiple roles on their health.
Health Care for Women International, 18(44), 355–368.
Wilkins, K. L., & Woodgate, R. L. (2006). Transition: A con- Dracup, K., Cronenwett, L., Meleis, A. I., & Benner, P. E.
ceptual analysis in the context of siblings of children (2005). Reflections on the Doctorate of Nursing practice.
with cancer. Journal of Pediatric Nursing, 21(4), 256–265. Nursing Outlook, 53(4), 177–182.
Dracup, K., Cronenwett, L., Meleis, A. I., & Benner, P. E.
Wilson, S. A. (1997). The transition to nursing home life: (2005). Reply to letter to the editor on reflections on
A comparison of planned and unplanned admissions. the Doctorate of Nursing practice. Nursing Outlook,
Journal of Advanced Nursing, 26, 864–871. 53(6), 269.
Facione, N. C., Dodd, M., Holzemer, W., & Meleis, A. I.
Secondary Sources (1997). Help seeking for self discovered breast symptoms:
Books Implications for early detection. Cancer Practice, 5(4),
Meleis, A. I. (2001). (Ed.). Women’s work, health and quality 220–227.
Hall, J. M., Stevens, P. E. & Meleis, A. I. (1992). Developing
of life. Binghamton: Haworth Press. the construct of role integration: A narrative analysis of
Meleis, A. I., Isenberg, M., Koerner, J. E., Lacey, B., & women clerical workers’ daily lives. Research in Nursing
& Health, 15(6), 447–457.
Stern, P. (1995). Diversity, marginalization, and cultur-
ally competent health care: Issues in knowledge develop-
ment. Washington: American Academy of Nursing.
Meleis, A. I., Lipson, J. G., Muecke, M., & Smith, G. (1998).
Immigrant women and their health: an olive paper.
Indianapolis, (IN): Sigma Theta Tau International.
St. Hill, P., Lipson, J., & Meleis, A. I. (2002). (Eds.). Caring
for women cross-culturally: a portable guide, Philadelphia:
F.A. Davis.

394 UNIT IV  Nursing Theories

Hall, J. M., Stevens, P. E., & Meleis, A. I. (1992). Experi- May, K. M., & Meleis, A. I. (1987). International nursing:
ences of women clerical workers in patient care areas. guidelines for core content. Nurse Educator, 12(5),
Journal of Nursing Administration, 22(5), 11–17. 36–40.

Hall, J. M., Stevens, P. E., & Meleis, A. I. (1994). Marginal- Meleis, A. I. (1992). Community participation and involve-
ization: A guiding concept for valuing diversity in ment: Theoretical and empirical issues. Health Services
nursing knowledge development. Advances in Nursing Management Research, 5(10), 5–16.
Science, 16(4), 23–41.
Meleis, A. I. (1992). Directions for nursing theory devel-
Hattar-Pollara, M., & Meleis, A. I. (1995). Stress of immi- opment in the 21st century. Nursing Science Quarterly,
gration and the daily lived experience of Jordanian 5(3), 112–117.
immigrant women. Western Journal of Nursing
Research, 17(5), 521–539. Meleis, A. I. (1992). On the way to scholarship: From master’s
to doctorate. Journal of Professional Nursing, 8(6), 328–334.
Hattar-Pollara, M., & Meleis, A. I. (1995). Parenting ado-
lescents: The experiences of Jordanian immigrant Meleis, A. I. (1992). Nursing: A caring science with a distinct
women in California. Health Care for Women Interna- domain. Sairaanhoitaja,(6), 8–12.
tional, 16(3), 195–211.
Meleis, A. I. (1996). Culturally competent scholarship: Sub-
Hattar-Pollara, M., Meleis, A. I. & Nagib, H. (2000). A study stance and rigor. Advances in Nursing Science, 19(2), 1–16.
of the spousal role of Egyptian women in clerical jobs.
Health Care for Women International, 21(4), 305–317. Meleis, A. I. (2001). Small steps and giant hopes: violence
on women is more than wife battering. Health Care for
Hattar-Pollara, M., Meleis, A. I., & Nagib, H. (2003). Multiple Women International, 23, 313–315 (Editorial).
role stress and patterns of coping of Egyptian Women in
Clerical Jobs. Transcultural Nursing, 14(2), 125–133. Meleis, A. I. (2001). Women’s work, health and quality of
life: It is time we redefine women’s work. Women and
Im, E., Meleis, A. I. & Lee, K. A. (1999). Cultural compe- Health, 33(1/2), xv-xviii.
tence of measurement scales of menopausal symptoms:
use in research among Korean women. International Meleis, A. I. (2002). Whither international research? Journal
Journal of Nursing Studies, 36, 455–463. of Nursing Scholarship, First Quarter 4–5 (Editorial).

Im, E., Meleis, A. I., & Park, Y. S. (1999). A feminist critique Meleis, A. I. (2003). Brain Drain or Empowerment. Journal
of the research on menopausal experience of Korean of Nursing Scholarship, 35(2), 105. (Guest Editorial).
women. Research In Nursing and Health, 22, 410–420.
Meleis, A. I. (2005). Shortage of nurses means a shortage
Im, E., & Meleis, A. I. (2001). An international imperative of nurse scientists. (Editorial). Journal of Advanced
for gender-sensitive theories in women’s health. Journal Nursing, 49(2), 111.
of Nursing Scholarship, 33(4), 309–314.
Meleis, A. I. (2005). Safe womanhood is not safe mother-
Jones, P., & Meleis, A. I. (2002). Caregiving between two hood: policy implications. Health Care for Women
cultures: an integrative experience. Journal of Transcul- International, 26(2), 464–471.
tural Nursing, 13(3), 202–209.
Meleis, A. I. (2005). Arabs. In J. Lipson, & S. Dibble,
Jones, P. S., Jaceldo, K. B., Lee, J. R., Zhang, X. E., & Meleis, (Eds.). Culture and clinical care: a practical guide.
A. I. (2001). Role integration and perceived health in San Francisco: University of California San Francisco
Asian American women caregivers. Research in Nursing Nursing Press.(pp. 42–57).
and Health, 24, 133–144.
Meleis, A. I. (2006). Human capital in health care: a resource
Jones, P. S., & Meleis, A. I. (1993). Health is empowerment. crisis of a caring crisis? Global Health Link 139, 6–7, 21–22.
Advances in Nursing Science, 15(3), 1–14.
Meleis, A. I., Arruda, E. N., Lane, S., & Bernal, P. (1994).
Jones, P. S., Zhang, X. E., & Meleis, A. I. (1978). Transforming Veiled, voluminous and devalued: Narrative stories about
vulnerability. Western Journal of Nursing Research, 25(7), low-income women from Brazil, Egypt & Colombia.
835–853. Advances in Nursing Science, 17(2), 1–15.

Laffrey, S. C., Meleis, A. I., Lipson, J. G., Solomon, M., & Meleis, A. I. & Bernal, P. (1994). Domestic workers in
Omidian, P. A. (1989). Assessing Arab-American Colombia as spouses: Security and servitude. Holistic
health care needs. Social Science and Medicine, 29(7), Nursing, 8(4), 33–43.
877–883.
Meleis, A. I. & Bernal, P. (1995). The paradoxical world of
Lane, S. D., & Meleis, A. I. (1991). Roles, work, health per- muchacha de por dia ín Colombia. Human Organization,
ceptions, and health resources of women: A study in an 54, 393–400.
Egyptian delta hamlet. Social Science and Medicine,
33(10), 1197–1208. Meleis, A. I., Douglas, M., Eribes, C., Shih, F., & Messias,
D. (1996). Employed Mexican women as mothers and
partners: Valued, empowered and overloaded. Journal
of Advanced Nursing, 23, 82–90.

CHAPTER 20  Afaf Ibrahim Meleis 395

Meleis, A. I., & Dracup, K. (2005). The case against the Meleis, A. I., Kulig, J., Arruda, E. N., & Beckman, A.
DNP: history, timing, substance, and marginalization. (1990). Maternal role of women in clerical jobs in
Online Journal of Issues in Nursing, 10(3), Manuscript 2: southern Brazil: Stress and satisfaction. Health Care for
Retrieved from: www.nursingworld.org/ojin/topic28/ Women International, 11(4), 369–382.
tpc28_2.htm.
Meleis, A. I., Mahidal, V. T., Lin, J. Y., Minami, H., &
Meleis, A. I., & Fishman, J. (2001). Rethinking the work in Neves, E. P. (1987). International collaboration in
health: gendered and cultural expectations. Health Care research: Forces and constraints—by leaders from
for Women International, 22, 195–197 (Editorial). Thailand, People’s Republic of China, Japan, and Brazil.
Western Journal of Nursing Research, 9(3), 390–399.
Meleis, A. I., Hall, J. M., & Stevens, P. E. (1994). Scholarly
caring in doctoral nursing education: Promoting diver- Messias, D. H., Regev, H., Im, E., Spiers, J., Van, P., &
sity and collaborative mentorship. Image: Journal of Meleis, A. I. (1997). Expanding the visibility of
Nursing Scholarship, 26(3), 177–180. women’s work: Policy implications. Nursing Outlook,
45, 258–264.
Meleis, A. I., & Im, E. (1999). Transcending marginalization
in knowledge development. Nursing Inquiry, 6(2), 94–102. Nelson, M., Proctor, S., Regev, H., Barnes, D., Sawyer, L.,
Messias, D., Yoder, L., & Meleis, A. I. (1996). The Cairo
Meleis, A. I., & Im, E. O. (2002). Grandmothers and women’s action plan: A challenge to nursing. Image: Journal of
health: From fragmentation to coherence. Health Care for Nursing Scholarship, 28(1), 75–80.
Women International, 23(2), 207–224.
Neves Arruda, E. N., Larson P. J., & Meleis A. I. (1992).
Meleis, A. I., & Lindgren, T. (2001). Show me a woman Comfort: Immigrant Hispanic patients’ views. Cancer
who does not work! Journal of Nursing. Third Quarter, Nursing, 15(6), 387–394.
209–210.
Sawyer, L., Regev, H., Proctor, S., Nelson, M., Messias, D.,
Meleis, A. I., & Lipson, J. (2003). Cross-cultural health Barnes, D., Meleis, A. I. (1995). Matching vs. cultural
and strategies to lead development of nursing prac- competence in research: a methodological note. Research
tice. In J. Daly, S. Speedy, & D. Jackson (Eds.), Nurs- in Nursing and Health, 18, 531–541.
ing Leadership (pp. 69–88). Philadelphia: Churchill
Livingstone. Siantz, M. L. & Meleis, A. I. (2007). Integrating cultural
competence into nursing education and practice: 21st
Meleis, A. I., Lipson J. G., & Paul, S. M. (1992). Ethnicity century action steps. Journal of Transcultural Nursing,
and health among five Middle Eastern immigrant 18(1), 86–90.
groups. Nursing Research, 41(2), 98–103.
Stevens, P. E., Hall, J. M., & Meleis, A. I. (1992). Examining
Meleis, A. I., Messias, D. K. H., & Arruda, E. N. (1995). vulnerability of women clerical workers from five ethnic
Women’s work environment and health: Clerical workers racial groups. Western Journal of Nursing Research,
in Brazil. Research in Nursing and Health, 19, 53–62. 14(6), 754–774.

Meleis, A. I., & Stevens, P. E. (1992). Women in clerical Stevens, P. E., Hall, J. M., & Meleis, A. I. (1992). Narratives
jobs: Spousal role satisfaction stress and coping. Women as a basis for culturally relevant holistic care: Ethnicity
& Health, 18(1), 23–40. and everyday experiences of women clerical workers.
Holistic Nursing Practice, 6(3), 49–58.
Messias, D. K. H., Hall, J. M., Meleis, A. I. (1996). Voices of
impoverished Brazilian women: Health implications of Van, P., & Meleis, A. I. (2003). Coping with grief after invol-
roles and resources. Women and Health, 24(1), 1–20. untary pregnancy loss: perspectives of African-American
women. Journal of Obstetric, Gynecologic, & Neonatal
Messias, D. K. H., Im, E., Page, A., Regev, H., Spiers, J., & Nursing, 32(1), 28–39.
Meleis, A. I. (1997). Defining and redefining work:
Implications for women’s health. Gender and Society,
11(3), 296–323.

21C H A P T E R

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).

Credentials and Background Pender was born August 16, 1941, in Lansing,
of the Theorist Michigan. She was the only child of parents who ad-
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
of nursing was to help people care for themselves. In 1964, Pender completed her baccalaureate in
Pender contributes to nursing knowledge of health nursing at Michigan State University. She credits
promotion through her research, teaching, presenta- Helen Penhale, assistant to the dean, who streamlined
tions, and writings. her program for fostering her options for further edu-
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

her major from nursing as she pursued her graduate CHAPTER 21  Nola J. Pender 397
degrees. She earned a master’s degree in human was funded by the National Institutes of Health.
growth and development at Michigan State University Susan Walker, Karen Sechrist, and Marilyn Frank-
in 1965. “The M.A. in growth and development influ- Stromborg tested the validity of the HPM (Pender,
enced my interest in health over the human life span. Walker, Sechrist, & Stromborg, 1988). The research
This background contributed to the formation of a team developed the Health Promoting Lifestyle Pro-
research program for children and adolescents,” stated file, an instrument used to study the health-promoting
Pender. She completed her PhD in psychology and behavior of working adults, older adults, patients un-
education in 1969 at Northwestern University. Pender’s dergoing cardiac rehabilitation, and ambulatory pa-
(1970) dissertation research investigated develop- tients with cancer (Pender, Murdaugh, & Parsons,
mental changes in encoding processes of short-term 2002). Results from these studies supported the HPM
memory in children. She credits Dr. James Hall, doc- (Pender, personal communication, July 19, 2000).
toral program advisor, with “introducing me to con- Subsequently, more than 40 studies tested the predic-
siderations of how people think and how a person’s tive capability of the model for health-promoting
thoughts motivate behavior.” Several years later, she lifestyle, exercise, nutrition practices, use of hearing
completed master’s-level work in community health protection, and avoidance of exposure to environmen-
nursing at Rush University (Pender, personal com- tal tobacco smoke (Pender, 1996; Pender, Murdaugh,
munication, May 6, 2004). & Parsons, 2002).

