867134

research-article2019
TCNXXX10.1177/1043659619867134Journal of Transcultural NursingMcFarland and Wehbe-Alamah

Theory

Journal of Transcultural Nursing

Leininger’s Theory of Culture Care

1­–18
© The Author(s) 2019
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DOI: 10.1177/1043659619867134
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With a Historical Retrospective and a journals.sagepub.com/home/tcn

View Toward the Future

Marilyn R. McFarland, PhD, RN, FNP-BC, CTN-A1 ,

and Hiba B. Wehbe-Alamah, PhD, RN, FNP-BC, CTN-A, FAAN1

Abstract
An historical overview of Leininger’s Theory of Culture Care Diversity and Universality also known as the Culture Care
Theory (CCT) and evolution of the Sunrise Enabler are presented along with descriptions of the theory purpose, goal, tenets,
basic assumptions, major core constructs, and orientational definitions. Recent articles, books, and book chapters provide
relevant exemplars to enhance scholarly understanding and application of theory constructs. Proposed future directions
encompass using the CCT to guide research of discovery and translational research projects for evidenced-based nursing
practice; develop nursing courses and curricula to prepare culturally competent nurses; guide future culturally competent
administrative and leadership policies and procedures; inform public policy related to cultural diversity and underserved
populations; promote grant writing initiatives to enhance cultural diversity in hiring nursing staff, supervisors, and faculty; and
promote admission of nursing students from underserved and/or diverse backgrounds.

Keywords
Leininger, transcultural, culture care theory, ethnonursing, modes, health, environmental context, worldview

Historical Beginnings
Dr. Madeleine Leininger’s earliest work in developing the
Theory of Culture Care Diversity and Universality (also
known as the Culture Care Theory or CCT) occurred during
her study with the Gadsup People in the Eastern Highlands
of Papua New Guinea. The earliest conceptualizations of the
theory were introduced with the ethnonursing method in her
doctoral dissertation (Leininger, 1966). Her findings were
explicated further in a later review article about the Gadsup
study published in the Journal of Transcultural Nursing
(Leininger, 1993).
The evolution of the theory can be traced forward from
Leininger’s (1978) groundbreaking dissertation through the
1970s, which saw publication of her first transcultural nurs-
ing text, Transcultural Nursing: Concepts, Theories, and
Practices. In this volume, she presented her earliest transcul-
tural nursing theory ideas including assumptions, definitions,
and propositions as well as other theories and studies about
cross-cultural nursing and caring phenomena. Leininger also
presented an early conceptual and theory-generating model
(Figure 1; Leininger, 1978, p. 39) that, along with 30 identi-
fied ethnonursing care constructs, she asserted could be used
to conduct transcultural nursing studies (Leininger, 1988a).
In this depiction, early conceptualizations of both the CCT
and the Sunrise Model (which later became the Sunrise
Enabler) can be discerned. For example, social structure fea-
tures evolved into cultural and social structure dimensions;
care constructs became care expressions, patterns, and prac-
tices; and nursing interventions based on research findings
developed into the culture care modes of decisions and
actions.
In the first transcultural study, Horn (1978) described
childrearing with the Muckleshoot people using Leininger’s
(1978) early conceptual model. Horn (1995) revisited these
findings when the theory had been more fully developed.
One of the earliest versions of the Sunrise Enabler (Figure 2),
depicting CCT dimensions as a theory of nursing, was pub-
lished in a Nursing Science Quarterly article titled,
“Leininger’s Theory of Nursing: Cultural Care Diversity and
Universality” (Leininger, 1988b). In that article, Leininger
(1988b) heralded the development of nursing theories as the
1
The University of Michigan–Flint, Flint, MI, USA
Corresponding Author:
Marilyn R. McFarland, PhD, RN, FNP-BC, CTN-A, School of Nursing, The
University of Michigan–Flint, 303 East Kearsley Street, 2162 William S.
White Building, Flint, MI 48502-1950, USA.
Email: mmcf@umich.edu
2 Journal of Transcultural Nursing 00(0)
Figure 1.  Leininger’s conceptual and theory-generating model to study transcultural and ethnonursing constructs.
Note. Reproduced from Leininger (1978, p. 39).
means to establish a sound basis for the nursing discipline.
She presented her views about the nature and definition of a
theory, asserting that the current quantitative view of theory
as “a set of interrelated concepts, definitions, propositions, or
hypotheses with specified and measurable relationships to
predict and control phenomena” (Polit & Hungler, 1983, p.
101, as cited in Leininger, 1988b) was only one way to view
a theory. Leininger (1988b) described her commitment to
discovering the epistemological sources of nursing knowl-
edge related to cultural care, with its inherent meanings and
characteristics. She claimed that a different approach was
needed because the concept of care had not been studied
from diverse cultural viewpoints. Therefore, an open qualita-
tive approach was required to discover the people’s emic
(local or insider views) about the meanings, patterns, and
expressions of care from a holistic perspective. Leininger
explained that her conceptualizations about the CCT were
derived from anthropology with new formulations made
within nursing care perspectives and presented eight assump-
tive premises of the theory. In addition, Leininger (1988b)
predicted that nurses would use the theory to discover diverse
perspectives about care and differences and similarities in
caring for clients using culturally based data to guide nursing
care practices. In 1991, Leininger published her first CCT
book with a preamble by Dr. Jean Watson, another early care
theorist who was Leininger’s colleague and student. Watson
stated, “The work represents a milestone, in that it brings
together historical, philosophical, and theoretical founda-
tions of the culture care theory itself, along with the ethnon-
ursing method” (Watson, 1978, p. viii).
The Sunrise Enabler as a Conceptual Theory
Guide
In the first edition of Leininger’s theory book (1991a), she
described the Sunrise Model as a cognitive map to orient and
depict the influencing dimensions, components, and facets or
major concepts of the theory with an integrated total view of
these dimensions. Later, Leininger (1997) introduced the
Sunrise Model as a conceptual theory guide and enabler,
stating,
It serves as a cognitive guide to tease out culture care phenomena
from a holistic perspective of factors influencing care in cultures.
. . . The model is not the theory per se, but depicts areas that need
to be examined in relation to the theory tenets and the specific
domain under inquiry. (p. 40)
The second and third editions of Leininger’s theory books
were published in 2006 (Leininger & McFarland, 2006) and
2015 (McFarland & Wehbe-Alamah, 2015a). In 2006,
Leininger placed the Sunrise Enabler in the ethnonursing
McFarland and Wehbe-Alamah 3
Figure 2.  Sunrise Model to depict dimensions of cultural care
diversity and universality: A theory of nursing.
Note. Reproduced with permission from Leininger (1988a, p. 157).
method section of Chapter 1, stating, “The Enabler is used as
a major guide throughout the [ethnonursing] study to explore
comprehensive and multiple influences on care and culture”
(Leininger, 2006a, p. 24). In 2018, McFarland and Wehbe-
Alamah continued documenting the historical evolution of
the theory, which included numerous revisions to the Sunrise
Enabler (McFarland, 2018a; Wehbe-Alamah, 2018c).
Recent updates to the theory and the Sunrise Enabler (Figure
3) include the introduction of biological factors as a dimension
of cultural and social structure factors and integrative care as a
new CCT construct (McFarland, 2018a; Wehbe-Alamah,
2018c). The addition of biological factors in 2018 ensures the
inclusion and assessment of physical and mental illnesses (par-
ticularly culture-bound and culture-specific conditions), hered-
itary and genetic conditions, and those influencing and/or being
influenced by generic and professional care (McFarland,
2018c; Wehbe-Alamah, 2018c). This developing factor
emerged from studies in which physical conditions, illnesses,
and syndromes were a major care focus for the cultural group
under study. Its placement in the Sunrise Enabler (under cul-
tural and social structure dimensions and above care expres-
sions, patterns, and practices) recognizes the fact that biological
factors influence and are influenced by cultural and social
structure dimensions as well as the other factors depicted in the
sunrays (H. B. Wehbe-Alamah, personal communication,
October 2015).
Integrative care was added to the Sunrise Enabler as a
concept described by Leininger (2002d) as “the safe, congru-
ent, and creative ways of blending together holistic, generic,
and professional care knowledge and practices so that the
client experiences beneficial outcomes for wellbeing or to
ameliorate a human condition or lifeway” (p. 148). While
integrative holism encompasses nursing, it also extends to
multidisciplinary and interdisciplinary professional health
care practices that blend with client-specific cultural and
generic care values, beliefs, and preferences for promoting
healing and wellness.
Culture Care Theory Overview
This overview encompasses commentary and reflections on
how the theory has evolved to the present and how it may
change in the future to meet new local, national, and global
challenges in nursing and health care. In addition, published
studies guided by the CCT in the past 5 years (2014 to 2019)
are described as examples supporting the ongoing scholarly
work being conducted with the theory, which has contributed
to its ongoing evolution.
The theory with its focus on care and culture [was] held by
Leininger as the heart and soul of nursing and essential for
developing new transcultural nursing knowledge and practices
and to move nursing into a predicted multicultural and global
world. (Leininger, 2006a, p. 7)
Purpose and Goal
The purpose of the CCT is to help researchers and clinicians
discover, document, know, and explain the interdependence
of care and cultural phenomena while noting the differences
and similarities between and among cultures (McFarland,
2018c; McFarland & Wehbe-Alamah, 2015b). The theory
was designed to help guide the nurse researcher in discover-
ing new meanings, patterns, expressions, and practices
related to culture care that have influenced the health and
well-being of individuals, families, and cultural groups. In
the discovery process, both similarities (commonalities) and
diversities (differences) can be identified as culture-specific
modalities to provide culturally congruent care related to the
desired goal of health or well-being (McFarland, 2018c;
McFarland & Wehbe-Alamah, 2015b).
The goal of the theory is to provide culturally congruent
care that contributes to the health and well-being of people or
4 Journal of Transcultural Nursing 00(0)

