As you read the article you choose for this assignment, consider the questions below

What is cultural competence? Why is it important for healthcare professionals? 

How do communication skills support organizational culture, mission, and philosophy and improve cultural competence? 

How can the points presented in the article help the healthcare industry improve how its professionals relate to one another as well as the patients they serve? 

Your critique must meet the requirements below. 

Your critique must be at least three pages in length, not including the title and reference pages. 

Identify the main topic or question and the author’s intended audience. 

Comment on the article by sharing your opinions on what appears to be valid and invalid. 

Discuss if you agree with the author’s assertions, and share why you do or why you do not agree.   

All sources used, including the textbook, must be referenced; paraphrased and quoted material must have accompanying citations. All references and citations used must be in APA style.

RESEARCH ARTICLE Open Access

The challenge of cultural competence in
the workplace: perspectives of healthcare
providers
Stephane M. Shepherd1*, Cynthia Willis-Esqueda2, Danielle Newton3, Diane Sivasubramaniam4 and Yin Paradies5

Abstract

Background

: Cross-cultural educational initiatives for professionals are now commonplace across a variety of
sectors including health care. A growing number of studies have attempted to explore the utility of such
initiatives on workplace behaviors and client outcomes. Yet few studies have explored how professionals
perceive cross-cultural educational models (e.g., cultural awareness, cultural competence) and the extent to
which they (and their organizations) execute the principles in practice. In response, this study aimed to explore
the general perspectives of health care professionals on culturally competent care, their experiences working
with multi-cultural patients, their own levels of cultural competence and the extent to which they believe their
workplaces address cross-cultural challenges.

Methods

: The perspectives and experiences of a sample of 56 health care professionals across several health
care systems from a Mid-Western state in the United States were sourced via a 19-item questionnaire. The
questionnaire comprised both open-ended questions and multiple choice items. Percentages across participant
responses were calculated for multiple choice items. A thematic analysis of open-ended responses was
undertaken to identify dominant themes.

Results

: Participants largely expressed confidence in their ability to meet the needs of multi-cultural clientele
despite almost half the sample not having undergone formal cross-cultural training. The majority of the sample
appeared to view cross-cultural education from a ‘cultural awareness’ perspective – effective cross-cultural care
was often defined in terms of possessing useful cultural knowledge (e.g., norms and customs) and facilitating
communication (the use of interpreters); in other words, from an immediate practical standpoint. The principles
of systemic cross-cultural approaches (e.g., cultural competence, cultural safety) such as a recognition of racism,
power imbalances, entrenched majority culture biases and the need for self-reflexivity (awareness of one’s own
prejudices) were scarcely acknowledged by study participants.

Conclusions

: Findings indicate a need for interventions that acknowledge the value of cultural awareness-
based approaches, while also exploring the utility of more comprehensive cultural competence and safety
approaches.

Keywords: Cultural competence, Cultural safety, Cultural humility, Diversity training, Public health

* Correspondence: sshepherd@swin.edu.au
1Centre for Forensic Behavioural Science, Swinburne University of
Technology, 1/582 Heidelberg Rd, Alphington, Melbourne, Victoria, Australia
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Shepherd et al. BMC Health Services Research (2019) 19:135
https://doi.org/10.1186/s12913-019-3959-7

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mailto:sshepherd@swin.edu.au

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

Background
In recent decades, several key public health care reports
and research studies on health care experiences have in-
dicated that particular cultural groups are more likely to
be underserved, perceive negative treatment, and receive
differential treatment outcomes [1–3]. In response,
health care systems in North America and other
CANZUS nations, have endeavored to adapt their ser-
vice delivery practices and policies to improve the qual-
ity and access of health care to culturally and
linguistically diverse groups [4–7]. Industry objectives in
health care settings contemporaneously aspire to, i) im-
prove cross-cultural communication ii) enhance respon-
siveness to the health care needs of diverse patients iii)
reduce health care provider discrimination and iv) re-
duce health care disparities. Health care organizations
have embraced and enlisted a variety of cross-cultural
educational approaches (e.g., cultural awareness, cultural
competence etc.) to achieve these objectives.
Cross-cultural education training for health care profes-

sionals is now commonplace and in some settings, man-
dated [8, 9]. Its principles are often embedded within the
strategic plans of health organizations, and human resource
departments will often oversee the advancement of such
initiatives. Participating health care systems usually employ
one, or a combination, of several popular cross-cultural
models that have emerged over the past four decades.
These include, but are not limited to, cultural awareness,
cultural competence, cultural safety, cultural humility and
cultural intelligence. There are also multiple off-shoots in-
cluding anti-racism training and diversity training. The
cross-cultural models overlap considerably though they
have differing emphases. Cultural awareness focuses on
learning about the norms and customs of multi-cultural
groups [10]. Cultural safety is concerned with protecting
the culture of vulnerable groups by identifying biases and
power imbalances within organizational structures [11].
Cultural humility promotes openness and non-judgement
while allowing the client to determine how their culture
impacts their experiential reality and by extension, the
clinical encounter [12]. Cultural intelligence focuses on an
individual’s capacity to first recognize and then success-
fully function in various cultural environments foreign to
their own [13]. And cultural competence (though often
used generically) is an institutional framework that ex-
pands an organization’s internal and external capacity to
support and implement protocols that improve worker at-
titudes, cross-cultural communication, staff diversity, and
ongoing relationships with multi-cultural communities
and stakeholders [14]. The adoption of these models, or
aspects of the models, are believed to ultimately reduce
the obstacles that still contribute to the poor health care
experiences and unmet health needs of particular cultural
minority groups [15].

While the uptake of cross-cultural education models has
been widespread across health care systems, evidence for
the models’ ability to reduce cross-cultural health care dis-
parities has been slim. There has been some confirmation
of temporary improvements in practitioner attitudes and
patient experiences post model implementation (usually in
the form of a workshop), however the impact on patient
treatment outcomes has been largely negligible [16–18].
While there are possible associated explanations for these
findings (e.g., model implementation integrity, methodo-
logical rigor of validation studies, broader organizational
factors) is it uncertain as to why current cross-cultural edu-
cation strategies have not had stronger effects. In fact, there
is evidence indicating that certain delivery styles (e.g., coer-
cive, shame-and-blame) of cross-cultural education may
have unintended contrary outcomes for participating staff
[8, 19]. Other literature has offered some speculation as to
why such trainings and associated initiatives may fall short
in achieving anticipated outcomes in health care settings
[20–23]. Shepherd [9] points to the impracticality of retain-
ing and then utilizing ‘quickly-learned’ cultural knowledges,
customs and interaction styles beyond cross-cultural work-
shops. The potential for essentializing and/or homogenizing
cultural groups leading to stereotypical pre-conceptions has
also been referred to [22, 24–26]. Moreover, numerous fac-
tors may impact a cross-cultural clinical encounter beyond
cultural differences (e.g., personality, temperament, cogni-
tive ability, level of education, socio-economic status, men-
tal health, universally poor service delivery). It is clear that
further research efforts are required to explore how cross-
cultural education is typically delivered, received and imple-
mented in various health care settings.
One way to acquire this information is to ascertain