After earning her PhD, Pender notes a shift in her Pender provided leadership in the development of
thinking toward defining the goal of nursing care as nursing research in the United States. Her support of
the optimal health of the individual. A series of con- the National Center for Nursing Research in the
versations with Dr. Beverly McElmurry at Northern National Institutes of Health was instrumental to its
Illinois University and reading High-Level Wellness by formation. She has promoted scholarly activity in nurs-
Halpert Dunn (1961) inspired expanded notions of ing through involvement with Sigma Theta Tau Inter-
health and nursing. Her marriage to Albert Pender, national, as president of the Midwest Nursing Research
an Associate Professor of business and economics Society from 1985 to 1987, and as chairperson of the
who has collaborated with his wife in writing about Cabinet on Nursing Research of the American Nurses
the economics of health care, and the birth of a son Association. She has served as a Trustee of the Midwest
and a daughter provided increased personal motiva- Nursing Research Society since 2009 (http://nursing.
tion to learn more about optimizing human health. umich.edu/faculty-staff/nola-j-pender). Inducted as a
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
text, Health Promotion in Nursing Practice, which was As a leader in nursing education, Dr. Pender
published in 1982. Based on subsequent research, the guided many students and mentored others. Over her
HPM was revised and presented in a second edition 40 years as an educator, she facilitated the learning of
in 1987 and in a third edition in 1996. The fourth baccalaureate, masters, and PhD students. She has
edition of Health Promotion in Nursing Practice was mentored a number of postdoctoral fellows. In 1998,
co-authored by Pender, Carolyn L. Murdaugh (PhD), the University of Michigan School of Nursing hon-
and Mary Ann Parsons (PhD) and published in 2002, ored Pender with the Mae Edna Doyle Award for ex-
and a fifth edition was published in 2006. cellence in teaching. She is a Distinguished Professor
at Loyola University of Chicago School of Nursing.
In 1988, Pender and colleagues conducted a
study at Northern Illinois University, DeKalb, which A recipient of many awards and honors, Dr. Pender
has served as a distinguished scholar at a number of

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

CHAPTER 21  Nola J. Pender 399

MAJOR CONCEPTS & DEFINITIONS Perceived Self-Efficacy
The major concepts and definitions presented are Perceived self-efficacy is judgment of personal capa-
found in the revised HPM (Pender et al, 2006). The bility to organize and execute a health-promoting
following are individual characteristics and experi- behavior. Perceived self-efficacy influences perceived
ences that affect subsequent health actions (Pender, barriers to action, so higher efficacy results in low-
curriculum vitae, 2000). ered perceptions of barriers to the performance of
the behavior.
Prior Related Behavior
Frequency of the same or similar behavior in the Activity-Related Affect
past. Direct and indirect effects on the likelihood of An activity-related affect describes subjective posi-
engaging in health-promoting behaviors. tive or negative feelings that occur before, during,
and following behavior based on the stimulus prop-
Personal Factors erties of the behavior itself. Activity-related affect
Categorized as biological, psychological, and socio- influences perceived self-efficacy, which means the
cultural. These factors are predictive of a given be- more positive the subjective feeling, the greater is
havior and are shaped by the nature of the target the feeling of efficacy. In turn, increased feelings of
behavior being considered. efficacy can generate further positive affect.

Personal Biological Factors Interpersonal Influences
Included in these factors are variables such as age, These influences are cognitions concerning behav-
gender, body mass index, pubertal status, meno- iors, beliefs, or attitudes of others. Interpersonal
pausal status, aerobic capacity, strength, agility, and influences include norms (expectations of signifi-
balance. cant others), social support (instrumental and emo-
tional encouragement), and modeling (vicarious
Personal Psychological Factors learning through observing others engaged in a
These factors include variables such as self-esteem, particular behavior). Primary sources of interper-
self-motivation, personal competence, perceived sonal influences are families, peers, and health care
health status, and definition of health. providers.

Personal Sociocultural Factors Situational Influences
Factors such as race, ethnicity, acculturation, educa- Situational influences are personal perceptions and
tion, and socioeconomic status are included. cognitions of any given situation or context that can
facilitate or impede behavior. They include percep-
The following are behavioral-specific cognitions tions of available options, demand characteristics,
and affects that are considered of major motiva- and aesthetic features of the environment in which
tional significance; these variables are modifiable given health-promoting behavior is proposed to
through nursing actions (Pender, 1996). take place. Situational influences may have direct or
indirect influences on health behavior.
Perceived Benefits of Action
Perceived benefits of action are anticipated positive The following are immediate antecedents of
outcomes that will result from health behavior. behavior or behavioral outcomes. A behavioral event
is initiated by a commitment to action unless there
Perceived Barriers to Action is a competing demand that cannot be avoided, or a
Perceived barriers to action are anticipated, imag- competing preference that cannot be resisted (Pender,
ined, or real blocks and personal costs of undertak- personal communication, July 19, 2000).
ing a given behavior.
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
Perceived health status Behavioral factors health-promoting behaviors

Perceived benefits of Cues to action
health-promoting behaviors

Perceived barriers to
health-promoting behaviors

FIGURE 21-1  H​ ealth 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.)

Use of Empirical Evidence CHAPTER 21  Nola J. Pender 401
model identifies concepts relevant to health-promoting
The HPM, as depicted in Figure 21–1, served as a behaviors and facilitates the generation of testable
framework for research aimed at predicting overall hypotheses (Pender, Murdaugh, & Parsons, 2002).
health-promoting lifestyles and specific behaviors
such as exercise and use of hearing protection (Pender, The HPM provides a paradigm for the develop-
1987). Pender and colleagues conducted a program ment of instruments. The Health Promoting Life-
of research funded by the National Institute of Nurs- style Profile and the Exercise Benefits-Barriers Scale
ing Research to evaluate the HPM in the following (EBBS) are two examples.* These instruments
populations: (1) working adults, (2) older commu- serve to test the model and support further model
nity-dwelling adults, (3) ambulatory patients with development.
cancer, and (4) patients undergoing cardiac rehabili-
tation. These studies tested the validity of the HPM The purpose of the Health Promotion Lifestyle
(Pender, personal communication, May 24, 2000). A Profile instrument is to measure health-promoting
summary of findings from earlier studies is included lifestyle (Pender, 1996). The Health Promotion Life-
in the 1996 edition of Health Promotion in Nursing style Profile II (HPLP-II), is a revision of the original
Practice (Pender, 1996). Studies further testing the instrument for research.† The 52-item, four-point,
model are discussed in the fifth edition of Health Likert-style instrument has six subscales: (1) health
Promotion in Nursing Practice (Pender, Murdaugh, & responsibility, (2) physical activity, (3) nutrition,
Parsons, 2006). The fifth edition includes an emphasis (4) interpersonal relations, (5) spiritual growth, and
on the HPM as applied to diverse and vulnerable (6) stress management. The mean can be derived for
populations and addresses evidence-based practice. each subscale, or a total mean signifying overall health-
promoting lifestyle (Walker, Sechrist, & Pender, 1987).
The rationale for revision of the HPM stemmed The instrument provides assessment of a health-
from the research. The process of refining the HPM, promoting lifestyle of individuals and is used clinically
as published in 1987, led to several changes in the by nurses for patient support and education.
model (see Figure 21–1) (Pender, 1996). First, im-
portance of health, perceived control of health, and The HPM identifies cognitive and perceptual
cues for action were deleted. Second, definition of factors as major determinants of health-promoting
health, perceived health status, and demographic behavior. The EBBS measures the cognitive and
and biological characteristics were repositioned as perceptual factors of perceived benefits and perceived
personal factors in the 1996 revision of the HPM barriers to exercise (Sechrist, Walker, & Pender,
(Pender, 1996) and the fourth edition of Health Pro- 1987). The 43-item, four-point, Likert-styled instru-
motion in Nursing Practice (Pender, Murdaugh, & ment consists of a 29-item benefits scale and a 14-item
Parsons, 2002) (Figure 21–2). Third, the revised barriers scale that may be scored separately or as a
HPM (see Figure 21–2) added three new variables whole. The higher the overall score on the 43-item
that influenced the individual to engage in health- instrument, the more positively the individual per-
promoting behaviors (Pender, 1996): ceives the benefits to exercise in relation to barriers to
• Activity-related affect exercise (Sechrist, Walker, & Pender, 1987). The EBBS
• Commitment to a plan of action is useful clinically for evaluating exercise perceptions.
• Immediate competing demand and preferences
Major Assumptions
The revised HPM focuses on 10 categories of deter-
minants of health-promoting behavior. The revised The assumptions reflect the behavioral science
perspective and emphasize the active role of the
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
Immediate competing
Perceived demands
benefits
of action (low control)
and preferences
Prior Perceived
related barriers (high control)
behavior to action

Perceived
self-efficacy

Personal Activity-related Commitment Health-
factors: affect to a promoting
biological, behavior
psychological, Interpersonal plan of action
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
as follows: 3. Persons value growth in directions viewed as posi-
1 . Persons seek to create conditions of living through tive and attempt to achieve a personally acceptable
balance between change and stability.
which they can express their unique human health
potential. 4. Individuals seek to actively regulate their own
behavior.

5. Individuals in all their biopsychosocial complexity CHAPTER 21  Nola J. Pender 403
interact with the environment, progressively trans-
forming the environment and being transformed 8. Persons are more likely to commit to and engage
over time. in health-promoting behaviors when significant
others model the behavior, expect the behavior
6 . Health professionals constitute a part of the inter- to occur, and provide assistance and support to
personal environment, which exerts influence on enable the behavior.
persons throughout their life spans.
9. Families, peers, and health care providers are
7. Self-initiated reconfiguration of person-environment important sources of interpersonal influences
interactive patterns is essential to behavioral change that can increase or decrease commitment to and
(pp. 54–55). engagement in health-promoting behavior.

Theoretical Assertions 10. Situational influences in the external environ-
ment can increase or decrease commitment to or
The model depicts the multifaceted natures of persons participation in health-promoting behavior.
interacting with the environment as they pursue health.
The HPM has a competence- or approach-oriented 1 1. The greater the commitment to a specific plan of
focus (Pender, 1996). Health promotion is motivated action, the more likely health-promoting behav-
by the desire to enhance well-being and to actualize iors are to be maintained over time.
human potential (Pender, 1996). In her first book,
Health Promotion in Nursing Practice, Pender (1982) 12. Commitment to a plan of action is less likely to
asserts that complex biopsychosocial processes moti- result in the desired behavior when competing
vate individuals to engage in behaviors directed toward demands over which persons have little control
the enhancement of health. Fourteen theoretical asser- require immediate attention.
tions derived from the model appear in the fourth edi-
tion of the book, Health Promotion in Nursing Practice 13. Commitment to a plan of action is less likely to
(Pender, Murdaugh, & Parsons, 2002): result in the desired behavior when other actions
1 . Prior behavior and inherited and acquired charac- are more attractive and thus preferred over the
target behavior.
teristics influence beliefs, affect, and enactment of
health-promoting behavior. 1 4. Persons can modify cognitions, affect, and the
2. Persons commit to engaging in behaviors from interpersonal and physical environments to cre-
which they anticipate deriving personally valued ate incentives for health actions (pp. 63–64).
benefits.
3. Perceived barriers can constrain the commitment Logical Form
to action, the mediator of behavior, and the actual
behavior. The HPM was formulated through induction by use
4. Perceived competence or self-efficacy to execute a of existing research to form a pattern of knowledge
given behavior increases the likelihood of com- about health behavior. The HPM is a conceptual
mitment to action and actual performance of be- model from which middle-range theories may be de-
havior. veloped. It was formulated with the goal of integrat-
5. Greater perceived self-efficacy results in fewer per- ing what is known about health-promoting behavior
ceived barriers to specific health behavior. to generate questions for further testing. This model
6. Positive affect toward a behavior results in greater illustrates how a framework of previous research fits
perceived self-efficacy, which, in turn, can result in together, and how concepts can be manipulated for
increased positive affect. further study.
7 . When positive emotions or affect is associated
with a behavior, the probability of commitment Acceptance by the Nursing Community
and action is increased. Practice

Wellness as a nursing specialty has grown in promi-
nence, and current state-of-the-art clinical practice
includes health promotion education. Nursing profes-
sionals find the HPM relevant, as it applies across the