Figure 3.  Sunrise Enabler.

Note. Reproduced with permission from McFarland and Wehbe-Alamah (2018b, p. 47).

help them face disabilities, dying, or death using the three for the provision of best care practices by future generations
modes of culture care decisions and actions. Ultimately, the of nurses in a global world. Such knowledge is essential for
goal is to establish a body of transcultural nursing knowledge current and future professional nursing care practice as well
McFarland and Wehbe-Alamah 5
as for use by multidisciplinary health care providers and
other clinicians. This body of knowledge continues to change
and transform nursing and health care with meaningful ben-
efits to people from similar and diverse cultures (McFarland,
2018c). The theory has guided nurses and other health care
providers toward explicating care meanings so that culture
care values, beliefs, and lifeways can serve as accurate and
reliable bases for coparticipatively making culture-specific
care decisions and actions with clients as well as a way to
identify universal or common care features (Leininger,
1991b; McFarland, 2018c). The theory states that nurses can-
not separate worldviews, social structure factors, and cul-
tural beliefs or practices (lay/folk/generic and professional)
from health, wellness, illness, or care when working with
cultures because these factors are closely linked and interre-
lated (Leininger, 1991b; McFarland, 2018c). Cultural and
social structure factors such as technology, religion, family
and kinship, politics, cultural beliefs and practices, econom-
ics, physical conditions, and biological factors are significant
forces affecting care and influencing health/wellness pat-
terns and well-being (Leininger, 2006a; McFarland, 2018c).
The theorist long believed that discovering all forms of
generic care beliefs, values, patterns, and expressions held
by cultures and combining them with professional care prac-
tices hold essential importance in the provision of culturally
congruent care (Leininger, 1978, 2002b, 2006a; McFarland,
2018c; McFarland & Wehbe-Alamah, 2015b).
Tenets
Tenets are the beliefs that undergird a theory. Leininger con-
ceptualized and formulated four major tenets for the CCT
(Leininger, 1996, 1988b; McFarland, 2018c).
The first theoretical tenet was that “care diversities and
universalities exist . . . among and between cultures in the
world” (Leininger, 2002b, p. 78). However, Leininger
asserted that culture care meanings and uses first have to be
discovered in order to establish a body of transcultural
knowledge. In their study findings, many transcultural nurses
have discovered diversities and universalities in care themes
and patterns: Burkett, Morris, Anthony, Shambley-Ebron,
and Manning-Courtney (2017); Chiatti (2019); and López-
Entrambasaguas, Fernández-Sola, and Granero-Molina
(2015). However, more universal than diverse care themes
and patterns have been discovered and reported. In explana-
tion, Leininger commented that, compared with care diversi-
ties, care universalities may be more covert and embedded in
informant data descriptors (M. M. Leininger, personal com-
munication, January-August, 2012).
The second theoretical tenet was “worldview [and]
social structure factors—such as religion, economics, edu-
cation, technology, politics, kinship, 3, environment, [and]
language—and generic care and professional care factors
. . . greatly influence culture care meanings, expressions,
and patterns in different cultures” (Leininger, 2002b, p. 78).
The theorist maintained that knowing these factors (for a
particular culture or group) was necessary to providing
them with meaningful and satisfying care and predicted
that these would be powerful influencers on culturally
based care (Leininger, 2002b). Additionally, to confirm that
these factors influence health, well-being, illness, and
death, she contended that they needed to be discovered
directly from the cultural informants themselves. For exam-
ple, the biological factors construct was added to the cul-
tural and social structure dimensions and Sunrise Enabler
based on findings from studies in which cultural data were
confirmed directly from study informants (Kelch & Wehbe-
Alamah, 2018; McFarland, 2018c; Strang & Mixer, 2016;
Wolf et al., 2014).
The third theoretical tenet was “both generic (emic or the
insider’s view) and professional (etic) health factors in
diverse environmental contexts greatly influence health and
illness outcomes” (McFarland, 2018c, p. 41; see also
McFarland & Wehbe-Alamah, 2015b) and therefore “need to
be taught, researched, and brought together into care prac-
tices for satisfying care for clients, which leads to their health
and wellbeing” (Leininger, 2002b, 2006a). Leininger (2006a)
added this tenet based on supporting data from published
studies about resident care in culturally focused nursing
homes (McFarland, 1997; McFarland & Zehnder, 2006) as
well as other community settings (Leuning, Small, & van
Dyk, 2002). Later studies provided further support for this
tenet (Burkett et al., 2017; Chiatti, 2019; Mixer et al., 2015;
Mixer, Fornehed, Varney, & Lindley, 2014; Sensor, 2018;
Wolf et al., 2014).
The fourth theoretical tenet was the conceptualization of
the three major culture care decisions and action modes
(Table 1) used to plan culturally congruent care for clients’
general health and well-being or to help them face death or
disabilities (Eipperle, 2015; Leininger, 2002b; McFarland,
2018c). First, the social structure factors of the individual,
family, or group are studied, assessed, and responded to in a
dynamic and coparticipatory nurse-client relationship. Next,
the researcher or clinician draws on these factors and the cli-
ents’ generic and professional care practices and other influ-
encers to develop an individualized care plan using the three
modes (Eipperle, 2015; Leininger, 1991b, 2002b; McFarland,
2018c).
Coleman, Garretson, Wehbe-Alamah, McFarland, and
Wood (2016) conducted a translational implementation
study to reduce bariatric surgical patients’ 30-day emer-
gency department visits and hospital readmissions. The
researchers used the three culture care modes to integrate
care approaches to change provider care practices in a way
that enhanced their cultural competency, thereby improving
client health outcomes. Stone, Mixer, and Mendola (2019)
explored advanced care planning and decision making
among homeless adults in a study that encouraged partici-
pants to share their life story in a supportive workshop
setting.
6 Journal of Transcultural Nursing 00(0)

