Theoretical Sources

Leininger’s theory is derived from the disciplines of anthropology and nursing (Leininger, 1991b, 1995c;
Leininger & McFarland, 2002b, 2006). She defined transcultural nursing as a major area of nursing
focused on the comparative study and analysis of diverse cultures and subcultures in the world with
respect to their caring values, expressions, healthillness beliefs, and patterns of behavior. The purpose
of the theory was to discover human care diversities and universalities in relation to worldview, social
structure, and other dimensions cited, and then to discover ways to provide culturally congruent care to
people of different or similar cultures in order to maintain or regain their well-being or health, or to face
death in a culturally appropriate way (Leininger, 1985b, 1988b, 1988c, 1988d; as cited in 1991b). The
goal of the theory is to improve and provide culturally congruent care to people—care that is beneficial
and useful to the client, family, or culture group (Leininger, 1991b). Transcultural nursing goes beyond
an awareness state to that of using Culture Care nursing knowledge to practice culturally congruent and
responsible care (Leininger, 1991b, 1995c). Leininger has stated that there will be nursing practice that
reflects nursing practices that are culturally defined, grounded, and specific to guide nursing care
provided to individuals, families, groups, and institutions. She contends that because culture and care
knowledge are the most holistic means to conceptualize and understand people, they are central to and
imperative to nursing education and practice (Leininger, 1991b, 1995c; Leininger & McFarland, 2002a,
2006). She states that transcultural nursing is one of the most important, relevant, and highly promising
areas of formal study, research, and practice because we live in a multicultural world (Leininger, 1984a,
1988a, 1995c; Leininger & McFarland, 2002a, 2006). She predicts cultural nursing knowledge and
competencies will be imperative to guide all nursing decisions and actions for effective and successful
outcomes (Leininger, 1991b, 1995c, 1996a, 1996b; Leininger & McFarland, 2002a, 2006). Leininger
(2002a) distinguishes between transcultural nursing and cross-cultural nursing. The former refers to
nurses prepared in transcultural nursing who are committed to develop knowledge and practice in
transcultural nursing, whereas cross-cultural nursing refers to nurses who apply anthropological
concepts (Leininger, 1995c; Leininger & McFarland, 2002a). She specifies international nursing and
transcultural nursing as follows: international nursing focuses on nurses functioning between two
cultures; and, transcultural nursing focuses on several cultures with a comparative theoretical and
practice base (Leininger, 1995c; Leininger & McFarland, 2002a). Leininger describes the transcultural
nurse generalist as a nurse prepared at the baccalaureate level who is able to apply transcultural nursing
concepts, principles, and practices generated by transcultural nurse specialists (Leininger, 1989a, 1989b,
1991c, 1995c; Leininger & McFarland, 2002a). The transcultural nurse specialist prepared in graduate
programs receives in-depth preparation and mentorship in transcultural nursing knowledge and
practice. This specialist has acquired competency skills through postbaccalaureate education. “This
specialist has studied selected cultures in sufficient depth (values, beliefs, and lifeways) and is highly
knowledgeable and theoretically based about care, health, and environmental factors related to
transcultural nursing perspectives” (Leininger, 1984b, p. 252). The transcultural nurse specialist is an
expert field practitioner, teacher, researcher, and consultant with respect to select cultures. This
individual values and uses nursing theory to develop and advance knowledge within the discipline of
transcultural nursing (1995c, 2001). Leininger (1996b) holds and promotes a new and different type of
theory. She defines theory as the systematic and creative discovery of knowledge about a domain of
interest or a phenomenon that is important to understand or to account for some unknown
phenomenon. She believes nursing theory should take into account creative discovery about individuals,
families, and groups, and their caring, values, expressions, beliefs, and actions or practices based on
their cultural lifeways to provide effective, satisfying, and culturally congruent care. If nursing practices
fail to recognize the cultural aspects of human needs, there will be evidence of dissatisfaction with
nursing services, which limits healing and well-being (Leininger, 1991b, 1995a, 1995c; Leininger &
McFarland, 2002a, 2006). Leininger (1991b) developed her Theory of Culture Care Diversity and
Universality, based on the belief that people of different cultures can inform and are capable of guiding
professionals to receive the kind of care they desire or need from others. Culture is the patterned and
valued lifeways of people that influence their decisions and actions; therefore, the theory is directed
toward nurses to discover and document the world of the client and to use their emic viewpoints,
knowledge, and practices with appropriate etic (professional knowledge) as bases for making culturally
congruent professional care actions and decisions (Leininger, 1991b, 1995c). Culture Care is a broad
nursing theory because it takes into account the holistic perspective of human life and existence over
time, including the social structure factors, worldview, cultural history and values, environmental
context (Leininger, 1981), language expressions, and folk (generic) and professional patterns viewed in
terms of culture. These are some of the essential bases for discovery of grounded care knowledge,
which is the essence of nursing leading to the well-being of clients and therapeutic nursing practice. The
Culture Care Theory is inductive and deductive, derived from emic (insider) and etic (outsider)
knowledge (1991b). The theory is neither a middlerange nor macro theory but is best viewed broadly
with specific domains of interest (1991b, 1995c; Leininger & McFarland, 2002a, 2006). According to
Leininger (2002c), the Theory of Culture Care Diversity and Universality has several distinct features. It is
focused explicitly on discovering holistic and comprehensive Culture Care, and it can be used in Western
and nonWestern cultures because of multiple holistic factors found universally. It is purposed to
discover comprehensive factors influencing human care such as worldview, social structure factors,
language, generic and professional care, ethnohistory, and the environmental context. It has three
theoretical practice modalities to arrive at culturally congruent care decisions and actions to support
well-being, health, and satisfactory lifeways for people. The theory is designed to ultimately discover
care—what is diverse and what is universally related to care and health—and has a comparative focus to
identify different or contrasting transcultural nursing care practices with specific care constructs. The
ethnonursing method has enablers designed to tease out in-depth informant emic data that can be used
for cultural health care assessments. The theory may generate new knowledge in nursing and health
care for culturally congruent, safe, and responsible care.

MAJOR CONCEPTS & DEFINITIONS

Leininger developed terms relevant to the theory. The major terms are defined here, and one can access
the full theory from her works (Leininger, 1991b, 1995c; Leininger & McFarland, 2002a, 2006).

Human Care and Caring

The concept of human care and caring refers to the abstract and manifest phenomena with expressions
of assistive, supportive, enabling, and facilitating ways to help self or others with evident or anticipated
needs to improve health, a human condition, or lifeways, or to face disabilities or dying.

Culture

Culture refers to patterned lifeways, values, beliefs, norms, symbols, and practices of individuals,
groups, MAJOR CONCEPTS & DEFINITIONS or institutions that are learned, shared, and usually
transmitted from one generation to another.

Culture Care

Culture Care refers to the synthesized and culturally constituted assistive, supportive, enabling, or
facilitative caring acts toward self or others focused on evident or anticipated needs for the client’s
health or well-being, or to face disabilities, death, or other human conditions.

Culture Care Diversity

Culture Care diversity refers to cultural variability or differences in care beliefs, meanings, patterns,
values, symbols, and lifeways within and between cultures and human beings.

Culture Care Universality

Culture Care universality refers to commonalities or similar culturally based care meanings (“truths”),
patterns, values, symbols, and lifeways reflecting care as a universal humanity.

Worldview

Worldview refers to the way an individual or a group looks out on and understands the world about
them as a value, stance, picture, or perspective about life and the world.

