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Course: Fundamentals of Nursing

Topic: Purnell Model: Domains Part I

The Nurses International Community

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Module Goals

Learners will be able to

List the titles of the initial six of Purnell’s 12 domains.
Describe the topics addressed by two of the first six domains.
Describe two methods to apply Purnell’s domains to a specific client.

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Purnell’s Model for Cultural Competence

Used by email permission from L. Purnell 2018

https://www.semanticscholar.org/paper/A-Description-of-the-Purnell-Model-for-Cultural-Purnell/1217143db1198ea7d5e28a5b47ef2927c64f7c2c

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Purnell Model: Domain- Overview / Heritage

Topics to be assessed include:

Origin
Residence
Topography
Economics
Politics
Education
Occupation

Purnell, 2018

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The domain of Overview/Heritage is an initial summary of the different aspects of many cultures. The topics in this slide will be examined more deeply in other domains. It is essential for nurses to understand that any client brings multiple parts of their cultural background to any nurse-patient interaction. How a client has been raised, fed, and educated impacts their values and beliefs. The location they came from, and they house they lived in affects their past experiences. What has been a significant part of their culture shapes their attitudes and current thinking. Nurses must learn about each client’s heritage, in order to better understand that client. This enables the nurse to provide more effective, and culturally competent care. This level of care can improve client’s satisfaction, and more importantly, healthcare outcomes. This video gives one example: https://thinkculturalhealth.hhs.gov/resources/videos/cultural-and-religious-beliefs

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Impact of Overview / Heritage Domain

Clients (individual, family, or community) possess specific cultural heritages.
A client’s heritage may impact their current healthcare beliefs and values.
Learning about a client’s experiences and beliefs improves nursing care.
Each nurse has a cultural heritage, which may affect their healthcare beliefs.
Becoming more culturally aware increases the nurse’s own self-awareness.

Purnell, 2018

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Assessing a Client’s Cultural Heritage

The nurse can assess the client’s cultural heritage by asking:

What is your ancestry?
Were your parents born in this country, or another?
Have you lived in other parts of the world?
What is your education level, and occupation?
Are there health concerns related to your work?
Is your current income adequate for your needs?

Purnell, 2018

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Assignment: Journal Entry

Cultural competency begins with an open attitude towards clients. Every nurse brings their own cultural beliefs to client care. Create a journal post that answers:

What is my cultural background?
Have my beliefs changed over time?
How might my cultural beliefs differ from a client’s?
Do my beliefs impact my ability to become culturally competent?

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Every human being has some specific culture, evident as their background, beliefs, practices, and values. These may be so deeply ingrained that individuals are unaware of their existence. Because humans hold to different versions of these cultural backgrounds, one individual may be faced with challenging differences when interacting with another individual. Nurses often provide care for clients (individuals, families, or communities) who have cultures very different that the nurse’s. In order to provide the best nursing care, it is essential to be able to acknowledge and include the client’s cultural values when caring for them. Before a nurse can plan how to include culturally-appropriate care for a client, the nurse must be aware of their own cultural background. In order to avoid nurse-client conflict. the nurse must acknowledge that potential for conflict, and then identify effective ways to provide for the client’s cultural needs.

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Purnell Model: Domain- Communication

Topics to be assessed include:

Dominant languages/dialects
Word context
Voice/Tone contact
Facial expressions

Distancing/Touch
Greetings/Names

Purnell, 2018

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Assessing a Client’s Communication Methods

The nurse can assess the client’s communication preferences by asking the following questions:

By what name do you prefer to be called?
What is the language that you use?
Do you speak any other language?
Do you mind being touched by nurses, or other individuals?
Do you wish to be greeted with a handshake, nod, or other?
Observe if the client maintains eye contact, or avoids it

Purnell, 2000

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Communication should be a two-way process. Nurses should understand that clients may have preferences regarding communication methods. It is essential to begin each meeting or interview by asking about the client’s choices for communicating. If language is unclear, the nurse should seek out alternative methods to enhance communication, and then proceed. Some options for improving communication may include official translators, word or picture boards, or sign language. Whatever methods chosen should guarantee correct, complete translation that does not include bias or omitted content, In general, family members are not the best translators, as they may lack knowledge of medical terms, and may produce translations that are incomplete or include bias, such as minimizing material that may be uncomfortable for the client or family member. Touch can be an effective communication method, but only after getting clear client approval to use that.

