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Acta Paulista de Enfermagem

Print version ISSN 0103-2100On-line version ISSN 1982-0194

Acta paul. enferm. vol.20 no.3 São Paulo July/Sept. 2007 



A critical analysis of gerontological nursing practice guided by Leininger's theory of culture care diversity and universaity*


Involucramiento de la teoría del cuidado cultural en la sustentabilidad del cuidado gerontológico



Karina Silveira de Almeida HammerschmidtI; Ivete Palmira Sanson ZagonelII; Maria Helena LenardtII

IPos-graduand in the Nursing at the Paraná Federal University - UFPR, Curitiba (PR), Brazil
IIDNS, Senior Professor in the Nursing Graduate Program at the Paraná Federal University - UFPR, Curitiba (PR), Brazil

Autor Correspondente




This article reports a critical analysis of gerontological nursing practice guided by Leininger's theory of Culture Care Diversity and Universality. A LILACS database search was performed from January 1970 to June 2006. The analysis suggests that gerontological nursing care based on Leininger's theory needs further development; there is very little published research. The pluralism point of view of the process of taking care of the elderly requires close approximation, active involvement, respect, commitment, and responsibility from health care providers. Appropriate methods of taking care of the elderly should focus on the promotion and maintenance of health, emancipated care, and independence and autonomy. The report of this critical analysis might encourage further development of nursing care to the elderly.

Keywords: Geriatric nursing; Elderly; Nursing care


RESUMEN: Se trata de un ensayo reflexivo de la práctica de enfermería gerontológica, fundamentado en la Teoría de la Diversidad y Universalidad del Cuidado Cultural de Leininger, que resalta el proceso del cuidar involucrado con las cuestiones culturales del individuo. Se realizó una investigación bibliográfica en la base de datos LILACS; en el período de enero de 1970 a junio del 2006. Se capta que el desarrollo del cuidado gerontológico fundamentado en esta teoría necesita profundización, pues la literatura aun es escasa. La visión pluralista del proceso de cuidar incita aproximaciones y compromisos sólidos entre el profesional y el ser anciano, acentúa los principios de respeto, compromiso y responsabilidad. La introducción de métodos adecuados en el proceso de cuidar del anciano, interactúa con la promoción de la salud en búsqueda de la sustentabilidad y del cuidado emancipable, posibilita la independencia y autonomía para el ser anciano/familia/comunidad. Se espera que estas reflexiones sirvan como estímulo para el desarrollo de las competencias necesarias para la práctica del cuidado gerontológico digno de la persona anciana.

Descriptores: Enfermería geriátrica; Anciano; Cuidados de enfermería




Elders have specific health care needs. There are particularities intrinsic to this ever growing population, which calls for an increasingly capacitated staff to provide the special health care they require.

The valorization movement and discussions regarding the aspects that permeate the elderly population became more intensive in the mid-1970s. Studies and reflections on these issues are considered relatively recent. Therefore, from a broader view, little is known about elders and the aging process.

There are three divisions in aging: primary, secondary or pathological, and tertiary or terminal. Primary aging is a universal phenomenon which affects everyone. It is progressive and results in a reduced ability to adaptation. Moreover, it is correlated with numerous factors, like diet, exercise, life style, and other aspects that could lead to different forms of aging(1).

Secondary or pathologic aging refers to the changes caused by aging-related illnesses, which should not be confused with the normal changes in this process.

Tertiary or terminal aging is characterized by a considerable increase in cognitive and physical impairment in a relatively short period of time. Eventually, death takes place; either due to age-related illnesses or to the accumulation of normal and pathological aging effects(1).

Regarding aging and pathologies, it is worth emphasizing that:

"elders with one or more illnesses […] could be considered healthy elders if compared to others with the same illnesses but with no control over them, with resulting sequelae and associated incapacities […], healthy elders are physically and mentally healthy, independent regarding their everyday life, socially integrated, have family support, and financial independence. Most importantly, elders should maintain their autonomy, feel happy, and be socially integrated; emphasizing that health and longevity are inseparable concepts"(2).

Elder's lifestyle depends upon their life concepts, beliefs, values, and knowledge, which are variables integrating the culture of individuals, families, or communities. In addition, the implied complexity of nursing care and the consequences of the caregiver/elder relationship evidences the importance of considering and integrating the elders' culture in the principles of geriatric health care. The cultural framework is understood as approaching the multiple dimensions that comprise the lifestyle of certain individuals, considering their beliefs, values, and knowledge. This approach permits healthcare professionals to approach elders, their families, and their life contexts.

