Cultural competency wheel: advancing a model to characterize the domains and attributes of cultural competency from published nursing literature via integrative review

Abstract

Background

International migration and globalization have dramatically transformed healthcare delivery over recent decades, intensifying the need for cultural competency among healthcare providers. While numerous studies explore cultural competency in nursing, a comprehensive framework synthesizing its core domains and attributes from existing literature remains absent. This study analyzes nursing literature to develop an integrated model capturing the essential domains and attributes of cultural competency.

Methods

An integrative review of empirical and theoretical literature was conducted using five major databases: Embase, Scopus, Web of Science, CINAHL, and PubMed. From an initial pool of 493 papers identified through cultural competency and nursing-related search terms, 58 articles were selected for final analysis following screening by three independent reviewers using Covidence. Data analysis involved descriptive assessment, quality evaluation, and thematic coding using MaxQDA Analytics Pro 2020 software.

Results

Analysis yielded a novel Cultural Competency Wheel Model comprising five interconnected domains: Culture, Team, Patient, Action, and Self. Each domain integrates specific attributes across three dimensions: cultural knowledge (Core, Cadre, Client, Change, Character), competence/skills (Comprehension, Connection, Conversation, Cultivation, Contemplation), and caring values (Critical, Collegial, Congenial, Centrifugal, Committal).

Conclusion

Study findings reveal cultural competency as a complex, multidimensional construct requiring healthcare providers to master three essential components: (1) comprehensive knowledge of self, team dynamics, and patient backgrounds; (2) practical skills spanning healthcare delivery, team collaboration, and patient support; and (3) professional values encompassing personal, interpersonal, and broader institutional contexts. This model provides a structured framework for developing cultural competency initiatives in healthcare education, research, and practice.

Clinical trial number

Not applicable.

Introduction

Cultural competency in healthcare has become a valuable concept in nursing and the caring sciences, as the number of international migrants has continued to increase in recent decades. Approximately 3.6% of the global population (281 million) are international migrants [1] despite the recent mobility and travel limitations during the coronavirus pandemic. Almost three out of four migrants are between 20 and 64 years old, and nearly half (48%) are women [2]. While most international migrants are located in Europe and Asia, the United States remains the top destination of choice, and India remains the top country of origin (Trivedi et al., 2024). This steadily evolving global phenomenon has a significant impact on public health, as migration is recognized as a social determinant of health [3, 4] and a contributor to health inequalities [5, 6]. Literature often shows that migration often results in poorer health outcomes [7], unequal access to health services [8], and a higher incidence of mortality [9] and morbidity due to chronic conditions [10], among other negative consequences. Also, healthcare providers (HCPs) usually encounter challenges in managing care for migrants due to language and cultural barriers [11], contradicting norms, and ethical beliefs [12].

As the number of migrants continues to increase, there is an urgent need to develop a culturally conscious and diverse human resource. The importance of a healthcare workforce that mirrors the diversity of its communities in terms of race, gender, immigration status, physical health, and socioeconomic level cannot be undermined. When healthcare workers are diverse and trained, the best possible care is provided to the multicultural and heterogeneous patient population [13]. Other notable advantages of organizational diversity are better quality of patient care, strengthened provider-patient relationships, improved financial outcomes, and optimal team function [14]. Also, this setup can enhance cultural competence and foster a deeper understanding of the unique needs of health consumers coming from diverse demographic and geographic backgrounds [13].

Cultural competence is essential as it guarantees that healthcare services are patient-centric, respectful, and responsive to individual client needs. Culturally competent care becomes even more critical in increasingly multicultural healthcare [15] and requires healthcare providers to understand the global health contexts that contribute to health disparities [16], including awareness of socioeconomic factors, access to healthcare [17], and behavioral and cultural factors [18]. It can minimize care disparities and foster overall well-being, benefiting not only migrants but also other vulnerable groups. Vulnerable populations can include but are not limited to ethnic minorities, refugees, immigrants, LGBTQ+ individuals, low-income communities, and those with limited access to resources [19, 20]. Culturally competent healthcare providers possess the right attributes in various domains (knowledge, skills, and values) necessary to tailor-fit healthcare services to meet the unique needs of individuals facing social, economic, or health disparities [21].

Health professional training institutions and regulatory agencies are progressively incorporating cultural competency and cultural safety into accreditation standards, as well as into pre-service and in-service training programs [22]. In one study, over 40% (n = 23) of healthcare providers reported that their cultural background often made patients from other cultures uncomfortable, and one-fifth (n = 12) believed it sometimes caused patients of colour to feel anxious. Just over half (57%) had received cross-cultural training, which primarily focused on learning the norms and customs of other groups. Fewer than 15% (n = 8) were ‘extremely satisfied’ with their knowledge, 64.3% (n = 36) were ‘satisfied,’ 16.1% (n = 9) were neutral, and 3.6% (n = 2) were dissatisfied. Most participants recommended regular, mandatory cultural competence training, with cross-cultural education identified as the leading strategy for improving organizational cultural care [23]. Although cultural competency and safety are increasingly emphasized in training and accreditation, many healthcare providers report gaps in knowledge and confidence, underscoring the importance of assessing cultural competence [24].