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Impact of Communication

●Client’s preferred language should be used whenever possible.

●Client’s preferred means of communication may be different than the nurse’s.

●Communication can be verbal, non-verbal, or both.

●Non-verbal communication can be misunderstood if not clarified early.

●The client’s understanding of volume and tone of speech should be examined.

●Eye contact and facial expressions carry different meanings in different cultures.

National Standards for for Cultural and Linguistic Competency

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https://thinkculturalhealth.hhs.gov/clas/standardshttps://thinkculturalhealth.hhs.gov/clas/standards

It is essential to learn about a client’s communication very early in the process of providing care. There are standards for best practices in healthcare communication.

( https://thinkculturalhealth.hhs.gov/clas/standards) It is best for the nurse to acknowledge their need for understanding, listen closely the client’s response, and watch for non-verbal signals as part of that response. Because there are variation within any one specific language or cultural group, it is not possible to make assumptions about any specific client. Sub-dialects, or different interpretations of non-verbal signals may exist within groups. This is where cultural humility is so important- misunderstanding a simple non-verbal signal can cause confusion, distrust, or other complications for both the client and the nurse.

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Critical Thinking Question

A nurse enters the room of a newly admitted client who is an older woman. The client immediately lowers her head. She does not speak, nor maintain eye contact.

What is a possible reason for the client’s actions?
What is the nurse’s best action in response?
How might the nurse’s response affect the client’s healthcare?

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Non-verbal communication is highly important. The client is making a statement without speaking. There are several possible reasons for this behavior. One may be that the client is demonstrating humility in front of the nurse. It may be that the client does not speak the same language as the nurse, and she is avoiding the use of her own language. She may be tired, attempting to rest and avoiding interaction. The unconsciously culturally competent nurse would recognize some cultural significance in the client’s behavior. The best response is for the nurse to quietly approach the client without speaking initially. Then, the nurse should quietly state her name and role. Next, ask the client for permission to continue the conversation, asking if she will allow the nurse to ask a few questions. Those questions should begin with clarifying the client’s preferred method of communication. The use of an appropriate interpreter may be essential. Being able to effectively communicate with the client improves their healthcare, by avoiding errors, and encouraging client autonomy. Here is a video which shows an interpreter: https://thinkculturalhealth.hhs.gov/resources/videos/working-with-an-interpreter

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Purnell Domain: Family Roles and Organization

Topics to be assessed include:

Head of household
Gender roles
Goals and priorities
Developmental tasks
Roles of aged
Extended family
Alternative lifestyles

Purnell, 2018

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Impact of Family Roles and Organization

Assessment of this domain can provide helpful planning data about:

Family roles and obligations
Family structure and organization
Family priorities and desired outcomes
Preferences for decision-making processes
Supports, strengths, and assets

Assessment can also provide unexpected information

The nurse cannot assume that a different culture will have the similar views, values, or patterns.

Purnell,2018

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Assessing a Client’s Family Roles and Organization

The nurse can explore the client’s family roles and organization by asking the following kinds of questions:

What is your marital/partner status?
Who lives in your household?
What are roles and duties of adults in your family?
Who makes most of the decisions in your family?
What are priorities for your family?
What do your family members expect from you?

Purnell,2018

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Suppose you were traveling with your parents in a foreign country. Suppose a hospital there needed to provide culturally competent care to your mother or father.

Using this domain of Purnell’s model (2019), how would you describe your family to a nurse at the foreign hospital?
Draw a diagram or a tree that represents your family’s structure
Explain how your family makes healthcare decisions

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Purnell Model: Domain - Workforce Issues

Topics to be addressed include:

Cultural adaptation
Autonomy
Language barriers

Purnell, 2018

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Assessing a Client’s Workforce Issues

Using an open attitude, the nurse can assess the client’s workforce issues by asking the following questions:

What type of work do you do?
What type of work have you done in the past?
Are you concerned about working with someone different from you?
Do language challenges exist in your current work?
Do you consider yourself a “loyal” worker?
Can you make independent decisions at work?

