Culture has been explored by a number of theorists, such as Leininger, Purnell and others. Leininger’s cultural care diversity and universality theory (CCDU) provides culturally congruent care to individuals, families, groups, communities and institutions. The CCDU theory has been widely used as a theoretical framework in culture-related subjects. A
theoretical framework can be used to describe relations between different variables, and it can be considered the map that guides researchers through the process of their research (Sinclair, 2007). Different studies on particular subjects use different theoretical frameworks; there is
no right or wrong theoretical framework to use when examining a topic, as every topic can be examined from different perspectives. As the major component of this study is the qualitative part, which mainly focuses on barriers and cultural factors that affect pain management, Leininger’s CCDU theory is useful because it describes the relations between the different variables of cultural aspects. In addition, the CCDU theory highlights the factors that influence care—especially in multicultural settings such as Saudi Arabia. Although Leininger’s CCDU theory is specific for nursing care and research, it is broad enough to identify the cultural factors that influence pain. Thus, Leininger (1996) advocated that
professional nurses should develop an appreciation of the cultural conceptualisation of pain in all of its different aspects, such as personal experiences, responses to it, communication about it and pain management.
Leininger’s CCDU theory has its background in the concept of care as a central component of nursing (Erkes, Parker, Carr & Mayo, 2001). During the development of this theory,
Leininger identified care and cultural knowledge as factors that determine nurses’
understanding of the various forms of compliance, healing and wellness. This brought about Leininger’s CCDU theory, which is the only theory of nursing that outlines a relationship between cultures and nursing (Al-Aameri, 2000).
Leininger later developed the Sunrise Model (1991) to serve as a cognitive map to support and guide nursing practice. The Sunrise Model (see Figure 2.1) demonstrates the
interrelationships of the concepts of the CCDU theory and highlights the factors that influence care, such as religion, politics, economics, worldview, environment, cultural values, history, language and gender.
Figure 2.1: Sunrise Model
The CCDU theory assists nurses to learn about the worldview of a group or individual. A cultural group derives its cultural and social structure dimensions from its members’ individual worldviews, but it is also shaped by the environment and language contexts in which it exists. There is variation among different cultural groups in relation to the manner in which each cultural and social structure dimension is lived and experienced. The CCDU lists the following seven cultural and social structure dimensions:
• technological factors
• kinship and social factors • cultural values and lifeways • political and legal factors • economic factors
• educational factors.
In their effort to provide culturally compatible care, nurses use a combination of aspects from generic (traditional) and professional healthcare systems. This approach ensures unique, custom-made care for each individual or group. In this regard, the following three modalities are the considerations that guide nurses’ judgement, decision-making and actions:
• cultural care preservation/maintenance • cultural care accommodation/negotiation • cultural care re-patterning/restructuring.
Culture care preservation and maintenance implies the need to conserve existing behaviours and lifestyles that are good for health. Culture care accommodation ‘refers to those assistive, supporting, facilitative, or enabling professional actions and decisions that help people of a designated culture to adapt to, or to negotiate with, others for a beneficial or satisfying health outcome with professional care providers’ (Leininger, 1991, p. 48). Culture care repatterning and restructuring:
refers to those assistive, supporting, facilitative, or enabling professional actions and decisions that help a client(s) reorder, change, or greatly modify their lifeways for new, different, and beneficial healthcare patterns while respecting the client(s) cultural values and beliefs and still providing a beneficial or healthier lifeway than before the changes were co-established with the client(s) (Leininger, 1991, p. 49).
Leininger emphasises the meaning and significance of one’s culture in the process of generating health and caring behaviour for an individual (Lasch, 2000). This followed the realisation that patients from different backgrounds place greater importance on the care they receive than the nurses attending to them. Thus, there was a need to establish a theoretical framework in order to discover, explain and predict aspects of care and develop the CCDU in response to the various studies on culture care (Cairns, Thompson & Wainwright, 2003).
According to Leininger (1995), the four nursing paradigms of person, environment, health and nursing are not enough. For Leininger, nursing is both a discipline and a profession; therefore, the word ‘nursing’ cannot explain the phenomenon of nursing. Instead, ‘care’ is the word that should be used to explain the practice of nursing. This is markedly different from that of other scholars and authors. In addition, Leininger finds the term ‘person’ too limiting and culture-bound to explain nursing, as the concept of ‘person’ as an individual entity does not exist in all cultures. The word ‘health’ also tends to mean different things to different people, depending on the discipline through which they first knew the word (Al-Aameri, 2000). As a substitute for ‘environment’, Leininger prefers to use the term ‘environmental context’, which is more encompassing of physical, ecological, socio-political and even cultural settings.
In this case, care is seen to arise from the need to solve human problems; thus, it occurs in a cultural context (Watt-Watson et al., 2001). Culture is therefore defined as a set of behaviours that set one community apart from any other that exists on earth. This definition presents care as a universal and diverse concept. Culture is composed of emic (insider) and etic (outsider) points of view. When studying the relationship between care and culture, ethno-history is another factor that influences this relationship profoundly.