Using Leininger’s Culture Care Theory to examine the idiom of distress experienced by nursing faculty working with pre licensure students during the COVID-19 pandemic

Contributor: Judith M. Pare, PhD, RN

“Care can be an individual, familial, tribal, communal, organizational, or institutional value or expression; it can be held as a single value or a system of belief” (McFarland & Wehbe-Alamah, 2015, p. 220). The purpose of this blog is to demonstrate use of Leininger’s (2002) Culture Care Theory (CCT) as a foundation to provide culturally congruent care for urban-based nursing faculty who are working to prepare prelicensure nursing learners to emerge as competent practitioners during the COVID-19 pandemic. The CCT was chosen as the framework for this paper so as to contribute to recognition of the diversity that exists amongst prelicensure faculty and the need to develop strategies that support culturally congruent care.

On March 13, 2020, the then U.S. President formally declared the coronavirus pandemic  a national emergency., which was soon recognized as a public health crisis. Soon after that declaration, nursing faculty were challenged to quickly implement various teaching and learning modalities including a shift to online and other virtual methodologies for teaching didactic courses. Clinical learning was temporarily halted for some learners and others were reassigned to settings where they were able to safely provide care while observing CDC protocols related to personal protective equipment. This public health crisis required nursing faculty to consider weighing the value of continuing nursing education as it had traditionally been against the potential health and safety risks to and stress experienced by learners both personally and professionally (Dewart, et. al., 2020). The consequences of this ongoing public health crisis have consistently required nursing faculty to support their personal transcultural self-efficacy (TSE) and the TSE of their diverse nursing learners. More than one year later we now prioritize an examination of the long-term physical, emotional and psychosocial impacts that this public health crisis continues to have on nursing faculty and nursing learners.

Culture Care Theory (CCT) and Transcultural Self-Efficacy

Leininger describes the process of cultural self-assessment as “know thyself” which is critical for identifying potential misconceptions, ethnocentric tendencies, and predetermined views that may otherwise greatly restrict the information gathered for cultural assessments of others. There are a variety of instruments that may be utilized by faculty members engaged in the process of self-assessment. The Transcultural Self-Efficacy Tool (TSET) is a particularly useful measure of how faculty can come to “know thyself” through self-assessment of their individual transcultural self-efficacy (TSE). The degree to which individuals perceive their ability to perform the specific transcultural nursing skills needed for culturally competent and congruent care (Jeffreys, 2000).

The current public health crisis that has evolved from the global COVID-19 pandemic may have eroded faculty confidence in assessing their personal needs as well as the cultural competence needs of learners. It behooves faculty to take this opportunity to engage in self-assessment to enhance their own transcultural self-efficacy so they can then provide support to learners and facilitate their resilience to enhance learners’ TSE.

The four major tenets that are foundational to the CCT (Leininger, 2002a) provide direction for ways in which TSE can be extended. The first tenet is that “diversities and universalities exist in care…among and between cultures in the world (Leininger, 2002b). Leininger (2002) asserted that culture care meanings and uses must be discovered to establish foundational knowledge in transcultural care. Faculty need to first understand the physical, medical, and emotional consequences that the COVID-19 pandemic has on their own TSE before they can support learners who may be experiencing unimaginable stressor due to the pandemic.

Leininger’s (2002a) second tenet involves worldview and social structure factors that may be contributing to issues such as accessing primary health care, adhering to public health mandates, returning to the workforce, and vaccine hesitancy. Faculty who engage in a self-assessment of these issues recognize potential barriers and biases and how to move past the barriers and biases to support diverse learners who may be experiencing similar concerns.

Leininger’s (2002a) third tenet recognizes both the emic (insider’s) and the etic (outsider’s or professional) views of health and environmental factors that influence health. The onset of the COVID-19 pandemic resulted in faculty being isolated from family members, peers and a dependent on virtual technologies to support students and their learning needs.

