PUTTING LEININGER ’ S NURSING THEORY “ CULTURE CARE DIVERSITY AND UNIVERSALITY ” INTO OPERATION IN THE CURRICULUM-PART 1

The culturally diverse South African society necessitates inclusion o f transcultural nursing in the curriculum. This article focuses on research regarding the putting o f Leininger's nursing theory into operation in the curriculum to provide a scientific base for the inclusion o f such nursing. The research process and results are discussed. OPSOMMING Die multikulturele aard van die Suid-Afrikaanse samelewing noodsaak insluiting van transkulturek verpleegkunde by die kurrikulum, gegrondop 'n verpleegteorie. Hierdie artikel is gerig op navorsing ten einde Leininger se verpleegteorie in die kurrikulum te operasion^iseer. Die navorsingsproses en resultate word deur die outeur bespreek


INTRODUCTION
The culturally diverse South African society necessitates a new perspective on nursing education and curriculum development.There is increasing need for transcultural nursing in the curriculum to enable graduates to render congruent cultural nursing care.Successful health care delivery based on primary health care, is dependent on congruent cultural nursing care (Sekgobela 1986:30;MacDonald 1987:32); Burrows (1983:478) regards an ethnocentric curriculum as a form o f in stitu tio n a liz e d racism re su ltin g in inadequate nursing care.
Man is acknowledged as a cultural being in the philosophies of many nursing schools.Chater (1975:429) argues that a philosophy is rarely reflected in all phases of the curriculum although a nursing theory guides all phases of, and provides a scientific base for, the curriculum (Aggleton & Chalmers 1989:24, Brower & Baker 1976:686).
With reference to transcultural nursing.Brink (1990:523) says "cultural diversity remains elusive without a tJteoretical framework Farr (1978:294-299) recommends that man as a culmral being be acknowledged in nursing school philosophies and that inclusion of cultural content in the curriculum be based on an appropriate nursing theory.

IM PLICATIONS OF LEIN IN GER'S NURSING THEORY FOR THE CURRICULUM
The focus of this theory is to discover care diversities and universalities in order to provide culturally congruent care (Leininger 1991a: 11 & Leininger 1991 b:39).Putting Leininger's nursing theoiy into operation therefore can be instrumental in preparing the nursing student to deliver congruent cultural care.The existing ethnocentric curriculum, based mainly on Euro-American values, thus will make way for a curriculum which reflects not only a biomedical, but also a sociocultural perspective on health related matters.Because a nursing theory influences all phases of the curriculum, the use of Leininger's nursing theory should result in bnnging congruent cultural nursing education to a multicultural student population

Research question
The research question on which the study was based, is: How can L ein in g er's N ursing Theory "Culture Care Diversity and Universality " be operationalized in the curriculum?

Aim
The aim of the study was to gain insight into culturally congruent nursing education by means of an exploratory study.Mouton and Marais (1992:45) regard willingness to explore new ideas and suggestions as essential for a good exploratory study.

Goal
The goal was to promote culturally congruent care through formulation of guidelines for the operating of Leininger's nursing theory, in order to include transcultural nursing in the curriculum.

Objectives
The objectives were: • to analyze and evaluate Leininger's nursing theory.
• to operationalize Leininger's nursing theory in the curriculum.

Research design and method
A flexible, non-em pirical, exploratory research design involving the method of theoretical reflection, was utilized.Steyn (1981:34) explains this method as the gathering and systematic critique of data by means of deductive and inductive thought processes.Such a study, according to Engelbrecht (1989:61), is interpretativetheoretical in nature.
Data were gathered by means of a literature study.According to Mouton and Marais (1992:45) a literature study can be applied successfully to an exploratory study.Expert publications regarding the relationship between culture and the cuniculum, as well as culturally congruent care, were subjected to analysis and critique Data gathering and analysis were done sim ultaneously A conceptual framework (Figure 1) and data reduction plan (Table 1) were developed to guide data gathering and analysis.