Cultural and Social Structure Dimensions

Cultural and social structure dimensions refer to the dynamic, holistic, and interrelated patterns of
structured features of a culture (or subculture), including religion (or spirituality), kinship (social),
political characteristics (legal), economics, education, technology, cultural values, philosophy, history,
and language.

Environmental Context

Environmental context refers to the totality of an environment (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.

Ethnohistory
Ethnohistory refers to the sequence of facts, events, or developments over time as known, witnessed, or
documented about a designated people of a culture.

Emic

Emic refers to local, indigenous, or the insider’s views and values about a phenomenon.

Etic

Etic refers to the outsider’s or more universal views and values about a phenomenon.

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.

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 wellbeing) and to deal with disabilities, dying, or other human
conditions in culturally congruent and beneficial ways.

Culture Care Preservation or Maintenance

Culture Care preservation or maintenance refers to those assistive, supportive, facilitative, or enabling
professional actions and decisions that help people of a particular culture to retain or maintain
meaningful care values and lifeways for their well-being, to recover from illness, or to deal with
handicaps or dying.

Culture Care Accommodation or Negotiation

Culture Care accommodation or negotiation refers to those assistive, supportive, facilitative, or enabling
professional actions and decisions that help people of a designated culture (or subculture) to adapt to or
to negotiate with others for meaningful, beneficial, and congruent health outcomes.

Culture Care Repatterning or Restructuring

Culture Care repatterning or restructuring refers to the assistive, supportive, facilitative, or enabling
professional actions and decisions that help clients reorder, change, or modify their lifeways for new,
different, and beneficial health outcomes.

Culturally Competent Nursing Care

Culturally competent nursing care refers to the explicit use of culturally based care and health
knowledge in sensitive, creative, and meaningful ways to fit the general lifeways and needs of
individuals or groups for beneficial and meaningful health and well being, or to face illness, disabilities,
or death.

Use of Empirical Evidence

For more than 6 decades, Leininger has held that care is the essence of nursing and the dominant,
distinctive, and unifying feature of nursing (1970, 1981, 1988a, 1991b; Leininger & McFarland, 2002a,
2006). She has found that care is complex, elusive, and embedded in social structure and other aspects
of culture (1991b; Leininger & McFarland, 2006). She holds that different forms, expressions, and
patterns of care are diverse, and some are universal (Leininger, 1991b; Leininger & McFarland, 2002a,
2006). Leininger (1985a, 1990b) favors qualitative ethnomethods, especially ethnonursing, to study care.
These methods are directed toward discovering the people-truths, views, beliefs, and patterned lifeways
of people. During the 1960s, Leininger developed the ethnonursing method to study transcultural
nursing phenomena specifically and systematically. The method focuses on the classification of care
beliefs, values, and practices as cognitively or subjectively known by a designated culture (or cultural
representatives) through their local emic people-centered language, experiences, beliefs, and value
systems about actual or potential nursing phenomena such as care, health, and environmental factors
(Leininger, 1991b, 1995c; Leininger & McFarland, 2002a, 2006). Although nursing has used the words
careand caringfor more than a century, the definitions and usage have been vague and used as clichés
without specific meanings to the culture of the client or nurse (Leininger, 1981, 1984a). “Indeed, the
concepts about caring have been some of the least understood and studied of all human knowledge and
research areas within and outside of nursing” (Leininger, 1978, p. 33). With the transcultural care theory
and ethnonursing method based on emic (insider views) beliefs, a person gets close to the discovery of
people-based care, because data come directly from people rather than the etic (outsider views) beliefs
and practices of the researcher. An important purpose of the theory is to document, know, predict, and
explain systematically through field data what is diverse and universal about generic and professional
care of the cultures being studied (Leininger, 1991b). Leininger (1984a, 1988a) holds that detailed and
culturally based caring knowledge and practices should distinguish nursing’s contributions from those of
other disciplines. The first reason for studying care theory is that the construct of care has been critical
to human growth, development, and survival for human beings from the beginning of the human
species (Leininger, 1981, 1984a). The second reason is to explicate and fully understand cultural
knowledge and the roles of caregivers and care recipients in different cultures to provide culturally
congruent care (Leininger, 1991b, 1995c, 2002a, 2002b, 2002c). Third, care knowledge is discovered and
can be used as essential to promote the healing and well-being of clients, to face death, or to ensure the
survival of human cultures over time (Leininger, 1981, 1984a, 1991b). Fourth, the nursing profession
needs to systematically study care from a broad and holistic cultural perspective to discover the
expressions and meanings of care, health, illness, and well-being as nursing knowledge (Leininger,
1991b, 1995c, 2002a, 2002b, 2002c). Leininger (1991b, 1995c, 2002a, 2002b, 2002c) finds that care is
largely an elusive phenomenon often embedded in cultural lifeways and values. However, this
knowledge is a sound basis for nurses to guide their practice for culturally congruent care and specific
therapeutic ways to maintain health, prevent illness, heal, or help people face death (Leininger, 1994). A
central thesis of the theory is that if the meaning of care can be fully grasped, the well-being or health
care of individuals, families, and groups can be predicted, and culturally congruent care can be provided
(Leininger, 1991b). Leininger (1991b) views care as one of the most powerful constructs and the central
phenomenon of nursing. However, such care constructs and patterns must be fully documented,
understood, and used to ensure that culturally based care becomes the major guide to transcultural
nursing therapy and is used to explain or predict nursing practices (Leininger, 1991b). To date, Leininger
has studied several cultures in depth and has studied many cultures with undergraduate and graduate
students and faculty using qualitative research methods. She has explicated care constructs throughout
cultures in which each culture has different meanings, cultural experiences, and uses by people of
diverse and similar cultures (Leininger, 1991b, 1995c; Leininger & McFarland, 2002a, 2006). New
knowledge continues to be discovered by transcultural nurses in the development of transcultural care
practices with diverse and similar cultures. In time, Leininger (1991b) contends, diverse and universal
features of care and health will be documented as the essence of nursing knowledge and practice.
Leininger believes that nurses must work toward explicating care use and meanings so that culture care,
values, beliefs, and lifeways can provide accurate and reliable bases for planning and effectively
implementing culture-specific care and for identifying any universal or common features about care. She
maintains that nurses cannot separate worldviews, social structures, and cultural beliefs (folk and
professional) from health, wellness, illness, or care when working with cultures, because these factors
are closely linked. Social structure factors such as religion, politics, culture, economics, and kinship are
significant forces affecting care and influencing illness patterns and well-being. She emphasizes the
importance of discovering generic (folk, local, and indigenous) care from the cultures and comparing it
with professional care (Leininger, 1991b). She has found that cultural blindness, shock, imposition, and
ethnocentrism by nurses continue to reduce the quality of care offered to clients of different cultures
(Leininger, 1991a, 1994, 1995c; Leininger & McFarland, 2002a, 2006). She points out that nursing
diagnoses and medical diagnoses that are not culturally based are known to create serious problems for
some cultures that lead to unfavorable outcomes (Leininger, 1990c). Culturally congruent care is a
powerful healing force for the quality health care that clients seek most when they come for care by
nurses, and it is realized when culturally derived care is known and used.

Major Assumptions

Major assumptions of Leininger’s Culture Care Theory of Diversity and Universality were derived from
Leininger’s definitive works on the theory (Leininger, 1991b; Leininger & McFarland, 2002a, 2006).

