Comparison of Four Cultural Competence Models in Transcultural Nursing





Madeleine Leininger – Transcultural Nursing Theory Model

Group 1: Packet of Materials

Lovely Denis

Marie Andree Colas

Mary Auman

Patricia Philippe

Wendy Filias

South University

I. Background

a. Madeleine M. Leininger’s Transcultural Nursing Theory

b. Place of origin, education, expertise, published works.

II. Four Metaparadigms

a. Health

b. Environment

c. Nursing

d. Person

III. Theoretical concepts

IV. Concept #1

V. Concept #2

VI. Conceptual Framework – Leininger’s Sunrise Model

VII. Theoretical Assumptions

VIII. Strength and weaknesses

IX. Article Summaries

X. Theory implication for nursing practice, education, research

a. Implications on Practice

b. Implications on Nursing Education

c. Implications on Nursing Research

XI. Conclusion

XII. References


Madeleine Leininger was born in July 13, 1925 and raised in Sutton, Nebraska. She developed an interest in nursing due to an aunt who suffered from a congenital heart problem. In 1948, she was awarded a nursing diploma from St. Anthony’s Hospital of Nursing. Shortly after, she continued her undergraduate education at Benedictine College and Creighton University before earning a master of science in nursing from Catholic University of America in 1954. Leininger returned to school at the University of Washington in order to better ground her work in cultural and social anthropology, in which she was awarded a PhD in 1966. Later that same year, she taught the first class in transcultural nursing at the University of Colorado. Leininger published her first book, Nursing and Anthropology: Two Worlds to Blend (1970), with the purpose of introducing nurses to the anthropological concepts most relevant to nursing work. She had been the first professional nurse granted an anthropology PhD, and remained the only one for several years (Ray, 2012).

Leininger conceptualized the theory of culture care with a foundation in anthropology. She was the first to write about transcultural nursing. At the time she was working as a mental health specialist with children from diverse cultural backgrounds, and quickly realized that her one dimensional culturally insensitive mental health training was rather ineffective in her practice. Furthermore, she observed that those working around her took no interest in the cultural differences of the patients, and consistently failed to consider and integrate patient’s cultural and ethnic background in their plan of care developmentIn 1998, the Fellows of the American Academy of Nursing awarded Leininger the title of “Living Legend.” She continued to refine her theories and publish articles through the last years of her life (Salem 2016). Leininger passed away peacefully on August 10, 2012 in Omaha, Nebraska (Ray, 2012).

Four metaparadigms

Transcultural Nursing. Transcultural nursing refers to a formal area of humanistic and scientific knowledge and practices focused on holistic culture care – caring – phenomena and competencies to assist individuals or groups to maintain or regain their health or well-being and to deal with disabilities, dying, or other human conditions in culturally congruent and beneficial ways (McFarland, R 2014). Leininger (2007) describes nursing as a means to know and help cultures.

Health. Health refers to a state of well-being or a restorative state that is culturally constituted, defined, valued, and practiced by individuals or groups and that enables them to function in their daily lives (McFarland, 2014).

Environmental. Environmental context refers to the environment as a whole – physical, geographic, and sociocultural – situation, or event with related experiences that give interpretative meanings to guide human expressions and decisions with reference to a particular environment or situation (Leininger, 2008)

Person: According to Leininger (2008), every human has generic care knowledge and practices and usually professional care knowledge and practices, which vary transculturally and individually. The concept of human care and caring refer to the abstract and manifest phenomena with expressions of assistive, supportive, enabling, and facilitating ways to help self or others with evident and anticipated needs to improve health, a human condition, or lifeways, or to facilitate disabilities or dying (Leininger, 2008).

In addition to the four metaparadigms, Leininger introduced other concepts specific to her theory that she considers to be valuable to transcultural theory. Those concepts are: care, culture, the constructs of emic and etic, culturally congruent care, care diversity, care universality, worldview, and ethno history (McFarland, M. & Wehbe-Alamah, H. B., 2015). Two of those concepts, culture and worldview will be defined in this paper.

