Leininger’s Theory of Nursing:

Cultural Care Diversity and Universality

MADELEINE M. LEININGER, RN; PHD*

This paper is focused on the essential features of the nursing theory

of cultural diversity and universality. An overview of the essential
care
features is discussed to show how the theory was developed and how it
has evolved during the past three decades. The theory was initiated from
clinical experiences recognizing that culture, a wholistic concept, was
the missing link in nursing knowledge and practice. Through a creative
process of concept explication, reformulation, and resynthesis, the the-
ory of cultural care was set forth as a guide for the development of
nursing knowledge. The concept of culture was derived from anthropol-
ogy and the concept of care was derived from nursing. The theorist holds
that cultural care provides the broadest and most important means to
study, explain, and predict nursing knowledge and concomitant nursing
care practice. The ultimate goal of the theory is to provide cultural
congruent nursing care practices. The author contends that if one fully
discovers care meanings, patterns, and processes, one can explain and
predict health or well-being. The assumptions, definitions, and theoret-
ical explanations related to cultural care are presented with the sunrise
model to depict the major components of the theory.

One of the most exciting and important de-
velopments in the history of nursing has been
the development of nursing theories to estab-
lish a sound basis for-the discipline of nursing
and to guide nursing practice. During the past
four decades, a cadre of nurse theorists has
been active focusing on the systematic study
of the nature and critical elements that char-
acterize the discipline of nursing. As a conse-
quence, a number of different theories with
diverse conceptualizations of nursing have
been developed and continue to be examined.
Nursing theories have markedly stimulated
the intellectual, clinical, and research per-
spectives of nurses requiring them to think
anew about the nature and meaning of nurs-
ing as a discipline and profession. This move-
ment has led to critical positions and debates
among scholars of nursing about the core ele-
ments and epistemological bases of nursing
knowledge. It also encouraged nurses to shift
from the medical paradigm to a nursing para-
digm.
Key Words: Cultural Care Theory. Leininger, Sunrise
Model
Received April 12, 1988
Accepted May 30, 1988
*
Wayne State University, Detroit, MI.
Since the early 1960s, nursing has been in
- an era of theory construction, refinement, and
systematic examination. Questions, such as
the following, have been asked. What charac-
terizes the essential nature and essence of
nursing? What constitutes the essential na-
ture of nursing knowledge? What is different
about nursing knowledge compared with that
of other health disciplines? These questions
and related ones have been central to the ad-
vancement of nursing as a discipline and
profession.
As one of the early nurse theorists who be-
gan to develop the theory of cultural care di-
versity and universality in the 1950s, the au-
thor was interested in the nature of nursing
and how nursing differed from medicine in its
knowledge base and practice. The idea for the
theory began while studying the role of the
clinical specialist in child psychiatric nursing
in 1954 and while documenting the ways that
care and nursing practice could accurately de-
scribe and reflect nursing knowledge. The au-
thor firmly held to the position that care is the
essence of nursing and the central, domi-
nant, and unifying feature of nursing. Care
was viewed as a powerful means to help clients
recover from illnesses or unfavorable human
life conditions (Leininger, 1978). Through in-
tense observation, it soon became clear to the
author that children of different cultural back-
grounds had different expectations and re-

152

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sponses to nurses as care providers. It was
critical that clinical specialists recognize and
respond to these differences. Children of dif-
ferent cultures were different and needed a
culturally based framework to guide their
nursing care. Care and culture were inextric-
ably linked together and could not be sepa-
rated in nursing care actions and decisions.
The theory of cultural care diversity and uni-
versality was born and it was the children who
taught the author that the missing link in care
was culture. No longer could all children be
treated alike nor could it be assumed that they
had similar needs. What constituted cultural
care diversities and universalities was the ma-
jor domain to be explored anew as the basis
for sound nursing practice; thus, the theory
was conceived and developed in relation to a
perspective with social science roots.