Nursing

1. Care is the essence of nursing and a distinct, dominant, central, and unifying focus. 2. Culturally
based care (caring) is essential for wellbeing, health, growth, and survival, and to face handicaps
or death. 3. Culturally based care is the most comprehensive and holistic means to know,
explain, interpret, and predict nursing care phenomena and to guide nursing decisions and
actions. 4. Transcultural nursing is a humanistic and scientific care discipline and profession with
 the central purpose to serve individuals, groups, communities, societies, and institutions. 5.
Culturally based caring is essential to curing and healing, for there can be no curing without
caring, but caring can exist without curing. 6. Culture Care concepts, meanings, expressions,
patterns, processes, and structural forms of care vary transculturally with diversities
(differences) and some universalities (commonalities).

Person

7. Every human culture has generic (i.e., lay, folk, or indigenous) care knowledge and practices and
usually professional care knowledge and practices, which vary transculturally and individually. 8. Culture
Care values, beliefs, and practices are influenced by and tend to be embedded in the worldview,
language, philosophy, religion (and spirituality), kinship, social, political, legal, educational, economic,
technological, ethnohistorical, and environmental context of cultures.

Health

9. Beneficial, healthy, and satisfying culturally based care influences the health and well-being of
individuals, families, groups, and communities within their environmental contexts. 10. Culturally
congruent and beneficial nursing care can occur only when care values, expressions, or patterns are
known and used explicitly for appropriate, safe, and meaningful care. 11. Culture Care differences and
similarities exist between professional and client-generic care in human cultures worldwide.

Environment

12. Cultural conflicts, cultural impositions practices, cultural stresses, and cultural pain reflect the lack of
Culture Care knowledge to provide culturally congruent, responsible, safe, and sensitive care. 13. The
ethnonursing qualitative research method provides an important means to accurately discover and
interpret emic and etic embedded, complex, and diverse Culture Care data (Leininger, 1991b, pp. 44–45)

The universality of care reveals the common nature of human beings and humanity, whereas diversity of
care reveals the variability and selected, unique features of human beings.

Theoretical Assertions

Tenets are the positions one holds or the givens that the theorist uses with a theory. In developing the
Culture Care Theory, four major tenets were conceptualized and formulated (Leininger, 2002c, 2006): 1.
Culture Care expressions, meanings, patterns, and practices are diverse, and yet there are shared
commonalities and some universal attributes. 2. The worldview consists of multiple social structure
factors (e.g., religion, economics, cultural values, ethnohistory, environmental context, language, and
generic and professional care), which are critical influencers of cultural care patterns to predict health,
well-being, illness, healing, and ways people face disabilities and death. 3. Generic emic (folk) and
professional etic care in different environmental contexts can greatly influence health and illness
outcomes. 4. From an analysis of the previously listed influencers, three major actions and decision
guides were predicted to provide ways to give culturally congruent, safe, and meaningful health care to
cultures. The three culturally based action and decision modes were the following: (1) Culture Care
preservation or maintenance, (2) Culture Care accommodation or negotiation, and (3) Culture Care
repatterning or restructuring. Decision and action modes based on culture care were predicted as key
factors to arrive at congruent, safe, and meaningful care.

Leininger has maintained that documentation of these tenets was necessary in order to provide
meaningful and satisfying care to people, and they are predicted to be powerful influencers on culturally
based care. These factors needed to be discovered directly from the informants as influencing factors
related to health, well-being, illness, and death. The modes set forth in the four tenets are Culture Care
preservation or maintenance; Culture Care accommodation and negotiation; and Culture Care
repatterning or restructuring. The researcher draws upon findings from the social structure, generic and
professional practices, and other influencing factors while studying culturally based care for individuals,
families, and groups. These factors are studied, assessed, and responded to in a dynamic and
participatory nurse-client relationship (Leininger 1991a, 1991b, 2002b; Leininger & McFarland, 2002a).

ALLIGOOD, 436

Transcultural nursing is a growing and highly relevant area of study and practice today that has great
relevance for nurses living and functioning in a multicultural world. This area of study and practice often
leads to some entirely different ways of knowing and helping people of diverse cultures. With a
transcultural focus, nurses think about differences and similarities among people regarding their special
needs and concerns to develop different ways to assist clients. As nurses discover the client’s particular
cultural beliefs and values, they learn ways to provide sensitive, compassionate, and competent care
that is beneficial and satisfying to the client. Gaining a deep appreciation for cultures with their
commonalties and differences is one of several goals of transcultural nursing. At the same time, the
nurse discovers many nursing insights about her own cultural background and how to use such
knowledge appropriately with clients whether in a particular community, hospital, or other type of
health care service. Transcultural nursing is an area that opens many new windows of knowledge and
competency that have previously been unknown to nurses. In this chapter, several essential
transcultural nursing concepts will be defined and discussed along with specific examples to guide
nursing practices as used in transcultural nursing. In addition, generic and professional nursing care are
defined and explained as major concepts, showing the differences and similarities as they relate to the
practice of transcultural nursing. In the last section several recurrent, clinical, transcultural nursing
incidents with interpretations are presented to help nurses understand and envision the therapeutic
nature of transcultural nursing. Several questions are raised so the reader can reflect on ideas regarding
transcultural nursing and can thus provide nursing care that is culturally competent, safe, and
congruent. Discovering thewhys of each transcultural incident with the concepts helps the nurse to gain
in-depth knowledge of a culture. In this chapter consider that you are functioning or living with cultures
largely unknown to you. You might envision yourself in a hospital assigned to care for a client who spoke
a different language, was dressed differently, and acted in strange ways. You are baffled by what you see
and hear, but eager to know how you could give good nursing care. How would you feel? What would
you do? This is a transcultural nursing situation that many nurses face today in most hospitals, homes,
and health services. The situations offered in this chapter challenge one to realize the critical need for
transcultural nursing knowledge, principles, and skills to work with cultural strangers in therapeutic
ways.

Major Concepts and Definitions in Transcultural Nursing

In the evolution and development of this field of study and practice, it is essential for nurses to
understand the major concepts, constructs, theories, and principles of transcultural nursing. The term
construct is used to indicate several concepts embedded in phenomena such as care or caring. Concept
refers to a single idea, thought, or object. Transcultural nursing leaders have identified, studied, defined,
and explicated a number of concepts and constructs so nurses can use the ideas in meaningful and
appropriate ways. Such fundamental knowledge can assist nurses to communicate effectively with
others and to avoid unfavorable conflicts or troublesome interactions. It is, therefore, essential that
nursing students study the concepts and apply the ideas to real-life situations. In Chapter 1 the general
definition of transcultural nursing was presented, but let us reflect further on its essential features.
Transcultural nursing is a substantive area of study and practice focused on comparative cultural care
(caring) values, beliefs, and practices of individuals or groups of similar or different cultures.
Transcultural nursing’s goal is to provide culture-specific and universal nursing care practices for the
health and well-being of people or to help them face unfavorable human conditions, illness, or death in
culturally meaningful ways. 1,2 This definition of transcultural nursing has many important ideas such as
the focus on discovering culture-care values, beliefs, and practices of specific cultures or subcultures to
assist people with their daily health care needs. The comparative viewpoint is emphasized to identify
differences and similarities among or between cultures. It is this comparative viewpoint that enables the
nurse to identify culture-specific and commonalities of care of clients or groups. The major goal of
transcultural nursing is to tailor-make nursing care to reasonably fit the client’s culture-specific
expectations and care needs for beneficial health care outcomes and to identify any universal or
common care practices. Culturally congruent care becomes the desired and ultimate goal of
transcultural nursing. As one ponders further about transcultural nursing, the idea of human-care
(caring) values, beliefs, and practices becomes a central focus for nurses to learn about and practice
transcultural nursing. The author has declared since the late 1940s that care is an essential human need
and the essence of nursing on which the profession should be focusing.3,4 Nursing is a caring profession
and discipline that directs nurses to discover and provide knowledgeable and skilled care to clients. I
have defined nursing as a learned, humanistic, and scientific profession and discipline focused on human
care phenomena and caring activities in order to assist, support, and facilitate or enable individuals or
groups to maintain or regain their health or wellbeing in culturally meaningful and beneficial ways, or to
help individuals face handicaps or death. 5 This definition reinforces the idea of care as the essence and
fundamental focus of nursing and transcultural nursing.