Concept # 1

Culture Leininger defined culture as the learned, shared and transmitted values, beliefs, norms and lifeways of a particular culture that guide thinking, decisions, and actions in patterned ways. Leininger 2006, (as cited by McFarland, & Wehbe-Alamah, 2015). According to Leininger, culture can be viewed as the blueprint for guiding human actions and decision and includes material and nonmaterial features of any group or individual. McFarland & Wehbe (2015), from an anthropological perspective view culture as a broad and most comprehensive means, to know, explain and predict people’s lifeways over time and in different geographic locations. Since culture is based on an individual’s belief and varies from person to person nurses must be able to deliver culturally competent care to all regardless of their religion, values, belief, race and culture.

Concept # 2

Worldview “refers to the way people trend to look out upon their world or their universe to form a picture or value stance about life or the world around them.” (Leininger 2006, as cited by McFarland & Wehbe, 2015). Worldview provides a broad perspective of one’s orientation to life, people or groups that influence care or caring responses and decisions. According to McFarland and Wehbe, (2015) worldview guide one’s decision and actions, especially related to health and wellbeing as well as care actions.

Theoretical Assumptions

1) Care is essential for human growth, well-being, and survival and to face death or disabilities (Leininger, 1988, p.155).

2) There are diverse and universal forms, expressions, patterns, and processes of human care that exist transculturally (p.155)

3) Care is the essence of nursing and the distinct, dominant and unifying feature of nursing (p.155).

4) Culture care is the broadest means to know, explain, account for and predict nursing care phenomena and to guide nursing care practices (p.155).

5) Knowledge of meanings and practices derived from world views, social structure factors, cultural values, environmental context, and language uses are essential to guide nursing decisions and actions in providing culturally congruent care (p.155).

6) Care is essential to curing; however, there can be no curing without caring, but there can be caring without curing (p.155).

7) Culture have folk and professional care values, beliefs, and practices that influence cultural care values, beliefs, and practices that influence cultural care practices in western and nonwestern cultures (p.155).

8) Nursing is a transcultural phenomenon requiring knowledge of different cultures to provide care that is congruent with the clients’ lifeways, social structure, and environmental context (p.156)

Leininger Sunrise Model

Conceptual Framework

Leininger’s Sunrise Model

The sunrise model is a conceptual picture that portrays the components of Leininger’s transcultural nursing theory. It studies how the components influence the care and health status of individuals and families. The transcultural theory has diverse components such as social factors, cultural values and beliefs, folk and professional health systems. It helps the researcher examine how these components interact with each other in a gestaltic or whole perspective (Leininger, 1988). The structure of cultural care theory is represented by the sunrise model. It describes the relationship between anthropological and nursing beliefs. The sunrise model connects the concepts of the theory with clinical practices. The three concepts that are utilized by the sunrise model are: cultural care maintenance/preservation, cultural care negotiation/accommodation, and cultural care restructuring/re-patterning. Cultural preservation is when nurses provide support to patients for their cultural practices. Some examples include acupuncture for anxiety and pain relief for medical interventions. Cultural negotiation is supporting the patient and family members to carry out cultural activities that cannot harm the patient’s health or other members in the healthcare setting. Cultural restructuring is done when certain cultural practices may cause harm to the patient or others in their environment (Albougami, 2016).

Strengths and weaknesses the model


1) The Transcultural Theory concentrates on the philosophy impression in the providing care to patients and helping the nurses to be ethnically subtle. Therefore, nurses should be mindful on diverse cultures which require them to respond to patient needs for adequate nursing care (Rivera, 2018)

2) Relationships and concepts are at the abstraction level making it applicable in various situations. Thus, the concept is made to be highly generalizable (Rivera, 2018)

3) Leininger’s highlighting of care as the nursing core when compared to other approaches which focused on health, environment, nursing and people is considered to be a significant strength. (Rivera, 2018)


1) The concept might be the main source of error during clinical choices like the misunderstanding of results and values placed by individuals. The patient’s uniqueness must be considered for aid in data taking (Rivera, 2018).