Assessing the skills of culturally competent healthcare providers is essential for ensuring that professionals can effectively integrate culturally safe care into their practice. Various frameworks and tools are available to assess healthcare providers’ cultural competency, such as the Campinha-Bacote model of cultural competence in healthcare delivery or the Purnell Model for Cultural Competence are helpful. On the one hand, the Campinha-Bacote model advances five constructs, namely cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. On the other hand, Purnell’s model for cultural competence urges healthcare providers to approach patient care holistically and consider the various aspects of patients’ cultures [25]. In terms of skills, tools such as the Communication Assessment Tool (CAT) or the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health care can be used in both clinical and community settings. The CAT evaluates aspects such as language use, use of interpreters, and non-verbal communication skills [26]. In contrast, CLAS can be used to assess healthcare providers’ cultural competence skills [27]. Ultimately, comprehensive tools such as the Cultural Self-Efficacy Scale (CSES) assess both cultural competence knowledge and skill [28]. Evaluating the values of culturally competent healthcare providers involves the assessment of attitudes and beliefs, having deep respect for the diversity of cultures, acknowledging one’s personal biases, and being open to learning from others [29, 30]. Although multiple instruments exist to evaluate cultural competence from the knowledge, skills, and values/attitude dimensions, there is no universally accepted framework that summarizes these attributes in a single model [31], more so for nurses and healthcare providers caring for vulnerable clients. This study aspires to conduct an integrative review of literature from the aforementioned concepts, describe the landscape of the topic, and develop an overarching model to describe the domains and attributes of cultural competency from nursing literature.

Research methods

An integrative review was carried out to extract the domains and attributes of cultural competency among healthcare providers from theoretical and empirical papers. A standard approach was adopted [32] consisting of the following procedures: (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis, and (e) presentation. A search strategy was developed using Embase, Scopus, Web of Science, CINAHL, and PubMed research databases using keywords: nurse(s)(ing), cultur(e)(al) competence/humility, diversity, international, and acculturation. A total of 493 articles were uploaded to an online review data management, Covidence. This approach automatically removed 31 duplicates, resulting in 462 initial title and abstract screening studies. Of this number, 362 papers are considered irrelevant, producing 80 studies for second-level full-text review. Finally, 58 studies are considered for final analysis after the exclusion of 22 studies due to mismatch with the review objectives, non-inclusion of the vulnerable population group, non-availability of full-text articles, and categorized as non-English manuscripts. The final articles were evaluated using a 6-scale Authority, Accuracy, Coverage, Objectivity, Date, Significance or AACODS checklist [33] and 0–100% scoring Mixed Methods Appraisal Tool or MMAT [34] for theoretical and empirical papers, respectively. The PRISMA flow diagram is shown in Fig. 1. Articles were categorized based on article type, healthcare provider involved, region of origin, and area of practice. The purpose of the articles was also summarized using a spreadsheet application. The manuscripts were read, highlighted, and coded individually by three independent authors based on emergent concepts and themes using MaxQDA Analytics Pro 2020 software (version release 22.8). The codes were compared, combined, and summarized using tables and figures. The study protocol was not registered.

Fig. 1.

Prisma flow diagram

Results

Article bibliometrics

Table 1 displays the bibliometric characteristics of the 58 extracted articles. Most articles are empirical (n = 46; 79.31%), nurse-centered (n = 43; 74.14%), and are focused on the clinical settings (n = 34; 58.62%). Most articles came from the American region (n = 30; 51.72%), with documents coming from Europe (n = 15; 25.86%), Western Pacific (n = 9; 15.52%), East Mediterranean (n = 3; 5.17%) and African regions (n = 1; 1.72%).

Table 1.

Article bibliometrics [n = 58]

Characteristics	f	%
Article type
Theoretical	12	20.69
Empirical	46	79.31
Total	58	100
Healthcare Provider(s)
Nurse	43	74.14
Nurse + others	15	25.86
Total	58	100
Region
American	30	51.72
European	15	25.86
Southeast Asia	0	0.00
Western Pacific	9	15.52
East Mediterranean	3	5.17
Africa	1	1.72
Total	58	100
Area
Clinical	34	58.62
Education	2	3.45
Community health	15	25.86
Research	1	1.72
Multiple	6	10.34
Total	58	100

Article descriptions and critical appraisal

Table 2 showcases the descriptions and critical appraisals of the articles. The outcome reveals that the 46 empirical studies, ranging from 60% to 100%, demonstrated robust methodological integrity, as evidenced by.an average MMAT score of 91%, In contrast, the 12 theoretical articles, ranging from 3 to 6, yielded an acceptable average AACODS score of 5. Assessment of the article’s purposes reveals a substantial focus on the relationship between cultural competence and patient outcomes, evaluation of training and educational programs, and identification of challenges and barriers that hinder healthcare delivery practices.

Table 2.

