Nursing Theories of Madeleine Leininger and Florence Nightingale

Nursing is a discipline that emphasizes the importance of caring in society and values the human life. There is a variety of different perspectives on nursing and various approaches that are called theories. They constitute frameworks that dictate the basic knowledge and care concepts nurses have to adhere to in order to help their patients. Two of the most noteworthy theories of nursing are Madeleine Leininger’s Transcultural Theory of Nursing and Florence Nightingale’s Environmental Theory. The first theory states that nursing care must always be compliant with the patient’s culture, group, or institution and coincide with their values, beliefs, worldviews, and lifestyles. The second theory postulates that nurses have to provide their patients with the environment that would be most beneficial for their health and speedy recovery, taking into consideration all the external factors at play. Both theories are well-established and have significantly affected the nursing professionals’ attitude towards their job, yet they are different in many aspects. Thus, it is interesting to analyze and compare the two theories in the context of their background, basic concepts, and application.

Backgrounds of the Theories

Madeleine Leininger was among the first theorists in the sphere of culture-oriented nursing, starting in the 1950s, she wanted to discover the features and practices that were inherent strictly to nursing, not medicine. One of these features, according to her, was care, which she considered to be the “essence of nursing and the central, dominant, and unifying feature of nursing” (Leininger, 1988, p. 152). Working as a mental health specialist with children, she observed that their expectations and attitudes towards care provided by the nurses were dictated by their cultural backgrounds, thus she recognized the importance of these differences. Having realized a direct link between care and culture, she developed the theory of Cultural Care Diversity and Universality, which could provide a framework for professionals to follow when dealing with patients of various cultures.

Florence Nightingale was a pioneer of the nursing discipline, and, today, many scholars recognize her as the first person to produce a nursing theory. The creation of the Environmental Theory was inspired by Nightingale’s experience as a nurse during the Crimean War of 1853-1856. When attending to injured soldiers, she noticed that many of them were left in unsanitary conditions, which inevitably led to a high mortality rate in the British Army. Her proposal to introduce basic hygiene practices, such as hand-washing, caused the death rate to decrease from 42.7 to 2.2 in six months (Donahue, 1996, as cited in Koffi & Fawcett, 2016). In 1859, Nightingale published a book titled Notes on Nursing, where she postulated the basics of her theory. She stated that every nurse’s job was to observe patients and their environment and detect factors which would ensure healing (McEwen & Wills, 2019). Her works and teaching became the foundation of the nursing discipline and are still widely used by modern professionals.

Philosophical Underpinnings of The Theories

The philosophical basis of Leininger’s Theory of Diversity and Universality comprises the author’s own perspective on the nurses’ role, her professional experiences, personal beliefs, and Christian background. She strongly believes that nursing professionals have a moral obligation to rely on the approach that considers the culture of their patients, viewing it as “a major contribution to humanity” (Leininger & McFarland, 2002, p. 34). Another philosophical reason for developing this theory rests on her concern about the possibility of modern technologies eradicating “caring from spiritual, cultural, historical, environmental, and other perspectives” (Leininger & McFarland, 2002, p. 26). Thus, the transcultural nursing, as envisioned by Leininger, constitutes a holistic approach which involves adjusting nurses’ attitude to fit patients’ values and spiritual principles. According to the theory, the nursing professionals should be not only tolerant, but also able to understand on a deep psychological level the cultural environment of others, neglecting their own.

Nightingale’s philosophy in the context of the Environmental Theory has been characterized differently by various scholars, some considered it a broad philosophy, others believed it to be a foundational one. For example, Dossey (2010) wrote that the main idea of her philosophy was caring, while leadership and global action only supported it (as cited in McEwen & Wills, 2019). Her view of nursing as a profession was revolutionary for her age since, during the Victorian era, nurses were often compared to home servants who also cared for the ill (Black, 2019). She also insisted that for a person to become a nurse, they had to perceive nursing as a calling, and not as a paid position, linking it to true enthusiasm (McDonald, 2017). Nightingale’s prolific work has allowed her to establish nursing as a separate discipline, and her philosophical outlook has become the foundation for other theories; thus, her philosophy can be considered a grand one.

Major Assumptions, Concepts, and Relationships

Leininger’s theory outlines several basic concepts, which include the provision of culturally congruent nursing care, recognizing cultural differences and universalities, as well as emic and etic views. Emic refers to the beliefs, values, practices, and knowledge that belong to patients, while etic refers to the same factors but concerning the medical professionals, doctors and nurses (McEwen & Wills, 2019). The culturally congruent nursing manifests itself in the obligation for nurses to be transculturally aware and prepared, which can help them identify health outcomes of their patients and promote wellness (McFarland, 2019). Some of Leininger’s assumptions include care as the essence and the focus of nursing, the necessity of humanistic care as the basis for human health and survival, and caring as the premise for healing. Thus, the theorist established and stressed the relationship between care and culture, believing that this was the key to patients’ successful recovery.

One of Nightingale’s basic assumptions was that a proper environment, clean and sanitary, as well as nutritious food and comfortable beds, were vital for healing. Achieving such environment was possible only if five basic factors were maintained, “pure air, pure water, efficient drainage, cleanliness, and light” (Nightingale, 1860, as cited in McEwen & Wills, 2019, p. 143). The theory’s underlying concepts include human, environment, health, and nursing; she believed that the relationship among them had to be always considered by medical professionals. She perceived nursing as an art, not science, and wrote that it implied a considerable degree of independence; for example, nurses had to make their own observations of the patients and report them to physicians. Nightingale’s idea about the relation between the sick and their environment laid the groundwork of the nursing profession and is used to this day.