2) Problems may arise when integrating or adapting the different can cause cultural shock to the nurse. Consequently, the approach does not give any attention to the symptoms, diseases as well as treatment (Rivera, 2018)

Article # 1: Transcultural nursing strategies for carers of people with dementia

Dementia affects people from all social ranges. People living with this disease experience memory, cognitive, language, and daily self-care deficits. As this disease progresses, the affected party usually requires a lot of social support. Caregivers can be overwhelmed by the physical, emotional, and economic stressors from taking care of a demented person. They often need help from multidisciplinary health, social, and financial systems (Bunting, 2016).

This literature review was done in London and it explored the effects of caring among different cultural groups and it offered recommendations for cultural appropriate caregiver support interventions. Transcultural nursing focuses on individual needs of the person’s background to provide cultural compatible, meaningful, and beneficial care. Different cultures have different perceptions about dementia (Bunting, 2016).

In most community dementia is seen as a normal aging process. In minority groups it is seen as possession of a spirit or craziness. This often leads to shame, isolation, and reluctance to ask for help. People from BAME groups don’t often get the services they need to help them cope with dementia. Carer or caregiver stress affects individuals from different cultures differently. Social support affects a caregiver’s stress level. White caregivers had more social support from family and friends. Substance abuse was used as a coping mechanism for depressive white British groups. Looking at similarities and differences among cultures can help with providing cultural congruent caregiver support interventions. A good support system and statutory services reduced caregiver stress and had a positive effect on patients with dementia. Some statutory services include respite care, day care, and educational programs. Brotaty and Donk (2009) mentioned that caregivers who are trained develop confidence in the way they cope, and they experience less burden and depressive symptoms. Lopez et al (2012) discovered that self-adequacy mixed with spiritual aspects is associated with lower levels of depression (Bunting, 2016). The values of an individual are a motivation in the decision to care for a patient. The Care Act 2014 says that caregiver have a right to support that promotes their wellbeing. Interventions should be made within the context of individuals in their family, cultural groups and wider society. Congruence with cultural values can be promoted by enhancing services for all groups. Self-efficacy can be promoted through caregiver education and by reinforcing effective coping strategies. A change in the normal behavior in a person increases stress for a family caregiver (Bunting, 2016).

Nurses should teach family caregiver about the nature of dementia, identify minimizing strategies and talk through problematic issues. By doing this, the nurse can minimize perception of norm transgression. Different groups have different stressors and caregiver react differently to them. Nurses should offer cultural congruent advice for these caregivers. A caregiver values can help them find meaningfulness in caring for a patient with dementia. Nurses should also listen, avoid exploitation and speak on the caregiver behalf to improve high quality cultural congruent services (Bunting, 2016). This study was done to analyze how caregiver stress affects people of different ethnic and cultural groups. These people react differently to care giver stress. Cultural identity influences how people perceive burden and coping styles. Nurses should promote congruence with cultural values and provide effective support and social inclusion for all service users (Bunting, 2016).

Article # 2: Transcultural nursing: Its importance in nursing practice

With the reality of today’s healthcare system where care needs to be delivered to a growing multiethnic population, nurses need to not only be qualified and knowledgeable but also be culturally competent to deliver quality and individualized care to people with various diverse cultural backgrounds. Maier-Lorentz (2008), in this article introduces us to changes that are essential to the implementation of effective transcultural nursing. She also identifies key factors defining transcultural nursing and offers possible methods to deliver and promote competent nursing care. Due to the rapid growth of the multiethnic population, the delivery of care needs to be adjusted. To reflect the changes, nurses must have substantial knowledge of other cultures in order to deliver competent nursing care. They must deliver and plan holistic care by considering patient needs from a multicultural perspective. Cultural competence care is the ability for a nurse to understand the fundamental difference between cultures (Maier-Lorentz, 2008), works with people of different cultures and most importantly care for them with respect. According to the author, the Transcultural theory of Leininger brought a powerful and major contribution in the delivery of culturally competent care. Nurses should be capable of delivering competent cultural care to all patients regardless of race, culture, beliefs, values, practices as well as myths and rituals passed from generation to generation.

