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What is Cultural Competence and How to Develop It?

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This article will help better understand cultural competence and its components. Adopted cross-cultural attitude strategies will help to develop and enhance the ability to practice effective communication in intercultural situations.

Working and living in a global society requires the ability to create interactions and relationships with people who are different from oneself. It is critical to know how to assess our cultural competency and evaluate our own cultural behaviors. Globalization and diversity lowered the barriers that once separated cultures both internationally and domestically (Garneau & Pepin, 2015). Cultural competency skills can help businesses run more productively, and efficiently. Practicing cultural competency skills can also elevate your customer service skills. Exceptional customer service gives you the ability to set your business apart from your competitors and keeps your customers returning to your business.

What is culture?

In 1951, Kluckhohn explained culture as sharing a pattern of thinking, feeling, reacting, and problem-solving. Culture is a dynamic relational process of shared meanings that originate in the interactions between individuals (Carpenter-Song, Schwallie, & Longhofer, 2007). In 2010, Gregory and colleagues emphasized that culture must be considered in historical, social, political, and economic contexts. Betancourt (2004) defined culture as a pattern of learned beliefs, values, and behavior that are shared within a group; it includes language, styles of communication, practices, customs, and views on roles and relationships. Edgar Schein (2010) described a culture as "shared beliefs, values, and assumptions of a group of people who learn from one another and teach to others that their behaviors, attitudes, and perspectives are the correct ways to think, act, and feel." Psychologists argue that unfamiliar culture negatively affects an individual's sensemaking mechanisms and determine their behavioral responses. As a result, individuals cannot accurately perceive, interpret, explain, and predict the behavior of people with different cultural background(s) (Muzychenko, 2008).

What is cultural intelligence?

Cultural intelligence is the ability to interpret the stranger's behavior the way the stranger's compatriots would (Muzychenko 2008). For example, if employees don't feel as if their manager understands or respects their culture, employees may find it hard to trust the leader or work as a team.

What is cultural competence?

Current research on cultural competence focuses on sensitivity to cross-cultural differences and the ability to adapt to other cultural environments (e.g., Hansen, Pepitone-Arreola-Rockwell, & Greene, 2000), or reflective awareness of cultural influences on one's thoughts and behaviors (Chao, Okazaki, & Hong, 2011). Muzychenko (2008) defined cultural competence as the appropriateness and effectiveness of one's behavior in an alien cultural environment. Wilson, Ward, and Fischer (2013) defined cultural competence as "the acquisition and maintenance of culture-specific skills" for very practical reasons:

• function effectively within a new cultural context. 
• interact effectively with people from different cultural backgrounds.

Williams (2001) defined cultural competence as " the ability of individuals and systems to work or respond effectively across cultures in a way that acknowledges and respects the culture of the person or organization being served " p.1.

Why do we need to develop cultural competence?

Developing cultural competence helps us understand, communicate with, and effectively interact with people across cultures. It gives us the ability to compare different cultures with our own and better understand the differences. Unconsciously, we bring our own cultural frame of interpretation to any situation. This is not to say that culture alone determines how one interprets a situation. One's own unique history and personality also play an important role (Hofstede, 2002).

How do we develop an attitude and components of cultural competence?

Developing cross-cultural attitudes allows one to develop skills for better engaging with people from all kinds of cultures. Cross-cultural skills demonstrated through the ability to communicate with respect; recognize others' values, accept knowledge, skills, and talents; and tolerate, engage, and celebrate the success of others. Deardorff defined competence as " the ability to communicate effectively and appropriately in intercultural situations based on one's intercultural knowledge, skills, and attitudes " (Deardorff, 2006, pp. 247-248). We adopted Deardorff (2006) cross-cultural attitude strategies that help you to develop and enhance one's ability to practice effective communication in intercultural situations:

• Practice openness by demonstrating acceptance of difference.
• Be flexible by demonstrating acceptance of ambiguity.
• Demonstrate humility through suspension of judgment and the ability to learn.
• Be sensitive to others by appreciating cultural differences.
• Show a spirit of adventure by showing curiosity and seeing opportunities in different situations.
• Use a sense of humor through the ability to laugh at ourselves.
• Practice positive change or action by demonstrating a successful interaction with the identified culture.

Borchum (2002) described cultural competence as " a non-linear dynamic process that is never-ending and ever expending. It is built on increases in knowledge and skill development related to its attributes " p. 5. We synthesized and adopted Williams's (2001) and Martin and Vaughn's (2007) studies that can assist in better understanding of components of cultural competency. These attributes will guide you in developing cultural competence:

• Self-knowledge and awareness about one's own culture.
• Awareness of one's own cultural worldview.
• Experience and knowledge of different cultural practices.
• Attitude toward cultural differences.

In conclusion, our global society necessitates interactions and relationships with people who are different from oneself. By developing one's own cultural competence, productivity and efficiency may increase and in turn improve one's customer service skills. Customers who feel valued and understood will return for repeat business.

Burchum, J. L. R. (2002, October). Cultural competence: An evolutionary perspective . In: Nursing Forum : (Vol. 37, No. 4, p. 5). Blackwell Publishing Ltd.

Carpenter-Song, E. A., Schwallie, M. N., & Longhofer, J. (2007). Cultural competence reexamined: critique and directions for the future.  Psychiatric Services ,  58 (10), 1362-1365.

Betancourt, J. R. (2004). Cultural competence—marginal or mainstream movement?  New England Journal of Medicine ,  351 (10), 953-955.

Chiu, C.-Y., Lonner, W. J., Matsumoto, D., & Ward, C. (2013). Cross-Cultural Competence: Theory, Research, and Application . Journal of Cross-Cultural Psychology , 44 (6), 843–848.

Garneau, A. B., & Pepin, J. (2015). Cultural competence: A constructivist definition.  Journal of Transcultural Nursing ,  26 (1), 9-15.

Gregory, D., Harrowing, J., Lee, B., Doolittle, L., & O'Sullivan, P. S. (2010). Pedagogy as influencing nursing students' essentialized understanding of culture. International Journal of Nursing Education Scholarship, 7(1), 30. doi:10.2202/1548-923X.2025

Hofstede, G. J., Hofstede, G., & Pedersen, P. B. (2012). Exploring culture: exercises, stories, and synthetic cultures . Boston: Intercultural Press.

Hofstede, G. J., Pedersen, P. B., & Hofstede, G. (2002).  Exploring culture: Exercises, stories, and synthetic cultures . Nicholas Brealey.

Martin, M., & Vaughn, B. (2007). Cultural competence: The nuts and bolts of diversity and inclusion.  Strategic Diversity & Inclusion Management ,  1 (1), 31-38.

Muzychenko, O. (2008). Cross-cultural entrepreneurial competence in identifying international business opportunities .  European Management Journal ,  26 (6), 366-377.

Schein, E. H. (2010).  Organizational culture and leadership  (Vol. 2). John Wiley & Sons.

Williams, B. (2001). Accomplishing cross cultural competence in youth development programs.   Journal of Extension ,  39 (6), 1-6.

Wilson, J., Ward, C., & Fischer, R. (2013). Beyond culture learning theory: What can personality tell us about cultural competence?  Journal of cross-cultural psychology ,  44 (6), 900-927.

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Cultural Competence

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Cultural awareness ; Cultural sensitivity

Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals to facilitate effective work in cross-cultural situations (Cross et al. 1989 ). Linguistic competence is an important component of cultural competency because language is a key aspect of culture.

“Culture” is defined as an integrated pattern of learned human behaviors (e.g., styles of communication, customs) and beliefs (e.g., views on roles and relationships) shared among groups (Robins et al. 1998 ; Donini-Lenhoff and Hendrick 2000 ). The word “competence” implies having the capacity to function effectively with a cultural group (Cross et al. 1989 ).

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A key reason for cultural competence in health services administration and public health is to deliver the highest quality of care to all patients, regardless of race or ethnicity, cultural or religious background, or...

