Production of knowledge based on the Theory of Culture Care Diversity and Universality: documental research

Objectives: To analyze the abstracts that relate nursing to the Theory of Culture Care Diversity and Universality, published in the annals of the main national scientific events in the category, over a 12-year period. Methods: documental research carried out in the annals of the Brazilian Nursing Congress and the National Nursing Research Seminar. Data collection took place from July/2018 to June/2019 using a form. Data was analyzed using descriptive statistics and content analysis. Results: 99 studies were analyzed, and three categories emerged: Cultural diversity, emic perspective, and cultural context: possibilities for applying the theory; Incongruencies and peculiarities of the care sectors: limitations of the application of the theory; Knowledge production to improve care: implications for professional nursing practice. Final Considerations: the investigated scientific production enabled the construction of knowledge of cultural aspects related to nursing care and showed similarities and variations in care practices.


INTRODUCTION
The incessant production of knowledge in the nursing area is guided by the search for the development and application of theoretical, philosophical, and methodological references that underpin professional practice. In this sense, nursing theories provide conceptual, epistemological and descriptive bases of care for the construction of their own knowledge that delimit professional performance in the fields of teaching, research, assistance and management (1) .
The construction of scientific knowledge in the field of nursing began in the 1950s, with the development of nursing theories (1) . A few years earlier, in 1947, it was promoted by the Brazilian Nursing Association, which was called the Brazilian Association of Registered Nurses, the first Brazilian Nursing Congress (CBEn), in the city of São Paulo (2) . In 1979, the first National Nursing Research Seminar (SENPE) was promoted, in which methodologies and lines of research in nursing were emphasized. In 1982, in the second edition of this event, the discussion on lines of research sought to define priorities in serving the population's health and the needs of the profession (3) .
The events are spaces for the dissemination of scientific works, discussion and reflection about nursing and the population's health (2) . It is noteworthy that the collective work at these events seeks to develop nursing for life, committed to people and guided by ethical principles, to respond to the contemporary challenges of the profession and prepare it for the future (4) .
Regarding nursing care, studies that seek a basis in the human sciences, such as anthropology, are notorious. Nursing's approach to the anthropological concept of culture in Brazil is marked by the arrival of nurse Madeleine Leininger and dissemination of the Theory of Culture Care Diversity and Universality (TDUCC), in the 1980s, at the first Brazilian Symposium on Nursing Theories (5) . With this event, the academic environment awoke to the need to seek knowledge and strategies to think about the relationship between the concepts of culture and nursing care.
Since then, scientific productions related to the concept of culture have grown, although still little explored at the national level (6) . In addition, a variety of references from different areas of knowledge, isolated or combined, in different scenarios, have been used to study the culture related to nursing.
Culture encompasses life values, beliefs, norms and practices, which are learned, shared and transmitted in specific groups and direct thoughts, decisions and actions (5) . The use of TDUCC and qualitative research methods are ways to approach the meanings of care in different cultures in a multicultural society. In this sense, health care is understood as a cultural system, constituted by the popular and professional subsystems, and culturally congruent care is the main objective of the theory. In nursing, knowledge about differences and similarities between cultures is essential for actions and decisions that lead to the health and well-being of clients and to coping with diseases and death (7) .
In a bibliographic research carried out to identify the characteristics of theses and dissertations related to nursing and culture, based on anthropology, it was observed that the most used theoretical framework was TDUCC, in 43% of the 124 theses and dissertations analyzed. These results showed that the spread of this theory in Brazilian nursing is related to the implications of cultural aspects on health and illness (6) . The disclosure of the cultural perspective enables the development of nursing care actions and decisions in a participatory and satisfactory way to people (8) . In addition, the consideration of beliefs and generic knowledge that people have strengthens the professional performance of nurses (9) .
In this study, the production of nursing knowledge related to TDUCC, published in scientific events, was focused. The guiding question is: What is the scope of the production of knowledge disseminated in scientific events involving nursing and TDUCC, in the Brazilian scenario? The panorama of this production contributes to its greater visibility, clarification of the characteristics, analysis of these studies and elucidation of the advances in this knowledge.

OBJECTIVES
To analyze the abstracts that relate nursing to the Theory of Culture Care Diversity and Universality, published in the annals of the main national scientific events in the category, over a 12-year period.

Ethical aspects
Public domain documents were analyzed; thus, there was no need for the project to be evaluated by the Research Ethics Committee.

