1. Student Paper
Cultural Competency in Baccalaureate Nursing Education: A
Conceptual Analysis
Deborah Byrne, RN, MSN, La Salle University, Villanova
University
Abstract
The ability to deliver culturally competent nursing care is an
expected competency of
undergraduate nursing education programs. The American
Association of Colleges of Nursing
(AACN) and the National League for Nursing (NLN) have
developed toolkits that provide nurse
educators with models and teaching strategies to facilitate
student learning in cultural
competency. However, the concept of cultural competency
varies as does the best method for
integrating and evaluating cultural competency in undergraduate
nursing curriculum. With the
growing number of diverse clients, it is imperative that nursing
students deliver culturally
competent care. This article explores the current view of the
concept of cultural competency from
the standpoint of nursing education and the methods used to
evaluate cultural competency in
undergraduate nursing education programs.
Keywords: cultural competency, simulation,
undergraduate nursing education, cultural

2. awareness, cultural humility
Background and Significance
Health care is increasingly complex, diverse,
and growing in the United States. The United
States Census Bureau (2009) predicts that the
U.S. population of non-European Caucasians will
be equivalent to Caucasian Americans by 2050.
According to Healthy People 2020, there are
significant health disparities among minority
groups. A fundamental goal of Healthy People
2020 is to eliminate health disparities for all
groups (U.S. Department of Health and Human
Services [USDHHS]). The need for culturally
competent health care is essential to reduce
health disparities and ensure positive health
outcomes.
The National League for Nursing (NLN) and
American Association of Colleges of Nursing
(AACN) include culturally appropriate care in their
accreditation standards and have developed
toolkits for nurse educators to assist with
incorporating cultural competency in
undergraduate nursing curricula (NLN, 2009;
AACN, 2008). There is, however, no consensus in
the literature regarding effective ways to teach
cultural competency to undergraduate
baccalaureate nursing students. Most nursing
programs in the United States include the concept
and skill of cultural competency as a program
outcome and attempt to integrate cultural
competency into their curricula. Attempts at
integration have been reported as inadequate in
developing culturally competent nurses (Brennan

3. & Cotter, 2008). As the diversity of the population
increases, so too must the cultural competency of
nurses in practice. It is imperative that
undergraduate nursing students develop cultural
competency knowledge, awareness, and skills
while experiencing didactic courses, clinical, and
simulation experiences.
Culture is integral to how people view death,
birth, illness, and health (Delgado et al., 2013).
For individuals to seek health care, they need to
feel safe and secure with their providers. Health
care providers need to understand client culture
and deliver culturally sensitive and competent
care to achieve the best patient outcomes. For
health care providers to deliver culturally
competent care, they must be aware of their own
biases about the culture they are serving to
prevent poor patient outcomes (Campinha-
Bacote, 2007).
In nursing education, interaction with culturally
diverse clients, families, and communities is
essential for student development of cultural
competence (Campinha-Bacote, 2003).
Integration of cultural nursing skills, knowledge,
and attitudes will produce the best outcomes.
Cultural knowledge is the basis of cultural
competence, but it is the application of knowledge
in clinical, simulation, and immersion experiences
that will develop culturally competent nurses
(Campinha-Bacote, 2003). The concept analysis
model by Walker and Avant (1988) clarifies
understanding of the various attributes of the term
cultural competence. This method provides a
systematic process by which a concept can be

4. clarified further by identifying the attributes,
antecedents, and consequences of the concept.
In order to deliver quality care to a diverse
population, it is imperative that nurse faculty
incorporate cultural competency skills in
undergraduate nursing programs.
Background of Concept
Culture is defined as a pattern of traditions,
beliefs, values, norms, symbols, and meanings
among a group of people (Campinha-Bacote,
2007). Competency refers to performing, ‘‘in a
manner that is satisfactory to the demand of the
situation, to interact effectively with the
environment’’ (Thomas, 1993, p. 429). The
definition of the concept cultural competence
varies, but a commonly used definition of cultural
competency is ‘‘the ongoing process in which the
healthcare professional continuously strives to
achieve the ability and availability to work
effectively within the cultural context of the patient
(individual, family, community)’’ (Campinha-
Bacote, 2003, p. 5). Cultural competency is
embedded in various fields of study, including
social and behavioral sciences, law, and nursing.
All three disciplines profess the same definition of
culture but apply the term cultural competency
based on relevance to their respective fields
(Singer, 2012; Gould & Martindale, 2013;
Leininger & McFarland, 2002).
Numerous definitions of culture are based in
the social and behavioral sciences; however,
there are four basic concepts that the social and

5. behavioral sciences use in their definitions
(Singer, 2012). The first concept describes culture
as learned through the process of socialization
from birth. This concept is incorporated in many
psychological interpretations of culture. The
second concept is that all members of the same
group share the same cultural values and beliefs.
This concept is broad and does not include
subgroups of larger cultural groups. For example,
in the Jewish faith there are multiple subgroups
with shared values and beliefs; each has some
variation from the larger group (IJS Israel &
Judaism Studies, n.d.). The third concept of
culture is the adaptability of a cultural group to
social and environmental conditions, and the
fourth concept states that culture is an ever-
changing process (Singer, 2012). The third and
fourth concepts appear crucial to delivering
culturally competent care. Each generation
presents with new circumstances that affect the
care they receive. An older Hispanic client may
believe in folklore to treat illnesses, but a younger
Hispanic client may prefer technology and
modern medicine.
In the legal field, cultural competency and
sensitivity are increasingly important when
performing child custody evaluations (Gould &
Martindale, 2013). The authors define culture as a
‘‘pattern of traditions, beliefs, values, norms,
symbols, and meanings’’ (Gould & Martindale,
2013, p. 3.). More than half the U.S. population
are from immigrant families, and many of the
families are experiencing separation or divorce. In
the field of matrimonial law, it is understood that
cultural competence has three broad dimensions.