the views and experiences of health care professionals
themselves. Cross-cultural training workshops are often
validated by health care professionals via pre-post inter-
vention surveys. However, the insights and perceptions
of health care professionals are infrequently sought
when attempting to develop, define or refine effective
cross-cultural practice. Few studies globally, have ex-
plored the perceptions of professionals on cross-cul-
tural education initiatives in health care. A number of
studies from Australia (samples < n = 20) explored the barriers to effective cross-cultural communication as identified by health workers and the importance they afforded to cultural competence [27–30]. Similar stud- ies were conducted with small samples of nurses in Scotland [31] and Ireland [32]. In North America, a study from Canada assessed attitudes towards cultural competence for 170 registered nurses [33] and a study from USA explored how 31 public health nurses gauged their own levels of cultural competence and experi- ences of culturally competent care [34]. The opinions of both health care providers and medical staff on some

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 2 of 11

of the challenges faced when working with diverse cli-
entele, were obtained in the context of broader studies
on cross-cultural health care in the USA [35] and
Sweden [36]. Furthermore, health care professionals’
perceptions of their own cultural competence has been
examined across professions (i.e., physicians compared
to nurses) [37] and in relation to their alignment with
patient observations [38]. Overall, the above literature
illustrates that health care professionals, despite posses-
sing varying levels of cross-cultural knowledge, largely
acknowledge the importance of cross-cultural aware-
ness and demonstrate a willingness to improve their
cross-cultural communication skills. Language barriers,
low client health literacy and bureaucratic constraints
are regularly offered as barriers to effective cross-cul-
tural service delivery [27–30]. It is clear however, that
further research is warranted in this space to acquire a
more nuanced understanding of how health care pro-
viders and professionals view and experience intercul-
tural encounters, and the educational initiatives
implemented to enhance such encounters. In response,
this study aims to gather and explore i) the general
perspectives of health care professionals on culturally
competent care, ii) their experiences working with
multi-cultural patients, iii) their perceptions of their
own levels of cultural competence and iv) the extent to
which they believe their respective organizations
address cross-cultural challenges in the workplace. Pro-
fessionals were recruited from health care systems in a
Mid-Western region of the USA where no prior
research of this nature has been conducted. We antici-
pated that the majority of professionals will value the
importance of cross-cultural education and training but
may differ with regards to both their own and their or-
ganization’s perceived knowledge, and which aspects of
cross-cultural education they believe are relevant to
their practice.

Methods
Participants
Participants were recruited across three major health
care systems and one university student health center
from a Mid-Western state in America. The first health
system, a major university medical training facility
comprises a network of two hospitals and 40 clinics.
The second health system, is a state-run network of
over 30 major hospitals and clinics. The third, is a re-
gional faith-based network of 14 hospitals and over 400
clinics. The university student health center provides a
range of medical services on a major university campus.
Combined, the three health systems and university stu-
dent health center, operate the majority of medical
facilities in the state.

Materials
Participants completed a 19-item questionnaire ascer-
taining their general perspectives on culturally compe-
tent care, their experiences working with multi-cultural
patients, their own levels of cultural competence and the
extent to which they believe their organizations
addressed cultural competence in the workplace. The
questions were both multiple choice (n = 15) and
open-ended (n = 4). For the multiple choice questions,
participants were asked the extent to which they agree
or disagree with various general statements (e.g., Do you
think health service providers should consider a patient’s
cultural background when treating them?), to reflect on
how often their own skills align with best practice
cross-cultural care (e.g., Do you feel that you attend to
the cultural needs of patients from difference cultural
backgrounds?) and the importance they afford to various
skillsets (Do you think it is important to learn about dif-
ferent cultures as part of your practice?). Open ended
questions prompted participants to elaborate on their
perceptions and experiences (e.g., What areas of cultural
awareness/competence do you feel that you and/or your
organisation perform well?). The combination of both
closed and open-ended questions allowed for a baseline
understanding of participant views across key ideas,
which could then elucidated through nuanced personal
narratives.
The questionnaire was developed by the study authors

through their own expertise and after reviewing the rele-
vant public health and cross-cultural health care literature.
Questions were selected based on their relevance to the
study (e.g., health care environments) and their alignment
with the expectations and principles of cross-cultural
communication philosophies (e.g., cultural competence,
cultural awareness, cultural safety). No previous validated
questionnaire specifically tailored to the cross-cultural ex-
periences of health care professionals was located for use.

Procedure
Researchers contacted participating health care net-
works in mid-2016 to ascertain their interest in being
involved in the study. After receiving support from
their respective internal review boards, the organiza-
tions distributed an online link to the study survey to
clinical and professional staff via email. The link was
accompanied with a short passage enquiring if staff
were interested in participating in an anonymous online
research study survey on cross-cultural health care ser-
vice delivery experiences.
Individuals who opted to click on the study link were

presented with a digital consent form outlining the re-
quirements and their involvement in the study. After con-
senting, participants then completed the anonymous
online health care provider cross-cultural experiences

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 3 of 11

survey. The questionnaire was conducted on an online re-
search survey software program. The duration of partici-
pation ranged from 10 to 30min. All participants received
a $10 online gift voucher for their contribution. Data was
collected across the months of August and September in
2016. It is unknown as to exactly how many staff at each
organization received the study recruitment email.

Data analyses
A mixed methods study design was employed. First, per-
centages across participant responses were calculated for
all multiple choice items. Second, the four open-ended
questions were then qualitatively analysed. After extract-
ing the data from the online research survey program, a
thematic analysis was undertaken by a primary coder (au-
thor DN) using a progressive process of classifying, com-
paring, grouping and refining groups of text segments to
create and then clarify the definition of categories, or
themes, within the data [39]. For the purposes of reliabil-
ity, another coder (author SS) independently coded a sub-
section of interview notes and cross-checked these with
the findings of the primary coder. Following coding, dom-
inant themes were cross-checked between raters until a
consensus was reached. Participant percentages across
categories for the 19 multiple choice questions were calcu-
lated and tabled.