Article descriptions and critical appraisal

No.	Author(s)	Title	Type	Purpose	Critical Appraisala,b
1	Wyckoff [35]	LGBT Cultural Competence of Acute Care Nurses	Research	Examine how LGBT cultural competence training affects the nurse cultural competence of LGBT patients.	80%
2	Adams [36]	Indigenous cultural competence in nursing and midwifery practice	Theoretical	Focus on practical steps that nurses and midwives can undertake to improve their practice when working with Indigenous Australian clients	6
3	Jung-Wong Ahn [37]	Structural Equation Modeling of Cultural Competence of Nurses Caring for Foreign Patients	Research	Construct and test a hypothetical model including factors related to the cultural competence of nurses caring for foreign patients	100%
4	Alharbi et al. [38]	Cultural Competency Among Pediatric Registered Nurses in Saudi Arabia: A Cross-Sectional Design	Research	Assess the relationship between cultural competency and demographic factors among pediatric RNs in SA.	100%
5	Amiri et al. [39]	Challenges of Transcultural Caring Among Health Workers in Mashhad-Iran: A Qualitative Study	Research	Explore the healthcare staff’s experience caring for Immigrants in Mashhad- Iran.	100%
6	Barnard [40]	Providing culturally sensitive psychiatric-mental health nursing care to Native Americans	Theoretical	Describe the lessons non-Native American practitioners learned while practicing on the reservation and suggest ways others can best serve the population.	6
7	Bauce et al. [41]	Cultural Competence and Psychological Empowerment Among Acute Care Nurses	Research	Describe the relationship between cultural competence and psychological empowerment among acute care nurses in one urban hospital in Southern Connecticut.	100%
8	Brown et al. [42]	Cultural Competence of Student Registered Nurse Anesthetists in Illinois	Research	Examine the level of perceived cultural competence of student registered nurse anesthetists (SRNAs) in Illinois and make educational recommendations.	80%
9	Casillas et al. [43]	Is the Front Line Prepared for the Changing Faces of Patients? Predictors of Cross-Cultural Preparedness Among Clinical Nurses and Resident Physicians in Lausanne, Switzerland	Research	Evaluate healthcare providers’ cross-cultural preparedness for commonly encountered vulnerable patient profiles.	80%
10	Castro & Ruiz [44]	The effects of nurse practitioner cultural competence on Latina patient satisfaction	Research	Explore the relationship between the degree of cultural competence in nurse practitioners (NPs) and patient satisfaction measures among Latinas.	80%
11	Chae et al. [45]	Experience of migrant care and needs for cultural competence training among public health workers in Korea	Research	Explore the experiences of public health workers (PHWs) providing health care for migrants living in Korea and clarify the need for cultural competence training.	100%
12	Chae & Park [46]	Organisational cultural competence needed to care for foreign patients: A focus on nursing management	Research	Explore the organizational level of the cultural competence needed to care for foreign patients from the Korean clinical registered nurses’ perspective.	100%
13	Chae et.al. [47]	A multilevel investigation of cultural competence among South Korean clinical nurses	Research	Investigate individual and organizational characteristics associated with South Korean clinical nurses’ cultural competence.	100%
14	Chen & Huang [48]	Exploring the growth trajectory of cultural competence in Taiwanese paediatric nurses	Research	Explore the evolution of cultural competence in Taiwanese pediatric nurses.	100%
15	Cicolini et al. [49]	Cultural Competence Among Italian Nurses: A Multicentric Survey	Research	Assess Italian nurses’ cultural competence, as they are increasingly called upon to care for people of foreign origins.	100%
16	Davis & Smith [50]	Infusing cultural competence training into the curriculum: describing the development of culturally sensitive training on dementia communication	Theoretical	Report on an interdisciplinary project to infuse cultural competence training in dementia communication care into nursing and nurse assistant training.	5
17	de Beer & Chips [51]	A survey of cultural competence of critical care nurses in KwaZulu-Natal	Research	Describe the self-rated levels of cultural competence of nurses working in critical care settings in a selected public hospital in SA.	80%
18	De & Richardson [52]	Using cultural safety to enhance nursing care for children and young people	Theoretical	Define culture and explain the importance of considering people’s cultural values, beliefs, and practices when providing care.	6
19	Dobrowoska, et al. [53]	European intensive care nurses’ cultural competency: An international cross-sectional survey	Research	Determine the level of cultural competence of European critical care nurses.	100%
20	Gaston [54]	African-Americans’ perceptions of health care provider cultural competence that promote HIV medical self-care and antiretroviral medication adherence	Research	Examine the relationship between African-American patients’ perceptions of the cultural competence of their HIV healthcare providers and the adherence of these patients to medical self-care and antiretroviral therapy (ART).	80%
21	Gaya-Sancho et al. [55]	Perception and Experience of Transcultural Care of Stakeholders and Health Service Users with a Migrant Background: A Qualitative Study	Research	Explore the perspectives of key stakeholders and healthcare users with an MM background on transcultural care in four European countries.	100%
22	Gergely [56]	Cultural Competency Matters Calling for a Deeper Understanding of Healthcare Disparities Among Nurse Leader	Research	Explore the knowledge, motivation, and organizational influences that affect nurse leaders in leading their teams in providing culturally competent care to patients of all ethnic and racial backgrounds.	80%
23	Gobeyn [57]	Caring for undocumented immigrants	Theoretical	Employ the three-step process outlined where healthcare professionals can systematically address and overcome many of these challenges.	3
24	Grady [58]	Enhancing Cultural Competency in Home Care Nurses Caring for Hispanic/Latino Patients	Research	Utilize Campinha-Bacote’s Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals—Revised (IAPCC-R, 2003), a single-session pilot educational program to enhance culturally responsive home care nursing	80%
25	Hassan et al. [59]	A qualitative study of healthcare professionals’ experiences of providing maternity care for Muslim women in the UK	Research	Investigate HPCs lived experiences of providing maternity care for Muslim women	100%
26	Heitzler [60]	Cultural Competence of Obstetric and Neonatal Nurses	Research	Measure the cultural competence level of obstetric and neonatal nurses, explore relationships among cultural competence and selected sociodemographic variables, and identify factors related to cultural competence.	100%
27	Hernandez et al. [61]	Building Culturally Competent Compassion in Nurses Caring for Vulnerable Populations	Research	Understand the process of building culturally competent compassion in nurses who care for vulnerable populations.	100%
28	Hietapakka et al. [62]	Testing the psychometric properties of the Finnish version of the cross-cultural competence instrument of healthcare professionals (CCCHP)	Research	Test the validity of the Finnish version of Bernhard et al.’s Cross-Cultural Competence instrument of Healthcare Professionals (CCCHP).	100%
29	Jones [63]	Hospital Based Nurse Cultural Competence Program Evaluation: A Mixed Methodological Study	Research	Measure the extent to which nurses exhibit cultural competence in an acute care hospital setting.	100%
30	Kaur et al. [64]	Evaluation of an online communication skills training programme for oncology nurses working with patients from minority backgrounds.	Research	Develop and assess the feasibility of an online communication skills training intervention to increase cultural competence amongst oncology nurses working with individuals from minority backgrounds.	80%
