Cultural Competence

The client-oriented model of cultural competence in healthcare organizations Giovanni Di Stefano , Eleonora Cataldo and Chiara Laghetti

Dipartimento di Scienze Psicologiche, Pedagogiche e della Formazione, Università degli Studi di Palermo , Palermo, Italy

ABSTRACT The paper aims to propose a new model of cultural competence in health organizations based on the paradigm of client orientation. Starting from a literature review, this study takes inspiration from dimensions that characterize the cultural competence of health organizations, and re-articulates them in more detail by applying a client orientation view. The resulting framework is articulated into six dimensions (formal references; procedures and practices; cultural competences of human resources; cultural orientation toward client; partnership with community; and self-assessment) that define the ability of a health organization to achieve its mission, acknowledging, understanding, and valorizing cultural differences of internal clients (staff) and external clients (consumers). This study makes an effort to address the paucity of studies linking approaches to managing cultural diversity in health organizations with cultural competence within the framework of client orientation.

ARTICLE HISTORY Received 30 March 2017 Accepted 3 October 2017

KEYWORDS Cultural competence; health organizations; client-oriented model

Introduction

Globalization has deeply changed the profile of both the workforce and the users of organizations in the societies of the new millennium. One important ques- tion is how to deal with growing cultural diversity in such a way that it may produce positive results – in terms of productivity and service quality, well-being and satisfaction – for organizational systems and for people, both workers and users.

The Diversity Management (DM) approach aims to accomplish such a result by adopting a heterogeneous viewpoint in order to lever cultural differences and treat them as an added value rather than an obstacle. In fact, the premise for managing diversity is the recog- nition of differences as positive attributes of an organ- ization, rather than as problems to be solved [1]. In this way, diversity may become a source of competitive advantage, increase the quality of organizational life and ultimately be advantageous for business [2]. The point is not, therefore, the acceptance of differences, but the creation of an inclusive environment and the commitment to valuing them. This can be made poss- ible through a culture of inclusion that creates a work environment nurturing teamwork, participation, and cohesiveness. However, many organizations do not see the advantages that cultural diversity could bring to them and how well-managed cultural diversity may achieve a competitive edge in the market.

The topics of cultural differences and disparities that may result from them have been already described in healthcare organizations, since the emerging challenges of providing health services in a growing multi-ethnic

world [3,4]; within these organizations, the approach of intercultural DM and the cultural competence are considered a priority. In particular, cultural compe- tence is a powerful instrument for managing cultural diversity in multicultural settings, since it improves quality and eliminates racial/ethnic disparities in organizations. The goal of cultural competence is to create a healthcare system and workforce that are capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency.

Although cultural competence may be considered an important need for every contemporary organiz- ation, since the growing pressures of globalization to develop international influence or operating on an international scale, it is indeed a core requirement for healthcare organizations, since the exigency they have to respond to the specific needs of any person seeking help, and the related concerns that come from working with culturally diverse patient groups, in order to alle- viate, at least in part, health disparities related to racial and ethnic differences.

The aim of this work is to propose a client-oriented model of cultural competence, meaning the ability of a health organization to acknowledge, understand, and value cultural differences of internal clients (staff) and external clients (consumers), as well as the ability to commit to achieving its mission, taking account of clients’ cultural identity and the individual needs. In order to respond to this objective, we reviewed the literature on cultural competence to identify a set of elements that define a culturally competent

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CONTACT Giovanni Di Stefano giovanni.distefano@unipa.it Dipartimento di Scienze Psicologiche, Pedagogiche e della Formazione, Università degli Studi di Palermo , Viale delle Scienze, Ed. 15, Palermo 90128, Italy

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2019, VOL. 12, NO. 3, 189–196 https://doi.org/10.1080/20479700.2017.1389476

organization within the framework of client orien- tation. EBSCO, MEDLINE, Scopus, and Web of Science databases were searched for relevant peer- reviewed articles regarding the organizational cultural competence and client orientation in healthcare.