Results
Data were collected from a total of 56 health care
workers. Four additional individuals elected not to
consent to participate in the study after viewing the
information statement and consent form page. Due to
the anonymous nature of the study, the distribution of
participants across the four health care organizations
was unknown. The mean age of the sample was 38.66
(SD: 12.03, range 20–65) years. The majority were
female (n = 52, 92.9%). Over 85% (n = 48) of the sam-
ple identified as White/Caucasian, with 8.9% (n = 5)
identifying as Hispanic/Latino, 3.6% (n = 2) identifying
as Middle Eastern and 1.8% (n = 1) identifying as
African-American. The self-described professions of the
participants included Nurse/Nurse Practitioner (n = 18,
32.1%), Mental Health Professionals (n = 9, 16.1%), Med-
ical Assistants (n = 7, 12.5%), Hospital/Clinic Administra-
tors (n = 7, 12.5%), Medical Receptionist (n = 5, 8.9%),
Physicians (n = 3, 5.4%), Physiotherapists (n = 2, 3.6%),
Interpreters (n = 2, 3.6%), Pharmacist (n = 1, 1.8%), Com-
munity Support Worker (n = 1, 1.8%), Medical Lab Tech-
nician (n = 1, 1.8%). Regarding years of experience in their
current profession, 26.8% (n = 15) of the sample reported
more than 20 years of experience, 23.2% (n = 13) reported
between 11 and 20 years of experience, 21.4% (n = 12) re-
ported between 5 and 10 years of experience, and 28.6%
(n = 16) reported less than 5 years of experience.

Participant perceptions on the importance of cross-
>cultural education and communication in health care
settings are presented in Table . The vast majority of
participants clearly believed that cultural considerations
are an important component of best practice health care
and that professionals should be learning about different
cultural groups. Responses varied as to whether one’s
organization should be making improved efforts to meet
the needs of diverse clientele and whether

perceived importance they afforded to having staff from
diverse cultural backgrounds represented at their work-
place. Almost three-fifths (39.3%, n = 22) of the sample
believed staff diversity to be ‘extremely important’, 28.6%
(n = 16) believed staff diversity to be ‘important’ and a
further 12.5% (n = 7), 17.9% (n = 10), 1.8% (n = 1),
believed staff diversity to be moderately, slightly, or not
at all important, respectively. Most participants (91.1%,
n = 51) acknowledged that bi-lingual staff worked at
their organization. Three participants (5.4%) did not pro-
vide an answer to this question.
Participant perceptions of their own cross-cultural

awareness experiences and capabilities are presented in
Table 2. Health care providers acknowledged that they
regularly treat patients of color and that they would
commonly attend to their needs. The majority also
noted that sometimes, and for some, often, it was more
challenging to treat or engage with patients from a
different cultural background to their own. Over 40%
(n = 23) of participants believed that their cultural back-
ground often makes patients from other cultural back-
grounds uncomfortable. Moreover one-fifth (n = 12) of
the sample thought that their cultural background
sometimes made patients of color feel anxious or ner-
vous. Participants were also asked to describe how sat-
isfied they were with their own perceived level of
cross-cultural knowledge. Under 15% (n = 8) reported
that they were ‘extremely satisfied’ with their level of
knowledge, 64.3% (n = 36) were ‘satisfied’ with their
level of knowledge, 16.1% (n = 9) were neither dissatis-
fied or satisfied, and 3.6% (n = 2) were ‘dissatisfied’. No
participant reported ‘extreme dissatisfaction’ with their
level of cross-cultural knowledge.

Thematic analysis
Participants responded to four open-ended questions on
cross-cultural health care delivery. They were asked to re-
flect on ways to improve cross-cultural health care and
the extent to which they perceived their organizations to
be suitably performing in this area. Each question and the
associated response themes are presented below.

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 4 of 11

What factors/skills do you think could improve cross-
cultural health care?
Education/training
Many (n = 31) participants believed that formal cross-
cultural education and training would indeed improve
their organization’s capacity to provide cross-cultural
health care. Most of the suggestions were oriented to
learning about multi-cultural customs.

“Knowledge regarding different cultures and customs”.
(Registered Nurse).

“Educational lecturers and/or classes that can assist
others in learning about diverse cultures”.
(Community Support Worker).

Some felt that this education should be mandatory or
at least regularly provided to staff.

“Regular educational seminars/courses on addressing
different cultures in health care settings”. (Registered
Nurse).

Two participants felt that education and training
should have a particular focus on systemic issues experi-
enced by patients from minority backgrounds.

“Trainings of awareness, bias and privilege”. (Mental
Health Professional).

“Increased education regarding institutional inequality
on the local, state, and national levels”. (Mental
Health Professional).

Interpreter services
The second most common response theme was having
interpreter services available and accessible to all
patients.

“Interpretation services throughout all clinics in the
area”. (Medical Assistant).

Some participants also suggested that that there
should be more bi-lingual professionals.

Table 1 Cross-cultural perceptions of health care professionals (Agree – Disagree)

Health care provider questions Strongly
Agree
% (n)

Agree Neither Agree/
Disagree

Disagree Strongly
Disagree

Do you think health service providers should consider a patient’s cultural
background when treating them?

60.7 (34) 28.6 (16) 3.6 (2) 5.4 (3) 1.8 (1)

Cultural awareness is important in providing best-practice health care. 75.0 (42) 23.2 (13) 1.8 (1) – –

Being able to effectively communicate cross-culturally with patients is important
to best practice health care.

83.9 (47) 16.1 (9) – – –

Do you think it is important to learn about different cultures as part of your practice?

75.0 (42) 21.4 (12) 3.6 (2) – –

Do you think learning about different cultures improves service delivery with
multi-cultural patients?

75.0 (42) 21.4 (12) 3.6 (2) – –

Do you feel that your organization could do a better job at accommodating the needs
of patients from diverse cultures?

8.9 (5) 35.7 (20) 35.7 (20) 16.1 (9) 3.6 (2)

Do you think other cultural models of health are useful to complement conventional
health care approaches?

17.9 (10) 35.7 (20) 35.7 (20) 10.7 (6) –

n = 56

Table 2 Cross-cultural perceptions of health care professionals (Always – Never)

Health care provider questions Always
% (n)

Often Sometimes Rarely Never

Do you feel that you attend to the cultural needs of patients from different cultural .
backgrounds

39.3 (22) 55.4 (31) 5.4 (3) – –

How often do you treat patients of color? 80.04 (45) 16.1 (9) 3.6 (2) – –

Is it more difficult to engage with/treat people from a different culture to your own? – 21.4 (12) 62.5 (35) 14.3 (8) 1.8 (1)

Do you think your cultural background makes some patients from different cultural
backgrounds uncomfortable?