RESEARCH PROCESS
The research was completed in four phases: Phase 1 Phase one comprised description, analysis and evaluation of Leininger's nursing theory and included three steps: Step 1 Description of Leininger's nursing theory.
Step 2 Development of a conceptual framework for analysis and evaluation of the theory (Table 2).
Step Durmg phase two, a literature study was undertak en to ex p lo re C h rism a n 's expansionist approach (1990:2-3), the author suggests that this hum anist approach complements Leininger's nursing theory Whereas L eininger's nursing theory is abstract and focuses on transcultural nursing as a formal field of study, the expansionist approach is a client centrcd one, through which the client can be approached (Chrisman 1991a:2-5) Within the context of this study, the expansionist approach can be used to: Rgure 1 Concaptual framework for data gathmlng, analysis and presentation • organize transcultural nursing curriculum content and identify associated clinical competence according to the principles of congruent cultural care (ie knowledge, respect and negotiation).
• include both the biomedical and socio cultural perspectives on health matters in the curriculum, therefore putting an end to ethnocentrism in nursing education.
• ensure congruent cultural care by using the nursing process within the cultural context during clinical teaching Phase 3 Phase three com prised the putting of Leininger's nursing theory into operation in the curriculum.This phase was completed in three steps Step 1 A literature study regarding the merit of curriculum development based on a nursing theory and implications of a nursing theory for the curriculum was done Step 2 Development and description of a conceptual fram ew ork for data gathenng, -analysis and -presentation.
(Figure 1), as well as a data reduction plan (Table 1) was drawn up.
Step 3 Data gathering and atulysis by means of the conceptual framework (Figure I) and data reduction plan (Table 1) was carried out.
Phase 4 Phase four involved the formulation of guidelines for including transcultural nursing in the curriculum.

RESULTS
The study resulted in the formulation of such guidelines and a brief overview of these guidelines is presented (Sec Table 3).

General
Nursing theory as a foundation for curriculum developm ent has im plications for the directive, formative and functional phases of the curriculum.

Directive phase
An analysis of the situation is undertaken to determine the social characteristics and health The curriculum therefore must provide for personal and professional development of the student so that, by completion of the course of study, the student will: • show resp ect for the d ig n ity and uniqueness of man in his social-cultural and religious context and approaches and understand him as a psychological, physical, social and cultural being within this context [South African Nursing Council 1988: Paragraph (6X2Xm)].
• be able to prom ote com m unity involvement within a multicultural context at any point along the health\disease continuum in all stages of the life cycle [South African Nursing Council 1988: Paragraph (6X2Xm)].

Form ative phase
Inclusion of transcultural nursing content is achieved by a combination of curriculum developm ent m odels.A co u rse in anthropology is followed by transcultural n ursing units o f in stru ctio n in close association with related nursing subjects.For instance, cultural diversities and universalities regarding pain-experience and its alleviation should form part of the pain module.
Table 2 Analysis and evaluation of Leininger's nursing theory L o g ical flow from philo-sophk»U a ssu m p tio n s to propositions.
S ym m etry an d beauty.

Prin cip les an d propositions Pragm atkss
Utility.
Contribution to nursing.

M etaparadigm c o n ce p ts
The integrated approach is followed during clinical teaching to enable the student to apply principles of congruent cultural care while attending to the client holistically.The principles of congruent cultural care are k now led ge, respect and n egotiation (Chrisman 1991 b:36).
The anthropology course should include units on:a) Culture • Cultural concepts.
• The seven cultural and social structure d im ensions o f L eininger.These dimensions are cultural uni versals, but also culturally diverse in nature.
b) The relationship between culture and health • Cultural factors affecting health.
• Perceptions of health and sickness.
• Sickness behaviour, including pathways to health and treatment strategies The transcultural nursing units of instruction include; a) A comparative study of at least two of the main cultures in the region served by the nursing school, by means o f Leininger's seven cultural and social structure dimensions.This is followed by units related to specific nursing subjects For instance -Ethical issues within cultural context, in the Ethos and Professional Practice module.
• Cultural beliefs and practices associated with pregnancy and labour, in the midwifery modules.
b) Subject content to promote self know ledge in the student.Self knowledge includes knowledge regarding personal and professional values the nurae brings to the health care situation and which may lead to stereotyping of and prejudice towards clients.
c) Subject content related to cultural issues are included in the curriculum in order to promote moral development o f the student.Examples of cultural issues are human rights within the cultural context and the effect ethnocentrism has on the quality o f nursing care (Leininger 1991a: 13;Mattson 1987:207).
One of the principles of cultural congruent care (namely negotiation) implies clinical competence.Clinical competence assumes integration of knowledge, attitudes and skills needed to function as a registered nurse (Mallik 1988:11).Negotiation is a social skill which includes listening to the client's view, explaining the professional view, comparing the two view points and arriving at a compromise for a workable and safe care plan (Chrisman 1990;13-14).Such compromise implies social, communication and higher cognitive skills on the nurse's part.Listening and explaining are communication skills.
Comparing involves critical analytical thought processes and compromising implies social skills Within the transcultural nursing context, these skills are used to develop a negotiated nursing care plan according to L eininger's three modes o f nursing le Table 3 Including transculturai nursing In the curriculum: Planning quide