Toward a definition of cultural competence for health organizations

Since the 1980s, several scholars have paid attention to the construct of cultural competence, focusing on stu- dents [5–7], research [8], policy organizations [9], counseling services [10–12], and above all, the human service sector – social work and healthcare [3,4,13–24]. With specific reference to healthcare organizations, the concept of cultural competence was used not only in reference to the individual’s ability to provide care in a culturally appropriate way but also in relation to systems and organizations.

Cultural competence has been defined variously in the literature. For example, Green [20] first defined it as the ability to conduct professional work in a way that is consistent with the expectations, which mem- bers of a distinctive culture regard as appropriate among themselves. This definition emphasizes the worker’s ability to adapt professional tasks and work styles to the cultural values and preferences of clients. According to Cross et al., cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among pro- fessionals and enable that system, agency, or those pro- fessionals to work effectively in cross-cultural situation [25],p.1. Sue defines cultural competence as the ability to engage in actions or create conditions that maximize the optimal development of client and client systems [11],p.817. According to the National Quality Forum, cultural competence is the ongoing capacity of health- care systems, organizations, and professionals to pro- vide for diverse patient populations high-quality care that is safe, patient- and family centered, evidence based and equitable [26],p.2. Last but not least, Betan- court et al. [3] define cultural competence as the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring deliv- ery to meet patients’ social, cultural, and linguistic needs.

Despite these differences, authors seem to agree that cultural competence is an active and developmental process that is ongoing and never reaches an endpoint. Cultural competence develops over time through train- ing, experience, guidance, and self-evaluation [4,14,25]. In connection to such a general statement, Campinha- Bacote views cultural competence in the specific field of healthcare as the ongoing process in which the health- care provider continuously strives to achieve the ability to effectively work within the cultural context of the cli- ent (individual, family, community) [4],p.181. Scholars

tend to consider cultural competence as increasingly important for healthcare quality [13,14,15,22], and believe that there is a link between cultural competence and reducing or eliminating racial and ethnic dispar- ities in health care [7,16,27].

Although the centrality of cultural competence in health practice appears to be a widely accepted concept [3,13,14], still exists a scarce research on the effects and the outcomes of developing culturally competent healthcare organizations [16,28]. Nevertheless, there is some evidence that the implementation of cultural competence models improves the ability of health sys- tems and their workers to provide services to culturally diverse patient groups, reducing disparities in quality of health care [13,15,16].

Main models of cultural competence

Several models of cultural competence have been developed in the last two decades; in them, the dimen- sions of this construct were delineated with particular attention to individuals and organizations.

Cross et al. [25], focusing on systems of care, pro- pose a continuum that ranges from cultural destructive- ness, that is destructive attitudes, policies, and practices toward diverse cultures and individuals within a cul- ture to cultural proficiency or advanced cultural compe- tence, i.e. attitudes, policies, and practices that hold culture in high esteem, with the intermediate stages of cultural incapacity, in which the organization not intentionally seeks to be culturally destructive, but rather is not able to help minority clients, cultural blindness, that is believing that all people are the same and that approaches used by a dominant culture are universally applicable, cultural pre-competence, namely realizing weaknesses in serving minorities and attempting to improve service for a specific part of the population, and cultural competence, i.e. adapt- ing a service model to the needs of minorities, expand- ing cultural knowledge and resources, conducting cultural self-evaluation continuously. In order to assess at which of these stages a given organization is, one may evaluate the entity of five essential elements that contribute to a system’s ability to become more cultu- rally competent: (1) the propensity to valuing diversity, that is the awareness, acceptance, and respect of differ- ences in lifestyle, communication, behaviors, values, and attitudes; (2) the cultural self-assessment, specifi- cally the ability of the system to assess itself and have a sense of its own culture; (3) the dynamics of differ- ence, or the ability of the organization to manage mis- interpretation and misjudgment when a member of one culture interacts with other from a different one; (4) the institutionalization of cultural knowledge, namely how much organization provides cultural knowledge to their workers about family system, values, history, and etiquette of specific populations;

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and, finally, (5) the adaption to diversity, i.e. the sensi- bility of the organization to adapt its approaches in order to create a better fit between the needs of min- ority groups and services available.