1.8 (1) 39.3 (22) – 41.1 (22) 17.9 (10)

Do you think that some patients of color feel anxious/nervous around you during
treatment?

– 1.8 (1) 19.6 (11) 42.9 (24) 35.7 (20)

n = 56

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 5 of 11

“More providers who are bilingual or who offer
services in languages other than English”. (Mental
Health Professional).

Diversification of staff
One participant expressed that organizations should aim
for cultural diversity when recruiting staff.

“Increased recruitment and hiring of professionals who
are people of color and people of other-than-white
cultural identities and experiences”. (Mental Health
Professional).

What areas of cultural awareness/cultural competence do
you feel that you or your organization perform well?
Access to interpreters
Nineteen participants commented positively on the
provision of interpreters to patients requiring language
assistance. “We provide free interpreters for any clients
who need one” (Hospital/Clinic Administrator). “I love
that we have interpreters here” (Registered Nurse). “We
provide on-site interpreters to translate for the patients
to provide the best quality care”. (Interpreter).

Cultural awareness/sensitivity
Eleven participants believed that their organization was
culturally aware, respectful of cultural customs and
mindful of the specific needs of patients from different
cultural backgrounds. “We are sensitive to everyone’s
needs and go over and beyond to meet those expecta-
tions” (Medical Receptionist). “There is a general cultural
expectation in the organization that we are welcoming
and respectful of all kinds of people” (Mental Health Pro-
fessional). “We try to be accommodating when at all pos-
sible regarding cultural customs” (Hospital/Clinic
Administrator).

Education/training
A number of participants reported that their organization
encouraged a commitment to cross-cultural training. This
was evidenced by cross-cultural training undertaken by
staff. “Having training to make us aware of cultural beliefs”
(Mental Health Professional). “Education about our popu-
lation (catchment area) was provided so providers and
staff had some background and understanding” (Regis-
tered Nurse). “Monthly diversity trainings” (Mental Health
Professional).

Culturally diverse staff members
Five participants believed that their organization benefit-
ted from hiring diverse staff members. This was viewed
as being of great value to the multi-cultural patients

attending their organization. “Our organization does an
excellent job of hiring diverse staff members, for the most
part, especially in our refugee services and support staff
positions” (Mental Health Professional). “Having pro-
viders and staff with different cultural backgrounds has
been useful” (Hospital/Clinic Administrator).

Assessment of needs/rapport development
Some participants underscored the benefits of directly
asking patients about their cultural needs and how best
they could be accommodated. “Asking how we can best
care for their cultural needs at first appointment” (Reg-
istered Nurse). Other participants reported that profes-
sionals at their organization spent some time ‘getting to
know’ patients from different cultural backgrounds in
order to establish a relationship of trust. “We treat a lot
of different cultures and we ask questions sometimes in
order to get to know them…culturally some people need
more time with a doctor than others which can make it
difficult but can also be beneficial in creating a bond”
(Interpreter).

Resources
Four participants commented positively on their organiza-
tion’s provision of cross-cultural educational resources for
both patients – “We have information printed in different
languages for communication of medical information”
(Physician), and staff – “Education and resources related to
all cultures available to staff” (Registered Nurse).

What was the nature of the training?
This open-ended question followed the initial yes/no
question, “Did your health care training include a cul-
tural awareness/competence component”, to which
57.1% (n = 32) participants affirmed that they had re-
ceived some form of cultural training as part of their
professional education. The thematic responses from
these 32 participants are illustrated below.

Format
Ten participants indicated that the training they had
undertaken was online. A smaller number of partici-
pants stated that cross-cultural training was conveyed
through presentations from guest speakers and a fur-
ther two participants claimed that their training was
obtained through clinical experience. The majority of
participants stated that the training was a requirement
for all staff members. “The cultural competence training
is an online course which all staff must complete when
they are first hired, and then annually afterwards”
(Mental Health Professional). “Required for licensing”
(Mental Health Professional).

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 6 of 11

Content
Participants described the content of the training as pri-
marily focused on “cultural norms and differences”
(Nurse Practitioner, Physiotherapist).

How would you improve the cultural competence of your
organization?
Further education/training
Most participants believed that cultural competence train-
ing should be “regular” (Interpreter) and “mandatory”
(Registered Nurse). More specifically, several participants
suggested that training should involve “speakers from dif-
ferent cultural backgrounds” (Hospital/Clinic Administra-
tor). “It would be helpful to have training/discussions with
people from different cultures/ethnic backgrounds who are
willing to meet with health care staff in order to learn
about their cultures/norms and how health care providers
would be most effective in helping those clients” (Nurse
Practitioner). Some participants advocated for regular
organizational-wide meetings for staff to have discussions
about cultural competence. “Talking about the problems
we may encounter based on culture” (Interpreter). Others
felt that any cultural education should only focus on the
cultural groups within the organization’s catchment area.
“Education in regards to the geographical location of the
patients we provide health service to” (Hospital/Clinic Ad-
ministrator). “More detailed training on the specific cul-
tures that are prevalent in the area rather than presenting
it as more global” (Registered Nurse). Only one participant
referred to discriminatory behaviors. “Increase account-
ability for micro-aggressions, institutional inequality, ra-
cism, sexism etc. with the understanding that we all have
these issues and the most important thing is to be aware of
them and work to challenge them within ourselves” (Men-
tal Health Professional).

Staff diversity
Although few participants commented on staff diversity,
disagreement was evident. Three participants believed
that their organization would be more culturally compe-
tent if there was greater cultural diversity among staff
members. “Increase the number of staff members of color
and staff members who are multi-lingual” (Mental
Health Professional). In contrast, two participants stated
that cultural background was not the main priority when
hiring new staff members. “I hire the best person for the
job, not for their cultural background” (Hospital/Clinic
Administrator).

Already competent
Several participants believed that their respective organiza-
tions were already meeting cultural competence principles.
“My clinic provides excellent services and a willingness to
diversify amongst multiple different cultures” (Medical

Assistant). “I feel we provide all cultures with adequate
care” (Physician).

