EL MODELO DE COMPETENCIA CULTURAL DE PURNELL: DESCRIPCIÓN Y USO EN LA PRÁCTICA, EDUCACIÓN, ADMINISTRACIÓN E INVESTIGACIÓN

As immigration continúes throughout the world, nurses will work with patients from cultures that are unknown to them. Therefore, it is necessary to have a model and theoretical framework to assess a patient from a culture different from that of the nurse. Additionally, it is advantageous to have a model that all healthcare practitioners can use. This article presents a description and use of the Purnell Model for Cultural Competence in practice, education, administration, and research. Nurses, physicians, and other healthcare practitioners can use this Model with the 12 domains in the hospital, in the home, or in the community. Also, they can use the Model in medicine, surgery, pediatrics, obstetrics, or psychiatry. The Purnell Model for Cultural Competence, developed in 1995, is an example of a model that has pertinence to all healthcare practitioners. This article provides a description of the Model and its domains, lists the major assumptions upon which the Model is based, and the use of the Model in practice, education, administration, and research. A personal philosophy of the author of this article that practitioners is all healthcare disciplines need much of the same general information about culture, reinforced the necessity of developing a grand theory and model for culture. In some respects, the development of the Model is an ethnographic approach to promote an understanding of culture about the human situation during periods of illness, maintaining health, health promotion. The Model focuses on both the emic and etic views of the patient, the family, and the community. THE DEVELOPMENT AND DESCRIPTION OF THE MODEL The Development of the Model Both deductive and inductive reasoning was used in the deve2.° Semestre 1999 • Año III N.° 6 98 • Cul tura de los Cuidados lopment of the Purnell Model for Cultural Competence, and it is a product of his lived experiences, observations, personal lectures, clinical practice, formal research, and teaching. In the majority of communities, the recipients of healthcare are seen as continuously adapting to a changing society, trying to maintain their most important valúes and beliefs as they interact in an increasingly diverse technologically global society. The healthcare practitioner has the primary responsibility for creating an environment that is open to collecting health information. The Model can be used in primary, secondary, tertiary prevention. Major influences that shape people's worldview and identification with their cultural group are called the primary and secondary characteristics of culture. These characteristics influence the degree a person self-identifies with his/her cultural group. Table I lists the primary and secondary characteris-

El Modelo de Purnell de Competencia Cultural, que se desorrolla en 1995, es un ejemplo de modelo pertinente para todos los profesionales de los cuidados en salud.Este artículo proporciona la descripción del modelo, sus dominios, los supuestos mayores en los que el Modelo se basa, y el uso de éste en la práctica, la educación, la administración, y la investigación.La filosofía personal del autor de este artículo, que mantiene la postura de que todos los practicantes de las disciplinas de los cuidados en salud necesitan mucha información general sobre la cultura, refuerza la necesidad de desorrollar una teoría amplia y un marco teórico de un modelo centrado en la cultura.El desarrollo del modelo constituye un acercamiento etnográfico que promueve la comprensión cultural de situaciones humanas durante períodos de enfermedades, y el mantenimiento y promoción de la salud.El Modelo enfoca los aspectos emic y etic mediante las opiniones del paciente, de la familia, y de la comunidad.
La siguiente es una descripción breve de los 12 dominios y sus conceptos principales.Para una definición más completa y ejemplos de los conceptos, nos referiremos al libro de Purnell y Paulanka (1998) Transcultural health care: A culturally competent approach que se cita en la bibliografía.Cada uno de estos dominios tiene un cuadro separado que incluye una serie de sugerencias y preguntas que el profesional del cuidado puede usar con la finalidad de evaluar a un grupo o a una persona.Estos cuadros, que determinan el marco teórico, no se incluyen aquí debido a las limitaciones de espacio, pero si se incluyen en el libro anteriormente citado.