Human Care as Essence of Nursing

In considering nursing as a caring profession and discipline, it is important to remember that nursing as a
profession has a societal mandate to serve people. The professional nurse is challenged to serve others
who need the assistance of a person prepared and qualified to respond to or who can anticipate the
actual or covert care needs of people. Nurses are professional persons who are ultimately held
responsible for and accountable to people in a particular society or culture to give care that will help
people to regain and maintain their health and to prevent illnesses. Nurses, however, function best as
professional persons when they know and understand different cultures in relation to their experiences,
human conditions, and cultural care values and beliefs. Today all professional nurses need to be
culturally prepared to be effective and beneficial to clients. Nursing as a culture also has culturally
defined modes of functioning and being which may change over time with societal changes. However, as
a discipline the culture of nursing expects that nurses will discover and use knowledge that is distinctive
and explains and interprets nursing’s focus and essence.6 Most importantly, nursing as a discipline
implies that there is a substantive body of knowledge to guide its members’ thinking and actions. The
discipline of nursing needs to focus more on care/caring to explain health and well-being in different or
similar cultures. Care, health, and well-being are central to what nursing is or should be.7 Transcultural
nurses are contributing some new, unique, and significant knowledge to nursing with the comparative
care focus and with ways to use this knowledge to serve people of a specific culture, or a society
worldwide. In a number of publications I have discussed human care and caring as the central, distinct,
and dominant foci to explain, interpret, and predict nursing as a discipline and profession, and
encourage the reader to study them.8–13 Human care, a noun, refers to a specific phenomenon that is
characterized to assist, support, or enable another human being or group to achieve one’s desired goals
or to obtain assistance with certain human needs. In contrast, human caring is focused on the action
aspect or activitiesto provide service to other human beings. Differences in the meanings of care (noun)
and caring (an action mode) are extremely important in understanding and practicing transcultural
nursing caring as a professional art. More explicitly, I have defined care and caring as follows:13

Care (noun) refers to an abstract or concrete phenomenon related to assisting, supporting, or enabling
experiences or behaviors or for others with evidence for anticipated needs to ameliorate or improve a
human condition or lifeway.
Caring (gerund) refers to actions and activities directed toward assisting, supporting, or enabling another
individual or group with evident or anticipated needs to ease, heal, or improve a human condition or
lifeway or to face death or disability.

These definitions of care and caring with culture are the foundational constructs of transcultural nursing
and characterize the nature and focus of the discipline. They guide nurses in discovering care knowledge
and ways to provide direct care. Care is embedded in culture as an integral part of culture that
challenges nurses to understand both care and culture together to practice transcultural nursing.

Culture and Nursing Culture comes from the discipline of anthropology. Culture has been defined and
used by anthropologists and other social scientists for over 100 years. The term culture, however, was
limitedly used and was not valued and explicated in nursing until I raised awareness that culture was a
crucial and major dimension of nursing in the mid 1950s. Gradually and by 1990, culture began to be
discussed and used in a variety of ways with some questionable and imprecise uses. Definitions are
important in any discipline, and thus these definitions were developed early for transcultural nursing:

Culture refers to the learned, shared, and transmitted knowledge of values, beliefs, and lifeways of a
particular group that are generally transmitted intergenerationally and influence thinking, decisions, and
actions in patterned or in certain ways.14,15

Subculture is closely related to culture, but refers to subgroups who deviate in certain ways from a
dominant culture in values, beliefs, norms, moral codes, and ways of living with some distinctive
features that characterize their unique lifeways.15,16

Theory of Culture Care: Vision, Hurdles, and Creative Actions

During the past five decades, the theory of Culture Care Diversity and Universality has been developed
to establish and advance the discipline of nursing and improve the quality of health care to cultures. The
theory was one of the earliest nursing theories and the only theory focused explicitly on human care and
cultural relationships. The theory was conceptualized as comprehensive, holistic, and different from
traditional orientations of nursing. The identity, meaning, and expressions of care/caring in diverse
cultures and subcultures needed to be discovered, explained, and understood for a multicultural world.
Initially in the 1960s, the theory was slow to be recognized and valued because it was so “foreign and
different” to many nurses. Gradually, the theory became meaningful and today is one of the most
relevant and important theories to obtain knowledge and help nurses and others care for people of
diverse cultures. Currently, the theory is in great demand and viewed by many nurses and practitioners
as essential for quality health care and to help specific cultures receive meaningful care. Likewise the
ethnonursing method is being used to discover some of the most covert and embedded culture and care
phenomena. In this first part, an overview with a brief history of the theory of Culture Care Diversity and
Universality by the theorist is presented, which is followed by the ethnonursing research method and
selected research findings from the theory. The first book on the theory, entitledCulture Care Diversity
and Universality: A Theory of Nursing, was published in 1991 and remains the definitive theory.1
However a few refinements, clarifications, and new ideas are presented here to update and reaffirm the
theory. Most significantly, this book has twenty-four guest transcultural nurse experts who share their
findings with the use of the theory, the ethnonursing research method, and ways to provide culturally
based care to Western and non-Western cultures The reader is encouraged to read these chapters and
other publications where the theory has been presented with the ethnonursing research method and
findings. It is estimated there are over 600 publications today showing the use of the theory, the Sunrise
Model, and scientific research findings. The Journal of Transcultural Nursing has some excellent refereed
examples of using the theory that were conducted by transcultural nurse researchers and experts.

