Culture: Cultural Competence Model, Part 1
Cultural Competence
Model: an Introduction
Welcome to the Understanding the Cultural Components of Care Class. This course is
part of the Cultural Competence in Long Term Care Program.
This will provide a
general introduction to the concept of Cultural Competence, and will lay a foundation for
specific topics that will be considered in the rest of the series.
The face of the United States is constantly changing, and this is increasingly reflected in
the aging population. As the American community is becoming more multi-cultural, so
are our residential communities and nursing homes. The cultural backgrounds of
residents greatly affect many aspects of care. The complex factors that create a culture
interact to form unique caregiving needs in residents. The purpose of this course is to
help you to understand the factors that create your resident’s cultural background and
how to incorporate them into the most appropriate care plan for each resident.
Course Objectives
In the process of this course, you will learn:
™ What cultural competence is and why it is important to best serve clients
™ The difference between stereotyping and understanding cultural differences and the
ethics of these considerations
™ The Purnell model of cultural competency1
™ The Primary and Secondary Characteristics of Culture
™ The factors that contribute to Culture
™ How various factors can interact, both exacerbating one another or contradicting one
another
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Culture: Cultural Competence Model, Part 1
™ Ways to investigate the factors that have influenced client behavior, social
interactions, and decision-making
Introduction
Residents come from a wide variety of cultural backgrounds, and these don’t disappear
merely because they are living in multicultural communities. Cultural heritage has a
profound influence on every aspect of our lives, many of which we may not recognize or
have ever considered. Often people consider culture as merely being race or ethnicity.
In reality, culture is the entirety of societal factors that affect who we are as individuals,
how we interact in the world, the decisions that we make, the emotions that we feel and
how we choose to express them, and the behaviors that we exhibit.
When you consider your own culture, think of all of the society groups that you belong to
or have ever belonged to. This might include your religion (or religions if you have
changed in your life), race, ethnicity, your nationality(ies). It might also include whether
you have served in the military or if you were part of a political party. There might be
other groups that affect your behaviors/decisions/interactions that you wouldn’t
ordinarily consider. All of these would be part of your culture, or part of the social
factors that influence you.
For instance, you might be an outdoor enthusiast because you were raised in a rural
setting (urban vs. rural residence is an often unconsidered cultural factor). It might also
be because your family couldn’t afford hotels when you were a child (socio-economic
status is a major cultural factor) and so family vacations were spent camping.
These
factors then affect the decisions that you make about how to spend your free time
(choosing hiking over golf), ways in which to relate to your children (i.e. quality time
spent fishing or camping), where you want to live, your occupation, and any number of
other social and personal choices. In this situation, it is easy to see how many factors
other than race/religion/ethnicity have affected our behaviors and decision-making.
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Culture: Cultural Competence Model, Part 1
In addition to group identities and how these play a role in each person’s culture, our
roles within groups are a major component of our complete cultural background. In your
own life, you may have been an employee; you may have been a boss. You might be a
child as well as a parent and/or a grandparent. Various cultural factors affect how you
behave within each of these roles. Some religions have proscribed behavior for various
familial roles.
Some regional cultures have behaviors for family roles that are not
dictated but are considered the norm. For instance, my paternal grandmother is from
Southern Alabama. My maternal grandmother is a first generation immigrant whose
American rearing was in Cleveland, Ohio. Both women had very different ideas about
their own roles as mothers and grandmothers and about my role as a daughter or
granddaughter that determined our interactions, and also affected my own attitudes and
behaviors toward elderly women. From this example, it is easy to see how the roles we
play in social organization are also a part of our cultural background.
You might be from a religious culture that promotes motherhood as a primary virtue. If
you are a woman, this religious culture will affect how and when you become a mother.
When you interact with people who are from a culture that values something else above
motherhood, it is possible that there can be a cultural clash.
In order to minimize
cultural clashes in a multi-cultural society, it is important to have cultural competence.
We must recognize and understand the factors that affect our value systems, as well as
learning more about some of the major value systems that are advocated in different
cultural subsets.
