Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Summary of Key Models Related to Cultural Competence

Cultural Competence Continuum i, ii

Cultural competence at the organizational and individual level is an ongoing developmental process. The following chart is designed to highlight selected characteristics that organizations may demonstrate along two stages of the cultural competence continuum.


Moving Towards Cultural Competence

  • Cultural destructiveness acknowledges only one way of being and purposefully denies or outlaws any other cultural approaches.
  • Cultural incapacity supports the concept of separate but equal; marked by an inability to deal personally with multiple approaches but a willingness to accept their existence elsewhere.
  • Cultural blindness fosters an assumption that people are all basically alike, so what works with members of one culture should work within all other cultures.
  • Cultural pre-competence encourages learning and understanding of new ideas and solutions to improve performance or services.
  • Cultural competence involves actively seeking advice and consultation and a commitment to incorporating new knowledge and experiences into a wider range of practice.
  • Cultural proficiency involves holding cultural differences and diversity in the highest esteem, pro-activity regarding cultural differences, and promotion of improved cultural relations among diverse groups.

Theoretical frameworks for cultural competence training

Crandall, George, Marian and Davis  describe theoretical frameworks for the design of cultural competency training. They stress that educators must initially determine the level of competence desired appropriate to the developmental stages of the learners. The frameworks can be used to design course content and educational experiences and to help determine changes in students’ knowledge, skills and attitudes.

The Crondell, et al. models communication theories were used to inform the design, implementation and evaluation of diversity training. Howell’s communication theory describes levels of communication competence. Howell describes five levels as:

Level 1 unconscious competence
Level 2 conscious incompetence
Level 3 conscious competence
Level 4 unconscious competence
Level 5 unconscious supercompetence

Level of Competence (Howell)117 Behaviours Relate to Level of Cultural Competence (Culhane-Pera et al)117
Unconscious incompetence
(Level 1)
Level 1: No insight about the influence of culture on medical care
Conscious incompetence
(Level 2)
Level 2: Minimal emphasis on culture in medical setting
Conscious competence
(Level 3)
Level 3: Acceptance of the roles of cultural beliefs ,values and behaviours on health disease and treatments
Unconscious competence
(Level 4)
Level 4: Incorporation of cultural awareness into daily medical practice
Unconscious supercompetence
(Level 5)
Level 5: Integration of attention to culture into all areas of professional life

Crandall, SJ., George, G., Marian, GS., & Davis, S. (2003).  Applying Theory to the Design of Cultural Competency Training for Medical Student: A Case Study.  Academic Medicine, 78(6).

Models that reflect and/or describe cultural competence on a continuum

  • The Diversity Competency model is used to conduct an assessment of an organization’s diversity initiatives in nursing. Drivers, linkages, cultures and measurement are four main elements of the model.
  • Process model of cultural competence has constructs of cultural awareness, cultural knowledge, cultural skill, cultural encounters and cultural desire.
  • A five-part change process model for diversity management with performance indicators for each stage. The stages range from ‘discovery: emerging awareness of racial and ethnic diversity as a significant strategic issue’ to ‘revitalization’. The performance indicators are based on best practices in health services organizations and in the business sector.
  • A model for assessing and intervening in conflict in health care settings.

i, ii

  1. Definitions source: Adapted by T. Goode (2004) from: Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a Culturally Competent System of Care, Volume 1. Washington, DC: CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center. Available at: (accessed 11/05). Available at: (Accessed 7/28/06).
  2. Graph Source: Goode, T.D. and Harrison S. (2004). Cultural Competence Continuum. Policy Brief 3, 5. Washington, DC:National Center for Cultural Competence-Bureau of Primary Health Care Component, Georgetown University Child Development Center. (accessed 11/05)

These characteristics have been adapted and expanded from original work of Cross, et al., in several ways: (1) to ensure their relevance for health care organizations; (2) to incorporate salient items from the NCCCOs Policy Brief 1 checklist (Cohen & Goode, 1999), and (3) to emphasize the role of health care organizations in research.