The author considers cross-cultural communication to be an excellent source of knowledge and acquisition of skills for nurses. This communication put more emphasis on nonverbal cues than verbal ones. Those cues are: eye contact, touch, silence, space and distance, and healthcare beliefs. All those factors are important during the delivery of care since their meanings may vary from one culture to another. By instance, eye contact, which is the one who differs the most between cultures (Maier-Lorentz, 2008), can be a sign of disrespect in a culture when here in the USA, the nurses are encouraged to keep eye contact when speaking with patient. In some cultures, it is disrespectful to touch someone, when here in the USA, touch is part of the nurse-patient relationship. While silence might be a sign of miscommunication or misunderstanding for the nurse, it can be a positive reaction or attitude in another culture. Space and distance and healthcare beliefs needs to be taken in consideration in the cultural competency care where other culture differences must be considered with respect. Three steps are essential to attain cultural competence: adoption of attitudes to promote transcultural nursing care by using caring, empathy, openness, flexibility from a cultural perspective; development of awareness for cultural differences, by being aware of the cultural differences; and performance of a cultural assessment to obtain information about patient’s care from his perspective. Different factors of transcultural nursing are also identified by the author whom put the accent on “desire”. To be able to deliver competent cultural care, nurses must want to achieve cultural competency (Maier-Lorentz, 2008). Awareness, knowledge, skills and encounters are the other factors considered by the author in the transcultural care. The author also mentioned the dilemma with the acceptance of the advance directive which varies from one culture to another.


Even though the author presents other factors which need to be considered in the delivery of culturally competent nursing, she believes that the transcultural theory of Leininger has a major contribution in support of transcultural nursing and daily nursing practice. Overall, I share the opinion of the author who suggests that funding must be allocated for education, research in order to ensure cultural competency in nursing care.

Article #3: Diabetes-specific nutrition algorithm: a transcultural program to optimize diabetes and prediabetes care.

The article focuses on the investigation of transcultural impacts on management of diabetes-specific nutrition program. The study has revealed several transcultural impacts that affect success of this program. The matter is that U.S. as well as global com-munities are heterogenous nowadays, so numerous cultural diversities coexist in a single society. That reflects on differences in health beliefs, needs, and attitudes towards nutrition, which is why patient-centered approaches take diverse focuses. As a result, the study suggested a simplified form of program that can be implemented on the international scale, if cultural aspects are managed with a better accuracy. There are several methodological cornerstones that are applicable to every single ethnic group, and they can be utilized for a weighted and effective approach.

Diabetes Type 2 is a widespread problem, and it is mainly addressed with implementation of a balanced nutrition. However, cultural differences and health beliefs make such nutrition management inaccessible for cultural diversities. It is becoming abundantly clear that insufficient cultural competency in this respect is a pivotal factor for fostering appropriate nutrition behaviors among ethnic diversities affected with diabetes Type 2.  What is more, many populations, due to their health beliefs, are not cognizant of the need for nutrition management, which is why it is critical to educate these populations in terms of their cultural backgrounds.

The article reveals transcultural implications and suggests respective updates to nutrition management. The current state of knowledge is sufficient to offer effective nutrition programs to diverse populations, but they are hardly feasible in clinical practice and strong presence of various cultures within a single community. That is why simplification of the current standards to nutrition management for cultural diversities is a pivotal course of action, as long as these populations need to receive affordable, accessible, and continuous care

Internationally respected health care experts in diabetes and nutrition from Brazil, Canada, China, Mexico, The Netherlands, Panama, Spain, Taiwan, and the United States were invited for interview. The interview results have been analyzed in relation to Made-line Leininger transcultural theory and compared with clinical trials that use either standard modes of nutrition management or simplified ones. These interpretations are used in creation of a conceptual framework that presents more convenient and diversity-friendly nutrition management guidelines. Hence, this model is based on the expertise of various nutrition experts of all over the world, thereby providing intercultural insights on the issue.

Transcultural factors do play important role in formation of the nutrition program, as differences in health beliefs and cultural backgrounds do affect specific eating behaviors as well as attitudes towards specific types of food. Representatives of diverse populations need to receive nutrition management that is congruent with their cultural and ethnic backgrounds. Current approaches are affective, but the study has introduced a simplified model that is applicable to a variety of diverse groups.