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

application in a variety of settings. A research program CHAPTER 21  Nola J. Pender 405
tested the applicability of the model to children 10 to
16 years of age (Robbins, Gretebeck, Kazanis, & CASE STUDY
Pender, 2006). Cultural and diversity considerations Thomas, a 26-year-old graduate student of Cuban
support model testing in diverse populations. descent, comes to the college health clinic to dis-
Accessibility cuss his perceived weight problem. He tells you
Pender and others have supported the model through that he wants a more business-like look and wants
empirical testing as a framework for explaining health to have more energy. He says that he is tired of
promotion. The Health Promoting Lifestyle Profile having his belly fall over his belt. In your physical
is an instrument used to assess health-promoting assessment, you find that Thomas is 5 feet 11inches,
behaviors (Pender, Murdaugh, & Parsons, 2006). The weighs 260 pounds, and has mild hypertension
model continues to evolve through planned pro- (132/90 mm Hg). His mother has a history of dia-
grams of research. Continued empirical research, betes mellitus, and he tells you that high blood
especially intervention studies, further refine the pressure runs in the family. His 64-year-old father
model. Research foci continue upon evidence-based had a heart attack 1 year ago. His electrocardio-
and effective health promotion strategies that serve gram demonstrates normal sinus rhythm. He does
the individual within the context of the community not smoke. He says that his stress level is high,
(Pender, Murdaugh, & Parsons, 2010). because he is working on his master’s thesis.
Importance Thomas leaves to have some screening blood work
Pender identified health promotion as a goal for the and makes an appointment to see you next week.
twenty-first century, just as disease prevention was a You begin some preliminary planning. Analysis of
task of the twentieth century. The model describes the this case study follows to illustrate the use of the
interaction between the nurse and the consumer HBM in action with Thomas:
while considering the role of environment in health 1. What online state-of-the-science resources
promotion (Pender, Murdaugh, & Parsons, 2010).
Pender responded to the political, social, and per- would you use to help you in planning disease
sonal environment of her time to clarify nursing’s role prevention and health promotion?
in delivering health promotion services to persons of n The Agency for Healthcare Research and
all ages. The model fosters thinking about future op-
portunities and influences the use of technological Quality provides a “Guide to Clinical Pre-
advances such as the electronic health record as a ventive Services,” which lists the latest
means to achieve prevention and health promotion available recommendations on preventive
(Pender, Murdaugh, & Parsons, 2010). interventions: screening tests, counseling,
immunizations, and medication regimens
Summary for more than 80 conditions. Age-specific
periodic screenings based on gender and
The movement to greater responsibility and account- individual risk factors are available from
ability for successful personal health practices re- the website (http://www.ahrq.gov/clinic/
quires the support of the nursing profession through uspstfix.htm). The consumer section offers
development of evidence-based practice. The HPM downloadable files for your personal digital
evolved from a substantive research program and assistant as another resource.
continues to provide direction for better health prac- n Go to http://www.ahrq.gov/research/
tices. The model guides further research in various obesity.htm. Look under the Screening and
populations. Dr. Pender’s visionary leadership contin- treatment.
ues to influence health promotion–related education, n Healthy People 2020 includes a comprehen-
research, and policy. sive set of disease prevention and health
promotion objectives developed to improve
the health of all people in the United States
during the first decade of the twenty-first
century (http://www.healthypeople.gov).

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

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

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

n Pender, N. J. (1986, Oct.). Enhancing wellness
through nursing research (Videotape). Recorded

CHAPTER 21  Nola J. Pender 407

REFERENCES Pender, N. J. (1997b). Health promotion in nursing practice
(3rd ed.). Stamford, (CT): Appleton & Lange. [Korean
Bandura, A. (1977). Self-efficacy: Toward a unifying theory translation].
of behavioral change. Psychology Review, 84(2), 191–215.
Pender, N. J. Faculty-Staff profile, University of Michigan
Becker, M. H. (1974). The health belief model and personal School of Nursing. Retrieved from http://nursing.umich.
behavior. Thorofare, (NJ): Charles B. Slack. edu/faculty-staff/nola-j-pender.

Dunn, H. L. (1961). High-level wellness. Arlington, (VA): Pender, N. J., Baraukas, V. H., Hayman, L., Rice, V. H., &
Beatty. Anderson, E. T. (1992). Health promotion and disease
prevention: Toward excellence in nursing practice and
Feather, N. T. (1982). Expectations and actions: Expectancy- education. Nursing Outlook, 40(3), 106–120.
value models in psychology. Hillsdale, (NJ): Lawrence
Erlbaum Associates. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2002).
Health promotion in nursing practice (4th ed.). Upper
Hendricks, C., Murdaugh, C., & Pender, N. (2006). The Saddle River, (NJ): Prentice-Hall.
adolescent lifestyle profile: Development and psycho-
metric characteristics. Journal of National Black Nurses Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006).
Association, 17(1), 1–5. Health promotion in nursing practice (5th ed.). Upper
Saddle River, (NJ): Pearson/Prentice-Hall.
Lusk, S. L., Hong, O. S., Ronis, S. L., Eakin, B. L., Kerr,
M. J., & Early, M. R. (1999). Effectiveness of an inter- Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2010).
vention to increase construction worker’s use of hear- Health promotion in nursing practice (6th ed.). Upper
ing protection. Human Factors, 41(3), 487–494. Saddle River, (NJ): Pearson.

Lusk, S. L., Kwee, M. J., Ronis, D. L., & Eakin, B. L. (1999). Pender, N. J., Walker, S. N., Sechrist, K. R., & Stromborg,
Applying the health promotion model to development M. F. (1988). Development and testing of the health
of a worksite intervention. American Journal of Health promotion model. Cardiovascular Nursing, 24(6),
Promotion, 13(4), 219–226. 41–43.

Pender, N. J. (1970). A developmental study of conceptual, Robbins, L. B., Gretebeck, K. A., Kazanis, A. S., & Pender,
semantic differential, and acoustical dimensions as N. J. (2006). Girls on the Move program to increase
encoding categories in short-term memory (Doctoral physical activity participation. Nursing Research 55(3),
dissertation, Northwestern University). Dissertation 206–216.
Abstracts International, A, 30(10), 4283.
Sechrist, K. R., Walker, S. N., & Pender, N. J. (1987).
Pender, N. J. (1975). A conceptual model for preventive Development and psychometric evaluation of the
health behavior. Nursing Outlook, 23(6), 385–390. exercise/barriers scale. Research in Nursing and Health,
10, 357–365.
Pender, N. J. (1982). Health promotion in nursing
practice. New York: Appleton-Century-Crofts. Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The
health-promoting lifestyle profile: Development and
Pender, N. J. (1987). Health promotion in nursing practice psychometric characteristics. Nursing Research, 36(2),
(2nd ed.). New York: Appleton & Lange. 76–80.

Pender, N. J. (1996). Health promotion in nursing practice
(3rd ed.). Stamford, (CT): Appleton & Lange.

Pender, N. J. (1997a). Health promotion in nursing practice
(3rd ed.). Stamford, (CT): Appleton & Lange. [Japanese
translation].

BIBLIOGRAPHY Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2002).
Health promotion in nursing practice (4th ed.). Upper
Primary Sources Saddle River, (NJ): Prentice Hall.
Books
Pender, N. J. (1982). Health promotion in nursing practice. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006).
Health promotion in nursing practice (5th ed.). Upper
New York: Appleton-Century-Crofts. Saddle River, (NJ): Pearson/Prentice Hall.
Pender, N. J. (1987). Health promotion in nursing practice
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2010).
(2nd ed.). New York: Appleton & Lange. Health promotion in nursing practice (6th ed.). Upper
Pender, N. J. (1996). Health promotion in nursing practice Saddle River, (NJ): Pearson.

(3rd ed.). Stamford, (CT): Appleton & Lange.

408 UNIT IV  Nursing Theories

Book Chapters Dissertation
Pender, N. J. (1984). Health promotion and illness preven- Pender, N. J. (1970). A developmental study of conceptual,

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.
ing diagnosis (pp. 80–91). Philadelphia: Saunders.
Pender, N. J. (1986). Health promotion: Implementing International Journal Articles
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).
Menlo Park, (CA): Addison-Wesley. Assessing the efficacy of denture cleaners with quantitative
Pender, N. J. (1987). Health and health promotion: The light-induced fluorescence (qlf). European Journal of
conceptual dilemmas. In M. E. Duffy & N. J. Pender Prosthodontics & Restorative Dentistry, 15(4), 165–170.
(Eds.), Conceptual issues in health promotion: Report Garcia, A. W., Broda, M. A., Frenn, M., Coviak, C.,
of proceedings of a wingspread conference (pp. 7–23). Pender, N. J., & Ronis, D. L. (1997). Gender and devel-
Indianapolis: Sigma Theta Tau International. opmental differences in exercise beliefs among youth
Pender, N. J. (1989). Languaging a health perspective for and prediction of their exercise behavior [Japanese
NANDA taxonomy on research and theory. In R. M. translation]. The Japanese Journal of Nursing Research,
Carroll-Johnson (Ed.), Classification of nursing 30(3), 51–61.
diagnoses (pp. 31–36). Philadelphia: Lippincott. Garcia, A. W., George, T. R., Coviak, C. & Pender, N. J.
Pender, N. J. (1989). The pursuit of happiness, stress, and (1997). Development of the child/adolescent activity
health. In S. Wald (Ed.), Community health nursing: log: A comprehensive and feasible measure of leisure-
Issues and topics (pp. 145–175). Englewood Cliffs, time physical activity. International Journal of Behav-
(NJ): Prentice-Hall. ioral Medicine, 4(4), 323–338.
Pender, N. J. (1998). Motivation for physical activity Shin, Y., Jang, H., & Pender, N. J. (2001). Psychometric
among children and adolescents. In J. Fitzpatrick & evaluation of the Exercise Self-Efficacy Scale among
J. S. Stevenson (Eds.), Annual review of nursing research Korean adults with chronic diseases. Research in
(Vol. 16, pp. 139–172). New York: Springer. Nursing & Health, 24(1), 68–76.
Pender, N. J. (2004). Health promotion interventions for Shin, Y. H., Hur, H. K., Pender, N. J., Jang, H. J., & Kim, M.
culturally diverse populations: Can we meet the chal- (2006). Exercise self-efficacy, exercise benefits and
lenge? In W. Kunaviktikul (Ed.), Improving life through barriers, and commitment to a plan for exercise among
health promotion: Nurses making a difference (pp. 11–26). Korean women with osteoporosis and osteoarthritis.
Chaing Mai, Thailand, Chotana Press. International Journal of Nursing Studies 43(1), 3–10.
Pender, N. J. (2005). A Global Agenda for health promotion. Shin, Y., Pender, N. J., & Yun, S. (2003). Using method-
In W. Kunaviktikul (Ed.), Toward success in health promo- ological triangulation for cultural verification of com-
tion (pp. 11–23). Chaing Mai, Thailand, Chotana Press. mitment to a plan for exercise scale among Korean
Pender, N. J., & Pender, A. R. (1989). Attitudes, subjective adults with chronic diseases. Research in Nursing &
norms, and intentions to engage in health behaviors. Health, 26(4), 312–321.
In C. A. Tanner (Ed.), Using nursing research (NLN Shin, Y., Yun, S., Pender, N. J., & Jang, H. (2005). Test of
Pub. No. 15–2232, pp. 466–472). New York: National the health promotion model as a causal model of
League for Nursing. commitment to a plan for exercise among Korean
Pender, N. J., & Sallis, J. (1995). Exercise counseling by adults with chronic disease. Research in Nursing &
health professionals. In R. Dishman (Ed.), Exercise Health, 28(2), 117–125.
adherence (2nd ed.). Champaign, (IL): Human Kinetics. Waring, D. T., Pender, N., & Counihan, D. (2005).
Pender, N. J., Sallis, J., Long, B. J., Calfas K. J. (1994). Health Mandibular arch changes following nonextraction
care provider counseling to promote physical activity. In treatment.[see comment]. Australian Orthodontic
R. K. Dishman (Ed.). Advances in exercise adherence Journal, 21(2), 111–116.
(pp. 213–235). Champaign, (IL): Human Kinetics. Wu, T. Y., & Pender, N. (2005). A panel study of physical
Pender, N. J., & Stein, K. F. (2002). Social support, the self activity in Taiwanese youth: Testing the revised health-
system and adolescent health and health behaviors. promotion model. Family & Community Health, 28(2),
In L. L. Hayman, M. M. Mahon, & J. R. Turner (Eds.), 113–124.
Health behavior in childhood and adolescence (pp.37–66). Wu, T. Y., Pender, N., & Noureddine, S. (2003). Gender differ-
New York: Springer. ences in the psychosocial and cognitive correlates of phys-
ical activity among Taiwanese adolescents: A structural

equation modeling approach. International Journal of CHAPTER 21  Nola J. Pender 409
Behavioral Medicine, 10(2), 93–105. Pender, N. J. (1974). Patient identification of health