Study type
It is a documental research (10) , qualitative, in which the primary source of information was the scientific production published in annals of the main national scientific events in nursing. The recommendations of the Standard for Reporting Qualitative Research (SRQR) (11) were followed for the elaboration of the article regarding the title and summary, introduction, method, results and discussion.

Data source
The study material was obtained from Annals of CBEn and SENPE, through printed and electronic media, available in the collection of the headquarters of the subsections of the Brazilian Nursing Association, personal collections and from the Graduate Programs in Nursing or online. These are two of the main and oldest events held regularly. This material encompasses a little explored scientific production, not analyzed by consultants or editors, and presents potential production in the area. Chart 1 describes the characteristics of this material regarding the event, central theme, city, and year.

Data collection and organization
The abstracts were identified by reading the titles and selected according to the inclusion criteria: be published in the sample period from 2007 to 2018; mention Madeleine Leininger's theoretical or methodological framework; have one or more of the descriptors "culture", "cross-cultural nursing", "Leininger", "anthropology" and "ethnography". The sample period included the scientific production of 12 years, to obtain a comprehensive number of the most recent studies on the theme; and as of 2007, due to the concentration of studies. The growth in the number of publications on the subject over the years, especially since 2009, is related to the expansion of post graduate courses in nursing (6) .
Data collection took place from July 2018 to June 2019 using a form containing the following information: name of the event, year, title of the abstract, authors, institution, region of Brazil, objectives, methodology, results, final considerations, and the interface TDUCC nursing. To characterize the analyzed studies, quantitative information was organized in Microsoft Excel spreadsheets and reviewed by a researcher and a doctoral student from the research group that developed the study. The study audit was carried out by four teachers from the research group in which the article was prepared.

Data analysis
Quantitative information was analyzed using descriptive statistics and presented in a graph and in descriptive language. Qualitative information was coded and categorized by similarities and differences, based on the objective of the study, according to content analysis (12) , and discussed in the light of TDUCC and the current literature. For the analysis of knowledge production, qualitative information was described and synthesized in the categories that showed possibilities, limitations, and implications of the application of TDUCC in nursing practice.
The interpretations and classifications performed by the authors of the analyzed abstracts were respected, without making judgments about their knowledge, belief, or conduct. The bibliographies used were treated fairly, without any discrimination.

RESULTS
99 studies published from 2007 to 2018 were analyzed, 75 publications from CBEn and 24 from SENPE. A greater number of publications was observed in the years 2009 and 2013 (n = 16; n = 17, respectively). As for the regions where the studies were carried out, the Southeast (n = 27) and the South (n = 27) predominated, followed by the Northeast (n = 23), North (n = 8) and Center-West (n = 3), being that were not mentioned in 11 studies.
Regarding the research scenarios (n = 54) and experience reports (n = 18), there was a predominance of the hospital institution (n = 21), followed by the communities (n = 11), health units (n = 8), schools and universities (n = 8), specialized clinics (n = 6), maternity hospitals (n = 2) and public spaces (n = 2). Still, 13 did not mention the scenario, and a study was conducted in a nephrology clinic and households.
The scientific production analyzed showed that the use of TDUCC is linked to the search for the intersection of the sectors of popular and professional care. This intersection is aimed at culturally congruent care, through actions congruent with both sectors, and has been explored in diverse populations and contexts. In Chart 2, the objectives and types of studies carried out in the nursing field are highlighted, based on TDUCC. From the analyzed studies, the following categories emerged: 1 -Cultural diversity, emic perspective and cultural context: possibilities of application of TDUCC; 2 -Incongruencies and peculiarities of the care sectors: limitations of the application of TDUCC; 3 -Production of knowledge to improve care: implications for professional nursing practice.

DISCUSSION
In the years when there was a greater number of selected abstracts, the themes of the events related to care were observed, such as, in the 15th SENPE, in 2009, "Nursing: knowledge, care and citizenship"; and at the 65th CBEn, in 2013, "Nursing and caring for life". It is suggested that the number of publications about TDUCC is influenced by the theme of the events. TDUCC is known as nursing theory in the holistic line, with a focus on addressing meaningful care in diverse cultures (7) . The predominance of the South, Southeast and Northeast regions is in line with what was observed in the literature and can be attributed to the greater number of researchers studying the topic in these regions (6) .
Ethnography has been the methodology of choice in most studies that have addressed the anthropological cultural aspects of health, disease, and care. TDUCC has its own method for the knowledge of emic and etic data, which influence the results of care practices (7) . In addition, other methodologies focused on culture in the anthropological sense, which shows the scope of this concept in the field of nursing and limitations of the ethnographic methodology. According to authors (32) , research nurses need to seek new ways to produce ethnographic knowledge for the interpretation of experiences through interpersonal relationships and recognition of the limitations of the concept of culture.
A variety of study scenarios and informants, developed in hospitals, communities, health units, schools, universities, specialized clinics, maternities, and public spaces, showed an interest in exploring the TDUCC-nursing interface in the development of care congruent with different cultures, although there is still little knowledge about the application of TDUCC in professional practice. However, weakness was observed in some studies when the research scenario was not included. The identification and description of the cultural scenario is fundamental in research based on TDUCC, because, in theory, beliefs, norms, values and lifestyles of the group to which people belong are considered (6) , which are influenced by the context and surroundings.