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References and Reading

Betancourt, J. R., Green, A. R., & Carrillo, E. J. (2002). Cultural competence in health care: Emerging frameworks and practical approaches . New York: The Commonwealth Fund.

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Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center.

Donini-Lenhoff, F. G., & Hendrick, H. L. (2000). Increasing awareness and implementation of cultural competence principles in health professions education. Journal of Allied Health, 29 (4), 241–245.

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LaVeist, T. (2002). Race, ethnicity and health: A public health reader . San Francisco: Wiley.

Robins, L. S., Fantone, J., Hermann, J., Alexander, G., & Zweifler, A. (1998). Improving cultural awareness and sensitivity training in medical school. Academic Medicine, 73 (Suppl. 10), S31–S34.

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Arredondo, E. (2020). Cultural Competence. In: Gellman, M.D. (eds) Encyclopedia of Behavioral Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-39903-0_172

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1 Introduction

• Published: January 2013
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This chapter explains the need for cultural competency in our growing diverse society. Noting that diversity is not limited to ethnic or racial domains, it defines diversity thoroughly and provide examples. It defines what is culturally competent research and what is not. The authors present a cultural competency continuum that shows at one end “cultural destructiveness” and at the other end “cultural proficiency.” The chapter concludes by identifying and discussing a 5-component framework for conducting culturally competent research: valuing diversity, conducting cultural self-assessment, managing the dynamics of difference, acquiring and integrating cultural knowledge, and adapting to diversity and cultural contexts.

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Global Cognition

Cultural competence: what, why, and how.

by Winston Sieck updated September 20, 2021

Building relationships and working successfully with different others can seem like a major challenge.

But you can enjoy the rewards, while keeping frustration to a minimum.

The key to making them work is cultural competence.

What is cultural competence?

Cultural competence is defined as the ability to work effectively with people from different cultural backgrounds. Cultural competence is comprised of four components or aspects:

• a diplomatic mindset,
• agile cultural learning,
• reasoning about other cultures, and
• a disciplined approach to intercultural interactions.

We go through each of these competency areas in more depth, below. Essentially, cultural competence is a set of skills and knowledge that can help you learn, reason, solve problems, and interact comfortably when you’re working with people from different cultures. Cultural competence can be improved through training, education, and experience.

In our increasingly connected world, it’s not surprising that we are encountering people from all manner of backgrounds in our workplaces. Whether you are leading a diverse team to develop a new product, treating patients from different walks of life, promoting stability in a conflict zone, or teaching in a multicultural classroom, cultural competence is critical to your success in the professional realm.

Why improve your cultural competence?

Cultural competence can help you do your job more effectively. What does that mean in practice?

Cross-cultural teamwork has many benefits. But, working in a culturally diverse environment sometimes comes with differences of opinion and tension.

Cultural competence can allow you to detect problems early and prevent knee-jerk reactions is situations that initially seem puzzling or even provoking. This allows you to connect and build mutual trust with the people you work with. These relationships can provide fresh insights and innovative solutions to problems. They can even give you the inside scoop on others in your environment who don’t support your agenda.

Relating better to people you work with, so you can get things done. That’s a realistic objective with obvious benefits.

What are the essential cultural competencies for work?

To address this question, Louise Rasmussen and Winston Sieck of Global Cognition studied professionals with extensive experience working across cultural boundaries. Their paper , “Culture-general competence: Evidence from a cognitive field study of professionals who work in many cultures,” was published in the International Journal of Intercultural Relations .

One of the unique features of their research was that participants were required to have a wide range of cultural experiences to be included in the studies. It was not enough to be deeply immersed in one foreign culture. This enabled the research team to tease out general cross-cultural skills that apply when working with someone from any group.

In addition, in contrast to previous work, the team did not ask these seasoned professionals for their opinions about cultural competence. Instead, the researchers dug into their lived experiences using cognitive task analysis to uncover the skills they used to meet their most challenging interactions.

The researchers identified four broad cultural competency domains that the experts used to create successful cross-cultural relationships.

Diplomatic Mindset

Diplomacy is the art of dealing with people in a thoughtful and effective way. Though it’s often talked about in connection with international relationships, diplomacy and tact can be applied to every interaction we have with people from other cultures or social backgrounds.

A diplomatic mindset starts with a focus on what you are trying to accomplish. And recognizing that you need to work with diverse others to meet your goals. It means being aware of your own worldview and realizing that your own background shapes how you see things.

Doing so helps you understand how you are viewed by the person you are interacting with. It also helps you manage your own attitudes toward the other person’s culture. Making it easier to find ways to get the job done despite your differences.

Cultural Learning

Professionals who successfully navigate cross-cultural relationships actively learn cultural norms, language and customs in an ongoing fashion. There’s far too much to know about peoples and cultures to think that you can read a book or take a class and be done with it.

Rasmussen and Sieck found that cross-cultural experts deliberately seek out the experiences and relationships that will advance their cultural understanding rather than remaining fixed in their own narrow experience.

They were also sensitive to the limits and biases of their guides. Hence, they’d consult and check a variety of sources such as web sites, books (even fiction), local informants, and colleagues to get a full understanding of the range of views within a culture.

Cultural learning does not only take place in preparation for an interaction, it continues afterward as well. The professionals would often seek feedback from natives of their host country after an experience to find out what they got wrong and what they could do better in the future.

Cultural Reasoning

Cultural reasoning helps you make sense of cultural behaviors that initially seem odd. Like a scientist with an unexpected result, treat puzzling behaviors as opportunities to deepen your understanding of the culture. Dig in and figure out why they do what they do.

If you’re walking into a situation completely fresh, with no context to draw from, all is not lost. Taking a moment to reflect on the ‘why’ likely leads you to discover a few possible alternatives.

Maybe she was trying to get a read on your personal values to gauge how we’ll you’ll work together. Or, maybe he was trying to get a rise out of you, to get a sense of how well you manage conflict.

It may not be possible to figure out a person’s real motivation is in the moment. But, with practice, you’ll find that you can regularly take the point of view of diverse people you’re working with. You can more readily consider their beliefs and desires in the moment and use that perspective to work together more effectively.

Once you discover people’s beliefs and motives, you’re in a better position to spot the differences that cause misunderstandings and conflict . And, you have your hands on the levers to influence their perceptions and decisions if you need to.

Intercultural Interaction

Showing you’ve taken the time to learn a custom or bit of language goes a long way to build rapport with someone from a different culture. Yet, it’s natural to feel awkward and uncertain, or even silly, and so avoid giving it a try.

Fortunately, there is a natural tendency for people to positively respond to someone’s attempts to address language and cultural norms, regardless of their performance level.

For example, using a customary greeting in a person’s native tongue will be seen positively even if it hits the limit of your language skills.

The connection begins in the attempt. Mastery happens over time.

One trick the seasoned professionals use is to plan their critical intercultural communications in advance. This goes beyond rehearsing that greeting to getting your nuanced talking points down before a difficult negotiation.

No matter how much you’ve planned, sometimes interactions go poorly. People from other cultures sometimes want fundamentally different things than you. And, as is the case within any group of people, sometimes they really are just rude.

Cross-cultural experts draw on deep reserves of discipline to face these situations. They manage their reactions and the impression they make, which often earns them greater respect in the process.

How to cultivate cultural competence within your team or organization

You might be able to influence the cultural competence of others within your team or organization. Here are four ways you can get started:

Make cultural competence part of your team or organization’s narrative

To do that, include cultural competence in your policies, mission or vision statements, project plans, and other resources or documents that define your expectations for your people.

Be sure to get buy-in from key stakeholders and influencers within your team or organization. They are the ones who will take your vision from paper and to practice.

Recognize and reward instances of cultural competence. Even if it’s just with positive attention.

Deliberately foster dialogue with and between teammates or subordinates around cultural issues

To get the conversation started, you can share this article. You might organize discussions of cultural issues or experiences around the following activities:

• Get people to report on cultural surprises that occur within the context of your work.
• Discuss them as a group.
• Try to take the cultural other’s perspective.
• Come up with some alternative hypotheses about the beliefs and motivations behind the behaviors.
• Locate cultural mentors inside or outside your team or organization and ask them questions.
• Compare their answers.