Journal Articles information received during hospitalization. Nursing
Berg, A. O., Allan, J. D., Frame, P. S., Homer, C. J., Johnson, Research, 23(3), 262–267.
Pender, N. J. (1975). A conceptual model for preventive
M. S., Klein, J. D., et al. Research. (2002). Newborn health behavior. Nursing Outlook, 23(6), 385–390.
hearing screening: recommendations and rationale. Pender, N. J. (1984). Physiologic responses of clients with
American Journal of Nursing, 102(11), 83–89. essential hypertension to progressive muscle relaxation
Berg, A. O., Allan, J. D., Frame, P. S., Homer, C. J., Lieu, training. Research in Nursing and Health, 7, 197–203.
T. A., Mulrow, C. D., et al; U S Preventive Services Task Pender, N. J. (1985). Effects of progressive muscle relax-
Force. (2002). Screening for chlamydia infection: rec- ation training on anxiety and health locus of control
ommendations and rationale. U.S. Preventive Services among hypertensive adults. Research in Nursing and
Task Force. American Journal of Nursing, 102(10), Health, 8, 67–72.
87–92; discussion 93. Pender, N. J. (1987). Interview: James Michael McGinnis,
Brimmer, P. F., Skoner, M., Pender, N. J., Williams, C. A., MD, MPP. Family and Community Health, 10(2),
Fleming, J. W., & Werley, H. H. (1983). Nurses with 59–65.
doctoral degrees: Education and employment charac- Pender, N. J. (1988). Research agenda: Identifying research
teristics. Research in Nursing and Health, 6, 157–165. ideas and priorities. American Journal of Health Promo-
Eden, K. B., Orleans, C. T., Mulrow, C. D., Pender, N. J., & tion, 2(4), 42–51.
Teutsch, S. M. (2002). Does counseling by clinicians Pender, N. J. (1988). Research agenda: The influences of
improve physical activity? A summary of the evidence health policy on an evolving research agenda. American
for the U. S. Preventive Services Task Force, Annals of Journal of Health Promotion, 2(3), 51–54.
Internal Medicine, 137(3), E208–E215. Pender, N. J. (1989). Health promotion in the workplace:
Educating APHs for implementing the guidelines for Suggested directions for research. American Journal of
adolescents in bright futures: Guidelines of health Health Promotion, 3(3), 38–43.
supervision of infants, children, and adolescents. Pender, N. J. (1990). Expressing health through lifestyle
Nursing Outlook, 45(6), 252–257. patterns. Nursing Science Quarterly, 3(3), 115–122.
Frank-Stromborg, M., Pender, N. J., Walker, S. N., & Pender, N. J. (1990). Research agenda: A revised research
Sechrist, K. R. (1990). Determinants of health- agenda model. American Journal of Health Promotion,
promoting lifestyle in ambulatory cancer patients. 4(3), 220–222.
Social Science and Medicine, 31(10), 1159–1168. Pender, N. J. (1992). Making a difference in health policy.
Garcia, A. W., Broda, M. A. N., Frenn, M., Coviak, C., Nursing Outlook, 40(3), 104–105.
Pender, N. J., & Ronis, D. L. (1995). Gender and devel- Pender, N. J. (1992). Reforming health care: Future direc-
opmental differences in exercise beliefs among youth tion. Nursing Outlook, 40(1), 8–9.
and prediction of their exercise behavior. Journal of Pender, N. J. (1992). The NIH strategic plan: How will
School Health, 65(6), 213–219. it affect the future of nursing science and practice?
Garcia, A. W., Broda, M. A. N., Frenn, M., Coviak, C., Nursing Outlook, 40(2), 55–56.
Pender, N. J., & Ronis, D. L. (1997). Gender differ- Pender, N. J. (1993). Creating change through partnerships.
ences: Exercise beliefs among youth. Reflections, Nursing Outlook, 41(1), 8–9.
23(1), 21–22. Pender, N. J. (1993). Health care reform: One view of the
Garcia, A. W., Pender, N. J., Antonakos, C. L., Ronis, future. Nursing Outlook, 41(2), 56–57.
D. L. (1998). Changes in physical activity beliefs and Pender, N. J. (1993). Reaching out. Nursing Outlook, 41(3),
behaviors of boys and girls across the transition to 103–104.
junior high school. Journal of Adolescent Health, 5, Pender, N. J., Barkaukas, V. H., Hayman, L., Rice, V. H., &
394–402. Anderson, E. T. (1992). Health promotion and disease
Hendricks, C., Murdaugh, C., & Pender, N. (2006). The prevention: Toward excellence in nursing practice and
adolescent lifestyle profile: Development and psycho- education. Nursing Outlook, 40(3), 106–112, 120.
metric characteristics. Journal of National Black Nurses Pender, N. J., Bar-Or, O., Wilk, B., & Mitchell, S. (2002).
Association, 17(2), 1–5. Self-efficacy and perceived exertion of girls during
Pender, N. J. (1967). The debate as a teaching and learning exercise. Nursing Research, 51(2), 86–91.
tool. Nursing Outlook, 15(12), 42–43. Pender, N. J., & Pender, A. R. (1980). Illness prevention
Pender, N. J. (1971). Students who choose nursing: Are and health promotion services provided by nurse prac-
they success oriented? Nursing Forum, 16(1), 64–71. titioners: Predicting potential consumers. American
Journal of Public Health,70(8), 798–803.

410 UNIT IV  Nursing Theories benefits/barriers scale. Research in Nursing and Health,
Pender, N. J., & Pender, A. R. (1986). Attitudes, subjective 10, 357–365.
Walker, S. N., Kerr, M. J., Pender, N. J., & Sechrist, K. R.
norms, and intentions to engage in health behaviors. (1990). A Spanish language version of the health promot-
Nursing Research, 35(1), 15–18. ing lifestyle profile. Nursing Research, 39(5), 268–273.
Pender, N. J., Sechrist, K. R., Stromborg, M., & Walker, Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The
S. N. (1987). Collaboration in developing a research health-promoting lifestyle profile: Development and psy-
program grant. Image: The Journal of Nursing Scholar- chometric characteristics. Nursing Research, 36(2), 76–81.
ship, 19(2), 75–77. Walker, S. N., Volkan, K., Sechrist, K. R., & Pender, N. J.
Pender, N. J., Smith, L. C., & Vernof, J. A. (1987). Building (1988). Health-promoting life styles of older adults: Com-
better workers. American Association of Occupational parisons with young and middle-aged adults, correlates
Health Nurses Journal, 35(9), 386–390. and patterns. Advances in Nursing Science, 11(1), 76–90.
Pender, N. J., Walker, S. N., Frank-Stromborg, M., & Sechrist, Whitehead, D., Shin, Y., Yun, S., Pender, N. J., & Jang, H.
K. R. (1990). Predicting health-promoting lifestyles in the (2005). Letter to the editor. “Test of the Health Promo-
workplace. Nursing Research, 39(6), 326–332. tion Model as a causal model of commitment to a plan
Pender, N. J., Walker, S. N., Sechrist, K. R., & Frank- for exercise among Korean adults with chronic disease”
Stromborg, M. (1988). Development and testing of the (Shin, Pender, & Yun, 2003; published in April 2005
health promotion model. Cardiovascular Nursing, issue. Research in Nursing & Health 28(4), 357–361.
24(6), 41–43. Whitlock, E. P., Orleans, C. T., Pender, N., & Allan, J.
Pignone, M. P., Ammerman, A., Fernandez, L., Orleans, (2002). Evaluating primary care behavioral counseling
C. T., Pender, N., Woolf, S., et al. (2003). Counseling to interventions: An evidence-based approach. American
promote a healthy diet in adults: A summary of the Journal of Preventive Medicine, 22(4), 267–284.
evidence for the U.S. Preventive Services Task Force. Wu, T. Y., & Pender, N. (2002). Determinants of physical
American Journal of Preventive Medicine, 24(1), 75–92. activity among Taiwanese adolescents: An application
Porter, C. P., Pender, N. J., Hayman, L. L., Armstrong, of the health promotional model. Research in Nursing
M. L., Riesch, S. K., & Lewis, M. A. (1997). Educating & Health, 25(1), 25–36.
APNs for implementing the guidelines for adolescents Wu, T. Y., Pender, N., & Yang, K. P. (2002). Promoting
in bright futures: Guidelines of health supervision of physical activity among Taiwanese and American
infants, children, and adolescents. Nursing Outlook, adolescents. Journal of Nursing Research, 10(1), 57–64.
45(6), 252–257. Wu, T. Y., Ronis, D. L., Pender, N., & Jwo, J. (2002). Devel-
Robbins, L. B., Gretebeck, K. A., Kazanis, A. S., & Pender, opment of questionnaires to measure physical activity
N. J. (2006). Girls on the Move program to increase physi- cognitions among Taiwanese adolescents. Preventive
cal activity participation. Nursing Research 55(3), 206–216. Medicine, 35(1), 54–64.
Robbins, L. B., Pender, N. J., Conn, V. S., Frenn, M. D.,
Neuberger, G. B., Nies, M. A., et al. (2001). Physical Secondary Sources
activity research in nursing. Journal of Nursing Scholar- Dissertations and Theses
ship, 33(4), 315–321. Al-Obeisat, S. M. (1999). Prenatal care utilization among
Robbins, L. B., Pender, N. J., & Kazanis, A. S. (2003).
Barriers to physical activity perceived by adolescent girls. Jordanian women (health care utilization, health pro-
Journal of Midwifery & Women’s Health, 48(3), 206–212. motion model). Dissertation Abstracts International,
Robbins, L. B., Pender, N. J., Ronis, D. L., Kazanis, A. S., & 60–04B, 1525.
Pis, M. B. (2004). Physical activity, self-efficacy, and Anderson, J. K. (2008). Predictors of health promoting be-
perceived exertion among adolescents. Research in haviors and health-related quality of life in post myocar-
Nursing & Health, 27(6), 435–446. dial infarction adults. (Doctoral Dissertation). Retrieved
Robbins, L. B., Pis, M. B., Pender, N. J., & Kazanis, A. S. fromProQuest Dissertations & Theses A&I database.
(2004). Physical activity self-definition among adoles- (UMI No. 304324280).
cents. Research & Theory for Nursing Practice, 18(4), Anthony, J. S. (1999). Mental health correlates of self-advocacy
317–330. in health care decision-making among elderly African-
Robbins, L. B., Pis, M. B., Pender, N. J., & Kazanis, A. S. Americans (Doctoral dissertation, George Mason Univer-
(2004). Exercise self-efficacy, enjoyment, and feeling sity). Dissertation Abstracts International, 59–12B, 6259.
states among adolescents. Western Journal of Nursing Bagwell, M. M. (1988). Wellness in two developmental
Research, 26(7), 699–715; discussion 716–621. phases of employed adults.Unpublished doctoral disser-
Sechrist, K. R., Walker, S. N., & Pender, N. J. (1987). Devel- tation, Texas Woman’s University, Houston.
opment and psychometric evaluation of the exercise

Baker, O. G. (2003). Relationship of parental tobacco use, CHAPTER 21  Nola J. Pender 411
peer influence, self-esteem, and tobacco use among
Yemeni American adolescents: Mid-range theory test- ProQuest Dissertations & Theses A&I database, UMI
ing. Dissertation Abstracts International, 64–03B, 1175. No. 866326866.
(University Microfilms No. AAT3086416) Costanzo, C. (2005). Physical activity counseling interven-
tion for women age 50–75 within the community. Uni-
Barnett, F. C. (1989). The relationship of selected cognitive- versity of Nebraska Medical Center, In ProQuest Digital
perceptual factors to health-promoting behaviors of ado- Dissertations [database on-line]. Retrieved from http://
lescents.Unpublished doctoral dissertation, University www.proquest.com/ (publication number AAT:
of Texas, Austin. 3165167).
Cunningham, G. D. (1989). Health promoting self care
Beunting, J. A. (1990). Psychosocial variables and gender behaviors in an older adult community. Dissertation
as factors in wellness promotion. Unpublished doctoral Abstracts International, 50–11B, 4968.
dissertation, State University of New York at Buffalo. Douchand Brown, S. E. (2009). Health promotion behaviors
among African American women. (Doctoral dissertation).
Bilderback, L. K. (1990). Health-promoting behaviors and Retrieved from ProQuest Dissertations & Theses A&I
perceived health status of rural families: A descriptive- database, UMI No. 304929507.
correlational study. Masters Abstracts International, Dunham, K. L. (1992). Health promoting lifestyles of
29–01, 0089. nursing faculty. Masters Abstracts International, 31–02,
0760.
Bolio, S. M. (1999). Reported health-promoting behaviors Easom, L. R. (2003). Determinants of participation in
of incarcerated males (prisoner health, family support). health promotion activities in rural elderly caregivers.
Dissertation Abstracts International, 60–02B, 0575. Dissertation Abstracts International, 64–02B, 636,
University Microfilms No. AAT3081342.
Bond-Kinkade, M. A. (1999). The relationship of locus of Edmonds, J. C. (2006). The relationship of weight, body image,
control and participation in health-promoting behaviors self-efficacy, and stress to health-promoting behaviors:
among kidney transplant recipients. Masters Abstracts A study of college educated African American women.
International, 37–06, 1815. The Catholic University of America, Washington, D. C.
Retrieved from ProQuest Digital Dissertations database
Bruna, A. C. (1998). Health promoting behaviors of at: http://www.proquest.com/ (publication number AAT
rural Kansas women throughout the lifespan. Masters 3214670).
Abstracts International, 37–01, 234. Espelin, J. M. (2010). Substance abuse education for under-
graduate nursing students: A target approach to program
Burrill, E. B. (1998). Health conception, family health evaluations. (Doctoral Nursing Practice Thesis). Retrieved
work and health promoting lifestyle practices in Latin from ProQuest Dissertations & Theses A&I database,
American Mennonite families. Masters Abstracts UMI No. 759116956.
International, 37–01, 239. Elliott, J. L. (2010). Improving the discharge process of ante-
natal admissions during pregnancy. (Master’s Thesis).
Butler, M. R. (1995). Self-esteem and health-promoting life- Retrieved from ProQuest Dissertations & Theses A&I
style as predictors of health-risk behavior among older database, UMI No. 860597183.
adolescents. Unpublished doctoral dissertation, Texas Ellis, J. R. (1990). Health status, health behavior, multidi-
Woman’s University, Houston. mensional health locus-of-control and factors in the
development of personal control in individuals with
Carroll, S. A. (1995). The relationship of choice of infant rheumatoid arthritis. Unpublished doctoral disserta-
feeding method and influencing factors among Hispanic tion, University of Texas, Austin.
mothers of the Permian basin. Masters Abstracts Interna- Fast, A. (2009). Diabetes prevention in primary school-age
tional, 34–03, 1147. children (Master’s Thesis). Retrieved from ProQuest Dis-
sertations & Theses A&I database, UMI No. 305168357.
Carter, L. M. (1990). Functional wellness among older Fehir, J. S. (1988). Motivation, and selected demographics
adults: The interface of motivation, lifestyle, and as determinants of health-promoting lifestyle behavior
capability. Unpublished doctoral dissertation, Texas in men 35 to 64 years old: A nursing investigation.
Woman’s University, Houston. Dissertation Abstracts International, 50–05B, 1851.
Felarca, C. U. (2012). A burning problem: Skin protection
Chandrasekhar, R. (1999). Cues to action which influence practices among college nursing students and non-nursing
engagement in health-promoting behaviors among
nursing students. Masters Abstracts International,
37–02, 0587.