Table 1.  Culture Care Decision and Action Modes.

Decision/action mode Definition

Culture care preservation and/or maintenance
Culture care accommodation and/or negotiation
Culture care repatterning and/or restructuring
Assistive, supportive, facilitative, or enabling professional acts or decisions that
help cultures to retain, preserve, or maintain beneficial care beliefs and values or
to face illness, disability, dying, and death.
Assistive, accommodating, facilitative, or enabling creative provider care actions
or decisions that help cultures adapt to or negotiate with others for culturally
congruent, safe, and effective care for their health, well-being, or to deal with
illness, injury, disability, and dying.
Assistive, supportive, facilitative, or enabling professional actions and mutual
decisions that would help people reorder, change, modify, or restructure their
lifeways and institutions to achieve better health care patterns, practices, or
outcomes.

Note. Adapted from Eipperle (2015) and McFarland (2018c).

Table 2.  Eleven Assumptive Premises of the Culture Care Theory.

•• Care is the essence and central dominant, distinct, and unifying focus of nursing.
•• Humanistic and scientific care is essential for human growth, well-being, health, survival, and to face dying, death, and disabilities.
•• Care (caring) is essential to curing or healing, for there can be no curing without caring (this assumption had profound relevance
worldwide).
•• Culture care is the synthesis of two major constructs (culture and care) that guide the researcher to discover, explain, and account
for health, well-being, care expressions, and other human conditions.
•• Culture care expressions, meanings, patterns, processes, and structural forms are diverse but some commonalities (universalities)
exist among and between cultures.
•• Culture care values, beliefs, and practices are influenced by and embedded in the worldview, in social structure factors (e.g.,
spirituality, religion, life philosophy, kinship, politics, economics, education, technology, biological factors, and cultural values), and in
the ethnohistorical and environmental contexts.
•• Every culture has generic (lay, folk, naturalistic; mainly emic) and usually some professional (etic) care to be discovered and used for
culturally congruent care practices.
•• Culturally congruent and therapeutic care occurs when culture care values, beliefs, expressions, and patterns are explicitly known
and used appropriately, sensitively, and meaningfully with people of diverse or similar cultures.
•• Leininger’s three theoretical modes of care (culture care modes) offer new, creative, and different therapeutic ways to help people of
diverse cultures.
•• The ethnonursing research method and other qualitative paradigmatic research methods offer important means to discover largely
embedded, covert, epistemic, and ontological culture care knowledge and practices.
•• Transcultural nursing is a discipline that has a body of knowledge and practices designed to help caregivers attain and maintain the
goal of providing culturally congruent care for health and well-being.

Note. Adapted from McFarland (2018c, p. 42).

