Description of the Theory
The Purnell Theory for Cultural Competence began as an organizing framework during 1991 when the author, Purnell Larry, was lecturing undergraduate students and identified the need for staffs and students to have a framework through which they could learn about the cultures of their patients including their families as well as their own cultures. Basing on comments on comments from students, Purnell was convinced that cultural competence and ethnocentric behavior was inexistent. As a result, the Purnell Model for Cultural Competence was developed as an organizing framework having precise questions and a format that could be used to assess culture in clinical practice settings. All healthcare disciplines place an emphasis on communication as well as the need to know the ethno-cultural beliefs of patients. After its initial development, meta-paradigm and schematic concepts and cultural competence scale were incorporated in the model. The major assumptions of the Purnell’s model for cultural competence draw on a broader perspective, which implies that they are applicable in all environmental contexts and practice disciplines. In this regard, a healthcare provider who is cultural competent tends to be aware of his/her thoughts, existence, environment and sensations and does not let these factors influence the patient receiving care. Cultural competence entails adapting care in a way that it is consistent with the patient’s culture. The following are the major assumptions of the Purnell’s model for cultural competence:
All healthcare disciplines require the same information regarding cultural diversity.
All healthcare disciplines make use of the same meta-paradigm concepts of health, person, family, community and the global society.
There is no culture that is better than the other; instead, they are merely different.
There are core similarities across all cultures.
There are differences within, between and among cultures.
Cultures are subject to change gradually in a society that is stable;
The level to which a culture differs from the dominant culture is determined by the secondary and primary characteristics of culture.
If patients are co-participants in health care and are given the choice in selecting health-related interventions, plans and goals, then, there will be an improvement in health outcomes.
Culture exerts a significant impact on a person’s interpretation of healthcare and how he/she responds to care.
Families and individuals fit in numerous cultural groups.
Each person deserves to be respected for his/her cultural heritage and uniqueness.
Caregivers require both specific and general cultural information in order to offer care that is both culturally competent and sensitive.
Assessments, plans and interventions that are culturally competent tend to improve patients’ care.
Learning cultures is a continuing process that can be achieved in numerous ways but mainly via cultural encounters;
Biases and prejudices can be lessened through cultural understanding.
Effectiveness of care can be improved through reflecting on distinctive understanding of the life ways, beliefs, and values of individual acculturation patterns and diverse populations.
Cultural and racial differences need the adaptations of the standard interventions.
Cultural awareness tends to improve the self-awareness of the caregiver.
Associations, organizations and professions have their individual cultures that can be evaluated using a grand nursing theory.
The Purnell’s model for cultural competence draws upon several theories and a research base of family development, communication, administrative and organizational theories including other disciplines such as linguistics, economics, history, religion, pharmacology, nutrition ecology, biology, physiology and anatomy, psychology and sociology. The primary characteristics of culture comprise of concepts such as religious affiliation, age, gender, color, race and nationality whereas the secondary characteristics of culture comprises of concepts such as occupation, socioeconomic status, sexual orientation, political beliefs, military experience, parental and marital status and physical characteristics among others. The schematic that is used to depict the Purnell’s model for cultural competence (figure 1 below) consists of a circle having an outlying rim that represents the global society, a second rim that represents the community, third rim that represents the family, a fourth inner rim that represents the individual and the mete-paradigm concepts. The inside of the concentric circles comprises of 12 pie-shaped wedges that are used to depict the cultural domains and their respective constructs. In the model, domains are interrelated and that each domain is influenced by a number of other domains. The centre of the Purnell’s model for cultural competence is empty; this denotes the unknown facets of a given cultural group. The bottom of the model has a saw-toothed line that is used to denote the level of cultural consciousness. The saw-toothed line is linked to the healthcare provider. Since the meta-paradigm concepts in the Purnell’s model for cultural competence draw upon a broad perspective, they are not a reflection of a specific ethnic, cultural or national values and beliefs. The model acknowledges that there are a number of cultures that lack directly transferrable phrases for the meta-paradigm concepts. As a result, caregivers may be compelled to adapt the meta-paradigm concepts to match the cultural needs of the patient. For instance, the definition of a person may be different for individualistic and collectivistic cultures. A case in point is in Western cultures, whereby a person is defined as a standalone unique individual whereas in other cultures, a person may be defined with respect to a family or any other group. The following table summarizes the 12 domains in the model.
Domain Brief Description
Overview/Heritage Comprises of concepts that are related to occupation, educational status, reasons for immigration, politics, current residence, nationality, and the impacts of topography of nationality and current residence
Communication Comprises of concepts linked to the dominant dialects and language; variations in language use such as voice intonations, tone and volume; non verbal communication aspects such as eye contact, acceptable greetings, spatial distancing, touch, facial expressions and body language among others; social time versus clock time; and utilization of names
Family roles and organization Comprises of concepts associated with gender roles and household head; developmental tasks of adolescents and children; family priorities and roles; child rearing practices; and views regarding alternative lifestyles like sexual orientation, single parenting and marriages that are childless.