A Brief History on Developing the Theory

The initial idea to develop a nursing theory about human caring with a focus on cultural differences and
similarities began in the late 1940s while caring for patients (as they were called in those early days) in a
general hospital. This was before high technologies dominated hospitals and the workday of nurses’ and
physicians’time and activities. World War II had ended, but only a few technologies and medicines had
entered the daily life of nurses. Nurses were expected to know and spend time caring for patients and
families. As a consequence, I frequently heard patients say to nurses, “It is your nursing care that helped
me get well”; “You took good care of me and now I am well”; “Your care was more helpful than the
physician’s quick drop-in to see me.” These comments and others made me aware of the importance of
human caring and healing. However, giving “good care or nursing care” was a cliche limit- ´ edly
understood in terms of the mutual meaning to the patient and the nurse. Unquestionably, the term
“care” was important in nurse-patient relationships, but care and caring had not been systematically
studied, taught, or researched in the pre-1950 history of nursing. It was largely unknown but a linguistic
cliche and practice ´ goal. I found care was of great clinical and intellectual interest to me, but wondered
why nurses used care and caring and failed to study and explain care with explicit meanings, uses, and
documented evidence to patients and nurses in both the classroom and clinical areas. It became an even
greater mystery to me while caring for people of diverse cultures, such as Italians, Jewish, German,
Africans, and many others in the hospital and in homes. The care responses and needs of clients were
different, but faculty, clinical staff, and nursing literature were of limited help to me and especially with
cultures. Granted, I held care was important to human beings, but the cultural care differences had not
been studied nor available in the literature in the 1940s. In the mid 1950s I experienced a great need to
understand care phenomena and meanings while functioning as a graduate child psychiatric nurse in a
child guidance residence in the midwestern United States.2 As the first, clinical, child psychiatric nurse
specialist and therapist, I was attempting to help children from several different cultures, namely,
Appalachian, German, Jewish, and Euro-Americans.3 I was baffled about caring for these children of
different cultures who openly expressed differences in the way they wanted to be cared for during the
day and night. I had received no educational preparation in my undergraduate and graduate programs
about cultures. I was seriously handicapped to respond to these children’s needs. This was a cultural
shock as I was not able to help the children of different cultures. I soon took steps to remedy the
situation by pursuing graduate (Ph.D) study in anthropology and doing field research study in a non-
Western culture for nearly two years. This opened my eyes, ears, and desire to establish a new field I
called transcultural nursing to remedy a critical and major need in nursing. While studying culture and
social anthropology, I remained focused on human care and its relevance to theory and transcultural
nursing.4,5 From the pre1950 literature I found that the term “nursing care” was used by nurses, but
care phenomena was not defined and explicated. Likewise, care with cultures was also not studied by
anthropologists. Care was awaiting full study within nursing and transculturally. Indeed, care was a
linguistic cliche in nursing with the meaning to ´ nurses and clients with therapeutic practices and
outcomes largely unknown in nursing textbooks and general usage. There were virtually no articles,
research studies, or nursing courses explicitly focused on care or caring phenomena with different
cultures.6,7 It appeared to me that two of the most powerful constructs, namely culture and care, were
missing in nursing theory and research and woefully neglected in clinical practices. I found no nursing
research studies or theories focused explicitly on the relationship of culture to care. It was evident that
both care and culture were taken for granted, were ignored, or were the invisible and unknown
phenomena in nursing in the pre-1950s. There were nurses, however, who had encountered cultures,
but had not studied them in systematic or scholarly ways. Interestingly, there were no graduate nurses
prepared in graduate cultural and social anthropology courses or programs even though the discipline of
anthropology was over 100 years old and had been available to nurses to study in universities. Nor were
anthropology courses required or recommended in nursing curricula. Instead, many medical pathology,
physical, chemistry, and psychology courses were major requirements in most nursing programs that
reflected a strong medical and pathologic disease focus. Recognizing these midcentury realities about
culture and care as two potentially major and important domains to be fully studied and incorporated
into nursing, I began to take steps to remedy the situation. I made bold proclamations that care was the
essence of nursing and a dominant, central, and unifying focus in nursing that needed to be fully studied
to explain and advance the discipline and profession of nursing.8−10 Theoretical hunches were needed
to explain and show the therapeutic benefits of care phenomena such as compassion, nurturance,
protection, comfort, and other care expressions with their meanings and specific uses with cultures. I
believed that humanistic care was essential for human growth, survival, and health, but varied between
and within cultures.11 The study and use of specific cultural care knowledge was much needed to
prevent illnesses, promote healing, maintain health, and be of general help in recovery from illness. I
also held that culture and care were holistic phenomena with powerful meanings within cultures.
Culture and care also had patterns that had to be identified, used, and studied over time with cultures.
Culture was the learned, adaptive, shared ways of people with identifiable patterns, symbols, and
material and nonmaterial data. Anthropologically, all human beings are born, live, and die within a
culture. Culture had biological, physical, spiritual, and historical features for nurses to know and
understand in health, illness, or other human conditions.12 Theoretically, culture and care needed to be
closely interfaced, synthesized, and brought into meaningful relationships for the new field of
transcultural nursing. There were selected concepts that needed to bring figuratively two worlds
together for transcultural care to occur. Bonding cultural and care as “culture care” I held that I could
bring some entirely new insights and knowledge into nursing to care for people of diverse cultures. I
further predicted that the worldview, social structure, historical, language uses, and environmental
factors could offer powerful explanatory knowledge to understand culture care phenomena. In addition,
the arts, humanities, and other knowledge areas could offer meaningful care to cultures.13 These broad,
holistic, and yet specific knowledge areas were important for the new field of transcultural nursing and
nursing in general. The idea of discovering what is universal and diverse about human care worldwide
also intrigued me as a sound basis to establish global, and ultimately transcultural, nursing practices. I
predicted that such knowledge was imperative by the year 2020 or earlier for nurses to care for people
of different cultures. The universality of culture care was based on the philosophical belief that all
human beings needed care to survive, grow, get well, and be human. Care was a commonality among
cultures. The diversity of culture care was based on the belief that human beings were born, raised, and
showed differences or variabilities from universal or common care features. Nurses need to discover
these individual and group differences and respond to such variabilities. Treating all cultures alike in care
was of concern to me and could lead to nontherapeutic or destructive outcomes. I speculated that both
universal and diversity laws of culture care could be established for the scientific and humanistic
dimensions of transcultural nursing as the new field of nursing for the future. Most importantly, I held
that nursing theories and knowledge development must be greatly expanded and holistic from past and
present local and Western views. Transculturally, there are many different ways of knowing that go
beyond empirical, personal, aesthetic, or ethical nursing theories. Cultures influence and shape ways of
knowing and explaining that may be religious (spiritual), materialistic, technological, experiential, and
culture-value based theories. It remains the challenge for transcultural theorists and researchers to
remain open to different ways of knowing and especially what is diverse or universal about culture care
and other related knowledge areas. This was an essentially new theoretical, philosophical, and epistemic
perspective to prepare transcultural nurses’ need to discover Western and non estern transcultural care
knowledge.

