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Theoretical reflections of Leininger’s cross-cultural care in the context of Covid-19

Reflexiones teóricas del cuidado transcultural de Leininger en el contexto de Covid-19

ABSTRACT

Objective

To reflect on cross-cultural care for the population based on the theoretical assumptions and concepts of Leininger’s Transcultural Theory, related to the recommendations for combating the Covid-19 pandemic.

Method

Reflective theoretical study based on culturally competent care, related to the Brazilian reality, using the conceptual attributes of care, culture, and worldview. Critically articulated the reasonings about the guidelines for preserving, accommodating, and repatterning actions for the care of people.

Results

The nurse must know cross-cultural care in order to consider individual and/or collective treatment and respect the existing differences in beliefs and values. This premise corroborates the adherence to Covid-19 prevention and treatment recommendations. The lack of knowledge about the transmissibility and invisibility of the virus and the risk factors, combined with the cultural diversity of the population, can make it difficult to adhere to health recommendations.

Final considerations

Cross-cultural care favors the practice of health education and can provide conditions for greater adherence of the population to nursing actions.

Keywords
Nursing theory; Transcultural nursing; Nursing care; Coronavirus infections; Covid-19

RESUMEN

Objetivo

Reflexionar sobre la atención intercultural para la población a partir de los supuestos y conceptos teóricos de la teoría transcultural de Leininger, relacionados con las recomendaciones para combatir la pandemia de Covid-19.

Método

Estudio teórico reflexivo basado en el cuidado culturalmente competente, relacionado con la realidad brasileña, utilizando los atributos conceptuales del cuidado, la cultura y la cosmovisión. Se articuló críticamente el razonamiento sobre las directrices para preservar, acomodar y repotenciar las acciones de atención a las personas.

Resultados

La enfermera debe conocer los cuidados interculturales para considerar el tratamiento individual y/o colectivo y respetar las diferencias existentes en cuanto a creencias y valores. Esta premisa apoya la adhesión a las recomendaciones de prevención y tratamiento de Covid-19. El desconocimiento de la transmisibilidad y la invisibilidad del virus y de los factores de riesgo, junto con la diversidad cultural de la población, pueden dificultar el cumplimiento de las recomendaciones sanitarias.

Consideraciones finales

La atención transcultural favorece la práctica de la educación para la salud y puede proporcionar condiciones para una mayor adhesión de la población a las acciones de enfermería.

Palabras clave
Teoría de enfermería; Enfermería transcultural; Atención de enfermería; Infecciones por Coronavirus; Covid-19

RESUMO

Objetivo

Refletir sobre o cuidado transcultural à população a partir dos pressupostos teóricos e conceitos da Teoria Transcultural de Leininger, relacionados às recomendações para o combate da pandemia da Covid-19.

Método

Estudo teórico reflexivo baseado no cuidado cultural competente, relacionado à realidade brasileira, utilizando-se os atributos conceituais de cuidado, cultura e visão de mundo. Articularam-se de modo crítico os raciocínios sobre a orientações de preservar, acomodar e repadronizar ações para o cuidado das pessoas.

Resultados

O enfermeiro deve conhecer o cuidado transcultural para considerar o tratamento individual e ou coletivo e respeitar as diferenças existentes sobre as crenças e valores. Essa premissa corrobora para a adesão às recomendações de prevenção e tratamento da Covid-19. O desconhecimento sobre a transmissibilidade e invisibilidade do vírus e dos fatores de risco, aliados à diversidade cultural da população, podem dificultar a adesão às recomendações sanitárias.

Considerações finais:

O cuidado transcultural favorece a prática da educação em saúde e pode proporcionar condições para maior adesão da população às ações de enfermagem.

Palavras-chave
Teoria de enfermagem; Enfermagem transcultural; Cuidados de enfermagem; Infecções por Coronavirus; Covid-19

INTRODUCTION

The fight against the Covid-19 pandemic is challenging in terms of population adherence to the health recommendations guided by the World Health Organization (WHO); Ministry of Health; Brazilian State and Municipal Governments. With the spread of the disease in all countries of the world, nursing became very visible and its role on the frontline favored advances in the construction of knowledge. The use of theoretical references of nursing becomes useful to support the actions of the practice of care in health education for the general population.

Among the renowned theorists who postulated constructs and concepts about nursing care, Leininger's Theory of Diversity and Universality of Cultural Care (TDUCC) was chosen due to the potential of conceptual abstraction of the theory to understanding the problems surrounding the issue of health related to the spread of Covid-19.

It is justified that reflecting on care from the perspective of people and understanding the sociocultural origin of health complications11. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
https://doi.org/10.14198/cuid.2018.51.01...
-22. Reis AT, Santos RS, Paschoal Júnior A. O cuidado à mulher na contemporaneidade: reflexões teóricas para o exercício da enfermagem transcultural. Rev Min Enferm. 2012 [cited 2020 Apr 10];16(1):129-35. Available from: http://www.reme.org.br/artigo/detalhes/510
http://www.reme.org.br/artigo/detalhes/5...
in the pandemic context, corroborates the planning. Care based on respect and knowledge about how people and/or specific populations adhere or not to health recommendations and universal protocols may reflect the level of basic knowledge of hygiene and health education of this population.