Discussion

Cross-cultural educational initiatives for professionals
are now commonplace across a variety of sectors
including health care. A growing number of studies
have attempted to explore the utility of such initiatives
on workplace behaviors and client outcomes. Yet few
studies have explored how professionals perceive
cross-cultural educational models (e.g., cultural aware-
ness, cultural competence) and the extent to which they
(and their organizations) execute the principles in prac-
tice. This study aimed to address this gap in the literature
by gathering the perspectives of a sample of health care
workers from a Mid-Western state in the United States of
America. The insights gained from the research provide a
useful contribution to the practical literature on cross-cul-
tural professional training. It is important to ascertain the
attitudes and professional experiences of health workers
when working cross-culturally, to assist in developing
functional and effective trainings that are endorsed by the
very professionals that they are designed for.
Like prior research [29, 31, 33, 35], the vast majority

of the sample acknowledged that a consideration of a
client’s culture was of importance. Possessing cultural
knowledge was widely perceived to be ‘best practice’
and necessary for effective cross-cultural communica-
tion and service delivery. Half the sample agreed that
alternative cultural models of health would augment
existing approaches to care. There is a wide body of lit-
erature illustrating culturally bound models of health
and symptom expression styles that are believed to de-
viate from, or partially overlap with western diagnostic
categories [40, 41]. Other participants may have been
unaware of the differing concepts of health and well-
being possessed by particular cultural groups. Some
may also have perceived that certain cultural or ‘folk’
health beliefs clash with conventional methods to the
detriment of their patient, a view documented in prior
research with health professionals [27–29, 42]. None-
theless, approximately 95% of the sample believed that
they always or often attend to the cultural needs of
their patients. This near consensus arose despite over
80% of participants sharing that they often or sometimes
found it more difficult to engage with or treat patients
from cultures different to their own. Additionally, almost
60% acknowledged that their own culture may make some
patients uncomfortable. The sample’s apparent confidence
in their own abilities to work effectively cross-culturally
despite obvious challenges may reflect workplaces com-
mitted to cultural competence initiatives and diversity.
Some participants in this study may also genuinely be
equipped with cultural knowledge and the facility to

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 7 of 11

recognize the limitations of their own knowledge when
working with different cultures as per the cultural humil-
ity model. However, there is also a possible incongruity
between the assumption that one is commonly addressing
cultural needs and the frequent experiencing of challenges
when working with minority patients, which may signal
an over-confidence and/or unawareness. This is often
referred to in the cultural safety literature as a failure to
interrogate one’s own cultural beliefs, and how a vocation
may have built-in entrenched dominant culture norms
and standards that impact cross-cultural clinical encoun-
ters [43]. It was unknown as to how participants discerned
that their cultural background had made their patients un-
comfortable. They may have been acutely aware of how
the dominant culture is viewed through the lens of histor-
ically oppressed minority patients. Alternatively, they may
have received negative feedback or complaints from pa-
tients because of their actions.
In a similar pattern to the above findings, just over half

of the sample (57%) had received some form of cross-cul-
tural training as part of their overall health care education,
yet almost 80% were satisfied with their level cultural
knowledge. The cross-cultural training undertaken, was
largely described as learning about the norms and customs
of other cultural groups (either online or through presen-
tations) which is reminiscent of the cultural awareness
model. Alternative cross-cultural models (cultural humil-
ity, cultural safety) critique the cultural awareness
approach for homogenizing cultural groups, and effect-
ively ‘trading in stereotypes’ [12, 44]. A possible discrep-
ancy between real and perceived cross-cultural knowledge
is conceivable here.
Participants were asked to outline what areas of

cross-cultural care they believed that they (or their
organization) perform well. Answers here, would perhaps
illuminate the apparent confidence many participants pos-
sessed when working cross-culturally despite a significant
minority not having undertaken formal cross-cultural train-
ing. The availability of interpreters was the most common
example of effective cross-cultural care as denoted by par-
ticipants. A lack of interpreter services has been identified
as a common obstacle for cross-cultural service delivery in
prior studies [27, 29, 30, 34]. There was also a belief from
numerous participants, that their respective organizations
were culturally respectful and attentive to the cultural
needs of clients. Several participants stated that their orga-
nizations offer cultural training (some on a regular basis),
employ multi-cultural staff, and provide educational
resources for staff and patients. Staff diversity was empha-
sized as beneficial for multi-cultural patients. Perhaps
this was in regard to their capacity to speak languages
other than English – over 90% of participants indicated
that they work alongside bi-lingual staff. It is possible
from the above testimony that many participants work

in organizations that possess some of the attributes al-
lied with the cultural competence model. Cultural com-
petence is an organizational-wide approach to enhancing
effective cross-cultural communication which includes a
number of interconnecting initiatives (e.g., staff diversity,
staff training, interpreter services, improving staff attitudes
to cross-cultural care) [15]. Such a framework could
potentially engender a safe multi-cultural working envir-
onment despite staff not having undergone direct cultural
training themselves. In contrast, it is perhaps more likely
that participants viewed effective cross-cultural care as es-
sentially a communication matter as opposed to a multi-
faceted institutional framework. Rather than perceiving
cross-cultural care as a broader phenomenon encompass-
ing power imbalances, dominant culture biases and
contrasting worldviews (interpretations seldom articulated
by the sample), most participants may have simply
regarded cross-cultural care from an immediate practical
standpoint whereby interactive/informational barriers
require alleviation; hence the highlighting of interpreter
services, staff bi-linguicism and assessment rapport devel-
opment. Starr and Wallace [34] found that the availability
(or lack of) interpreters and gender-specific providers were
some of the most commonly raised themes in a sample of
American public health nurses when discussing culturally
competent care. Only a small number of participants
referred to diversity hiring strategies directly. A tension be-
tween affirmative action and colour-blind approaches was
evident among some of the responders.
Participants were asked to identify which factors/attri-

butes improve cross-cultural care, and more pointedly, to
offer recommendations to improve the cultural compe-
tence of their own organizations. Two main themes were
canvassed in relation to the first question. Participants
cited the need for ongoing cross-cultural education and
training in the workplace. Responses again appeared to
denote the cultural awareness approach – a focus on cul-
tural norms, customs and health beliefs – which is the
most common form of cross-cultural education univer-
sally, yet the most criticized in the literature. Only two
participants described the need for training to encompass
themes of systemic bias and privilege which reflect the
cultural safety approach. Cross-cultural education was the
leading recommendation among the sample for improving
organizational cultural care. A desire for regular staff
meetings on cross-cultural issues was posited. There was
also a preference among several respondents to focus
attention on the cultural needs of clientele within the or-
ganization’s catchment area, a recommendation proffered
in previous research. No participants referred to any bur-
eaucratic procedures that constrained their ability to work
effectively cross-culturally, a finding noted in several prior
studies [27, 29, 30]. Somewhat surprisingly, several partici-
pants disclosed that their organizations were already

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 8 of 11

culturally competent and as such, did not offer any rec-
ommendations to improve cross-cultural care. Cultural
competence is often described by its proponents as an
evolving process rather than a ‘clear-cut’ actuality [45].
There is some evidence however from the same mid-west-
ern region that multi-cultural patients are generally satis-
fied with their treatment from health care providers.
Shepherd et al. [46] found that racial minorities from a
mid-Western state reported that they had good access to
health care services, were not afraid to visit mainstream
medical services and experienced low levels of racism and
poor treatment.