While cultural competence is important generally for living and functioning in a multicultural society, it is particularly important to administrators of senior care facilities.
People from a wide variety of cultures are coming together and living in close proximity.
Some nursing homes or assisted living communities cater to residents from a specific
cultural background, but most are open to residents from a variety of backgrounds and
therefore cultural competence becomes imperative. Even if they are all of the same race
or religion, there are many other cultural factors that will affect their behaviors and
preferences. For instance, a former administrator confided in me that one of the most
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Culture: Cultural Competence Model, Part 1
challenging factors that she faced in the earlier years of service was overcoming
economic differences in residents. Residents sometimes had clashes of values and
priorities with each other or with the staff due to a vastly different economic background.
Just because your residents and/or staff all are of the same race or religion, it is still
important to understand the many factors that contribute to culture in order to prevent
culture clashes or inadvertent offense-taking.
It is important to understand how the elderly population is changing, and the cultural
backgrounds that contribute to this population in the United States.
The U.S. Census Bureau has released the 2000 Census information, including the
ethnic makeup of the elderly population. Race and ethnicity are some of the primary
characteristics that we consider when referring to cultural diversity within a population.
The racial/ethnic makeup of the American senior population is changing.
An April 2006 article in Seniorjournal.com summarizes a U.S. Census Bureau analysis
as follows:
Ethnic composition of elderly US Population in 1990 vs. 2003
Racial or Ethnic Group
1990
2003
Non-Hispanic Whites
86.6%
83%
Blacks
8.1%
8%
Asians
1.4%
3%
Hispanics
3.7%
6%
Projections indicate that by 2030, the composition of the older population will
be more diverse: 72% non-Hispanic White, 11% Hispanic, 10% Black, and
5% Asian.
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Culture: Cultural Competence Model, Part 1
The older Hispanic population, projected to grow from currently just over 2
million in 2003 to nearly 8 million in 2030, will become larger than the older
Black population.
The older Asian population is also projected to experience a large increase,
expected to be almost 4 million by 2030.2
The proportion of the elderly of a particular ethnicity is not directly correlated to the
proportion of that ethnic group that will be represented in residential or nursing facilities.
There are a number of cultural factors that will be addressed later in the course that
affect whether an individual will require professional caregiving.
Regardless of the
proportion, as this population increases, the number of residents of a particular ethnic or
racial background will increase around the nation.
Other primary considerations are age, generation, nationality, color, gender, and
religion. It is impossible to understand the intricacies of all possible religions, since
there are literally hundreds of different religious groups/sects recognized in the United
States. For this program, you will learn about larger religious groups in general rather
than in minute detail.
The Census Bureau does not collect statistics about religion, but there are indications
that the religious diversity of the American populace is also changing. The American
Religious Identification Survey (ARIS) 2001 was based on a random digit-dialed
telephone survey of 50,281 American residential households in the continental U.S.A.
(48 states). This survey was based solely on individual religious affiliation, rather than
on membership in a particular organization. Respondents were asked an open-ended
question, and were given no prompting or choices for the survey.
This survey is of
the general population rather than the elderly population, per se.