The questions about the absence of drug therapy based on scientific evidence, the difficulties related to the amount of vaccine doses available and the discontinuation of the vaccination campaign and the non-adherence to social distancing and preservation of lives at the expense of political interests, increased the cases of the disease.

A radical change in people’s behavioral pattern at this moment deserves reflections on how nurses can develop care actions.

It is recognized that the foundation on the theoretical assumptions of TDUCC brings possibilities to observe and associate the differences between populations and their respective habits. From there, data on habits, beliefs and culture can support nursing care practice, as a tool for instrumentation and registration for nurses11. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
https://doi.org/10.14198/cuid.2018.51.01...
-22. Reis AT, Santos RS, Paschoal Júnior A. O cuidado à mulher na contemporaneidade: reflexões teóricas para o exercício da enfermagem transcultural. Rev Min Enferm. 2012 [cited 2020 Apr 10];16(1):129-35. Available from: http://www.reme.org.br/artigo/detalhes/510
http://www.reme.org.br/artigo/detalhes/5...
.

In view of the pandemic, which for many still Covid-19 is unknown and not harmful, there is difficulty in recognizing and adhering to its containment guidelines.

Drastic and prolonged changes in social and work lifestyles were observed, with the need to avoid crowding, closing establishments, guidelines to stay at home, as well as the limitation of interpersonal contacts and reduction of proximity.

Important restrictive actions were effective to contain the spread of the virus in many countries, however in Brazil they were fought. In addition, there were differences in the level of adherence and restrictive behavior both by the population and by government officials at the federal and state level.

It is considered here that aspects related to cultural diversity and time for the population to adapt may have resulted in different patterns of behavior.

Adaptive changes are still needed in care during the Covid-19 pandemic, demonstrated here as an example of how to consider culture in collective health care, depending directly on awareness, acceptance and acquisition of individual knowledge.

Cross-cultural nursing bases the practice and instrumentalizes it so that nurses can predict the change in people's behavior and understand the sociocultural origin of most health complications. It is based on the principle that cross-cultural care can interfere with the achievement of positive results in relation to the acquisition of new individual and collective habits.

Thus, the application of the TDUCC33. Melo LP. A contemporaneidade da Teoria do Cuidado Cultural de Madeleine Leininger: uma perspetiva geo-política. Ensaios Ciênc: Ciênc Biol Agrárias Saúde. 2010 [cited 2020 Apr 10];14(2):20-32. Available from: https://www.redalyc.org/articulo.oa?id=26019017002
https://www.redalyc.org/articulo.oa?id=2...
provides assumptions and subsidies aligned with cross-cultural care, as it subsidies the collection of information and helps in the implementation of actions and new behavioral patterns; recognition of differences and grounding the practice of nursing care.

Considering the different cultural contexts, based on the knowledge of the TDUCC, nursing can propose care actions that consider people’s beliefs and their values built over time, and conciliate educational and care adaptations to the population’s way of life, so that sanitary restrictions are obeyed. Thus, the practice of care becomes effective and meaningful.

A common health care nowadays is to preserve lives, and it should be the essence and priority for all peoples, regardless of the cultural diversity existing in the world.

Given the exposed scenario and the urgent need for actions based on cross-cultural care to increase the likelihood of changes in behavior and adherence of the general population to health recommendations, and that they can prevent the increase in cases of Covid-19, it is justified the present theoretical reflection.

Thus, the objective of this study was to reflect on the cross-cultural care of the population based on the theoretical assumptions and concepts of the TDUCC, related to the recommendations for combating the Covid-19 pandemic. We sought to demonstrate the reflections on the interrelationship of the concepts of TDUCC, proposed by Leininger11. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
https://doi.org/10.14198/cuid.2018.51.01...
in the construction of knowledge in cross-cultural nursing care in the context of the Covid-19 pandemic.

Context of the Covid-19 pandemic

The WHO Guidelines44. World Health Organization (CH). Infection prevention and control during health care when COVID-19 is suspected: interim guidance 25 January 2020. Geneva: WHO; 2020 [cited 2020 abr 20]. Available from: https://apps.who.int/iris/bitstream/handle/10665/330674/9789240000919-eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand...
which guide universal actions to be adopted by the world population in combating the pandemic caused by Covid-19, require care for oneself and for others. The pandemic caused by the new coronavirus started in December 2019, in the city of Wuhan, China, where the first cases were reported as pneumonia of unknown etiology. The pathogen has been recognized as a new virus, called Coronavirus-2 related to Severe Acute Respiratory Syndrome (SARS-CoV-2). The pathology caused by SARS-CoV-2 was then named Coronavirus 19 Disease (Covid-19) and recognized by the WHO as an International Public Health Emergency55. Spellberg B, Haddix M, Lee R, Butler-Wu S, Holtom P, Yee H, et al. Community prevalence of SARS-CoV-2 among patients with influenza like illnesses presenting to a Los Angeles Medical Center in March 2020 [research letter]. JAMA. 2020;323(19):1966-7. doi: https://doi.org/10.1001/jama.2020.4958
https://doi.org/10.1001/jama.2020.4958...
.