Hurdles and Challenges Related to the Theory

Before the theory of Culture Care would be accepted and take on meaning within nursing and as a new
discipline, however, there were several challenging hurdles that had to be faced. These hurdles are
helpful to understand in developing this new field, using a different theory in nursing and different
approach to nursing practice. The first major hurdle to understand the theory of Culture Care was to
help nurses shift their thinking and mode of practice from being so wed to the medical model with
physician expectations and medical treatment regimes that was clearly evident in the 1960s and 1970s
to an emphasis on a discipline of nursing with human caring and transcultural caring knowledge and
practices. For in the post World War II period, nurses were deeply involved with medical ideas and
performing medical tasks to treat and cure diseases. Many new treatments were brought into hospitals
after the War, and nurses struggled to keep abreast of these new medical symptoms, treatments,
procedures, and practices. Some creative nursing innovations and practices were evident, but there was
limited time, money, and support to make them fully known and used. The study of caring phenomena
of diverse cultures remained limitedly known, studied, and of interest to most nurses. A second major
hurdle to face was that there were no formal, explicit, or specific nursing theories in the pre-1950s
except for a few conceptual notions. Peplau’s philosophy supported her ideas of therapeutic
nursepatient relationships in psychiatric nursing.14 This major contribution was not developed as a
theory until the 1990s when I assisted a doctoral student with this effort. Nursing theories needed to be
developed and valued to guide and advance nursing science and care practices. In the late 1950s, I
encouraged nurses to hold nursing’s first conferences on nursing science, which was a new challenge for
many nurses as the word theory was generally viewed as “ivory tower stuff.” Many nurses and
physicians could not see the usefulness of nursing theories as nurses were “doers and practical” and
were mainly expected to carry out physicians’ orders in keeping with the old culture of nursing.15
Physicians greatly feared that if nurses pursued academic study about theories and did research, they
would lose their “handmaidens.” So, developing and using theories in nursing was a major hurdle to deal
with in developing and promoting my theory in the 1960s and 1970s. Third, to establish the theory of
Culture Care Diversity and Universality, another major hurdle wasto encourage nurses to study cultures
and care phenomena to understand and use the theory appropriately. Since there were very few
professional nurses prepared in anthropology to study cultures, there was limited knowledge about
cultures and the potential contribution of culture to nursing and caring. Courses in sociology and
psychology had different focuses and seldom provided in-depth specific knowledge of cultures with
anthropological theory-research perspectives. As the first Ph.D. graduate nurse prepared in cultural
anthropology, I encourage many nurses to study anthropology as an excellent foundation to
transcultural nursing. I wrote the first book, Nursing and Anthropology: Two Worlds to Blend, to show
reciprocal potential contributions of anthropology to nursing and the reverse.16 Gradually, several
nurses began to take anthropology courses in the 1970s; these nurses were intrigued with culture. They
needed to incorporate care into nursing. Care was missing in anthropology as culture was in nursing. A
few nurses became leaders in education, research and clinical practices in transcultural nursing, but
several remained in anthropology and were lost to nursing. In 1968 I launched the Committee on
Nursing and Anthropology (CONA) to help nurse anthropologists bridge, critique, and build transcultural
nursing perspectives as they dialogued with anthropologists. The fourth major hurdle was to establish
undergraduate and graduate courses to prepare nurses in transcultural nursing theory. Graduate
courses and programs were much needed to prepare nurses as competent teachers, researchers, and
clinicians in transcultural nursing. Still today, it is a major challenge to establish courses and programs in
transcultural nursing within different university schools of nursing. Almost single-handedly I established
four programs in transcultural nursing and many courses with field experiences so nurses were prepared
in the new discipline. By the mid 1980s, transcultural nursing courses and programs had been
established in several universities with a research-theory focus. Gradually, the Culture Care theory
began to be meaningful and used as a guide for transcultural nursing research, teaching, assessments,
and patient care. Through academic study nurses soon realized the importance of transcultural nursing
in caring for many recent immigrants, refugees, and cultural strangers who were seeking health care
from nurses. Indeed, community nurses were often working directly with new immigrants from
Vietnam, Southeast Asia, and other countries. They urgently needed transcultural concepts, principles,
and theoretical ideas to help them. The need for transcultural nursing education and practices far
exceeded the limited financial and personal resources for nurse preparation and practice. As a
consequence, cultural clashes, conflicts, racism, and other unfavorable practices became evident in
health care settings where there were no formal educational preparation and faculty in transcultural
nursing. In England, Africa, Europe, and other places the need was clearly evident in client care services.
In the United States, the birthplace of transcultural nursing in the 1950s, some schools of nursing slowly
began to value transcultural nursing so that by the 1990s several graduate and undergraduate courses
and programs were established. A major hurdle, however, remained with the critical need for prepared
faculty and more academic courses in transcultural nursing to teach and guide students. Afifthmajor
hurdle was getting nurses to value and practice human care and caring and from a transcultural focus in
educational programs and in practices. There were many nurses who had difficulty accepting care and
caring as the essence and central focus of nursing and transcultural nursing.17,18 There were United
States nursing leaders who strongly objected to human care as the essence of nursing as they held that
care was “too feminine,” “too soft,” and would “never be acceptable to consumers, nurses, and
physicians as it had limited relevance and could not be studied and measured.” Instead, these United
States nurse leaders began to promote health, nursing, person, and environment as the major foci of
nursing and the central concepts of the metaparadigm of nursing.19 Still today, in some schools these
four concepts are used, taught, and written about with care and culture blatantly absent. Gradually, care
has gained use by nursing students and worldwide nursing literature. This change was largely brought on
by a small group of nurse scholars that I encouraged and spearheaded to focus on care phenomena in
1978. This Conference Care group later became the International Association of Human Caring. These
care scholars such as Gaut, Ray, Bevis, Watson, Horn, Leininger, and others studied and demonstrated
the importance and therapeutic values of humanistic and scientific care in healing and well-being.20−24
Nurses from the Transcultural Nursing Society also became very active studying care with a transcultural
nursing focus.25 Care as the essence of nursing is gradually changing nurses’ views to value care within a
transcultural perspective. Transcultural knowledge has shown that some cultures do not focus on the
person but focus on family or groups. For example, Eastern and Latin American cultures value and focus
on families, groups and communities as central to their caring lifeways and beliefs. Moreover, one
cannot declare nursing as central to nursing as it is unacceptable to use the same term to explain
nursing. The concept of care in my theory of Culture Care showed the power and relevance of care in
nursing when known and studied with a culture care perspective. Thus the four earlier metaparadigm
concepts were questioned, but some nurses and schools still hold to them because of lack of
transcultural knowledge about care and cultures. Most encouraging, and through persistent education
in transcultural nursing, culture and care are today being valued more and studied in teaching, research,
and in several clinical practices. This major change from 1965 until 2001 has occurred with transcultural
nursing care being the major focus that is now known and used in nursing. It is as if care “has always
been there” by some nurses who were unaware of the great difficulties to bring care into transcultural
nursing and as a major focus of nursing in early years. A sixth major hurdle, before the theory of Culture
Care and transcultural nursing could be understood, valued, and studied, was related to the fact that
nurse scholars prior to 1965 were relying heavily on quantitative research methods as the only means
for “scientific knowledge” and methods acceptable to science, medicine, and nursing as a discipline.
Diverse qualitative research methods had been limitedly studied, known, and used in nursing in the pre-
1970s except for few descriptive narratives and surveys. While in doctoral study, I learned about diverse
qualitative methods in anthropology, philosophy, and the humanities. I learned about ethnographic and
ethnological qualitative methods and did the first studies in nursing with these methods in the early
1960s in a non-Western culture.26 I also developed and used a new method I called ethnonursing,
which was designed to focus explicitly on transcultural and related nursing phenomena. I used this
method with the Culture Care theory in the 1960s in studying the New Guineans in the Eastern
Highlands. This was the first nursing research method developed in nursing.27 After teaching and
conducting qualitative research studies with many nursing students for 15 years, I published the first
nursing research book in 1985, entitled Qualitative Research Methods in Nursing.28 These steps were
major hurdles to help nurses discover embedded and complex care and culture phenomena in different
contexts as quantitative methods were inadequate to tease out enormously rich, valuable, and largely
unknown data for nursing and for the new body of transcultural nursing knowledge. I encouraged
nurses, through my teaching and research, to use and value qualitative research and especially the
research on the ethnonursing method with “enablers” where the method and the theory systematically
fit with each other to get meaningful and accurate data. Cultural informants liked this ethnonursing
research method, and nurses saw new hope as they had been borrowing methods, models, theories,
and instruments from nonnursing fields that often failed to discover full meanings and explain nursing
phenomena. Gradually, diverse qualitative research methods took hold in schools of nursing in the
United States by the mid 1980s along with the ethnonursing method. There are some nurse
anthropologists who still remain wed to ethnography and are not using the ethnonursing and other
promising qualitative methods. Valuing and learning to use qualitative methods was a major change in
nursing and worldwide. These methods are generating some entirely new scientific discoveries about
nursing, but especially in transcultural nursing that go beyond empiricism. The culture of nursing often is
reluctant to use entirely new methods and different ways to know and establish a new order of
functioning such as using the ethnonursing method and transcultural nursing. These historical hurdles
are important to realize and appreciate as transcultural nursing was developed, taught, and shaped into
a new world of nursing and people care.