31	Keiswetter and Brotemarkle [65]	Culturally Competent Care for HIV-Infected Transgender Persons in the Inpatient Hospital Setting: The Role of the Clinical Nurse Leader	Theoretical	Explain the role of the clinical nurse leader in providing culturally competent care for HIV patients.	5
32	Kim-Godwin and McMurry [66]	Perspectives of Nurse Practitioners on Health Care Needs Among Latino Children and Families in the Rural Southeastern United States: A Pilot Study	Research	Explore perspectives of nurse practitioners on health care needs among Latino children and families in the rural Southeastern United States	100%
33	Lutz et al. [67]	Assessment of Emergency Department Health Care Providers Readiness for Managing Intimate Partner Violence and Correlation with Perceived Cultural Competence.	Research	Examine the relationships between readiness for managing intimate partner violence and cultural competence among emergency department health care providers.	80%
34	Majda et al. [68]	Cultural Competence and Cultural Intelligence of Healthcare Professionals Providing Emergency Medical Services	Research	Measure and assess the cultural competencies and cultural intelligence of medical professionals working in hospital emergency departments (HEDs) and hospital emergency rooms	100%
35	Margolies and Brown [69]	Increasing cultural competence with LGBTQ patients	Theoretical	Provide insight on LGBTQ people, their health risks and disparities, and how nurses can prepare to care for the LGBTQ population.	5
36	Martin and Barkley [70]	Improving cultural competence in end-of-life pain management	Theoretical	Discuss cultural factors that may influence end-of-life pain management, describe methods for incorporating cultural sensitivity into pain assessment.	5
37	Matteliano and Street [71]	Nurse practitioners’ contributions to cultural competence in primary care settings	Research	Document unique ways Nurse Practitioners (NPs) contribute to delivering culturally competent healthcare to diverse and underserved patient populations in urban primary care practices.	100%
38	Mobula et al. [72]	Cultural Competence and Perceptions of Community Health Workers’ Effectiveness for Reducing Health Care Disparities	Research	Examine the association of provider and staff self-reported cultural competency (cultural motivation, power and assimilation attitudes, and behaviors) and preparedness to deliver cross-cultural care with attitudes regarding the effectiveness of CHWs in reducing health care disparities.	100%
39	Murphy [73]	Building Culturally Competent Practice with Sexual and Gender Minorities Using Nonviolent Communication	Theoretical	Build trust among SGMs and health care providers and implement the Nonviolent Communication Process in clinical settings.	5
40	Noble et al. [74]	Attitudes of Midwives Concerning Attitudes of Midwives Concerning Jewish Couples	Research	Examine nurse-midwives general cultural competence and ethnic attitudes toward Jewish couples of varying degrees of religious identification during the birth process and the relationship between background data, ethnic attitudes, and cultural competence	80%
41	Papadopoulus et al. [75]	Empowering refugee families in transit: the development of a culturally competent and compassionate training and support package	Research	Describe the development of a culturally competent and compassionate training and support package (TSP) for nurses, social and health care workers, and volunteers, focusing on parenting needs among unsettled refugees fleeing conflict.	100%
42	Patterson et al. [76]	Cultural competency and microaggressions in the provision of care to LGBT patients in rural and appalachian Tennessee	Research	Examine LGBT cultural competence and microaggressions among healthcare providers in rural Tennessee.	80%
43	Perveen et al. [77]	Awareness of Nurses Regarding Culturally Competent Care in Hospitals of Punjab: Cross Sectional Study	Research	Analyze nurses’ awareness regarding culturally competent care in three selected hospitals in Punjab.	80%
44	Philips et al. [78]	In their own words: patient navigator roles in culturally sensitive cancer care	Research	Describe the self-identified roles in providing culturally competent care	100%
45	Qureshi et al. [79]	An Assessment of Lesbian, Gay, Bisexual, and Transgender Health Competencies Among Bachelors-Prepared Registered Nurses in Graduate-Level Study	Research	Assess graduate nursing students’ lesbian, gay, bisexual, and transgender (LGBT)-specific health competencies.	100%
46	Renault [80]	Cultural Competence Education for Care Coordinators	Research	Conduct a 1-hour class on cultural competence for care coordinators and nurses in a homecare organization in Southern Ontario, and to determine if there was an increase in cultural competence knowledge of Aboriginal people.	60%
47	Roosevelt et al. [81]	Clinically and Culturally Competent Care for Transgender and Nonbinary People	Theoretical	Guide nurses caring for transgender and gender nonbinary people during the perinatal period.	5
48	Ruud [82]	Cultural Humility in the Care of Individuals Who Are Lesbian, Gay, Bisexual, Transgender, or Queer	Theoretical	Describe the application of cultural humility in the care of LGBTQ people, review key concepts of sexual orientation and gender identity, and provide definitions of common terms.	4
49	Seeleman et al. [83]	Deficiencies in culturally competent asthma care for ethnic minority children: a qualitative assessment among care providers	Research	Explore those mechanisms in pediatric asthma care that lead to deficiencies in the care process for ethnic minority patients.	80%
50	Segalovich et al. [84]	Cultural Competence of Mental Health Nurses in Israel	Research	Examine and evaluate the degree of cultural competence of mental health nurses in Israel.	100%
51	Skinn [85]	Cultural Competence among Oncology Nurses	Research	Assess the Skinn Model of Cultural Competence (SMCC).	80%
52	Suurmond et al. [86]	Towards culturally competent pediatric oncology care: A qualitative study from the perspective of care providers	Research	Explore those obstacles in pediatric cancer care that lead to barriers in the care process for ethnic minority patients.	100%
53	Suurmond et al. [87]	Cultural competence among nurse practitioners working with asylum seekers	Research	Explore the cultural competencies that nurse practitioners working with asylum seekers	80%
54	Tong et al. [88]	Nurses’ experiences of providing transcultural nursing care to minority patients in Yunnan province: A descriptive qualitative study	Research	Explore nurses’ experiences of providing transcultural nursing care to patients from ethnic minorities in Yunnan province, China	80%
55	Traister [89]	Improving LGBTQ Cultural Competence of RNs Through Education	Research	Establish an understanding of the knowledge and attitudes of RNs about LGBTQ people and the impact of an educational intervention.	80%
56	Xiao et al. [90]	Evaluation of a nurse-led education program to improve cross-cultural care for older people in aged care	Research	Evaluate the effect of a nurse-led cross-cultural care program on the cultural competence of Australian and overseas-born care workers.	100%
57	Yeo et al. [91]	Oncology nursing: Educating advanced practice nurses to provide culturally competent care	Theoretical	Highlight significant cancer disparities among diverse populations, (b) describe how cultural belief systems influence cancer care and decision-making, and (c) explicate the need to prepare advanced practice nurses (APNs) for careers that include cancer care of diverse and vulnerable populations through formal oncology theoretical educational programs such as the Advanced Practice Oncology Nursing Program for Diverse and Underserved Populations at Thomas Jefferson University School of Nursing.	4
58	Yilmaz et al. [92]	Investigating intercultural effectiveness of pediatric nurses in a Turkish hospital	Research	Measure the intercultural effectiveness level of pediatric nurses and to explore relationships between the level of intercultural effectiveness and some sociodemographic variables in pediatric nurses.	80%