Covid-19 has four modes of transmission, whether by contact, droplet or aerosol: transmission from contaminated surfaces; by asymptomatic; pre-symptomatic or symptomatic people66. Qun L, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med.2020;382(13):1199-207. doi: https://doi.org/10.1056/NEJMoa2001316
https://doi.org/10.1056/NEJMoa2001316...
. The clinical condition ranges from oligo/asymptomatic to severe pneumonia, which includes Shock and Severe Acute Respiratory Syndrome (SARS). The frequent signs and symptoms in cases of clinical manifestation were: fever; dry cough; asthenia; dyspnea; myalgia and respiratory secretion77. Zhou F, Ting Y, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. doi: https://doi.org/10.1016/S0140-6736(20)30566-3
https://doi.org/10.1016/S0140-6736(20)30...
.

Nurses can use everyday facts and examples, in the form of metaphors, to bring together the understanding of guidelines that can facilitate people's daily lives. The use of theoretical assumptions by nurses facilitates and supports guidelines to propose and adapt alternatives that are congruent with the health recommendations and characteristics of each individual/population.

In this context, the use of the means of communication and the Internet between families and health units; tele-orientation and telemedicine; video calls are alternatives imposed by social distancing and social isolation. People’s access to information is often restricted to television and radio, due to the lack of communication via the Internet.

In the area of school education and religious practice, the use of virtual rooms for meetings were essential adaptations to maintain remote teaching and religious traditions. The drive-thru system; scheduling appointments for attendance of any nature; home office work are behavioral actions and attitudes that had to be implemented to maintain the survival of daily activities.

Thus, for the present theoretical reflection, issues related to the control of the pandemic and its relationship with cultural differences between individuals were considered. The cultural aspect is essential for the awareness and attitude of the population, as it can determine the appropriate and desired health behavior at this moment. Nursing based on cross-cultural concepts can contribute efficiently and resolutely to reach desired levels of health and compliance with health requirements, as well as reduce the levels of transmissibility of the disease.

The health recommendations contradicted cultural, religious and leisure habits of people and populations such as: distancing and social isolation; hand hygiene frequently; rigor in relation to personal and collective hygiene measures; changes in the social habit of greeting; avoid crowds for leisure and face-to-face meetings in general. It involved changing practices and traditions, such as simply receiving and greeting people with hands or kisses on the cheek. However, the preservation of human life is a priority at this time.

The use of the TDUCC concepts can contribute to guide the actions of nurses with vulnerable populations and support changes in people’s attitudes and habits.

The TDUCC and the Sunrise conceptual model

Theoretical conceptualization included the terms care, culture and worldview. The theoretical construct called care is defined as something essential for the conservation, evolution and competence to face life situations, considering assistance, aid and behaviors that favor, stimulate or improve the individual’s condition. The TDUCC influenced care actions based on the perspective of people and not on the perspective of nurses and is characterized by holistic and human care to the family, individual and community88. Dee Ray MA. Remembering: my story of the founder of Transcultural Nursing, the late Madeleine M. Leininger, PhD, LHD, DS, RN, CTN, FAAN, FRCNA (Born: July 13, 1925; Died: August 10, 2012). J Transcult Nurs. 2019;30(5):429-33. doi: https://doi.org/10.1177/1043659619863089
https://doi.org/10.1177/1043659619863089...
.

The nurse’s role in cultural care planning may interfere with the patterns of beliefs, values ​​and practices of individuals in a community and influence individual actions, decisions and thoughts, however, they must have prior knowledge of human expressions, of the social structure, cultural, education and of health11. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
https://doi.org/10.14198/cuid.2018.51.01...
.

Thus, cross-cultural care must provide for cultural diversity, demographic transformations and people’s change, as most of the health complications of individuals are from sociocultural origin11. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
https://doi.org/10.14198/cuid.2018.51.01...
-22. Reis AT, Santos RS, Paschoal Júnior A. O cuidado à mulher na contemporaneidade: reflexões teóricas para o exercício da enfermagem transcultural. Rev Min Enferm. 2012 [cited 2020 Apr 10];16(1):129-35. Available from: http://www.reme.org.br/artigo/detalhes/510
http://www.reme.org.br/artigo/detalhes/5...
.

The definition of care, according to the TDUCC, emphasizes the understanding of diversity (inequality) and universality (equality) between cultures associated with care. Thus, the nurse needs to assist and facilitate the patient’s search for well-being and offer pertinent care to the culture, in order to achieve the expected results99. Barbosa MEM, Corso ER, Scolari GAS, Carreira L. Interdisciplinarity of care to the elderly with Alzheimer’s disease: reflection to the light of the theories of Leininger and Heller. Esc Anna Nery. 2020;24(1):e20190083. doi: https://doi.org/10.1590/2177-9465-EAN-2019-0083
https://doi.org/10.1590/2177-9465-EAN-20...
-1111. Muñoz-Henríquez M, Pardo-Torres MP. Signifcado de las prácticas de cuidado cultural en gestantes adolescentes de Barranquilla. Aquichan. 2016;16(1):43-55. doi: https://doi.org/10.5294/aqui.2016.16.1.6
https://doi.org/10.5294/aqui.2016.16.1.6...
.