USO EN LA PRÁCTICA, EDUCACIÓN, ADMINISTRACIÓN E INVESTIGACIÓN
Práctica: El Modelo es flexible con un alto grado de fluidez entre dominios y niveles.Actualmente el cuidado de la salud hace énfasis en el equipo sanitario que puede beneficiarse de un modelo que es apropiado y aceptable por la multidisciplinaridad que provee al personal.Son los Practicantes del cuidado de la salud quienes pueden evaluar, planear e intervienir de manera competente en una cultura y tienen oportunidades para mejorar la salud de la persona, de la familia, o de la comunidad.El Modelo puede guiar el desarrollo de herramientas, estrategias planificadas, e intervenciones individuales, que pueden encauzar el desarrollo continuo del modelo y las teorías.
Administración: No se limita la cultura a los clientes y a los familiares; también incluye proyec-tos educativos y organizaciones del cuidado de la salud.Como el Modelo incluye un dominio de asuntos de trabajo, la línea no-lineal de competencia cultural, se puede usar para evaluar la cultura de la organización y los asuntos culturales entre profesionales.La Cultura de una organización refleja la estructura social, los antecedentes históricos, los valores, las tradiciones, los procesos de actuación, las políticas y los procedimientos, los procesos de evaluación, que revelan el grado al que la diversidad en el pensamiento, debería reflejar, y comportar aliento o tolerancia hacia la multiculturalidad.Gerentes han usado al Modelo y marco teórico para promover la aceptación de nuevos profesionales en grupos de empleados donde se da la multiculturalidad.Un comité ético ha usado el Modelo para observar "la complacencia del cliente" y el "cuidado apropiado" de las perspectivas del cliente y de los profesionales.Otra facilidad del cuidado cultural fue el uso del modelo en el caso de empleados nuevos para así ayudarlos a aprender la cultura de la organización; un proceso similar al aprendizaje de la cultura de los clientes.Una facilidad, a largo plazo, del cuidado es el uso de dominios seleccionados del modelo para guiar el cuidado y desarrollar planes para sus residentes judíos porque muchos de los practicantes del cuidado de salud no eran judíos y por tanto no conocían las prácticas ortodoxas de estos.
Raramente las acciones de los profesionales del cuidado de salud tienen el lujo de ser evaluadas por cada cliente de forma comprensiva como el Modelo nos permite.Se puede aumentar la información que se tiene del cliente con encuentros repetidos.Observaciones astutas, la creencia en la diversidad, y unas buenas ganas de aprender de los clientes, son requisitos adicionales para una eficacia en la competencia trans-cultural dentro de la práctica clínica, en la educación, en la administración, y en la investigación.Las competencias culturales en las sociedades de hoy no son un lujo, sino más bien una necesidad.

ABSTRACT
As immigration continúes throughout the world, nurses will work with patients from cultures that are unknown to them.Therefore, it is necessary to have a model and theoretical framework to assess a patient from a culture different from that of the nurse.Additionally, it is advantageous to have a model that all healthcare practitioners can use.This article presents a description and use of the Purnell Model for Cultural Competence in practice, education, administration, and research.Nurses, physicians, and other healthcare practitioners can use this Model with the 12 domains in the hospital, in the home, or in the community.Also, they can use the Model in medicine, surgery, pediatrics, obstetrics, or psychiatry.
The Purnell Model for Cultural Competence, developed in 1995, is an example of a model that has pertinence to all healthcare practitioners.This article provides a description of the Model and its domains, lists the major assumptions upon which the Model is based, and the use of the Model in practice, education, administration, and research.A personal philosophy of the author of this article that practitioners is all healthcare disciplines need much of the same general information about culture, reinforced the necessity of developing a grand theory and model for culture.In some respects, the development of the Model is an ethnographic approach to promote an understanding of culture about the human situation during periods of illness, maintaining health, health promotion.The Model focuses on both the emic and etic views of the patient, the family, and the community.