Article #4: Reflections on violence against women in the perspective of Madeleine Leininger

The conceptual framework used in this study is Madeline Leininger-Transcultural Nursing Theory in which the essence of nursing is focused on caring. Broch, Crossetti, & Riquinho (2017) explain that the purpose of the study is to find out how Leininger’s transcultural theory assists nurses in dealing with situations of violence against women. It is important to identify practice specific concepts that this article anchors on in relation to Madeline Leininger’s Theory. They are the concepts of cultural preservation/maintenance of care, cultural adjustment/negotiation of care, and re-patterning/restructuring of care to two major propositions of the Leininger-Transcultural Nursing Theory.

The first proposition is that culture care values, believes and practices are embedded in kinship social, economic and political context of culture. In this article Broch et al. (2017) includes the concept of re-patterning/restructuring of care to aid, support and train people new and different patterns that are healthy and culturally significant. The researchers found that in the kinship social factor violence is perpetuated throughout generations. The culture reinforces differences between men and women and the day to day interaction of beliefs as norms and truths. These in fact are roles established by tradition that can be changed.  In the economic factor financial and emotional dependence perpetuates violence by an intimate partner. In this area because of the extent of this problem there have been changes in legislation in-order to fight against violence against women. In addition, public debates aim to raise awareness in society to fight against violence (Broch et al., 2017).

Another proposition is that cultural-based care is the most holistic way to interpret nursing care phenomena and guide interventions. This article includes the concept of cultural preservation/maintenance of care to assist nurses in guiding evidence-based care. Broch et al., (2017) stresses the importance of cultural professional actions guided by training to assist the patient with her coping process. Victims of violence experience shame, guilt, and humiliation. They have also experienced sexual and psychological harm as well. The role of the nurse is to provide ethical, caring interventions without prejudice (Broch et al., 2017). The concept of cultural adjustment/negotiation also is used in this assumption to help the victim adapt to a satisfactory state of health that will include negotiation with present circumstances.

Broch et al. (2017) reflected on violence against women from the perspective of Madeleine Leininger’s Sunrise categories.  They achieved their work in Brazil by completing a qualitative, descriptive study of the type reflective analysis using books, scientific articles and manuals. Their goal was to address the issue of violence against women in South America at the Inter-American Convention on the prevention, punishment and eradication of violence against women. Broch’s et al. (2017) intent was to provide evidenced based technical knowledge to health care professionals in addition to seeking subsidies to health care. Their conclusion supports the Leininger-Transcultural Nursing Theory by discovering specific values and practices in a culture significant way.

Violence against women is a global issue. Advanced Practice Nurses can apply Madeleine Leininger’s Sunrise Enabler in a thought-provoking way to fight for human rights and violence against women. This can be done in a holistic and culturally sensitive way.

Article #5: Bridging obstacles to transcultural caring relationships—Tools discovered through interviews with staff in pediatric oncology care

The study explores how nurses address transcultural barriers in work with immigrant families in terms of pediatric oncology care. This aspect occurs to be extremely important in the Swedish context of healthcare, whereas immigrant families are exposed to financial burdens of affording expensive health services and multiple barriers in culture and language. That is why transcultural bridging is suggested as the primary tool for addressing obstacles of these families concerning care for their children. This is the process that involves not only transcultural nursing tools but also active communication, organizational management, and patient advocacy. The study reveals that intercultural competences of local nurses do help families to overcome the stress and understand the process of care for their children throughout all stages.

The study takes place in Sweden, whereas 17% of populations are immigrants, among which almost 350 children aged 0 to 19 suffer from cancer annually, which is why transcultural issues must be addressed. Profound differences in culture, absence of relevant culture of health, or simple lack of finance are the main constraints that are encountered by immigrant families with the children that have cancer of various types. Exposure to multiple stresses, especially in unfamiliar environments are strong barriers for treatment of such children, which is why it is critical to provide culturally competent care and guidance for these families.

Extent of transcultural competences of nurses must be verified in relation to their efficacy in care for immigrant families. This aspect appears to be extremely effective in oncology treatment of children from immigrant families, which is why measuring the cur-rent level of intercultural competences is critical. The identified level of competency will indicate what gaps should be filled in the future and whether Swedish nurses are capable of managing such complex cases. By the same token, the study intends to understand how these immigrant families are able to adjust to new environments and whether such dramatic change does affect the state of children with oncologic illnesses. Five focus group interviews and five complementary individual interviews have been con-ducted. The results of these interviews have been applied to the theoretical framework based on Madeline Leininger theory of transcultural nursing, thereby identifying the level of nurse’s competencies in this respect.