Notes:^a Research articles scored using Pluye et al.‘s [34] Mixed Methods Appraisal tool (MMATS) in %; ^b Theoretical articles scored using Tyndall’s [93] Authority, Accuracy, Coverage, Objectivity, Date, Significance (AACODS) in whole number

Domains and attributes of cultural competency

Table 3 presents the summary of the domains and attributes of cultural competency. Five domains were identified from the literature, namely Culture, Team, Patient, Action, and Self. Attributes, themes, and their definition and exemplars are indicated in each domain based on (cultural) knowledge, (competent) skills, and (caring) values, as shown in the table.

Table 3.

Domains and attributes of cultural competency

	Attributes
Domains	(Cultural) Knowledge	(Competent) Skills	(Caring) values
Culture	Core – knowledge of basic culture	Comprehension – skills for understanding culture	Critical – culture-driven values
	• Cross-cultural diversity  • Language (verbal and non-verbal)  • Terminologies  • Safety  • Worldviews	• Assessment  • Sharing information  • Interpretation  • Establishing trust  • Ensuring privacy	• Respect  • Justice  • Humility  • Trust  • Empathy
Team	CADRE – knowledge of team	Connection – skills for collaboration	Collegial – team-driven values
	• Team profile  • Roles and responsibilities  • Staff diversity  • Social norms and expectations  • Group dynamics	• Proactive  • Staff engagement  • Organization and systems  • Relationship cultivation  • Team building	• Professionalism  • Accountability  • Teamwork  • Open-minded  • Ethnocentric
Patient	Client – knowledge of patient	Conversation – skills for communication	Congenial – client-driven values
	• Race and religion  • Uniqueness  • Beliefs  • Health, Epidemiology  • Intervention	• Therapeutic Communication  • Client engagement  • Involving significant others  • Building rapport  • Using interpreters	• Advocacy  • Sensitivity  • Sensibility  • Compassion  • Acceptance
Action	Change – knowledge of challenges	Cultivation – skills for practice transformation	CENTRIFUGAL – action-driven values
	• Trends and issues  • Problem  • Disparity  • Barriers  • Politics	• Safeguarding  • Facilitating  • Educating  • Empowering  • Bridging gaps (research)	• Lifelong learning  • Adaptive, Flexible  • Creative  • Innovation  • Efficiency
Self	Character – knowledge of oneself	Contemplation – skills for self-awareness	Committal – self-driven values
	• Identity  • Values  • Beliefs  • Coping strategies  • Mindfulness	• Reflection  • Self-assessment, examination  • Decision-making (shared)  • Self-regulation  • Independence	• Motivation  • Confidence  • Commitment  • Positivity  • Goal-driven