Rodgers’ model, instead, focuses on the identifi- cation of attributes of cultural competence rather than the development of a definition of the concept. Rodgers [29] identifies seven attributes of cultural competence: cultural awareness, i.e. developing con- sciousness of culture and the ways in which culture shapes values and beliefs; cultural knowledge, that is a continued acquisition of information about different cultures and an essential underpinning of cultural understanding; cultural understanding, specifically the ongoing development of insights related to the influ- ence of culture on the beliefs, values, and behaviors of diverse groups of people by which one can begin to address problems such as marginalization and sub- jection that may be the result of beliefs and values of one culture differing from those of the dominant cul- ture; cultural sensitivity that develops as one comes to appreciate, respect, and value cultural diversity and, in so doing, one also comes to realize how one’s own personal and professional cultural identity influences practice; cultural interaction, namely the personal con- tact, communication, and exchanges that occur between individuals of different cultures; cultural skill, or the ability to communicate effectively with those from other cultures, including the incorporation of the client’s beliefs, values, and practices into the pro- vision and planning of care and also varying pro- cedures and techniques to accommodate cultural beliefs; cultural proficiency, that is the commitment to change through some activities as the sharing of information.

A different model is proposed by Purnell [23]. It is based on the assumption that cultural competence is not a linear process in which a healthcare provider – or any organization – progresses from unconscious incompetence, a condition in which it is unaware that is lacking knowledge about another culture, to con- scious incompetence, to one in which is aware, and from this to a state in which it has a conscious compe- tence, learning about the client’s culture and providing culturally specific interventions, to the optimal con- dition in which it automatically provides congruent care to clients of diverse cultures, namely it holds an unconscious competence.

Finally, Campinha-Bacote’s model views cultural competence as the ongoing process whereby the healthcare provider continuously strives to achieve the ability to effectively work within the cultural con- text of the client (individual, family, and community) [4]. Campinha-Bacote’s model is composed of five major constructs that have an interdependent relation- ship with each other: cultural awareness, that is the self- examination and exploration of one’s cultural and

professional background; cultural knowledge, i.e. the pursuit and achievement of a sound educational foun- dation about diverse cultural and ethnic groups; cul- tural skill, namely the ability to collect relevant cultural data regarding the client’s presenting problem, to conduct cultural assessments and culturally based physical assessments; cultural encounters, or the pro- cess that encourages the cross-cultural interactions between healthcare provider and clients from culturally diverse background; and, finally, the cultural desire, that is the motivation of the healthcare provider to want to become culturally aware, knowledgeable and skillful, and familiar with cultural encounters.

Although all the models presented so far have had some success and have been implemented in a wide variety of programs in medical schools, the concept of culture competence must go beyond the traditional notion of ‘competency’, involving the fostering of a critical consciousness of the self, others, and the world and a commitment to addressing issues of societal relevance in health care [30]; also, they seem to consider cultural competence only as a means to provide a culturally specific service for users of differ- ent ethnicities.

The model here proposed, which we call the Client- Oriented Model of Cultural Competence, is instead designed mainly as a tool for the management and development of human resources from different cul- tural backgrounds. In our proposal, a culturally compe- tent organization aims to promote positive intercultural encounters among colleagues, then between providers and consumers. The organization must be culturally competent with regard to internal customers to dispense a culturally competent service to external customers.

The client-oriented model of cultural competence

The Client-Oriented Model of Cultural Competence can be considered as a model that, inspired by the DM approach, aims to link the task of managing cul- tural diversity in health organizations with cultural competence, within the framework of client orien- tation. In this model, the cultural competence is defined as the ability of a healthcare organization to achieve its mission (service delivery), acknowledging, understanding, and valorizing cultural differences of internal clients (staff) and external clients (consumers).

Within the proposed model, we posit that the client orientation view may be considered a specific key element for healthcare organizations. In fact, the focus on provider–client relationship may give added value to healthcare services: for example, when health- care providers either do not speak the client’s language or are insensitive to cultural differences, the quality of health care can be compromised [13]. Under this point

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of view, a client-oriented healthcare organization is a system that responds effectively to language, and in a more general sense, to psycho-social needs of their cli- ents. Also, the respect, the sensitivity, and the under- standing for clients’ culture and values appear to be related to the ability of healthcare providers to offer provisions of health services [3,4,13].