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Culture: Cultural Competence Model, Part 1
Self-Described Religious Identification of Adult Population: 19903 and 20014
Adult population, total*
Religious group
Total Christian
1990: 175,440
1990
2001
151,496 159,506
2001:
207,980
Religious group
1990
2001
Total other religions
5,853
7,740
3,137
2,831
Catholic
46,004
50,873
Jewish
Baptist
33,964
33,830
Muslim/Islamic
527
1,104
denomination supplied
17,214
4,647
Buddhist
401
1,082
Methodist/Wesleyan
14,174
14,150
Unitarian/Universalist
502
629
9,110
9,580
Hindu
227
766
denomination supplied
8,073
14,150
Native American
47
103
Presbyterian
4,985
5,596
Scientologist
45
55
Pentecostal/Charismatic
3,191
4,407
Baha’i
28
84
Episcopalian/Anglican
3,042
3,451
Taoist
23
40
Saints
2,487
2,787
New Age
20
68
Churches of Christ
1,769
2,593
Eckankar
18
26
Jehovah’s Witness
1,381
1,331
Rastafarian
14
11
Seventh-Day Adventist
668
724
Sikh
13
57
Assemblies of God
660
1,106
Wiccan
8
134
Holiness/Holy
610
569
Deity
6
49
Church of Christ
599
1,378
Druid
(NA)
33
Church of the Nazarene
549
544
Santeria
(NA)
22
Church of God
531
944
Pagan
(NA)
140
Orthodox (Eastern)
502
645
Spiritualist
(NA)
116
Evangelical **
242
1,032
Ethical Culture
(NA)
4
Protestant-no
Lutheran
Christian-no
Mormon/Latter-Day
Congregational/United
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Culture: Cultural Competence Model, Part 1
Mennonite
235
346
Christian Science
214
194
Other unclassified
837
386
No religion specified,
Church of the Brethren
206
358
Born Again **
204
56
Nondenominational **
195
2,489
Disciples of Christ
144
492
Humanist
Reform
161
289
Secular
Apostolic/New Apostolic
117
254
No religion
Quaker
67
217
Refused to reply
Full Gospel
51
168
Christian Reform
40
79
Foursquare Gospel
28
70
Fundamentalist
27
61
Salvation Army
27
25
25
71
total
14,331 29,481
Atheist
Agnostic
(NA)
902
1,186
991
29
49
(NA)
53
Reformed/Dutch
13,116 27,486
4,031 11,246
Independent Christian
Church
All counts are in thousands.
NA Not available.
* Refers to the total number of adults in all fifty states. All other figures are based on projections
from surveys conducted in the continental United States (48 states).
** Because of the subjective nature of replies to open-ended questions, these categories are the
most unstable as they do not refer to clearly identifiable denominations as much as underlying
feelings about religion. Thus they may be the most subject to fluctuation over time.
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Culture: Cultural Competence Model, Part 1
Race/Ethnicity and religion are just two examples of that show the diversity of primary
cultural factors in the American elderly population. As previously mentioned, culture
affects each of us in both extrinsic and intrinsic ways. The cultural components that
affect the behaviors and preferences of the residents within long term care facilities
must be understood in order to best serve the residents and their families, as well as to
ensure smooth staff relations. The ability to understand the cultural characteristics and
factors that contribute to the creation of an individual’s culture is referred to as Cultural
Competence.
One’s cultural competence can be categorized in one of the four following ways:
Unconsciously incompetent – someone who is completely unaware of cultural
effects and factors, but is unaware that these factors even affect behavior and
interactions. These individuals are most at risk of isolating or offending residents
or residents’ families by being insensitive to cultural effects and being unaware of
how this insensitivity is perceived.
Consciously incompetent – someone who is aware that culture is important and
affects behaviors and interactions, but is also aware that they do not know much
about the underlying or contributing factors. These individuals are most likely to be
seeking more information about cultures different from their own and the effect of
various cultural effects. (Since you are taking a course about cultural competency,
you most likely fall into this category).
Unconsciously competent – someone who is sensitive to cultural differences and
behaves in a manner that respects cultural effects on behaviors and choices, but
who may not be aware that they are reacting to cultural factors.
Consciously competent – someone who understands the effects of cultural
characteristics and factors on individual behaviors and preferences and has
actively sought better understanding of these factors. (At the end of this program,
hopefully, you will fall into this category.) This may be on an individual level, by
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Culture: Cultural Competence Model, Part 1
recognizing cultural factors and learning more about an individual’s approach to
these cultural factors.
It may also be done in a more general manner by
understanding the interactions of culture and learning more about different cultures
generally in an effort to behave in a more sensitive manner.