Discussions like this can help you set or define a positive vision. Seeing examples of outcomes of handling intercultural interactions wisely will motivate your people to improve their cultural competence.

Provide cultural competence instruction and other professional development

Incorporating a cross-cultural training program can be a reasonable option, if it’s done well. Do you have someone who develops or delivers cultural competence or diversity instruction within your team or organization? Or, are you evaluating existing options on the market?

In either case, be sure the folks who develop the content you use:

• Understand what cultural competence is.
• Promote the specific cultural skills and knowledge that are important for your people to learn.
• Give examples of how cultural competence will change and improve the ways your people do their jobs.

When you talk to instruction developers or vendors, you can use the competencies in this article as a starting point for describing the positive behaviors you expect within your team or organization.

Set realistic objectives for the change you want to see.

It’s important to keep in mind that developing cultural competence is not a one-shot enterprise. It takes time and practice. No single book, article, workshop, course, or even immersion is going to get the job done.

Use the information in this article to define a specific and realistic vision for the changes you want to see within your team or organization. And, make a plan for how you will sustain and advance your people’s cultural competence.

How to avoid pandering and related pitfalls

When you engage with people from other cultures, it can be tempting to think that you can’t be yourself. You might even feel that you need to pretend to be someone who’s willing to go along with pretty much anything.

The thing is, people in other cultures are people too. They have likes and dislikes just like you. And, they can sense when you’re not being real.

Similarly, studying up on other expressions, customs, and interests is great. But it’s important to think carefully about how you use that information.

Picking up others’ gestures or attire can sometimes seem like mocking or intruding on another’s identity.

There’s a fine line between paying respect and pandering. You have to read reactions and adapt to circumstances . Going overboard showing respect can sometimes cause you to lose it.

Instead, be yourself. If you’re genuine, people pick up on that and appreciate it.

Regardless of your industry or the type of workplace in which you are employed, cultural competence plays an important role in your daily environment. As a leader or a part of team, recognizing and dealing cultural differences will create a more productive workplace as well as a happier setting for everyone who is there. In today’s modern world, cultural competence is a necessity for everyone.

Image Credit: rawpixel

Rasmussen, L. J., & Sieck, W. R. (2015). Culture-general competence: Evidence from a cognitive field study of professionals who work in many cultures . International Journal of Intercultural Relations , 14(3), 75-90.

Sieck, W. R., Smith, J. L., & Rasmussen, L. J. (2013). Metacognitive strategies for making sense of cross-cultural encounters . Journal of Cross-Cultural Psychology , 44, 1007-1023.

Click below to check out Save Your Ammo , a guide to cultural competence in demanding situations.

About Winston Sieck

Dr. Winston Sieck is a cognitive psychologist working to advance the development of thinking skills. He is founder and president of Global Cognition, and director of Thinker Academy .

Reader Interactions

December 11, 2017 at 10:56 am

Your Article is spot-on. I have worked in special education, teaching nonverbal communication to those whose neurological syndrome prevented or interfered with perceiving and interpretation of nonverbal signals. I liked the term “mitigation” for instruction in this area. Simple, one-sentence guidelines were teased out to get satisfying results in unstructured play involving small plastic human figures and settings, such as disasters, searches, aggressive wild animals, and exploration. (Thanks to Star Trek for these models.)

December 11, 2017 at 9:42 pm

Thanks for sharing your thoughts and experiences, Jean. Sounds like a fascinating and useful intervention that you developed.

January 8, 2018 at 10:09 am

Thanks for the very interesting article – love the Star Trek references (even as a non-Trekkie). I appreciate the concise way you’ve presented the data and created the 4 broad dimensions. Very easy and fast read, yet chock full of relevant information. Good use of research time!

January 11, 2018 at 12:09 pm

Glad you enjoyed it, Mary – and found it useful. Thanks for stopping by!

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Cultural Competency: Research

• Clinical Resources
• Public Health Resources
• Additional Resources

GW Resources

• GW Anti-Racism Coalition (ARC)
• Cultural Competence Resources for professional development in the area of cultural competence, compiled by SMHS Office of Diversity and Inclusion
• Race in America Lecture Series GW Office for Diversity, Equity, and Community Engagement

Resources from Organizations

• National Center for Cultural Competence at Georgetown University
• Think Cultural Health a part of the DHHS Office of Minority Health
• Cultural Competency in Nursing Education American Association of Colleges of Nursing
• 2020 Institute for Nursing Leadership Critical Conversation on Health Equity and Racism Videos, summary report, and resource library from the American Academy of Nursing Institute for Nursing Leadership
• Culturally Competent Nursing Care: A Cornerstone of Caring Office of Minority Health
• AAMC Publication "Assessing Change: Evaluating Cultural Competence Education and Training"
• Tool for Assessing Cultural Competence Training (TACCT) "67-item self-administered assessment tool that can be used by medical schools to examine all components of the entire medical school curriculum"
• NIH Ending Structural Racism
• Health Initiative of the Americas (UC-Berkeley) Resources include: - Research directory, reports, and policy briefs - Spanish-English dictionary of health terms
• Lesbian, Gay, Bisexual, and Transgender Health (CDC) "These pages provide information and resources on some of the health issues and inequities affecting LGBT communities. Links to other information sources and resources are also provided. Some of this information is designed for members of the general public. Other information has been developed for health care providers, public health professionals, and public health students."
• Cochrane Equity Methods Group - resources for planning, conducting, and reporting your equity-relevant systematic review - additional training and support for conducting equity-related reviews

Training Opportunities

• Implicit Bias: A Practical Guide for Healthcare Settings 40-minute training video for healthcare practitioners and trainees
• Implicit Bias (DCRX: THE DC CENTER FOR RATIONAL PRESCRIBING) "This module provides an overview of implicit bias, and how it is manifested in everyday clinical decision-making. Viewers will learn about the underlying psychology and neuroscience of implicit associations, and assess their own biases to increase self-awareness. This course also describes debiasing strategies and best practices to mitigate risks of the impact of bias on treatment and care."
• Cultural Competence Courses Courses availalble in various formats and for a variety of different audiences "CDC TRAIN is a gateway into the TRAIN Learning Network, the most comprehensive catalog of public health training opportunities. TRAIN is a free service for learners from the Public Health Foundation."
• Minority Health/Health Disparities Courses Courses availalble in various formats and for a variety of different audiences "CDC TRAIN is a gateway into the TRAIN Learning Network, the most comprehensive catalog of public health training opportunities. TRAIN is a free service for learners from the Public Health Foundation."
• Learning Resources Webinars, learning modules, webinars, and videos from the National LGBTQIA+ Health Education Center, a program of the Fenway Institute more... less... Topics include Introduction to LGBTQIA+ Health; Collecting Sexual Orientation and Gender Identity Data; Pre-Exposure Prophylaxis (PrEP); HIV/STI Treatment and Prevention; LGBTQIA+ Children and Youth; Behavioral Health; Transgender Health; and more.
• Addressing the need for lgbtq-affirming cancer care: a focus on sexual and gender minority prostate cancer survivors "This training aims to help social workers and other health care professionals better support sexual and gender minority cancer patients, with a specific focus on the needs of sexual and gender minority prostate cancer survivors."

Key Terms and Definitions

"Attitudes and behaviors, which are characteristic of a group or community." ( HRSA , 2019)

• Cultural Competence

"A set of similar behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations." ( HRSA , 2019)

Another definition for cultural competence comes from the Center for Substance Abuse Treatment. Substance Abuse: Administrative Issues in Outpatient Treatment . Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2006. (Treatment Improvement Protocol (TIP) Series, No. 46.) Chapter 4. Preparing a Program To Treat Diverse Clients . 