It is articulated into the following six dimensions:

(1) Formal references related to cultural competence; (2) Procedures and practices; (3) Cultural competences of human resources; (4) Cultural orientation toward clients; (5) Partnership with community; (6) Self-assessment.

These dimensions are described below in detail.

Formal references

The first dimension of the Client-Oriented Model of Cultural Competence regards written formal organiz- ational statements about mission, values and prin- ciples, goals and policies, beneficiaries, and vision. In a culturally competent organization, formal references explicitly stress the importance of cultural competence, consider the cultural diversity of staff members as a resource to be valuable, and include members of differ- ent cultures as beneficiaries of the service. A culturally competent governance establishes policies and goals that help ensuring the delivery of the service in a cultu- rally responsible way, by involving various groups in the decision-making process [27]. The organizational statements must be communicated to staff and consu- mers, and the language in the formal references must acknowledge the cultural diversity of personnel and population served. In other terms, an organization is culturally competent when, even before delivering its services to implement the provision of services, it defines its own primary task in a culturally sensitive way, taking care to distribute its own purposes, prin- ciples, and values within the system and in the whole territory and encouraging the sharing of the same goals and principles among staff and users.

Procedures and practices

The second dimension regards the practices of man- agement and development of human resources. In relation to service delivery procedures, in agreement with Hernandez et al. [27], we believe that cultural competence in service ensures ad hoc services that reflect the needs of consumers. A healthcare organiz- ation should have a database containing information about each user’s clinical history, culture of origin, and reported impact ensuing the first encounter with the organization, to ensure a culturally competent

service. This database, continuously updated, will be a guide for health providers, who will be able to provide the most appropriate service, in timely fashion and in the most appropriate way, to the specific patient. In relation to management and development of human resources practices, efforts should be made to recruit, select, and hire multicultural administrative staff and medical personnel, who should be representative of the cultures existing in the community and able to speak the languages of the populations served [31,32]. Racial/ethnic diversity in the healthcare leadership and workforce has been clearly connected with the delivery of quality care to diverse patient populations [3].

So conceived, procedures and practices serve the more general objective to render a healthcare organiz- ation a culturally competent system; this, in turn, should allow to create a multicultural environment, which is a setting ready to receive people, both consu- mers and staff, of different cultures. In other words, a culturally competent organization, which has designed and created through its procedures and practices a physical and symbolic multicultural environment, ensures users’ open access to services through the elim- ination of socio-cultural barriers see [3,27]. First, the absence of language barriers, i.e. multilingual bro- chures, documents/information materials allows effec- tive communication between providers and consumers. The organization will monitor consumers’ needs on-site through such devices as anonymous questionnaires on the services offered.

As a customer-oriented system, the organization will offer the opportunity to provide feedback also to the staff, who will be able thus to report problematic issues encountered in the workplace and provide sug- gestions to improve the service. Thus, the organization creates, maintains, and improves a work environment that is conducive to the well-being and development of all employees [17,33]. Such devices will increase the sense of belonging in the workplace (affective com- mitment) and employees will identify with the organiz- ation and its values. The physical–spatial structure with its premises and furnishings is nothing more than the expression of the organization’s system of values based on acceptance, respect, and appreciation of cul- tural differences. The culture of an organization, in fact, is primarily inferred from the observation of its visible and tangible aspects, along with the public actions of its members.

Cultural competences of human resources

The third dimension focuses on attitudes and skills of personnel required to provide culturally acceptable care, developed through training, which are: awareness of own beliefs and bias; knowledge, acknowledgment of, and respect for, beliefs and values of other cultures;

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relational skills in intercultural encounters with co- workers and consumers; appropriate language and effective communication; multicultural team-working skills. A large part of the literature suggests some of these beliefs/attitudes and skills are components of cul- tural competence [11,12,18,21,24,25]. In particular, Sue et al. [12] list some of the culturally competent counse- lor’s attitudes and skills, namely: valuing and respect- ing differences in beliefs, values, language, and helping practices; awareness and knowledge of own and clients’ cultural heritage and experiences, attitudes, values, biases, and stereotypes; ability to engage in a variety of verbal and nonverbal helping responses.

