The Purnell Model and Theory for Cultural Competence

Written by Brandon L.
April 26, 202413 min read

In this era of multiculturalism and diversity, healthcare workers are facing new kinds of challenges, such as competency and racial, gender, and ethnic disparities. As a result, there is a need for cultural competence, which is seen as a key component for reducing these disparities. Cultural competence in health refers to an organization's ability to provide effective healthcare services that meet a patient's social, cultural, and linguistic needs. Through cultural competence, stakeholders can consider the diversity of patients when planning, implementing, and evaluating health education and promotion programs and interventions. The Purnell Model for Cultural Competence is a broadly utilized framework to develop cultural competence in healthcare settings.

In this guide, our nursing writers will explore the Purnell model of cultural competence and explain how it applies in the medical setting.

The Purnell Model

The Purnell model for cultural competence was developed by Larry D. Purnell and Betty J. Paulanka in 1995 as a tool to encourage the importance of cultural awareness.

It proposes that healthcare workers are bound to encounter patients with diverse backgrounds in their day-to-day life in clinical settings. Thus, they should understand these diverse backgrounds and learn how to maneuver and overcome any challenges faced to ensure they deliver quality care to all.

Purnell's model provides a basis for healthcare workers to understand concepts and features such as language, values, beliefs, and customs relating to different cultures as a way to promote culturally competent healthcare.

Purnell's model consists of four circles of varying sizes, each representing all the meta paradigms applied to nursing, and the inner circle consists of 12 cultural domains. The following is an illustration of the model.


The meta paradigms are ideas that relate to nursing and other healthcare aspects that are critical in providing individual care to patients.

The innermost part of the circle is subdivided into wedges, each depicting the 12 cultural domains and their concepts, which provide the organizational framework of the model. The darker part of the circle depicts an unknown phenomenon. The jagged line along the bottom represents the nonlinear concept of cultural consciousness.

The 12 Cultural Domains

These cultural domains consist of concepts that must be considered when evaluating patients. These should not be viewed as separate entities, but one should recognize that they can influence each other; thus, one must view them as a unified whole. The 12 domains are essential for assessing the cultural aspects of an individual, family, or group include:

  1. Overview, inhabited localities, and topography- This refers to a person's origin and is crucial in helping healthcare workers understand themselves and their patients. The following are questions that a nurse can ask during assessment:
  1. Communication- Refers to an individual's ability to express themselves and provide verbal and nonverbal cues. Furthermore, it deals with the interactions has been exposed to throughout their life with those close to them, such as family, friends, etc. Some of the questions that can be asked at this point include:

The nurse performing these assessments should keenly observe the patient's speech patterns to determine whether they are high or low context. Patients coming from high-context cultures place greater emphasis on being silent.

  1. Family roles and organization- Refers to different family hierarchies and structures that determine or influence a person's communication and actions. Questions in this context include:
  1. Workforce issues- Represent how the different aspects within a workplace could affect an individual. It refers to concepts related to aspects such as autonomy, assimilation, ethnic communication styles, etc. Assessment at this point will include questions such as:
  1. Biocultural ecology- refers to concepts of disparities between different cultural and racial groups, such as skin color, physical appearance, topographical diseases, and the differences in how drugs are metabolized by the body. During the assessment, a healthcare worker should ask the following questions:
  1. High-risk behaviors- each culture or ethnic group has high-risk behaviors, for instance, drinking or smoking, but the degree to which they happen varies. Questions at this point may include
  1. Nutrition- Healthcare workers must consider nutrition because each culture has different ways of cooking and consuming food, as well as the types of food they eat. Thus, questions like these should be asked:
  1. Pregnancy and childbearing practices- this includes practices on fertility and sanctioned and unsanctioned birth control methods. Questions at this point may include;
  1. Death rituals- refer to how individuals view death. Caregivers must consider the following issues when attending to patients,
  1. Spirituality- Refers to the religious practices of an individual. The following questions should come up when attending to patients.
  1. Healthcare practices- different cultures have their practices concerning matters of health. The following questions could be considered:
  1. Healthcare providers- this involves the perception and use of traditional, magic religious, and Western biomedical healthcare practitioners. In addition, the issue of the caregiver's gender may come into question. Questions posed at this point include:

Please note that the Purnell model of cultural competence is viewed as a holistic organizing framework consisting of specific questions and a set-up for addressing culture. Knowing ethnocultural diversity can significantly improve the effectiveness of all healthcare services. Furthermore, the model has been classified as a holographic and complexity theory because a healthcare discipline can apply the model and framework.