The culture construct consists of the grouping of beliefs, values and norms of a given reality and social community. Understanding the culture of each individual/community favors the treatment and decision-making of nurses, but this requires time and clinical reasoning about decision-making in care practice1010. Jiménez-Ruiz I, Martinez PA. Famale genital mutilation and transcultural nursing: adaptation of the Rising Sun Model. Contemp Nurse. 2017;53(2):196-202. doi: https://doi.org/10.1080/10376178.2016.1261000
https://doi.org/10.1080/10376178.2016.12...
.

According to Leininger11. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
https://doi.org/10.14198/cuid.2018.51.01...
,33. Melo LP. A contemporaneidade da Teoria do Cuidado Cultural de Madeleine Leininger: uma perspetiva geo-política. Ensaios Ciênc: Ciênc Biol Agrárias Saúde. 2010 [cited 2020 Apr 10];14(2):20-32. Available from: https://www.redalyc.org/articulo.oa?id=26019017002
https://www.redalyc.org/articulo.oa?id=2...
, appropriating and considering the content of knowledge of the culture of people and groups to provide care is essential, because due to cultural diversity exist different ways of thinking and practicing health actions, which can change and interfere in the reality of care. Understanding the culture of the community to be cared for favors the approach of nurses, who will be able to accurately assess the demand for health care, in addition to establishing a professional bond.

Finally, the worldview theoretical construct is established as the way in which each individual sees the world/universe and builds a framework of attitude or value regarding the relationship between themselves and the world. Leininger11. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
https://doi.org/10.14198/cuid.2018.51.01...
,33. Melo LP. A contemporaneidade da Teoria do Cuidado Cultural de Madeleine Leininger: uma perspetiva geo-política. Ensaios Ciênc: Ciênc Biol Agrárias Saúde. 2010 [cited 2020 Apr 10];14(2):20-32. Available from: https://www.redalyc.org/articulo.oa?id=26019017002
https://www.redalyc.org/articulo.oa?id=2...
adds how this postulate can harm or favor the individual’s life, mentions that deviations in the discrimination of the caregiver’s perception and cultural awareness contribute to the patient’s lack of confidence, resulting in non-adherence, lack of communication, negative endings and health inequality1212. Leininger M, Mc Farland M. Culture care diversity and universality: a worldwide nursing theory. 2th ed. Boston: Jones and Barlett Pubs; 2006..

In a conceptual model called Sunrise, Leininger proposed four levels of abstraction and the interrelationship of his theory concepts.

At the first level, the dimension of cultural and social structure involves technological factors; religious and philosophical; companionship/kinship and social; cultural values and ways of life; political and legal; economic and educational factors. These influence the worldview, the standard of care and the expressions arising from individual groups, families and institutions around their perceptions of the world99. Barbosa MEM, Corso ER, Scolari GAS, Carreira L. Interdisciplinarity of care to the elderly with Alzheimer’s disease: reflection to the light of the theories of Leininger and Heller. Esc Anna Nery. 2020;24(1):e20190083. doi: https://doi.org/10.1590/2177-9465-EAN-2019-0083
https://doi.org/10.1590/2177-9465-EAN-20...
.

In the sequence proposed by the theoretical, level two is based on the study of the first level, where the nurse will carry out this knowledge with the patient and/or population, being them, family, individual, group within a health system, researching meanings and expressions regarding care1212. Leininger M, Mc Farland M. Culture care diversity and universality: a worldwide nursing theory. 2th ed. Boston: Jones and Barlett Pubs; 2006.-1313. McFarland MR, Wehbe-Alamah HB. Leininger’s Theory of Culture Care Diversity and Universality: an overview with a historical retrospective and a view toward the future. J Transcult Nurs. 2019;30(6):540-57. doi: https://doi.org/10.1177/1043659619867134
https://doi.org/10.1177/1043659619867134...
.

On the third level, Model Sunrise highlights popular and professional systems; beliefs; values and nursing. The theorist postulates the recognition of differences and similarities, that is, specific and universal particularities of the culture of the individual/family/group studied1212. Leininger M, Mc Farland M. Culture care diversity and universality: a worldwide nursing theory. 2th ed. Boston: Jones and Barlett Pubs; 2006.-1313. McFarland MR, Wehbe-Alamah HB. Leininger’s Theory of Culture Care Diversity and Universality: an overview with a historical retrospective and a view toward the future. J Transcult Nurs. 2019;30(6):540-57. doi: https://doi.org/10.1177/1043659619867134
https://doi.org/10.1177/1043659619867134...
. Here, the nurse identifies what the individual considers important in his life in the situation he is experiencing, after which the problem is named, which is equivalent to the identification of nursing diagnoses.