• The capacity for people to increase their knowledge and understanding of cultural differences
• The ability to acknowledge cultural assumptions and biases
• The willingness to make changes in thought and behavior to address those biases

Cultural Humility

"It is a process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. It is a process that requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care. And it is a process that requires humility to develop and maintain mutually respectful and dynamic partnerships with communities on behalf of individual patients and communities in the context of community-based clinical and advocacy training models." (Tervalon and Murray-Garcia,1998)

Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998 May;9(2):117-25. doi: 10.1353/hpu.2010.0233. PMID: 10073197 . Access the PDF via Himmelfarb.

Masters C, Robinson D, Faulkner S, Patterson E, McIlraith T, Ansari A. Addressing Biases in Patient Care with The 5Rs of Cultural Humility, a Clinician Coaching Tool. J Gen Intern Med. 2019 Apr;34(4):627-630. doi: 10.1007/s11606-018-4814-y. Epub 2019 Jan 8. PMID: 30623383 ; PMCID: PMC6445906.

Cultural Safety

See: Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition (Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S. J., & Reid, P., 2019). The article presents a number of definitions for different terms, as collected from a literature review, and recommends a definition for cultural safety. 

Culturally Adapted Health Care

See January 2020 article from County Health Rankings for background reading 

Critical Consciousness

"critical consciousness... places medicine in a social, cultural, and historical context and ... is coupled with an active recognition of societal problems and a search for appropriate solutions" (Kumagai & Lypson, 2009)

Kumagai, A. K., & Lypson, M. L. (2009). Beyond cultural competence: Critical consciousness, social justice, and multicultural education: Academic Medicine , 84 (6), 782–787. https://doi.org/10.1097/ACM.0b013e3181a42398

Statistical Discrimination

"occurs when providers respond to the inherent uncertainty of the diagnostic and treatment processes by interpreting the data and information relevant to a minority patient differently from the way they do with white patients"... involves "misusing and misapplying factually accurate information to reach an inaccurate conclusion concerning the specific patient."

See pages 98-99 in Matthew (2015). 

Matthew, D. (2015). Just medicine : a cure for racial inequality in American health care . New York University Press.

Available online through Himmelfarb. 

Structural Competency

"the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non-compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health" ( Metzl & Hansen 2014 )

See also: Spring 2014 article, With Understanding Comes Empowerment , from New Physician and Sep 2014 article,  Structural Competency Meets Structural Racism: Race, Politics, and the Structure of Medical Knowledge , from AMA Journal of Medical Ethics. 

Conducting Research

• Considerations for employing intersectionality in qualitative health research. Abrams JA, Tabaac A, Jung S, Else-Quest NM. Soc Sci Med. 2020 Aug;258:113138. doi: 10.1016/j.socscimed.2020.113138. Epub 2020 Jun 16. PMID: 32574889; PMCID: PMC7363589.
• Sexual & Gender Minority Research Office (SGMRO) (NIH) "The Sexual & Gender Minority Research Office (SGMRO) coordinates sexual and gender minority (SGM)–related research and activities by working directly with the NIH Institutes, Centers, and Offices. The Office was officially established in September 2015 within the NIH Division of Program Coordination, Planning, and Strategic Initiatives (DPCPSI)."
• Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use Heidari S, Babor TF, De Castro P, Tort S, Curno M. Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev. 2016 May 3;1:2. doi: 10.1186/s41073-016-0007-6. PMID: 29451543; PMCID: PMC5793986.
• Integrating Sex-Gender for Informative Clinical Trials: Points to Consider " Integrating sex-gender considerations into clinical trials facilitates analysis of biological and social variables and gender-sensitive methodologies that support scientific rigor, lead to clinical relevance, and protect vulnerable participants. This overview of best practices includes links to tools and references to support sex-gender integration into clinical trials."
• Equity and Inclusion Guiding Engagement Principles "guiding engagement principles for placing diversity, equity, and inclusion at the center of health research partnerships. Developed by PCORI’s Advisory Panel on Patient Engagement, the four principles—Inclusion, Equitable Partnerships, Trust/Trustworthiness, and Accountability/Actionability—are offered to ensure that diversity, equity, and inclusion are an explicit goal of partnerships from the start."
• Indigenous Research Toolkit (UBC) "the resources on this page comprise a toolkit that will assist researchers already involved in Indigenous research with the various steps of their research collaborations"
• Sex/Gender Methods Group (Cochrane) Background and resources for addressing sex and gender in health research synthesis, including systematic reviews
• PhenX SDOH Toolkit Find standard data collection protocols for research
• Minority Health and Health Disparities Research Framework [NIMHD] "The framework serves as a vehicle for encouraging NIMHD- and NIH-supported research that addresses the complex and multi-faceted nature of minority health and health disparities, including research that spans different domains of influence (Biological, Behavioral, Physical/Built Environment, Sociocultural Environment, Healthcare System) as well as different levels of influence (Individual, Interpersonal, Community, Societal) within those domains. The framework also provides a classification structure that facilitates analysis of the NIMHD and NIH minority health and health disparities research portfolios to assess progress, gaps, and opportunities."

Database Search Tips

Mesh (medical subject heading) terms for  pubmed  and  medline  searches:.

• Cultural Competency
• Cultural Diversity
• Culturally Competent Care
• Clinical Competence
• Professional Competence
• Stereotyping
• Unconscious, Psychology
• Weight Prejudice

CINAHL Subject Heading terms for CINAHL  searches:

• Transcultural Care
• Transcultural Nursing
• Professional Practice

Search Filters:

• Health Equity Filters (ISSG Search Filters Resource)
• Population Groups Filters (ISSG Search Filters Resource)
• Health Disparities and Minority Health (Ovid Expert Searches, scroll down to find)

Additional Databases

• Sage Research Methods Core Research methods full-text collection provides access to 1,000+ books, reference works, and journal articles in research methods, statistics, and evaluation.
• Health Equity: Public Health Genomics and Precision Health Knowledge Base (CDC) "online, continuously updated, searchable database of genomics and precision health information and publications relevant to health equity. Health equity is when everyone has the opportunity to be as healthy as possible. Search terms are derived from a list provided by the Association for Territorial Health Officials which includes terms such as diversity, health disparities, and others. The search algorithm combines terms in health equity with those of genomics and precision health"
• AHRQ Social Determinants of Health Database (Beta Version) "These files contain the beta version of AHRQ’s database on Social Determinants of Health (SDOH), which was created under a project funded by the Patient Centered Outcomes Research (PCOR) Trust Fund. The purpose of this project is to create easy to use, easily linkable SDOH-focused data to use in PCOR research, inform approaches to address emerging health issues, and ultimately contribute to improved health outcomes." more... less... "Variables in the files correspond to five key SDOH domains: social context (e.g., age, race/ethnicity, veteran status), economic context (e.g., income, unemployment rate), education, physical infrastructure (e.g, housing, crime, transportation), and healthcare context (e.g., health insurance). The files can be linked to other data by geography (county and zip code). The database includes two documentation files and two types of publicly available data files."
• Office of Minority Health Resource Center "The Office of Minority Health Resource Center is a nationwide service of the Office of Minority Health that provides minority health literature, research and referrals for consumers, community organizations and health professionals. The Resource Center offers a variety of information resources, including access to online document collections, database and funding searches, and customized responses to requests for information."

Datasets and Data Sources

• Minority Health Social Vulnerability Index (SVI) uses data from the United States Census Bureau and other public sources to help identify communities that may need support before, during, and after disasters, with a focus on minority racial, ethnic, and language groups as well as medical vulnerability. The dashboard has three sections: a sidebar menu, a bar chart, and a map

Governent Reports and Publications

• National Healthcare Quality and Disparities Reports (AHRQ) "Tools for measuring healthcare quality, including the National Healthcare Quality and Disparities Reports, AHRQ Quality Indicators, and ambulatory clinical performance measures."
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Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients

Diversity is the one true thing we all have in common. Celebrate it every day. — Author Unknown

The 2002 Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare , brought into stark focus the issues of inequities based on minority status in health care services. The IOM report concluded that, “Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare” ( 1 ). Persons in racial and ethnic minority groups were found to receive lower-quality health care than whites received, even when they were insured to the same degree and when other health care access-related factors, such as the ability to pay for care, were the same ( 1 ). Clients in minority groups were also not getting their needs met in mental health treatment ( 2 , 3 ). The IOM report was a primary impetus for the cultural competence movement in health care.