6. Attorneys and child evaluators need to have an
awareness of their own beliefs toward different
cultures and an awareness of the expectations of
their clients. They also need to utilize culturally
appropriate assessment tools when conducting
evaluations with culturally diverse people. The
International Journal for Human Caring114
attorneys and evaluators are aware of the
importance of delivering culturally competent
assessments to properly arrange the best custody
arrangement for children. Gould and Martindale
(2013) noted the lack of literature providing
guidance on how to address cultural issues in
child custody assessments.
There are several components to integrating
cultural competency into a child custody
evaluation: interviews, psychological testing,
direct parent-child observations, record review,
expert opinions, cultural relativism, and
responsible opinion formulation. Cultural
sensitivity and awareness must be integrated into
all of these components. The evaluator should
retain professional interpreters when necessary
when interviewing a parent or child. The evaluator
should also be cognizant of the family’s beliefs,
customs, and attitudes when evaluating direct
parent-children observations, psychological
testing, and record review. Experts engaged in
the case should also be familiar with the cultural
background of the child and parents.

7. In nursing, culture has been defined as by
Leininger and McFarland (2002) as, ‘‘the learned
and shared beliefs, values, and lifeways of a
designated or particular group that are generally
transmitted intergenerationally and influence
one’s thinking and action modes’’ (p. 9). This
definition has been central in transcultural nursing
and allows for a holistic approach to delivering
culturally congruent nursing care. Both definitions
and their concepts guide nurses delivering care to
diverse groups of clients.
There have been numerous studies regarding
cultural competency in nursing (Jeffreys & Dogan,
2013; Jeffreys & Dogan, 2012; Kardong-Edgren
et al., 2010; Kardong-Edgren & Campinha-
Bacote, 2008; Krainovich-Miller et al., 2008;
Noble, Nuszen, Rom, & Noble, 2014; Caffrey,
Neander, Markle, & Stewart, 2005; Reyes,
Hadley, & Davenport, 2013). In nine studies,
students measured the cultural awareness level
based on self-perception reports. These studies
all had cultural competency as a program
outcome in a nursing curriculum and tested
various teaching methods and interventions to
increase cultural competency. The studies also
showed a positive outcome when cultural
competency was integrated throughout the
curriculum.
The application of cultural competence in
social and behavioral sciences, law, and nursing
is closely related and shares similar concepts. In
social and behavioral science, law, and nursing,
cultural competence is needed to ensure positive
and fair outcomes. In social and behavioral

8. sciences, cultural competency is implemented in
many fields including psychology. A psychologist
needs to be culturally competent to deliver best
practices. If psychologists are not aware of client
culture, they can cause undue harm. In law, a
child custody evaluator needs to deliver culturally
competent care in order to ensure the optimal
custody arrangement is made for the child. In
nursing, a nurse needs to practice culturally
congruent care in order to ensure positive health
outcomes and reduce health disparities.
Significance of the Concept for Nursing
There are several cultural competency
theories and models in the literature related to
nursing. Campinha-Bacote’s Cultural Competence
Model (2007) has been widely documented in
global nursing research studies. Her model has
five interdependent constructs: cultural
awareness, cultural knowledge, cultural skill,
cultural encounters, and cultural desire.
Campinha-Bacote (2007) contends that as
individuals move toward cultural competence,
they must experience all of these constructs. A
pilot study by Delgado et al. (2013) evaluated the
effectiveness of implementing a 1-hour class on
cultural competence at a large Midwestern
medical center. In this study, the Inventory for
Assessing the Process of Cultural Competence
Among Healthcare Professionals–Revised
(IAPCC-R) was administered to participants to
assess baseline cultural competence prior to an
intervention, and then another assessment was
given at 3 and 6 months post training. This

9. instrument was developed by Campinha-Bacote
based on her cultural competency conceptual
model and integrates five cultural competency
constructs. The intervention was a 1-hour class to
promote cultural competency and show the
impact of cultural competency on quality of care.
The intervention included participants examining
their own ethnic heritage, issues related to health
care, and implications for health care providers.
Participants included registered nurses, patient
care assistants, and unit secretaries. Results
showed a statistically significant difference (p¼
.02) in cultural awareness over time (Delgado et
al., 2013). Kardong-Edgren et al. (2010)
evaluated cultural competency in graduating
baccalaureate nursing students. The investigators
evaluated six nursing program outcomes with
different methodologies for teaching cultural
competence. They used the IAPCC-R to measure
cultural competency in graduating nursing
students. All the participating nursing programs
integrated Campinha-Bacote’s cultural care model
into the nursing curriculum except for Program 1,
which did not integrate any specific cultural care
model in the curriculum. The results showed an
increase in all five constructs by implementing this
conceptual model in the undergraduate nursing
programs (Kardong-Edgren et al., 2010).
Jeffreys (2009) also developed a conceptual
model, the Cultural Competency and Confidence
model (CCC). In a study by Jeffreys and Dogan
(2013), an instrument was administered to
evaluate culturally specific care provided for a
diverse population. The Clinical Cultural

10. Competency Evaluation Tool (CCCET) was based
on the CCC model. In the model, Jeffreys defines
cultural competence as a ‘‘multi-dimensional
learning process that integrates transcultural skills
in all three education learning domains (cognitive,
practical, and affective), involves transcultural
self-efficacy (TSE), and aims to achieve culturally
congruent care’’ (Jeffreys & Dogan, 2013, p.
189). The CCCET has three subcategories
including provision of cultural-specific care,
cultural assessment, and cultural sensitivity. The
instrument was administered to second-semester
students at the end of their medical-surgical
course. The findings in this study suggest that
educational interventions in the clinical setting
move nursing students from a passive role to an
active role (Jeffreys & Dogan, 2013).
In all three studies, cultural competency
conceptual models framed the research. Some
authors agree that cultural competency models
are needed to guide teaching cultural
competence; however, disagreements center on
the best way to integrate the models into the
curriculum. The literature supports the proposition
that delivering culturally congruent care can
decrease health disparities.
Attributes of the Concept
There are several characteristics of the
concept of cultural competence in the literature:
(a) cultural awareness, (b) cultural knowledge, (c)
cultural skill, (d) cultural encounters, (e) cultural
desire, (f) cultural sensitivity, and (g) cultural
humility. Cultural awareness is the self-evaluation

