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Introduction
Healthcare is an ever-changing industry. New technology, research, advancements and discoveries all shape the landscape of modern healthcare. Patients, too, are ever-changing. Global migration creates a dynamic patient profile as different cultures and ethnic groups relocate around the world. Studies show that patients are more comfortable in a healthcare system that provides culturally sensitive care to them (Tavallali, Jirwe & Kabir, 2017). Patients may feel isolated if there is a language barrier and feel misunderstood if their cultural preferences and beliefs are not acknowledged. This may discourage the patient from seeking care in the future (Rosa, 2018), and may decreases patient satisfaction, which is damaging to healthcare systems in a satisfaction-driven reimbursement system. Nursing theories exist to guide care and assist in developing appropriate interventions. The Theory of Cultural Care Diversity and Universality by Madeline Leininger was designed to provide culturally competent care to assist in bridging the gap between caregivers and patients and remains a solid choice for this institution to implement by way of pictogram cards to assist in translation for patients with limited English.
A Detailed Look at the Theory
The Cultural Care Diversity and Universality Theory (CCDUT) by Madeleine Leininger provides structure and framework to enable nurses to guide their care in a culturally competent manner. The theory examines not only cultural care, but also sheds light on similarities that unite us and diversities that make us unique (McEwen & Wills, 2014). It has been repeatedly tested and studied in many different situations. It remains applicable across a variety of settings, even in delicate and complex situations, such as victims of a violent relationship (Broch, Oliveira Crossetti, & Lisboa Riquinho, 2017). This theory will be a strong choice for this healthcare system to guide the nursing staff on implementing quality and culturally appropriate care.
Background of a Theorist
It would be impossible to discuss the CCDUT without discussing the theorist. Madeline Leininger was both a researcher and a scholar. Through years of careful observation coupled with a background in anthropology, Leininger was able to first formulate the beginnings of the theory during the late 1950s. The theory was refined and honed over the course of the three doctoral degrees the theorist earned (Petiprin, 2016). It was during this time that Leininger first recognized that transcultural nursing could be viewed as a separate and distinct practice unto itself (McEwen & Wills, 2014), and even on to become a Certified Transcultural Nurse (Petiprin).
Classification
Though the principals of the theory are very clear, the classification of the theory is somewhat ambiguous. Leininger is considered by some sources to be a high-middle ranged theorist, but by others to be a grand theorist (McEwen & Wills, 2014). The CCDUT certainly has many elements of a grand theory. It has a much wider scope than the traditional middle-range theory and provides a conceptual framework for how the care is to be delivered in a culturally competent manner. These are characteristic of a grand theory. However, the theory does not completely fit into the classic definition of a grand theory, as a grand theory traditionally cannot be tested. Leininger found a way to collect empirical data on the application of the theory (McEwen & Wills, 2014). Because of the wide-range of application and the validity in many circumstances, this theory will be considered a grand theory for this healthcare institution, as it will provide guidance and structure without narrowing focus of care.
Assumptions of the Theory
There are multiple assumptions in the CCDUT. Petiprin outlined thirteen assumptions in the 2016 writeup and analysis of the CCDUT. Out of the 13 assumptions, five of them deal directly with basic nursing care. It is stated that care is at the very core of nursing and is vital for the overall health and healing of the population. In fact, without such care, healing or curing could not exist. Furthermore, nursing care transcends boundaries and reaches the global population. In each culture, care exists. It may be through professional means or via amateur application, but the concept of care is a universality. Further assumptions address the transcultural aspect of care. As Petiprin explains, though every culture has care, the actual care values are heavily influenced by a cultural context; everything from politics to religion. Culturally congruent care exists when the nurse recognizes these differences and acts upon them in a meaningful way. If congruency is not achieved, then patients may experience anxiety, or be put under a moral or ethical stress. Conversely, if congruency is achieved, then it contributes to the overall health and well-being of not only the patient, but the families and the larger social structure as well (Petiprin, 2016).
Concepts and Propositions of the Theory
The CCDUT has a strong focus on cultural care. Transcultural nursing is a study that compares cultures. It is both humanistic and scientific in nature (Denisco & Barker, 2016). The purpose of Transcultural Nursing is to generate knowledge related to the nursing care of people who value their cultural heritage. Culture, culture care, and the differences and similarities (also known as diversities and universals) in the culture care are all major concepts in transcultural nursing. Other concepts of note are language expressions, perceptions, beliefs, and practice of individuals or groups of a culture (McEwen & Wills, 2014).
Major propositions of the CCDUT include the desire to provide culturally competent nursing care to a diverse group of people and cultures. Leiningers desire was that nurses understood an individuals view of illness, and to focus on recognizing and understanding cultural similarities and differences (McEwen & Wills, 2014). Knowledge of cultures, and different ethnic groups, serves to enhance and provide a positive influence on nursing care and health.