Elders' families, from this perspective, are understood as a group and strong ally of the health care professional in the development of geriatric care. It is presumed that nursing, as a profession providing essentially cross-cultural care, focuses on providing people with humane care in a significant, congruent, and respectful way, considering their cultural values and lifestyles(3).

One of the paths to successfully developing geriatric care is through cultural care, defined as "cognitively known values, beliefs, and standardized expressions, which help, support, or capacitate other individuals or groups to maintain their wellbeing, improve a condition or human life, or face death and impairments"(4-5). Cultural care is part of the necessary premises for the construction of a sustainable geriatric care development model.

To develop geriatric care, there must be interaction with elderly-beings, with a view to understanding and learning about their way of living, as well as that of their families and/or people involved in the process. This journey to geriatric care is founded on the multiplicity of cultural principles. The later refer to the multiple dimensions of elderly life, including spatial, physical, economic, social, and environmental dimensions. Thus, this journey increases the chances of the developed care being sustainable, in addition to fostering the awareness and apprehension of the amplitude that integrates the process of geriatric health care in nursing.

In this view, the purpose of this reflective assay is to unveil aspects concerning geriatric health care founded on the Theory of Cultural Care Diversity and Universality(3-4) with a view to support dignified health care to elderly people.



This is a reflective assay concerning the involvements of the cross-cultural theory on the sustainability of geriatric health care. The literature material was identified by means of a survey in the LILACS database. The researched period was from January 1970 to June 2006. The primary keywords used were geriatric care or Theory of Cultural Care Diversity and Universality; secondary keywords: elderly or old age or aging; and tertiary: geriatrics or nursing. Texts were included in the survey provided they explicitly used or conceived the cross-cultural theory or geriatric nursing care in the abstract.

Regarding the results, data were subdivided into two subsections: Human aging and geriatrics; and Contributions of the cross-cultural theory to geriatric nursing care.



The surveyed references were exclusively in the Portuguese Language. For the keyword geriatric care, four references were found, whereas seven references were found for Theory of Cultural Care Diversity and Universality. The keyword elderly rendered several references, but only four were associated with geriatric care and none concerned the Theory of Cultural Care Diversity and Universality.

The terms old age, aging, geriatrics, and nursing, also provided many references. However, only one or two for each term were related to geriatric care. Moreover, when analyzed in terms of the Theory of Cultural Care Diversity and Universality, no references were found, except when using the term allied with the keyword nursing, which yielded five articles, in this case.

The findings show that few articles available in LILACS address geriatric care and the Theory of Cultural Care Diversity and Universality. Nearly no references regarding both themes simultaneously were found. Hence, the following section presents a clarification of the subjects involved in this article, based on the performed literature survey.



Human aging and geriatrics

Starting from the presupposition that aging is something personal, a phase in life, which is intrinsically associated with objective issues, and subjective to each person and to the present context, it is implied that aging begins with birth and ends with death. The rhythm of aging is influenced by several intrinsic variables, as well as the context of life, including multiple dimensions: social, economic, cultural, spatial, and the environment.

It should be stated that old age is a moment in life with particular values and characteristics. In this phase, people go though changes, concerning several aspects, including their organic structure, metabolism, biochemical balance, immunity, nutrition, functional mechanisms, and their intellectual, emotional, and social features. Physiological and physiopathological conditions should also be considered, since they present age-associated differences.

"Old age is a biological phenomenon: the elder's organism has certain singularities; there are psychological consequences: certain behaviors are considered, with reason, as particular to advanced age. As all human situations, it has an existential dimension: it changes one's relation with time and, therefore, their relation with the world and with their own history also changes"(5)



Until today, there is no overall consensus regarding what "old age" is, mainly because functional or chronological age does not always correspond to the aging process. Hence, it is believed that it is not possible to define old age exclusively by one's chronological age. Rather, it is determined by one's current conditions; biological, psychological, and social, altogether. Furthermore, subjective age is also part of this process.