Chen, C. (1995). Physical exercise and sense of well-being
among Chinese elderly in Taiwan. Unpublished doctoral
dissertation, University of Texas, Austin.

Chhim, D. (2011). Comparison of health-promoting life-
styles of family nurse practitioner students and non-
nursing students (Master’s Thesis). Retrieved from

412 UNIT IV  Nursing Theories health. Unpublished doctoral dissertation, Medical
College of Georgia, Augusta.
college students (Master’s Thesis). Retrieved from Pro- Haus, C. S. (2003). Medication management strategies
Quest Dissertations & Theses A&I database, UMI No. used by community-dwelling older adults living alone.
1011321588. Dissertation Abstracts International, 64–07B, 3188.
Furr, S. B. (2009). The school nurse’s perception of health (University Microfilms No. AAT3097641)
promotion behavior. (Master’s Thesis). Retrieved from Hemstron, M. M. (1993). Relationships and differences in
ProQuest Dissertations & Theses A&I database, UMI definition of health, perceived personal competence, per-
No. 1467914. ceived health status and health-promoting lifestyle profile in
Gabry, H. (2005). Understanding the relationship between three elderly cohorts. Unpublished doctoral dissertation,
health behavior during pregnancy and health locus of Rush University College of Nursing, Chicago.
control among Arab and non-Arab women to reduce high Hubbard, A. B. (2002). The impact of curriculum design
risk pregnancy. George Mason University, Washington, on health promoting behaviors at a community college
D.C. Retrieved from ProQuest Digital Dissertations in south Florida. Dissertation Abstracts International,
at:http://www.proquest.com/ (publication number AAT 63–06, 2112.
3167540). Hubbard, D. (1987). The patterns of family interaction
Gasalberti, D. (1999). Early detection of breast cancer by that promote positive child health behaviors. Masters
self-examination: The influence of perceived barriers Abstracts International, 26–04, 0419.
and health conception (cancer detection). Dissertation Hudak, J. W. (1988). A comparative study of the health
Abstracts International, 60–01B, 0129. beliefs and health-promoting behaviors of normal
Gautam, B. (2011). Factors predicting exercise behavior of weight and overweight male Army personnel. Disserta-
graduate students. (Doctoral dissertation). Retrieved tion Abstracts International, 50–06B, 2337.
from ProQuest Dissertations & Theses A&I database. Hung, S.-L. (2009). The relationship of lifestyle behavior and
UMI No. 3497803. occupational characteristics to selected health problems
Gava, M. Z. (1996). The AIDS crisis: Examining factors that among truck drivers in Taiwan. (Doctoral dissertation).
influence use of condoms by young adult Zimbabwean Retrieved from ProQuest Dissertations & Theses A&I
males. Unpublished doctoral dissertation, University database, UMI No. 3383206.
of Michigan, Ann Arbor. Jadalla, A. A. (2007). Acculturation, health, and health
Gerard, M. S. (1993). Factors related to long-term physical behaviors of adult Arab Americans. Loma Linda
activity following coronary artery bypass graft surgery. University, California. Retrieved from ProQuest Digital
Unpublished doctoral dissertation, Rush University Dissertations at:http://www.proquest.com/ (publication
College of Nursing, Chicago. number AAT 3282707).
Gillis, A. J. (1993). The relationship of definition of health, Jones, C. J. (1991). Relationship of participation in health
perceived health status, self-efficacy, parental health- promotion behaviors to health-related hardiness and
promoting lifestyle, and selected demographics to health- other selected factors in older adults. Unpublished doc-
promoting lifestyle in adolescent females. Unpublished toral dissertation, Texas Woman’s University, Houston.
doctoral dissertation, University of Texas, Austin. Kalampakorn, S. (2000). Stages of construction workers’
Grabowski, B. J. (1997). Determinants of health promotion use of hearing protection. Dissertation Abstracts
behavior in active duty Air Force personnel. Masters International, 61–07B, 3508.
Abstracts International, 36–01, 0156. Keegan, J. P. (2011). Predictive ability of Pender’s Health
Hagerstrom, G. (2010). Personal factors, perceptions, Promotion Model for physical activity and exercise
influences and their relationship with adherence behav- participation for people with spinal cord injury: A
iors in patients with diabetes. (Doctoral dissertation). hierarchical regression analysis. (Doctoral dissertation).
Retrieved from ProQuest Dissertations & Theses A&I Retrieved from ProQuest Dissertations & Theses A&I
database, UMI No. 3442416. database, UMI No. 3488940.
Harms, J. M. (1995). Health-promoting behaviors in Kerr, M. J. (1994). Factors related to Mexican-American
exercising and nonexercising seniors: A comparison. workers use of hearing protection (noise). Dissertation
Masters Abstracts International, 34–02, 0719. Abstracts International, 50–08B, 3238.
Harrison, R. L. (1993). The relationship among hope, Kohlbry, P. W. (2006). Exercise self-efficacy, stages of exercise
perceived health status, and health-promoting lifestyle change, health promotion behaviors, and physical activity
among HIV seropositive men. Unpublished doctoral in postmenopausal Hispanic women. Unpublished Ph.D.,
dissertation, New York University. University of Illinois at San Diego, California. Retrieved
Hatmaker, D. D. (1993). The effects of individual factors and
health promotion during pregnancy on maternal-child

from ProQuest Digital Dissertations at: http://www. CHAPTER 21  Nola J. Pender 413
proquest.com/ (publication number AAT 3218201).
Kurtz, A. C. (1996). Correlates of health-promoting lifestyles prepregnant body mass index. (Doctoral dissertation).
among women with rheumatoid arthritis. Unpublished Retrieved from ProQuest Dissertations & Theses A&I
doctoral dissertation, Columbia University Teachers database, UMI No. 3467224.
College, New York. Oh, H. (1993). Health promoting behaviors and quality
Lee, N. (1987). Health knowledge and health-promoting of life of Korean women with arthritis. Dissertation
behavior in Chinese students. Masters Abstracts Abstracts International, 54–08B, 4083.
International, 27–01, 0086. Parker, T. J. (2008). Factors influencing early detection of
Lewallen, L. P. (1995). Barriers to prenatal care in low- breast cancer in African American women (Master’s
income women. Unpublished doctoral dissertation, Thesis). Retrieved from ProQuest Dissertations &
University of North Carolina at Chapel Hill. Theses A&I database, UMI No. 1467917.
Long, J. J. (2012). Comparison of health-promoting lifestyles Phillips, P. S. (1993). Health promoting behaviors of
in adult patients with and without primary care provider adults attending a worksite health fair. Masters
continuity (Master’s Thesis). Retrieved from ProQuest Abstracts International, 32–05, 1375.
Dissertations & Theses A&I database, UMI No. 1511365. Pichayapinyo, P. (2005). The relationship of perceived
Luther, C. H. (2003). Living the coming of osteoporosis: benefits, perceived barriers, social support, and sense
Health promotion behaviors of women at risk for of mastery on adequacy of prenatal care for first-time
osteoporosis in Mississippi. Dissertation Abstracts Thai mothers. The Catholic University of America,
International, 64–08B, 3746, University Microfilms Washington, D.C. Retrieved from ProQuest Digital
No. AAT3101544. Dissertations at: http://www.proquest.com/ (publication
Martinelli, A. M. (1996). A study of health locus of control, number AAT 3169867).
self-efficacy, health promotion behaviors, and environ- Polsingchan, S. (2010). Health-Promoting Behaviors in Thai
mental factors related to the self-report of the avoidance persons with Chronic Renal Failure. (Doctoral disserta-
of environmental smoke in young adults. Unpublished tion). Retrieved from ProQuest Dissertations & Theses
doctoral dissertation, Catholic University of America, A&I database, UMI No. 3446004.
Washington, D. C. Rothschild, S. L. (1996). Mental health representations of
McCullagh, M. C. (1999). Factors affecting hearing attachment: Implications for health-promoting behavior
protector use among farmers. Dissertation Abstracts and perceived stress. Unpublished doctoral dissertation,
International, 61–02B,780. Ohio State University, Columbus.
McKeon, F. M. (1997). Health-promoting behaviors: Rummel, C. B. (1991). The relationship of health value and
Predictors of early vs. late initiation to prenatal care. hardiness to health-promoting behavior in nurses. Un-
Masters Abstracts International, 35–05, 1390. published doctoral dissertation, New York University.
McMemamin, C. A. (2002). Parental perception concern- Sakraida, T. J. (2002). Divorce transition, coping responses,
ing the use of peak flow meters in the child with and health promoting behavior of midlife women. Disser-
asthma. Masters Abstracts International, 41–05, 1420. tation Abstracts International, 62–12B, 5646, University
Medcalf, P. L. (1988). Value placed on health and number Microfilms No. AAT3037817.
of health promoting behaviors of adults. Masters Sallee, A. M. (1996). The relationship of health locus of
Abstracts International, 27–04, 0492. control and participation in health-promoting behaviors
Merren, V. A. (1991). Determinants of health promotion among older hypertensive persons. Masters Abstracts
in the elderly. Masters Abstracts International, 29–04, International, 34–18, 2349.
0648. Sapp, C. J. (2003). Adolescents with asthma: Effects of
Mitchell, M. L. (1993). Effects of a self-efficacy intervention personal characteristics and health-promoting lifestyle
on adherence to antihypertensive regimens. Unpublished behaviors on health-related quality of life. Dissertation
doctoral dissertation, University of Rochester. Abstracts International, 64–05B, 2131, University
Moore, E. J. (1992). The relationship among self-efficacy, Microfilms No. AAT3092071.
health knowledge, self-rated health status, and selected Smith Hendricks, C. K. (1992). Perceptual determinants
demographics as determinants of health promoting of early adolescent health promoting behaviors in one
behavior of older adults. Unpublished doctoral Alabama black belt country. Unpublished doctoral
dissertation, University of Akron. dissertation, Boston College.
Nodine, P. M. (2011). The contribution of physical activity Spencer, S. A. (2007). Effects of physiological and cognitive
to sleep parameters in pregnancy within the context of perceptual factors on health promotion practices in Army
reservists. Unpublished Ph.D., University of Illinois,
Chicago. Retrieved from ProQuest Digital Dissertations

414 UNIT IV  Nursing Theories Wilson, A. H. (1991). Health promoting behaviors among
married and unmarried mothers. Dissertation Abstracts
at: http://www.proquest.com/ (publication number International, 52–06B, 2999.
AAT 3267048).
Stone, S. A. (1990). The relationship between self-esteem Wisnewski, C. A. (1996). A study of the health-promoting
and health promoting behaviors in working women. behavioral effects of an exercise educational intervention
Masters Abstracts International, 30–04, 1326. in adult diabetics. Unpublished doctoral dissertation,
Stutts, W. C. (1997). Use of the health promotion model to Texas Woman’s University, Houston.
predict physical activity in adults. Unpublished doctoral
dissertation, University of North Carolina, Chapel Hill. Yang, K. (2005). Physical activities among Korean midlife
Suwonnaroop, N. (1999). Health-promoting behaviors in immigrant women in the United States. Unpublished
older adults: The effect of social support, perceived Ph.D., The University of Texas, Austin. Retrieved from
health status, and personal factors. Dissertation ProQuestDigital Dissertations at: http://www.proquest.
Abstracts International, 60–08B, 3854. com/ (publication number AAT 3184818).
Tapler, D. A. (1996). The relationship between health value,
self-efficacy, health barriers, and health behavior prac- Yue, S. P. (1998). Assessing the needs of the post-cardiac
tices in mothers. Unpublished doctoral dissertation, event population in a rural southeastern New Mexico
Texas Woman’s University, Houston. community. Masters Abstracts International, 36–06, 1594.
Tashiro, J. (1996). Health promoting lifestyle behaviors of
college women in Japan: An exploratory study. Disser- Yuhos, J. L. (1997). Health patterns of nurses who smoke.
tation Abstracts International, 57–04B, 2486. Masters Abstracts International, 36–01, 0166.
Thompson, E. M. (1995). A descriptive study of women who
successfully quit smoking. Unpublished doctoral disser- Journal Articles
tation, Georgia State University, Atlanta. Agazio, J. G., Ephraim, P. M., Flaherty, N. B., & Gurney,
Turner, S. J. (1989). Health protective behavior and the
elderly: Hemoccult testing for early colorectal cancer C. A. (2002). Health promotion in active-duty military
detection. Masters Abstracts International, 28–02, 0277. women with children. 35(1), 65–82.
Vines, W. R. (1991). Psychological stress reaction, coping Callaghan, D. (2005). Healthy behaviors, self-efficacy, self-
strategies, and health promotion lifestyles among care, and basic conditioning factors in older adults.
hospital nurses. Unpublished doctoral dissertation, Journal of Community Health Nursing, 22(3), 169–178.
University of Alabama at Birmingham. Callaghan, D. M. (2005). The influence of spiritual growth
Warner, K. D. (2000). Health-related lifestyle behaviors of on adolescents’ initiative and responsibility for self-care.
twins: Interpersonal and situational influences. Disser- Pediatric Nursing, 31(2), 91–95.
tation Abstracts International, 61–03B, 1331. Callaghan, D. (2006). Basic conditioning factors’ influ-
Warren, M. T. (1993). The relationships of self-motivation ences on adolescents’ healthy behaviors, self-efficacy,
and perceived personal competence to engaging in a and self-care. Issues in Comprehensive Pediatric Nursing,
health-promoting lifestyle for men in cardiac rehabilitation 29(4), 191–204.
programs. Unpublished doctoral dissertation, New York Callaghan, D. (2006). The influence of basic conditioning
University. factors on healthy behaviors, self-efficacy, and self-care
White, D. A. (1994). The relationship of intrinsic motiva- in adults. Journal of Holistic Nursing, 24(3), 178–185.
tion and health beliefs on positive health behavior in Calvert, W. J., & Bucholz, K. K. (2008). Adolescent risky
pregnant adolescents. Masters Abstracts International, behaviors and alcohol use. Western Journal of Nursing
34–02, 0730. Research, 30(1), 147–148.
White, D. E. (2005). Women’s expectations and experiences of Campbell, J., & Kreidler, M. (1994). Older adults’ percep-
role performance following coronary artery bypass surgery. tions about wellness. Journal of Holistic Nursing, 12(4),
Unpublished Ph.D., Georgia State University. Retrieved 437–447.
from ProQuestDigital Dissertations at: http://www. Campbell, M., & Torrance, C. (2005). Coronary angioplasty:
proquest.com/ (publication number AAT 3194604). Impact on risk factors and patients’ understanding of
White, J. L. (1996). Outcomes of an individualized health the severity of their condition. Australian Journal of
promotion program for homebound older community Advanced Nursing, 22(4), 26–31.
residents. Unpublished doctoral dissertation, Texas Chen, C., Kuo, S., Chou, Y., & Chen, H. (2007). Postpartum
Woman’s University, Houston. Taiwanese women: Their postpartum depression, social
Willis, J. L. (2001). The effect of multiple roles in the support and health-promoting lifestyle profiles. Journal
health promotion activities of college women. Masters of Clinical Nursing, 16(8), 1550–1560.
Abstracts International, 39–05, 1382. Chen, M., James, K., Hsu, L., Chang, S., Huang, L., &
Wang, E. K. (2005). Health-related behavior and
adolescent mothers. Public Health Nursing, 22(4),
280–288.