11. of our personal biases and prejudices about
individuals from a culture different than our own
and requires individuals to explore their own
cultural heritage (Campinha-Bacote, 2007). Since
biases are ingrained in the mind and not easily
recognized, cultural competence is difficult to
accomplish. Van Ryn and Burke (2000)
investigated 193 physician-patient interactions.
Findings revealed that physicians rated African-
American patients as less intelligent, less
educated, less likely to comply with medical
advice, and more likely to abuse drugs (van Ryn
& Burke, 2000).
Cultural knowledge is the process of acquiring
a strong educational base about culturally diverse
groups. This construct includes the common
knowledge of health-related beliefs, disease
incidence and prevalence, treatment efficacy, and
diagnostic clarity (Campinha-Bacote, 2007). For
example, the genetic disease Tay-Sachs is more
prevalent in the Jewish-American community
(National Tay-Sachs & Allied Diseases, n.d.).
Nurses who practice culturally competent care
possess the knowledge and skills to identify at-
risk Jewish patients for genetic screening.
Cultural skill is the ability to perform culturally
competent care, including collecting relevant
2016, Vol. 20, No. 2 115
Student Paper
cultural data and performing a culturally sensitive

12. health assessment. Several assessment
instruments are available on cultural assessment,
which health care providers can employ to ensure
accurate assessment is obtained from an
individual, group, or community.
Cultural encounters are interactions with
patients from diverse backgrounds (Campinha-
Bacote, 2007). The purpose of cultural
encounters is to improve verbal and nonverbal
communication with different cultures. The
exposure to diverse cultures will assist in
obtaining effective communication skills and
increasing awareness of other cultures.
Additionally, cultural desire is the motivation of an
individual to participate in the process of
becoming culturally competent (Campinha-
Bacote, 2007). The motivation of the individual
must be genuine for the process to be successful.
To achieve this construct, the individual has to
possess the characteristics of caring, sacrifice,
commitment to social justice, and humility.
The concept of caring is fundamental to the
construct of cultural desire and is based on a
humanistic view of caring (Campinha-Bacote,
2007). Cultural sensitivity is the acceptance and
understanding of cultural differences. The
implementation of cultural sensitivity produces
better health outcomes because the practitioner is
sensitive to the beliefs, values, and attitudes of a
different culture (Burnard, 2005). For example, a
culturally sensitive, female, registered nurse
would possess the cultural knowledge to refrain
from shaking hands with a male Muslim patient.
Cultural humility is the ability of individuals to be

13. humble and think less of themselves. This
concept translates into the realization that one’s
own culture is not paramount (Schuessler, Wilder,
& Byrd, 2012). Schuessler et al. (2012) used
reflective journaling to evaluate undergraduate
nursing students’ level of cultural humility. Results
showed novice nursing students began to
understand cultural humility by interacting with
patients from different cultures. Students stated
they began to be aware of how other cultures
interacted with each other and with health care
practitioners.
Model Case
Kate, a community health registered nurse,
cares for Mary, an elderly client who lives alone in
an inner city housing complex. Mary is an 85-
year-old African-American woman with several
chronic conditions including diabetes,
hypertension, peripheral vascular disease (PVD),
obesity, and transient ischemic attacks. Mary has
been hospitalized several times in the past year
for exacerbation of her chronic conditions. Upon
arriving at Mary’s home, Kate notices the
unhealthy food on Mary’s kitchen counter, lack of
assistive devices, and swelling in Mary’s lower
extremities.
Kate has been working in this community for
several years and is aware of the beliefs, values,
behaviors, and past experiences of this African-
American community. As a result, Kate
understands the importance and value of religion
in this community. The church in this community
serves not only as a place of worship but also as

14. a community of support. Therefore, Kate has
developed a relationship with the church leaders
in this community. She also has an open line of
communication with various social programs in
this community.
Upon assessing Mary, Kate is aware of Mary’s
mistrust of health care providers based on past
encounters. In addition, Mary has a reluctance to
ask for help and likes to eat good ‘‘home
cooking.’’ Mary is on a fixed income and believes
she cannot afford to eat healthier. Mary has
missed several doctor’s appointments owing to
her lack of transportation.
Kate acknowledged and was sensitive to
Mary’s mistrust of health care professionals and
worked to develop a trust-based relationship with
Mary. Kate developed a comprehensive care
plan, in collaboration with Mary, to reduce her
frequent hospital admissions. Kate was sensitive
to the importance of religion to Mary and
contacted the minister of her church to see if they
had any programs to assist seniors with running
errands and transportation to medical
appointments. In addition, Kate contacted a local
senior group to see if they had social gatherings
to help combat Mary’s loneliness. Kate found a
food cooperative (co-op) that was not far from
Mary’s apartment.
Within 6 months of implementing this
comprehensive plan of care, Mary did not have
any hospital admissions, started to enjoy outings
with people from the senior center, and received
rides from church volunteers to visit her

15. physicians. Mary started going with a friend to the
food co-op to begin eating healthier. Mary
expressed feeling respect and understanding
from Kate, and they continue to work together.
Overall, Mary’s health has improved, and she
feels she is a participant in her health.
This model case demonstrates positive health
outcomes when culturally competent care is
delivered. This client represents an underserved
minority group that faces health disparities at an
alarming rate (USDHHS, 2010). The registered
nurse is aware of the culture of the group that she
serves and has developed the knowledge, skills,
and attitude needed to deliver culturally
competent care. The registered nurse also
demonstrated a cultural desire and sensitivity to
customs and beliefs held by the cultural group.
The client responded positively to the nurse’s
recommendations because she said she felt the
nurse listened and respected her beliefs and
feelings.
Borderline Case
Joseph is a registered nurse with 20 years
experience caring for a largely Hispanic
population. Through his work experience, Joseph
has learned a few key Spanish terms in order to
communicate with his patients. He feels confident
interacting with patients in the Hispanic
community. He is aware that many Hispanic
patients use complementary medicine and
implement healing traditions different from
American culture. Joseph is caring for an elderly
Hispanic woman named Maria who presents with