The author realized she had no background
in anthropology to understand culture and to
link culture with care. Knowledge of cultural
factors in nursing was absent. Moreover, there
were no other professional nurses with grad-
uate preparation in anthropology. Anthropol-
ogy was not a part of nursing curricula nor
part of the thinking of nurse theorists and
educators in those early days. This reality led
the author to doctoral preparation in anthro-
pology in order to develop the theory in a
knowledgeable way. The need for the new field
of transcultural nursing to prepare nurses to
function in a multicultural world became
clear. As the first nurse anthropologist with
doctoral preparation in cultural anthropology,
the author developed knowledge and research
for the new field of transcultural nursing with
a focus on cultural care theory (Leininger,
1970, 1978). It took time and in-depth study
to link culture and care into a meaningful
relationship. The theory of cultural care diver-
sity and universality was difficult to formulate
because there was so much to understand
about different cultures in the world and nurs-
ing’s perspectives of cultural phenomena. At
the same time, the need arose to develop
courses and programs in transcultural nursing
so that the theory could be appropriately used.
There were few nurses interested in anthro-
pology in those days; nurses were deeply in-
volved in medical tasks and the physical and
technical needs of clients. Gradually, tran-
scultural nursing and cultural care made
sense to some nurses. The author’s firm con-
viction about the importance of transcultural
nursing led her to prepare a cohort of nurses
to try the ideas espoused in the theory.
As nurses became prepared in transcultural
nursing, the theory became meaningful to
more practicing nurses. Transcultural nurses
and others began using the cultural care the-
ory with enthusiasm. Likewise, nursing stu-
dents’ began to use the theory in the clinical
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areas as they worked with clients from differ-
ent cultural backgrounds. As students identi-
fied cultural differences, they could see areas
of cultural conflicts between clients and
nurses that needed to be addressed. Transcul-
tural nursing concepts and cultural care the-
ory gave nurses an entirely new way to under-
stand individuals, families, and cultures. The
focus on culture care differences and similar-
ities to describe, explain, and predict nursing
outcomes was gradually viewed by nurses as
essential to professional practice. These brief
historical ideas of the evolution of a theory
help one to realize that theories with entirely
new or different ideas take time, persistence,
and creative strategies to develop. Likewise, it
takes time, education, and leadership to help
skeptics and potential followers to use the the-
ory.
The Theorist’s View of the Nature and Definition
-
of a Theory
Before a theory can be understood, the the-
orist’s views in general must be known. Cur-
rently, the literature abounds with ideas from
nurse theorists who have been educated to
view a theory as &dquo;a set of interrelated concepts,
definitions, propositions or hypotheses with
specified and measurable relationships to pre-
dict and control phenomena under study&dquo;
(Polit and Hungler, 1983, p. 101). This tradi-
tional definition of a theory (and its variants)
is derived from the elements and criteria used
in a quantitative paradigm. The theory re-
quires rigid operational definitions of specified
relationships among a priori variables that can
be controlled, measured, and verified in pre-
cise ways. This perspective of theory is only
one way to view theory and it can seriously
limit the discovery of phenomena that are un-
known, vaguely known, or that cannot be es-
tablished as operationally defined variables
prior to a research investigation. The author
was committed to discovery of the epistemo-
logical sources of nursing knowledge related
to cultural care with its inherent meanings
and characteristics as the goal of the theory.
The concept of care had not been studied from
different cultural viewpoints, and thus an
open approach was essential to discover the
unknown attributes of care from a compara-
tive cultural perspective. A qualitative ap-
proach was imperative to identify, describe,
and account for unknown aspects of cultural
care. Indeed, there was a critical need for the-
ories that would lead to the discovery of the
people’s emic (local or insider’s) views of the
meanings, symbols, patterns, and expressions
of cultural care and nursing from a wholistic
perspective. The open ethnographic or anthro-
pological qualitative approach was selected to
153
discover the unknown, subtle, or less objective
facts of care, as well as the subjective dimen-
sions, and to explicate patterned expressions
of cultural care within naturalistic contexts
and without use of predetermined (a priori)
variables.
Thus, the author made a bold break from
the view in nursing that a theory must be
tested through explicit preconceived or etic
(researcher’s or outsider’s) views about vari-
ables to prove something. This latter philo-
sophical and theoretical stance would not per-
mit a full and accurate account of clients’
knowledge about care. Theories tested through
the scientific method with the rigid proce-
dures, rules, and controlled conditions of logi-
cal positivism eventually gave way to the an-
thropological, a theory- and knowledge-gener-
ating mode of open inquiry (Leininger, 1985a).