Previous Application of the Theory
Through the years the CCDUT has been implemented in a number of different situations and locales. In Nursing Practice in Healthy Youth from the Perspective of the Transcultural Theory of Leininger , Carvalho, Rocha & Rocha (2015) discuss and analyze the beneficence nursing contributes to a healthy adolescent population in via CCDUT. Adolescence is a psychosocial and physiological transformation which are influenced by culture, religion, education and socioeconomic territory in which they reside. The ability to recognize and understand similar and different characteristics between individuals closing the gaps in healthcare for adolescents from age ten to nineteen years of age. This healthcare gap needs improvement to impact healthy development and security needs. Eight workshops were held to addressing issues aimed at the adolescent age group highlighting topics of teen pregnancy, violence, STD/AIDS, drugs, bullying healthy eating habits and other topics associated with this developmental phase of life. Fifteen adolescents were randomly selected to participate in an interview process for thirty minutes to capture the verbal expression of individual perceptions of reality within the participants environment. Interestingly, testimony from one participant noted the perception of health differed from researchers. The researchers focus was the disease process, while the young group was more concerned with the current reality of suicide, homicides, traffic accidents and depression. From this study Carvalho, Rocha & Rocha concluded there is a need to allow space for adolescence in the healthcare setting to discuss experiences focusing on a holistic therapeutic approach to care needs of youth in the reality in which they live. Healthcare should not just take place in a specific location but be integrated within the community.
In a 2017 report, Broch, Oliveira Crossetti and Lisboa Riquinho used a qualitative, descriptive study of a reflective analysis of Leiningers CCDUT in relation to the care of victims of violence against women (VAW). The purpose of the study was to determine if the theory would be able to help nurses care for these patients. In the study, the researchers call attention to the fact that VAW is a world-wide phenomenon and is extremely complex, with many different factors contributing to the cycle of violence. The Sunrise Model from the CCDUT is a visual representation of the concept and allowed for the researchers to map the many causes of the VAW. There was representation for the social aspect of the violence, environmental considerations, educational levels of the people involved, their relationships, religion and traditions, as well as legal components. It is anticipated that by applying this model, the nurse can classify and assess the individual components and direct and customize the care provided to best fit the individual patient. In a situation as complex and challenging as VAW, the researchers determined that Leiningers theory was comprehensive enough to provide holistic care yet flexible enough to adapt to the individual situation.
Researchers have recognized that interaction with different cultural groups are common, and happen more frequently than in the past, especially among those working in the health care system. A study completed by Gasiorek and van de Poel (2018) assessed the issue of cultural encounters within the hospitals in Vienna, Austria. Cultural intelligence causes appropriate behaviors based on verbal and non-verbal abilities, and aids coordinate the application of cultural knowledge when encountering the role and performance (Gasiorek & van de Poel, 2018). The authors completed a comparative study to measure how nurses viewed their cultural abilities and how it relates to the care provided to diverse patient populations when speaking their native language, and/or a second language. The study found that nurses felt less condent in their cultural skills if they were not able to communicate with their patients in their first language.
Proposed Integration
In this health institution, an important application of the CCDUT is through translation. Translation resources are not equal in all healthcare institutions. Not all facilities have the resources of in-house translators, Virtual Reality Interpreter devices or immediate access to resources. This institution faces challenges in the availability of a quick translation tool for nursing care when traditional translators are not readily available.
Standardization of an alternative communication process for in-hospital non-English speaking patients for basic needs has tremendous potential for cross-cultural communication and reduces communication challenges and the risk of miscommunication. Pictogram communication has been proven to be a form of communication that is fast, simple, user-friendly for all ages and disabilities, designed for acute needs, intuitive and independent of language or country of origin and visual images are processed 60,000 times faster than text (Wolk, Wolk & Glinkowski, 2017). The inability to effectively communicate increases anxiety and frustration, decreases patient satisfaction and can lead to poor outcomes (Meuter, Gallois, Segalowitz, Ryder & Hocking, 2015).
Leiningers CCDUT provides culture-specific or universal care that would be compatible, safe and beneficial for diverse and similar cultures for health, healing, and well-being and assist people who face disability and death (McFarland & Wehbe-Alamah, 2014). Leiningers three cultural care modes are preservation/maintenance, accommodation/negotiation and repatterning/restructuring. These models offer diverse therapeutic ways to support individuals of different cultures (Petiprin, 2016). The integration of the pictogram tool will apply the CCDUT through the mode of culture care accommodation, which encourages nurses to think outside of the box to help patients adapt or negotiate the environment with a shared goal of optimal health outcomes (Petiprin).
With a university pictogram tool, the aim is to provide a quick communication tools to be utilized in the absence of immediate language interpreter services to reduce anxiety, fear, loss of control over self-care and miscommunication. The organizational priority is a safety initiative for patients with limited English proficiency. Nurses can champion efforts to promote effective communication and safety making a difference in outcomes, impact cost savings to the institution and increase patient satisfaction. Safety is essential for the quality care, and existing research has validated language barriers threaten patient safety (Rosse, Bruijne, Suurmond, Essink-Bot & Wagner, 2015).