Leininger’s (2002a) fourth tenet utilizing three major culture care decisions and action modes: assessing the social structure factors of the individual, family, or other group, and collaborating with persons to develop and implement a participatory plan of care that empowers the individuals towards enhanced cultural competency and positive health outcomes.

Idioms of Distress and the Use of the TSET

The culmination of the months of ongoing stress and separation may be expressed by faculty as idioms of distress, defined by Nichter (1981) as:

            In any given culture, a variety of ways exist to express distress. Expressive modes are culturally constituted in the sense that they initiate particular types of interaction and are associated with culturally pervasive values, norms, generative themes, and health concerns (p. 179).

The idioms of distress that faculty may be experiencing as a consequence of the COVID-19 pandemic may manifest as excessive worry, and other psychological symptoms, sleep disturbances, and various somatic complaints. The process of engaging in a cultural self-assessment will allow faculty to identify the source of their idioms of distress and implement self-care practices to lessen or resolve this distress. When faculty achieves an enhanced sense of TSE, self-efficacy, they will be better equipped to recognize idioms of distress in their diverse learners.


Leininger’s (2002) CCT reminds us that faculty and members of health care teams should utilize the evidence from the body of transcultural knowledge and the CCT as a guide for assessment of mental health. Andrews and Boyle (2012), stated that to provide culturally congruent care, for persons experiencing idioms of distress and leaders have to become knowledgeable about concepts such as cultural imposition, ethnocentrism, and cultural explanation, then complete a self-assessment of their own TSET prior to performing a TSET of others. The process of engaging in a cultural self-assessment could provide faculty members opportunities for reflection on their cultural beliefs values and practices and how their personal idioms of distress may be magnified by the events surrounding the pandemic. The goal of this process will be to enhance the cultural sensitivity, cultural competence, and cultural confidence of faculty working with learners from diverse backgrounds and experiences that have also been impacted by the COVID-19 crisis.


Andrews, M. M., & Boyle, J. S. (2019). The Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model. Journal of Transcultural Nursing30(4), 323- 330.

Dewart, G., Corcoran, L., Thirsk, L., & Petrovic, K. (2020). Nursing education in a pandemic: Academic challenges in response to COVID-19. Nurse education today92, 104471.

Leininger. (2002a). Culture Care Theory: A Major Contribution to Advance Transcultural Nursing Knowledge and Practices. Journal of Transcultural Nursing13(3), 189–192.

Leininger, M.M. (2002b). The theory of culture care and ethnonursing research method. In M.M. Leininger and M.R. McFarland (Eds.), Transcultural nursing: Concepts theories, research & practice (3rd ed., pp 71-98). New York: McGraw-Hill Publishing.

McFarland, M. R., & Wehbe-Alamah, H. (2018). Care, caring and nursing practice. In M.R. McFarland and H.B. Wehbe-Alamah (Eds.), Leininger’s transcultural nursing: Concepts, theories, research & practice. (4th ed., pp. 217-230). Burlington, MA: Jones and Bartlett Learning.

Nichter, M. (1981). Idioms of distress: Alternatives in the expression of psychological distress: A case from South India. Culture, Medicine & Psychiatry 57. P. 379-408. doi: 10.1007/BF00054782

About Judith Pare

Judith Paré PhD, RN, is an experienced nurse educator who joined the University of Massachusetts as an adjunct Associate Clinical Professor in 2017. On June 1, 2021 Judith assumed her role as Clinical Professor & Program Director for the Accelerated Bachelor of Science in Nursing Program for the College of Nursing and Health Sciences. Her areas of expertise include the rural nursing, psychiatric nursing, and community health. Judith is a published author and a national speaker in the fields of Alzheimer care and the lived experiences of rural and remote nurses. Judith’s writings include multiple publications focusing the lived experiences of rural and remote nurses. Recently, Judith collaborated on two chapters in the sixth edition of Winters, C. Rural nursing: Concepts, theory, and practice, which was released in September, 2021.

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