The author’s definition of theory is different
from current mainstream nurse theorists but
most congruent with anthropology and tran-
scultural nursing. The author believes that the
discovery of care as a concept in nursing was
stifled until the use of the qualitative. ap-
proach, with the research methods of ethnog-
raphy and phenomenology, became known to
nurses (Leininger, 1985a). In addition,
nurses devalue the concept of care because
they have not studied it in depth as a theory
and as a phenomenon to be explained in its
own right (Leininger, 1986; Deers, 1988).
Some nurse leaders cannot envision care as a
theoretical concept in its own right as a phe-
nomenon to be studied, but rather see it as a
concrete action or practice (Lundh, Soder, &
Waerness, 1988).
This leads to the author’s definition of the-
ory as sets of interrelated knowledge
meanings and experiences that describe, ex-
plain, predict, or account for some phenome-
non (or domain of inquiry) through an open,
creative, and naturalistic discovery process.
This perspective is critical to discover, account
for, confirm, and explain unknown or vaguely
known phenomena. It is essential to the de-
velopment of nursing knowledge to document
and describe new insights and possibilities not
yet known or explicated. The use of inductive
strategies to get to people (emic) truths, reali-
ties, and other life-death knowledge about hu-
man conditions is essential. The theory of cul-
tural care diversity and universality is con-
gruent with methods that support the
discovery of &dquo;people truths&dquo; in human living
contexts rather than methods that follow the
researcher’s preconceived views. The theory
can guide researchers to discover naturalistic
inquiry patterns and expressions of cultural
care within diverse environmental contexts
and social structures.
Watson’s (1985) definition of theory lends
support to the author’s. She states that &dquo;a
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theory is an imaginative grouping of knowl-
edge, ideas and experiences that are repre-
sented symbolically and seek to illuminate a
given phenomenon&dquo; (p. 1). Steven’s (1979) def-
inition of theory further supports Watson’s in
that she states &dquo;a theory is a statement that
purports to account for or characterize some
phenomenon&dquo; (p. 1).
In general, a theory is effective if it can
discover, explain, interpret, and predict a phe-
nomenon. different ways to define
There are
and use theories; there is
no one right way to
generate, test, analyze, and evaluate theories.
More scientists are beginning to use qualita-
tive approaches for inquiry to expand knowl-
edge, especially in the human sciences (Capra,
1983; Leininger, 1985a; Reason & Rowan,
1981).
Conceptualization of the Theory of Cultural Care
The theorist of cultural care holds that care
is the essence of nursing and provides dis-
a
tinctconcept to describe, explain, and predict
nursing (Leininger, 1984, 1988b). Care should
be central to nursing paradigms or metapara-
some digms and supported by the concepts of health
and environmental contexts. The author re-
jects the idea that nursing and person explain
nursing, for one cannot explain nor predict the
same phenomenon one is studying. Nursing is
the phenomenon to be explained. Moreover,
person, per se, is not sufficient to explain
nursing as it fails to account for groups, fam-
ilies, social institutions, and cultures. Nursing
is not only concerned with person as an indi-
vidual concept but includes groups, collectivi-
with ties, and institutions. It is ironic that some
nurses fail to recognize care in the metapara-
digms of nursing, or as the crucial dimension
to explain and predict as a theoretical phenom-
enon. Only a few theorists, such as Watson
(1985) and Orem (1980) focus on care as im-
portant or central to nursing, a phenomenon
to be explained and predicted. However, in the
past decade, more nurses are beginning to fo-
cus on care and there are more research stud-
ies, publications, and writings specifically on
the care phenomenon than at any time in the
past history of nursing. For example, before
the 1970s, there were less than 30 nursing
articles, very few research studies, and vir-
tually no books specifically directed to the
study of the care phenomenon per se, whereas
in 1987, there were more than 500 nursing
articles and 28 books by nurses addressing
care research, theory, and clinical findings in
the United States (Leininger, in press).
The author’s conceptualization of the theory
of cultural care was derived from anthropology
with new formulations made within nursing
care perspectives. Her philosophy of nursing,
with care inherent to the nature of nursing, is
based on extensive clinical nursing experi-
ences, readings, and anthropological ideas of
Homo sapiens with cultures that have sur-
vived through time. People are born, live, be-
come ill, and die within a cultural belief and
practice system, but are dependent upon hu-
man care for growth and survival. Such ideas
and others required in-depth study and analy-
sis. It was a creative challenge to select, syn-
thesize, and reconstruct knowledge from an-
thropology and nursing to develop the theory
of cultural care. It required in-depth under-
standing of different cultures of the world and
social structures. The language usages, sym-
bols, and meanings about care in diverse cul-
tures had to be understood in order to derive
the essences and patterns of cultural care.