Clinical Applications/Usefulness/Value to Extending Nursing Science, Testability

The Cultural Care Diversity and Universality theory has been applied and tested on many occasions and has proved its significance and value for the nursing science. According to Blasdell (2017), a substantial component of Leininger’s theory lies in the fact that it is widely applicable because “theory generation may occur at multiple levels (macro range, middle range, and micro range)” (p. 4). Many scientists and scholars used the theory as a framework for their research; for example, Chiatti (2018) conducted a study which identified and described the culture care practices of Ethiopian immigrants in the United States. Farren (2015) carried out a literature review of research dedicated to discovering cultural differences in perceptions of cancer survivors, promoting culturally congruent care for adult patients (as cited in McEwen & Wills, 2019). The theory’s value is also substantiated by the existence of such publications as the Journal of Transcultural Nursing, which seek to further expand the knowledge base of Leininger’s theory.

Nightingale’s works are still relevant today since they became the foundation of the nursing science and, for more than a century, have influenced nursing theorists of the world. Apart from being a writer, she developed special nursing programs that were based on her proposals and were used both in England and the U.S. (McEwen & Wills, 2019). Modern scientists still utilize the ideas outlined by Nightingales in her books; for example, the theory was applied to addressing the problems concerning the environment of patients with colostomy (Afsha & Dildar, 2016). Such studies continue to demonstrate the testability of Nightingale’s concepts, and their success shows that her theory is valuable for further development of the nursing science even under the contemporary circumstances. Nightingale’s work has substantially impacted the sphere of health care and presents a useful framework for many medical professionals.

Comparison of the Use of Both Theories in Nursing Practice

As it was explained earlier, both Leininger’s and Nightingale’s theories are widely used in the nursing practice, yet each of them possesses its own distinctive features, which make them suitable for different types of purposes. Implementation of the transcultural theory can hardly be successful without proper hygiene practices considered most important in the Environmental Theory. For example, if the concepts of Leininger’s theory were applied to wounded soldiers during the Crimean War left on the battlefield in anti-sanitary conditions, this would not produce any positive effect on their health. Similarly, Leininger wrote that concentrating on patients’ physical environment and health was “not sufficient and failed to explicate human care/caring phenomena and to use cultural care knowledge” (Leininger & McFarland, 2002, p. 32). Applying Nightingale’s theory certainly brings patients more comfort and ensures that they do not die from infections, yet often, wellness depends on psychological factors that are covered by the transcultural approach.

Since the theory of Cultural Care Diversity and Universality and the Environmental theory address two different aspects of nursing, psychological and physical, respectively, they do not conflict and can be used together. Combining the two theories can provide a holistic approach that would be likely to yield better results and health outcomes for patients. For example, relying on such framework can benefit American nurses who travel to remote foreign areas to deliver humanitarian assistance. Improving the physical environment of their patients and adjusting their methods to be compliant with the local culture will help nurses establish better communication with the people they care for and assist them in recovery.

Examples of Application in the Emergency Department Setting

The theory of Transcultural Care can be successfully applied in the emergency department setting, as it is vital for every nurse to be aware of different cultural aspects of patients with diverse backgrounds. For example, many ethnic groups still use a variety of ethnomedical techniques and treatments that often can be harmful to a sick person’s body and can potentially have serious consequences, including death. Nurses who are acquainted with Leininger’s theory can realize that the patient’s condition might have been caused by the aforementioned activities and swiftly make the right decision that can be life-saving for the person.

Nightingale’s theory is recognized as universally applicable to any clinical setting since all patients require a clean and safe environment, and the emergency department is not an exception. Idrees & Shah (2017) present a clinical scenario where the application of the Environmental theory positively affected a patient’s health. A person who was admitted to an emergency room with diabetes did not take a bath for a week since he experienced difficulty moving, was overeating, and had a fever. The nurse provided the patient with a towel bath, encouraged him to drink more water, and kept the window in his room open to alleviate the fever symptoms. Thus, she adjusted the environment to be conducive to the patient’s recovery and successfully implemented Nightingale’s theory.


The Transcultural theory is parsimonious in its terms, concepts, and basic aspects and presents a framework that can be easily comprehended by both professionals and the general public. The proposals outlined in this theory can be readily implemented without employing any additional resources on the part of the nursing professionals. Leininger managed to formulate her theory in such way that it can be described by one term “culturally congruent nursing care,” which allows anyone to instantly understand the basic idea behind it.

Nightingale’s Environmental Theory is also parsimonious in its essence since the author concisely proposes her ideas and notions. She establishes a link between patients’ health and their environment, stating that the latter directly affects the wellbeing of the former. Her theory and its primary message can be easily conveyed by any person and present no difficulty in understanding. It can be succinctly formulated as follows: nurses have to ensure that their patients’ environment promotes their recovery and wellness.


Madeleine Leininger’s Transcultural Theory of Nursing and Florence Nightingale’s Environmental Theory constitute approaches that have considerably affected the nursing science. Both authors were inspired to develop their philosophies by experiences they observed during their work as nurses. Leininger began developing her ideas while working as a mental health specialist with children, whereas Nightingale’s work was a reaction to the events she witnessed at war, which prompted her to seek new solutions. Leininger stressed the importance of the culture and care relationship, while Nightingale stated that patients’ environment directly affected their health outcomes. The assumptions and ideas of the theories have been widely tested and applied on many occasions, and, nowadays, have become the foundation for various nursing frameworks. They address different factors of nursing, psychological and physical, and, thus, can be combined for achieving better results in practice. The theories can also be applied in the emergency department setting, the transcultural one helps ensure nurses’ awareness of patients’ cultural aspects, while Nightingale’s theory allows to adjust the environment to improve patients’ health. Both theories have been concisely and efficiently formulated, which makes them easily understandable and instantly recognizable.


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