Purpose and Goal of the Theory

The central purpose of the theory of Culture Carewas to discover, document, interpret, explain, and
even predict some of the multiple factors influencing care from an emic (inside the culture) and an etic
(outside the culture) view as related to culturally based care. With the ethnonursing research method
and theory, the researcher was challenged to discover the similarities and diversities about human care
in different cultures. The theory was predicted to help guide the nurse researcher to discover new
meanings, patterns, expressions, and practices related to culture care that influenced the health and
well-being of cultures or to assist them to face death or disabilities. Ultimately, the goal was to establish
a body of transcultural nursing knowledge for current practices and for future generations of nurses in a
global world.29 The goal of the theory was stated to provide culturally congruent care that would
contribute to the health or well-being of people or to help them face disabilities, dying, or death using
the three proposed modes of nursing care actions and decisions.30 In the discovery process, both
similarities (commonalities) and diversities (differences) would be identified with specific modalities to
provide culturally congruent care related to the desired goal of health or well-being. The term culturally
congruent care was first coined by me in the 1960s as the goal of the theory of Culture Care, which is
now used but not always recognized by others as coming from me.

Philosophical Beliefs, Assumptions, and Hunches with the Culture Care Theory

In developing the theory, several philosophical ideas, assumptions, and beliefs are important to state.
Philosophically, I believed that human beings were essentially good with caring attributes as created by
God. I believed that diverse cultures were created for a purpose, but our challenge as nurses is to
discover, respect, understand, and help cultures as needed with a caring ethos and with other health
professionals. Philosophically, I held that the nursing profession had a moral and ethical responsibility to
discover, know, and use culturally based caring modalities as one of our unique and distinct
contributions to humanity. Our transcultural nursing challenge was to ultimately discover worldwide,
comparative, culture care phenomena using the theory to develop humanistic and scientific culture care
knowledge for practice. Research findings from the theory were predicted to support a body of
transcultural nursing research knowledge for the discipline of transcultural nursing. The theory findings
would provide epistemic data for providing meaningful and appropriate decisions and actions for
culturally congruent, safe, and responsible care to people of diverse cultures. Through current and
future studies of many cultures in the world over an extended period of years, ultimately, there would
be an identifiable body of universal and diversity knowledge that nurses would know and could be used
among nurses worldwide. Such fundamental scientific and humanistic discipline knowledge would offer
different ways of knowing and practicing nursing. It would go beyond current empirical and physical
evidence-based knowledge to new kinds of therapeutic practices. Focusing on culturally based care was
an ambitious and futuristic goal for a distinct, unique, and unifying hallmark of nursing and transcultural
nursing. Traditional nursing needed to shift to global transcultural nursing in the immediate future to
serve people in meaningful ways. Nurses needed to be grounded in transcultural nursing and not just
have a unicultural focus. This philosophical stance was a very futuristic and visionary idea in the 1950s
for nurses to function in a global world. More importantly and philosophically, nurses needed to greatly
expand their worldview and to know how to care for many different cultures worldwide. Nursing was far
too local, national, and parochial in the midcentury and needed a theory to expand its research,
knowledge, and practice focus. The Culture Care theory was developed to remedy this concern. To reach
these philosophical ideals and practical goals, nurses had to expand their worldview to a multicultural
one for studying immigrants, minorities, poor, wealthy, oppressed, homeless, disabled, and many more
cultures and subcultures. To do this, nurse leaders needed to be prepared in transcultural nursing
through substantive and rigorous graduate programs. They needed to demonstrate competencies to
function with individuals, extended families, groups, clans, subcultures (elderly, drug abusers, etc.),
communities, and in institutions with diverse cultures. Nurses in the mid 20th century needed a breadth
and depth of transcultural nursing knowledge to guide and substantiate their actions and decisions.
However, shifting nurses from the medical model of mastering medical symptoms, diagnoses, and
treatment of pathological diseases to a transcultural holistic caring profession focused on care
maintenance, wellness, and prevention of illness was a major hurdle and challenge. Teaching nurses
how cultures have prevented illnesses and maintained holistic healthy lifeways over time and
intergenerationally was difficult and complex. At the same time, nurses would use relevant and
appropriate knowledge from nursing, medicine, anthropology, the humanities, and other fields that
might be appropriately incorporated into transcultural nursing caring practices. Anthropologically, I had
learned from my field studies that Western diseases and illnesses were often very different from non-
Western cultures, and so a comparative knowledge base was essential in transcultural nursing. From my
clinical professional nursing experiences, I believed that consumers of diverse cultures needed and
expected nurses to be respectful, compassionate, and humanistic in their caring practices. How to
redirect nurses into a caring ethos with different cultures in culture-specific ways would be essential in
transcultural nursing, and the theory should guide this discovery. Moreover, I was concerned that nurses
were fast becoming technologists and masters of sundry tasks with limited caring practices. Discovering
and developing culturally based caring knowledge and competencies related to care phenomena such as
respect, comfort, being present, offering protection, reassurance, compassion, and many other caring
modalities needed to be rigorously studied in-depth with cultures under transcultural nurse mentors.
Establishing ways to fit caring with the client’s cultural values, beliefs, and expectations was needed.
Cultural caring constructs should become valued as linked to cultures and benefits. There was also the
continued challenge to change nurses’ image from “technicians,” “extensions of the physician,” “mini
docs,” “physician’s handmaidens,” and “shot givers” to sensitive and competent transcultural caring
nurses who could make therapeutic caring decisions for people of diverse and similar cultures. All of
these philosophical beliefs, goals, hunches, and patterns of thinking and planning led me to the
theoretical tenets and assumptions of the theory of Culture Care Diversity and Universality.

Theoretical Tenets and Specific Hunches

In conceptualizing the theory, the firstmajor and central theoretical tenet was that care diversities
(differences) and universalities (commonalties) existed among and between cultures in the world;
however, their meanings and uses had to be discovered to establish a body of transcultural nursing
knowledge.31 It was predicted that diverse and similar care concepts, forms, meanings, expressions, and
patterns existed with cultures, but were largely unknown to nurses and others. The discovery of this
wealth of potentially rich knowledge would guide and provide new knowledge for nurses and better
care to cultures. A second major theoretical tenet was that the worldview, social structure factors such
as religion, economics, education, technology, politics, kinship (social), ethnohistory, environment,
language, and generic and professional care factors would greatly influence cultural care meanings,
expressions, and patterns in different cultures. These factors also needed to be discovered for holistic
and meaningful care to people as these dimensions had been woefully missing in nursing assessments,
theories, and care practices. They were predicted to be powerful influencers to know and understand
culturally based care for individuals, families, and groups and to function in health institutions.
Moreover, these dimensional factors needed to be discovered directly with cultural informants from
emic data as influencing (not casual) factors related to the health, wellbeing, illness, and death.
Discovery of these dimensions with generic (folk, lay and naturalistic) care was predicted to be different
from professional care practices in which the latter could lead to cultural clashes, racism, cultural
imposition, and other nontherapeutic outcomes. Generic care was limitedly known in nursing and, if
known, was not used in culture-specific ways. Cultural conflicts and gaps between professional and
generic care were predicted to be of major concern for therapeutic culturally congruent care. The third
major theoretical tenet conceptualized and incorporated within the theory were the three major care
actions and decisions to arrive at culturally congruent care for the general health and well-being of
clients or to help them face death or disabilities. These three theoretical practice modes that had to be
discovered with clients (informants) and used in care were as follows: 1) culture care preservation
and/or maintenance, 2) culture care accommodation and/ or negotiation, and 3) culture care
restructuring and/or repatterning.32 To arrive at these appropriate modes in client care, the researcher
draws on findings that had been generated from social structure, generic and professional practices, and
other influencing factors while studying culturally based care for individuals, families, and groups. Then
the researcher with cultural informants (or in assessment care practices) discusses the best ways to
provide culturally congruent and beneficial care modalities. The three modes might all be used, but
maybe only one modality is used. The transcultural nurse researcher creatively identifies with clients (as
coparticipants in decision making) the most appropriate, beneficial, safe, and meaningful ways that fit
the client’s (family) values, beliefs, and lifeways. These three theoretical modalities were a highly
creative and new way for nurses to give care and to shift from symptom, disease, and medical treatment
management modalities to culturally based caring. Thus the Culture Care theory had both an abstract
intellectual discovery focus and a focus on discovering daily and nightly living ways of cultures. Obtaining
grounded culturally based data was a powerful guide for the three modes. Already, the research findings
from the three modes of action and decision have been extremely beneficial to clients of diverse or
similar cultures to meet their specific needs, values, and expectations in professionally responsible and
safe ways. The three transcultural care actions are viewed by many nurses as “refreshingly different”
from present-day nursing practices. They are a valuable means to incorporate holistic culture-care
findings with specific care needs that fit the client’s culture and are often not included in symptom
management practices. The three modes of action and decision, however, require highly creative
thinking and explicit use of both emic and etic findings derived from the culture. Dominant culture-care
constructs such as “being present,” “protective care,” “filial care,” and many others become major foci
to guide care practices using appropriate knowledge sources. Again, carefully selected medical, nursing,
and other knowledge sources as genetics and humanities may be used only if appropriate and safe. The
reader is encouraged to study care constructs already discovered and discussed in this book and others
with specific cultures.33