THE DEVELOPMENT AND DESCRIPTION OF THE MODEL
The Development of the Model Both deductive and inductive reasoning was used in the deve-lopment of the Purnell Model for Cultural Competence, and it is a product of his lived experiences, observations, personal lectures, clinical practice, formal research, and teaching.In the majority of communities, the recipients of healthcare are seen as continuously adapting to a changing society, trying to maintain their most important valúes and beliefs as they interact in an increasingly diverse technologically global society.The healthcare practitioner has the primary responsibility for creating an environment that is open to collecting health information.The Model can be used in primary, secondary, tertiary prevention.Major influences that shape people's worldview and identification with their cultural group are called the primary and secondary characteristics of culture.These characteristics influence the degree a person self-identifies with his/her cultural group.Table I lists the primary and secondary characteristics of diversity.The Model is a conceptualization of múltiple theories and research based on administrative theories, anthropology, sociology, anatomy and physiology, biology, psychology, religión, history, nutrition, and the clinical settings of nursing and medicine.
The diagram of the Purnell Model is a circle, with an outlying rim representing global society, a second rim representing community, a third rim representing the family, and an inner rim representing the person.The interior of the circle is divided into 12 pie-shaped wedges with the cultural domains and their concepts.The domains have bidirectional arrows indicating that each domain relates to and is affected by all the other domains.Under each domain are múltiple concepts.The center of the Model is empty, representing unknown aspects about the cultural group.At the bottom of the Model is an eróse line that represents the non-linear concept of cultural competence.This line primarily relates to the healthcare provider, although this line can also represent the degree of cultural competence of an organization.

Stages of Cultural Competence:
Cultural competence is seen as a non-lineal progression.A person gains cultural competence, progresses, regresses, and then progresses at a higher level when he/she obtains additional knowledge and skills and has encounters with people from different cultures.The culturally competent practitioner needs to develop knowledge of his/her existence, sensations, thoughts, and surroundings without letting these factors have an undue influence on those for whom care is provided.Cultural competence is the adaptation of health care in a manner that is congruent with the culture of the client, and therefore, a non-linear process.

Metaparadigm Concepts:
The metaparadigm concepts identified in the Model are global society, community, family, and person.Because these metaparadigm concepts are defined from a broad perspective, they do not reflect one particular national, cultural, or ethnic beliefs and valúes.It is recognized that some cultures do not have directly translatable words for these concepts, Therefore, the healthcare practitioner will need to adjust the definitions of these concepts according to the culture of the patient.For example, a person is defined differently between collectivist and individualistic cultures.In Western cultures (usually individualistic), the person is someone who stands alone as a unique individual.In other cultures, the person is defined in relation to the family or another group, not as a unique individual.The diagram of the Model is represented in Figure I, and the metaparadigm concepts are defined in Table II.

Table II Metaparadigm Concepts
• Community: A group or class of people who have a common interest or identity and live in a specified lócale.
• Family: Two or more people who are emotionally involved with each other.They can, but not necessarily, live in cióse proximity to each other and can be blood or non-blood related.
• Global Society: Seeing the world as one large community of multicultural people.
• Health: A state or wellness as defined by a person or ethnic group and generally includes physical, mental, and spiritual aspects as they interact with the family, with the community, and with the global society.
• Person: A human being, one who constantly adjusts to the environment, biologically, sociologically, and physiologically.