Conceptualizing cultural care diversities and
universalities was important to establish what
is similar and different about care within and
among cultures. The author believes that the
ultimate goal of cultural care theory is to pro-
vide culturally congruent nursing care. Thus,
the theory was derived from the disciplines of
anthropology and nursing and constructed to
fit nursing’s distinct and essential perspective
about generic and professional care worldwide
(Leininger, 1970, 1978, 1985a, 1988a).
Transcultural nursing concepts and
cultural
’
care theory gave nurses an
entirely new way to understand
individuals, families, and cultures.
The author predicts that a continued in-
depth analysis and systematic documentary
study of the care phenomenon will lead to a
full explication of the essences and the epis-
temological roots of nursing care knowledge to
guide nursing decisions and practices. Com-
parative studies of cultural care patterns, val-
ues, and practices will greatly enrich and ex-
tend nursing knowledge, especially emic per-
spectives. Such knowledge should be valuable
to guide nurses in keeping people well and
preventing illnesses and disabilities and to
support the well-being statuses of individuals,
families, and cultures. Professional care based
on generic care will be a powerful means to
promote health (or well-being) and to preserve
healthy ways of life for people of diverse and
similar cultures.
With this theory, the author predicts that
cultural care knowledge and practices will
have meaningful functions and structural pat-
terns derived from the cultural values, world
views, social structures, and environmental
contexts of diverse cultures. Folk and profes-
sional care practices are predicted to be uni-
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versal, yet the beliefs, values, and practices
vary, with some universal features. The cul-
tural theory is held to be the broadest and
care
most wholistic guide to study human beings
with their lifeways, cultural values and be-
liefs, symbols, material and nonmaterial
forms, and living contexts.
Finally, the author has predicted three dom-
inant modes to guide nursing decisions and
actions in order to provide cultural congruent
care. They are (a) cultural care maintenance
or preservation, (b) cultural care accommoda-
tion or negotiation, and (c) cultural care re-
structuring and repatterning (Leininger,
1985a). The creatively designed nursing deci-
sions and actions will be congruent with the
lifeways of individuals, families, or groups as
a basis to support the goal of cultural con-
gruent care. If the latter goal of the theory is
met, clients will find that nursing care reason-
ably fits with or is similar to cultural beliefs,
values, and lifeways. Cultural congruent nurs-
ing care is, therefore, predicted to provide
meaningful, satisfying, and beneficial care to
clients. In sum, the purpose of the theory is to
describe, account for, interpret, and predict
cultural congruent care in order to attain the
ultimate goal of the theory, namely, to provide
quality care to clients of diverse cultures that
is congruent, satisfying, and beneficial to
them.
Assumptive Premises of the Theory
Several assumptive premises have been
identified related to the theory (Leininger
1979, 1985b). They are as follows.
1. Care is essential for human growth, well
being, and survival and to face death or
disabilities.
2. There are diverse and universal forms,
expressions, patterns, and processes of hu-
man care that exist transculturally.
3. Care is the essence of nursing and the dis-
tinct, dominant and unifying feature of
nursing.
4. Culture care is the broadest means to know,
explain, account for and predict nursing
care phenomena and to guide nursing care
practices.
5. Knowledge of meanings and practices de-
rived from world views, social structure fac-
tors, cultural values, environmental context,
and language uses are essential to guide
nursing decisions and actions in providing
cultural congruent care.
6. Cultures have folk and professional care val-
ues, beliefs, and practices that influence
cultural care practices in Western and non-
Western cultures.
7. Care is essential to curing; however, there
can be no curing without caring, but there
can be caring without curing.
155
 8. Nursing is a transcultural phenomenon re-
quiring knowledge of different cultures to
provide care that is congruent with the
clients’ lifeways, social structure, and envi-
ronmental context.
Theoretical Definitions of Orientation Related to
the Theory
As discussed above, operational definitions
are inappropriate in research with an open
discovery theory, for the researcher seeks
emic knowledge derived from people and en-
vironmental contexts as the epistemological
and ontological sources of cultural care knowl-
edge. The researcher has no desire to manip-
ulate, control, or use tightly defined ideas or
variables that have been pre-selected before a
study begins, but instead uses an inductive
mode to generate ideas or fresh knowledge and
to get accurate views and experiences. Orien-
tation definitions may be used and altered as
one studies a culture in order to fit the people’s
frame of reference and their world views and
other ideas derived firsthand from them. The
informants’ definitions and interpretation
may replace the researcher’s usage in time.