Assumptive Premises practices during the postpartum period. This researcher

The major tenets of the CCT led to the formulation of theo-
retical assumptions a researcher could use with diverse cul-
tural groups in different locations. The 11 major assumptions
(Table 2) were derived from Leininger’s definitive works,
including subsequent changes discovered and confirmed by
her and other researchers (McFarland, 2018c).
Strang and Mixer (2016) stated five CCT assumptive
premises to guide a study about malaria care among the
Maasai in southern Kenya. These researchers reported that
their assumptive premises derived from the CCT were sup-
ported by discoveries from their study, which contributed to
the evolutionary theory building of the CCT (Strang & Mixer
2016). Hascup (2018) used four assumptive premises in her
study about Mexican American women’s cultural beliefs and
reported several theoretical implications that supported three
CCT assumptive premises: understanding the Mexican
American women’s worldview and social structure dimen-
sions in a naturalistic context, understanding that the the
Mexican American culture has generic and professional care
knowledge that differs from Anglo American’s care prac-
tices, and understanding that Mexican American beliefs have
similarities and differences with current Mexican beliefs that
have changed over time (Hascup, 2018).
Central Constructs
Several central constructs used in the CCT have been
described and defined in numerous ethnonursing studies
(Leininger, 1991a, 1995b, 2001; Leininger & McFarland,
McFarland and Wehbe-Alamah 7
2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018).
These constructs were adapted further in more recent ethnon-
ursing studies by Strang and Mixer (2016, 2018), Sensor
(2018), and Wolf et al. (2014). Unlike operational defini-
tions used in quantitative studies, these constructs or theory
definitions are orientational. After 1978, the orientational
definitions were adapted from the theory formulations to
help researchers be open to uncovering new dimensions of
the theory constructs and encourage discovery of new quali-
tative knowledge from cultural groups. This is a major differ-
ence between the CCT and other nursing theories, which
have predetermined definitions usually reflecting the
researchers’ interests or viewpoints (Leininger, 1978).
Care.  Referring to both an abstract or a concrete phenomenon,
the theorist defined care as assistive, supportive, and enabling
experiences or ideas toward others (Leininger, 2002b, 2006a;
McFarland, 2018c; McFarland & Wehbe-Alamah, 2015b).
The term caring refers to actions, attitudes, and practices used
to help others toward healing and well-being (Leininger,
2002b; McFarland, 2018c). As a major theory construct, care
includes both folk and professional care and has been pre-
dicted to influence and explain health or well-being for similar
and diverse cultures (Leininger, 1978). Based on current
research findings, care is a largely embedded and invisible
phenomenon—often taken for granted—that sometimes is
challenging for nurses to quickly identify and understand
completely (Eipperle, 2015; Leininger, 1991a, 2002b; McFar-
land, 2018c). However, over the past six decades many books,
book chapters, white papers, and journal articles based on sup-
porting research studies have become accessible to nurses,
enabling them to use their own discovery of and knowledge
about care meanings from both similar and diverse cultures.
Some relevant exemplars include Missal, Clark, and Kovaleva
(2016) and Sensor (2018). In addition, some researchers have
confirmed culture care constructs from those previously dis-
covered in earlier ethnonursing studies. For example, Strang
and Mixer (2016, 2018) confirmed four formerly discovered
care constructs: respect for/about lifeways, acceptance, purg-
ing, and interest in/about.
Culture.  This major construct, central to the CCT, has been
adapted from a century of anthropological concepts. Leini-
nger (1991a, 2002b, 2006a) defined culture as the learned,
shared, and transmitted values, beliefs, norms, and lifeways
of a particular culture that guide thinking, decisions, and
actions in patterned ways. From an anthropological perspec-
tive, culture usually is viewed as the broadest and most com-
prehensive means to know, explain, and predict people’s
lifeways over time and in different geographic locations.
Moreover, culture is more than symbolic social interactions
and rituals, as it transcends ethnicity and kinship relation-
ships. Culture forms the blueprint for guiding human actions
and decisions by individuals and groups and has both mate-
rial and nonmaterial features. Cultural phenomena
distinguish human beings from nonhumans (Leininger as
cited by McFarland & Wehbe-Alamah, 2015b).
Culture Care. Transculturally prepared nurses advance cul-
ture care knowledge in many ways by conceptually uniting
culture and care and confirming this relationship through
research and practice. Using this approach in nursing can be
an encouraging practice for both nurse and client. The power
of the dual construct of culture care to help discover and
understand illness, wellness, and other human health expres-
sions remains an important focus in transcultural nursing.
The theorist held that the practice of conceiving and linking
culture and care phenomena together holds great power for
explaining health and illness. Leininger (1978) conceptual-
ized culture and care phenomena as synthesized and closely
linked with interrelated ideas. Both culture and care require
full, rigorous study with attention to their embedded and
constituted relationships to each other as human care phe-
nomena (McFarland & Wehbe-Alamah, 2015b; Wehbe-Ala-
mah, 2018b). In an ethnonursing study with the Yupik people
of Alaska, Embler, Mixer, and Gunther (2015) discovered
three new culture care constructs (community as family, end-
of-life preparation, and allowing presence) and substantiated
the care construct of family involvement. Chiang-Hanisko
(2018) presented an ethnohistorical comparative perspective
about care and caring among Taiwanese Americans that was
reflected in three culture-specific care themes: culture
reflected in national and cultural identity, culture care as
preservation of Taiwanese folk health care beliefs, and caring
expressed as unconditional emotional and physical support
of Taiwanese loved ones.
Emic and Etic.  These concepts are major parts of the CCT.
The term emic refers to the local, indigenous, or insider’s
cultural knowledge and view of specific phenomena; etic
refers to the outsider’s or stranger’s (often a health profes-