In conceptualizing the theory, the Sunrise Model was developed to guide nurses like a visual and
cognitive map to remain sensitive to multiple factors influencing culture care outcomes. The Sunrise
Model is not the theory per se but a guide or enabler to consider multiple factors related to the major
theoretical tenets to be studied and to the theory premises. After four decades, the Sunrise Model has
been heralded by many nurses as most helpful in discovering holistic and particularistic aspects bearing
on human care in diverse cultures. The Sunrise Model will be explained shortly.

Assumptive Premises of the Theory

Several assumptive theoretical premises (like givens) were formulated to support the theorist’s position,
tenets, and hunches. They are the following:34,35 1. Care is the essence of nursing and a distinct,
dominant, central, and unifying focus. 2. Culturally based care (caring) is essential for well-being, health,
growth, and survival and to face handicaps or death. 3. Culturally based care is the most comprehensive
and holistic means to know, explain, interpret, and predict nursing care phenomena and to guide
nursing decisions and actions. 4. Transcultural nursing is a humanistic and scientific care discipline and
profession with the central purpose to serve individuals, groups, communities, societies, and
institutions. 5. Culturally based caring is essential to curing and healing, for there can be no curing
without caring, but caring can exist without curing. 6. Culture-care concepts, meanings, expressions,
patterns, processes, and structural forms of care vary transculturally with diversities (differences) and
some universalities (commonalities). 7. Every human culture has generic (lay, folk, or indigenous) care
knowledge and practices and usually professional care knowledge and practices, which vary
transculturally and individually. 8. Culture-care values, beliefs, and practices are influenced by and tend
to be embedded in the worldview, language, philosophy, religion (and spirituality), kinship, social,
political, legal, educational, economic, technological, ethnohistorical, and environmental context of
cultures. 9. Beneficial, healthy, and satisfying culturally based care influences the health and well-being
of individuals, families, groups, and communities within their environmental context. 10. Culturally
congruent and beneficial nursing care can only occur when care values, expressions, or patterns are
known and used explicitly for appropriate, safe, and meaningful care. 11. Culture-care differences and
similarities exist between professional and client-generic care in human cultures worldwide. 12. Cultural
conflicts, cultural imposition practices, cultural stresses, and cultural pain reflect the lack of culture-care
knowledge to provide culturally congruent, responsible, safe, and sensitive care. 13. The ethnonursing
qualitative research method provides an important means to accurately discover and interpret emic and
etic embedded, complex, and diverse culture-care data.

The universality of care reveals the common nature of human beings and humanity, whereas diversity of
care reveals the variability and selected, unique features of human beings.

Orientational Theory Definitions

With the qualitative paradigm, orientational definitions are generally used rather than operational ones
as found in quantitative-oriented theories and methods. The following definitions are used with the
Culture Care theory as a guide to discover culture care phenomena:41 1. Human Care/Caring refers to
the abstract and manifest phenomena with expressions of assistive, supportive, enabling, and facilitating
ways to help self or others with evident or anticipated needs to improve health, a human condition, or a
lifeway or to face disabilities or dying. 2. Culture refers to patterned lifeways, values, beliefs, norms,
symbols, and practices of individuals, groups, or institutions that are learned, shared, and usually
transmitted intergenerationally over time. 3. Culture Care refers to the synthesized and culturally
constituted assistive, supportive, and facilitative caring acts toward self or others focused on evident or
anticipated needs for the client’s health or well-being or to face disabilities, death, or other human
conditions. 4. Culture Care Diversity refers to cultural variabilities or differences in care beliefs,
meanings, patterns, values, symbols, and lifeways within and between cultures and human beings. 5.
Culture Care Universality refers to commonalties or similar culturally based care meanings (“truths”),
patterns, values, symbols, and lifeways reflecting care as a universal humanity. 6. Worldview refers to
the way an individual or group looks out on and understands their world about them as a value, stance,
picture, or perspective about life or the world. 7. Cultural and Social Structure Dimensions refers to the
dynamic, holistic, and interrelated patterns of structured features of a culture (or subculture), including
religion (or spirituality), kinship (social), political (legal), economic, education, technology, cultural
values, philosophy, history, and language. 8. Environmental Context refers to the totality of an
environment (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. 9. Ethnohistory refers to the sequence of facts, events, or developments over
time as known, witnessed, or documented about a designated people of a culture. 10. Emic refers to the
local, indigenous, or insider’s views and values about a phenomenon. 11. Etic refers to the outsider’s or
more universal views and values about a phenomenon. 12. Health refers to a state of well-being or
restorative state that is culturally constituted, defined, valued, and practiced by individuals or groups
that enables them to function in their daily lives. 13. 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. 14.
Culture Care Preservation and/or Maintenance refers to those assistive, supportive, facilitative, or
enabling professional actions and decisions that help people of a particular culture to retain and/or
maintain meaningful care values and lifeways for their well-being, to recover from illness, or to deal with
handicaps or dying. 15. Culture Care Accommodation and/or Negotiation refers to those assistive,
supportive, facilitative, or enabling creative professional actions and decisions that help people of a
designated culture (or subculture) to adapt to or to negotiate with others for meaningful, beneficial, and
congruent health outcomes. 16. Culture Care Repatterning and/or Restructuring refers to the assistive,
supportive, facilitative, or enabling professional actions and decisions that help clients reorder, change,
or modify their lifeways for new, different, and beneficial health care outcomes. 17. Culturally
Competent Nursing Care refers to the explicit use of culturally based care and health knowledge in
sensitive, creative, and meaningful ways to fit the general lifeways and needs of individuals or groups for
beneficial and meaningful health and well-being or to face illness, disabilities, or death.

These orientational definitions allow informants and practitioners to discover care, health, and illness
conditions within a cultural perspective. The above definitions facilitate emic and etic data discoveries
from informants in naturalistic ways and in accord with the theory of Culture Care. Some social-structure
definitions are found in the primary theory book, which the reader may wish to review.42 From the
above philosophy, purpose, goal, major tenets, assumptions, and definitions of the theory of Culture
Care, the nurse moves forward to systematically discover care and health outcomes. It is important to
state here that other health and educational disciplines are using the theory and the method, but with
slight modifications to fit their discipline focus. In fact some physicians, dentists, social workers, hospital
and university administrators, and those of other disciplines are using the theory with the Sunrise Model
and Enablers to obtain holistic, comprehensive, and specific areas of understanding of human beings,
groups, and institutions in diverse cultures and contexts.

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