The following terms have been used as provi-
sional guides to inductive or deductive acqui-
sition of data (Leininger, 1978, 1985b).
1. Culture refers to the learned, shared, and
transmitted values, beliefs, norms, and life
practices of a particular group that guides
thinking, decisions, and actions in pat-
terned ways.
2. Care (noun) refers to phenomena related to
assisting, supportive, or enabling behavior
toward or for another individual (or group)
with evident or anticipated needs to amel-
iorate or improve a human condition or
, lifeway.
3. Caring (verb) refers to actions directed to-
ward assisting, supporting, or enabling an-
other individual (or group) with evident or
anticipated needs to ameliorate or improve
a human condition or lifeway.
4. Cultural care refers to the cognitively
known values, beliefs, and patterned
expressions that assist, support, or enable
another individual or group to maintain
well-being, improve a human condition or
lifeway, or face death and disabilities.
5. Cultural care diversity refers to the vari-
ability of meanings, patterns, values, or
symbols of care that are culturally derived
by humans for their well-being or to im-
~
prove a human condition and lifeway or to
face death.
6. Cultural care universality refers to com-
mon, similar, or uniform meanings, pat-
terns, values, or symbols of care that are
culturally derived by humans for their well-
being or to improve a human condition and
lifeway or to face death.
7. World view refers to the way people tend
to look upon the world or universe to form
156
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a picture or value stance about their life
and the world about them.
8. Social structure refers to the dynamic na-
ture of interrelated structural or organi-
zational factors of a particular culture (or
society) and how these factors function to
give meaning and structural order, includ-
ing religious, kinship, political, economic,
educational, technological, and cultural
factors.
9. Environmental context refers to the total-
ity of an event, situation, or particular ex-
perience that gives meaning to human
expressions, including social interactions
and physical, ecological, emotional, and
cultural dimensions.
10. Folk health (well being) system refers to
traditional or local indigenous health care
or cure practices that have special mean-
ings and uses to heal or assist people,
which are generally offered in familiar
home or community environmental con-
texts with their local practitioners.
11. Health refers to a state of well-being that
is culturally defined, valued, and practiced
and which reflects the ability of individuals
(or groups) to perform their daily role activ-
ities in a culturally satisfactory way.
12. Professional health system refers to
professional care or cure services offered
by diverse health personnel who have been
prepared through formal professional pro-
grams of study in special educational insti-
tutions.
13. Cultural care preservation or mainte-
. nance refers to those assistive, supportive,
or actions and deci-
enabling professional
sions that clients of a particular cul-
help
ture to preserve or maintain a state of
health or to recover from illness and to face
death.
14. Cultural care accommodation or negotia-
tion refers to those assistive, supporting,
or enabling professional actions and deci-
sions that help clients of a particular cul-
ture to adapt to or negotiate for a beneficial
or satisfying health status or to face death.
15. Cultural care repatterning or restructur-
ing refers to those assistive, supportive, or
enabling professional actions or decisions
that help clients change their lifeways for
new or different patterns that are cultur-
ally meaningful and satisfying or that sup-
port beneficial and healthy life patterns.
The Sunrise Model: Conceptual Components of
the Theory
The sunrise model was developed and re-
fined over the past three decades to provide a
gestaltic view of the major and interrelated
components of the theory. The model (Fig. 1)
is not the theory per se but a conceptual pic-
ture to depict the components of the theory to
study how these components influence the
care and health status of individuals, families,
groups, and sociocultural institutions. It is a
 Figure 1. Sunrise model to depict dimensions of cultural
wholistic conceptualization to help the re-
searcher systematically study the theory’s di-
verse components, such as world view, social
structure factors, cultural values and beliefs,
and folk and professional health systems, and
how these components interface with each
other in a gestaltic perspective. Thus, the re-
searcher is able to see the whole conceptual
picture of the theoretical components.