The “Culture” domain requires knowledge of basic culture (Core), skills for understanding culture (Comprehension), and culture-driven values (Critical). Attributes ranged from understanding cross-cultural diversity and worldviews to skills in communication and trust building, as well as values such as empathy and respect. Knowledge of the team (Cadre), collaboration skills (Connection), and team-driven values (Collegial) define the “Team” domain. This domain emphasizes knowledge of team dynamics, collaborative skills, and values such as professionalism and accountability. Culturally competent healthcare providers must have the knowledge of the patient (Client), skills to communicate with them (Conversation), and possess client-driven values (Congenial) – as these attributes define the “Patient” domain. This focused on understanding patient backgrounds, engaging through therapeutic communication, and upholding client-centered values, such as advocacy and compassion. Likewise, having the skills to transform practice (Cultivation), values related to action (Centrifugal), and knowledge of current challenges (Change) is necessary as it defines the “Action” domain. This domain addressed knowledge of systemic challenges, transformative practice skills, and action-oriented values including innovation and adaptability. Finally, for the domain “Self”, nurses and healthcare providers must know themselves (Character), have the skills of self-reflection (Contemplation), and acquire self-related values (Committal) to be culturally competent. This domain encompasses personal identity and beliefs, reflective skills, and values driven by self-awareness, such as motivation and commitment. Other specific attributes for each of the five domains are also depicted in Table 3.

Figure 2, entitled “Cultural Competency Wheel,” was developed to visually represent the domains and attributes in a single figure. The wheel-like model (Fig. 2) indicates interconnectedness and holism among the themes, with each area contributing to the framework of culturally competent care. The wheel symbolizes how all five domains are interdependent, with no single domain being able to stand on its own.

Fig. 2.

Cultural competency wheel: domains and attributes of cultural competency

Discussion

Article bibliometrics

This review revealed that most articles are empirical, with nurses being the most prominent healthcare providers involved in culturally competent care. This result stems from the notion that articles on cultural competency require a data-driven approach. Additionally, the preponderance of nurses as article subjects is expected, as they represent the largest portion of the healthcare workforce that provides holistic care to diverse patient populations [94]. Empirical studies are important to develop evidence-based practices that can transcend cultural boundaries, such as cultural competency [95] in examining its concepts and relevance [44, 95–97], particularly among nurses who hold rich population-based knowledge, skills, and expertise, connect with several professionals and community settings, and collaborate with diverse healthcare professionals [98]. In nursing, cultural competency is one of the foundational principles [99] and has gained a substantial presence in several nursing curricula [100]. Given that nurses require appropriate intercultural communication skills to interact competently with multicultural populations in various settings [101], global recommendations have been made to incorporate cultural information and training into nursing students’ study programs to prepare them for handling diverse patient populations [102].

Results also showed that studies on cultural competency are primarily relevant in regions where migration status continues to rise and in specialized areas of practice that involve a high degree of direct patient interaction (e.g., clinical settings, hospitals). Over the years, the region of the Americas has catered to numerous minority populations and immigrants, thereby strengthening its status as the most prominent receiving territory [103, 104]. Recent data indicate that the Americas have experienced an increase in immigrant populations from the European region, as well as a more consistent rise in flows from other countries [105]. Globalization has also contributed to the recent increase in migration rates in several countries, driving population movements (Segal, 2019) and thereby increasing cultural diversity [106]. Migration also has an impact on globalization as it amplifies socio-economic, cultural, and political relations across borders [107].

Cultural competency articles are mostly focused on clinical areas where cultural awareness can significantly impact communication, patient satisfaction, and general health outcomes [108, 109]. For several years, healthcare professionals working in clinical settings have consistently called for addressing cultural diversity and its implications for health outcomes [110], particularly in the use of appropriate verbal [108] and non-verbal communication skills [111]. Interestingly, the importance of cultural awareness and inclusivity is also being highlighted in clinical trial research [112] as a means to enhance the representativeness of racial and ethnic groups in scientific discourse [113, 114].