Cultural competency emphasizes the need for health care systems and providers to be aware of, and responsive to, patients’ cultural perspectives and backgrounds ( 4 ). Patient and family preferences, values, cultural traditions, language, and socioeconomic conditions are respected. The concepts of cultural competence and patient-centered care intersect in meaningful ways. The IOM’s Crossing the Quality Chasm ( 5 ) document defines patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (p. 3). Both patient centeredness and cultural competence are needed in striving to improve health care quality ( 6 , 7 ). To deliver individualized, patient-centered care, a provider must consider patients’ diversity of lifestyles, experience, and perspectives to collaborate in joint decision making. Patient-centered care has the potential to enhance equity in health care delivery; cultural sensitivity may likewise enhance patient-centered care ( 6 ). Indicators of culturally sensitive health care identified in focus groups of low-income African-American, Latino American, and European American primary care patients included interpersonal skills, individualized treatment, effective communication, and technical competence ( 8 ). The U.S. Office of Minority Health has set national standards for culturally and linguistically appropriate health care services ( 9 ). The Principal Standard is that health care must “provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs” (p. 1).

Five key predictors of culture-related communication problems have been identified in the literature: cultural differences in explanatory models of health and illness, differences in cultural values, cultural differences in patients’ preferences for doctor–patient relationships, racism and perceptual biases, and linguistic barriers ( 10 ). Physicians are often poorly cognizant of how their communication patterns may vary with respect to the characteristics of the individual they are treating ( 11 ). This unconscious preconceptualization is termed implicit bias , which refers to the attitudes or stereotypes that affect understanding, actions, and decisions in an unconscious manner ( 12 ). All people experience these—even those who strive to maintain a multicultural orientation and openness to diversity. Health care providers must openly reflect on and discuss issues of the patient’s culture, including ethnicity and race, gender, age, class, education, religion, sexual orientation and identification, and physical ability, along with the unequal distribution of power and the existence of social inequities, to effectively coconstruct a treatment plan that is patient centered and culturally sensitive.

Merging Cultural Competence With Cultural Humility

Cultural humility ( 13 ) involves entering a relationship with another person with the intention of honoring their beliefs, customs, and values. It entails an ongoing process of self-exploration and self-critique combined with a willingness to learn from others. Authors have contrasted cultural humility with the concept of cultural competence. Cultural competence is characterized as a skill that can be taught, trained, and achieved and is often described as a necessary and sufficient condition for working effectively with diverse patients. The underlying assumption of this approach is that the greater the knowledge one has about another culture, the greater the competence in practice. The concept of cultural humility, by contrast, de-emphasizes cultural knowledge and competency and places greater emphasis on lifelong nurturing of self-evaluation and critique, promotion of interpersonal sensitivity and openness, addressing power imbalances, and advancement of an appreciation of intracultural variation and individuality to avoid stereotyping. Cultural humility encourages an interpersonal stance that is curious and other-oriented ( 14 , 15 ).

The infusion of cultural humility into cultural knowledge has been coined competemility : the merging of competence and humility ( 16 ). Cultural competemility is defined as “the synergistic process between cultural humility and cultural competence in which cultural humility permeates each of the five components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters” ( 16 ). The competemility position allows a meaningful connection with each patient as a unique individual, with diverse perspectives, culture, and lifestyles. Cultural competemility necessitates a consciousness of the limits of one’s knowledge and the awareness of the ever-present potential for unconscious biases to limit one’s viewpoint ( 15 , 16 ).

Practicing Cultural Competence and Cultural Humility

Cultural competence, cultural humility, and patient-centered care are all concepts that endeavor to detail essential components of a health care system that is sensitive to patient diversity, individual choice, and doctor–patient connection. A culturally competent health care workforce highlights five components: cultural awareness, knowledge, skill, desire, and encounters. Cultural humility focuses on identifying one’s own implicit biases, self-understanding, and interpersonal sensitivity and cultivating an appreciation for the multifaceted components of each individual (culture, gender, sexual identity, race and ethnicity, religion, lifestyle, etc.), which promotes patient-centered approaches to treatment. The new concept of competemility is the synergistic combination of cultural competence with cultural humility. Health care professionals need both process (cultural humility) and product (cultural competence) to interact effectively with culturally diverse patients ( 17 ).

Establishing a collaborative mutual partnership with diverse patients requires an open, self-reflective, other-centered approach to understanding and formulating the patients’ strengths and difficulties and coconstructing the treatment plan. Below are tips for practicing cultural competence and cultural humility.

Get to know your community. Who lives there, and what are the resource disparities in the community? Is there a large immigrant or refugee population? What are the most common ethnicities and languages spoken? What is the climate in the community regarding cultural diversity?

• Consider whether politics or laws, such as immigration laws or a recent federal government move to eliminate protections in health care for transgender Americans ( 18 ), are adding to the stress of diverse communities.
• If you, as the physician, are a person of color, consider how that affects your practice and work with diverse patients. If you are European American, reflect on the implicit biases that may affect your practice with diverse patients and theirs with you.
• Pay attention to office practices: do they enhance an atmosphere of welcoming everyone? Are interpreter services available, if needed?
• Ask patients by which pronoun they would prefer to be addressed.
• Use a journal to jot down potential implicit biases and observations about rapport building, for ongoing self-reflection.
• Don’t assume. Ask the patient about background, practices, religion, and culture to avoid stereotyping.
• Reassure by words and actions that you are interested in understanding the patient and helping to coconstruct a plan to fit his or her needs. State upfront that this is a collaborative process and that you welcome input on the process (communicating openly with each other) and the product (treatment plan).
• Ask directly what the patient wants to achieve with the psychiatric consultation/treatment. This can help identify patient goals and treatment methods.
• A family genogram may help clarify family dynamics, cultural background, and possible generational trauma.
• Ask directly about experiences of discrimination, bullying, traumas, or harassment. Are there fears associated with minority status?
• Identify strengths, interests, and resilience factors.
• Discuss patient-centered care to determine whether this is understood or if this is an unfamiliar practice. Get patient input about collaborating in health care decisions. For patients who are accustomed to the doctor being the one making all the decisions, consider initiating a request for decisions, even small ones, to reinforce with them that you want to know their preferences and help them become comfortable with making health care decisions and communicating wants and needs.
• Inquire about what the patient feels would be helpful. Are there cultural practices or herbal remedies that they have already tried—and what was the result? Are there religious, cultural, or individual convictions that affect choice of treatment?
• Ask during the session whether the patient has any clarification of information that he or she didn’t feel the physician appropriately understood. If using an interpreter, make sure that he or she is interpreting the full discussion (and not summarizing, which loses the nuance and some meaning).
• After the session, ask the patient if he or she felt understood, if he or she understands the process, and if there is anything else he or she would like to add to be better understood.
• Model coconstruction of the treatment plan by asking about goals and helping the patient consider possible methods of meeting those goals.
• Clarify the patient’s preference for family involvement and, depending on the age and competence of the patient, what information will be communicated to the family.

Dr. Stubbe reports no financial relationships with commercial interests.

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• Cultural Competence

Nowhere are the divisions of race, ethnicity, and culture more sharply drawn than in the health of the people in the United States. Despite recent progress in overall national health, disparities continue in the incidence of illness and death among African Americans, Latino/Hispanic Americans, Native Americans, Asian Americans, Alaska Natives, and Pacific Islanders, as compared with the US population as a whole.

Health and human service organizations are recognizing the need to enhance services for culturally and linguistically diverse populations. Providing culturally and linguistically appropriate healthcare services requires an understanding of cultural competence .