Workforce issues Comprises of concepts linked to individualism, ethnic styles of communication, gender roles, assimilation, acculturation, autonomy and healthcare practices in the country of origin
Bio-cultural ecology Comprises of racial and ethnic differences regarding skin color and physical differences such as topographical, endemic, hereditary and genetic diseases
High risk behaviors Comprises of concepts such as the use of recreational drugs, alcohol and tobacco; non utilization of safety measures; deficiency in physical activity; and high risk sexual behaviors
Nutrition Comprises of concepts such as sufficient food intake; food preferences, taboos and rituals; meanings associated with food; and how food is consumed during instances of illness
Pregnancy and child rearing practices Comprises of concepts associated with fertility practices; birth control methods and practices; views regarding pregnancy; taboo, restrictive and prescriptive practices relating to pregnancy, postpartum treatment and birthing
Spirituality Entails the use of prayer and religious practices; cultural behaviors that give meaning to life; and the sources of strength for the patient
Health care practice Entails the emphasis of care (preventive or acute); individual responsibility for his/her health; beliefs regarding traditional and biomedical; perceptions about mental illness and organ transplantation and donation
Health care practitioner Comprises of the perceptions, use and status of allopathic biomedical, magicoreligious and traditional care providers as well as the gender of the caregiver.
Published Studies that Have Tested or Used Purnell’s Model for Cultural Competence
Anderson, L. M., Scrimshaw, C., Fullilove, M., Fielding, J. E., Normand, J. et al. (2003). Culturally Competent Healthcare Systems: A Systematic Review. American Jourbal of Preventive Medicine , 24 (3S), 68-78.
Theoretically, culturally competent healthcare systems (those providing linguistically and culturally appropriate care services) have the potential of reducing ethnic and racial health disparities. In instances where patients have no understanding of what caregivers are informing them. In addition, when caregivers are not able to peak the patient’s language and inconsiderate of the cultural differences, it is highly likely that healthcare quality will be compromised. In this regard, Anderson et al (2003) performed a systematic review of five interventions aimed at improving cultural competence of care systems, which included use of healthcare settings that are culturally specific, utilization of culturally and linguistically appropriate health care education materials, providing cultural competence training to healthcare providers, using interpreter services, and recruiting and retaining staff to mirror the cultural diversity of the community being served. Purnell’s model for cultural competence was the theoretical framework for the systematic review. Anderson et al (2005) established the effectiveness of these culturally competence interventions using measures such as health outcome improvements, patient satisfaction, and racial and ethnic healthcare disparities. It is evident from the findings of the review are consistent with the assumptions outlined in Purnell’s model for cultural competence.
Beach, M., Price, E., Gary, T., Robinson, K., Gozu, A., Palacio, A., et al. (2005). Cultural competence: a systematic review of health care provider educational interventions. Medical Care , 43 (4), 356-73.
Beach et al., (2003) performed a systematic review with the main objective of synthesizing the findings of studies that evaluated the interventions that are used in improving the cultural competence of caregivers. Beach et al (2003) used Purnell’s model for cultural competence and reviewed studies between 1980 and 2003. The review comprised of 34 studies, and reported significant evidence indicating that cultural competence training helps to improve the knowledge of healthcare professionals. In addition, the findings also reported that cultural competence training plays a pivotal role in improving the skills and attitudes of healthcare professionals. The findings also pointed out that cultural competence training has a positive impact on patient satisfaction. Overall, it is apparent that the findings reported in the study are consistent with the assumptions held by the Purnell’s model for cultural competence, which implies that the Purnell’s model for cultural competency functioned extremely well with regard to the objectives of the study. Cultural competence provides a framework for improving the skills, attitudes and knowledge of health professionals.
Sunil, K., Cheyney, M., & Engle, M. (2009). Cultural Competency in Health Care: Evaluating the Outcomes of a Cultural Competency Training Among Health Care Professionals. Journal of the National Medical Association , 101 (9), 886-892.
Sunil, Cheyney & Engle (2009) undertook a study to explore the effectiveness of a cultural competence training program, which was designed with the aim of improving the skills and knowledge of healthcare administrators and providers who engage in trans-cultural clinical encounters. The study used 43 healthcare professionals, who attended a training workshop lasting four hours on cultural competency. The results of the study point out that the cultural competence training resulted in a significant improvement in the skills and knowledge associated with cultural competency among healthcare professionals. Overall, the results of the study are consistent with the assumptions of Purnell’s model for cultural competence in the sense that culturally competent healthcare professionals understand the healthcare experiences of clients coming from different backgrounds and are effectively equipped to work in trans-cultural clinical settings.