Initial investigation for the communication pictograms library will address basic needs, personal items, comfort care, emotional safety and procedures and created with input from a team of RN staff, ancillary staff, physicians, educators, interpreters (if applicable to institution) and interdisciplinary departments to develop the most commonly encountered symbols of communication. Collaboration with a local community college for artwork, best user-friendly layout (flip chart, laminated charts, paper handout, etc.) and design addressing basic needs, personal items, comfort care, emotional security and pain that is easy to understand and interpreted across different cultures.
After review by the input team and Internal Review Board (IRB) roll out for testing will be determined based upon cost, recommendations from IRB about ethical parameters, patient consent for participation and implementation process. All staff utilizing the pictogram communication process will participate in provided in-service education classes and competency skills assessment. Limited English proficiency will be self-determined, and nurses will assess the level of stress with communication to determine the need for the alternative communications process of communication adjunct to provide culturally congruent safe care for consenting Vietnamese, Chinese and Spanish adults over the age of 18 until sample group is completed. Sample group will be five men and five women from each language group for equality of gender perception when analyzing and comparing data.
Quantitative measurement of patient satisfaction will be measured by an increase in Press Ganey scores and HCAHPS survey results over a given period after the implementation of pictogram communication process if there is the ability to extract sample participants from surveys responses. This may not give an accurate result due to failure to respond and a limited understanding of a survey written in English. A qualitative questionnaire of three questions and two and open-ended questions will be reviewed before discharge and produced in the languages appropriate for the sample group or completed in English with an interpreter in conjunction with discharge education to evaluate the patients perception of care, communication and to determine the usefulness of the pictogram communication process. Alternately, a follow up phone interview with an interpreter may be used. An ethnographic approach through observation and documentation research method developed by Leininger can be applied throughout hospitalization to assess patient and family engagement, social interaction and were decisions and care beneficial, satisfying and meaningful. This mixed method will allow analysis and comparisons of cultures to determine the effectiveness and satisfaction of pictogram communication (Berkowitz, 2016). After data is analyzed and compared, challenges and lessons learned will be determined to modify practice and decide if this change in practice is appropriate and sustainable for adoption and integration into daily care of the patient with limited English proficiency.
Conclusion
Madeleine Leininger was a highly educated theorist with years of experience observing different cultures leading to the creation of the CCDUT. The CCDUT has a wide-reaching potential for application and has been successfully implemented in many previous situations. Currently this healthcare institution has no quick and easy tool to allow effective communication with non-English speaking patients. Development and implementation of a pictogram tool has the potential to raise patient and nurse satisfaction and provide a culturally congruent way for the nurses in this institution to deliver safe and effective care.
References
Berkowitz, B. (2016). The patient experience and patient satisfaction: Measurement of a complex dynamic. Online Journal of Issues in Nursing, 21(1), 12.
Broch, D., Oliveira Crossetti, M. G., & Lisboa Riquinho, D. (2017). Reflections on violence against women in the perspective of Madeleine Leininger. Journal of Nursing UFPE / Revista De Enfermagem UFPE, 11(12), 5079-5084.
de Oliveira Carvalho, A., Santiago da Rocha, S., & de Souza Rocha, K. N. (2015). Nursing practice in healthy youth from the perspective of the transcultural theory of Leininger. Ciencia, Cuidado E Saude, 14(4), 1546-1554.
Denisco, S. M., & Barker, A. M. (2016). Advanced Practice Nursing Essential Knowledge for the Profession (3rd ed.). Jones and Bartlett Learning.
Gasiorek, J., & van de Poel, K. (2018, February ). Language-specific skills in intercultural healthcare communication: Comparing perceived preparedness and skills in nurses first and second languages. Nurse Education Today, 61, 54-59.
McEwen, M. & Wills, E. M. (2014) Theoretical Basis for Nursing (4th ed.). Philadelphia, PA: Wolters Kluwer Health.
McFarland, M. R., Wehbe-Alamah, H. B., & Leininger, M. M. (2015). Leiningers culture care diversity and universality: A worldwide nursing theory. Burlington, MA: Jones & Bartlett Learning.
Meuter, R. I., Gallois, C., Segalowitz, N. S., Ryder, A. G., & Hocking, J. (2015). Overcoming language barriers in healthcare: A protocol for investigating safe and effective communication when patients or clinicians use a second language. BMC Health Services Research, 15(1), 1-5.
Petiprin, A. (2016). Leiningers Culture Care Theory. Web.
Rosa, W. E. (2018). Transcultural pain management: Theory, practice, and nurse-client partnerships. Pain Management Nursing, 19(1), 23-33.
Tavallali, A. G., Jirwe, M., & Kabir, Z. N. (2017, March). Cross-cultural care encounters in paediatric care: minority ethnic parents experiences. Scandanavian Journal of Caring Sciences, 31(1).
van Rosse, F., de Bruijne, M., Suurmond, J., Essink-Bot, M., & Wagner, C. (2016). Language barriers and patient safety risks in hospital care. A mixed methods study. International Journal of Nursing Studies, 5445-53.
WoBk, K., WoBk, A., & Glinkowski, W. (2017). A cross-lingual mobile medical communication system prototype for foreigners and subjects with speech, hearing, and mental disabilities based on pictograms. Computational and Mathematical Methods in Medicine, 2017, 1-9.
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