sionals’) views and institutional knowledge about culture
care phenomena (Leininger, 1978; McFarland & Wehbe-
Alamah, 2015b; Wehbe-Alamah, 2018b). While these two
terms were derived from linguistics, Leininger (1978) recon-
ceptualized them to assist in the discovery of contrasting cul-
ture care phenomena. Leininger (1978, 2006a) wanted to
differentiate between the client’s insider care knowledge and
that of researchers, outsiders, or professionals. She also
believed that it was essential to determine what was univer-
sal (or common) and what was different (or diverse) among
cultures with respect to care and caring. Over the past
decades of transcultural nursing research, the constructs of
emic and etic have proven invaluable for explicating differ-
ences and similarities among the knowledge and practices of
cultural informants versus those of professional nurses
(Leininger, 1991b; Wehbe-Alamah, 2018b).
Integrative Care. Leininger discussed this construct as the
desired outcome of generic and professional care when
8 Journal of Transcultural Nursing 00(0)
appropriately and meaningfully used in therapeutic prac-
tices. She defined integrative care as safe, congruent, and
creative ways of blending holistic, generic, and professional
care knowledge and practices so that the client experiences
beneficial outcomes for well-being or amelioration of a
human condition or lifeway (Leininger, 2002d).
Recognizing the holistic nature of culturally congruent
care that transculturally prepared nurses currently provide,
this newer construct blends professional care and generic
care, replacing the phrase nursing care practices. This evolu-
tionary change is reflected in the most recently revised
Sunrise Enabler (McFarland & Wehbe-Alamah, 2018b).
Integrative care also includes interdisciplinary and interpro-
fessional care, a process in which many professional health
care providers come together to provide holistic, client-cen-
tered integrative care. Mixer et al. (2015) found that Hispanic
and Caucasian families of children in a pediatric acute care
setting valued care integration, in which professionals used
some culture-specific generic and folk remedies.
Culturally Congruent Care. This concept refers to culturally
based care knowledge, actions, and decisions used in sensi-
tive and knowledgeable ways to appropriately and meaning-
fully fit the cultural values, beliefs, and lifeways of clients
for their health and well-being, or to prevent illness, disabili-
ties, or death (Leininger, 2006a; McFarland, 2018b). Since
its inception, the major goal of the CCT was to help caregiv-
ers provide culturally congruent care (Leininger, 1978).
Hascup (2018) discovered cultural knowledge about
Mexican American women’s beliefs and practices during the
postpartum period that was essential for nurses providing
culturally congruent care to this group. Chiatti (2019) dis-
covered culturally congruent care preferences of Ethiopian
immigrants, including the desire to preserve their cultural
heritage in the United States as a vital sense of self and com-
munity and maintain religion and prayers as central to a
healthy life.
Culture Care Diversity.  This concept refers to the differences
or variabilities among human beings regarding culture care
meanings, patterns, values, lifeways, symbols, or other fea-
tures related to providing beneficial care to clients of a spe-
cific culture (Leininger, 2006a, 2015). When studying the
culture care of Somali immigrant refugees in Minnesota,
Wolf et al. (2014) identified several gender-based differences
in care preferences.
Culture Care Universality. This concept refers to the com-
monly shared or similar culture care phenomena of individu-
als or groups with recurrent meanings, patterns, values,
lifeways, or symbols that serve as guides for caregivers to
provide assistive, supportive, facilitative, or enabling care
for healthy outcomes (Leininger, 2006a, 2015). In their study
about parenting African American children with autism, Bur-
kett et al. (2017) discovered two universal care themes
(respect and faith) and two diverse themes (mother care vs.
father care).
Health.  This concept refers to a state of well-being that is
culturally defined, valued, and practiced and reflects the abil-
ity of the individuals or groups to perform the daily activities
of their role in culturally expressed, beneficial, and patterned
lifeways (Leininger, 1991b, 2015). Health is a restorative
state of well-being that is culturally constituted, defined, val-
ued, and practiced by individuals or groups, which enables
them to function in their daily lives (Leininger, 2015). Edu-
cational levels also influence health literacy, which affects
patients’ ability to understand and navigate the health care
system and, therefore, has a direct bearing on health.
These definitions of health have been confirmed by
numerous ethnonursing researchers. Sensor (2018) found
three cultural health beliefs, practices, and experiences of
migrant Dominicans living in the United States: “Stress
affects health and wellbeing, family support and faith in God
are essential, [and the] use of folk and professional care to
treat illness and maintain health” (p. 1). While studying the
perceptions of Muslim nurses in Kuwait about the role of
Islamic values in their nursing practice, Atkinson (2015)
found the commonly held belief among participants that reli-
gious teachings promote health.
Ethnohistory.  Leininger (1978) reconceptualized this anthro-
pology theory construct for a nursing perspective. In doing
so, she redefined ethnohistory as the past facts, events,
instances, and experiences of human beings, groups, cul-
tures, and institutions that occur over time in particular con-
texts that help explain past and current lifeways about culture
care influencers of health and well-being or death (Leininger,
2002b, 2015). Ethnohistory is an essential dimension to con-
sider when providing culturally congruent care. Important
past and current events and conditions within the historical
context of cultures and their caring modalities are important
caring practices to discover and know transcultural nursing
knowledge, especially when studied within the context of
care and well-being (McFarland, 2018c; McFarland &
Wehbe-Alamah, 2015b). Embler, Weiss, and Mixer (2018)
described the profound effects that racial profiling and forced
acculturation left on the ethnohistory and lifeways of Yupiit
people in Alaska. Fang and Stewart (2018) found that the
combined influences of health system factors, sociocultural
factors, and traditional health and spiritual beliefs about hep-
atitis B affected the willingness of immigrant Hmong people