As the researcher uses the model, one can
focus on specific areas, such as the individual,
family, group, or institution and study care
phenomena in relation to the different com-
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care diversity and universality: A theory of nursing.
ponents of the theory. The researcher is free
to start the discovery process according to per-
sonal interest regarding care. The nature, pat-
terns, meanings, and characteristics of care
can be systematically investigated. The model
should not be used from a casual, linear, or
positivistic perspective, but rather with the
goal to discover the essence, meanings, and
patterned expressions of generic and profes-
sional care. Because this base of care knowl-
edge is still relatively unknown, the author
supports qualitative ethnomethods to obtain
grounded knowledge derived from key and
157
general informants about the different com-
ponents depicted in the model and from the
theoretical statements presented earlier. Teas-
ing out illusive and embedded ideas from social
structure, world view, and cultural beliefs
about care is a difficult and important chal-
lenge. With an open inquiry manner, inform-
ants are encouraged to share their ideas and
experiences about care and its relationship to
different components of the theory and to ex-
plore the meanings of care to predict or explain
health or well-being states.
To study the tenets of the theory, the re-
searcher moves to discover the nature, pat-
terns, and expressions of cultural care and
health in diverse folk and professional health
systems. The nursing system in cultures is a
major part of the professional system. The folk
health system of different cultures is an ex-
tremely rich source of data from which to gain
an understanding of care and health practices.
For example, the author has identified a num-
ber of folk health beliefs and practices impor-
tant to clients, but often these practices are in
conflict with nurses’ professional modes of
believing and acting (Leininger, 1988b, in
press). As one studies these systems, it is im-
portant to ask about non-caring beliefs and
practices in both the folk and professional
systems to fully understand care and health
practices. Keen observation with an open ex-
ploratory posture is essential to discover the
similarities among cultures so that universal
care features as well as differences can be
identified within folk and professional health
systems.
In the sunrise model, there are three modes
proposed for making nursing decisions and
taking actions for cultural congruent care.
These modes are usually identified from and
acted upon using data that have been derived
from a comprehensive study of individuals,
families, and groups. These grounded and sub-
stantive data derived from key and general
informants, observations, participatory expe-
riences, and other research strategios provide
important information to determine which
mode of decision would be most appropriate,
beneficial, or satisfying to the clients.
As the researcher uses the theory in an open
inductive or empirically derived way to obtain
first hand emic data from different informants
in their natural and familiar environmental
contexts, one can identify themes and pat-
terns of differences and similarities about
care. Gentle and sensitive probing is needed to
discover the subtle meanings and interpreta-
tions of care, such as comfort, succorance,
attention, presence, and many other care con-
structs still so limitedly known in their full
meanings and uses in nursing. The inform-
ants’ emic knowledge and experiences are far
more important for grounded data than the
158
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researcher’s etic a priori viewpoints. These
emic care constructs are invaluable to explain,
develop, and guide nursing actions and deci-
sions, and they give clues to ways clients ex-
pect to receive culturally congruent care. How
these care constructs influence the health or
well-being of individuals, families, groups, or
institutions in different cultures is of major
importance in establishing the substantive
knowledge of nursing.
Throughout the inductive discovery process,
the researcher describes and documents di-
verse and common features about care with
informants of a particular culture. Findings
from each culture study are contrasted with
findings from other studies to identify both
universal and diverse patterns and themes
among cultures. Care concepts, such as stress
alleviation, trust, involvement with touch,
stimulation, comfort, engrossment, tender-
ness, and empathy, may be similar or differ-
ent. In keeping with qualitative methods, the
researcher uses criteria such as confirmation,
credibility, saturation, recurrence, and others
to evaluate the findings in light of the theory
(Leininger, 1985a).
By use of the theory, nurses will
discover different
perspectives about
care.
Cultural care theory is used primarily to gen-
erate grounded and substantive data about
care meanings, patterns, experiences, and
other aspects of care. It is used to generate
new or to gain different insights
knowledge
about of diverse cultures. By use of the
care
theory, not only will nurses discover different
perspectives about care, but they will realize
there differences and commonalities in
are
caring for clients using culturally based data
to guide nursing care practices. It is also pos-
sible to develop hypotheses from qualitative
findings of the theory or to conduct quantita-
tive research studies on cultural care. Exam-
ples of hypotheses, questions, themes and re-
lated areas have been presented previously
(Leininger, 1978, 1985b, 1988a, 1988b).