What is Cultural Competence?

What's the difference cultural competence, awareness, and sensitivity, how does cultural competence apply to hiv/aids, viral hepatitis, std, and tb prevention, hiv/aids, tb and cultural competence, general cultural competence information, assessing organizational and practitioner cultural competence, understanding and targeting specific populations.

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).( 1 )

Cultural competence requires that organizations:

• have a defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally.
• have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge and (5) adapt to diversity and the cultural contexts of the communities they serve.
• incorporate the above in all aspects of policy making, administration, practice, service delivery, and involve systematically consumers, key stakeholders, and communities.

Cultural competence is a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge, and skills along the cultural competence continuum.( 2 )

Cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes .( 3 )

Principles of cultural competence include:( 4 )

• Define culture broadly.
• Value clients' cultural beliefs.
• Recognize complexity in language interpretation.
• Facilitate learning between providers and communities.
• Involve the community in defining and addressing service needs.
• Collaborate with other agencies.
• Professionalize staff hiring and training.
• Institutionalize cultural competence.

Improved quality of care is the outcome measure that indicates whether implementing training programs, policies, and culturally or linguistically appropriate standards makes a difference. A new trend in the literature suggests that using cultural competency in a focused or strategic way can be a helpful adjunct to the quality improvement process. For example, if a program wants to analyze patterns of broken appointments, it might examine variables such as age, gender, or race/ethnicity. If the analysis reveals that adolescents have the highest rate of broken appointments, the program can target specific strategies to this group. Does the clinic need to have weekend hours, when teens can more easily slip away from home? Would providing free transportation or reminder calls from caseworkers help? Does the provider reflect a youth-sensitive approach to the clinic's client base?( 5 )

Cultural competence emphasizes the idea of effectively operating in different cultural contexts, and altering practices to reach different cultural groups. Cultural knowledge, sensitivity, and awareness do not include this concept. Although they imply understanding of cultural similarities and differences, they do not include action or structural change.( 6 )

From Health Resources and Services Administration (HRSA) Care ACTION: Improving HIV/AIDS Care in a Changing Environment, August 2002, Mitigating Health Disparities Through Cultural Competence:

The recent National Academy of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care states that "racial and ethnic minorities tend to receive a lower quality of health care than nonminorities, even when access-related factors, such as patients' insurance status and income, are taken into account."( 7 ) These findings and others like them are not news to people concerned with the care of individuals living with HIV disease. Study after study has demonstrated unequal access to care and poorer health outcomes among certain segments of the HIV-positive population. For example, analysis of data from the HIV Cost and Services Utilization Study revealed that compared with nonminorities, women and African Americans with HIV disease who are receiving care are less likely to receive antiretroviral therapy, protease inhibitors, and prophylaxis for pneumocystis pneumonia. These disparities remained even after adjusting for gender, age, education, and insurance coverage.( 8 ) Follow up in 1997 revealed improvements, but African Americans and Hispanics were still only about half as likely as whites to participate in HIV clinical trials or to get experimental medicines. Other minorities were also less likely than whites to get experimental treatment.( 9 ) Disparities in access to quality care extend beyond race and gender to other segments of the population that are often marginalized. For example, HIV-infected injection drug users are less likely to receive antiretroviral therapy than non-drug users are.( 10 ) It follows that disparities in access to quality HIV care are related to disparities in survival, which have been reflected in AIDS mortality data for some time.( 11 )

Being competent in cross-cultural functioning means learning new patterns of behavior and effectively applying them in the appropriate settings.( 12 ) For HIV/AIDS prevention and treatment to succeed, the special needs and life contexts of those who are marginalized because of race, ethnicity, socioeconomic status (SES), sexual orientation, age, or gender must be sensitively addressed. Cultural competence must be demonstrated not only by intervention programs and staff, but also by surveillance staff, researchers (and their investigations), as well as by those delivering prevention services, care, and treatment programs to those who are HIV-infected.

Learn More About Cultural Competence

Case Studies in Cultural Competency From the AIDS Education Training Center--National Multicultural Center

Electronic Library From the AIDS Education Training Center--National Multicultural Center

AIDS Education and Training Center National Multicultural Center Web resources on cultural competency including marginalized populations, provider stigma, and HIV health literacy

TB and Cultural Competency From the New Jersey Medical School Global Tuberculosis Institute

Resources from the AIDS Education Training Centers National Resource Center

Cultural Competency and Tuberculosis Care: A Guide for Self-Study and Self-Assessment

Case Studies: Videos From the American Academy of Family Physicians

National Standards for Culturally and Linguistically Appropriate Services in Health Care From the Health and Human Services Department's Office of Minority Health

The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS) From the Office of Minority Health

A Physician's Practical Guide to Culturally Competent Care From the Office of Minority Health, the Website offers CME and CEU credit and equips health care professionals with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve

A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations From the Office of Minority Health

Cultural and Linguistic Competency From the Office of Minority Health

Culture, Language, and Health Literacy HRSA list of online cultural competency resources. Includes culture/language specific and disease/condition specific resources, guidelines for clinicians, research, online training resources, health professional education resources, and more

HIV Provider Cultural Competency Self-Assessment From the AIDS Education and Training Center National Multicultural Center

From National Minority AETC:

Patient Provider Interaction  Web Resources from The Provider's Guide to Quality and Culture

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Article contents

Reflection and intercultural competence development.

• Luciara Nardon Luciara Nardon Sprott School of Business, Carleton University
• https://doi.org/10.1093/acrefore/9780190224851.013.64
• Published online: 25 February 2019

Increasing levels of cultural diversity requires a system of higher education structured to facilitate intercultural learning and develop individuals who are prepared to work in a culturally diverse environment, and can make decisions and manage people cognizant of cultural differences. Three main approaches to facilitate intercultural learning in the classroom have emerged: transfer of cultural knowledge, cultural experiences, and reflection on experience. Each of these approaches has a role to play at different stages of intercultural development. Three stages of intercultural development are proposed: (1) Monocultural stage, referring to a stage in which individuals are unaware of cultural differences; (2) Cross-cultural stage, in which individuals recognize and understand cultural differences but lack behavioral skills to deal with them; and (3) Intercultural stage, in which individuals can draw on a repertoire of behaviors to influence and shape intercultural interactions in ways that facilitate understanding and create opportunities for cooperation. Reflection on experience is proposed to be particularly useful to support the development of intercultural competence. Reflection is a thinking process focusing on examining a thought, event, or situation to make it more comprehensible and to learn from it. A four-step reflection process is proposed: (1) Describe experience; (2) Reflect on experience; (3) Learn from experience; and (4) Apply learning. Suggestions on using reflection in the classroom are proposed.

• cross-cultural
• intercultural
• intercultural learning
• intercultural competence

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Effectively teaching cultural competence in a pre-professional healthcare curriculum

• Karen R. Bottenfield 1 ,
• Maura A. Kelley 2 ,
• Shelby Ferebee 3 ,
• Andrew N. Best 1 ,
• David Flynn 2 &
• Theresa A. Davies 1 , 2  

BMC Medical Education volume  24 , Article number:  553 ( 2024 ) Cite this article

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There has been research documenting the rising numbers of racial and ethnic minority groups in the United States. With this rise, there is increasing concern over the health disparities that often affect these populations. Attention has turned to how clinicians can improve health outcomes and how the need exists to educate healthcare professionals on the practice of cultural competence. Here we present one successful approach for teaching cultural competence in the healthcare curriculum with the development of an educational session on cultural competence consisting of case-based, role-play exercises, class group discussions, online discussion boards, and a lecture PowerPoint presentation.

Cultural competence sessions were delivered in a pre-dental master’s program to 178 students between 2017 and 2020. From 2017 to 2019, the sessions were implemented as in-person, case-based, role-play exercises. In 2020, due to in-person limitations caused by the COVID-19 pandemic, students were asked to read the role-play cases and provide a reflection response using the online Blackboard Learn discussion board platform. Evaluation of each session was performed using post-session survey data.