-Cultural diversity, emic perspective and cultural context: possibilities of application of Theory of Culture Care Diversity and Universality
The studies analyzed showed that there are variations in values, beliefs and practices, according to cultural contexts. Such variations reflect cultural diversity and can be made known by revealing the emic perspective (in the ways in which the natives express their own culture) and by comparing the similar and diverse aspects of these expressions. Thus, the recognition of cultural diversity, emic perspective and cultural context is an opportunity for application of TDUCC.
Nurses serve people of various ethnic origins and diverse cultural characteristics, which shows cultural diversity and the impossibility of homogenizing care (24) . TDUCC conducts nursing care in an ethical manner, to consider the particularities of users in different care settings (26) . In a study that addressed the cultural context in which the Chart 2 -Synthesis of studies that link nursing with the Theory of Culture Care Diversity and Universality, according to type of study and objective, Curitiba, Paraná, Brazil, 2019

Study type Objective
Ethnonursing Describe the use of medicinal plants by the family in caring for quilombola children (13) .

Ethnonursing
Identify how adolescents perceive daily life in the community, describe the perception of healthy adolescents and analyze how nursing can contribute to their care (14) .

Ethnonursing
Understand how the process of moral construction of health workers occurs, for professional performance based on autonomy (15) .

Ethnography
Understand the experience of the cancer patient based on the choice of nursing diagnoses, based on crosscultural care (16) .

Ethnography
Know the care rituals developed in preparation for home birth (17) .
Ethnography Describe popular practices in wound care (18) .

Descriptive
Understand the socio-cultural aspects that contribute to treatment adherence by patients with arterial hypertension (19) .

Descriptive
Identify particularities observed by nurses when attending Haitian children (20) .

Descriptive
To raise the perceptions of professionals from family health teams about professional care in assisting indigenous children (21) .

Descriptiveexploratory
Identify maternal cultural values and discuss the mothers' knowledge and practices in relation to the care of their newborn child (22) .

Exploratory
Estimate the magnitude of tuberculosis in the Munduruku ethnic group, relate it to the cultural context and describe the therapeutic itineraries in the treatment of tuberculosis (23) .

Reflection
Promote reflections on the possibilities of applicability of TDUCC in welcoming with risk classification (24) .

Reflection
Reflect critically on the theories used in nursing research (25) .

Integrative literature review
Evaluate the evidence available in the literature about TDUCC and the contribution to the field of nursing (26) .

Literature review
Identify the influence of culturally congruent nursing care in assisting women with hypertensive syndromes during pregnancy (27) .

Convergentassistance research
Analyze the applicability of popular and professional knowledge and discuss limits and possibilities for the integration of such knowledge and practices in the implementation of a care plan for the prevention and treatment of pressure injuries, to be developed by hospitalized elderly companions (28) .
Case study Implement the nursing process in the care of patients with colon adenocarcinoma (29) .

Documental
Describe the aspects contained in the National Curriculum Guidelines for the undergraduate nursing course that foster skills for the care of people with disabilities (30) .

Experience report
Insert the academic in university extension, considering the social determination of health in the care of elderly patients (31) .
Note: TDUCC -Theory of Culture Care Diversity and Universality.
knowledge and practices of hospitalized elderly caregivers about the prevention and treatment of pressure injuries are developed, it was observed that they have knowledge and experience from the popular sector and incorporate elements from the professional sector. In this perspective, dialogue and reflection strategies were proposed for their participation and cultural congruence of care (28) . In a Support House of the Women's Network to Combat Cancer, the authors' interpretations showed that the experience and ways of dealing with diseases vary according to the cultural context. In this way, cultural aspects revealed comprehensive and individualized nursing care for cancer patients (16) . In indigenous villages and in the Indigenous Health Assistance House, it was observed that each indigenous person built a therapeutic itinerary and went through the popular and professional sectors to develop their own care (23) .
Thus, in order to develop culturally congruent care, nursing professionals are required to have knowledge about different cultures and contexts (13) . However, cultural variations in nursing care are poorly understood. In this sense, TDUCC analyzes similar and diverse aspects of care according to the ways in which human beings express world views and meanings in cultural contexts (5,8) .
Similarly, in the literature, TDUCC grounded qualitative research with the aim of analyzing quilombola mothers' perceptions of pediatric urgency and emergency. The authors identified meanings of urgency varied and elaborated according to experiences and worldviews. In the quilombos' scenarios, characterized by the distance from urban centers and shortages of transport, the participants mentioned social and infrastructure problems that interfere with access to health services. For the researchers, the consideration of the users' perspective provides parameters for the organization of health services, decision making and problem solving in daily life (33) .