Implications
Findings from the study should be considered in light of
several limitations. First, caution is advised when general-
izing results beyond Mid-Western health care settings.
Second, the sample, like previous cohorts in the extant
literature, was predominantly female and white/Caucasian.
Prior research has suggested that female health care staff
are more likely to possess patient-centered communica-
tion styles [47, 48] which may be more conducive to
cross-cultural care. Ohana & Mash [38] discovered that
discrepancies between physicians’ perceptions of their
own cultural competence and their patients’ perceptions
are reduced if the physician is female. Moreover, few cul-
tural minorities participated, which may reflect the demo-
graphics of health care professionals in the region, and
more broadly, the state population. Health professionals
from cultural minority backgrounds may be more cogni-
sant of the systemic and/or historical challenges faced by
minority patients and may therefore be inclined to sup-
port broader cross-cultural educational approaches that
address explicit/implicit discrimination, power structures
and historical injustices [11, 12, 49–51]. Furthermore, the
exact response rate in the study was unknown – health
systems were unable to disclose how many study invita-
tions were distributed across their respective networks.
Third, no direct patient data was collected to corroborate
the cohort’s generally optimistic assertions that they and
their organizations provide care that is meeting the needs
of their multi-cultural clientele. Prior research has found a
weak relationship between medical professionals’ percep-
tions of their own cultural competence and their patient’s
perceptions of their cultural competence [38]. Last, the
terminology on the questionnaire (i.e., ‘diverse cultures’,
‘cultural background’ etc.) was left open to interpretation.
It is possible that these broad descriptors may have influ-
enced responses.
The health workers in our sample appeared to view

cross-cultural education from a ‘cultural awareness’ per-
spective. Effective cross-cultural care was often defined
in terms of cultural knowledge (e.g., norms and customs)
and facilitating communication (the use of interpreters).

A dearth of respondents referred to broader, systemic
components of cross-cultural care such as a recognition of
racism (explicit and implicit), power imbalances,
entrenched majority culture biases and the need for
self-reflexivity (awareness of one’s own prejudices). Al-
though a number of participants supported workplace
diversity, this appeared to be in the course of improved
communication with minority patients rather than advo-
cating for diversity per se, or for cultural diversity at the
executive, or ‘decision-making’ levels. As speculated earl-
ier, cross-cultural education was perhaps viewed as an im-
mediately applied or ‘hands on’ phenomenon rather than
a holistic, structural approach. Prior research has found
that clinicians have a preference for ‘active behavioural
simulations’ as a cross-cultural training method [52].
While most models of cross-cultural education encom-

pass learning about the ‘other’ to some degree, simply
absorbing the health beliefs, idiosyncrasies and traditions
of particular cultural groups is somewhat superficial and
as such, unlikely to advance cross-cultural communication
[9, 44]. Advocates of later cross-cultural models (cultural
competence, cultural humility, cultural safety) would in-
deed stress the need to augment the cultural awareness
styled training undertaken and demanded by participants
in the study. The compelled awareness of one’s own biases
and their institutions’ potential to marginalize patients
from non-mainstream cultural groups would be likely
additions to teachings. In fact proponents of later models
may argue that the over-confidence displayed by some
participants in our study could be a reflection of their in-
ability to recognize their own limitations and prejudices –
and as such, underscoring the need for participants to
undergo broader, holistic training. Intuitively, there is
merit to multi-faceted models that incorporate socio-his-
torical and political factors. At the same time, robust evi-
dence for cross-cultural educational models, regardless of
their content, is meagre [9, 44, 53–55]. Interpreter and
bi-lingual health worker services possess some empirical
support [56–58] though further research is warranted
[17]. Thus, a conundrum unfolds whereby participants
appear to be content with a limited model (in cultural
awareness) yet the more expansive, recommended alterna-
tives (cultural safety etc.) have yet to demonstrate rigorous
utility beyond anecdotal evidence. The potential conse-
quences of politically charged ‘blame and shame’ ap-
proaches (which are more likely to occur within cultural
safety-styled trainings) have also been documented [8, 19].
Further research is required to rigorously test the validity
of the various models and their specific assumptions. It is
also important to ensure that cross-cultural models are
relevant to specific workplaces, flexible enough to address
immediate challenges identified by frontline staff, and seek
realistic, practical goals that are clear, quantifiable and
have evidence for their utility.

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 9 of 11

Conclusions
This study finds that health care professionals from a
Mid-Western region of the USA value the possession
and pursuit of cultural knowledge when working with
multi-cultural populations. Practical cross-cultural
approaches endorsed by staff (e.g., interpreter services)
appeared to be enthusiastically supported and were
thought to be associated with effectual cross-cultural
care. However, the principles of systemic cross-cultural
approaches (e.g., cultural competence, cultural safety)
were scarcely acknowledged by study participants. The
findings indicate a need for interventions that acknow-
ledge the value of cultural awareness-based approaches,
while also exploring the utility of more comprehensive
cultural competence and safety approaches.

Abbreviations

CANZUS: Canada, Australia, New Zealand, United States; USA: United States
of America

Acknowledgements

Not applicable.

Funding

The research was partially funded by a Swinburne University of Technology
2016 Research Development Grant.

Availability of data and materials

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

Authors’ contributions

SS designed the study, performed the analyses and wrote the manuscript.
CWE co-designed the study and assisted with manuscript preparation. DN
performed the qualitative analysis and reviewed the manuscript. YP and DS
assisted in conceptualising the study and made substantial revisions to the
manuscript. All authors have read and approved the submitted manuscript.

Ethics approval and consent to participate

Informed consent was obtained from participants via the following process.
After receiving support from their respective internal review boards, health
care organizations distributed an online link to the study survey to clinical
and professional staff via email. The link was accompanied with a short
passage enquiring if staff were interested in participating in an anonymous
online research study survey on cross-cultural health care service delivery
experiences.
Individuals who opted to click on the study link were presented with a
digital consent form outlining the requirements and their involvement in the
study.
Ethical permission for this research was obtained by a mid-Western university
Institutional Review Board (IRB Number: 20160716266 EX).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

Author details

1Centre for Forensic Behavioural Science, Swinburne University of
Technology, 1/582 Heidelberg Rd, Alphington, Melbourne, Victoria, Australia.
2Department of Psychology, University of Nebraska-Lincoln, Burnett Hall,

Lincoln, NE, USA. 3School of Social & Political Sciences, The University of
Melbourne, Gratton Street, Melbourne, Victoria, Australia. 4School of
Psychological Sciences, Swinburne University of Technology, John St,
Hawthorn, Melbourne, Victoria, Australia. 5Alfred Deakin Research Institute for
Citizenship and Globalisation, Deakin University, Burwood, Melbourne,
Victoria, Australia.