On the fourth level, congruent nursing care is developed, described by three modes of care/action: Preservation/Maintenance of Cultural Care, which concerns actions that support cultures to remain and preserve their values and beliefs; Accommodation/Negotiation of Cultural Care, it is up to the acts that help cultures to agree or adjust congruent care and Repatterning/Restructuring of Cultural Care, these are mutual actions and measures or capabilities that contribute to individuals transforming or restructuring their form and entities for better health care models1212. Leininger M, Mc Farland M. Culture care diversity and universality: a worldwide nursing theory. 2th ed. Boston: Jones and Barlett Pubs; 2006.-1313. McFarland MR, Wehbe-Alamah HB. Leininger’s Theory of Culture Care Diversity and Universality: an overview with a historical retrospective and a view toward the future. J Transcult Nurs. 2019;30(6):540-57. doi: https://doi.org/10.1177/1043659619867134
https://doi.org/10.1177/1043659619867134...
.

The conceptualization of the TDUCC demonstrated relevance to the practical issues required by the pandemic context, especially in the reflection on adherence to the imposed sanitary measures. Culturally, people have different values and habits and so the epidemiological results are also diverse.

Development of reflection under the light of Leininger’s TDUCC in the perspective of the Covid-19 pandemic

Health care for the general population, affected by the threat of Covid-19, can be approached by nursing in order to constitute a form of cross-cultural care. The universal recommendations advocated by the WHO and national bodies of each country involved, comprise measures of hygiene, prevention of contagion and social isolation that have a high impact on flattening the curves, which can grow exponentially if the population does not adhere to the new social, economic and health habits.

Thus, for reflective reasoning, it was used the model called “Sunrise”22. Reis AT, Santos RS, Paschoal Júnior A. O cuidado à mulher na contemporaneidade: reflexões teóricas para o exercício da enfermagem transcultural. Rev Min Enferm. 2012 [cited 2020 Apr 10];16(1):129-35. Available from: http://www.reme.org.br/artigo/detalhes/510
http://www.reme.org.br/artigo/detalhes/5...
,1313. McFarland MR, Wehbe-Alamah HB. Leininger’s Theory of Culture Care Diversity and Universality: an overview with a historical retrospective and a view toward the future. J Transcult Nurs. 2019;30(6):540-57. doi: https://doi.org/10.1177/1043659619867134
https://doi.org/10.1177/1043659619867134...
, to demonstrate the factors involved in the relationship of adherence or health recommendations by the general population, based on the four levels of abstractions.

In daily practice, and as an example, the difficulty of adherence of elderly people to health recommendations is cited, as it requires a sudden change in social and cultural habits that are so ingrained in their lives. Another important and instigating aspect of the present reflection is the non-recognition by people that an invisible microorganism is configured as a dangerous enemy to the point of altering social coexistence, leisure, and work practices. New habits emerged as study meetings and distance work via Internet.

The acceptance of new meanings, such as changing habits and adherence to actions of distancing and even social isolation, can be influenced by the population’s lack of knowledge about the invisibility and pathogenicity of the virus and, finally, notions of microbiology. These aspects can substantially interfere with the population’s adherence to health recommendations, and consequently, with the spread of the virus.

Thus, the TDUCC provides theoretical support to nurses to carry out the planning of cross-cultural care, based on the concepts of care, culture and worldview, based on the reflective process. The understanding of these factors by nurses contributes to select strategic actions to increase the population’s adherence to sanitary measures.

The assumptions described in the Sunrise model1313. McFarland MR, Wehbe-Alamah HB. Leininger’s Theory of Culture Care Diversity and Universality: an overview with a historical retrospective and a view toward the future. J Transcult Nurs. 2019;30(6):540-57. doi: https://doi.org/10.1177/1043659619867134
https://doi.org/10.1177/1043659619867134...
comprise the dimension of the cultural and social structure: technological factors; religious and philosophical factors; companionship and social factors; cultural values and ways of life; political and legal factors; economic factors and educational factors. They help in understanding the reality experienced by the individual/community.

So we have as Technological Factors those that refer to a technology that scientifically allows to investigate microscopic pathogenic beings; makes it possible to employ “linguistically” adequate arguments so that the sender of the message makes himself understood by the receiver of the message; which symbolic arguments should be used in communication, for cultural care, considering the “invisibility” of the new coronavirus. It is important to mention, as a technological factor, the advances in science and the best scientific evidence that guide and influence the adoption of new behaviors.

The Religious and Philosophical Factors positively influence the promotion of moments of prayer, meditation and spirituality. However, they can present aspects that contribute to non-adherence, by influencing the feeling that a major higher power would grant divine protection, and a hope that would dispense the recommended care and guidance.

Regarding the Companionship/Kinship and Social Factors, with the elderly, people from the risk group (due to the age factor, over 60 years and the presence of comorbidities) there were reflections on the resistance to maintaining social distance, therefore reaching to the consensus that they spent a lifetime following a routine of activities, even receiving medical guidance to go out, play sports, stay active, sunbathe, among others. Facts that in the current pandemic scenario are opposed, with the “stay at home”. Another point that corroborated the reflections on these factors was the information against maintaining social distancing and/or relaxing it, which influences and corroborates with non-adherence.

The Political and Legal Factors comprise decisions and attitudes observed by political and legal representatives, which contribute to influencing attitudes of adherence, and non-adherence to universal recommendations for combating the coronavirus.