Conway, A. E., McClune, A. J., & Nosel, P. (2007). Down CHAPTER 21  Nola J. Pender 415
on the farm: Preventing farm accidents in children. Kahawong, W., Phancharoenworakul, K., Khampalikit, S.,
Pediatric Nursing, 33(1), 45–48.
Taboonpong, S., & Chittchang, U. (2005). Nutritional
Costanzo, C., Walker, S. N., Yates, B. C., McCabe, B., & health-promoting behavior among women with
Berg, K. (2006). Physical activity counseling for older hyperlipidemia. Thai Journal of Nursing Research 9(2),
women. Western Journal of Nursing Research 28(7), 91–102.
786–810. Kerr, M. J., Lusk, S. L., & Ronis, D. L. (2002). Explaining
Mexican American worker’s hearing protection use
Daggett, L. M., & Rigdon, K. L. (2006). A computer- with the health promotion model. Nursing Research,
assisted instructional program for teaching portion 51(2), 100–109.
size versus serving size. Journal of Community Health Kerr, M. J., Savik, K., Monsen, K. A., & Lusk, S. L. (2007).
Nursing, 23(1), 29–35. Effectiveness of computer-based tailoring versus
targeting to promote use of hearing protection.
Esperat, C., Feng, D., Zhang, Y., & Owen, D. (2007). Health Canadian Journal of Nursing Research 39(1), 80–97.
behaviors of low-income pregnant minority women. Lohse, J. L. (2003). A bicycle safety education program for
Western Journal of Nursing Research, 29(3), 284–300. parents of young children. Journal of School Nursing,
19(2), 100–110.
Evio, B. D. (2005). The relationship between selected deter- Lucas, J. A., Orshan, S. A., & Cook, F. (2000). Determinants
minants of health behavior and lifestyle profile of older of health-promoting behavior among women ages 65
adults. Philippine Journal of Nursing, 75(1), 23–31. and above living in the community. Scholarly Inquiry for
Nursing Practice, 14(1), 77–100.
Guarnero, P. A. (2006). Health promotion behaviors Maes, C., & Louis, M. (2007). Advanced nurse practitio-
among a group of 18–29 year old gay and bisexual ners and sexual history taking practices among older
men. Communicating Nursing Research, 39, 298. adults. Communicating Nursing Research, 40, 464.
McCullagh, M., Lusk, S. L., & Ronis, D. L. (2002). Factors
Guarnero, P. A. (2007). Staying healthy: How are young influencing use of hearing protection among farmers:
gay and bisexual men doing? Communicating Nursing A test of the Pender health promotion model. Nursing
Research, 40, 429. Research, 51(1), 33–39.
McDonald, P. E., Brennan, P. F., & Wykle, M. L. (2005).
Gusain, S. (2008). Nursing and self-motivation for elderly. Perceived health status and health-promoting behaviors
Nursing Journal of India, 99(1), 5–7. of African-American and white informal caregivers
of impaired elders. Journal of National Black Nurses’
Hageman, P. A., Walker, S. N., & Pullen, C. H. (2005). Association, 16(1), 8–17.
Tailored versus standard internet-delivered interven- McMurry, T. B. (2006). A comparison of pharmacological
tions to promote physical activity in older women. tobacco cessation relapse rates. Journal of Community
Journal of Geriatric Physical Therapy, 28(1). Health Nursing 23(1), 15–28.
Mendias, E. P., & Paar, D. P. (2007). Perceptions of health and
Hensley, R. D., Jones, A. K., Williams, A. G., Willsher, L. B., self-care learning needs of outpatients with HIV/AIDS.
& Cain, P. P. (2005). One-year clinical outcomes for Journal of Community Health Nursing 24(1), 49–64.
Louisiana residents diagnosed with type 2 diabetes and Milne, J. L., & Moore, K. N. (2006). Factors impacting self-
hypertension. Journal of the American Academy of Nurse care for urinary incontinence. Urologic Nursing 26(1),
Practitioners, 17(9), 363–369. 41–51.
Montgomery, K. S. (2002). Health promotion with adoles-
Huang, T., & Dai, F. (2007). Weight retention predictors cents: Examining theoretical perspectives to guide re-
for Taiwanese women at six-month postpartum. search. Research & Theory for Nursing Practice, 16(2),
Journal of Nursing Research 15(1), 11–20. 119–134.
Morowatisharifabad, M. A., & Shirazi, K. K. (2007). Deter-
Hui, W. H. (2002). The health-promoting lifestyles of minants of oral health behaviors among preuniversity
undergraduate nurses in Hong Kong. Journal of (12th-grade) students in Yazd (Iran): an application of
Professional Nursing, 18(2), 101–111. the health promotion model. Family & Community
Health 30(4), 342–350.
Hulstein, P., & Berg, J. A. (2007). Premenstrual symptoms Nies, M. A., & Motyka, C. L. (2006). Factors contributing
and academic stress in rural college women. Communi- to women’s ability to maintain a walking program.
cating Nursing Research 40, 540. Journal of Holistic Nursing 24(1), 7–14.

Johnson, R. L. (2005). Gender differences in health-
promoting lifestyles of African Americans. Public
Health Nursing 22(2), 130–137.

Johnson, R. L., & Nies, M. A. (2005). A qualitative per-
spective of barriers to health-promoting behaviors of
African Americans. ABNF Journal 16(2), 39–41.

Kaewthummanukul, T., Brown, K. C., Weaver, M. T., &
Thomas, R. R. (2006). Predictors of exercise participa-
tion in female hospital nurses. Journal of Advanced
Nursing 54(6), 663–675.

416 UNIT IV  Nursing Theories Smith, A. B., & Bashore, L. (2006). The effect of clinic-
Olson, A. F., & Berg, J. A. (2006). Theoretical foundations based health promotion education on perceived health
status and health promotion behaviors of adolescent
of promoting perimenopausal bone health. Communi- and young adult cancer survivors. Journal of Pediatric
cating Nursing Research 39, 279. Oncology Nursing, 23(6), 326–334.
Phuphaibul, R., Leucha, Y., Putwattana, P., Nuntawan, C.,
Tapsart, C., Tachudhong, A., et al. (2005). Health pro- Smith, S. A., & Michel, Y. (2006). A pilot study on the
moting behaviors of Thai adolescents, family health effects of aquatic exercises on discomforts of pregnancy.
related lifestyles and parent modeling. Thai Journal of Journal of Obstetric, Gynecologic, and Neonatal Nursing
Nursing Research 9(1), 28–37. 35(3), 315–323.
Piazza, J., Conrad, K., & Wilbur, J. (2001). Exercise behav-
ior among female occupational health nurses. Influence Srof, B. J., & Velsor-Friedrich, B. (2006). Health promotion
of self efficacy, perceived health control, and age. in adolescents: a review of Pender’s Health Promotion
AAOHN Journal, 49(2), 79–86. Model. Nursing Science Quarterly 19(4), 366–373.
Pichayapinyo, P., O’Brien, M. E., Duffy, J. R., & Agazio, J.
(2007). The relationship of perceived benefits, per- Victor, J. F., de Oliveira Lopes, M. V., & Ximenes, L. B.
ceived barriers, social support, and sense of mastery on (2005). Analysis of diagram the health promotion
adequacy of prenatal care for first-time Thai mothers. model of Nola J. Pender [Portuguese]. ACTA Paulista
Thai Journal of Nursing Research 11(2), 106–117. de Enfermagem 18(3), 235–240.
Ronis, D. L., Hong, O., & Lusk, S. L. (2006). Comparison of
the original and revised structures of the health promo- Walker, S. N., Pullen, C. H., Hertzog, M., Boeckner, L., &
tion model in predicting construction workers’ use of Hageman, P. A. (2006). Determinants of older rural
hearing protection. Research in Nursing & Health 29(1), women’s activity and eating. Western Journal of Nursing
3–17. Research 28(4), 449–474.
Rothman, N. L., Lourie, R. J., Brian, D., & Foley, M.
(2005). Temple Health Connection: a successful collab- Wang, H. H. (2001). A comparison of two models of
orative model of community-based primary health health-promoting lifestyle in rural elderly Taiwanese
care. Journal of Cultural Diversity 12(4), 145–151. women. Public Health Nursing, 18(3), 204–211.
Schlickau, J. M., & Wilson, M. E. (2005). Breastfeeding as
health-promoting behaviour for Hispanic women: litera- Wang, W., Wang, C., Tung, Y., & Peng, J. (2007). Factors
ture review. Journal of Advanced Nursing 52(2), 200–210. influencing adolescent second-hand smoke avoidance
Shin, K. R., Kang, Y., Park, H. J., Cho, M. O., & Heitkem- behavior from the perspective of Pender’s health pro-
per, M. (2008). Testing and developing the health pro- motion model [Chinese]. Journal of Evidence-Based
motion model in low-income, Korean elderly women. Nursing 3(4), 280–288.
Nursing Science Quarterly 21(2), 173–178.
Sisk, R. J. (2000). Caregiver burden and health promotion. Wilson, M. (2005). Health-promoting behaviors of shel-
International Journal of Nursing Studies, 37(1), 37–43. tered homeless women. Family & Community Health
28(1), 51–63.

Yang, K., Laffrey, S. C., Stuifbergen, A., Im, E., May, K., &
Kouzekanani, K. (2007). Leisure-time physical activity
among midlife Korean immigrant women in the US.
Journal of Immigrant and Minority Health 9(4), 291–298.

22C H A P T E R

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).

Credentials and Background instructor, staff nurse, and head nurse on a medical-
of the Theorist surgical unit and opened a psychiatric unit while
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
cultural and social anthropology. Leininger was born In 1954, Leininger obtained a master’s degree in
in Sutton, Nebraska, and began her nursing career after psychiatric nursing from Catholic University of
graduating from the diploma program at St. Anthony’s America in Washington, D.C. She became employed
School of Nursing in Denver where she was also in the at the University of Cincinnati College of Health,
U.S. Army Nurse Corps. In 1950, she obtained a bach- where she began the first master’s-level clinical spe-
elor’s degree in biological science from Benedictine cialist program in child psychiatric nursing. She
College in Atchison, Kansas, with a minor in philoso- initiated the first graduate nursing program in
phy and humanistic studies. After graduation, she was psychiatric nursing at the University of Cincinnati
and a Therapeutic Psychiatric Nursing Center at the