Received: 18 October 2018 Accepted: 18 February 2019

References

1. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic

differences in patient perceptions of bias and cultural competence in health
care. J Gen Intern Med. 2004;19:101–10.

2. Smedley BD, Stith AY, Unequal Treatment NAR. Confronting racial and
ethnic disparities in health care. Washinton, D.C: the: National Academies
Press; 2002.

3. U.S. Department of Health and Human Services. 2016 National Healthcare
Quality and Disparities Report. (Publication No. 17–0001). Maryland, MD:
Agency for Healthcare Research and Quality; 2017.

4. Commonwealth of Australia. Cultural Competency in health: A guide for
policy, partnerships and participation. Canberra, ACT: Commonwealth of
Australia, National Health and Medical Research Council; 2006.

5. Government of Canada. Clinical practice guidelines for nurses in primary
care. 2015. https://www.canada.ca/en/indigenous-services-canada/services/
first-nations-inuit-health/health-care-services/nursing/clinical-practice-
guidelines-nurses-primary-care/introduction-clinical-practice-guidelines.html.
Accessed Feb 10 2018.

6. Nursing Council of New Zealand. Guidelines for Cultural Safety, the Treaty
of Waitangi and Maori Health in Nursing Education and Practice.
Wellington, NZ: Nursing Council of New Zealand; 2012.

7. Office of Minority Health. National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care. Rockville, MD: Office
of Minority Health. U.S: Department of health and human services; 2018.

8. Dobbin F, Kalev A. Why diversity programs fail. Harv Bus Rev. 2016; https://
hbr.org/2016/07/why-diversity-programs-fail. Accessed 5 April 2018.

9. Shepherd SM. Cultural awareness workshops should be abandoned (paper
submitted for review); 2018.

10. Paniagua FA. Multicultural aspects of counseling series, Vol. 4. Assessing and
treating culturally diverse clients: A practical guide. Thousand oaks, CA, US:
sage publications, Inc; 1994.

11. Papps E, Ramsden I. Cultural safety in nursing: the New Zealand experience.
Int J Qual Health Care. 1996;8:491–7.

12. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a
critical distinction in defining physician training outcomes in multicultural
education. J Health Care Poor Underserved. 1998;9:117–25.

13. Ng KY, Van Dyne L, Ang S. Cultural intelligence: a review, reflections, and
recommendations for future research. In: Ryan AM, Leong FTL, Oswald FL,
editors. Conducting multinational research: applying organizational
psychology in the workplace. Washington, DC: American Psychological
Association; 2012. p. 29–58.

14. Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a culturally
competent system of care: a monograph on effective Services for
Minority Children who are Severely Emotionally Disturbed. Washington,
DC: CASSP Technical Assistance Center, Georgetown University Child
Development Center; 1989.

15. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural
competence: a practical framework for addressing racial/ethnic disparities in
health and health care. Public Health Rep. 2003;118:293–302.

16. Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, et al. Cultural
competence: a systematic review of health care provider educational
interventions. Med Care. 2005;43:356–73.

17. Jongen C, McCalman J, Bainbridge R. Health workforce cultural competency
interventions: a systematic scoping review. BMC Health Serv Res. 2018.
https://doi.org/10.1186/s12913-018-3001-5.

18. Truong M, Paradies Y, Priest N. Interventions to improve cultural
competency in healthcare: a systematic review of reviews. BMC Health Serv
Res. 2014;14:99.

19. Legault L, Gutsell JN, Inzlicht M. Ironic effects of anti-prejudice messages:
how motivational intervention reduces (but also increases) prejudice.
Psychol Sci. 2011;22:1472–7.

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 10 of 11

https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/introduction-clinical-practice-guidelines.html

https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/introduction-clinical-practice-guidelines.html

https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/introduction-clinical-practice-guidelines.html

https://hbr.org/2016/07/why-diversity-programs-fail

https://hbr.org/2016/07/why-diversity-programs-fail

https://doi.org/10.1186/s12913-018-3001-5

20. Blasco M, Egholm Feldt L, Jakobsen M. If only cultural chameleons could fly
too: a critical discussion of the concept of cultural intelligence. Int J Cross-
cult Manag. 2012;12:229–45.

21. Carey M. The limits of cultural competence: an indigenous studies
perspective. Higher Education Research & Development. 2015;34:828–40.

22. Gregg J, Saha S. Losing culture on the way to competence: the use and
misuse of culture in medical education. Acad Med. 2006;81:542–7.

23. Shepherd S. Cultural awareness training for health professionals may have
unintended consequences. The British Medical Journal Opinion http://blogs.
bmj.com/bmj/2018/01/22/stephane-m-shepherd-cultural-awareness-
training-for-health-professionals-can-have-unintended-consequences/.
Accessed March 15 2018.

24. Causadias JM, Vitriol JA, Atkin AL. Do we overemphasize the role of culture
in the behavior of racial/ethnic minorities? Evidence of a cultural
(mis)attribution bias in American psychology. The American Psychologist.
2018;73:243–55.

25. Downing R, Kowal E. A postcolonial analysis of indigenous cultural
awareness training for health workers. Health Sociol Rev. 2011;20:5–15.

26. Stuart RB. Multiculturalism: Questions, not answers. Professional Psychology
Research and Practice. 2004;35:3–9.

27. Hughson J, Marshall F, Daly JO, Woodward-Kron R, Hajek J, Story D. Health
professionals’ views on health literacy issues for culturally and linguistically
diverse women in maternity care: barriers, enablers and the need for an
integrated approach. Aust Health Rev. 2018;42:10–20.

28. Truong M, Fuscaldo G. Optometrists’ perspectives on cross-cultural
encounters in clinical practice: a pilot study. Clin Exp Optom. 2012;95:37–42.

29. Truong M, Gibbs L, Paradies Y, Priest N. “Just treat everybody with respect”:
health service providers’ perspectives on the role of cultural competence in
community health service provision. The ABNF Journal. 2017;28:34–43.

30. Truong M, Gibbs L, Paradies Y, Priest N, Tadic M. Cultural competence in the
community health context: ‘we don’t have to reinvent the wheel. Australian
Journal of Primary Health. 2017;23:342–7.