In our opinion, it is of primary importance that employees of multicultural organizations be aware of the cultural basis of their behaviors, in such a way that they may realize that their beliefs do bear consequences on their actions in the workplace, possibly leading them to commit errors of assessment. It is also important that they know, accept, and respect the different cultures of co-workers and users. In fact, if staff members are not willing to accept co-workers culturally different from themselves, they will always have difficulties welcoming external customers, which are carriers of culturally specific needs, and this attitude of closure shall affect the delivery of an efficient service. Relational, communi- cation, and team-working skills are necessary to work in a multicultural context. In general, with the acquisition of relational skills, employees become capable of mana- ging intercultural encounters with colleagues and users, listening to others different from themselves, under- standing their needs, and managing their own behaviors on the basis of their cultural characteristics.

Culturally competent organizations aim to reduce the difficulty of interaction (i.e. misunderstanding, conflicts, and differences of views) between individuals of different cultures. To achieve this, it is also necessary to obtain specific multicultural team-working skills, which allow members to cooperate, share information, share their views, communicate effectively, and reach an agreement on the various clinical issues. Communi- cation skills seem to be essential to interact and work in multi-ethnic groups. In order for the team’s goal to be achieved and the environment to be positive, the com- munication must be clear and transparent, fluid and open, welcoming of others without judging, censor- ship, or misunderstandings.

Upon meeting a culturally different customer, it is important the staff adapt their communication style and pay attention also to nonverbal communication. As claimed by Campinha-Bacote [4], nonverbal com- munication techniques must take into consideration the client’s use of eye contact, facial expressions, body language, touch, and space. Nonverbal language and paraverbal language are the first channels of interaction and affect the transmission of the message more greatly than the spoken word. Communication with the user is

effective if there is correspondence between the verbal and the nonverbal channels. Therefore, our model puts special emphasis on communication skills and improves relationships among colleagues and between providers and users.

The organizations need to render all employees more sensitive to cultural issues through diversity edu- cation and cultural competence training, teaching them culturally adapted models of care or types of interven- tions [31], and developing their attitudes and skills necessary to deliver service in a culturally responsible manner. Staff members will be involved in group dis- cussions, i.e. case method and self-case method and exercises, such as simulations, role-playing which refer to their multicultural working environments, as well as outdoor training sessions centered on the rela- tional and communication skills and multicultural team-working skills development.

The importance of diversity and cultural compe- tence training and education is highlighted by a large part of the literature [3,5,7,11,15,17,18,25,30,32,34– 36], because cultural competence is mediated through the behavior of all human resources that act on both upper and lower levels of an organization. In this way, cultural competence does not stay a mere abstract concept, but rather it becomes a reflection of the skills, abilities, and actions of every resource.

In general, the organization must focus on the devel- opment of such interpersonal skills in order to be cus- tomer-oriented from a cultural standpoint. If the organization grants its employees a chance to acquire and exercise these competences in their workplace relationships, they will also become able to deal with users belonging to any ethnic group in a culturally sen- sitive and responsible way.

Cultural orientation toward clients

The fourth dimension is the one that best qualifies the Client-oriented Model of Cultural Competence. It is the analysis of user and staff needs and it regards also the knowledge of their cultural characteristics. Accord- ing to our definition, culturally competent organiz- ations are culturally client-oriented, insofar as they proactively look to meet the cultural needs of both internal and external users. Hernandez et al. [27] and Siegel et al. [32] have already stressed the importance of knowing the needs and cultural characteristics of the local population that constitutes most of the organ- ization’s user pool.