-Incongruencies and peculiarities of the care sectors: limitations of the application of Theory of Culture Care Diversity and Universality
Although culturally congruent care occurs at the intersection of the popular and professional sectors, there are situations in which the inconsistencies between them predominate, which imposes limitations on the application of TDUCC. In addition, the peculiarities of the care sectors need to be known for consideration in professional practices.
A study addressed the perceptions of professionals from family health teams about care in the care of indigenous children. The professionals faced contradictions between respect for the indigenous people's care practices and the performance of resolutive care based on the professional system (21) . In this sense, the challenge to integrate knowledge and popular care practices is relevant and, in particular, to subsidize professional nursing care practices (18) .
Cultural care represents values, beliefs and ways of life learned, transmitted and shared and, when the inconsistency between the professional and popular sectors occurs, the negotiation and repatterning of care practices are described in TDUCC (5) . Thus, the concept of cultural care considers that culture is constructed, dynamic and, therefore, modified. However, it is emphasized that the action of repatterning must be a care of the nursing professional when the practice of the popular sector has the potential to aggravate the disease or the risk of death.
In assisting women with hypertensive syndromes of pregnancy, authors stressed that cultural factors and ways of life, such as unbalanced eating habits, alcohol consumption and smoking, can accentuate risk conditions (27) . Similarly, adherence to antihypertensive treatment is influenced by the environment, worldview, health beliefs and lifestyle habits. The authors highlighted that it is in the interest of nursing to establish effective care practices and healthy living standards that lead to the health and well-being of individuals (19) .
On the other hand, it is emphasized that popular practices are developed to prevent health problems. An article based on ethno-nursing aimed to understand the beliefs and care practices of pregnant women in the Wayuu indigenous community, in Colombia. The study showed the development of practices to avoid complications in childbirth, such as sleeping position in the first three months, avoiding overeating during pregnancy, among others (34) . In ethnographic research carried out with families experiencing the gestational process, they developed preparation rituals, such as the use of lavender oil, low light, music therapy, cleaning the home, feeding the woman and the family, among others. It was observed that, in order to understand the care rituals of women in the gestational process, nursing professionals need to put their own cultural values and concepts in suspension (17) .
TDUCC proposes three modes of action for nurses to carry out cultural care (preservation and/or maintenance; accommodation and/or negotiation; and repatterning and/or restructuring) and considers variations in specific groups and in each individual (5) . However, TDUCC does not present particular guidelines, but general guidelines that guide cultural nursing care (26) . In the studies analyzed, we sought to deepen the specificities and variations of care according to the cultural characteristics of the investigated groups.
In this perspective, a study highlighted peculiarities of nursing care for pregnant women with hypertensive syndrome (27) . The authors stressed that such peculiarities were little explored in the research, although the ways of life directly and indirectly influence the health condition of these women; therefore, care cannot be predetermined, but adapted to the cultural aspects of each individual. In the hospital setting, a case study implemented the nursing process in the care of patients with colon adenocarcinoma. Care was preserved regarding religion, leisure and family ties; and negotiated for infection control and nutrition (29) .
In assisting Haitian children, nurses highlighted the difficulty of communicating with the family and little knowledge of Haitian culture. These results showed the need for studies with cultural approaches to improve the quality of nursing care (20) . It is observed that there are different ways of perceiving and practicing care, and communication is essential for reducing cultural barriers and considering the singularities of individuals and groups (30) .
In a qualitative research based on the theoretical framework of TDUCC and methodological of ethnonursing, the objective was to know the barriers present in the process of building cultural care for hospitalized children. The authors observed similarities and differences in the ways in which family members adapt to hospital rules and routines; and considered that the balance between the power of professionals and the autonomy of the family allows exchanges of experiences and knowledge, to minimize barriers and encourage participation in care (35) .