Addressing transcultural barriers is an important consideration for immigrant population, as it makes qualitative care more accessible and integrate these families in a global community. The nurses occur to have sufficient level of intercultural competences, which is why they are able to address the issues related to care for oncologic immigrant children. A so-called transcultural bridging occurs to be the only one solution in relation to the provision of affordable, continuous, and efficacious care for ethnic minorities. Moreover, transcultural bridging is aimed at proactive communication with these vulnerable populations, which is why advancement communication strategies for nurses has to be the direction for the future research and clinical practice.

Theory implication for nursing practice, education, research

The transcultural Nursing Theory with its Sunrise enabler to discover culture care can find its application in practice, education, research and even in administration.

Implications on Practice: The Leininger-Transcultural Nursing Theory is important for nursing practice because it can be used to apply culturally consistent application all over the world. America and the world are culturally diverse today and there is a need for Advanced Practice Nurses to be transculturally tender, accomplished, and knowledgeable. People and cultures constantly change. This nursing theory fits well in its application for applying culturally congruent health care.  Patients will receive a more satisfying way to obtain healthcare outcomes. Many times the nurse practitioner is the first person to apply primary clinical care to the patient. This can be not only done in a safe and effective way but in a more satisfying way to the patient. This concept of applying nursing practice is the broadest holistic way to guide the advanced practice nurse’s clinical practices in day to day interactions with client (Eipperle, 2015).

Culture care preservation and maintenance concept is used in nursing practice to support and enable professional decisions to help cultures preserve and maintain those beneficial cultural beliefs that assist in healthy lifestyles.  The concept of culture care accommodation and negotiation helps in adapting transactions that is fitting for a healthy lifestyle of the patient. Nursing care practices are adjusted to meet the needs of the culture by accommodating and negotiating with the client.  The concept of culture care re-patterning and or restructuring helps to achieve a mutual decision making process as the nurse modifies her nursing action to help the client with his holistic outcome. This will ensure and protect the patient’s safety and well-being (Eipperle, 2015) for instance the restructuring of a culture practice may be needed to prevent a serious compromise to his health.

Caring in a sensitive and flexible way is paramount to the practice of the advanced nurse practitioner. The three concepts are key factors when using the Leininger-Transcultural nursing theory in clinical practice (Eipperle, 2015)

The implication of the transcultural model in practice is very important in delivery of culturally congruent care that enhance healthcare outcomes. While delivering care to a patient from a transcultural perspective, to be culturally competent, the nurse must consider all the factors cited in the Sunrise enabler. According to Sagar (2002), it is most important to focus on the holistic dimensions, as described in the Sunrise Model to establish a therapeutic nurse patient culture care practice.

Implications on Nursing Education:

Transcultural Nursing education is a commitment to providing sensitive, congruent training using Leininger’s Transcultural nursing theory. Nursing faculty who teach this method apply a holistic process to training that has far reaching implications for patients and their families, students and themselves. This framework along with the ethno research method can be applied by nursing administrators for the micro-culture teaching of hospital staff as well (Sagar, 2015).

Spiritual professional care is the foundation for teaching and modeling Leininger-Transcultural Nursing theory. Faculty use care constructs such as reciprocal care, self-care, and respect which is essential when working with patients and families, students, fellow faculty, and communities. Values and beliefs in culture care should be reflected in the institutional vision and philosophy (Mixer, 2015).

The sunrise enabler within the Leininger-Transcultural Nursing theory is a tool used to discover, describe and synthesize a particular culture in order to understand their articulations, viewpoints and practices. The goal is to bring new nursing knowledge to cultural care nursing, application, theory and education.  Three concepts are used within the Sunrise enabler and are the ideas of cultural preservation/maintenance of care, cultural accommodation/negotiation of care, and re-patterning/restructuring of care. This is used in education to generate new transcultural data and apply it in an in-depth way to promote healthcare education (Omeri,2015) Within the cultural preservation concept the goal of education is to respect cultural beliefs that encourage formal education. In the cultural accommodation/negotiation of care concept the goal of education is to facilitate enhanced understanding by using techniques to assist in learning. In the re-patterning and restructuring of care concept the goal of education is to provide supportive actions that enhance Leininger’s Transcultural Nursing theory (Omeri, 2015).