16. shortness of breath. Joseph uses his limited
Spanish to communicate with Maria and her
family. The family speaks limited English, but
through hand gestures and some Spanish,
Joseph asks Maria and her family if they take any
over-the-counter herbal supplements or practice
any healing rituals.
About 4 hours into his shift, Joseph notices
Maria’s shortness of breath is increasing despite
breathing treatments and administration of
steroids. The attending physician contacts Maria’s
family physician and learns she has chronic
obstructive pulmonary disease (COPD) and just
finished a course of steroids. The dose of steroids
Maria is currently receiving is too low to explain
increased shortness of breath. Maria’s
medications are adjusted and within 2 hours her
shortness of breath decreased.
Upon reviewing this case with his nurse
manager, Joseph realized that although he
showed awareness toward this patient from a
different culture, he still did not have the cultural
knowledge and skill to call for a professional
interpreter. Joseph and the nurse manager
developed an in-service program to educate the
staff on the benefits of using a professional
interpreter.
This borderline case demonstrates the need to
develop cultural competency skills continually.
The nurse in this case had the self-efficacy
desire, awareness, and knowledge to perform a
culturally sensitive assessment on his patient but
did not have the knowledge or skill to utilize a

17. professional interpreter. Not using an interpreter
could have led to further harm of the patient.
Contrary Case
Lisa, a registered nurse, works on a busy
telemetry floor at a small community hospital with
a predominantly white population. She has had
little experience with people from a different
culture and does not think it is an important part of
her job. Lisa received a report on a 22-year-old,
African-American male patient named Anthony,
with a diagnosis of exacerbation of sickle cell
anemia. Lisa notes in her report that the patient is
requesting a stronger dose of hydromorphone for
increased pain. Lisa comments to the reporting
nurse, ‘‘Of course, I get the drug addict. This is
going to be a long shift.’’ Lisa enters Anthony’s
International Journal for Human Caring116
Student Paper
room and proceeds to perform a brief
assessment. Anthony appears in distress and
rates his pain as a 10 out of 10 on the pain scale.
He begs the nurse for more pain medication. Lisa
calls the attending physician and states, ‘‘The
patient, Anthony, in room 383, is complaining of
pain. He is getting plenty of pain medication and
is just drug seeking. I recommend we discontinue
his narcotics and give him ibuprofen. He will want
to go home quicker if we stop feeding his
addiction.’’ The physician discontinues the

18. hydromorphone, and Lisa gives Anthony
ibuprofen with a lecture about abusing narcotics.
Anthony remains in pain for the rest of Lisa’s shift.
Upon discharge, Anthony feels dissatisfied with
the care he received, and he develops a distrust
of physicians and nurses.
This case demonstrates a complete lack of
cultural competency of the nurse and physician.
The nurse did not demonstrate cultural
knowledge, skills, awareness, desire, sensitivity,
or humility. The nurse works with a predominantly
white population and lacked knowledge of sickle
cell anemia. However, if Lisa had the cultural
awareness, desire, and humility, she would have
educated herself about the disease. She would
have been culturally sensitive to the pain caused
by sickle cell anemia. She did not have the
cultural awareness of her own biases and
stereotypes of cultural humility to know that each
culture is different, which resulted in harm to the
patient.
Assumptions for the Concept
There are several assumptions about the
cultural competency model:
� Cultural competence is a life-long process.
� Cultural competence is a fundamental
component in delivering culturally congruent
care.
� Cultural awareness is essential for cultural
competence to occur.

19. � Rendering culturally competent care will
reduce health disparities.
These assumptions are based on experiential
knowledge and the literature (Campinha-Bacote,
2007; Jeffreys & Dogan, 2012).
Antecedents and Consequences
Prior to the development of cultural
competence, certain behaviors, attitudes, and
ideas must occur. The following are cultural
competency antecedents based on the literature:
� Self-awareness: Practitioners must be aware
of their own biases, stereotypes, and
attitudes toward other cultures. They must
also be aware of their own cultural heritage.
� Encounters: Practitioners’ past cultural
encounters can affect their interactions with
other cultures.
� Attitude: Practitioners’ attitudes must be
open, flexible, and sensitive to others.
� Communication: Practitioners’ level of
communication skills must be high in order
to effectively interact with other cultures.
� Knowledge: Practitioners should have a
basic knowledge of the prominent culture in
which they are delivering care.
� Self-efficacy: Practitioners should have the
confidence to deliver culturally competent

20. care.
When cultural competence has been
demonstrated, the consequences of those
behaviors and events result in improved health
outcomes. Behaviors represent the actions of
healthcare providers. If those actions or behaviors
are culturally competent, improved health
outcomes may follow for the patient. Events are
the actual interactions between healthcare
provider and patient. The following are cultural
competency consequences based on the
literature:
� Culturally competent registered nurses
deliver culturally congruent care to all
patients.
� Clients become active participants in their
health care.
� Clients have decreased fear of the health
care system and health care practitioners.
� Clients have increased satisfaction with
health care services.
Figure 1
A Cultural Competency Conceptual Model
2016, Vol. 20, No. 2 117
Student Paper

21. � Decreased health disparities are reported.
� Better health outcomes result by increasing
health promotion and preventive care.
� Nurse educators support culturally
competent practices in undergraduate
nursing students.
� Health status of ethnic, racial, and low-
income groups improves.
Conceptual Model
The conceptual model in Figure 1 illustrates
the cyclical direction of attaining cultural
competency. The antecedents need to exist in
order for the nurse to attain the characteristics
needed to reach cultural competency. If cultural
competency is reached, the consequences
demonstrate a benefit to the individual,
community, and nation.
Discussion of Concept
The concept of cultural competency is integral
to giving the best care possible to individuals,
families, and communities. It is imperative that
nursing students receive cultural competency
education in the classroom, and in clinical and
simulation settings. The literature establishes the
effectiveness of cultural competency education in
the classroom and study abroad. However, study
abroad and immersion experiences are expensive
and only available to a select few. The research
conducted on simulation (Jeffries, 2009; Miller,