Purnell, 2018

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The nurse must understand the client’s work history, not only their current situation. Some cultures define specific roles, based on age, gender, religious beliefs, sexual orientation, or family history. These cultural roles may be in conflict with their current work. To provide culturally competent care, nurses must seek out as much information as possible. Expectations regarding time differ among cultures. In one culture, arriving at work “on time” may mean 5 minutes before a worker is scheduled. In another culture, arriving “on time” may mean something completely different. If an employer and worker have different cultural views regarding time, this may result in conflicting expectations. Likewise, there may be differing cultural views regarding employer/employee roles. This may also impact a client’s ability to achieve success at work, or increase work-related stress for that client. To accurately and thoroughly assess a client’s workforce issues, the nurse must listen carefully, examine client’s statements closely, and provide an open, caring atmosphere,

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Impact of Workforce Issues

A client’s work is an important part of their life
Cultural challenges may exist in a client’s current work role
A client may have limited ability to make decisions about their work
A client’s work role may change over time
Language issues may complicate a client’s work situation
The educational level of a client may differ from the nurse’s

Society for Human Resource Management, 2020

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Many people spend a great deal of time in their work situations. This may be because they are immersed in their work, or because they are required to work long hours for financial reasons. Some people who have migrated to different locations may work at jobs that are different than what they have done previously. Clients may find cultural challenges due to specific beliefs about gender roles, or age-related roles. These challenges may create stress and role confusion fo the client. Language issues may complicate a client’s work situation, and become a challenge for them. Clients may also deal with work situations that do not allow for autonomy or independent decision-making. For some client, this may be challenging and lead to frustration, particularly if they are working in an area where they had been independent in the past.

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Case Study- Workforce Issues

A 46-year-old patient states that he immigrated 6 years ago. He worked as an engineer previously, but now is a factory worker. He sometimes omits medication prescribed for him, to save money.

The nurse’s first response is:

Remind him his medication is important
Refer him to social services
Contact his physician
Tell him you are sorry

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A- Telling the patient that medication should be his first priority minimizes any other challenges he has (including some he may not have disclosed to the nurse). B-Referring him to social service might be a good option, C- BUT contacting the patient’s physician may result in a change of medication that eliminates the financial problem. D- Telling the patient about other patients’ issues does nothing to fix his problem, and might be perceived as an uncaring or culturally incompetent remark by the patient. Answer C is the best option. (NOTE: An additional cultural consideration is the patient’s change in work role, since his migration. The nurse should understand the implications of this change, possibly producing stress, due to this role change. A client whose culture values a professional work role may experience frustration, anger, or shame related to this change in work status. The financial challenges he is experiencing may also have cultural implications)

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Purnell Model: Domain- Biocultural Ecology

Topics to be addressed include

Biological variations
Skin color
Heredity
Genetics
Ecology
Drug metabolism

Purnell, 2018

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Impact of the Domain Biocultural Ecology

Cultural groups vary greatly in physical and genetic characteristics.
Some clients may have preferences for specific characteristics.
Characteristics may not be within an individual’s control.
Environment has powerful effects on clients’ health status.
Genetic background can impact health, such as drug metabolism.
Nurses must acknowledge differences, while learning about their clients’ cultures.

Franco, FM, 2022

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Skin color is determined by genetics. However, members of some cultures may preferences for a particular skin tone. Some medical conditions have a strong genetic component, so nurses should ask clients about their family history, to determine if clients have specific risk factors. A client’s physical environment can have an impact on his health.(https://www.sciencedirect.com/science/article/pii/S1462901116300521?via%3Dihub). The types of foods that are preferred and / or available impact health status. Some medications for high blood pressure work more effectively for clients from specific genetic backgrounds. It is important for nurses to learn about the various cultural groups that they care for. This can improve clients’ health, and increase their satisfaction with healthcare services.

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Assessing a Client’s Biocultural Ecology

The nurse can assess a client’s bio-ecological health by asking:

Are there any genetic conditions that occur in your family?
Are there family members with major diseases (Cancer, Heart disease)?
Do you have any medication allergies?
Are there specific health problems in the area where you live?
With what ethnicity do you identify yourself?
Observe the client’s skin coloration and any evident disabilities.

Purnell, 2018

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

The nurse is caring for Tira, a female client with fever of unknown origin. Tira recently arrived alone as a refugee from a tropical country. She is in an isolation room, with a hospital interpreter available. Blood tests to identify the cause of her fever are pending.

What questions would the nurse ask to apply Purnell’s Domain “Biocultural ecology” when interacting with this patient?

