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Home , Cultural competence, Dominant culture

The Purnell Model for

Larry Purnell, PhD, RN, FAAN

The twenty^-first centujy has ushered ir\ an era of mul- the Model are presented. The primary) and secondary} ticulturalisrn and diuersity in health care. Cultural compe- characteristics of that determine the degree to tence, an essential component within the multidisciplinary which people adhere to their are also healthcare team, has become a major initiative. The included. Purnell Model of Cultural Competence is proposed as an Cultural general knowledge and skills ensures thai organizing framework to guide cultural competence providers have a process for "becoming" cuituraily com- among mu/t/discip/inary members of the healthcare team petent. This manuscript presents definitions of essential in a variety? of primar\;, secondary/, and tertiary settings. terminology for understanding culture and the Purnell First, essential definitions for understanding culture and Model for Cultural Competence. cultural concepts are introduced. A brief overview of the Purneil Model for Cultural Competence including pur- KEY WORDS: Purnell Model; Primary character- poses, underlying assumptions, and major components of istics; Secondary characteristics.

ealthcare professionals and healthcare organi- employment settings from multiple perspectives. zations are avidly addressing multicultural Increasing one's consciousness of diversity and racial and ethnic disparities in improves the possibilities for healthcare practitioners to health. Almost every health journal now has provide culturally competent care, and therefore articleHs addressing "cultural competence." Healthcare improved care. Cultural competence is a conscious professional and organizations have some type process and not necessarily linear. To add to the com- of standards, initiative, or statement encouraging its mem- plexity of learning culture, no standardization of terminol- bers to become culturally sensitive and/or culturally com- ogy related to culture and ethnicity exists. The definition petent. Moreover, one can now find workshops that of presented by one person or group is address culturally sensitive and culturally competent care the same definition that another person or group defines from a plethora of organizations and individuals. The as cultural competence or awareness. In an attempt to stress on culture and diversity is good because cultural reach consensus and standardize definitions of these and competence improves the health of the country's citizens. other terms commonly used in health care, the American However, culture is an extremely demanding and complex Academy of Nursing Expert Panel on Cultural concept, requiring providers to look at themselves, their Competence has been developing over the last two years patients, their communities, their colleagues, and their a White Paper that addresses this issue. This manuscript presents definitions of essential terminology as a starting point for understanding culture and the Purnell Model for Cultural Competence.

Larry Purnell, PhD, RN, FAAN, Professor, DEFINITIONS University of Delaware, College of Health and Nursing Sciences, Department of Nursing, Although anthropologists and sociologists have pro- McDowell Hall, Newark, Delaware. posed many definitions of culture Purnell defines culture as

THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 ...the totality of socially transmitted behavioral pat- broader cultural group, creating uncertainties for health- terns, arts, beliefs, values, customs, lifeways, and all care providers. For example, what is the politically correct other products of human work and thought charac- term: Hispanic or Latino? According to the Office of teristics of a population of people that guide their Minority Health (2004), both terms are acceptable. worldview and decision making. These patterns may However, some individuals prefer the term Hispanic, oth- be explicit or implicit, are primarily learned and trans- ers prefer the term Latino, and for others, neither term is mitted within the family, are shared by most members apporpriate and the person self-identifies with another of the culture, and are emergent phenomena that term more appropriate to the country of origin or ethnici- change in response to global phenomena. Culture is ty. Many times it is not necessary to label a person; how- learned first in the family, then in school, then in the ever, when it is necessary, simply ask the person how community and other social organizations such as the he/she wishes to be identified. church. (Purnell, 2003,p.3). Cultural competence has several characteristics and includes knowledge and skills as well as the following: Within all are , ethnic groups, or ethnocultural populations, groups who have experiences • Developing an awareness of one's own culture, different from those of the dominant culture with which existence, sensations, thoughts, and environment they identify; they may be linked by nationality, language, without letting them have an undue influence on socioeconomic status, education, sexual orientation, or those from other backgrounds; other factors that functionally unify the group and act col- • Demonstrating knowledge and understanding of lectively on each member with a conscious awareness of the client's culture, health-related needs, and these differences (Purnell, 2003). Additionally, subcultures meanings of health and illness; differ from the dominant cultural group and share beliefs • Accepting and respecting cultural differences; according to the primary and secondary characteristics of • Not assuming that the healthcare provider's culture (defined later in this manuscript). A specific exam- beliefs and values are the same as the client's; ple of how two people from the dominant American cul- • Resisting judgmental attitudes such as "different ture may vary follows; is not as good;" and • Being open to cultural encounters; Susan Jones, age 62, is an uninsured, single, • Being comfortable with cultural encounters; white Catholic lesbian who makes $20,000 a • Adapting care to be congruent with the client's year and practices aromatherapy. William culture; James, age 28, is an insured, heterosexual, mar- • Cultural competence is an individualized plan of ried, white male with 4 children and makes care that begins with performing an assessment $200,000 per year and believes strongly in high- through a cultural lens. technology health care. Organizational cultural competence is also important While these two people both come from the "domi- and essential for healthcare educational and service nant American culture," their worldview is probably very organizations. At a minimum, for an organization to be different due to their subcultures and primary and sec- culturally competent, the following should be in place. ondary characteristics of culture such as age, gender, sex- ual orientation, marital status, parental status, and socioe- • The mission and philosophy must address diver- conomic and insurance status. sity initiatives; Culture is largely unconscious and has powerful influ- • Culture must be included in the orientation pro- ences on health and illness. Healthcare providers must gram of all new employees; recognize, respect, and integrate clients' cultural beliefs • Diversity workshops must be provided on an on and practices into health prescriptions. Thus, the provider going basis; must be culturally aware, culturally sensitive, and have • Interpretation and translation services must exist, some degree of cultural competence to be effective in especially in the languages of the population they integrating health beliefs and practices into plans and serve; interventions. Cultural awareriess, essentially the objec- • Cultural brokers must include mentors for tive , has more to do with an appreciation employees unfamiliar with the culture of the of the external signs of diversity, such as arts, music, dress, patients; and physical characteristics. Cultural sensitivify has more • Directional signs must be posted in languages of to do with personal attitudes and not saying things that the populations who use the facility; might be offensive to someone from a cultural or ethnic • Culturally congruent meals are provided for background different from the healthcare provider's. patients; Moreover, culturally sensitive, politically correct language • An array of culturally diverse artwork and other changes over time, within ethnic groups, and within the objective signs of culture are displayed;

8 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 • The ethics committee has representation from the are strange, bizarre, or unenlightened, and therefore community and from the ethnocultural groups wrong (Purnell, 2003). Most of the literature in nursing served; addresses only the negative aspects of . • A concerted effort is made to recruit employees However, there is a positive aspect of ethnocentrism from representative of the populations they serve; and the patient's, family's, and community perspetives. • Any number of culturally specific services: e.g. a Ethnocentrism is responsible for cultural self-survival and hospital that serves the orthodox Jewish commu- helps people maintain self-worth and self-survival. These nity programs elevator doors to open automati- positive attributes can be negative when one uses his/her cally and on each floor on the Sabbath and to own worth in relation to others who are perceived to be provide kosher meals. inferior (Walker & Avant, 1995).