AC-nVITY D IR ECTIVE P H A S E 1 S m J A T IO N A N A L Y S IS
The prograirme cbiectives include the following irtentiora: -To develop the sludert's ability to approach and underetand the patient as a oitural being • To prorrxM comrunity development within the cultural corteM

Currictium development model:
A basic anthropology course is included in the curriculum -Tranacultural units of instruction thei builds upon the anthropology course, are included at strategic pants throughout the cum oium -Transculturai nursing is integrated into clinical teaching progrannmes The basic anthropology course corsists at.■ C iJtm l oorxsepts -Ovsrvtew of the seven aJtural and social structure dimensions of Lemnger as cultural umysrsals -Cultural factors ttut influence health -Percaptions regarding health and dissasa -Sickneaa behaviour, including pathways to haalth arvj treatmert strategies The tranacultural unils of inatrucbon include; -A connparativs study of at least two cultures by means ct the seven cultural arxl social structure dirrwnsions -Subiect content related to seH-^nowledge -Cultural ssu as  judgment, decision making and actions.The nursing student also lias to develop skills to perform a political function in the assessment of community health needs and priorities, communicating this information to politicians, as well as conflict management should health care be regarded by the community as incongruent to their needs or priorities (Adlem 1993:17).
Functional phase E ducational strategies ap p licab le to transculturai nursing are divided into approaches aimed at the: • development of a transculturai nursing knowledge base.
• development of respect • provision o f meaningful multicultural learning experiences.
• provision for individual differences among students.
Educational strategies for the development of a transculturai nursing knowledge base should not be aimed at teaching lists of cultural c h a ra c te ristic s w hich could lead to stereotyping o f clients (Germain 1992:3).Stern (1985:177) regards literature and personal experience as appropriate sources for gaining transculturai nursing knowledge.Personal experience can be attained by guest speakers, discussions and culture days (Brink 1990:523, Capers 1992:27;W oolfolk 1990:486-487).
Development of respcct can be achieved by strategies such as modelling and utilization of human and matenal resources, as well as simulation (Stem 1985:182-183).Examples could be observation of the life history of a person of another culture or a Culture Game, sim ulating culture shock (S tern 1985(S tern :182-183, Leimnger 1994:220):220).
Leininger (1991a:5) regards experential learning as appropriate for transculturai nursing.Kolb's experential learning cycle (personal experience, reflective observation, abstract conceptualisation and active experimenUtion) provides a theoretical base for multicultural learning expenences.this in turn provides for cognitive and afl"ective dimensions of learning (Kolb in Holbert & Thomas 1988:30-31).It can be applied to discussions and clinical teaching.Clinical teaching also should be implemented within the cultural context.Anderson (1987:9) writes: "ihe clinical encounter is a social process in which each party brings a set o f expectations and beliefs about the problem at hand The critical issue here is that both the perspectives o f the nurse and the patient and his or her family art legitimate " Gagnon (1983:128) states that clinical placements should provide the student w ith the opportunity to encounter culturally diverse groups in addition to focus on clinical specialities.The nursing process should be implemented within the cultural context which implies sociocultural assessment, a negotiated nursing care plan and implementation as well as evaluation, according to the biomedical and so cio cu ltu ral p ersp ectiv e (C hrism an 1990:11-13).
Individual differences among culturally diverse students include differences in learning styles, as well as diverse perspectives regarding achievem ent, motivation and reward.Inclusion of transcultural nursing in the curricu lu m im p lies m u lticu ltu ral education, taking into consideration cultural p lu ralism , ra th e r than im posing Euro-American values on a culturally diverse student population (Slavin 1986:508;Slavin 1991:451;Woolfolk 1990:527).