Clinical Case that is Appropriate for the Application of Purnell’s model for Cultural Competence – Offering Culturally Competent Care for Native Americans Giving Birth in Clinical Settings
Giving birth is considered a significant life event for Native American women as well as their families. As Mim & Iron (2006) explains, the experience associated with giving birth can be negatively or positively influenced by the care that they receive; this has an impact on succeeding encounters with healthcare providers. According to Beach, et al. (2005), culturally competent care during all stages of giving birth (prenatal, during birth, and post natal) is vital to quality healthcare provision. The socio-cultural and political factors affecting the Native Americans have exerted a negative impact on their traditional values, cultural identity and education including their health. Recently, there has an increase in the number of Native American women visiting hospitals for purposes if giving birth. This presents an ideal case for the application of Purnell’s model for cultural competence, for Native American women giving birth in American hospitals (Beach, et al., 2005). When dealing with Native American patients, there are numerous barriers that are likely to hamper the provision of quality care such as Native Americans’ belief in traditional spiritual healing systems; communication barriers; and other culture-specific factors associated with Native Americans that is likely to have an impact on the provision of care.
Application of Purnell’s Model for Cultural Competence in the above Clinical Case: Nursing Assessment and Interventions
In order to have cultural challenges when administering care to Native Americans, caregivers need to be culturally competent, which in this case, entails adapting nursing assessments and interventions to meet the particular needs of Native Americans. The first approach to provide culturally competent care to Native American women giving birth in hospitals is for the caregiver to have an understanding of the holistic view associated with the Native American culture. Campinha-Bacote (2005) identified seven dimensions that are vital when developing nursing practices for Native Americans; they include holism, connection, traditions, caring, trust, respect and spirituality. In the context of Native Americans, spirituality is the most significant; but it is least understood by caregivers. Customarily, the relationship with the child is perceived to commence prior to birth. Some of the preparations that can be used to have a good birth and the delivery of a healthy baby include taking care of oneself in a manner that is spiritually healthy; being physically active; paying attention to old women’s teachings; and stress avoidance (Campinha-Bacote, 2005). Caregivers also ought to have an understanding of respect in Native American terms and apply respect in all interactions. For Native Americans, respect is considered a reciprocal process, which recognizes, in action and words, the equality of communities and persons. Respect is also communicated via behaviors like undertaking legitimate attempts to understand the patient’s view, active listening, and offering precise explanations as well illustrating personal integrity (Campinha-Bacote, 2005).
Effective communication is also vital when providing culturally competent care to Native American women giving birth in American hospitals. In order for Native Americans to be involved wholly in their own medical care, health services ought to be available in Native American languages. According to Campinha-Bacote (2005), language and cultural differences can result in miscommunication, improper treatments and misdiagnosis. Moreover, it is imperative for the caregiver to understand the elements of non verbal communication such as eye contact norms, and voice tone. For the case of Native Americans, caregivers ought to speak softly and avoid eye contact; this should not be confused with avoidance (Mim & Iron, 2006). In addition, many Native Americans are reluctant to express pain; consequently, it is imperative for the healthcare professionals to understand that the absence of complaints about pain does not necessarily imply that the patient is not experiencing pain (Campinha-Bacote, 2005). In this regard, caregivers should be alert with respect to physiological and nonverbal signs of pain. Caregivers should always seek for permission of the patient before touching any part of the body; this is because touching is considered extremely personal among Native Americans. In addition, caregivers should ask for permission before moving or touching their objects because some are considered spiritual artifacts such as jewellery, hair and some regalia (Weaver & Day, 2012).
References
Anderson, L. M., Scrimshaw, C., Fullilove, M., Fielding, J. E., & Normand, J. (2003). Culturally Competent Healthcare Systems: A Systematic Review. American Jourbal of Preventive Medicine , 24 (3S), 68-78.
Beach, M., Price, E., Gary, T., Robinson, K., Gozu, A., Palacio, A., et al. (2005). Cultural competence: a systematic review of health care provider educational interventions. Medical Care , 43 (4), 356-73.
Campinha-Bacote, J. (2005). A biblically based model of cultural competence in the delivery of healthcare services. New York: Transcultural C.A.R.E. Associates.
Mim, D., & Iron, P. (2006). Strategies for Cultural Competency in Indian Health Care. Washington, D.C: American Public Health Association,.
Sunil, K., Cheyney, M., & Engle, M. (2009). Cultural Competency in Health Care: Evaluating the Outcomes of a Cultural Competency Training Among Health Care Professionals. Journal of the National Medical Association , 101 (9), 886-892.
Weaver, H., & Day, P. (2012). Health and the American Indian. New York: Routledge .