THE TWELVE DOMAINS
Although the 12 domains and their concepts flow from general to specific, the order in which the healthcare provider uses them will vary.For example, for a religiously devout person where the religión (e.g.Islam or Judaism) proscribes nutrition and communication practices, the healthcare provider will need to begin collecting data with spirituality instead of one of the other domains.The following is a brief description of the 12 domains and their major concepts.For a more complete description of the concepts, the reader is referred to the book by Purnell and Paulanka (1998), Transcultural health care: A culturally competent approach, which is listed in the referenees for this article.Each one of these domains has a sepárate table that includes a series of questions that the healthcare practitioner can use to evalúate a group or person.The tables, called the organizing framework, are not included here due to space limitations, but are included in the book.
• Overview/Heritage includes concepts related to the country of origin, present residence, the effeets of the topography of the country of origin and current residence, economics, politics, reasons for emigration, educational status, and oceupations.
• Communication includes concepts related to the dominant language and dialects; contextual use of the language; and paralanguage variations such as voice volume, tone, intonations, reflections, and willingness to share thoughts and feelings.Nonverbal Communications such as the use of eye contact, facial expressions, touch, body language, spatial distancing practices, and acceptable greetings; temporality in terms of past, present, or future worldview orientation; clock versus social time; and the use of ñames are also important communication variables.
• Family Roles and Organization includes concepts related to the head of the household and gender roles; family roles, priorities, and developmental tasks of children and adolescents; childrearing practices and roles of the aged and extended family members.Individual and family social status in the community; and views toward alternative life styles such as single parenting, sexual orientation, childless marriages, and divorce are also included in this domain.
• Workforce Issues include concepts related to autonomy, acculturation, assimilation, gender roles, ethnic communication styles, and healthcare practices from the country of origin.
• Biocultural Ecology includes variations in ethnic and racial origins such as skin color and physical differences in body stature; genetic, hereditary, endemic, and topographical diseases; and the differences in the way drugs are metabolized by the body.
• High Risk Behaviors includes the use of tobáceo, alcohol, and recreational drugs; lack of physical activity; increased caloñe consumption; nonuse of safety measures such as seatbelts, and helmets; and engaging in risky sexual practices.
• Nutrition includes having adequate food for satisfying hunger; the meaning of food; food choices, rituals, and taboos; enzyme deficiencies; and how food and food substances are used for health promotion and wellness and during illness.
• Pregnancy and Childbearing Practices includes fertility practices; culturally sanctioned and unsanctioned methods for birth control; views toward pregnancy; and prescriptive, restrictive, and taboo practices related to pregnancy, birthing, and postpartum.
• Death Rituals includes how the individual and the culture view death, rituals, and behaviors to prepare for death, and burial practices.Bereavement behaviors are also included in this domain.
• Spirituality includes religious practices and the use of prayer, behaviors that give meaning to life, and individual sources of strength.
• Health Care Practices includes the focus of health care such as acute or preventive; traditional, magicoreligious, and biomedical beliefs; individual responsibility for health; self-medicating practices; and views toward mental illness, chronicity, and organ donation and transplantation.Additionally, one's response to pain and the sick role are shaped by culture.Barriers to health care are included in this domain.
• Health Care Practitioner concepts include the status, use, and perceptions of traditional, magicoreligious, and Western biomedical health care providers.Additionally, the gender of the health care provider may have significance in some cultural groups.

MAJOR ASSUMPTIONS
The major assumptions in the Model are derived from the author's personal valúes as well as those of the healthcare environment and include health promotion and wellness, illness and disease prevention, health restoration, and rehabilitation.The assumptions are developed from a broad perspective allowing their use across practice disciplines and environmental contexts such as primary care settings, acute care settings, and long-term care and rehabilitative settings.Furthermore, the assumptions have two categories: one for the recepient of care and one for the health care provider.Explicit assumptions are included in Table III.

