The increasing scale of global migration has significantly transformed the demographic landscape of health care systems worldwide. This shift is marked not only by a growing number of patients from culturally and linguistically diverse (CALD) backgrounds but also by an increasingly heterogeneous clinical workforce (Destatis, 2023; Habermann & Stagge, 2015). While diversity enriches patient care, it also presents complex communication and interaction challenges in clinical settings. Patients from ethnic minority groups often experience disparities in health care, including unequal treatment, diagnostic errors, and reduced access to appropriate services. These inequalities are frequently attributed to language barriers (Lebano et al., 2020), culturally divergent health beliefs (Byrow, Pajak, Specker, & Nickerson, 2020), conflicting value systems (Dumke, Wilker, Hecker, & Neuner, 2024; Mösko, Gil-Martinez &, Schulz, 2013), and implicit bias or time constraints among health care professionals (Salam, Odenigbo, Newbold, Wanoush, & Schwartz, 2022; Karger, Lindtner-Rudolph, Mroczynski, Ziem, & Joksimovic, 2017).

A substantial body of literature confirms that culturally competent care can mitigate such disparities, leading to improved health equity, higher patient satisfaction, and better adherence to medical advice (Cheng, Emmanuel, Levy, & Jenkins, 2015; Curtis et al., 2019; Drewniak, Krones, & Wild, 2017; Horky, Andreola, Black, & Lossius, 2017). In response, cross-cultural training has become a widely adopted intervention across health systems. These programs aim to enhance health professionals’ cultural awareness, knowledge, and communication skills, and have demonstrated positive effects on individual competencies (Beck et al., 2024; Jongen, McCalman, & Bainbridge, 2018). Although evidence linking these trainings to patient-level outcomes remains limited, preliminary studies suggest promising results (Chae, Kim, Kim, Lee, & Park, 2020; Horvat, Horey, Romios, & Kis-Rigo, 2014). Additionally, higher cultural competence has been associated with reduced malpractice risk (Betancourt, 2006) and lower treatment costs due to improved communication and fewer misunderstandings (Schiaffino et al., 2020).

Despite these advancements, most cross-cultural training programs are profession-specific, designed primarily for doctors, nurses, or psychologists, and fail to reflect the inherently interdisciplinary nature of patient care in hospital environments. In practice, quality care depends on the coordinated interaction of multiple professionals, including not only clinical staff but also support roles such as cleaning personnel, interpreters, and administrative teams. These groups often have direct and meaningful contact with patients, yet are typically excluded from formal training efforts. This fragmentation limits the effectiveness of cultural competence initiatives and overlooks the broader organizational dimensions of intercultural communication in health care.

To address this critical gap, the present study develops, implements, and evaluates a multiprofessional cross-cultural training program aimed at a wide range of hospital staff engaged in direct patient interaction. The training incorporates evidence-based content drawn from existing cultural competence frameworks and adapts it to the needs of an interdisciplinary audience. Through a mixed-methods approach combining quantitative and qualitative data, the study assesses both the short-term impact of the training and the feasibility of integrating such programs into routine hospital operations. By targeting the often-overlooked non-clinical workforce alongside health professionals, this study offers a novel and inclusive model for institutional cultural competence development. To our knowledge, it is one of the first interventions to promote intercultural understanding across such a broad spectrum of hospital roles in a single unified training format.

Betancourt (2003) identified three distinct conceptual approaches to cross-cultural education: (A) the awareness/sensitivity approach, (B) the multicultural/categorical approach, and (C) the cross-cultural approach. Approach A emphasizes the development of attitudes such as curiosity, respect, and empathy among health care providers. It encourages participants to recognize how socio-cultural factors influence health beliefs and behaviors, engage in cultural self-reflection, and examine their own stereotypes and implicit biases.

Approach B focuses on the transmission of cultural knowledge. While this method can be beneficial in certain contexts—such as familiarizing professionals with the dominant culture of their practice environment—it carries the risk of reinforcing stereotypes or oversimplifying complex cultural identities if not handled with care. Finally, Approach C emphasizes the development of cross-cultural skills and practical tools, such as effective communication techniques and participatory decision-making strategies. Although these approaches are presented as distinct, Betancourt (2003) emphasizes that effective cross-cultural training often integrates elements from all three to comprehensively strengthen participants’ cultural competence.

Numerous studies have evaluated the effectiveness of various cross-cultural training designs for health professionals and medical students. These include multi-method curricula (Sarvarizadeh, Miri, Darban, & Farokhzadian, 2024), web-based cultural competence courses (Rahimi, Khodabandeh Shahraki, Fatehi, & Farikhzadian, 2023), community immersion programs (Pak-Gorstein et al., 2018), and interactive workshops (Kelley, Haas, Felber, Tracis, & Davis, 2019)—all of which have been shown to improve cultural competence in different professional settings. However, such trainings are typically tailored to individual professional groups—physicians (Corral, Johnson, Shelton, & Glass, 2017), nurses (Gradellini et al., 2021; Osmancevic, Steiner, Großschädl, Lohrmann, & Schoberer, 2025), or psychotherapists (Benuto, Casas, & O’Donohue, 2018)—and rarely reflect the interprofessional nature of clinical practice. Yet, in everyday hospital care, collaboration among diverse professional roles is essential.

Although a few initial efforts have been made to implement multiprofessional cross-cultural training in hospital settings (e.g., Dimitrova, Siebert, Borde, & Sehouli, 2022), systematic evaluations of their effectiveness and broader institutional integration remain limited. This highlights a significant gap in the current literature and underscores the need for inclusive training programs that address the diverse roles involved in patient care.

