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 global society- represented by the outermost rim, relates to seeing the world as an interconnected entity consisting of people from various ethnic and cultural backgrounds. Various concepts, such as globalization and the rapid changes in technology, influence the global society.
- Community (the second rim) – Healthcare workers must consider a person’s position and sense of community in the provision of culturally competent care. By considering a person's sense of community, nurses and other healthcare workers can acknowledge that communities have different values, beliefs, and ethics.
- Family (third rim)- Caregivers must consider a person’s relationship with their family. Patients determine to what degree they want their family members to be involved in their care. Thus, caregivers must consider who their patients consider family to deliver culturally competent care.
- Person (fourth rim)- healthcare workers must consider an individual to deliver culturally competent care. This is because each individual has their own distinct way of seeing the world. In other words, each person is guided by their own values, beliefs, and ideas. Thus, caregivers must consider all of these when caring for individuals.
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:
- 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:
- Where do you currently live?
- What is your ancestry?
- What’s your birth location?
- How many years have you been living in this country (or their country of origin)?
- What brought you to this country (the current country they are in)
- What was the land like when you lived there?
- Have you been to other places/ countries?
- What’s your income level?
- Can your income level help you afford insurance?
- What’s your education level?
- What’s your current occupation?
- 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:
- What are your legal names?
- Which name do you prefer to be called?
- What’s your primary language?
- Do you speak other languages? If yes, which ones?
- Can you fully share your opinions, thoughts, and feelings with those close to you?
- How do you wish people treated you? Do you prefer a handshake?
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.
- 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:
- What is your marital status?
- Who makes the biggest decision in the family?
- Do females make most decisions? What kind of decisions do they make?
- Do males make most decisions? What kind of decisions do they make?
- What are the primary duties of children?
- What are children prohibited from doing?
- What are adolescents supposed to do to portray a good image of themselves to the rest of the family? What can they do that will tarnish their reputation?
- 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:
- When do you report to work?
- Do you report to meetings on time?
- Do you think of yourself as a loyal employee?
- Are you assertive in your job?
- 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:
- Are you allergic to any medications?
- Did you experience any issues when you took over-the-counter (OTC) medications?
- Did you experience any issues when you took the prescribed medications?
- Which race do you identify with?
- 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
- Do you smoke? If yes, for how long
- Do you chew tobacco? If yes, for how long?
- Do you use recreational drugs? If yes, for how long?
- What types of exercises do you engage in each day?
- Do you wear a seat belt when in a vehicle?
- What kind of drink do you take? (wine, beer, spirits). How many glasses do you take each day?
- What measures/precautions have you put in place to protect yourself against sexually transmitted diseases?
- 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:
- What kind of diet are you on?
- What foods do you eat most?
- Are there foods you avoid?
- What foods do you eat when sick?
- What foods do you eat every day?
- What foods do you take are part of your cultural heritage?
- Do you take snacks between meals?
- Which foods do you take on special occasions?
- How do you store your food?
- Do you drink with your meals?
- How do you prepare different kinds of meat?
- Pregnancy and childbearing practices- this includes practices on fertility and sanctioned and unsanctioned birth control methods. Questions at this point may include;
- How many biological children do you have?
- What kind of birth control tools do you use?
- Do you eat special foods when pregnant? If yes, what are they?
- Do you exercise when pregnant? If yes, how often?
- What kind of food do you eat when pregnant and after delivery?
- Do you want anyone present with you when giving birth?
- Do you have someone to help you with the baby after delivery?
- Death rituals- refer to how individuals view death. Caregivers must consider the following issues when attending to patients,
- Are there special activities that must be performed when someone is dying?
- Would you want to be informed about your impending death?
- How do men and women in your culture grieve?
- What does death mean to you?
- Do you believe in life after death?
- Do children take part in death rituals?
- Spirituality- Refers to the religious practices of an individual. The following questions should come up when attending to patients.
- What is your religion?
- Are you deeply religious?
- How many times a day do you pray?
- What gives you meaning in life?
- Do you practice meditation?
- Healthcare practices- different cultures have their practices concerning matters of health. The following questions could be considered:
- What do you do when in pain? For instance, if you have a headache, what do you take?
- Who in your family can take care of you when you are sick?
- What measures do you take to ensure you stay healthy?
- What do you think about organ transplants?
- What do you think about blood transfusion?
- 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:
- Who do you see when you see? Nurses?
- Do you prefer doctors of the same gender to attend to you?
- Do you use traditional healers?
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.
- All healthcare workers must receive similar information about cultural diversity.
- All health workers share the same metaparadigm.
- Every culture shares core similarities.
- Some differences exist between and among different cultures.
- When patients take an active role in their care and have a choice in all matters related to their health goals, there will be a significant improvement in their health outcomes.
- Culture can influence a person’s health and responses to healthcare interventions.
- Every person must be respected for their uniqueness and cultural background.
- Culture changes gradually over time.
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:
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.
- Promote programs to recruit and retain diverse staff members.
- Promote cultural competency training for healthcare providers.
- Encourage interpretive services to ensure healthcare workers communicate effectively with people from different backgrounds.
- Providing appropriate materials for educating and informing healthcare workers of different cultural backgrounds.
- Fostering an environment of respect by providing inclusion policies and practices and creating a welcoming environment for all patients irrespective of their backgrounds.
- Including culture during orientations of new healthcare workers.
- Providing diversity workshops on an ongoing basis.
- Displaying culturally diverse artwork and other types of culturally appropriate objective signs.
- The organization’s mission statement must include diversity initiatives.
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.
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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