(from the central valley region of northern California) to
accept screenings and/or immunizations. Ojwang (2018)
described the sociocultural conceptualizations of disease
causation and experience as deeply embedded in the values,
beliefs, and practices of the Luo people of Kenya, conclud-
ing that their ethnohistory informs their worldview.
Rahemi’s (2019) and Rahemi, Dunphy, and Newman’s
(2019) cross-sectional studies of older Iranians who
McFarland and Wehbe-Alamah 9
immigrated to the United States during the first wave of
immigrants in the 1950s revealed findings the researchers
termed novel among contemporary elders. Despite two
beliefs—perceived communication problems within and a
mistrust of the U.S. health care system they deemed frag-
mented and strongly valued family and kinship ties and cul-
tural traditions—these well-educated participants preferred
to receive their end-of-life care in hospital settings. This
choice to avoid burdening their families is the opposite of
individuals from most traditionally oriented cultural immi-
grant groups (Rahemi et al., 2019).
Environmental Context.  This concept refers to the totality of
an event, situation, or particular experience that gives mean-
ing to people’s expressions, interpretations, and social inter-
actions within particular geophysical, ecological, spiritual,
sociopolitical, and technologic factors in specific cultural
settings (Leininger, 2002b; McFarland, 2018c). Strang and
Mixer (2016) shared their discovery of how environmental
context acted as both a facilitator and a barrier to effective
malaria care outcomes for the Maasai in Kenya. Their envi-
ronmental context issues included the geographic environ-
ment and location, their expectation of using traditional care
first, knowledge about care options, financial resources, and
use of insecticide-treated sleeping nets to prevent malaria
transmission. Steefel (2018)—reflecting through the lens of
the CCT about inmates’ needs, their own cultural views, and
environmental context issues—advocated for correctional
nurses developing cultural humility through a five-step con-
templative journey.
Worldview.  This concept refers to the way in which people
tend to look on their world or universe to form a picture or
value stance about life or the world around them (Leininger,
1978, 2002b; McFarland, 2018c). Worldview provides a
broad perspective about one’s orientation to life, people, or
groups that influences care or caring responses and deci-
sions. Worldview guides one’s lifeway decisions and actions,
particularly those related to health, well-being, caregiving,
and care receiving. Lee (2018) described how homeless
urban and rural Appalachian mothers found a sense of faith
and hope that allowed them to look toward the future. Wehbe-
Alamah (2015) studied folk care beliefs of traditional Leba-
nese and Syrian Muslims in the Midwestern United States,
discovering worldviews embedded in their Islamic religion
and unique cultural beliefs and practices. From a study of the
Luo tribe in Kenya, Ojwang (2018) discovered that their
worldview was embedded in their common historical experi-
ence linking all tribal members to a single, common ancestor
whom they held as the source of life. Their worldview as a
community was encoded in generic linguistic expressions
whose meanings were traditionally accessible only to insid-
ers. These expressions were recognized as elaborate kinship
ties that symbolically fulfilled the role of ancestors by influ-
encing the community’s fate.
Culture Care Modes of Decisions and Actions. In the CCT,
Leininger (1978) postulated three culture care decision and
action modes for providing culturally congruent nursing care
(Table 1). These highly innovative modes were unique in
nursing and health care. Leininger (1978) held that nurses
needed a variety of creative approaches to make care and
culture needs meaningful and helpful to clients. These deci-
sion and action modes (Eipperle, 2015; McFarland, 2018c)
are essential for effective care and caring and should be used
with discoveries made in ethnonursing research studies
guided by the CCT.
Leininger (1991b) proposed that in most circumstances,
culture care preservation and/or maintenance be considered
first, as many people already are providing meaningful and
acceptable care that can lead to beneficial outcomes for their
families and others. Many nurses from Western cultures
focus on interventions that make changes, believing that care
should be based solely on professional nursing knowledge
(Eipperle, 2015; Leininger, 2006a). However, it is important
to consider what people are doing right in caring for them-
selves and their families. Frequently, people are providing
excellent care in their homes or institutional, community, or
primary settings (McFarland, 2018c). In a study of Somali
immigrant new mothers in the United States, Missal et al.
(2016) found that these women appreciated the nurses’ sup-
port for the maintenance of three practices: playing calls to
prayer in newborns’ ears, mothers eating authentic Somali
foods, and promoting Somali community support to new
mothers and their children. For the provision of culturally
congruent care, these generic care practices should be main-
tained, supported, and even integrated into professional care
by nurses, educators, and students (Leininger, 2002d; Wehbe-
Alamah, 2018a). In international service-learning courses,
preserving and/or maintaining therapeutic care is an essential
lesson for nurses and nursing students (Knecht & Sabatine,
2015). They need to be guided by the care modes to consider
first what caring decisions and actions should be maintained
or preserved, then what should be accommodated or negoti-
ated, and only as a final resort what should be changed
(repatterned and/or restructured; Eipperle, 2015). In nursing
education, repatterning and/or restructuring potentially
harmful clinical care behaviors may begin in the classroom
setting by addressing student incivility. Educators exhibiting
caring behaviors and positive role modeling can help alter
negative socialization patterns frequently found in the nurs-
ing culture (Eipperle, 2018; Strouse & Nickerson, 2016).
Cultural and Social Structure Dimensions
Cultural and social structure dimensions, also major features
of the CCT (Leininger, 1978), refer to a culture’s dynamic,
holistic, and interrelated patterns of structured features.
Social structure phenomena encompass broad, comprehen-
sive, and special factors influencing care expressions and
meanings. These factors include but are not limited
10 Journal of Transcultural Nursing 00(0)