Assumptions of the Purnell Model

The following are some of the key assumptions of the Purnell model of cultural competence.

Cultural Competence is an Ongoing Process

Cultural competence is seen as an ongoing process, not an endpoint. One moves from one-point, unconscious incompetence (a place of not knowing about another’s culture) to conscious incompetence (being aware of not knowing that you lack knowledge about a person’s culture) to conscious competence (informing oneself about another person’s culture) to finally to unconscious competence (automatically providing culturally competent services to all patients of diverse backgrounds).

Purnell model makes it clear that for cultural competence to be effective, it must be valued by everyone involved.

Cultural competence is essential in healthcare settings because it prevents misunderstandings when delivering care.

For example, according to research conducted in Sri Lanka and published in the book Culture and Depression, a Western person suffering from major depression is more likely to be considered a “good Buddhist” because of their cultural orientation to what they consider to be the meaning of suffering.

Likewise, the Catholic Mediterranean tradition may consider complaints and suffering as social practices that make a person noble, according to the Naturalizing Whiteness: Cultural Competency and the Perpetuation of White Supremacy.

Application of Purnell Model of Cultural Competence

The Purnell model of cultural competence has significantly impacted the healthcare industry by increasing cultural awareness and improving cultural competence worldwide. The model has been successfully applied in areas like:

Clinical Practice

Clinicians can apply the Purnell model to identify and address cultural barriers in healthcare settings to ensure they provide culturally competent care and design future practices.

By incorporating the model, caregivers can provide culturally sensitive care that respects a person's beliefs, traditions, and values.

The model is used in qualitative research in master’s theses, doctoral dissertations, and quality improvement projects in various countries, including Australia, Japan, The Czech Republic, and Korea.


The model has been implemented in nursing programs at the baccalaureate, master’s, and doctoral levels. Doing this ensures that graduating students have the right knowledge to promote a culture of culturally competent care.

For example, the Society of Teachers of Family Medicine has put measures in place to ensure curriculum materials in all institutions teach cultural competence and sensitivity to medical residents and other healthcare workers. Research shows that healthcare students are taught cultural competence through simulation pedagogy.


Purnell's model has been incorporated into employee training to encourage the recognition and acceptance of diverse groups of staff members and patients. 

What the Federal Government is Doing to Ensure Cultural Competence Care

In 2000, the Centers for Medicare and Medicaid Services issued guidance emphasizing that federal funds were available to provide oral interpretation and written translation services.

In the same year, the Office of Minority Health of the Department of Health and Human Service provided 14 national standards to promote Culturally and Linguistically Appropriate Services (CLAS) in health care. These standards aim to rectify any inequalities in healthcare systems, ensuring they are more responsive to the individual needs of patients.

What Healthcare Industries are Doing to Achieve Cultural Competence

Becoming culturally competent is key to delivering quality health services to all individuals, irrespective of their culture, ethnicity, or race. That said, here are some actions taken by different health organizations worldwide.

Limitations of the Purnell Model of Cultural Competence

Although health research acknowledges the benefits of the Purnell model of cultural competence, they agree that the Purnell model of cultural competence falls short on a few accounts. First, the model suggests that there is a lot a person can learn from others, leading to stereotyping and biases.

Secondly, while the Purnell model states that cultural competence is a process, it suggests that there is an endpoint to becoming culturally competent.

Thirdly, the model does not account for what happens after culturally competent care has been provided to patients. It doesn't show whether the model is successful by considering the healthcare givers' conduct and consequences to the patients.

Final Word

Cultural competence is an essential component to consider in delivering high-quality services to diverse groups of people. Through the Purnell model, healthcare providers, including nurses, must learn how to provide equal services to all patients regardless of their color, beliefs, values, and cultural background.

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