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First priority is the establish communication with the patient. The nurse should introduce herself, and ask permission to speak with the patient. Then, ask Tira about any medication allergies she has. Inquire about the region of the country that she left. What is the climate like? Are there any health concerns related to the environment- water availability and safety; access to hygiene supplies; endemic diseases that may exist there. Ask about her experiences as a refugee- reason for migrating; accidents, illnesses or trauma during that time. Ask about her family – are there any chronic medical problems (such as Cardiac, Cancers, or other diseases? that have occurred in family members? The nurse should ask about her racial background (“With what race do you identify?”) and if there is a particular implications for race in her home country. Note the Tira’s skin tone, and identify any evident disabilities.Ask if Tira has any cultural beliefs, values or practices that the nurse should be aware of during Tira’s hospitalization.

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Purnell Model: Domain- High-risk Behaviors

Purnell, 2018

Topics to be addressed include

Tobacco
Alcohol
Recreational drugs
Physical activity
Safety

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Impact of Domain High-Risk Behaviors

Cultures may have differing, specific behaviors that they accept.
Cultural norms can impact a member’s health decisions.
Those decisions may have significant health implications.
Some accepted behaviors may put group members at risk of harm.
Nurses have an interest in promoting optimal health for clients.
Culturally accepted high-risk behaviors should be assessed by nurses.

Tariq & Gupta, 2022

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High risk behaviors may vary by culture. One definition of these behaviors is:High-risk behaviors are defined as acts that increase the risk of disease or injury, which can subsequently lead to disability, death, or social problems. The most common high-risk behaviors include violence, alcoholism, tobacco use disorder, risky sexual behaviors, and eating disorders. (https://www.ncbi.nlm.nih.gov/books/NBK560756/#:~:text=High%2Drisk%20behaviors%20are%20defined,sexual%20behaviors%2C%20and%20eating%20disorders.) This is the definition from the USA National Library of Medicine- referenced above. Nurses must be clear about which behaviors may have negative effects on their clients. At the same time, nurses should have the cultural humility to acknowledge their lack of understanding of a group’s cultural norms, and be open to learning about the group’s beliefs and values, as well as their chosen behaviors.

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Assessing a Client’s High Risk Behaviors

The nurse can assess high-risk behaviors that are part of a client’s culture by asking

Do you use tobacco in any form? What type and quantity?
How much alcohol do you drink in a day?
What type of alcohol (wine, spirits, beer)?
Do you use any recreational drugs?
Do you take precautions to avoid sexually transmitted diseases?
Do you get physical exercise every day?

Purnell, 2018

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Assignment: Journal Entry

Earlier in this lesson, you created a journal entry that examined your own cultural beliefs. Review what you wrote at that time. Then, create a journal post that answers the following questions:

How will I be able to provide culturally competent care to a client (individual, family, or community) whose culture values high-risk behaviors?

Identify any barriers to achieving that.

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References:

Ahmed S, Altaf N, Ejaz M, Zulfiqar Z, Janjua K, Festila D, Cristina N. Genetic variations in the drug metabolizing enzyme, CYP2E1, among various ethnic populations of Pakistan. PeerJ. 2020 Aug 19;8:e9721. doi: 10.7717/peerj.9721. PMID: 32879799; PMCID: PMC7443092. https://pubmed.ncbi.nlm.nih.gov/32879799/

Franco FM. Ecocultural or Biocultural? Towards Appropriate Terminologies in Biocultural Diversity. Biology (Basel). 2022 Jan 28;11(2):207. doi: 10.3390/biology11020207. PMID: 35205074; PMCID: PMC8869769. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8869769/

National Standards for Culturally and Linguistically Appropriate Services (CLAS). U.S. Department of Health and Human Services: Think Cultural Health. https://thinkculturalhealth.hhs.gov/clas/standards

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References:

Purnell, L. (2018). Update: The Purnell theory and model for culturally competent health care. Journal of Transcultural Nursing, 30(2):98-105. doi:10.1177/1043659618817587. https://pubmed.ncbi.nlm.nih.gov/12113149/

Society for Human Resource Management (June, 2020). Addressing the six sources of workplace cultural conflicts. https://www.shrm.org/resourcesandtools/hr-topics/behavioral-competencies/global-and-cultural-effectiveness/pages/addressing-the-six-sources-of-workplace-cultural-conflicts.aspx

Tariq,N. and Gupta, V. (2022). High risk behaviors. In: StatPearls, National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK560756/#:~:text=High%2Drisk%20behaviors%20are%20defined,sexual%20behaviors%2C%20and%20eating%20disorders

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