In our model, we take into consideration external customers; we are aware that cultural competence is an integral component of patient-centered care, but we plan to extend the analysis of needs and the knowledge of the cultural characteristics also to internal customers, because we consider an organization’s care for its staff an essential element within the construct of cultural

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competence. We also believe that the cultural character- istics of staff affect not only the interaction with multi- cultural clients – and, therefore, the quality of service, but also the interpersonal relationships among col- leagues. The quality of the latter must be guaranteed by the organization, through the promotion of effective communication styles and a positive emotional environ- ment. These aspects of working life promote employee satisfaction, which will impact customer satisfaction in the assessment of Total Quality Management. Accord- ing to this approach, in fact, the treatment of internal customer is transferred to the external customer. In other words, only if the organization is culturally com- petent with regard to staff, will it also be toward users. The ultimate goal is to provide quality service to multi- cultural users, but in order for an organization to be defined culturally competent, that organization must ensure a positive work environment for its own multi- cultural staff.

Partnership with community

Culturally competent healthcare organizations collab- orate with community partners, such as other public, private, or no-profit organizations that help minority groups. From such collaboration, useful feedback may emerge regarding the analysis of the needs and cultural characteristics of ethnic groups served, upon which the organization sets its own targets for inter- vention. The community partners are, therefore, con- sidered bridges, which bring together the providers and the consumers even before the latter start using the former’s services [13,19].

Preliminary meetings, during social events, orga- nized periodically (i.e. friendly soccer matches in which healthcare professionals and users of different ethnicity play on the same team), permit the establish- ment of a relationship of trust, which will make the members of minority groups likely to turn to the organization for need of care. In other words, through this continuous dialogue with the territory, the organ- ization makes culturally competent marketing, foster- ing relationships with potential multicultural users and making the service known to them, in a mutually advantageous process. With respect to minority com- munities’ users, such a process increases their ability to manage their own health needs more autonomously and use services more responsibly and with the aware- ness that, once within the organization, they will find a welcoming environment.

Broadly speaking, healthcare organizations should develop collaborative partnerships with communities and use a variety of mechanisms, both formal and informal, to facilitate community and patient or consu- mer involvement in designing and implementing cul- turally and linguistically appropriate services-related activities [13].

Self-assessment

Cross et al. [25] argue that the organization’s self- assessment is essential to the development of its cul- tural competence. On the basis of the literature [6,9,25], we highlight the importance of self-assessment on the part of a healthcare organization (qualitative and quantitative instruments), with particular atten- tion to service quality, consumer satisfaction, and per- sonnel well-being. These three aspects are closely related and the evaluation of each of them is inter- twined with the evaluation of the other two. The self- assessment is useful for the organization to continu- ously adapt its strategies. It is constituted as a continu- ous monitoring action, oriented to reviewing service delivery procedures, management practices, and human resources development, with the ultimate goal of developing the most appropriate strategies for a cul- turally competent system. It is also useful to assess the quality of the service provided, in terms of process and product quality, from an intercultural standpoint.

It is useful to evaluate users’ satisfaction, through the collection of their perceptions and opinions, by means of an on-site desk collecting questions and complaints as well as questionnaires submitted by users during their stay, with a constant focus on addressing the needs of different cultural groups. The on-site desk also allows internal clients to evaluate their own organ- ization, expressing their opinions and suggestions to improve service. In this regard, meetings will be called periodically in order to analyze the data collected from various multicultural sources, discuss, and give guide- lines to staff on how to provide those services in a cul- turally competent manner.

Even the community partners play an important role in the evaluation process and in the examination of the results of service delivery procedures. By acting as representatives of particular ethnic groups present in the territory in which the services are provided, community partners report those groups’ needs to the organization. For example, an association repre- senting the territory’s Tamil community could bring up a specific need for this clinic ethnic group, the organization would take note and, on this basis, become able to develop culturally competent prac- tices. In this self-assessment process, it is important for the organization to evaluate the welfare of its own multicultural staff. Even in this case, it is desir- able to develop qualitative/quantitative questionnaires and focus groups.