The latter means more than simply another form of defining old age; it is a form of representation the changes in the elderly population's profile, in which aging is accompanied by development, and, mainly, new possibilities regarding work, pleasure, knowledge, or lifestyle. The subjective age means a rupture with certain elder-related stigmas, like being inactive, unproductive, obsolete, lonely, and many others. However, loneliness, abandonment, and the particular physical condition of old age can not be disregarded. On the contrary, these aspects should be carefully considered while planning health care actions(6).

Population aging induces the need to make new social and health care service requirements. This involves health promotion issues, including personal aspects and those regarding the context of the elder's life.

"Therefore, a political effort is called for; with a view to including this population's needs in the social agenda"(7). These needs are multidimensional and have increasingly become more urgent. Hence, it is crucial that public policies be planned to meet the needs of this population.

The analysis of the aspects that permeate elders and aging shows it is possible to learn about this subject's coverage. It is emphasized that "to reach a healthy old age, health promotion should occur throughout one's life, because aging does not begin at 60. Rather, it is the sum and interaction of social processes, health, and behaviors during one's entire life"(8). People are responsible for building their own healthy aging and old age, which will depend upon their view of the world and how they feel in it, in a way that values are attributed to old age in its individual and global context.

In this profusion, geriatrics is continuously under development, aiming at longevity and elder's life quality. Elders should be treated different from adults considering health care. That is, their questions and health care needs should not be addressed in the same way. Knowing the concepts, terms, and theories that support geriatrics is essential.

"Geriatrics emerges as a specific and multidimensional knowledge area concerning aging. It establishes connections between scientific subjects. This includes nursing, which interacts and articulates with other areas, communicating ideas and integrating information to form determined knowledge. Moreover, this interaction also concerns organizing geriatrics-related research and education(9)".

Geriatrics is capable of recombining, reconstructing, and elaborating the synthesis of these knowledge subjects, incorporating them with concepts of analysis, instruments, and methodological techniques regarding health care. Therefore, it is capable of promoting research with an advantageous integration regarding the elderly. This factor gives an idea of complementarity between geriatrics theory and practice, not only regarding mere knowledge, but also in terms of increasing scientific knowledge with practical cognition, understanding it with real possibilities of change(10).

Involvements of the Theory of Cultural Care Diversity and Universality in geriatric nursing care

Geriatrics care involves promoting health to the elderly in a context that includes family, interactions, culture, conditions, and the community. The Ottawa Letter is a milestone for health promotion, since it was in this conference that health promotion was defined as a process of capacitating the community to act towards the improvement of health and life quality, with increased participation in controlling this process(11-13).

In geriatrics care, the main emphasis is on health promotion, which is understood as the search for changes in life conditions to make them dignified and adequate. It points to the transformation of individual processes regarding decision making, so that decisions are predominantly favorable to life quality and health. Moreover, it is guided by a group of collective actions and decisions to favor health and the improvement in wellbeing conditions(14).

Geriatric nursing care requires abilities and knowledge, and presupposes a dialectic relationship between health care professionals and elders. In addition, it requires a permanent posture of reflection from health care professionals as well as effective investments with a view to meeting the needs and providing all the potentialities that can be offered to the elderly.

The relationship between elders and health care professionals highlights aspects of micro and macro contexts, aiming at the emancipation of the elder, besides the individualized care involving family, creativity, effort, and the realistic solution for the identified needs.

Being an elder is a projection of the future that belongs to everyone, which becomes more and more difficult to be practiced as citizenship. Dignified care is a value, a right at any age, which should be emphasized in old age. It is an important determinant to the development of a healthy old age. From this approach, geriatric nursing health care promotion should take place through dignified care with a view to elucidating the path to well being.

It is possible to improve elderly patients' care by introducing appropriate methods to the process. With this view, the Theory of Cross-Cultural Care Diversity and Universality, developed by Madeleine Leininger, is pertinent to the proposition. Due to the need of perceiving and understanding the diversity of attitudes that elderly patients have, the aforementioned theory emerges in an attempt to provide health care professionals with support for seeking forms of appropriate care considering the preservation of elders' cultural identity.

Considering that life is a unique process, perceived in an exclusive way, and that the roots of behavior in specific situations are largely based on personal beliefs in addition to historical and cultural factors, it is observed that there is a need to approach and involve the Theory of Cultural Care Diversity and Universality in geriatrics care in nursing.