Article descriptions and critical appraisal

Most of the articles published aim to examine the relationship between cultural competence, patient perception, and health outcomes. Patient satisfaction has been discovered to be strongly associated with the cultural competence of healthcare providers, particularly of nurses [115, 116]. Therefore, cultural awareness training among health professionals can directly improve patient outcomes through culturally congruent, individually focused care [117–120]. The concepts of cultural humility and cultural safety were studied and linked to cultural competency. Cultural humility considers the tricultural nature of healthcare, a complex interaction of cultures among healthcare providers, and the medical culture that surrounds them [121]. In contrast, cultural safety acknowledges the challenges to effective clinical practice caused by an inherent power imbalance between the patient and the healthcare provider [122].

Articles in this review also evaluated several training and educational programs aimed at enhancing healthcare providers’ cultural competency from a multidimensional perspective. Continuing professional development is crucial in developing cultural awareness among healthcare providers [97]. Additionally, cultural care training is crucial in preparing medical and health-related students and professionals for global health [123]. As showcased in various studies, innovative approaches to training (i.e., flipped classroom, simulation) are gradually being introduced to effectively enhance the fundamental cultural care competencies of healthcare students and providers [124, 125]. Further research is needed to test the effectiveness and efficiency of emerging instructional strategies [124, 125], given the individual preferences for learning and the complexity and intensity of cultural care in healthcare settings [97].

The majority of the articles in this work received commendable appraisal scores. The high MMAT scores among empirical articles reflected their compliance with rigorous methodological processes and well-defined outcomes. This outcome is relevant as it addresses the issue of methodological rigor, which has limited the production of high-quality evidence in assessing the effectiveness of cultural competency training [126].

However, the appraisal of the theoretical articles showed moderate quality. This result may be attributed to the complexity of the subject and its rapid evolution [127], resulting in a lack of theoretical coherence on significant elements that constitute cultural competence [121]. Despite the increasing number of empirical studies on cultural competency, discrepancies still exist on universal and clear definitions [121, 128, 129]. Cultural competence in healthcare remains a broad concept with several theoretical underpinnings and contradicting opinions on its structure [130]. This outcome may have contributed to a surge in ethnic-related and cross-cultural health disparities and inconsistencies in healthcare practices [131]. Similarly, subjectivity is also a limitation as individual author concepts and interpretations may be difficult to quantify [31].

Domains and attributes of cultural competency

Multiple domains and attributes of cultural competency were captured from the literature. This outcome highlights the complexity of cultural competency, as it encompasses multiple factors and interconnected subjects that extend beyond simple cultural awareness [132, 133]. The emerging themes are comparable, but more encompassing than existing models of cultural competency.

The “Culture” domain encompasses knowledge of culture per se, including comprehension skills, and the enactment of several core values that should be innate to healthcare professionals. Knowledge of culture is primary, as it leads to improved treatment adherence and better-quality care. Understanding culture also fosters an inclusive environment, which significantly improves patient health outcomes [134–136]. For instance, Gaston [54] found out that the providers’ acknowledgment of patient culture promotes medication adherence for African-American patients diagnosed with HIV. Additionally, culturally appropriate communication leads to fewer clinical errors in medication and treatment protocols, particularly in areas such as the ICU, palliative care, and oncology [137–140]. Understanding patient culture reduces the likelihood of malpractice and legal risks, as it entails compliance with legal requirements and non-discriminatory patient care [141–143]. It is essential to develop interventions that take into account individual beliefs and practices.

The “Team” domain refers to the acknowledgment that quality, culturally appropriate healthcare is the work of a group of people (Gergely, 2018; Hietapakka et al., 2019; Martin & Barkley, 2016). This domain requires an in-depth knowledge of the team and its members [60], skills for collaborative practice [59, 64], and team-driven collegial values [57, 61, 72]. To provide culturally competent care, providers must understand, respect, and foster staff or co-worker diversity [56, 144]. Cultural diversity within the team improves the ability to address the complexities of patient care, making them more adaptable to diverse populations [68, 145]. This also highlights the importance of challenging healthcare team members’ beliefs by incorporating diverse perspectives from the team and acknowledging the potential presence of cultural biases [146]. Cultural humility is an ongoing process of self-exploration and self-critique combined with a willingness to learn from others [15]. This practice shows that understanding oneself and how a person relates with other people is a foundational principle of cultural competence. Working in groups is an excellent exercise to practice cultural competence. Based on this concept, previous scholars have suggested transforming from a hierarchical structure to a cooperative, multidisciplinary healthcare structure, which enables better interpersonal communication among healthcare personnel and may ultimately lead to safer and more effective services [147–149]. Knowledge, skills, and values related to creating a cohesive and strong healthcare team can foster team spirit, establish initial trust and understanding of cultural backgrounds, reduce stigma, facilitate mutual understanding, and provide role modeling [150, 151].

The “Patient” domain encompasses knowledge, skills, and attitudes that are linked to understanding the patient as a holistic individual. Several studies have shown that communicating effectively based on patient preferences [67, 152] and demonstrating cultural sensitivity to the recipients of care improves patient health outcomes [153, 154]. Knowing and understanding the patient’s background and preferences helps healthcare providers develop a more open attitude toward cultural differences. Knowing the individuality of the patient promotes a stronger partnership between the provider and the patient, making patients feel empowered to participate proactively in care decisions [145, 155, 156]. Culturally competent, patient-centered care, especially for vulnerable population groups, can be enhanced by understanding the language, providing language services to patients [157], including significant others [59], and incorporating culturally competent communication tools [158]. Evidence suggests that cross-cultural communication can be enhanced through training, active listening, empathy, and nonverbal communication [70, 73, 118].

