culture: cultural competence model, part 1 cultural competence model… mode… · ·...

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

© Tor Edwards 2007 Institute for Senior Living Education EasyCEU.com


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.



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 multi-

cultural 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



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.



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.



Self-Described Religious Identification of Adult Population: 19903 and 20014 Adult population, total* 1990: 175,440 2001: 207,980

Religious group 1990 2001 Religious group 1990 2001

Total Christian 151,496 159,506 Total other religions 5,853 7,740Catholic 46,004 50,873 Jewish 3,137 2,831

Baptist 33,964 33,830 Muslim/Islamic 527 1,104

Protestant-no

denomination supplied 17,214 4,647 Buddhist 401 1,082

Methodist/Wesleyan 14,174 14,150 Unitarian/Universalist 502 629

Lutheran 9,110 9,580 Hindu 227 766

Christian-no

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

Mormon/Latter-Day

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

Congregational/United

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



Mennonite 235 346 Other unclassified 837 386

Christian Science 214 194

Church of the Brethren 206 358

No religion specified, total 14,331 29,481

Born Again ** 204 56 Atheist (NA) 902

Nondenominational ** 195 2,489 Agnostic 1,186 991

Disciples of Christ 144 492 Humanist 29 49

Reformed/Dutch

Reform 161 289 Secular (NA) 53

Apostolic/New Apostolic 117 254 No religion 13,116 27,486

Quaker 67 217 Refused to reply 4,031 11,246

Full Gospel 51 168

Christian Reform 40 79

Foursquare Gospel 28 70

Fundamentalist 27 61

Salvation Army 27 25

Independent Christian

Church 25 71

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.



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



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 co-

author 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.



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)



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.



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



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



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.



Summary of Cultural Characteristics

Primary Characteristics

Age Generation Nationality Ethnicity Race Color Gender Religion

Secondary Characteristics

Educational status Socioeconomic status Occupation Military status Political beliefs Urban vs. rural residence Enclave identity Marital status Parental status Physical characteristics Sexual orientation



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/.


http://www.beyondintractability.org/essay/culture_negotiation/

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