Based on this premise, geriatrics care in nursing stems from the cultural context in which it should be provided and develops from the interactions between elderly patients/family/community. This theory helps nurses to discover and document the world of elderly patients and use their points of view, knowledge, and practice, along with their professional experience, as the bases to adopt actions and make professional decisions consistent with the culture.

Performing cultural care confirms part of the theory of nursing care integrality, it considers the perspective of human life and existence over time, including cultural and social factors, view of the world, history, cultural values, environmental context, language expressions, and popular and professional models. It is a determinant factor for health promotion, development, and maintenance, as well as for sustainability of health care actions. Hence three forms of nursing care decisions and actions are presented:

Maintaining or preserving cultural care refers to the professional actions and decisions regarding health care and preparation that help people of a certain culture to adjust or preserve health care values relevant for maintaining their wellbeing, recover from illnesses, or cope with impairment or death.

Accommodation or negotiation of cultural care refers to the creative actions and decisions regarding health care, support, facilitation or preparation that help people of a certain culture to adapt to others or negotiate with them to obtain a beneficial and satisfactory result from health care professionals.

Remodeling or restructuring cultural care refers to the professional actions and decisions regarding health care, support, facilitation and preparation that help clients to reorganize, change, or significantly modify their lifestyles to a new, different, and beneficial health care model, while respecting the cultural values and beliefs, and promotes a more beneficial and healthful lifestyle compared to the one before co-establishing the changes with clients3:48-49.

While providing nursing care as proposed by Leininger, health care professionals should make an initial approach to the elder, his/ her family and life context, including the several aspects involved in this experience. The purpose is to understand, learn, and evaluate the health care process developed by the subjects. "The cultural care approach permits health care to be extended to relatives, while nurses interact with family members and they see their real interest in sharing and helping the relative […]"(15). Reflections concerning elders' reality and experiences, as well as those of their families, serve as the basis for nurses to propose culturally consistent health care applicable to the life process of individuals and/or communities involved in the health care process, thus encouraging health care principles.

Nurses' challenge is to know and creatively combine nursing practice and generic community knowledge, thus guaranteeing and preserving the elders' cultural rights. The developed actions, taking the mentioned aspects into consideration, have a strong chance of becoming sustainable practices. Considering the need for creative nursing actions adequate to elders' reality, it appears that the cultural care methodology translates the patients' language.

The knowledge regarding cultural care should guide geriatric practices, making them more legitimated for considering and respecting the cultural knowledge of care, developed for elders. Nursing care founded on the cultural line contributes to breaking the barriers of impersonality of nurses towards patients. This is because, by trying to know elders integrally, nurses have more contact with patients' daily habits and events, changing their focus regarding elders, so that, this way, health care instructions can be dynamic, appropriate, and personalized.

In this approach, geriatric nursing care requires health care professionals to assist elders in a unique, creative, interested way with the view to sustaining the genuine geriatric care.



Knowledge regarding theoretical-conceptual and methodological frameworks of the geriatric subject and nursing theories are essential in nursing education, as well as for those who wish to create appropriate forms of involvement in elderly health care. It is essential to understand the characteristics concerning aging, situations of eugeria or pathogeny as well as the relevance of cultural aspects in order to perform geriatric research using the knowledge and also developing achievements regarding the dimension of elderly population citizenship. Helping the elderly, within their possibilities, to become emancipated, independent and autonomous, is essential to the development of dignified nursing health care for the elderly.

The development of geriatric health care founded on the Theory of Cultural Care Diversity and Universality could generate solid approximations and involvements between health care professionals and elderly patients, since the actions are planned, developed in collaboration, and based on the elders' experiences.

It is possible to introduce appropriate methods in the process of geriatric care, interacting with health promotion to seek process sustainability and the initiative to emancipatory health care, making independence and autonomy possible for elders.

This article presented part of the appropriate theoretical framework for geriatric nursing care, which approached cultural aspects. However, this framework is only close to the ideal preparation of health care professionals in the nursing team. It is expected that these reflections encourage the development of the competencies necessary to provide nursing care that sustains dignified geriatric care to elders.



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Autor Correspondente:
Karina Silveira de Almeida Hammerschmidt
R. Alferes Poli, 271 - Apto 1503 - Centro
Curitiba - PR - CEP. 80230-090

Artigo recebido em 03/07/2006 e aprovado em 29/05/2007



* Study carried out in the Nursing Masters Program at the Paraná Federal University - UFPR, Curitiba (PR), Brazil.

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