The word race has become a very controversial word, Culture as a Process at least in the . The Human Genome Project (2004) demonstrates that all human beings share a genet- Cultural competence is a process, not an endpoint ic code that is over 99 percent identical. Some people (See figure 1). One progresses (a) from unconscious minimize or dispute the concept of race and others stress incompetence (not being aware that one is lacking knowl- its importance given the major initiatives addressing racial edge about another culture), (b) to conscious incompe- and ethnic dispartiies in health care. However, the con- tence (being aware that one is lacking knowledge about troversial term race must still be addressed. Race is genet- another culture), (c) to conscious competence (learning ic in origin and includes physical characteristics that are about the client's culture, verifying generalizations about similar among members of the group, such as skin color, the client's culture, and providing culturally specific inter- blood type, hair and eye color. Difference among races is ventions), and finally (d) to unconscious competence significant when conducting health assessments, investi- (automatically providing culturally congruent care to gating hereditary and genetic diseases, and prescribing clients of diverse cultures). Unconscious competence is medication. People from a given racial group may, but do difficult to accomplish and potentially dangerous because not necessarily, share a common culture or : individual differences exist within specific cultural groups. e.g., most have black skin but a person To be even minimally effective, culturally competent care with white skin and no ancestry with people with black (really an individualized plan of care) must have the assur- skin may self-identity with the African American culture. ance of continuation after the original impetus is with- drawn; it must be integrated into and valued by the cul- Healthcare providers must assess the patient's and ture that is to benefit from the interventions. family's beliefs for effective health maintenance and well- ness, illness and disease prevention, and health restora- Each healthcare provider adds a new and unique tion. A belief is something that is accepted as true, espe- dimension to the complexity of providing culturally com- cially as a tenet or a body of tenets accepted by an indi- petent care. The way healthcare providers perceive them- vidual or group. A common belief among cultures is that selves as competent providers is often refiected in the way health, either good health or bad health, is ''God's Will." they communicate with clients. Thus, it is essential for Beliefs do not have to be proven; they are consciously or healthcare professionals to take time to think about them- unconsciously accepted as truths and must be included in selves, their behaviors, and their communication styles in the client's individualized plan of care, regardless of what relation to their perceptions of culture. Cultural self the provider thinks about them. awareness is a deliberate and conscious cognitive and All groups have similar or the same values but they emotional process of getting to know yourself: your per- vary in the degree and the intensity by which they are sonality, your values, your beliefs, your professional held by the group and by the individual. Values are prin- knowledge standards, your ethics, and the impact of these ciples and standards that have meaning and worth to an factors on the various roles played when interacting with individual, family, group, or community. Major cultural individuals who are different from yourself. The ability to values include versus , being understand oneself sets the stage for integrating new versus doing, hierarchial versus egalitarian status, youth knowledge related to cultural differences into the profes- versus elders, cooperation versus competetion, ascribed sional's knowledge base and perceptions of health inter- versus achieved status, change versus tradition, and for- ventions. Even then, traces of ethnocentrism may uncon- mality versus informailty, to name a few. The more one's sciously pervade one's attitudes and behavior. values are internalized, the more difficult it is to avoid the tendency toward ethnocentrism. Ethnocentrism, the uni- STEREOTYPING VERSUS GENERALIZATION versal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, prop- Stereotyping, an over simplified conception, opinion, er, and natural ways, can be a major barrier to providing or belief about some aspect of an individual or group of culturally competent care. Ethnocentrism perpetuates an people is a common occurrence among people, and attitude in which beliefs that differ greatly from one's own occurs at the intra-individual level, inter-individual level.

THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 and inter-group level (Stevens & Fiske, 1995). THE PURNELL MODEL EOR Stereotyping has both cognitive (categorization) and CULTURAL COMPETENCE motivational components, which bolsters self-esteem (Baumeister, Smart, & Boden. 1996; Fiske. 2000; Turner, The Purnell Mode! for Cultural Competence (See 1987). Stereotyping is a normal function and people Figure 1) started as an organizing framework in 1991 accentuate differences between categories and minimize when the author was teaching undergraduate students differences within categories (Capozza & Nanni, 1986). A and discovered the need for both students and staff to stereotype can be positive, "all Asians are good in math," have a framework for learning about their cultures and or negative, "all African American teenagers are sexually the cultures of their patients and families. Comments from promiscuous." Obviously these statements are example of staff and students made it dear that ethnocentric behav- subjective essentialism and entitativity (Yzerbyt, Corneille, ior and tack of cultural awareness, cu!tural sensitivity, and & Estrada, 2001) because not all Asians are good at math cultural competence existed. The Purnell Model was and not all African American teenagers are promiscuous. designed as a wholistic organizing framework with specif- However, stereotyping has advantages, including saving ic questions and a format for assessing culture that could perceivers' mental resources to allow them to operate be used across disciplines and practice settings. under a cognitive load (Pendry, 1998). A stereotype is, All healthcare discip!ines communication and however, an endpoint. need to know their client's ethnocultural beliefs. Although Given that stereotyping is a common occurrence, physicians, nurses, nutritionists, therapists, technicians, healthcare professionals must concentrate on impression morticians, home health aides, and other caregivers need management and validate cultural group generalizations. similar culturally specific information, the manner in Generalization, rules that groups adopt about other which the information is used may differ significantly groups, is a point, and the healthcare provider must see if based on the discipline, individual experiences, and spe- the individual fits the cultural pattern. Impression man- cific circumstances of interacting with the client. Each dis- agement begins with self awareness and is a conscious cipline has its own unique knowledge base to support its process through which providers must cognitively engage ways of knowing its clients as well as techniques, ro!es, to control stereotypical thinking (Pacquiao, 2000; norms, va!ues, ideo!ogies, attitudes, and beliefs, which Schneider, 1981). The value in making generalizations interlock to make a reinforced and supportive system about cultural groups is that the healthcare provider within its defined practice. An understanding of ethnocu!- knows what questions to ask. For example, in collectivist tural diversity improves the effectiveness of all healthcare cultures, such as Korean, Chinese, Filipino, and providers. Vietnamese to name a few, ingroup harmony is essential The Purnell Model has been classified by three well- to ingroup loyalty and to standards of behav- known nurse theorists as holographic and complexity the- ior. If the provider automatically assumes that the previ- ory because it includes a model and organizing frame- ous statement is tme, then that person is stereotyping the work that can be used by all healthcare providers in vari- person based on the characteristics of east Asian cultures. ous disciplines and settings. Additionally, these nurse the- Adopting such a generalization is a beginning point from orists early in 1998 confirmed that the Purne!! Model was which the provider must determine the extent to which not a conceptua! framework, but rather a grand theory. the patient and/or family adheres to these cultural charac- Although the professiona! community recognizes that teristics. scholarly controversy exists in distinguishing between a conceptual framework and grand theory, the va!ue and Some authorities believe that learning the charactris- utility of the Purnell Model has been documented in tics of cultural groups and that research on cultural groups developing cultural competence across disciplines and in can reinforce stereotyping (Dreher & MacNaughton, stimulating further inquiry and knowledge quest. 2002). These authorities maintain that the provider needs to only know a genera! cultural approach for assessments The Model is a circle, with an outlying rim represent- and may disregard cultural specific information. If the ing globa! , a second rim representing community, provider does not know cultural specific characteristics, a third rim representing family, and an inner rim repre- e.g. Mexican clients may use curanderos, masajistas, and senting the person. The interior ofthe circle is divided into sobadores (folk healers) for generic health care, they 12 pie-shaped wedges depicting cu!tural domains and would not know to specifically ask about them; and there- their concepts. The dark center of the circ!e represents fore, essential information may be missed. Knowing both unknown phenomena. Along the bottom of the mode! is the genera! and specific characteristics of the cultural a jagged line representing the nonlinear concept of cultur- group leads to an improved assessment allowing one to al consciousness. The 12 cultural domains (constructs) make an individualized plan of care. provide the organizing framework of the mode!.

10 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 Figure 1 - The Purnell Model for Cultural Competence

§ S ^ G ^.§

Unconsciously Incompetent - Consciously incompetent - Consciously competent - Unconsciously competent Primary characteristics of culture: age, generation, nationality, race, color, gender, Secondary characteristics of culture: educational status, socioeconomic status, occupation, military status, political beliefs, urban versus rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, and reason for migration (sojourner, immigrant, undocumented status)