Table III MAJOR ASSUMPTIONS
1.All health care professions need much of the same information about cultural diversity and share the metaparadigm concepts of global society, community, family, person, and health.2. One culture is not better than another culture; they are just different.3.There are core similarities shared by all cultures.4.There are differences within, between, and among cultures.5. Cultures change over time.6.The primary and secondary characteristics of culture determine the degree to which one varies from the dominant culture.7. If clients are co-participants in care and have a choice in health-related goals, plans, and interventions, health outeomes will be improved.8. Culture has powerful influence on one's interpretation of and responses to health care.9. Individuáis and families belong to several cultural groups.10.Each individual has the right to be respected for his/her uniqueness and cultural heritage.11.Caregivers need both cultural general and culture specific information in order to provide culturally sensitive and culturally competent care.12. Caregivers who can assess, plan, and intervene in a culturally competent manner will improve the care of clients for whom they care.13.Learning culture is an ongoing process and develops in a variety of ways, but primarily Students on a cultural immersion course to Belize gathered data and organized their clinical log according to the 12 domains and their associated concepts.Students also collected the same data while sightseeing, shopping, and observing people in their daily lives.On a weekly basis, students carne together for a discussion and analysis of their findings and hypothesized acceptable plans and interventions for this specific population.At the end of the course, the North American students and the Belizean students played cultural jeopardy, a game developed by the nutrition instructor.They used the Model to formúlate questions.The Belizean students enjoyed learning about the culture of the North American students also.Similar immersion courses have occurred in Nigeria, Honduras, and Nicaragua both as a group experience and as an independent study for a nursing student who assisted with Hurricane Mitch relief efforts.Using the Model was a valuable experience to guide data collection and to have a comprehensive view of the people and the culture.All students in these cultural immersion courses reported that they have renewed respect for all cultures.More complete information on one of these experiences can be obtained in an article by Purnell (1998).
Administration: Culture is not limited to patients and families; it includes educational and healthcare organizations also.Because the Model contains a domain, workforce issues, and the non-linear line of cultural competence, it can be used to evalúate the organizational culture and workforce issues.The culture of an organization is reflected in the social structure, historical antecedents, valúes, traditions, management processes, policies and procedures, and the evaluation processes, which reveal the degree to which diversity in thinking, reflecting, and behaving are encouraged or tolerated.Management has used the Model and organizing framework to promote acceptance of multicultural employees.An ethics committee had used the Model to look at "patient compliance and "appropriateness of care" from the perspectives of the client and the employees.Another healthcare facílity used the Model with preceptors who served as cultural brokers for new employees to learn the culture of the organization, a process similar to learning the culture of patients.A long term care facility used selected domains from the Model to guide and develop plans for their Orthodox Jewish residents because many of the non-Jewish care providers were not Jewish and were unfamiliar with Orthodox Jewish practices.
Research: Long range theories, hypotheses, and concepts can be supported by various qualitative research methods.Using selected concepts in selected domains and primary and secondary characteristics of culture, qualitative research can support, expand, define, and refine the Model through research on specific cultural groups, or conducting cross-cultural comparisons.The Model has been used to collect research data for research theses and dissertations and scholarly projects in the United States, Brazil, and Central America.

CONCLUSIÓN
The Purnell Model for Cultural Competence is in its infancy.Continued use over time will determine the valué and the importance of the Model to nursing and other healthcare professionals in the future.Dr. Purnell is currently developing propositions and hypotheses collecting data on the empirical use of the Model in practice, education, administration, and research and further developing the Model into a grand theory that will be accepted by all healthcare disciplines.The Model shows promise for future testing in three dimensions: a) through critical reasoning, b) through descriptions of personal experiences, and c) through application to practice.
Because the concepts of the Model are broad based and use theories from linguistics, history, administration, anthropology, sociology, anatomy and physiology, biology, psychology, religión, and nutrition, beginning empirical data indícate that the Model has substance.Continued use by practitioners, educators, administrators, and researchers will increase the empirical precisión of the Model by validating and expanding existing knowledge bases, developing additional mid-range theories, and incorporating cultural competence as an outcome of care.Given the complexities of ethnicity and culture, the Model and its accompanying organizing framework provides a systematic and comprehensive system for evaluating important variables such as valúes, beliefs, and practices of diverse individuáis, families, and groups.
Rarely do healthcare practitioners have the luxury to evalúate each client comprehensively on he first encounter as the Model allows.Over time the patient's datábase can be increased with repeated encounters.Astute observations, an openness to diversity, and a desire to learn from clients are additional requisites for effective cross-cultural competence in clinical practice, in education, in administration, and in research.Cultural competence in today's society is not a luxury; it is a necessity.