The “Action” domain relates to understanding change and mitigating its negative impact through the enactment of various roles and responsibilities necessary for culturally competent healthcare. The healthcare system is complex, involving a variety of trends, issues, and challenges related to inclusion, disparity, politics, and the environment. Healthcare providers must understand these dynamics and be prepared to perform multiple roles, ranging from educating patients to empowering them. Healthcare professionals must be informed about current trends in the healthcare system [159, 160] and be open and resilient to change. For instance, healthcare professionals should engage in Continuing Professional Development (CPD) activities, as it bridges the gap between actual and best interventions to provide culturally competent care [161, 162]. Another example is the adoption of emerging clinical modalities, such as the use of electronic health records (EHRs) and mobile health (mHealth), which have been evident in optimizing and accommodating the specific needs of diverse populations, especially during the COVID-19 pandemic [163–167]. Moreover, healthcare professionals who demonstrated the ability to effectively adapt care approaches, interventions, and treatment plans to address cultural differences and enhance patient-centered care exhibited higher levels of cultural competency [168].

Finally, the “Self” domain emphasizes the values, skills, and knowledge that a service provider brings to themselves. Knowing “thyself” links individual attributes (strengths and weaknesses) with cultural competency [169–172]. Acknowledging one’s professional and personal culture also promotes cultural competency [173]. Reflecting on personal values is known to shape professional behavior and patient interaction, making healthcare providers emotionally secure, resilient, empathetic, and adaptable [174–176]. Being aware of personal qualities and responsibilities provides equitable, patient-centered, and culturally competent care [177]. Outcomes in this area ultimately highlight the importance of integrating self-reflective practices and self-awareness in the profession.

This cultural competency wheel presents a comprehensive framework that can serve as both a theoretical foundation and a practical assessment tool in research examining cross-cultural interactions, organizational diversity initiatives, or the effectiveness of educational programs. Researchers could utilize this model to operationalize cultural competency by measuring participants’ development across the six domains (Core, Comprehension, Critical Culture, Cadre Connection, Collegial Team, and Patient Connection/Configuration), while the wheel’s centripetal design emphasizing Action, Cultivation, and Change provides a dynamic lens for understanding how cultural competency develops over time. The framework’s integration of individual awareness (Core), knowledge acquisition (Comprehension), analytical thinking (Critical Culture), and relationship-building capabilities (Connection domains) makes it particularly valuable for mixed-methods research that seeks to capture both quantitative skill development and qualitative transformation processes. Additionally, the wheel’s emphasis on lifelong learning and adaptive practices aligns well with longitudinal research designs that track the development of cultural competency across different contexts, making it an excellent tool for researchers investigating how individuals and organizations can more effectively navigate increasingly diverse environments while fostering inclusive and equitable outcomes.

Conclusion

International migration has fundamentally transformed the landscape of globalization, compelling healthcare providers to deliver culturally competent care across diverse patient populations, regardless of geographical, spatial, or socioeconomic boundaries. This study involved a comprehensive analysis of existing literature in developing an innovative, integrative model that delineates the essential domains and attributes of cultural competence in healthcare delivery – the Cultural Competency Wheel. The model identifies and elaborates on five critical domains of cultural competency, each encompassing specific knowledge requirements, skill sets, and core values that healthcare providers must cultivate. The findings highlight the complex and multifaceted nature of cultural competence in healthcare settings. While the methodology adhered rigorously to systematic review protocols and drew from established scientific databases, certain limitations warrant acknowledgment. Notably, the exclusion of non-English publications and gray literature may have omitted valuable insights into cultural competency frameworks. Future research would benefit from expanding the scope to include resources from non-indexed databases and incorporating emerging literature published in 2024 and beyond. Despite these constraints, the study yields significant implications for research, practice, and theoretical development in healthcare. The proposed model provides a foundation for developing quantitative metrics to assess cultural competence in empirical studies. Additionally, it offers practical value for curriculum designers and nursing administrators in creating comprehensive programs for developing cultural competence among both nursing students and practicing professionals. The framework can serve as a blueprint for implementing evidence-based approaches to enhance cultural competency across healthcare institutions.

Abbreviations

AACODS

Authority, Accuracy, Coverage, Objectivity, Date, Significance or

CAT

Communication Assessment Tool

CLAS

Culturally and Linguistically Appropriate Services

CSES

Cultural Self-Efficacy Scale (CSES)

MMAT

Mixed Methods Appraisal Tool

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Author contributions

RS, JAR, and MJD made equal contributions to both the composition of the manuscript and the review of the submitted document.

Funding

The authors did not receive funding meant for the publication of this manuscript.

Data availability

The data supporting this study’s findings are available from Our Lady of Fatima University. However, restrictions apply to their availability. The data were used under license for the current study and are not publicly available, but they are available from the authors upon reasonable request and with the permission of Our Lady of Fatima University.

Declarations

Ethics approval and consent to participate

The ethical clearance exemption certificate was obtained from the Institutional Ethics Research Board (IERC) of Our Lady of Fatima University (No.: 2023-IERC1-20741) in accordance with the Declaration of Helsinki. The manuscript does not involve human participants. Therefore, consent to participate is not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.