Table 3.  Exemplar Studies of Social Structure Dimensions.

Cultural and social structure dimensions Studies

Technological factors Kelch and Wehbe-Alamah (2018)
Religious, spiritual, and philosophical factors Christensen (2014) and Strang and Mixer (2016)
Kinship and social factors Chiatti (2019) and Wolf et al. (2014)
Cultural values, beliefs, and lifeways Missal et al. (2016), Mixer et al. (2014), and Moss (2014)
Biological factors Kelch and Wehbe-Alamah (2018)
Political and legal factors Christensen (2014)
Economic factors Abdulrehman, Woith, Jenkins, Kossman, and Hunter (2016) and Kelch, Wehbe-
Alamah, and McFarland (2015)
Educational factors Bhat, Wehbe-Alamah, McFarland, Filter, and Keiser (2015) and Kelch et al. (2015)

to technology factors; religious and philosophical factors;
biological factors; kinship and social factors; cultural values,
beliefs, and lifeways; political and legal factors; economic
factors; educational factors; environmental context; lan-
guage; ethnohistory; and cultural beliefs and values
(McFarland, 2018c; Wehbe-Alamah & McFarland, 2015a).
The theorist predicted that these diverse factors must be
understood because they directly or indirectly influence
health and well-being (Leininger, 1978). Until the advent of
transcultural nursing, social structure factors were neither
studied explicitly in nursing nor referenced to care (Leininger,
1978, 1991a). Using the CCT has helped nurses study and
apply these dimensions to achieve a holistic view of provid-
ing culturally congruent client care. Researching social
structure factors—using the Ethnonursing Research Method
and other qualitative and some quantitative methods—has
provided a wealth of invaluable insights about culturally
based care (McFarland, 2018c; McFarland & Wehbe-
Alamah, 2015b).
Madeleine Leininger earned her PhD as a sociocultural
anthropologist. As a nurse anthropologist, however, she was
aware of two powerful determinants of individual and popu-
lation health and well-being: the broader social and cultural
context of health as well as societal, cultural, and environ-
mental health (M. M. Leininger, personal communication,
1994). Leininger’s conceptualizations of social and cultural
factors as social structure dimensions of health date back to
her earliest CCT work from 1978. This work significantly
predates both that of Pender (1982) and the newly recog-
nized importance of social determinants of health in contem-
porary professional literature. Currently, social determinants
of health are being studied from a social policy perspective
(Baker et al., 2018). The determinants of health as promotive
behavior were proposed within the Health Promotion Model
(Pender, 1982). Palank (1991) also concluded, “Personal
lifestyles may not be a simple matter of informed choice,
[therefore] attention to the complex processes of societal
opportunities, cultural interpretations, and group-specific
attitudes must be studied further (p. 815).”
The exemplars of social structure dimensions presented in
Table 3 provide current, substantive nursing research findings
about key factors (technological, religious and spiritual, kin-
ship, social, biological, cultural, political, legal, educational,
and economic) discovered by transcultural nurse researchers
using the CCT to guide their ethnonursing studies.
Moreover, nursing education faculty have used the CCT
extensively to guide collegiate courses and programs that
address caring for diverse people across the United States
(American National University, 2019) and worldwide (de
Melo, 2013). Wehbe-Alamah and McFarland (2015b)
reported using the CCT as a guide in developing transcul-
tural nursing courses for graduate and undergraduate stu-
dents including exemplar course syllabi and learning
objectives. Mixer (2015) shared how the CCT theoretical
framework, which has been used and tested for more than 50
years, was useful for teaching students to provide care based
on current evidence and best practices discovered through
research rather than relying on rich clinical experiences
alone.
McFarland and Leininger (2002) postulated the need for
faculty and clinicians to be prepared transculturally to meet
the needs of diverse populations and avoid cultural imposi-
tion practices, ethnocentrism, and cultural conflicts or
clashes. Using the CCT, deRuyter (2015) explored the cul-
ture care expressions, beliefs, and practices of African
American students attending predominantly Euro-American
nursing programs to discover their educational experiences,
practices, and culture care patterns. Based on Leininger’s
CCT and Jeffrey’s Cultural Competence and Confidence
Model, Singleton (2017) described the positive outcomes on
Doctorate of Nursing Practice (DNP) students’ transcultural
self-efficacy achieved from an enhanced cultural compe-
tence curriculum. Zajac (2015) discovered how faculty could
demonstrate their understanding of ethnically diverse nurs-
ing students’ comfort care needs and improve their educa-
tional outcomes by adapting the three culture care modes of
decisions and actions. Jeffreys and Zoucha (2018) also com-
bined the CCT with the modes and Jeffrey’s model to form a
blended framework for a case-based teaching to promote cul-
tural congruence among nurses and other health care profes-
sionals with the aim of improved health care experiences and
outcomes for clients from multiracial and multiheritage
McFarland and Wehbe-Alamah 11
backgrounds. Other educators have used the CCT to guide
international learning courses. In addition to Knecht and
Sabatine (2015), Larson (2015) based her travel course for
nursing students learning about the Greek culture on the
social structure factors of the Sunrise Enabler. Zoucha and
Turk (2015) also used the CCT as the framework to develop
and implement an international nursing course for DNP stu-
dents conducted in Italy focused on global health, transcul-
tural nursing, social justice, vulnerability, and global health.
Discussion of Future Applications
The CCT stands as a useful guide for nursing scholarship,
research of discovery, and translational research to build
nursing knowledge for research, practice, education, policy,
and administration. Leininger (2002c) emphasized the con-
nection between research and practice when writing about
the future of transcultural nursing and the importance of “the
active advancement and use of transcultural nursing-based
knowledge and practices to serve a growing multicultural
world” (p. 577). Marion et al. (2016) discussed approaches
for integrating culturally congruent practices throughout the
nursing process to achieve nurse competency with the ANA
(2015) document, Scope and Standards of Nursing Practice,
Standard 8: Culturally Congruent Practice, and respond to
the strong need for cultural competence in advanced practice
nursing.
Research and Practice
Hansell stated,
Nursing conceptual models and theories [such as the CCT] are
critical to guide nursing practice. . . . We must progress to
systematic measurement and documentations of the outcomes of
that practice. . . . Nursing care without scientifically generated
theoretical underpinnings disintegrates into a fractured and
fragmented, task-oriented void of the essential components of a
scientifically-grounded profession. (as cited in Turkel et al.,
2018, p. 85)
Researchers continue to develop research of discovery stud-
ies guided by the CCT that contribute to the knowledge, dis-
cipline, and clinical practice of nursing through published
articles, presentations, and social media. Fawcett (2003)
stated that while all nursing research has value, research
based on a nursing-specific conceptual model needs to be
emphasized, because the advancement of discipline-specific
nursing knowledge can occur only when all nurse research-
ers identify which conceptual model guided their studies.
This idea was supported by Kirk et al. (2016), who stated the
importance for researchers to
clearly explain how they justified the selection of specific
framework constructs, integrated the framework throughout the
research process [in study design, data collection, and analysis],
and link[ed] determinants of implementation to outcomes to
contribute to this emerging field of research. (as cited by Curtis,
Fry, Shaban, & Considine, 2017, p. 867)
It also is essential to cite the most current literature from pri-
mary sources to ensure that studies and published companion
articles are substantive and credible as theoretical sources
and guides for future studies and translational projects.
Fawcett (2008) stated,
I have expressed my concern for the survival of the discipline
because too many researchers have abandoned or ignored
nursing conceptual models. . . . I can only hope that all readers
will appreciate the added value of nursing research that is guided
by an explicit nursing conceptual model. (p. 583)
Historically, transcultural nurse researchers have used
qualitative and/or quantitative knowledge discovery meth-
ods to conduct original research in order to help improve
nurses’ cultural competence and patients’ health outcomes
(Marion et al., 2016). “Translation of findings should be con-
sidered in initial study design and . . . a major consideration
when developing the study aim” (Curtis et al., 2017, p. 866).
A renewed call to action regarding Leininger’s three phases
of evolutionary transcultural nursing knowledge includes a
focus on continued awareness of culture care similarities and
differences, transcultural theory and research-based knowl-
edge of culture care and cultural competence, and implemen-
tation of culturally congruent care practices with health
outcome measurements (McFarland, 2018a). McFarland
(2018a) proposed a fourth evolving phase for transcultural
nursing (Figure 4) centered on evidence-based culturally
congruent practice and translational research to develop
effective care implementation strategies that promote adop-