Self-reported results from 2017 to 2020 revealed that the role-play exercises improved participant’s understanding of components of cultural competence such as communication in patient encounters (95%), building rapport with patients (94%), improving patient interview skills (95%), and recognition of students own cultural biases when working with patients (93%).

Conclusions

Students were able to expand their cultural awareness and humility after completion of both iterations of the course session from 2017 to 2019 and 2020. This session can be an effective method for training healthcare professionals on cultural competence.

Peer Review reports

It is projected that by the year 2050, racial and ethnic minority groups will make up over 50% of the United States population [ 1 ]. With a more multicultural society, growing concern has emerged over how to address the health disparities that effect these populations and the ways in which healthcare professionals can increase positive health outcomes. Continuing evidence suggests that many patients from racial and ethnic minority groups are not satisfied with the current state of healthcare which has been attributed to implicit bias on the part of physicians and current challenges faced by practitioners who feel underprepared to address these issues due to differences in language, financial status, and healthcare practice [ 2 , 3 , 4 ].

To contend with health disparities and the challenges faced by practitioners working with a more diverse population, healthcare educators have begun to emphasize the importance of educating healthcare workforce on the practice of cultural competence and developing a skilled-based set of behaviors, attitudes and policies that effectively provides care in the wake of cross-cultural situations and differences [ 4 , 5 , 6 ]. There are several curricular mandates from both medical and dental accreditation bodies to address this issue [ 7 , 8 , 9 ], and large amounts of resources, ideas, and frameworks that exist for implementing and training future and current healthcare providers on the inadequacies of the healthcare system and cultural competence [ 10 , 11 , 12 ]. These current institutional guidelines for accreditation and the numerous amounts of resources for training cultural competence, continue to evolve with work documenting the need for blended curriculum that is continuous throughout student education, starting early as we have done here with pre-dental students, including in-person didactic or online sessions, a service learning component, community engagement and a reflective component [ 4 , 5 , 13 , 14 ].

This study investigates teaching cultural competence in a healthcare curriculum. We hypothesized that early educational exposure to cultural competence through role playing case studies, can serve as an effective mechanism for training early pre-doctoral students the practice of cultural competence. Utilizing student self-reported survey data conducted in a predental master’s curriculum, in which two iterations of role-playing case studies were used to teach components of cultural competence, this study aims to evaluate and support research that suggests role-playing case studies as effective means for educating future clinical professionals on the practice of cultural competence.

This study was determined to be exempt by the Institutional Review Board of Boston University Medical Campus, Protocol # H-37,232. Informed consent was received from all subjects.

Data collection

The role-playing, case-based simulated patient encounter exercises were developed and administered at Boston University Chobanian & Avedisian School of Medicine to predental students in the Master of Science in Oral Health Sciences Program (see Table  1 ). From 2017 to 2020, we administered patient encounter cases [see Additional File 1 ] to students ( n  = 178) in the program as a portion of a case-based, role-playing exercise to teach the importance of cultural competence and cultural awareness during patient encounters. During years 2017–2019, real actors portrayed the patient and physician. In 2020, the session was conducted online via a discussion board through a Blackboard Course Site. The original case was published as part of a master’s students thesis work in 2021 [ 15 ].

Description of patient encounter cases 1 and 2

Patient Encounter Case 1 [see Additional file 1 ] is composed of two subsections, scenario 1 A and scenario 1B, and is centered around a patient/physician interaction in which a patient who is pregnant presents with pain upon urination. The physician in 1 A is short and terse with the patient, immediately looking at a urine sample, prescribing medication for a urinary tract infection, and telling the patient to return for a follow-up in 2 weeks. In scenario 1B, a similar situation ensues; however, in this scenario the physician takes more time with the patient providing similar care as the physician in 1 A, but asking for more information about the patients personal and medical history. At the conclusion of the scenario, the patient is offered resources for an obstetrician and a dentist based on the information that is provided about the patient’s background. The patient is then sent on their way and asked to follow-up in 2 weeks. The patient does not return.

Patient Encounter Case 2 [see Additional file 1 ] follows a similar format to the Patient Encounter Case 1. In scenario 2 A, the same patient from Case 1 returns with tooth pain after giving birth. The physician in 2 A, like 1 A, is short with the patient and quickly refers the patient to a dentist. In 2B, the physician again takes more time with the patient to receive background information on the patient, make a connection, and provides an antibiotic and dental referral.

Each Patient Encounter Case explored topics such as the importance of building a trusting physician/patient relationship, the importance of asking a patient for patient history, making a connection, and the importance of a physician taking all facets of a patient’s circumstances into consideration [ 15 ].

Session outline

The sessions conducted between 2017 and 2019 were composed of three parts: (1) enactment of an abridged patient encounter facilitated by session administrators, (2) group discussion and reflection during which time students were asked to critically reflect and discuss the theme and key take-aways from the role play exercise, and (3) a PowerPoint presentation emphasizing take-away points from the role-play exercise. At the conclusion of the cultural competence training sessions, students participated in a post-session Qualtrics generated survey administered electronically to assess each student’s feelings about the session [see Additional file 3 ].

Role-play enactment

Facilitators dressed-up in clothing to mimic both the physician and patient for all case scenarios in Patient Encounter Case 1 and Case 2. At the conclusion of the role play portion of each of the cases, the facilitators paused to lead students in a real-time class group discussion. After Case 1, students were asked questions such as: What did you think ? Were the patient’s needs met? Did you expect the patient to return? Following Case 2, similar questions were asked by the facilitators, including: What did you think ? Were the patient’s needs met? Did you expect the patient to accept help?

At the conclusion of this portion of the session, the facilitators led a larger general discussion about both cases and how they related to one another. Finally, the course session concluded with a PowerPoint presentation that reinforced the take-home points from the session [see Additional file 2 ] [ 15 ].

Change in session modality due to COVID-19 pandemic

In Fall 2020, due to the COVID-19 pandemic, the course modality moved to an online platform and consisted of three parts on a Blackboard Discussion Board (Blackboard, Inc.). Students were required to: (1) read each of the Patient Encounter Cases and add a brief reflection comparing the scenarios, (2) then comment on at least two peer’s posts in the discussion forum and (3) attend class to hear a PowerPoint presentation by a course session facilitator on the key take-aways from each scenario [ 15 ].

Student surveys

At the conclusion of the cultural competence training sessions, students participated in a post-session Qualtrics ( https://www.qualtrics.com ) generated survey administered electronically to assess each student’s feelings about the sessions [see Additional file 3 ]. The format of the survey included 5 questions with the following Likert scale response options: strongly agree, agree, disagree, strongly disagree. These post-session surveys were not required but rather optional [ 15 ].

A total of 178 students completed the cultural competence sessions between 2017 and 2020. Of these participants, 112 voluntarily completed a post-session survey on the effectiveness of the course in teaching cultural competence and cultural awareness during patient encounters. Between 2017 and 2019, 99 students completed post-session surveys following sessions with role play exercises. In 2020, 13 students completed post-session surveys following discussion board sessions.

Role-play exercises enhanced cultural competence

In responding to post-session survey questions following cultural competence sessions that included role-play exercises (2017–2019), 71% of students surveyed strongly agreed and 24% agreed that the role-play exercises helped them to identify the importance of communication in patient encounters. In asking participants if the role-play exercises made them more aware of different strategies to improve their patient interview skills, 72% strongly agreed and 23% agreed. Also, 68% of the students strongly agreed and 26% agreed that the exercises helped them to better identify the importance of building rapport and trust during patient encounters. When asked if the exercises helped the students to better understand their own bias and/or cultural awareness when working with patients, the results of the survey showed that 62% of students strongly agreed and 31% agreed with this statement. In addition, most students found the role-play exercises to be enjoyable (72% strongly agreed and 22% agreed). See results shown in Fig.  1 .

