The Purnell Model for Cultural Competence 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 culture that determine the degree to tence, an essential component within the multidisciplinary which people adhere to their dominant culture 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 cultural diversity 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 societies 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 cultural sensitivity 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 cultures are subcultures, 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 material culture, 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 ethnocentrism. • 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