Photo credit: Kathleen Leininger, Shiner, TX

417

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

Professor of Anthropology, and Director of Transcul- CHAPTER 22  Madeleine M. Leininger 419
tural Nursing Offerings until her semi-retirement in
1995. She directed the Center for Health Research active in consulting, writing, and lecturing. Her goal is
there for 5 years. While at Wayne State University, she to establish transcultural nursing institutes to educate
developed courses and seminars in transcultural and facilitate research on transcultural nursing and
nursing, caring, and qualitative research methods for health phenomena.
baccalaureate, master’s, doctoral, and postdoctoral
nursing students and for non-nursing students. Leininger has written or edited more than 30 books
Dr. Leininger taught and mentored students and listed in the bibliography of this chapter along with
nurses in field research in transcultural nursing. One more than 200 articles and 45 book chapters. She has
of the first nurse leaders to use qualitative research been featured in numerous films, videos, DVDs, and
methods in the 1960s, she taught these methods at research reports focused on transcultural nursing,
various universities in the United States and world- human care and health phenomena, the future of nurs-
wide. Leininger studied 14 cultures and continues to ing, and topics relevant in nursing and anthropology.
consult for research projects and institutions that are She served on eight editorial boards and refereed
using her Culture Care Theory. publications, and is involved with the Transcultural
Nursing Scholars Group and her website (www.made-
Leininger’s academic vitae includes nearly 600 con- leine-leininger.com). She is one of the most creative,
ferences, keynote addresses, workshops, and services productive, innovative, and futuristic authors in nurs-
as a consultant in the United States, Canada, Europe, ing, providing new and substantive research-based
Pacific Island nations, Asia, Africa, Australia, and the transcultural nursing content to advance nursing as a
Nordic countries. Educational and service organiza- discipline and a profession.
tions requested consultation on transcultural nursing,
humanistic caring, ethnonursing research, Culture Leininger has received many awards and honors for
Care Theory, and trends in health care worldwide. her lifetime professional and academic accomplishments.
She is in Who’s Who of American Women, Who’s Who in
In addition to transcultural nursing with care as a Health Care, Who’s Who in Community Leaders, Who’s
central focus, Leininger’s interests include comparative Who of Women in Education, International Who’s Who
education and administration, nursing theories, poli- in Community Service, Who’s Who in International
tics, ethical dilemmas of nursing and health care, quali- Women, and other such listings. Her name appears
tative research, future nursing and health care, and on the National Register of Prominent Americans and
nursing leadership. Her Culture Care Theory is used International Notables, International Women, and the
worldwide and is growing in relevance with the discov- National Register of Prominent Community Leaders.
ery of knowledge from diverse cultures. Leininger initi- She has received honorary degrees, including the LHD
ated the National Transcultural Nursing Society in 1974 from Benedictine College in Atchison, Kansas; a PhD
and established the National Research Care Conference from University of Kuopio, Finland; and a DS from the
in 1978 for nurses to study human care phenomena University of Indiana, Indianapolis. In 1976 and 1995,
(Leininger, 1981, 1984a, 1988a, 1990a, 1991b; Leininger Leininger was recognized for her significant contribu-
& Watson, 1990). She initiated the Journal of Transcul- tions to the American Association of Colleges of Nurs-
tural Nursing in 1989 and was editor until 1995. ing as its first full-time president. She received the
Russell Sage Outstanding Leadership Award in 1995
Leininger worked enthusiastically to persuade nurs- and is designated as a Fellow of the American Academy
ing educators and practitioners to incorporate trans- of Nursing and the Society for Applied Anthropology.
cultural nursing and culture-specific care concepts into Her affiliations include Sigma Theta Tau International,
nursing curricula and clinical practices for all aspects Delta Kappa Gamma, and the Scandinavian College of
of nursing (Leininger, 1991b, 1995c; Leininger & Caring Science in Stockholm, Sweden. She was a distin-
McFarland, 2002a; Leininger & Watson, 1990). She guished visiting scholar and lecturer at 85 universities
remained active in two disciplines and continued to in the United States and worldwide and was a visiting
contribute to nursing and anthropology at national and professor at universities in Sweden, Wales, Japan, China,
international conferences and meetings. Dr. Leininger Australia, Finland, New Zealand, and the Philippines.
resides in Omaha, Nebraska, and is semi-retired but While at Wayne State University, Leininger received the
Board of Regents’ Distinguished Faculty Award, the

420 UNIT IV  Nursing Theories successful outcomes (Leininger, 1991b, 1995c, 1996a,
Distinguished Research Award, the President’s Excel- 1996b; Leininger & McFarland, 2002a, 2006).
lence in Teaching, and the Outstanding Graduate
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
Theoretical Sources (Leininger, 1995c; Leininger & McFarland, 2002a).
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
respect to their caring values, expressions, health- Leininger describes the transcultural nurse gener-
illness beliefs, and patterns of behavior. alist as a nurse prepared at the baccalaureate level who
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 perspectives” (Leininger, 1984b,
Transcultural nursing goes beyond an awareness p. 252). The transcultural nurse specialist is an expert
state to that of using Culture Care nursing knowledge field practitioner, teacher, researcher, and consultant
to practice culturally congruent and responsible care with respect to select cultures. This individual values
(Leininger, 1991b, 1995c). Leininger has stated that and uses nursing theory to develop and advance
there will be nursing practice that reflects nursing knowledge within the discipline of transcultural nurs-
practices that are culturally defined, grounded, and ing (1995c, 2001).
specific to guide nursing care provided to individuals,
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

limits healing and well-being (Leininger, 1991b, 1995a, CHAPTER 22  Madeleine M. Leininger 421
1995c; Leininger & McFarland, 2002a, 2006). knowledge (1991b). The theory is neither a middle-
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
and health care for culturally congruent, safe, and
The Culture Care Theory is inductive and deduc- responsible care.
tive, derived from emic (insider) and etic (outsider)

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

Use of Empirical Evidence CHAPTER 22  Madeleine M. Leininger 423
theory is that the construct of care has been critical
For more than 6 decades, Leininger has held that care to human growth, development, and survival for
is the essence of nursing and the dominant, distinctive, human beings from the beginning of the human spe-
and unifying feature of nursing (1970, 1981, 1988a, cies (Leininger, 1981, 1984a). The second reason is to
1991b; Leininger & McFarland, 2002a, 2006). She has explicate and fully understand cultural knowledge
found that care is complex, elusive, and embedded in and the roles of caregivers and care recipients in dif-
social structure and other aspects of culture (1991b; ferent cultures to provide culturally congruent care
Leininger & McFarland, 2006). She holds that different (Leininger, 1991b, 1995c, 2002a, 2002b, 2002c). Third,
forms, expressions, and patterns of care are diverse, care knowledge is discovered and can be used as
and some are universal (Leininger, 1991b; Leininger & essential to promote the healing and well-being
McFarland, 2002a, 2006). Leininger (1985a, 1990b) of clients, to face death, or to ensure the survival of
favors qualitative ethnomethods, especially ethnonurs- human cultures over time (Leininger, 1981, 1984a,
ing, to study care. These methods are directed toward 1991b). Fourth, the nursing profession needs to sys-
discovering the people-truths, views, beliefs, and pat- tematically study care from a broad and holistic cul-
terned lifeways of people. During the 1960s, Leininger tural perspective to discover the expressions and
developed the ethnonursing method to study transcul- meanings of care, health, illness, and well-being as
tural nursing phenomena specifically and systemati- nursing knowledge (Leininger, 1991b, 1995c, 2002a,
cally. The method focuses on the classification of care 2002b, 2002c). Leininger (1991b, 1995c, 2002a, 2002b,
beliefs, values, and practices as cognitively or subjec- 2002c) finds that care is largely an elusive phenome-
tively known by a designated culture (or cultural repre- non often embedded in cultural lifeways and values.
sentatives) through their local emic people-centered However, this knowledge is a sound basis for nurses
language, experiences, beliefs, and value systems about to guide their practice for culturally congruent care
actual or potential nursing phenomena such as care, and specific therapeutic ways to maintain health, pre-
health, and environmental factors (Leininger, 1991b, vent illness, heal, or help people face death (Leininger,
1995c; Leininger & McFarland, 2002a, 2006). Although 1994). A central thesis of the theory is that if the
nursing has used the words careand caringfor more meaning of care can be fully grasped, the well-being
than a century, the definitions and usage have been or health care of individuals, families, and groups can
vague and used as clichés without specific meanings to be predicted, and culturally congruent care can be
the culture of the client or nurse (Leininger, 1981, provided (Leininger, 1991b). Leininger (1991b) views
1984a). “Indeed, the concepts about caring have been care as one of the most powerful constructs and the
some of the least understood and studied of all human central phenomenon of nursing. However, such care
knowledge and research areas within and outside of constructs and patterns must be fully documented,
nursing” (Leininger, 1978, p. 33). understood, and used to ensure that culturally based
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
care, because data come directly from people rather To date, Leininger has studied several cultures in
than the etic (outsider views) beliefs and practices of depth and has studied many cultures with undergradu-
the researcher. An important purpose of the theory is ate and graduate students and faculty using qualitative
to document, know, predict, and explain systemati- research methods. She has explicated care constructs
cally through field data what is diverse and universal throughout cultures in which each culture has different
about generic and professional care of the cultures meanings, cultural experiences, and uses by people of
being studied (Leininger, 1991b). diverse and similar cultures (Leininger, 1991b, 1995c;
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 4. Transcultural nursing is a humanistic and scien-
tific care discipline and profession with the central
health will be documented as the essence of nursing purpose to serve individuals, groups, communi-
knowledge and practice. ties, societies, and institutions.

Leininger believes that nurses must work toward 5. Culturally based caring is essential to curing and
explicating care use and meanings so that culture care, healing, for there can be no curing without caring,
values, beliefs, and lifeways can provide accurate and but caring can exist without curing.
reliable bases for planning and effectively implementing
culture-specific care and for identifying any universal or 6. Culture Care concepts, meanings, expressions,
common features about care. She maintains that nurses patterns, processes, and structural forms of care
cannot separate worldviews, social structures, and cul- vary transculturally with diversities (differences)
tural beliefs (folk and professional) from health, well- and some universalities (commonalities).
ness, illness, or care when working with cultures,
because these factors are closely linked. Social structure Person
factors such as religion, politics, culture, economics, 7. Every human culture has generic (i.e., lay, folk,
and kinship are significant forces affecting care and
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
for care by nurses, and it is realized when culturally care influences the health and well-being of indi-
derived care is known and used. viduals, families, groups, and communities within
their environmental contexts.
Major Assumptions 1 0. Culturally congruent and beneficial nursing care
can occur only when care values, expressions, or
Major assumptions of Leininger’s Culture Care The- patterns are known and used explicitly for appro-
ory of Diversity and Universality were derived from priate, safe, and meaningful care.
Leininger’s definitive works on the theory (Leininger, 1 1. Culture Care differences and similarities exist
1991b; Leininger & McFarland, 2002a, 2006). between professional and client-generic care in
Nursing human cultures worldwide.
1. Care is the essence of nursing and a distinct,
Environment
dominant, central, and unifying focus. 1 2. Cultural conflicts, cultural impositions practices,
2. Culturally based care (caring) is essential for well-
cultural stresses, and cultural pain reflect the lack
being, health, growth, and survival, and to face of Culture Care knowledge to provide culturally
handicaps or death. congruent, responsible, safe, and sensitive care.
3 . Culturally based care is the most comprehensive 13. The ethnonursing qualitative research method pro-
and holistic means to know, explain, interpret, and vides an important means to accurately discover
predict nursing care phenomena and to guide and interpret emic and etic embedded, complex,
nursing decisions and actions. and diverse Culture Care data (Leininger, 1991b,
pp. 44–45).

The universality of care reveals the common nature CHAPTER 22  Madeleine M. Leininger 425
of human beings and humanity, whereas diversity studying culturally based care for individuals, fami-
of care reveals the variability and selected, unique lies, and groups. These factors are studied, assessed,
features of human beings. and responded to in a dynamic and participatory
nurse-client relationship (Leininger 1991a, 1991b,
Theoretical Assertions 2002b; Leininger & McFarland, 2002a).

Tenets are the positions one holds or the givens that the Logical Form
theorist uses with a theory. In developing the Culture
Care Theory, four major tenets were conceptualized Leininger’s theory (1995c) is derived from anthropol-
and formulated (Leininger, 2002c, 2006): ogy and nursing but is reformulated to become trans-
1 . Culture Care expressions, meanings, patterns, and cultural nursing theory with a human care perspective.
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.
3 . Generic emic (folk) and professional etic care in Leininger is skilled in using ethnonursing, ethnog-
different environmental contexts can greatly influ- raphy, life histories, life stories, photography, and
ence health and illness outcomes. phenomenological methods that provide a holistic
4. From an analysis of the previously listed influencers, approach to study cultural behavior in diverse envi-
three major actions and decision guides were pre- ronmental contexts. With these qualitative methods,
dicted to provide ways to give culturally congruent, the researcher moves with people in their daily living
safe, and meaningful health care to cultures. The activities to grasp their world. The nurse researcher
three culturally based action and decision modes inductively obtains data of documented descriptive
were the following: (1) Culture Care preservation and interpretative accounts from informants through
or maintenance, (2) Culture Care accommodation observation and participation explicating care as a
or negotiation, and (3) Culture Care repatterning or major challenge within the method. The qualitative
restructuring. Decision and action modes based on approach is used to develop basic and substantive
culture care were predicted as key factors to arrive at grounded data-based knowledge about cultural care
congruent, safe, and meaningful care. to guide nurses in their work. Although other meth-
Leininger has maintained that documentation ods of research such as hypothesis testing and experi-
of these tenets was necessary in order to provide mental quantitative methods can be used to study
meaningful and satisfying care to people, and they are transcultural care, the method of choice depends
predicted to be powerful influencers on culturally upon the researcher’s purposes, the goals of the study,
based care. These factors needed to be discovered and the phenomena to be studied. Creativity and
directly from the informants as influencing factors experience of the nurse researcher to use different
related to health, well-being, illness, and death. The research methods to discover nursing knowledge are
modes set forth in the four tenets are Culture Care encouraged. However, Leininger holds that qualita-
preservation or maintenance; Culture Care accom- tive methods are important to establish meanings and
modation and negotiation; and Culture Care repat- accurate cultural knowledge.
terning or restructuring. The researcher draws upon
findings from the social structure, generic and profes- Leininger developed the Sunrise Enabler (Figure
sional practices, and other influencing factors while 22–1) in the 1970s to depict the essential components
of the theory. She has refined the sunrise, and thus the
evolved enabler is more definitive and valuable to

426 UNIT IV  Nursing Theories

CULTURE CARE

Worldview

Cultural & Social Structure Dimensions

Kinship & Cultural Values, Political &
Social Beliefs & Legal
Factors Lifeways Factors