Cultural Competence Session Survey Data from the Year 2017–2019. Survey data from students at Boston University’s Oral Health Sciences Program for the years 2017–2019. Data is presented as percent of respondents ( n  = 99)

Discussion boards and reflections enhanced cultural competence

Cultural competence sessions held during 2020 did not include role-play exercises due to the Covid-19 pandemic. Instead, students participated in discussion boards and reflections on Blackboard. In response to the post-session survey question asking if the discussion board exercises were helpful in identifying the importance of communication during patient encounters, 67% of students strongly agreed and 25% agreed with this statement. Also, 75% of students strongly agreed and 17% agreed that the discussion board exercises helped them identify the importance of building rapport and trust during patient contact. When asked if the exercises helped the students to better understand their own bias and/or cultural awareness when working with patients, the results of the survey showed that 67% of students strongly agreed and 25% agreed with this statement. In addition, most students found the discussion board exercises to be enjoyable (67% strongly agreed and 22% agreed). See results shown in Fig.  2 .

Cultural competence session survey data from the Year 2020. Survey data from students at Boston University’s Oral Health Sciences Program for the year 2020. Data is presented as percent of respondents ( n  = 13)

Student responses to the reflection portion of the online cultural competency sessions were recorded and categorized. Five themes were selected and 441 reflection responses were coded using NVivo (Version 12). The results showed that 29% of reflections demonstrated student’s ability to understand a holistic approach to clinical care, 24.3% understood the importance of collecting a patient history, 6.8% recognized the socioeconomic factors during a patient encounter, 27.9% reflected on the importance of the patient clinical relationship, and 12% on the effects on improving health outcomes (Table  1 ). Representative student responses to these themes are shown in Table  1 .

There exists a need to develop novel and effective means for teaching and training the next generation of healthcare professionals the practice of cultural competence. Thus, two iterations of a course session using case-based patient centered encounters were developed to teach these skills to pre-professional dentals students. Overall, the results of this study demonstrated that participation in the course, subsequent group discussion sessions, and take-away PowerPoint sessions significantly improved the participant’s understanding of the importance of communication skills and understanding of socioeconomic, environmental, and cultural disparities that can affect a patient’s health outcome.

According to results from the course session implemented in-person from 2017 to 2019, the role-playing exercise significantly improved participants understanding of important components that can be used to improve health outcomes that may be affected due to health disparities. Students were strongly able to identify the importance of communication in patient encounters, to understand strategies such as communication and compassionate care in patient encounters, identify the importance of building a patient-physician relationship with patients, and were able to recognize their own cultural biases. Similarly, in 2020, even with a change in course modality to on-line learning due to COVID-19, students were able to understand the same key take-aways from the course session as demonstrated by reflections using the discussion board regarding the need for a holistic approach to care, importance of the patient clinician relationship, and importance of taking a patient history. Despite promising implications of both iterations of the session, students completing the session online did not find the same success in “understanding my own bias/and or cultural awareness when working with patients.” This decrease may be attributed to change in course modality and the strengths of the role-play enactment of the patient encounter. It is important to recognize that additional learning components, including video recordings of the role-play enactment, may be necessary if the discussion board is used as the primary learning method in the future.

In contrast to previous studies that attempted to determine the effectiveness of cultural competence training methods, this session had many unique characteristics. The simulated role-playing exercise enabled student participants to see first-hand an interactive patient scenario that could be used as an example for when students begin working with patients or communicating with patients who are culturally diverse. Additionally, the nature of the cases created for the course session which were divided into a part A in which the patient physician was more straightforward when diagnosing and treating the patient and a part B with a more comprehensive and nurturing approach to care, allowed the students to compare the scenarios and make their own assumptions and comments on the effectiveness of each portion of the case. Another strength of this training, was the faculty with cultural competence training were uniquely involved in case creation and facilitation of the course session. According to previous studies with similar aims, it was noted that direct observation and feedback from a faculty member who had cultural competence training and direct contact with patients can provide students with a more memorable and useful experience when educating students [ 12 ]. The facilitators of this session were able to emphasize from their own personal experiences how to work with culturally diverse populations.

An important aspect of the 2020 iteration of the course session in which a discussion board format was used, was that it allowed students who may feel uncomfortable with sharing their thoughts on a case and their own biases, the opportunity to share in a space that may feel safer than in person [ 4 ]. Previous studies have mentioned challenges with online discussion boards [ 4 ] but here we had robust participation, albeit required. Students often contributed more than the required number of comments and they were often lengthy and engaging when responding to peers. Finally, in contrast to previous studies, this course session took place in a pre-professional master’s program, the M.S. in Oral Health Sciences Program at Boston University Chobanian & Avedisian School of Medicine. This program, in which students are given the opportunity to enhance their credentials for professional school, provided students with early exposure to cultural competence training. Students that completed this session in their early pre-professional curriculum should be better prepared than peers who did not receive any cultural competence training until they entered their designated professional school. This session is part of an Evidence Based Dentistry course, which incorporates a larger component of personal reflection that serves to engage students in critical thinking as they begin to develop the skills to be future clinicians. Students that understand different cultures, society and themselves through self-assessments will grow and be best suited in time to treat future patients [ 4 , 16 , 17 ].

One limitation of the present study was the number of survey participants that competed the post-session surveys, as survey completion was not required. Thus, the number of student participants declined over the years, reaching its lowest number of participants in 2020 when the discussion board course session was implemented, and students may have been over surveyed due to the pandemic. Another limitation to this study, was the lack of both a pre and post survey that could be used to determine how student’s understanding of cultural competence had evolved from their entry into the course to the conclusion of the course as well as individual bias and self-reporting measures.

In the future, the course should implement both a role-playing format and subsequent discussion board reflections within the same course session. Studies have shown that alternatives ways of drawing students to reflect whether role play, personal narratives, etc. can be extremely advantageous in developing personal reflection and awareness building competency [ 4 , 16 , 17 , 18 ]. It is noted that role-playing exercises that allow students to provide feedback with student colleagues can provide students with more insight into their own behaviors. It has also been shown in previous studies that student writing and reflection activities can also facilitate student’s reflections on their own beliefs and biases [ 4 , 11 ]. Reflective writing skills are an important and effective means for students to continue to gauge their cultural competence throughout the remainder of their academic training and as future clinicians [ 4 , 17 , 19 ]. Further, students may experience emotional responses through the process of reflective writing as they recognize personal bias or stereotypes, creating a profound and impactful response resulting in enhanced understanding of cultural differences and beliefs [ 4 ]. By combining both learning techniques, students would be able to understand their own bias and their classmates and create a dialogue that could be more beneficial than just one learning method alone. Furthermore, by implementing the discussion board into the role-playing session, as stated previously, students that are more cautious about sharing their point of view or about their own implicit bias in a traditional classroom setting would be able to express their opinions and facilitate a more comprehensive discussion more thoroughly.

Here we show an effective means to utilize role-play of a multi-scenario case-based patient encounter to teach pre-professional healthcare student’s components of cultural competence, emphasizing the importance of provider-patient interactions, holistic patient care, and patient history and socioeconomic factors in provider care. This study contributes to the larger body of work that seeks to address this important aspect of education as it relates to enhancing patient health care outcomes.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to acknowledge Boston University’s Chobanian & Avedisian School of Medicine’s Graduate Medical Science students and study participants.

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TAD designed the original study concept, taught the classes (roleplay), conducted the surveys, and collected data; MAK designed the original case and PowerPoint, and performed roleplay; DBF and SF evaluated data and drafted original figures; ANB assisted in drafting the manuscript; KRB finalized figures and the manuscript.

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Bottenfield, K.R., Kelley, M.A., Ferebee, S. et al. Effectively teaching cultural competence in a pre-professional healthcare curriculum. BMC Med Educ 24 , 553 (2024). https://doi.org/10.1186/s12909-024-05507-x

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Received : 27 October 2023

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DOI : https://doi.org/10.1186/s12909-024-05507-x

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