Leininger's Model No Panaceas

Much of Western medicine is predicated on the idea that a cure that works for one person should work for everyone else. If penicillin or measles vaccinations work on one patient or one set of patients then they should -- after have been through a thorough vetting process -- be able to work reliably with other patients. This is central to the most basic scientific model: One of the core aspects of science is that knowledge is generalizable and transferable. The scientist, and others like her, do not have to reinvent the wheel each time a person comes down with a strep throat: What has worked before will work again in predictable ways.

And the above is in many ways true: The human body does respond in relatively predictable ways to a range of medical interventions. But it is also true that there are non-physiological aspects of the practice of medicine. When a medical professional is working with a patient, that professional can never become so wedded to the scientific and the universal that she, or he, forgets to offer care that is culturally appropriate and therapeutic. This paper examines Leininger's model of culturally sensitive and competent nursing as it can be applied to a particular cultural group, the Cherokee American Indians.

Leininger (1988) described the "essential features" of her theory of cultural care diversity and universality for nurses being "initiated from clinical experiences recognizing that culture, a wholistic concept, was the missing link in nursing knowledge and practice."

Through a creative process of concept explication, reformulation, and resynthesis, the theory of cultural care was set forth as a guide for the development of nursing knowledge. The concept of culture was derived from anthropology and the concept of care was derived from nursing. The theorist holds that cultural care provides the broadest and most important means to study, explain, and predict nursing knowledge and concomitant nursing care practice. The ultimate goal of the theory is to provide cultural congruent nursing care practices. (Leininger, 1988, p. 152)

Leininger argues that the best nursing care -- the kind of care that she refers to as 'transcultural' -- will help the nurse (or other medical caregiver) discover the "meanings, patterns, and processes" in the ways in which people understand not simply specific treatments but much more broadly the overall concept and practice of care. This approach to nursing allows the nurse and the patient o build a mutually supportive and comprehensible model of the ways in which care itself becomes an ongoing part of the worlds of both of them.

Core Concepts of Transcultural Care

Leininger (2002) lists five major precepts of her concept of transcultural nursing care:

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, survival, and in facing handicaps or death.

3) Culturally-based care is the most comprehensive, holistic, and particularistic means to know, explain, interpret, and predict beneficial congruent care practices.

4) Culturally-based caring is essential to curing and healing, as there can be no curing without caring, although caring can occur without curing.

5) Culture care concepts, meanings, expressions, patterns, processes, and structural forms vary transculturally, with diversities (differences) and some universalities (commonalties). (p. 192)

Leininger, who is trained and educated both as a nurse and an anthropologist, emphasizes anthropological and ethnographic methods and techniques in working with patients.

These methods should in all probability be used by all health professionals at all times, but this is far from the case: Medical professionals, she argues, must listen carefully to their patients without imposing their own ideas before they have gathered all of the key information. They must bring their own scientific knowledge and medical training to bear on each case, but they must at the same time be aware that if information and care is not conveyed in a way that is culturally sensitive the patient may well not...

(Leininger, 2002, p. 192)
In other words, transcultural care creates a psychological and emotional space in which an individual feels that her or his culture is being acknowledged and respected while at the same time allowing that person to have access to all of the benefits of Western medicine. The following diagram explains the most important dynamics involved in the model:

(http://herkules.oulu.fi/isbn9514264312/html/graphic11.png)

This can be an extremely difficult process because the ideas that are present about healing in both traditional as well as modern cultures can often run counter to the predominant beliefs and practices of Western medicine, which can be seen to constitute a culture of its own (Malinski, 2009, p. 310).

From Theory to Praxis

So how these concepts and practices might be put into place when a nurse with this perspective begins to work with a Cherokee patient whose orientation is relatively traditional?

In order to answer this question, one must have some basic understanding of Cherokee culture and Cherokee ideas about healing. Unfortunately, as is the case with so much of the traditional healing knowledge and practices of so many of the nation's first peoples, much of what was traditionally known and practiced by members of Cherokee society who were tasked with healing themselves and others has been lost.

Other aspects of traditional Cherokee healing remain extant in the practice of the Cherokee people but are not shared outside of the group. This is not unusual and is something that a transcultural approach must take into account (Leininger, 2007, p. 13). There will often be a push on the part of Western professionals to feel that they have to vet a traditional practice to see if it meets the stringent demands of Western medical practice. However, this is not appropriate in a transcultural context: Part of working with patients from a fundamentally different culture is accepting that each side has both its areas of expertise and its rules of confidentiality (Malinski, 2002).

Just as a nurse would not discuss the treatment of one patient with another because of traditions of confidentiality in Western medicine, a traditionally focused Cherokee would not be willing to share certain traditional practices. One of the most important aspects of Leininger's model is that she provides a practical way in which a nurse can gain expertise in another culture since it is almost impossible to imagine that a nurse will not spend much of her or his career working with patients who are from a dramatically different culture (Clarke, 2009).

Therefore it is not only important that nurses learn to appreciate in the abstract the importance of cultural competence but potent methods to acquire the specific knowledge needed to put culturally competent practices into effect. The nurse who wishes to begin the process of becoming culturally competent can follow this process, which has an essential first task the determination of which people are key to have as informants or cultural experts.

One usually begins with a focus on an individual or small group and wherever one wishes and is comfortable with the model. Some nurses begin with a focus on generic and professional care, whereas others start at the top of the model with worldview, spiritual, family, political, and other areas. What is most crucial is listening with a very open mind to the informant, learning from them, and not imposing your ideas. One checks and rechecks ideas for accuracy as one uses the enablers with informants. (Leininger, 2002, p. 192)

The medical professional wishing to work with a Cherokee patient within the traditional (or semi-traditional) realm of that individual's model of healing (that is, of both health and disease) must understand that traditional Cherokee healing practices include both rituals and medicinal plants. This latter might seem…