In this course, you will learn more about culture by using the Purnell model, which was
developed by Larry Purnell, PhD., RN, FAAN. Dr. Purnell is Professor and Department
Head, Nursing and Health Services Administration, University of Delaware and is known
for his work, the Purnell Model for Cultural Competence and his recent book with coauthor Betty Paulanka, Transcultural Health Care: A Culturally Competent Approach.
He has developed this model as a way to envision, categorize, and organize the many
factors contributing to an individual’s culture.
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Culture: Cultural Competence Model, Part 1
The Purnell Model for Cultural Competence1
Unconsciously Incompetent - Consciously incompetent- Consciously competent - Unconsciously competent
Primary characteristics of culture: age, generation, nationality, race, color, gender, religion
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)
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Culture: Cultural Competence Model, Part 1
Characteristics of Culture
The primary characteristics of culture, as previously listed are age, generation,
nationality, ethnicity, race, color, gender, and religion. It might be worthwhile here to
make a distinction between ethnicity, race, and color (although ethnicity and race are
sometimes used almost synonymously, as above).
Dr. Suzanne Heurtin-Roberts, in a presentation to the National Committee on Health
and Vital Statistics distinguished race and ethnicity as follows:
Race is the categorization of parts of a population based on physical appearance
due to particular historical social and political forces.5
She notes that race is not genetically defined.
There are no racial genotypes to
delineate boundaries among races. Contrarily, race is socially defined based on
appearance. Appearances may/may not represent historical breeding populations
She defines an ethnic group as:
An ethnic group is a sub-cultural group of a multicultural society, usually based on
a common national or tribal heritage.
Ethnicity is based on heritage, experience, group membership, and it is not necessarily
geographically delineated. Ethnicity is situationally variable and generally determined by
persons/populations involved.
Thus, while race is a social category based on similar physical appearance, ethnicity is
a social category based on shared culture or cultural heritage. These categories are not
interchangeable. Any given racial group is not necessarily all the same ethnicity. For
example, people that are “white” or Caucasian racially come from a variety of ethnic
groups. Similarly, any given ethnic group is not necessarily composed of people of the
same race. For example, people that are Cuban may be of any racial group.
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Culture: Cultural Competence Model, Part 1
The term Color has very specific connotations as a cultural characteristic. While we
use color terms often to define race (black, white), color as a primary characteristic does
not refer to these terms. Color as a characteristic refers to gradations of skin tone, and
the ways in which the perception of color affect individuals within a cultural context. For
instance, while in India, people may be all the same racial and ethnic heritage, the
gradations in skin color have distinct cultural repercussions, both in social status and in
economic class.
Culture is more than just these primary characteristics, however. The Purnell model
delineates a host of secondary characteristics of culture:
educational status,
socioeconomic status, occupation, military status, political beliefs, urban vs. rural
residence, enclave identity, marital status, parental status, physical characteristics,
sexual orientation, and gender issues.
These characteristics are ways in which a person identifies internally or is identified
externally. Someone may be perceived by others as being of a certain culture that they
are not a part of or don’t identify with. For instance, a friend of mine who is an American
from Guam did some studying in Germany.
In Germany, the primary minority is
Turkish, and so my friend was perceived as being Turkish. He faced religious racism
that he had never had to face in Guam. His interactions and behaviors were influenced
by a culture that he was perceived to be part of, rather than one to which he actually
belonged.
There are many factors, both biological and social, both intrinsic and extrinsic, that
contribute to the cultural characteristics that an individual exhibits. Biological factors
and intrinsic factors can only affect culture in as much as they interact with some other
social or extrinsic factor. An example of this would be lactose intolerance, which is a
biological factor. This in and of itself cannot be said to be a cultural factor. However,
when one considers that many racial/ethnic groups that have high incidence of lactose
intolerance have no dairy production (or only use goats) and that traditional foods do not
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Culture: Cultural Competence Model, Part 1
include cows milk, it becomes obvious that this biological factor is interacting with social
factors to affect culture.
Remember that the characteristics of culture can and do change over time.