-Knowledge production to improve care: implications for professional nursing practice
In the third category, the studies analyzed showed that the application of TDUCC by nursing professionals involves the production of knowledge and promotes the improvement of care for the health and well-being of cultural groups. In planning care congruent with cultures, it is necessary to know the popular sectors, the professional sector's own values and the variations in cultural practices (13) .
The production of knowledge can contribute to advancing theory, in the sense of strengthening health professionals through the sharing of knowledge that leads to the construction of subjects and different behaviors in the ways of relating and acting. Thus, favorable conditions are developed for health care to occur (15) .
The use of the TDUCC assumptions underpinned the construction of knowledge about maternal care knowledge and practices for newborns in a riverside population (22) . Based on nursing theories, such as TDUCC, health education activities were planned to encourage the adoption of new life habits and behavioral changes in order to avoid compromising health (31) .
Furthermore, TDUCC and the ethnonursing method served as the basis for the study in a community in the periphery. The authors considered the development of means to provide the congruence of care with culture, maintenance or re-establishment of well-being a challenge (14) . The study op. cit corroborates the considerations of the current literature, having been carried out with academics of the postgraduate course in Nursing. The objective was to report the experience of knowledge construction based on nursing theories and points of tangency with the nurse's praxis. The authors highlighted the distance in relation to the application of the theories concepts in practice and the tendency of professionals to adhere to routine practices (1) .
However, authors reinforce the relevance in the application of TDUCC when they state that it favors the direction of nursing care around theories (24) . Thus, the development and use of nursing theories can contribute to the improvement of health care. Specifically, at TDUCC, the interdependent relationships of the concepts of care, culture and nursing are considered. Care, as an essence, is a central and distinctive part of nursing and well-being, health, survival, coping with diseases, disabilities and death; at the same time, it is shaped by cultural meanings, patterns, expressions and practices (8) .
One study critically addressed the theories used in nursing research. The authors highlighted the integration of research and practices with theories for the advancement of nursing science (25) . In this sense, the search for theoretical and methodological frameworks to support practices is emphasized, as well as the advancement of these frameworks in theory and practice. Studies linked to TDUCC bring about a deeper relationship between the concept of culture and health and nursing practices; and the theoretical, methodological, and practical aspects involved in these relationships.
The socio-cultural factors of individuals guide decisions regarding health care; thus, knowledge about the values, beliefs, styles and life experiences of human beings allows the construction of knowledge about nursing and health practices (9) . TDUCC's contributions permeate the recognition both of the cultural aspects that reveal similar and diverse care in specific groups and of the variations in each individual and over time (8) .
Nursing seeks to promote the health and well-being of human beings and, therefore, the improvement of the body of scientific knowledge through theories, to lead to individualized assistance based on ethical and scientific principles (1) . In addition, the development of the holistic perspective of patients, families and communities, and the foundation of professional and popular cultural knowledge, lead to effective nursing care, satisfactory and consistent with the reality of each human being (36) .

Study limitations
In this study, abstracts published in scientific events that lead to more condensed information were analyzed, which limit further analysis about the methodology and the use of the theoretical framework. In addition, TDUCC was delimited to approach the nursing-culture interface instead of other theories and references. However, the analyzed material presented a wide range of available studies, made it possible to focus on this theory and showed the panorama of the investigated scientific production.

Contributions to the field of Nursing
This study addressed the production of knowledge about the nursing-culture interface, focusing on TDUCC. The analysis of this production contributes to the theoretical development about nursing care, through the use of theory to build knowledge of cultural perspectives regarding health care in specific scenarios.

FINAL CONSIDERATIONS
The panorama of national scientific production showed a significant quantitative deficit in studies and evidenced the need to build knowledge through investigations about the diversity, variations, and modifications of care according to cultural contexts. The results highlighted the challenge of including content about cultural care in training, aiming at preparing nursing professionals to apply TDUCC.
For culturally congruent care, the application of TDUCC seeks the intersection of the popular and professional sectors, and the analyzed abstracts explored possibilities and limitations of this intersection, as well as the performance of nursing based on theoretical and scientific principles. The analyzed scientific production enabled the construction of knowledge of cultural aspects related to nursing care, as it covers the observation of reality, similarities and variations in care practices and the dynamics in which culture is constructed and modified.

FUNDING
We are grateful to the Coordination for the Improvement of Higher Education Personnel (CAPES) for the granted of scholarships to masters, doctorate and post-doctorate students.

ACKNOWLEDGMENT
We thank PhD Professor Astrid Eggert Boehs for contributions to the study.