Environmental Context,
Language & Ethnohistory

Religious & Economic
Philosophical Factors

Factors Influences

Technological Care Expressions Educational
Factors Patterns & Practices Factors

Holistic Health/Illness/Death
Focus: Individuals, Families, Groups, Communities or Institutions

in Diverse Health Contexts of

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

Transcultural Care Decisions & Actions

Culture Care Preservation/Maintenance
Culture Care Accommodation/Negotiation
Culture Care Repatterning/Restructuring

Code: (Influencers) © M. Leininger, 2004

Culturally Congruent Care for Health, Well-being or Dying –kl

FIGURE 22-1  ​Leininger’s Sunrise Enabler. (Copyright Madeleine Leininger, 2004. Used by permission.)

study the diverse elements or components of the theory, CHAPTER 22  Madeleine M. Leininger 427
and to make culturally congruent clinical assessments.
Selected information is offered here to introduce the generally used in quantitative studies. These tools are
reader to Leininger’s creative work of evolving theory often viewed as unnatural and [are] frightening to cul-
and Sunrise Enabler over time. The Sunrise Enabler tural informants” (Leininger, 2002c, p. 89).
symbolizes the rising of the sun (care) (Leininger, 1. The observation participation reflection enabler
1991b, 1995c; Leininger & McFarland, 2002a, 2006).
The upper half of the circle depicts components of the is used to facilitate the researcher in entering and
social structure and worldview factors that influence remaining with informants in their familiar or natu-
care and health through language, ethnohistory, and ral context during the study. The researcher gradu-
environmental context. These factors also influence the ally moves from the role of observer and listener,
folk, professional, and nursing system(s), which are the transitioning to that of participant and reflector
middle part of the model. The two halves together form with the informants. By moving slowly and politely
a full sun, which represents the universe that nurses with permission, the researcher does not disrupt
must consider to appreciate human care and health and therefore is able to observe what is naturally
(Leininger, 1991b, 1995c; Leininger & McFarland, occurring in the environment or with the people.
2002a, 2006). According to Leininger, nursing acts as 2. With the stranger to trusted friend enabler, the nurse
a bridge between folk (generic) and the professional researcher is able to learn much about oneself and
system. Three kinds of nursing care and decisions and the people and culture being studied. The goal with
actions are predicted in the theory: Culture Care pres- this guide is to become a trusted friend as one moves
ervation or maintenance, Culture Care accommodation from distrusted stranger to trusted friend and differ-
or negotiation, and Culture Care repatterning or ent attitudes, behaviors, and expectations can be
restructuring (Leininger, 1991b, 1995c; Leininger & identified. This process is essential for the researcher
McFarland, 2002a, 2006). to become trusted such that honest, credible, and
in-depth data may be discovered from informants.
The Sunrise Enabler depicts human beings as in- 3. The domain of “inquiry enabler” is a process used by
separable from their cultural background and social nurse researchers in each study to clearly establish
structure, worldview, history, and environmental con- the researcher’s interest and area of focus. The
text as a basic tenet of Leininger’s theory (Leininger, domain of inquiry is a “succinct tailor made state-
1991b, 1995c; Leininger & McFarland, 2002a, 2006). ment focused directly and specifically on Culture
Gender, race, age, and class are embedded in social Care and health phenomena” (Leininger, 2002c,
structure factors and are studied. Biological, emo- p. 92), stating questions or ideas related to the focus
tional, and other dimensions are studied from a holis- of the study, its purpose, and goals.
tic view and are not fragmented or separate. Theory 4. The acculturation health assessment enabler is an-
generation from this model may occur at multiple other important guide used with the method. It is
levels from the micro range (small-scale specific indi- essential when studying cultures to assess the
viduals) to study groups, families, communities, or extent of the informants’ acculturation as to
large-scale phenomena (several cultures). Leininger whether they are more “traditionally or nontradi-
has also developed several enablers to facilitate study- tionally oriented in their values, beliefs, and general
ing phenomena using the four phases of qualitative lifeways” (Leininger, 2002c, p. 92). This enabler is
data analysis. Most importantly, qualitative criteria used for both cultural assessments and ethnonurs-
are used to analyze the data; they are credibility, con- ing research studies.
firmability, meaning-in-context, saturation, repat-
terning, and transferability (Leininger, 1995c, 2002c). Acceptance by the Nursing Community
Practice
Leininger has developed four other enablers to assist
nurse researchers in their use of the ethnonursing Leininger identifies several factors related to the slow-
method. “Enablers sharply contrast with mechanistic ness of nurses to recognize and value transcultural
devices such as tools, scales, measurement instru- nursing and cultural factors in nursing practices and
ments, and other impersonal objective distancing tools education (Leininger, 1991b; Leininger & McFarland,
2006). First, the theory was conceptualized during the

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

related to improper care. Leininger’s demand for culture- CHAPTER 22  Madeleine M. Leininger 429
specific care based on theoretical insights has been criti- Leininger & McFarland, 2002a, 2006). Funds to support
cal for the discovery of diverse and universal aspects transcultural nursing are limited because biomedical
of care (Leininger, 1995c, 1996a, 1996b; Leininger & and technical research funds head the priority list.
McFarland, 2002b). A critical need remains for nurses to Transcultural nurses and other nurses interested in
be educated in transcultural nursing in undergraduate transcultural nursing research are continuing their
and graduate programs and for faculty prepared in research with limited funds. These nurses are leaders in
transcultural nursing to teach and guide research in sharing their research at conferences and instructional
nursing schools within the United States and in other programs related to transcultural nursing. They have
countries (Leininger, 1995c, 1996b; Tom-Orne, 2002). been instrumental in opening doors to transcultural
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,
California, where care was developed as a central The ethnonursing study by McFarland (1995,
theme for an undergraduate program in nursing. 2002), covered 2 years in the late 1980s, and compared
Course titles included Caring Concepts I & II, Caring Anglo-American and African-American groups living
of Families, and Professional Self Care (Leininger, in a residence home for the elderly in one large Mid-
1984a). During the late 1980s, four master’s and western United States city. This in-depth emic and etic
four doctoral programs in the United States offered culture care investigation revealed significant findings
transcultural nursing courses, research experiences, and highlighted the importance of using the three
and guided field study experiences (Leininger, 1995c). action and decision modes of the theory when caring
Leininger received numerous requests to give courses, for older adults. The culturally congruent care findings
lectures, and workshops on human care and transcultural were as follows:
nursing in the United States and other countries. The • Anglo-American and African-American older adults
demand for transcultural nurses exceeded available
faculty, money, and other resources. As the last cen- expect Culture Care preservation and maintenance
tury ended, Leininger put out a call for schools of their lifelong generic or folk care patterns.
of nursing to offer transcultural programs to meet • Doing for other residents rather than having a self-
the worldwide demand for many nurses and cultures care focus was a major care maintenance value for
(Leininger, 1995a, 1995b, 1996b). The programs are both cultures and was a dominant finding.
needed for practice and preparation for certification • Protective care was more important to African-
of transcultural nurses. There is a need for research American than to Anglo-American older adults,
and worldwide consultation. There are still inade- but nursing staff provided protective care and
quate research funds to study transcultural nursing practiced Culture Care accommodation for both
education and practice. Although the societal de- groups, such as accompanying them when they
mand for transcultural nurses is evident, educational desired to go for walks in the surrounding inner-
preparation remains weak and limited for nurses city neighborhood.
worldwide. • African-American nurses practiced culture accom-
modation when they linked their emic care with
Research generic care values and practices.
Nurses today are using Leininger’s Culture Care Theory Culture Care maintenance-preservation and Cul-
worldwide. This nursing theory is focused specifically ture Care accommodation-negotiation were new ways
on Culture Care and with a specific research method for nurses to provide culturally congruent and safe
(ethnonursing) to examine the theory (Leininger, lifeways care practices for older adults of both cultures.
1991b, 1995c; Leininger & McFarland, 2002a, 2006). Based on the findings, several institutional Culture
Approximately 100 cultures and subcultures had been Care policies were developed to guide professional
studied as of 1995 (Leininger, 1991b, 1995c, 1996a; older adult care. Application of the Culture Care
Theory to advanced practice nursing has been expli-
cated by McFarland and Eipperle (2008) proposing the

430 UNIT IV  Nursing Theories Burk, 2012). The method has been adapted for use in
theory as a “ . . . foundational basis for the educational retrospective metasynthesis studies as the Metaeth-
preparation, primary care contextual practice, and out- nonursing Research Method. McFarland, Webhe-
comes-focused research endeavors of advanced prac- Alamah, Wilson, and Vossos (2011) conducted a
tice nursing” using the three modes of care, the retrospective analysis of 24 doctoral dissertations
enablers, and the ethnonursing method. The authors based on the Culture Care Theory, presenting a syn-
emphasized integration of culturally congruent or sen- opsis of their findings which were found to be “...both
sitive care through direct and explicit approaches to be interpretive and explanatory, and further conceptu-
used by the nurse practitioner, who “ . . . needs to be alized from the themes and patterns of the original
able to sensitively and competently integrate Culture dissertation studies” and entailed “...new theoretical
Care into contextual routines, clinical ways, and formulations based on the Culture Care Theory [with
approaches to primary care practice through role mod- discovered] recommendations related to nursing
eling, policy making, procedural performance and practice . . . . [which were] predicted to make a sig-
performance evaluation, and the use of the advance nificant contribution to the discipline and practice of
practice nursing process” (McFarland & Eipperle, nursing as well as the epistemic and ontologic basis
2008). Concepts and methods for integrating emic and of culture care knowledge and evidence-based best
etic care approaches into primary care practice mo- practices” (p. 24).
dalities and the use of the education-research-practice
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
Further Development (Leininger, 1981, 1995c; Leininger & McFarland,
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
knowledge and practice into their programs of
The Ethnonursing Research Method “can be useful study. This trend is increasing the demand for com-
for research that addresses providing care in other dis- petent faculty in transcultural health care. Leininger
ciplines including education, administration, physical/ (1995c) believes that the development of transcul-
occupational/speech therapy, social work, pharmacy, tural institutes is essential to fill the growing need
medicine, and disciplines in which the meaning of for transcultural nurses prepared to work with other
research findings has implications for human care disciplines.
and health” (McFarland, Mixer, Webhe-Alamah, &

Present and future theories and studies in trans- CHAPTER 22  Madeleine M. Leininger 431
cultural nursing are essential to meet the needs of
culturally diverse people. The Culture Care Theory oriented theory that is broad, comprehensive, and
continues to grow worldwide. Both universal and worldwide in scope. Transcultural nursing theory ad-
diverse care knowledge is extremely important to dresses nursing care from a multicultural worldview
establish a substantive body of transcultural nursing perspective. It is applicable to groups and individuals
knowledge, and to make nursing a transcultural pro- who have a goal of rendering culture-specific nursing
fession and discipline. Leininger’s theory has gained care. The research has led to a vast amount of expert
worldwide interest and use because it is holistic, rele- knowledge largely unknown in the past. Aspects of
vant, and futuristic, and it deals with specific, yet culture, care, and health are identified because they
abstract, care knowledge. have an impact on nursing. More research is needed
for comparative purposes from both culture-specific
Critique data and universal care knowledge. More cultural
Clarity groups need to be studied and compared to validate
the caring constructs. The theory is most helpful
The Sunrise Enabler (see Figure 22–1) and other en- for the study of any culture and for comparative study
ablers mentioned earlier remain invaluable as guides of several cultures. Findings from the theory are
to study and practice with people of diverse and simi- being used in client care in a variety of health and
lar cultural needs. community settings worldwide to transform nursing
education and service. It is valued especially for de-
Simplicity veloping a new and different approach to the tradi-
Transcultural nursing theory is a broad, holistic, tional community nursing perspective.
comprehensive perspective of human groups, popu- Accessibility
lations, and species. The broad or generic concepts The transcultural nursing theory is researchable, and
are well organized and defined for study in specific qualitative research has been the primary approach to
cultures. Leininger’s Culture Care Theory is relevant discover largely unknown phenomena of care and
worldwide to guide nurse researchers in the concep- health in diverse cultures. This qualitative approach
tualization of research approaches to study culture. differs from the traditional quantitative research
The concepts and constructs related to social struc- method, which renders measurement the goal of
ture, environment, and language are extremely research. The ethnonursing research method is ex-
important and clearly defined for culturally based tremely rigorous and linguistically exacting in nature
knowledge grounded in the people’s world. Multiple and outcomes. One hundred thirty-five care con-
key concepts and interrelationships of concepts are structs have been identified, and more are being dis-
made explicit, especially to social structure factors. covered each day, with a wealth of other transcultural
Understanding the theory requires some basic nursing knowledge. An important attribute is the ac-
anthropological knowledge as well as considerable curacy of grounded data derived with ethno methods
transcultural nursing knowledge, to be used in an or from an emic or people’s viewpoint is leading to
accurate and scholarly fashion. When the theory has high credibility and confirmability, and a wealth of
been fully conceptualized, Leininger finds that empirical data. Ongoing and future research will lead
undergraduate and graduate nursing students are to additional care and health findings and implications
excited to use the theory and discover how practical, for ethnonursing practices and education to fit specific
relevant, and useful it is in their work. The Sunrise cultures and universal features. The qualitative criteria
Enabler (see Figure 22–1) becomes imprinted on of credibility and confirmability from in-depth studies
their minds as a way of knowing. of informants and their contexts are becoming clearly
evident. Unequivocally, the body of transcultural
Generality nursing knowledge that has been established over the
The transcultural nursing theory demonstrates the past decade has had a great impact on nursing and
criterion of generality because it is a qualitatively many health care systems (Leininger, 1995c; Leininger
& McFarland 2002a, 2006).