Leininger strongly recommended that transcultural nursing be included in undergraduate and graduate nursing education programs (Leininger and McFarland, 2002), to ensure nurses and affiliated health care providers are equipped with the knowledge necessary to deliver culturally competent care to the many cultures we interact with in the USA. Currently, many organizations such as The Joint Commission (TJC), American Association of College of Nursing (AACN) and, the National League of Nursing (NLN) put the emphasis on the cultural competency course in nursing program. The AACN, with the help of the California Endowment, developed Cultural competency in Baccalaureate Nursing education which promotes cultural competencies among nursing graduates (Sagar, 2002). The Leininger’s textbook is widely used in Nursing schools and most healthcare institutions nowadays offer formal cultural competency classes to their employees at the time of hire and subsequently yearly during annual updates.

Implications on Nursing Research:

Leininger’s nursing theory lends itself easily to qualitative research.  This method has the researcher asking questions such as what and why.  The premise of qualitative research is that reality is socially constructed, and the participants enrolled are familiar with the researcher’s questions.  Data are collected by interviews, observations, and documents (Miller, 2010) and that is the goal of traditional qualitative research. Madeline Leininger took qualitative research further and developed the ethno nursing method. This is used to discover care and health in diverse cultures as a goal. It seeks the participant’s ideas, perspectives and knowledge. It is used to improve care to clients of diverse cultures (McFarland, 2014). It is rigorous, systematic and detailed enough to study multiple cultures, but it is also an open inquiry method as well. Within the ethno research method Leininger devised 135 care constructs. These constructs are ways people deal with each other in their culture. Some examples include saving face, watchfulness, and sharing with others.  It helps the researcher develop meanings and symbols of the culture being studied. It also assists the nurse in learning cultural practices as well (Wehbe-Alamah, & McFarland, 2015).

In addition, Leininger created enablers to accompany the ethno nursing method. This would help friendly researchers bring out specific data from the participants. Some examples of enablers include the sunrise enabler, the stranger to trusted friend enabler, and the life history healthcare enabler. She used the domains of the sunrise enabler to create a coding system (Wehbe-Alamah, & McFarland, 2015).

Leininger devised the four phases of ethno nursing data analysis enabler. The first phase the researcher collects raw data from interviews or observations. In the second phase the data is coded and classified.  In the third phase patterns and meanings are recognized. In the fourth phase the researcher completes the data analysis, synthesis, and interpretation (Wehbe-Alamah, & McFarland, 2015).


Many theorists have been active during the past four decades. Madeleine Leininger discovered that care and culture were linked together, and they couldn’t be separated from each other. This belief led to the birth of the theory of cultural care diversity and universality. Cultural care theory is used to form new ideas and knowledge about care of diverse cultures. The main concepts of this theory are worldview and culture. Culture is learned and shared values that are passed down from generation. Worldview is the way people see the world and from that they can form a picture or value about life. The sunrise model is a conceptual picture that portrays the components of transcultural nursing theory. The theoretical assumptions of the theory focus on how care and culture are interrelated, and they are here to guide nursing decisions and actions. One of the strengths of the transcultural theory is that it concentrates on the philosophy impression in providing care to patients and helping nurses be ethically subtle. The ultimate purpose of the theory is to provide cultural suitable nursing care practices (Leininger, 1988).


Albougami, A. S. (2016). Comparison of Four Cultural Competence Models in Transcultural Nursing: A Discussion Paper. International Archives of Nursing and Health Care,2(4). doi:10.23937/2469-5823/1510053

Broch, D., Crossetti, M., & Riquinho, D.L. (2017). Reflections on violence against women in the perspective of madeleine leininger. Journal of Nursing,11(12). 5079 – 5084. doi: 10.5205/1981-8963-v11i12a22588p5079-5084-2017

Bunting, M. (2016). Transcultural nursing strategies for carers of people with dementia. Nursing Older People, 28(3), 21-25. Retrieved from