The Economic Factors are the needs of working to maintain the conditions to fulfill the obligations assumed with food, transport, education of children, housing. In relation to the elderly population, despite the fact that many have retirement benefits, the dependence on others to “come and go” for the purchase of food and medicine can reduce the rate of social isolation.

The Educational Factors encompass people’s formal level of education and knowledge acquired during their lives; access to information and knowledge about the disease, contagion, and severity for risk groups, such as the elderly, obese, hypertensive, diabetics, etc. Another negative influence is the false news transmitted by social networks and that have a negative influence on the behavior of the population’s adherence to the recommendations, as well as bad examples coming from famous personalities and people.

Another example was a news broadcasted from an Indian religious festival1414. g1.globo.com [Internet]. Rio de Janeiro: Globo, c2021[citado 2021 abr 13]. Celebração hindu promove aglomeração no Ganges em meio a alta nas infecções por Covid na Índia; [about 1 screen]. Available from: https://g1.globo.com/mundo/noticia/2021/04/13/celebracao-hindu-promove-aglomeracao-no-ganges-em-meio-a-alta-nas-infeccoes-por-covid-na-india.ghtml
https://g1.globo.com/mundo/noticia/2021/...
. There was an agglomeration of people motivated by local religious beliefs. This fact demonstrates how much a belief overlaps the preservation of life, as India has a large number of people infected by Covid-19.

Knowing the cultural diversity and predicting care actions corroborates to make people understand that the scientific evidence regarding disease prevention such as social distancing, use of masks and hygiene, vaccination are effective.

Figure 1 shows the diagram adapted from the Sunrise Model, with the specific contents of the analysis and reflection carried out in relation to the four levels of abstraction and the factors that can interfere with the population’s adherence or non-adherence to measures of social distancing. At these levels, some actions of cross-cultural care are exemplified.

Figure 1 -
Representative diagram of the Sunrise Model with adherence and non-adherence factors to social distancing for Covid-19, adapted from Leininger’s TDUCC. Botucatu-SP, 2020

The results of discussions and reflections on the concepts of TDUCC and the current Covid-19 pandemic made it possible to realize that practically all aspects listed in the first level of theory have important arguments when postulating the factors that we should consider in the investigation to understand the occurred phenomena.

Preserving, repatterning and accommodating actions must be influenced by the nurse, always respecting the way of life, since the lack of knowledge of a cause or even mistaken knowledge can cause damage1212. Leininger M, Mc Farland M. Culture care diversity and universality: a worldwide nursing theory. 2th ed. Boston: Jones and Barlett Pubs; 2006.,1515. Oliveira EAR, Rocha SS. The parents’ cultural care towards promoting child development. J Res Fundam Care Online. 2019;11(n. esp):397-403. doi: https://doi.org/10.9789/2175-5361.2019.v11i2.397-403
https://doi.org/10.9789/2175-5361.2019.v...
. Thus, care decisions must be made jointly with the patient, based on his popular system. The care plan must be done respecting the way of life, beliefs and values. Using TDUCC as support for care assistance, enables affinity and approximation with the patient, allowing to know his worldview and values. In this way, we were able to notice the way each person is cared for, which Leininger brings to us as the cultural diversity of care.

It is noticed the relevance of knowing the socio-cultural condition of the population in cultural care. The nurse recognizes the popular and professional system and has the role of articulating this care. So, it is possible to negotiate and normalize some behaviors. Cross-cultural care will only be favorable when nurses know their patients and value their essence.

Regardless of culture, nursing care must support patients, adapting to health professionals to achieve good results. After all, the role of nurses in the restructuring of cultural care is to allow populations to make informed decisions, taking into account their culture. With this, they will achieve benefits in their health and provide culturally competent care1616. Almeida IJS, Buarque BS, Guedes TG, Sette GCS, Cavalcanti AMTS. Scientifc evidence on cultural influence in child care. Rev Rene. 2017;18(6):840-6. doi: https://doi.org/10.15253/2175-6783.2017000600019
https://doi.org/10.15253/2175-6783.20170...
.

The global scenario of Covid-19 requires that, for the recommendations to be successful, actions of cross-cultural care must be considered. With the adoption of cross-cultural care, nurses can approach and enter the care environment, similarly to the individual, enabling care in this scenario of Covid-19 pandemic, breaking the hierarchical pattern, standardizing knowledge66. Qun L, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med.2020;382(13):1199-207. doi: https://doi.org/10.1056/NEJMoa2001316
https://doi.org/10.1056/NEJMoa2001316...
. Identifying the importance social knowledge, overcomes the old ideas of the health/disease process and projects them to a new vision of nursing, which goes beyond the curative model66. Qun L, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med.2020;382(13):1199-207. doi: https://doi.org/10.1056/NEJMoa2001316
https://doi.org/10.1056/NEJMoa2001316...
. To achieve good results, the language used for dialogue with patients also needs to be restructured, taking into account the level of knowledge and understanding of patients. However, the invisibility of the virus is a factor that sometimes makes the guidelines and measures in the figure above disregarded.