22. 2010; Shin, Park, & Kim, 2015) demonstrates the
effectiveness of using simulation to bridge the gap
between the classroom and practice.
The literature illustrates the effectiveness of
students engaging with patients of a different
culture in study abroad or immersion …
The client-oriented model of cultural competence in healthcare
organizations
Giovanni Di Stefano , Eleonora Cataldo and Chiara Laghetti
Dipartimento di Scienze Psicologiche, Pedagogiche e della
Formazione, Università degli Studi di Palermo , Palermo, Italy
ABSTRACT
The paper aims to propose a new model of cultural competence
in health organizations based
on the paradigm of client orientation. Starting from a literature
review, this study takes
inspiration from dimensions that characterize the cultural
competence of health
organizations, and re-articulates them in more detail by
applying a client orientation view.
The resulting framework is articulated into six dimensions
(formal references; procedures and
practices; cultural competences of human resources; cultural
orientation toward client;
partnership with community; and self-assessment) that define
the ability of a health
organization to achieve its mission, acknowledging,
understanding, and valorizing cultural
differences of internal clients (staff) and external clients
(consumers). This study makes an

23. effort to address the paucity of studies linking approaches to
managing cultural diversity in
health organizations with cultural competence within the
framework of client orientation.
ARTICLE HISTORY
Received 30 March 2017
Accepted 3 October 2017
KEYWORDS
Cultural competence; health
organizations; client-oriented
model
Introduction
Globalization has deeply changed the profile of both
the workforce and the users of organizations in the
societies of the new millennium. One important ques-
tion is how to deal with growing cultural diversity in
such a way that it may produce positive results – in
terms of productivity and service quality, well-being
and satisfaction – for organizational systems and for
people, both workers and users.
The Diversity Management (DM) approach aims to
accomplish such a result by adopting a heterogeneous
viewpoint in order to lever cultural differences and
treat them as an added value rather than an obstacle.
In fact, the premise for managing diversity is the recog-
nition of differences as positive attributes of an organ-
ization, rather than as problems to be solved [1]. In this
way, diversity may become a source of competitive
advantage, increase the quality of organizational life
and ultimately be advantageous for business [2]. The
point is not, therefore, the acceptance of differences,

24. but the creation of an inclusive environment and the
commitment to valuing them. This can be made poss-
ible through a culture of inclusion that creates a work
environment nurturing teamwork, participation, and
cohesiveness. However, many organizations do not
see the advantages that cultural diversity could bring
to them and how well-managed cultural diversity
may achieve a competitive edge in the market.
The topics of cultural differences and disparities that
may result from them have been already described in
healthcare organizations, since the emerging challenges
of providing health services in a growing multi-ethnic
world [3,4]; within these organizations, the approach
of intercultural DM and the cultural competence are
considered a priority. In particular, cultural compe-
tence is a powerful instrument for managing cultural
diversity in multicultural settings, since it improves
quality and eliminates racial/ethnic disparities in
organizations. The goal of cultural competence is to
create a healthcare system and workforce that are
capable of delivering the highest quality care to every
patient regardless of race, ethnicity, culture, or
language proficiency.
Although cultural competence may be considered
an important need for every contemporary organiz-
ation, since the growing pressures of globalization to
develop international influence or operating on an
international scale, it is indeed a core requirement for
healthcare organizati ons, since the exigency they have
to respond to the specific needs of any person seeking
help, and the related concerns that come from working
with culturally diverse patient groups, in order to alle-
viate, at least in part, health disparities related to racial

25. and ethnic differences.
The aim of this work is to propose a client-oriented
model of cultural competence, meaning the ability of a
health organization to acknowledge, understand, and
value cultural differences of internal clients (staff)
and external clients (consumers), as well as the ability
to commit to achieving its mission, taking account
of clients’ cultural identity and the individual needs.
In order to respond to this objective, we reviewed
the literature on cultural competence to identify a set of
elements that define a culturally competent
© 2017 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Giovanni Di Stefano [email protected] Dipartimento
di Scienze Psicologiche, Pedagogiche e della Formazione,
Università degli
Studi di Palermo , Viale delle Scienze, Ed. 15, Palermo 90128,
Italy
INTERNATIONAL JOURNAL OF HEALTHCARE
MANAGEMENT
2019, VOL. 12, NO. 3, 189–196
https://doi.org/10.1080/20479700.2017.1389476
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17.1389476&domain=pdf
http://orcid.org/0000-0001-7276-549X
mailto:[email protected]
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organization within the framework of client orien-
tation. EBSCO, MEDLINE, Scopus, and Web of
Science databases were searched for relevant peer-

26. reviewed articles regarding the organizational cultural
competence and client orientation in healthcare.
Toward a definition of cultural competence
for health organizations
Since the 1980s, several scholars have paid attention to
the construct of cultural competence, focusing on stu-
dents [5–7], research [8], policy organizations [9],
counseling services [10–12], and above all, the
human service sector – social work and healthcare
[3,4,13–24]. With specific reference to healthcare
organizations, the concept of cultural competence
was used not only in reference to the individual’s ability
to provide care in a culturally appropriate way but also
in relation to systems and organizations.
Cultural competence has been defined variously in
the literature. For example, Green [20] first defined it
as the ability to conduct professional work in a way
that is consistent with the expectations, which mem-
bers of a distinctive culture regard as appropriate
among themselves. This definition emphasizes the
worker’s ability to adapt professional tasks and work
styles to the cultural values and preferences of clients.
According to Cross et al., cultural competence is a set
of congruent behaviors, attitudes, and policies that
come together in a system, agency, or among pro-
fessionals and enable that system, agency, or those pro-
fessionals to work effectively in cross-cultural situation
[25],p.1. Sue defines cultural competence as the ability
to engage in actions or create conditions that maximize
the optimal development of client and client systems
[11],p.817. According to the National Quality Forum,
cultural competence is the ongoing capacity of health-
care systems, organizations, and professionals to pro-