Finally, the product evaluation aims to assess whether the organization’s clinical and economic results have been achieved. There is no doubt that the self-assess- ment process will have positive repercussions on all eth- nically diverse systems: leadership, on staff and users. Thanks to this self-assessment, it will be possible to deli- ver a high-quality service in a culturally competent

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manner, managing to keep costs reduced and enhance the contribution of each human resource involved.

Conclusion

The six dimensions of the Client-Oriented Model of Cultural Competence interact with each other, accord- ing to a principle of circularity (see Figure 1). Even though, thanks to such circularity, each dimension naturally ensues the previous one, the sequence cannot be considered too strictly in the study of an organiz- ation that is meant to assess whether it is culturally appropriate.

The theoretical model described here places pre- vious conceptualizations of cultural competence under the paradigm of client orientation. By doing so, the success of efforts to develop a culturally compe- tent healthcare organization may be meaningfully influenced by the ability of the organization and their practitioners to recognize, value, and respond to the needs of the specific clients being served, not only those who belong to racial and ethnic minority groups; in this sense, the model considers a set of dimensions that have a pervasive influence in determining clients’ healthcare experience. From this point of view, although the Client-Oriented Model of Cultural Com- petence identifies measurable dimensions associated with culturally competent organization, further research is needed to determine the best approaches and methods to measuring these factors. For example, the model may constitute the basis to develop a specific checklist to assist organizations to develop policies and structures that support a cultural competence specifi- cally framed within the client orientation. Owing to the multifaceted nature of the model, various indicators across multiple domains are required in order to obtain valuable and accurate information, but their identifi- cation goes beyond the purpose of this work.

An obvious broad implication of the adoption of the model here represented is, of course, that increased

cultural competence can reduce disparities in pro- vision of healthcare services. Conversely, at a more focused level, it is important to distinguish between the cultural competence of individual practitioners of healthcare and cultural competence at the organiz- ational level. At the individual level, some com- ponents of client-oriented cultural competence may be identified, for example, in the sensitivity and understanding of one’s own cultural identity, in having knowledge of other cultures’ beliefs, values and practices, and having the skills to interact effectively with clients’ diverse (sub)cultures. At the organiz- ational level, client-oriented cultural competence refers to a set of congruent policies, and structures that come together in a system: for example, creating structures for clients’ commitment, in order to involve them in the design and implementation of services they receive, or developing partnerships that acknowl- edge strengths and build upon a networks of support within diverse communities, taking into careful con- sideration the values and principles that underpin community engagement.

We believe that an organization is provided with cultural competence from the very moment in which it is created, insofar as its creation revolves around specific cultural values. These values will be acted upon through the organization’s own practices and procedures, the development of specific skills within its staff and the consequent creation of a multicultural environment. In this model, the organization is also open to dialoguing with its territory and is willing to constantly self-evaluate its own actions.

All dimensions must be addressed in the cultural competence development process. To assess whether an organization is culturally competent, we posit that it is not necessary, however, to follow the order of dimensions suggested here. Therefore, in our circular model, it is possible to start from any dimension to pro- ceed to the evaluation of any other one. For instance, if an organization is deemed culturally competent for the dimensions ‘Procedures and Practices’ and ‘Partnerships with community’, but it is not competent in regard to any other dimension, it is still possible to use those two successful dimensions to devise strategies to achieve competence in the others. When the tools are given to develop competence in all dimensions, the organization will have an orderly system and may operate indepen- dently in order to remain culturally competent.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Giovanni Di Stefano, PhD, is Assistant Professor of Work and Organizational Psychology at the University of Palermo, Italy. His research interests include the impact of organizational

Figure 1. The client-oriented model of cultural competence diagram.

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culture on human resource management practices, with particular emphasis on managing deviance and diversities, the organizational well-being, and the attachment to the workplace.

Eleonora Cataldo, psychologist,is an independent consultant and researcher based in Palermo, Italy. Specialist in person- nel selection, her research interests include the effectiveness of diversity management strategies.

Chiara Laghetti, psychologist,is an independent consultant and researcher based in Palermo, Italy. Her work and research interests include the multicultural diversity man- agement practices.

ORCID

Giovanni Di Stefano http://orcid.org/0000-0001-7276-549X

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