The action of performing social isolation is explored and always influenced through cultural knowledges. Care assistance will be influenced by the collective and individual culture, which may respond negatively or positively to guided care22. Reis AT, Santos RS, Paschoal Júnior A. O cuidado à mulher na contemporaneidade: reflexões teóricas para o exercício da enfermagem transcultural. Rev Min Enferm. 2012 [cited 2020 Apr 10];16(1):129-35. Available from: http://www.reme.org.br/artigo/detalhes/510
http://www.reme.org.br/artigo/detalhes/5...
.

Regarding the restructuring of care, sometimes a cultural adaptation is necessary in order to employ metaphors, such as the following example:

“When a person gets close to a waterfall, he/she may not see the water present in the breeze, however, feels the breeze... and the wind drives that breeze... and when a person speaks or sneezes, it also disperses the microorganisms present in the saliva and in the droplets that come out of mouth and breath and so the virus passes from one to the other...” (Authors)

This comparison of droplets and aerosols with the breeze of the waterfall can concretely transform the invisible in order to obtain understanding and adherence to recommendations, for example the distance between people and the use of facial masks and, in it, the attempt to explain how microorganisms spread and the importance of distancing. The waterfall here was used as a concrete phenomenon and a symbolic element present in people’s lives.

Using terms present in the culture to symbolize and make oneself understand is a restructuring of care according to Leininger, which corroborates with the fulfillment of the recommendations and can lead to changes. To maintain basic needs such as food, locomotion/transport and to maintain the acquisition of basic supplies, it is necessary to adhere to contagion precautions. In this sense, some routines needed to be repatterned, such as: hygiene measures with alcohol on surfaces that are almost never sanitized in this way, routinely, such as packaging and bags and other containers that transport food; hand hygiene with soap and water and/or alcohol gel before and after handling any object outside the home; handrail; doorknobs; interior of cars and public transport; the use of tissue face masks has also become necessary for individual and collective protection; reduction in the number of people inside commercial establishments and the minimum distance between them; the ritual of hygiene and cleaning in the homes and even with shoes and clothes for external use; cleaning of surfaces and furniture.

To bring the TDUCC concepts closer to people’s perception and the level of abstraction and understanding to issue culturally congruent guidelines, many attempts involving the repatterning of population attitudes in the fight against Covid-19 have been produced and, in this sense, the nursing guidelines must be consistent and provide adherence and behavior change.

The approximations between the conceptual assumptions of the TDUCC, from a reflective process of nurses on the practice of cultural care, have possibilities for a negotiation between knowledge and attitudes with the patient to preserve, accommodate and repattern care in relation to the adoption of measures of social distancing.

Nursing must favor cross-cultural care, that of preserving human lives, and transcending the limits of situations that do not favor it. The repatterning of attitudes and behaviors of the population can reframe and optimize adherence to sanitary measures.

The Leininger assumptions allowed this theoretical reflection and provided a foundation for nursing care practice in caring for people in the context of the Covid-19 pandemic.

FINAL CONSIDERATIONS

The cross-cultural view and theoretical assumptions postulated in Leininger’s Conceptual Model contribute to a differentiated view of adherence to measures of social distancing in relation to the dissemination of Covid-19. The concepts help to understand the different symbolic spaces considered for understanding the reality of the pandemic and its combat, a cross-cultural phenomenon perceived in this reflection.

With this, since January 2020, different perspectives of the world can be glimpsed after the declaration of the pandemic, where the WHO recommendations became cross-cultural.

Valuing human lives in all countries has become a priority in relation to economic, social, educational factors, among others.

With social isolation, quarantine and distancing, there is a reduction in borders and cultural diversities, due to the standardization of attitudes, never seen before, that science has instituted because it considers that they contribute to promoting the maintenance of life.

The Sunrise model contributes to bringing together the conceptual assumptions of Leininger's Theory with the current pandemic reality, that is, the factors that influence people’s health and well-being, as should be nursing care planning by nurses in the practice of cross-cultural care.

The scarcity of current publications on cross-cultural care from the perspective of TDUCC and on nursing care with Covid-19 were limiting elements for the reflective study. A stimulus for the development of discussions and reflections was the lack of reports on how nursing is situated in the current pandemic.

Acknowledgments

The present work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) - Funding Code 001.