27. vide for diverse patient populations high-quality care
that is safe, patient- and family centered, evidence
based and equitable [26],p.2. Last but not least, Betan-
court et al. [3] define cultural competence as the ability
of systems to provide care to patients with diverse
values, beliefs, and behaviors, including tailoring deliv-
ery to meet patients’ social, cultural, and linguistic
needs.
Despite these differences, authors seem to agree that
cultural competence is an active and developmental
process that is ongoing and never reaches an endpoint.
Cultural competence develops over time through train-
ing, experience, guidance, and self-evaluation [4,14,25].
In connection to such a general statement, Campinha-
Bacote views cultural competence in the specific field of
healthcare as the ongoing process in which the health-
care provider continuously strives to achieve the ability
to effectively work within the cultural context of the cli -
ent (individual, family, community) [4],p.181. Scholars
tend to consider cultural competence as increasingly
important for healthcare quality [13,14,15,22], and
believe that there is a link between cultural competence
and reducing or eliminating racial and ethnic dispar-
ities in health care [7,16,27].
Although the centrality of cultural competence in
health practice appears to be a widely accepted concept
[3,13,14], still exists a scarce research on the effects and
the outcomes of developing culturally competent
healthcare organizations [16,28]. Nevertheless, there
is some evidence that the implementation of cultural
competence models improves the ability of health sys-
tems and their workers to provide services to culturally
diverse patient groups, reducing disparities in quality

28. of health care [13,15,16].
Main models of cultural competence
Several models of cultural competence have been
developed in the last two decades; in them, the dimen-
sions of this construct were delineated with particular
attention to individuals and organizations.
Cross et al. [25], focusing on systems of care, pro-
pose a continuum that ranges from cultural destructive-
ness, that is destructive attitudes, policies, and practices
toward diverse cultures and individuals within a cul-
ture to cultural proficiency or advanced cultural compe-
tence, i.e. attitudes, policies, and practices that hold
culture in high esteem, with the intermediate stages
of cultural incapacity, in which the organization not
intentionally seeks to be culturally destructive, but
rather is not able to help minority clients, cultural
blindness, that is believing that all people are the
same and that approaches used by a dominant culture
are universally applicable, cultural pre-competence,
namely realizing weaknesses in serving minorities
and attempting to improve service for a specific part
of the population, and cultural competence, i.e. adapt-
ing a service model to the needs of minorities, expand-
ing cultural knowledge and resources, conducting
cultural self-evaluation continuously. In order to assess
at which of these stages a given organization is, one
may evaluate the entity of five essential elements that
contribute to a system’s ability to become more cultu-
rally competent: (1) the propensity to valuing diversity,
that is the awareness, acceptance, and respect of differ -
ences in lifestyle, communication, behaviors, values,
and attitudes; (2) the cultural self-assessment, specifi-
cally the ability of the system to assess itself and have

29. a sense of its own culture; (3) the dynamics of differ-
ence, or the ability of the organization to manage mis-
interpretation and misjudgment when a member of
one culture interacts with other from a different one;
(4) the institutionalization of cultural knowledge,
namely how much organization provides cultural
knowledge to their workers about family system,
values, history, and etiquette of specific populations;
190 G. D. STEFANO ET AL.
and, finally, (5) the adaption to diversity, i.e. the sensi -
bility of the organization to adapt its approaches in
order to create a better fit between the needs of min-
ority groups and services available.
Rodgers’ model, instead, focuses on the identifi-
cation of attributes of cultural competence rather
than the development of a definition of the concept.
Rodgers [29] identifies seven attributes of cultural
competence: cultural awareness, i.e. developing con-
sciousness of culture and the ways in which culture
shapes values and beliefs; cultural knowledge, that is a
continued acquisition of information about different
cultures and an essential underpinning of cultural
understanding; cultural understanding, specifically the
ongoing development of insights related to the influ-
ence of culture on the beliefs, values, and behaviors
of diverse groups of people by which one can begin
to address problems such as marginalization and sub-
jection that may be the result of beliefs and values of
one culture differing from those of the dominant cul-
ture; cultural sensitivity that develops as one comes to
appreciate, respect, and value cultural diversity and,

30. in so doing, one also comes to realize how one’s own
personal and professional cultural identity influences
practice; cultural interaction, namely the personal con-
tact, communication, and exchanges that occur
between individuals of different cultures; cultural
skill, or the ability to communicate effectively with
those from other cultures, including the incorporation
of the client’s beliefs, values, and practices into the pro-
vision and planning of care and also varying pro-
cedures and techniques to accommodate cultural
beliefs; cultural proficiency, that is the commitment to
change through some activities as the sharing of
information.
A different model is proposed by Purnell [23]. It is
based on the assumption that cultural competence is
not a linear process in which a healthcare provider –
or any organization – progresses from unconscious
incompetence, a condition in which it is unaware that
is lacking knowledge about another culture, to con-
scious incompetence, to one in which is aware, and
from this to a state in which it has a conscious compe-
tence, learning about the client’s culture and providing
culturally specific interventions, to the optimal con-
dition in which it automatically provides congruent
care to clients of diverse cultures, namely it holds an
unconscious competence.
Finally, Campinha-Bacote’s model views cultural
competence as the ongoing process whereby the
healthcare provider continuously strives to achieve
the ability to effectively work within the cultural con-
text of the client (individual, family, and community)
[4]. Campinha-Bacote’s model is composed of five
major constructs that have an interdependent relation-
ship with each other: cultural awareness, that is the self-