THE JOURNAL OF MULTIOULTURAL NURSING & HEALTH 11:2 Summer 2005 11 Healthcare providers can use this same process to under- • Learning culture is an ongoing process that stand their own cultural beliefs, attitudes, values, prac- develops in a variety of ways, but primarily tices, and behaviors. through cultural encounters (Campinha-Bacote, 2004). The purposes of the Purnell Model are to • Prejudices and biases can be minimized with cul- tural understanding. • Provide a framework for all healthcare providers • To be effective, health care must reflect the to learn concepts and characteristics of culture; unique understanding of the values, beliefs, atti- • Define circumstances that affect a person's cul- tudes, lifeways, and worldview of diverse popu- tural worldview in the context of historical per- lations and individual patterns. spectives; • Differences in race and culture often require • Provide a nnodel that links the most central rela- adaptations to standard interventions. tionships of culture; • Cultural awareness improves the caregiver's self- • Interrelate characteristics of culture to promote awareness. congruence and to facilitate the delivery of con- • When individuals of dissimilar cultural orienta- sciously sensitive and competent health care; tions meet in a work or therapeutic environment, • Provide a framework that rcfiects human charac- the likelihood for developing a mutually satisfy- teristics such as motivation, intentional ity, and ing relationship is improved if both parties in the meaning; relationship attempt to learn about each other's • Provide a structure for analyzing cultural data; culture. and • Culture is not border bound. Fteople bring their • View the individual, family, or group within their culture with then when they migrate. unique ethnocultural environment. • Professions, organizations, and associations have their own culture, which can be analyzed using a The explicit assumptions upon which the Model is grand theory of culture. based are METAPARADIGM CONCEPTS • All healthcare professions need similar informa- tion about cultural diversity. The macro aspects of this Model include the tradi- • All healthcare professions share the metapara- tional nursing metaparadigm concepts of global society, digm concepts of global society, family, person, community, family, and person. Although not all nurse and health. theorists support the nursing metaparadigm concepts • One culture is not better than another culture; (Leininger, 1997}, this author has found them to be they are just different. immensely valuable because they provide a wholistic and • Core similarities are shared by all cultures. global perspective. The theory and model are conceptu- • Differences exist within, between, and among alized from biology, , , economics, cultures. geography, history, ecology, physiology, psychology, • Cultures change slowly over time. political science, pharmacology, and nutrition as well as • The primary and secondary characteristics of cul- theories from communication, family development, and ture determine the degree to which one varies social support. The Model can be used in clinical practice, from the dominant culture. in formal and continuing education education, in • If clients are coparticipants in their care and have research, and in the administration and management of a choice in health-related goals, plans, and inter- healthcare services. ventions, their compliance and health outcomes Phenomena related to a global society include world will be improved. communication and politics; conflicts and warfare; natu- • Culture has a powerful influence on one's inter- ral disasters and famines; international exchanges in edu- pretation of and responses to health care. cation, business, commerce, and information technology; • Individuals and families belong to several cultur- advances in the health sciences; space exploration; and al groups. the expanded opportunities for people to travel around • Each individual has the right to be respected for the world cind interact with diverse societies. Global his or her uniqueness and . events that are widely disseminated by television, radio, • Caregivers need both cultural-general and cultur- satellite transmission, newsprint, and information technol- al-specific information in order to provide cultur- ogy affect all societies, either directly or indirectly. Such ally sensitive and culturally competent care. events create chaos while consciously and unconsciously • Caregivers who can assess, plan, intervene, and forcing people to alter their lifeways, worldviews, and evaluate in a culturally competent manner will acculturation patterns. improve the care of clients for whom they care.

12 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 In its broadest definition, community is a group of CONSTRUCTS AND CONCEPTS people having a common interest or identity and living in a specified locality. Community includes the physical, On a micro level, the Model has an organizing frame- social, and symbolic characteristics that cause people to work consisting of 12 domains, constructs, and their con- connect. Bodies of water, mountains, rural versus urban cepts, which are cotnmon to all cultures, subcultures, and living, and even railroad tracks help people define their ethnic groups. These 12 domains are interconnected and physical concept of community. Today, however, technol- have implications for health. The utility of this organizing ogy and the Internet allow people to expand their com- framework comes from its concise structure, which can be munity beyond physical boundaries. Economics, religion, used in any setting and applied to a broad range of empir- politics, age, generation, and marital status delineate the ical experiences and can foster inductive and deductive social concepts of community. Sharing a specific language reasoning in the assessment of cultural domains. They can or dialect, lifestyle, history, dress, art, or musical interest be used to formulate questions and statements for con- are symbolic characteristics of a community. People ducting research. Once cultural data are analyzed, the actively and passively interact with the community, neces- practitioner can fully adopt, modify, or reject healthcare sitating adaptation and assimilation for equilibrium and interventions and treatment regimens in a manner that homeostasis in their worldview. Individuals may willingly respects the client's cultural differences. Such adaptations change their physical, social, and symbolic community improve the quality of the client's healthcare experiences when it no longer meets their needs. and personal existence. A family; is two or more people who are emotionally connected. They may, but do not necessarily, live in close THE 12 DOMAINS OF CULTURE proximity to each other. Family may include physically and emotionally close and distant consanguineous rela- The 12 domains and their concepts essential for tives as well as physically and emotionally connected and assessing the cultural attributes of an individual, family, or distant non-blood-related significant others. Family struc- group are as follows: ture and roles change according to age, generation, mar- ital status, relocation or immigration, and socioeconomic • Overview, inhabited localities, and topography status, requiring each person to rethink individual beliefs includes concepts related to the country of origin, and lifeways. current residence, the effects of the topography of A person is a biopsychosociocultural being who is the country of origin and current residence, eco- constantly adapting to his or her environment. Human nomics, politics, reasons for emigration, and beings adapt biologically and physiologically with the value places on education. aging process; psychologically in the context of social rela- tionships, stress, and relaxation; socially as they interact • Communication includes concepts related to the with the changing community; and ethnoculturally within dominant language and dialects; contextual use the broader global society. In highly individualistic of the language; and paralanguage variations Western cultures, a person is a separate physical and such as voice volume, tone, intonations, reflec- unique psychological being and a singular member of tions, and willingness to share thoughts and feel- society. The self is separate from others. However, in high- ings. Nonverbal communications such as the use ly collectivist Asian cultures, the individual is defined in of eye contact, facial expressions, touch, body relation to the family, including ancestors, or another language, spatial distancing practices, and group rather than a basic unit of nature. acceptable greetings; temporality in terms of past, Health, as used in this article, is a state of wellness as present, or future worldview; clock versus social defined by people within their ethnocultural group. time; and the use of names are also important Health generally includes physical, mental, and spiritual communication variables. states. The concept of health, which permeates all meta- paradigm concepts of culture, is defined globally, nation- • Family roles and organization includes concepts ally, regionally, locally, and individually. People can speak related to the head of the household and gender about their personal health status or the health status of roles; family roles, priorities, and developmental the nation or community. Health can also be subjective or tasks of children and adolescents; childrearing objective in nature. practices and roles of the aged and extended In the center of the Purnell Model Is an empty circle. family members. Individual and family social sta- This circle represents unknown phenomena, practices, and tus in the community; and views toward alterna- characteristics of the individual or the group. In the case of tive life styles such as single parenting, sexual ori- healthcare providers, this circle can expand or contract entation, childless marriages, and divorce are depending upon the providers cultural self awareness and also included in this domain. the knowldege and skills they possess for working with cul- tually diverse clients, families, and communities. • Workforce issues include concepts related to

THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 13 autonomy, acculturation, assimilation, gender PRIMARY AND SECONDARY OF CULTURE roles, ethnic communication styles, and health- care practices from the country of origin. Major influences that shape peoples' worldview and the degree to which they identify with and adhere to their • Biocultura! ecology includes variations in specific cultural group of origin are called the primary and sec- ethnic and racial origins such as skin coloration ondary characteristics of culture. The primary characteris- and physical differences in body stature; genet- tics are nationality, race, color, gender, age, and religious ic, hereditary, endemic, and topographical dis- affiliation. Primary characteristics cannot easily be eases; and the differences in the way drugs are changed. If these characteristics such as religion or gender metabolized by the body. are changed, a significant stigma may attach to the indi- vidual from society. • High-risk behaviors includes the use of tobacco, The secondary characteristics include educational sta- cilcohol, and recreational drugs; lack of physical tus, socioeconomic status, occupation, military experi- activity; increased calorie consumption; nonuse ence, political beliefs, urban versus rural residence, of safety measures such as seatbelts, and hel- enclave identity, marital status, parental status, physical mets; and engaging in risky sexual practices. characteristics, sexual orientation, gender issues, reason for migration (sojourner, immigrant, or undocumented • Nutrition includes having adequate food for sat- status}, and length of time away from the country of ori- isfying hunger; the meaning of food; food choic- gin. People who live in ethnic enclaves and get their work, es, rituals, and taboos; enzyme deficiencies; and shopping, and business needs met without learning the how food and food substances are used for language and customs of their host country may be more traditional than people in their home country. health promotion and wellness and during illness Immigration status influences a person's worldview. For example, people who voluntarily immigrate generally • Pregnancy and childbearing practices includes acculturate more willingly; i.e., they modify their own cul- fertility practices; culturally sanctioned and ture as a result of contact with another culture. Moreover, unsanctioned methods for birth control: views acculturation has different degrees in different contexts. toward pregnancy; and prescriptive, restrictive, For example, a person my acculturate in the workforce in and taboo practices related to pregnancy, terms of language and practices, but speak their native birthing, and postpartum. language and adhere to traditional practices when at home. Similarly, they assimilate, that is, gradually adopt • Death rituals includes how the individual and the and incorporate the characteristics of the prevailing cul- culture view death, rituals, and behaviors to pre- ture more easily than people who immigrate unwillingly or pare for death, and burial practices. Bereavement as sojourners. Sojourners, who immigrate with the inten- behaviors are also included in this domain. tion of remaining in their new homeland only a short time, or , who think they may return to their • Spirituality includes religious practices and the home country, may not perceive the need to acculturate use of prayer, behaviors that give meaning to life, or assimilate. Additionally, undocumented individuals and individual sources of strength. (illegal aliens) may have a different worldview from those who have arrived with work visas as "legal immigrants." • Healthcare practices includes the focus of health care such as acute or preventive; traditional, magicoreligious, and biomedical beliefs; individ- CONCLUSION ual responsibility for health; self-medicating practices; and views toward mental illness, Today, each subgroup has the right to be respected chronicity, rehabilitation, and organ donation for its unique individuality. Most health-related education- and transplantation. Additionally, one's response al programs and service providers have statements to pain and the sick role are shaped by culture. addressing multicultural diversity. Organizations and indi- Barriers to health care are included in this viduals who understand their clients' cultural values, domain. beliefs, and practices are in a better position to be co-par- ticipants with their clients and provide culturally accept- • Healthcare practitioners concepts include the sta- able care. Accordingly, multidisciplinary healthcare pro- tus, use, and perceptions of traditional, magi- fessionals can use the Purnetl Model as a guide for assess- coreligious, and Western biomediccil healthcare ing, planning, implementing, and evaluating interven- providers. Additionally, the gender of the health- tions. Through a systematic appraisal for each client and individualizing care, improved opportunities for health care provider may have significance in some cul- promotion, illness and disease prevention, and health tural groups. restoration occurs. To this end, healthcare providers need