REFERENCES

  • 1. Preciado MM. Enfermería cultural: para cuidar en tiempos complejos [editorial]. Cult Cuidados. 2018;22(51):7-10. doi: https://doi.org/10.14198/cuid.2018.51.01
    » https://doi.org/10.14198/cuid.2018.51.01
  • 2. Reis AT, Santos RS, Paschoal Júnior A. O cuidado à mulher na contemporaneidade: reflexões teóricas para o exercício da enfermagem transcultural. Rev Min Enferm. 2012 [cited 2020 Apr 10];16(1):129-35. Available from: http://www.reme.org.br/artigo/detalhes/510
    » http://www.reme.org.br/artigo/detalhes/510
  • 3. Melo LP. A contemporaneidade da Teoria do Cuidado Cultural de Madeleine Leininger: uma perspetiva geo-política. Ensaios Ciênc: Ciênc Biol Agrárias Saúde. 2010 [cited 2020 Apr 10];14(2):20-32. Available from: https://www.redalyc.org/articulo.oa?id=26019017002
    » https://www.redalyc.org/articulo.oa?id=26019017002
  • 4. World Health Organization (CH). Infection prevention and control during health care when COVID-19 is suspected: interim guidance 25 January 2020. Geneva: WHO; 2020 [cited 2020 abr 20]. Available from: https://apps.who.int/iris/bitstream/handle/10665/330674/9789240000919-eng.pdf?sequence=1&isAllowed=y
    » https://apps.who.int/iris/bitstream/handle/10665/330674/9789240000919-eng.pdf?sequence=1&isAllowed=y
  • 5. Spellberg B, Haddix M, Lee R, Butler-Wu S, Holtom P, Yee H, et al. Community prevalence of SARS-CoV-2 among patients with influenza like illnesses presenting to a Los Angeles Medical Center in March 2020 [research letter]. JAMA. 2020;323(19):1966-7. doi: https://doi.org/10.1001/jama.2020.4958
    » https://doi.org/10.1001/jama.2020.4958
  • 6. Qun L, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med.2020;382(13):1199-207. doi: https://doi.org/10.1056/NEJMoa2001316
    » https://doi.org/10.1056/NEJMoa2001316
  • 7. Zhou F, Ting Y, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. doi: https://doi.org/10.1016/S0140-6736(20)30566-3
    » https://doi.org/10.1016/S0140-6736(20)30566-3
  • 8. Dee Ray MA. Remembering: my story of the founder of Transcultural Nursing, the late Madeleine M. Leininger, PhD, LHD, DS, RN, CTN, FAAN, FRCNA (Born: July 13, 1925; Died: August 10, 2012). J Transcult Nurs. 2019;30(5):429-33. doi: https://doi.org/10.1177/1043659619863089
    » https://doi.org/10.1177/1043659619863089
  • 9. Barbosa MEM, Corso ER, Scolari GAS, Carreira L. Interdisciplinarity of care to the elderly with Alzheimer’s disease: reflection to the light of the theories of Leininger and Heller. Esc Anna Nery. 2020;24(1):e20190083. doi: https://doi.org/10.1590/2177-9465-EAN-2019-0083
    » https://doi.org/10.1590/2177-9465-EAN-2019-0083
  • 10. Jiménez-Ruiz I, Martinez PA. Famale genital mutilation and transcultural nursing: adaptation of the Rising Sun Model. Contemp Nurse. 2017;53(2):196-202. doi: https://doi.org/10.1080/10376178.2016.1261000
    » https://doi.org/10.1080/10376178.2016.1261000
  • 11. Muñoz-Henríquez M, Pardo-Torres MP. Signifcado de las prácticas de cuidado cultural en gestantes adolescentes de Barranquilla. Aquichan. 2016;16(1):43-55. doi: https://doi.org/10.5294/aqui.2016.16.1.6
    » https://doi.org/10.5294/aqui.2016.16.1.6
  • 12. Leininger M, Mc Farland M. Culture care diversity and universality: a worldwide nursing theory. 2th ed. Boston: Jones and Barlett Pubs; 2006.
  • 13. McFarland MR, Wehbe-Alamah HB. Leininger’s Theory of Culture Care Diversity and Universality: an overview with a historical retrospective and a view toward the future. J Transcult Nurs. 2019;30(6):540-57. doi: https://doi.org/10.1177/1043659619867134
    » https://doi.org/10.1177/1043659619867134
  • 14. g1.globo.com [Internet]. Rio de Janeiro: Globo, c2021[citado 2021 abr 13]. Celebração hindu promove aglomeração no Ganges em meio a alta nas infecções por Covid na Índia; [about 1 screen]. Available from: https://g1.globo.com/mundo/noticia/2021/04/13/celebracao-hindu-promove-aglomeracao-no-ganges-em-meio-a-alta-nas-infeccoes-por-covid-na-india.ghtml
    » https://g1.globo.com/mundo/noticia/2021/04/13/celebracao-hindu-promove-aglomeracao-no-ganges-em-meio-a-alta-nas-infeccoes-por-covid-na-india.ghtml
  • 15. Oliveira EAR, Rocha SS. The parents’ cultural care towards promoting child development. J Res Fundam Care Online. 2019;11(n. esp):397-403. doi: https://doi.org/10.9789/2175-5361.2019.v11i2.397-403
    » https://doi.org/10.9789/2175-5361.2019.v11i2.397-403
  • 16. Almeida IJS, Buarque BS, Guedes TG, Sette GCS, Cavalcanti AMTS. Scientifc evidence on cultural influence in child care. Rev Rene. 2017;18(6):840-6. doi: https://doi.org/10.15253/2175-6783.2017000600019
    » https://doi.org/10.15253/2175-6783.2017000600019
  • Note

    Article elaborated from: Reflections of Leininger’s Theory of Diversity and Universality of Cultural Care (TDUCC) in the context of Covid-19: reflections carried out in a stricto sensu graduate course, between March and June 2020, weekly, by Google Meet.

Publication Dates

  • Publication in this collection
    22 Sept 2021
  • Date of issue
    2021

History

  • Received
    21 June 2020
  • Accepted
    17 May 2021
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