An
individual’s identification with these characteristics is dynamic. Note among even the
primary characteristics of culture- age, religion, nationality, and ethnicity all may change
many times or continuously over time. These changes are often just as significant in
understanding someone’s culture as the characteristics by which they can be currently
identified. Surely you have heard someone who lives in the city say “I’m just a country
boy/girl at heart.”
This person is referring to the dynamic but lasting effects of
secondary cultural characteristics (in this case, urban vs. rural residence). In this case,
the person still identifies with living in a rural residence, despite currently living in an
urban setting.
We must keep in mind as we consider cultural characteristics that understanding the
variations and influences that create culture is not the same thing as diminishing an
individual’s preferences and behaviors due to group membership. As Michelle LeBaron
reminds us:
Any generalization will apply to some members of a group some of the time.
This is best seen by considering generalizations about groups to which you
belong. If you hear that women or men tend to negotiate in this way, or
Americans in another way, what effect does it have on you as a member of
these groups? If you want to answer, "Actually, it depends," you are among
the majority, for most of us resist easy categorization and broad
classifications. At the same time, it can be useful to back up and attempt to
see ourselves and others from a distance so that the patterns and habits that
define what is "normal" in negotiation can be examined for what they are:
culturally bound and culturally defined common sense.6
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Culture: Cultural Competence Model, Part 1
The cultural heritage of any individual is composed of many characteristics that are
influenced by myriad factors.
These characteristics might have factors that either
coincide or conflict, and how these factors interact with one another determines
ultimately the culture of that individual. As you make an effort to understand culture,
you are able to move toward conscious competence and are better able to facilitate
cross cultural understanding and communication for yourself, your staff, and residents.
The use of the Purnell model will help to provide the framework to understand culture,
both the characteristics and the factors that affect them. The next segment will begin to
address the factors affecting culture as delineated by the Purnell model. As you move
ahead, bear in mind that when you think about or discuss an individual’s cultural
heritage, you should keep in mind that it refers to more than someone’s ethnic, racial, or
national heritage.
While the population of the facility that you administer (or for which you are employed)
may currently be composed of only one racial or ethnic group, considering the other
characteristics – both primary and secondary – is important to promoting a smooth
community for both residents and staff. In your life outside of the facility, conscious
competence helps to prevent miscommunications and cross-cultural conflicts.
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Culture: Cultural Competence Model, Part 1
Summary of Cultural Characteristics
Primary Characteristics
™
™
™
™
™
™
™
™
Age
Generation
Nationality
Ethnicity
Race
Color
Gender
Religion
Secondary Characteristics
™
™
™
™
™
™
™
™
™
™
™
© Tor Edwards 2007
Educational status
Socioeconomic status
Occupation
Military status
Political beliefs
Urban vs. rural residence
Enclave identity
Marital status
Parental status
Physical characteristics
Sexual orientation
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Culture: Cultural Competence Model, Part 1
Sources Cited
1. Purnell, Larry.
Purnell Model for Cultural Competence.
Used with Author’s
permission.
2. White Senior Citizens Declining Rapidly as Percent of Older Population: Immigration
reform highlights changing population demographics. 2006. SeniorJournal.com. Verified
June 2007.
3. Kosmin, B.A. and S.P. Lachman. 1990. ‘‘One Nation Under God: Religion in
Contemporary American Society.’’
4.
Kosmin, B.A. and A. Keysar. 2001. Institute for the Study of Secularism in
Society
and
Culture,
Trinity
College,
Hartford,
CT,
http://www.trincoll.edu/secularisminstitute (Copyright).
5. Heurtin-Roberts, S. Ph.D., M.S.W. Race and Ethnicity in Health and Vital Statistics.
2004. Presented to the National Committee on Health and Vital Statistics.
6. LeBaron, Michelle. "Culture-Based Negotiation Styles." Beyond Intractability. Eds.
Guy Burgess and Heidi Burgess. Conflict Research Consortium, University of Colorado,
Boulder. Posted: July 2003.
http://www.beyondintractability.org/essay/culture_negotiation/.
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