14 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 both general and specific cultural knowledge. One cannot ensures that providers have a process for "becoming" cul- possibly know all the diverse world cultures and their turally competent. characteristics. Cultural general knowledge and skills

REFERENCES

Baumeister, R., Smart, L, & Boden, J. (1996). Relation of Office of Minority Health. (2004). Retrieved October threatened egoism to violence and aggression: The 2004 from http://www.ohmrc.gov dark side of self-esteem. Ps\^chological Reuiew, 105, Pacquiao, D. (2000). Impression management: An alter- 5-33. native to assertiveness in intercultural communica- Campinha-Bacote. J. (2004). A Culturally Competent tion. Journal of Transcultural Nursing, 11(1), 5-6. Model of Care. Retrieved October 7, 2004 from Pendry, L. (1998). When the mind is otherwise engaged: http://www.transculturalcare.net/ Resource depletion and social stereotyping.European Capozza, D., & Nanni, R. (1986). Differentiation process Journal of Social Psychology, 28, 293-299. for social stimuli with different degrees of category Purnell, L. (2003). Transcultural diversity and health care. representativeness. European Journal of Social In L. Purnel! and B. F^ulanka (Eds.), Transcultural Psychology, 16, 399-412. health care: A culturally; competent approach, (2 ed., Dreher, M., & MacNaughton, A. (2002). Cultural compe- pp. 1-7). Philadelphia: F A. Davis. tence in nursing: Foundation or fallacy. Nursing Schneider, D. (1981). Tactical self-presentation: Towards Outlook, 50, 181-186. a broader conception. In J. T. Tedecshi (Ed.), Fiske, S. (2000). Stereotyping, prejudice, and discrimina- Impression management theory and social psijcholog- tion at the seam between centuries: Evolution, cul- ical research (pp. 23-40). NY: Academic Press. ture, mind, and brain. European Journal of Social Stevens, L, & Fiske, S. (1995). Motivation and cognition Psi;chotog];, 30, 299-322. in social life: A social survival perspective. Social Human Genome Project. (2004). Retrieved October 7, Cognition, 13, 189-214. 2004 from Walker, L, & Avant, K. (1995). Strategies for theory con- http://www.ornl.gov/sci/techresources/Human_ struction in nursing (3 ed). Norwalk, CT: Appleton & Genome/home.shtml Lange. Joint Commission on Accreditation of Healthcare Yzerbyt, V, Corneille, O., & Estrada, C. (2001). The inter- Organizations: Standards (2004). Retrieved July 18, play of subjective essentialism and entitativity in the 2004 from formation of stereotypes. Personality and Social htfp://www.jcaho.org/accredited-I-organizations/ Psychology Reuiew, (5)2, 141-155. ambulatory+care/standards/field -I- reviews/repl_fr.htm Leininger, M. (1997). Overview of the Theory of Culture Care with fhe ethnonursing research method. Journal of Transcultural Nursing, (8)2, 32-52.

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