tion of evidence-based transcultural practices in real-world
clinical settings. This fourth phase focuses on culturally
competent nurses implementing culturally congruent nursing
care practices that transcend all clinical, educational, admin-
istrative, and research settings. Nurse researchers and nurs-
ing organizations have responded by designing translational
transcultural projects for implementation in community and
clinical settings (American National University, 2019) that
can benefit populations from diverse cultures (Marion et al.,
2016). In so doing, these projects will meaningfully improve
health care outcomes, health, well-being, and quality of life
for people from diverse cultures and those experiencing
social and health disparities (McFarland, 2018a; McFarland
& Wehbe-Alamah, 2015b). Recent translational research
projects guided by the CCT using evidence-based practice
guidelines or literature conducted by advanced practice
DNP students include those by Bhat et al. (2015), Coleman
et al. (2016), Kelch et al. (2015), and Kaminen-Getzloff,
Creech, and McFarland (2018). Other application research
studies using the CCT in practice settings include Mixer
et al. (2014), Mixer et al. (2015), Rahemi (2019), and
Rahemi et al. (2019).
12 Journal of Transcultural Nursing 00(0)
Figure 4.  Evolutionary phases of transcultural nursing knowledge.
Note. Reproduced from McFarland (2018b, p. 9).
Curtis et al. (2017) stated,
Central to nurse-led research and knowledge translation is
dissemination. . . . A research study is not complete until the . . .
findings have been disseminated via presentations at professional
forums and/or published in a peer-reviewed journal, and where
appropriate recommendations regarding how the . . . findings
could be translated into clinical practice are made. . . . It is
equally important to publish studies with negative or equivocal
results [and] consider prospectively how findings will be
disseminated. (p. 863)
Education
Although the CCT has been used extensively to guide trans-
culturally focused courses, it has been proposed that
expanded theory applications would be beneficial as a guid-
ing framework for both undergraduate and graduate nursing
curricula and programs. The CCT core constructs—cultural
competence, culturally congruent care, generic and profes-
sional care, cultural diversity, and a view of health from the
perspective of patients and others—could be threaded
through every nursing curriculum course to enhance nursing
McFarland and Wehbe-Alamah 13
competence in the provision of culturally congruent care for
diverse clients. In addition, DNP projects that include educa-
tional programs about culturally congruent strategies for
implementing evidence-based guidelines for health care pro-
viders have the potential to produce measurable outcomes in
provider/staff practice changes as well as improved patient
health outcomes (White & Zaccagnini, 2017).
Health Policy
Ellenbecker and Edward (2016) stated,
Health policy research focuses on improving the access to care,
the quality and cost of care, and the efficiency with which care
is delivered. . . . The policy process framework provides a
context for improving the focus and design of research and
better explicating the connection between research evidence and
policy. (p. 208)
Waddell, Adams, and Fawcett (2017) explored nursing lead-
ers’ policy participation within the context of a nursing con-
ceptual model. The CCT has not been extensively documented
in published professional literature as a way to guide or
inform health policy initiative development. With its focus
on social and cultural factors that influence cultural compe-
tence, culturally congruent care, and health and well-being,
the CCT is a timely and relevant theoretical framework to
guide U.S. policy initiatives addressing macrosocial determi-
nants of health. Social injustice and health disparities affect
health outcomes, life expectancies, and all-cause mortality
including deaths resulting from heart disease, hypertension,
obesity, and diabetes (Keyes & Galea, 2016). As Marion
et al. (2016) pointed out, achieving competency for ANA
(2015) Standard 8 (Culturally Congruent Practice) at the
graduate level entails engaged advocacy and practices that
advance “organizational policies, programs, services, and
practices that reflect respect, equity, and values for diversity
and inclusion” (p. 69). This effort could be extrapolated fur-
ther to include participation in public policy initiatives as
well.
Administration, Leadership, and Grants
Administration and Leadership.  Historically, Leininger (1995a,
2002e, 2006b) advocated the integration of transcultural con-
structs and foci into the administrative policies and proce-
dures that guide nursing practice. She believed that educating
students about the CCT and how to apply the modes was
essential for helping nurse administrators become culturally
alert and realize
the importance of understanding and working with people from
many different cultures in the management processes, in
decision-making, and in setting institutional goals. . . . Practices
need to not only be congruent with changing cultural values,
beliefs, and lifeways in the workplace, but they also must
reasonably fit with societal and worldwide trends. (Leininger,
2006b, p. 367)
In addition, “the interest of administrators at a unit or organi-
zational level must be addressed to promote research transla-
tion into clinical practice” (Curtis et al., 2017, p. 866).
Connecting nursing’s scope and standards to transcultural
nursing and culturally competent care through nursing lead-
ership and administration is important work. Douglas et al.
(2014) proposed 10 universally applicable guidelines for
implementing culturally competent nursing care worldwide
(McFarland, 2018d). Guideline 9 encourages nursing leader-
ship to establish polices and guidelines for comprehensive
implementation and evaluation of culturally competent care
and recommends that health care organizations support their
interdisciplinary leaders, managers, and staff in developing
policies that reflect local cultural beliefs, norms, and care
practices (Douglas et al., 2014; McFarland, 2018d).
Numerous organizational and individual factors impact
[research] implementation and uptake, including . . . a lack of
continuing education and an unsupportive organizational
culture. . . . Implementing evidence by translating knowledge
[requires] planning and strategy that address the complexity of
healthcare systems, individual practitioners, managers, and
strong organizational support and patronage. (Curtis et al., 2017,
p. 867)
Furthermore, Hubbert (2018) recommended that adminis-
trators study the Sunrise Enabler to gain a cultural perspec-
tive on workplace conflicts. By employing the CCT in this
way, administrators can use the three culture care decision
and action modes to address cultural clashes in the course of
daily events. The application of the CCT to workplace con-
flict resolution by administrators and managers within a mul-
ticultural workforce aligns with the American Association of
Critical Care Nurses Healthy Workplace Environment for
Nurses initiative, which includes conflict resolution and
ways to address incivility and bullying (American Association
of Critical Care Nurses, 2005, 2019; Ulrich, Barden, Cassidy,
& Varn-Davis, 2019).
Grants.  Roussel (2020) stated 10 key criteria to be used when
writing translational science grants, with conceptual model
and theoretical justification listed as the third criteria. Spe-
cific questions to ask include the following: Does the pro-
posal clarify the key constructs to be measured? Does it
correspond to the overarching conceptual model or theory?
Is the measurement plan for each construct clear? Does the
analysis section demonstrate how relationships among con-
structs will be tested? (Roussel, 2020).
McFarland, Mixer, Lewis, and Easley (2006) used the
CCT to develop and implement a program facilitating bac-
calaureate nursing education for candidates from under-
served rural communities. More recently, Andrews and
Collins (2015) applied the CCT as a framework for a federal
14 Journal of Transcultural Nursing 00(0)
grant-funded program to teach clinicians to become more
culturally competent in their practice environments with per-
sons from diverse and underserved backgrounds. These proj-
ects serve as exemplars for future grant writing endeavors
supporting clinical, community, and academic programs that
improve the health and well-being of clients, residents, and
students.
Summation
This article provided a historical overview of the CCT as
developed by Dr. Madeleine Leininger, a nurse and a socio-
cultural anthropologist. The purpose, goal, tenets, and basic
assumptions of the theory along with the major core con-
structs with orientational definitions were described. Articles,
books, and book chapters reporting on the use of the CCT
published in the past 5 years (2014 to 2019) were cited as
relevant exemplars that enhance understanding of CCT
major core constructs. Proposed future directions encompass
using the CCT to guide research of discovery and transla-
tional research projects for evidenced-based nursing prac-
tice; develop culture-care based courses and nursing curricula
to prepare culturally competent nurses; guide future cultur-
ally competent administrative and leadership policies and
procedures; inform public policy related to cultural diversity
and underserved populations; promote grant writing initia-
tives to enhance cultural diversity in hiring nursing staff,
supervisors, and faculty; and aid in the admission of nursing
students from underserved and/or diverse backgrounds.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iDs
Marilyn R. McFarland https://orcid.org/0000-0002-9916-9898
Hiba B. Wehbe-Alamah https://orcid.org/0000-0001-7199-9868
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