LIMITATIONS
The interpretative nature of this study might have resulted in some degree of bias.Although nursing theory influences all phases of the curriculum, the evaluation phase was not included in the study, because it is considered as a separate research project.
Despite the limitations, the study contributes to a thorough exploration of the relationship between Leininger's nursing theory and the curriculum and provides the basis for further research in order to establish transcultural nursing as a formal field of study in South Africa.

Continuing education
P erson nel d ev elo p m en t reg ard in g transcultural nursing should be provided for lecturers and nursing practitioners responsible for accompaniment of students.

Research
It is recommended that research is undertaken into student evaluation within the transcultural nursing context, to enable lecturers to monitor the student's progress towards cultural co n g ru en t care.R esearch into the characteristics and health carc needs of the main cultures of the various regions, in order to ensure relevant curricula, is needed.

Curriculum development
It is recommended that: • curriculum evaluation be undertaken, guided by the guidelines in this study.
• curriculum development be undertaken within a regional context due to cultural diversity between the various regions • transcultural nursing be included in the curriculum according to the guidelines (Table 3) formulated for the inclusion of transcultural nursing.

CONCLUSION
This study focused on the putting o f Leininger's nursing theory into operation within the curriculum in order to include transcultural nursing.This was achieved by means of a non-empirical exploratory study.Inclusion of transcultural nursing in the curriculum will result into culturally co n g ru en t care and the provision o f multicultural education to students.
R IT E R I A H istorical developm ent.S e m a n tic integrity an d co n g ru e n ce with eatablished general know likJge: E stab lishe d general k n o w led g e ab ou t m an and health.C o rre sp o n d e n ce with a paradig m in nursing and betw een the theory an d It's undertying phik>-sophical assu m ptions.Level of ab stractkxi o f concepts.C larity and c o n siste n cy of principles, c o n ce p ts and p ropositions.Parsim ony.Ph ilo so p h k ^i assu m ptions C oherence:R elationsh ip to other nursing theories.

A
titajalion analysn hae b w n ImplafTwnted by maans of Leininger's s«v«n cultural and tocial itructura dimansions, namaly: -Technological lacton • Raligious and philoaophical factors -Kinwip and aocial lactors • Cultiral valuas and ways ol living • Politicai and lagal tadois -Economical (actors • Educational tactcis 2 ED U C A T IO N A L P H IL O S O P H Y Acknowrladgamart has baan givan to Man as oJtutal baings Tha intantion to approacti ttia patent holiaticelly wiithin tha cuRural ccnMKl haa baan statad 3 T E R M N O L O Q Y Tha tallowing oorKapts.as dafinad by Lainingar, ars indudad in tha tarminology 7 C L IN IC A L C O M P E T E N C E The following clinical skills are included Social skills -Socncultural asseasmant -Negotiation -Aaeei sm art of community needs -Conflict managemert Commurvcatkxi witNn the cultural cortext Higher cognitivs skills -Critical analitical thought proceesas -Protasaional |udgemer« -DeciSKn making whith regard to cullurs cars prasarvAion.accommodation or reatructunng Negotiation as an rtegration of the abovs skills COMPLETED FUNCTIONAL PHASE • EDUCATKM4AL STTtATEQIEB The educttiorwl strategies provide lor the lolkMing Devetopment of a knowledge base Utiliiation of the Meraturs as a aource of knowledge ExpenerVial learning Development of reepect Role modelling Utiliabon of human and material resources Expenertial leamng FaciMation of meaninglul mulb-cultural learning expenerxses CtmKal leaching is based on the pnnciples of expanerxaal learning Trarvcullural nunmg is applied to the nursing process Mullx:iitural ecucatxin.taking into account individual differences among studens with regard to the folkiwing -Learning styles -Perceptions regarding molivatxn, achievement and reward -Strategies th « requwe group and indrvidual work, ars aftemated

Table 1 Data reduction CATEGORY CODE
The Programme Objectives for the Education and Training of a Nurse (General, Psychiatric, Community) and Midwife [South African Nursing Council 1988:Paragraph(6X2)],should reflect the aim of developing the student's ability to render culturally congruent care.