31. examination and exploration of one’s cultural and
professional background; cultural knowledge, i.e. the
pursuit and achievement of a sound educational foun-
dation about diverse cultural and ethnic groups; cul-
tural skill, namely the ability to collect relevant
cultural data regarding the client’s presenting problem,
to conduct cultural assessments and culturally based
physical assessments; cultural encounters, or the pro-
cess that encourages the cross-cultural interactions
between healthcare provider and clients from culturally
diverse background; and, finally, the cultural desire,
that is the motivation of the healthcare provider to
want to become culturally aware, knowledgeable and
skillful, and familiar with cultural encounters.
Although all the models presented so far have had
some success and have been implemented in a wide
variety of programs in medical schools, the concept
of culture competence must go beyond the traditional
notion of ‘competency’, involving the fostering of a
critical consciousness of the self, others, and the
world and a commitment to addressing issues of
societal relevance in health care [30]; also, they seem
to consider cultural competence only as a means to
provide a culturally specific service for users of differ -
ent ethnicities.
The model here proposed, which we call the Client-
Oriented Model of Cultural Competence, is instead
designed mainly as a tool for the management and
development of human resources from different cul-
tural backgrounds. In our proposal, a culturally compe-
tent organization aims to promote positive
intercultural encounters among colleagues, then
between providers and consumers. The organization

32. must be culturally competent with regard to internal
customers to dispense a culturally competent service
to external customers.
The client-oriented model of cultural
competence
The Client-Oriented Model of Cultural Competence
can be considered as a model that, inspired by the
DM approach, aims to link the task of managing cul-
tural diversity in health organizations with cultural
competence, within the framework of client orien-
tation. In this model, the cultural competence is
defined as the ability of a healthcare organization to
achieve its mission (service delivery), acknowledging,
understanding, and valorizing cultural differences of
internal clients (staff) and external clients (consumers).
Within the proposed model, we posit that the client
orientation view may be considered a specific key
element for healthcare organizations. In fact, the
focus on provider–client relationship may give added
value to healthcare services: for example, when health-
care providers either do not speak the client’s language
or are insensitive to cultural differences, the quality of
health care can be compromised [13]. Under this point
INTERNATIONAL JOURNAL OF HEALTHCARE
MANAGEMENT 191
of view, a client-oriented healthcare organization is a
system that responds effectively to language, and in a
more general sense, to psycho-social needs of their cli-
ents. Also, the respect, the sensitivity, and the under-

33. standing for clients’ culture and values appear to be
related to the ability of healthcare providers to offer
provisions of health services [3,4,13].
It is articulated into the following six dimensions:
(1) Formal references related to cultural competence;
(2) Procedures and practices;
(3) Cultural competences of human resources;
(4) Cultural orientation toward clients;
(5) Partnership with community;
(6) Self-assessment.
These dimensions are described below in detail.
Formal references
The first dimension of the Client-Oriented Model of
Cultural Competence regards written formal organiz-
ational statements about mission, values and prin-
ciples, goals and policies, beneficiaries, and vision. In
a culturally competent organization, formal references
explicitly stress the importance of cultural competence,
consider the cultural diversity of staff members as a
resource to be valuable, and include members of differ -
ent cultures as beneficiaries of the service. A culturally
competent governance establishes policies and goals
that help ensuring the delivery of the service in a cultu-
rally responsible way, by involving various groups in
the decision-making process [27]. The organizational
statements must be communicated to staff and consu-
mers, and the language in the formal references must
acknowledge the cultural diversity of personnel and
population served. In other terms, an organization is
culturally competent when, even before delivering its
services to implement the provision of services, it

34. defines its own primary task in a culturally sensitive
way, taking care to distribute its own purposes, prin-
ciples, and values within the system and in the whole
territory and encouraging the sharing of the same
goals and principles among staff and users.
Procedures and practices
The second dimension regards the practices of man-
agement and development of human resources. In
relation to service delivery procedures, in agreement
with Hernandez et al. [27], we believe that cultural
competence in service ensures ad hoc services that
reflect the needs of consumers. A healthcare organiz-
ation should have a database containing information
about each user’s clinical history, culture of origin,
and reported impact ensuing the first encounter with
the organization, to ensure a culturally competent
service. This database, continuously updated, will be
a guide for health providers, who will be able to provide
the most appropriate service, in timely fashion and in
the most appropriate way, to the specific patient. In
relation to management and development of human
resources practices, efforts should be made to recruit,
select, and hire multicultural administrative staff and
medical personnel, who should be representative of
the cultures existing in the community and able to
speak the languages of the populations served [31,32].
Racial/ethnic diversity in the healthcare leadership
and workforce has been clearly connected with the
delivery of quality care to diverse patient populations
[3].
So conceived, procedures and practices serve the
more general objective to render a healthcare organiz-

35. ation a culturally competent system; this, in turn,
should allow to create a multicultural environment,
which is a setting ready to receive people, both consu-
mers and staff, of different cultures. In other words, a
culturally competent organization, which has designed
and created through its procedures and practices a
physical and symbolic multicultural environment,
ensures users’ open access to services through the elim-
ination of socio-cultural barriers see [3,27]. First, the
absence of language barriers, i.e. multilingual bro-
chures, documents/information materials allows effec-
tive communication between providers and
consumers. The organization will monitor consumers’
needs on-site through such devices as anonymous
questionnaires on the services offered.
As a customer-oriented system, the organization
will offer the opportunity to provide feedback also to
the staff, who will be able thus to report problematic
issues encountered in the workplace and provide sug-
gestions to improve the service. Thus, the organization
creates, maintains, and improves a work environment
that is conducive to the well-being and development
of all employees [17,33]. Such devices will increase
the sense of belonging in the workplace (affective com-
mitment) and employees will identify with the organiz-
ation and its values. The physical–spatial structure with
its premises and furnishings is nothing more than the
expression of the organization’s system of values
based on acceptance, respect, and appreciation of cul -
tural differences. The culture of an organization, in
fact, is primarily inferred from the observation of its
visible and tangible aspects, along with the public
actions of its members.
Cultural competences of human resources