31. Leishman J. Perspectives of cultural competence in health care. Nurs Stand.
2004;19:33–8.

32. Markey K, Tilki M, Taylor G. Understanding nurses’ concerns when caring for
patients from diverse cultural and ethnic backgrounds. J Clin Nurs. 2017.
https://doi.org/10.1111/jocn.13926.

33. Almutairi AF, Adlan AA, Nasim M. Perceptions of the critical cultural
competence of registered nurses in Canada. BMC Nurs. 2017. https://doi.
org/10.1186/s12912-017-0242-2.

34. Starr S, Wallace DC. Self-reported cultural competence of public health
nurses in a southeastern U.S. public health department. Public Health Nurs.
2009;26:48–57.

35. Mobula LM, Okoye MT, Boulware LE, Carson KA, Marsteller JA, Cooper LA.
Cultural competence and perceptions of community health workers’
effectiveness for reducing health care disparities. J Prim Care Community
Health. 2015;6:10–5.

36. Olt H. Healthcare providers’ perceptions of diversity and cultural
competence. Stockholm, Sweden: Karolinska Institutet; 2013.

37. Casillas A, Paroz S, Green AR, Wolff H, Weber O, Faucherre F, et al. Cultural
competency of health-care providers in a Swiss University hospital: self-
assessed cross-cultural skillfulness in a cross-sectional study. BMC Med Educ.
2014;14:19.

38. Ohana S, Mash R. Physician and patient perceptions of cultural competency
and medical compliance. Health Educ Res. 2015;30:923–34.

39. Fossey E, Harvey C, McDermott F, Davidson L. Understanding and
evaluating qualitative research. Aust N Z J Psychiatry. 2002;36:717–32.

40. Kirmayer LJ, Sartorius N. Cultural models and somatic syndromes.
Psychosom Med. 2007;69:832–40.

41. Lewis-Fernández R, Aggarwal NK, Bäärnhielm S, Rohlof H, Kirmayer LJ, Weiss
MG, et al. Culture and psychiatric evaluation: operationalizing cultural
formulation for DSM–5. Psychiatry. 2014;77:130–54.

42. Aggarwal NK, Cedeno K, Guarnaccia P, Kleinman L-FR. The meanings of
cultural competence in mental health: an explanatory focus group study
with patients, clinicians, and administrators. Springerplus. 2016;5:384.

43. Richardson S, Williams T. Why is cultural safety essential in health care? Med
Law. 2007;26:699–707.

44. Downing R, Kowal E, Paradies Y. Indigenous cultural training for health
workers in Australia. Int J Qual Health Care. 2011;23:247–57.

45. Goode TD, Jones W, Dunne C, Bronheim S. And the journey continues…
Achieving cultural and linguistic competence in systems serving children

and youth with special health care needs and their families. Washington,
DC: National Center for cultural competence, Georgetown University Center
for child and. Hum Dev. 2007.

46. Shepherd S, Willis-Esqueda C, Paradies Y, Sivasubramaniam D, Sherwood J,
Brockie T. Racial and cultural minority experiences and perceptions of
health care provision in a mid-western region. International Journal of
Equity in Health. 2018;17:33.

47. Jefferson L, Bloor K, Birks Y, Hewitt C, Bland M. Effect of physicians’ gender
on communication and consultation length: a systematic review and meta-
analysis. Journal of Health Services Research & Policy. 2013;18:242–8.

48. Rota DL, Hall JA, Aoki Y. Physician gender effects in medical
communication: a meta-analytic review. JAMA. 2002;288:756–64.

49. Henry BR, Houston S, Mooney GH. Institutional racism in Australian
healthcare: a plea for decency. Med J Aust. 2004;180:517–20.

50. Repo H, Vahlberg T, Salminen L, Papadopoulos I, Leino-Kilpi H. The cultural
competence of graduating nursing students. J Transcult Nurs. 2017;28:98–
107.

51. Sherwood J, Edwards T. Decolonisation: a critical step for improving
aboriginal health. Contemp Nurse. 2006;22:178–90.

52. Aggarwal NK. How do clinicians prefer cultural competence training?
Findings from the DSM-5 cultural formulation interview field trial. Acad
Psychiatry. 2016;40:584–91.

53. Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence education for
health professionals. Cochrane Database Syst Rev. 2014. https://doi.org/10.
1002/14651858.CD009405.pub2.

54. Lie DA, Lee-Rey E, Gomez A, Bereknyei S, Braddock CH III. Does cultural
competency training of health professionals improve patient outcomes? A
systematic review and proposed algorithm for future research. J Gen Intern
Med. 2011;26:317–25.

55. Shepherd SM. Cultural awareness workshops: limitations and practical
consequences. BMC Medical Education. 2019;19:14.

56. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health
disparities? A review and conceptual model. Med Care Res Rev. 2000;57:
181–217.

57. Fernandez A, Schillinger D, Grumbach K, Rosenthal A, Stewart AL, Wang F,
et al. Physician language ability and cultural competence. J Gen Intern Med.
2004;19:167–74.

58. Henderson S, Kendall E, See L. The effectiveness of culturally appropriate
interventions to manage or prevent chronic disease in culturally and
linguistically diverse communities: a systematic literature review. Health and
Social Care in the Community. 2011;19:225–49.

Shepherd et al. BMC Health Services Research (2019) 19:135 Page 11 of 11

Stephane M Shepherd: Cultural awareness training for health professionals can have unintended consequences

Stephane M Shepherd: Cultural awareness training for health professionals can have unintended consequences

Stephane M Shepherd: Cultural awareness training for health professionals can have unintended consequences

https://doi.org/10.1111/jocn.13926

https://doi.org/10.1186/s12912-017-0242-2

https://doi.org/10.1186/s12912-017-0242-2

https://doi.org/10.1002/14651858.CD009405.pub2.

https://doi.org/10.1002/14651858.CD009405.pub2.

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Abstract
Background
Methods
Results
Conclusions
Background
Methods
Participants
Materials
Procedure
Data analyses
Results
Thematic analysis
What factors/skills do you think could improve cross-cultural health care?
Education/training
Interpreter services
Diversification of staff
What areas of cultural awareness/cultural competence do you feel that you or your organization perform well?
Access to interpreters
Cultural awareness/sensitivity
Education/training
Culturally diverse staff members
Assessment of needs/rapport development
Resources
What was the nature of the training?
Format
Content
How would you improve the cultural competence of your organization?
Further education/training
Staff diversity
Already competent

Discussion
Implications
Conclusions
Abbreviations
Acknowledgements
Funding
Availability of data and materials
Authors’ contributions
Ethics approval and consent to participate
Consent for publication
Competing interests
Publisher’s Note
Author details
References