From the first transcultural care study in
the eastern highlands of New Guinea in the
early 1960s by the author to the present day
(including studies of 52 cultures, 30 of those
studied with other researchers), the findings
have been extremely informative and packed
with detailed cultural descriptions and emic
interpretations of the care phenomenon. For
example, these studies reveal that a) cultural
care has more diverse than similar meanings,
and the patterns of care expression have major
implications for building an extensive body of
 nursing knowledge; b) cultural care constructs
illusive and often embedded in cultural
are
values, kinship, religious systems, and envi-
ronmental contexts; c) care meanings and
interpretations require knowledge of local lan-
guage usages; d) marked differences exist be-
tween Western and non-Western cultures re-
garding care values, patterns, and practices
with signs of considerable conflicts, stresses,
and non-caring practices between care givers
and receivers of these different cultural ori-
entations ; and e) technological nursing prac-
tices tend to increase distance between client
and nurse in care relationships. Many other
findings have been generated from the 52 cul-
tures that have been studied and will be pre-
sented elsewhere. Largely emically derived
data are being used to guide culturally con-
gruent care practices for clients of diverse cul-
tures using the projected three modes of nuxs-
ing decision and action patterns depicted in
Figure 1.
Current and Future Uses of the
Theory
During the past decade, the theory has been
used by an increased number of nurses in the
United States and abroad. The present gener-
ation of nursing students are enthusiastic
users of the theory as they realize the critical
problems in working with clients from many
strange cultures in the United States and over-
seas. They also know they will be working with
more diverse clients as the health care world
becomes even more multicultural. This theory
has relevance and significance for nurses in
all cultures to reduce nurse burnout, cultural
shock, marked ethnocentrism, and many
other nursing conditions and practices.
Nurses from many different cultures in the
world are becoming critical of nursing theories
that do not fit their cultural ideologies, beliefs,
and values as recently noted in the literature
(Leininger, 1978, 1984, 1988b; Lundh, Soder,
& Waerness, 1988). As a theorist who fre-
quently visits and consults with nurses in
many different places in the world, the author
listens to these concerns and hears the value
of cultural care theory. The theory is broad
enough to incorporate nursing care ideas and
specific enough to develop culture-specific
care world wide. The theory is unique as a
guide to research to obtain in-depth knowledge
of particular cultures and of professional nurs-
ing’s culture care patterns and themes. The
interest in care as a central domain of nursing
to guide nursing care decisions and actions is
growing world wide with evidence to establish
care as nursing’s major and fundamental
knowledge base.
As nurses function in today’s world and
even more so by the 21st century, multicul-
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tural factors in all aspects of human care serv-
ices will be imperative. Comparative studies of
care from diverse cultures will be essential to
advance nursing knowledge and practices.
Nurses will need research findings to deal with
care differences and similarities in nursing
practices. Both micro- and macro-scale care
theories will be used as nurses expand their
world view about different nursing and health
_ care systems worldwide in order to be effective
practitioners, researchers, and educators in
other cultures.
In the future, the author predicts even
greater interest in human care theories and
use of research findings as personalized care
becomes a highly competitive and economi-
cally valued &dquo;product&dquo; by consumers and pro-
viders of quality health care services. Quality
health care will become a marketable item
with favorable positive cost benefits as it is
now being promoted in commercial busi-
nesses. Nursing is in a unique and enviable
position to demonstrate quality care based on
in-depth knowledge about the meanings and
experiences related to healing clients and pro-
viding effective health care promotion services
to the well, sick, disabled, or dying. Ethical
cultural values of care in diverse cultures and
environmental contexts have yet to be fully
explicated and understood in nursing. The the-
ory of cultural care diversity and universality,
Watson’s theory of existential care (1985) and
Parse’s theory of man-living-health ( 1981 ) are
some examples of highly promising new theo-
ries calling for alternative research ap-
proaches to knowledge generation and confir-
’mation. These theories are sufficiently broad
in scope to lead to the identification of knowl-
edge specific to cultures. Most importantly,
these theories, with the use of naturalistic
inquiry modes such as ethnonursing, phenom-
enology, and others, are getting to the well-
spring of the critical and essential nature of
nursing knowledge. By the early part of the
2lst century, there will be many nurses focus-
ing on human care and nursing with the the-
ory of cultural care diversity and universality
remaining the most meaningful and broadest
means to study people worldwide within dif-
ferent temporal, spatial, contextual, and mul-
tidimensional perspectives. The use of anthro-
pological and transcultural care knowledge is
essential for accurate reliable health care.
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