36. The third dimension focuses on attitudes and skills of
personnel required to provide culturally acceptable
care, developed through training, which are: awareness
of own beliefs and bias; knowledge, acknowledgment
of, and respect for, beliefs and values of other cultures;
192 G. D. STEFANO ET AL.
relational skills in intercultural encounters with co-
workers and consumers; appropriate language and
effective communication; multicultural team-working
skills. A large part of the literature suggests some of
these beliefs/attitudes and skills are components of cul -
tural competence [11,12,18,21,24,25]. In particular, Sue
et al. [12] list some of the culturally competent counse-
lor’s attitudes and skills, namely: valuing and respect-
ing differences in beliefs, values, language, and
helping practices; awareness and knowledge of own
and clients’ cultural heritage and experiences, attitudes,
values, biases, and stereotypes; ability to engage in a
variety of verbal and nonverbal helping responses.
In our opinion, it is of primary importance that
employees of multicultural organizations be aware of
the cultural basis of their behaviors, in such a way that
they may realize that their beliefs do bear consequences
on their actions in the workplace, possibly leading them
to commit errors of assessment. It is also important that
they know, accept, and respect the different cultures of
co-workers and users. In fact, if staff members are not
willing to accept co-workers culturally different from
themselves, they will always have difficulties welcoming
external customers, which are carriers of culturally

37. specific needs, and this attitude of closure shall affect
the delivery of an efficient service. Relational, communi -
cation, and team-working skills are necessary to work in
a multicultural context. In general, with the acquisition
of relational skills, employees become capable of mana-
ging intercultural encounters with colleagues and users,
listening to others different from themselves, under-
standing their needs, and managing their own behaviors
on the basis of their cultural characteristics.
Culturally competent organizations aim to reduce
the difficulty of interaction (i.e. misunderstanding,
conflicts, and differences of views) between individuals
of different cultures. To achieve this, it is also necessary
to obtain specific multicultural team-working skills,
which allow members to cooperate, share information,
share their views, communicate effectively, and reach
an agreement on the various clinical issues. Communi-
cation skills seem to be essential to interact and work in
multi-ethnic groups. In order for the team’s goal to be
achieved and the environment to be positive, the com-
munication must be clear and transparent, fluid and
open, welcoming of others without judging, censor-
ship, or misunderstandings.
Upon meeting a culturally different customer, it is
important the staff adapt their communication style
and pay attention also to nonverbal communication.
As claimed by Campinha-Bacote [4], nonverbal com-
munication techniques must take into consideration
the client’s use of eye contact, facial expressions, body
language, touch, and space. Nonverbal language and
paraverbal language are the first channels of interaction
and affect the transmission of the message more greatly
than the spoken word. Communication with the user is

38. effective if there is correspondence between the verbal
and the nonverbal channels. Therefore, our model
puts special emphasis on communication skills and
improves relationships among colleagues and between
providers and users.
The organizations need to render all employees
more sensitive to cultural issues through diversity edu-
cation and cultural competence training, teaching them
culturally adapted models of care or types of interven-
tions [31], and developing their attitudes and skills
necessary to deliver service in a culturally responsible
manner. Staff members will be involved in group dis-
cussions, i.e. case method and self-case method and
exercises, such as simulations, role-playing which
refer to their multicultural working environments, as
well as outdoor training sessions centered on the rela-
tional and communication skills and multicultural
team-working skills development.
The importance of diversity and cultural compe-
tence training and education is highlighted by a large
part of the literature [3,5,7,11,15,17,18,25,30,32,34–
36], because cultural competence is mediated through
the behavior of all human resources that act on both
upper and lower levels of an organization. In this
way, cultural competence does not stay a mere abstract
concept, but rather it becomes a reflection of the skills,
abilities, and actions of every resource.
In general, the organization must focus on the devel-
opment of such interpersonal skills in order to be cus-
tomer-oriented from a cultural standpoint. If the
organization grants its employees a chance to acquire
and exercise these competences in their workplace
relationships, they will also become able to deal with

39. users belonging to any ethnic group in a culturally sen-
sitive and responsible way.
Cultural orientation toward clients
The fourth dimension is the one that best qualifies the
Client-oriented Model of Cultural Competence. It is
the analysis of user and staff needs and it regards also
the knowledge of their cultural characteristics. Accord-
ing to our definition, culturally competent organiz-
ations are culturally client-oriented, insofar as they
proactively look to meet the cultural needs of both
internal and external users. Hernandez et al. [27] and
Siegel et al. [32] have already stressed the importance
of knowing the needs and cultural characteristics of
the local population that constitutes most of the organ-
ization’s user pool.
In our model, we take into consideration external
customers; we are aware that cultural competence is
an integral component of patient-centered care, but we
plan to extend the analysis of needs and the knowledge
of the cultural characteristics also to internal customers,
because we consider an organization’s care for its staff
an essential element within the construct of cultural
INTERNATIONAL JOURNAL OF HEALTHCARE
MANAGEMENT 193
competence. We also believe that the cultural character-
istics of staff affect not only the interaction with multi -
cultural clients – and, therefore, the quality of service,
but also the interpersonal relationships among col-
leagues. The quality of the latter must be guaranteed

40. by the organization, through the promotion of effective
communication styles and a positive emotional environ-
ment. These aspects of working life promote employee
satisfaction, which will impact customer satisfaction in
the assessment of Total Quality Management. Accord-
ing to this approach, in fact, the treatment of internal
customer is transferred to the external customer. In
other words, only if the organization is culturally com-
petent with regard to staff, will it also be toward users.
The ultimate goal is to provide quality service to multi -
cultural users, but in order for an organization to be
defined culturally competent, that organization must
ensure a positive work environment for its own multi-
cultural staff.
Partnership with community
Culturally competent healthcare organizations collab-
orate with community partners, such as other public,
private, or no-profit organizations that help minority
groups. From such collaboration, useful feedback
may emerge regarding the analysis of the needs and
cultural characteristics of ethnic groups served, upon
which the organization …