The Healthy Diversity project—Curriculum to Enhance Cultural Competence in Patient Care—was developed in response to this gap. Drawing on Betancourt’s integrative framework and informed by previous national initiatives on transcultural training (von Lersner, Baschin, Wormeck, & Mösko, 2016; Mews et al., 2018), the program combined all three educational approaches to address attitudes, knowledge, and skills comprehensively. It was specifically designed as a multiprofessional, interdisciplinary training involving a wide spectrum of hospital staff, including medical-technical assistants, nurses, physicians, and non-clinical personnel such as service and security staff. The program not only aimed to enhance individual cultural competence but also to foster cross-functional collaboration within increasingly diverse health care teams. Based on the positive evaluation outcomes, a follow-up initiative was launched to establish a sustainable training and mentoring system through the development of hospital-based cross-cultural brokers..

Training development

To develop an application-oriented curriculum for a cross-cultural training program tailored to a multiprofessional target group, we first conducted a review of existing literature on evaluated training models.

The developmental process involved three key stakeholder groups, firstly an international advisory board comprising four experts in adult education, cross-cultural medicine, migrant organizations, and the Hamburg Medical Chamber. Secondly, a stakeholder group of 13 representatives from various hospital-based professions involved in patient care, including emergency room staff, medical laboratory assistants, nurses, patient hotline operators, physical therapists, physicians, physiotherapists, service assistants, cleaners, social workers, spiritual care providers, and supply-chain assistants. Thirdly, a trainer group consisting of six academics with interdisciplinary backgrounds in Clinical Interpreting, Cultural Coaching, Modern Philology, Health Care Chaplaincy, Islamic Studies, Law, and Psychology.

Over the course of four structured workshops, the participants identified key cross-cultural challenges commonly encountered in day-to-day clinical practice. Based on these insights, the training concept was iteratively refined to ensure practical relevance. A comprehensive list of learning objectives was subsequently compiled and categorized into three domains: attitudes, knowledge, and skills (see Online Resource 1). These objectives served as the foundation for developing the curriculum and instructional materials for each training session.

Training Implementation

The resulting pilot program, titled Healthy Diversity: Cultural Competencies in Everyday Hospital Routines, consisted of four full training days (7.5 hours each), covering a total of seven modules (see Table 1). The sessions were facilitated primarily in tandem by the six academics mentioned earlier, each of whom brought both academic expertise and practical familiarity with clinical settings. A variety of didactic methods were employed, including case reports, role-plays, mindfulness-based exercises, and small-group work, to ensure the training was both interactive and practice-oriented.

The training was open to all hospital employees with direct patient contact. At the time of implementation, this included more than 6,000 individuals such as physicians, nurses, therapists, and support staff. The program was held on-site at the hospital in June 2018, with daily sessions running from 9:00 a.m. to 4:30 p.m. Participation was voluntary and free of charge. Upon successful completion of all training modules, participants received the certificate Intercultural Competencies in Everyday Hospital Life, as well as continuing education credits from the state’s Medical Association and the Registry of Professional Nurses.

To promote enrollment, the training was advertised through several internal channels, including the hospital’s newsletter, the website of its Academy for Education and Career, departmental meetings, mailing lists for various professional groups, and printed flyers.

The training was part of the broader initiative Healthy Diversity – Curriculum for Strengthening Intercultural Competencies in Patient Care, funded by the Robert Bosch Stiftung and additionally supported by the hospital’s Academy for Education and Career.

Sociodemographics

Relevant sample characteristics are presented in Table 2. All 17 participants reported regular contact, at least once a month, with individuals from a migration background, both professionally and privately. Six participants had previously attended intercultural training sessions.

Achievements and Constraints

As part of this project, a multiprofessional cross-cultural training program was developed, piloted, and evaluated to address the needs of all professional groups involved in direct patient care. The training curriculum was designed through an iterative and collaborative process involving professional experts and academics. This approach ensured the program was tailored to the hospital setting and responsive to the diverse educational backgrounds of the target participants. Previous research has shown that involving target groups in the development of educational interventions enhances their quality and relevance (Brett et al., 2014). In our case, this inclusive process brought attention to issues—such as discrimination against segments of the clinical workforce—that might have otherwise been overlooked if the curriculum had been designed solely from a top-down perspective.

When asked about the skills and knowledge they gained, participants reported increased understanding of behaviors previously perceived as unfamiliar or “foreign,” deeper reflection on their own cultural heritage and biases, and reduced insecurities when working with culturally diverse patients. These outcomes align with the training's intended learning objectives (Online Resource 1). While the quantitative pre-post analysis showed descriptive improvements in cross-cultural attitudes, skills, and knowledge/awareness, the changes were not statistically significant. This mirrors findings from other studies where the short duration of training was cited as a possible limitation (Majda, Zalewka-Puchala, Bodys-Cupak, Kurowska, & Barzykowski, 2021). Furthermore, given that many participants may have already possessed a relatively high baseline level of cultural competence—particularly in the motivation/curiosity dimension—the CCCHP may have been subject to ceiling effects, limiting its ability to detect meaningful change. This concern is supported by the original validation study, which reported positively skewed subscale distributions (Bernhard et al., 2015).Sensitivity analysis revealed that a large sample size would have been necessary to detect medium effect sizes reliably. For instance, a sample of at least 45 participants would be required to detect a medium effect with adequate power (Cohen, 1988). Consequently, the small sample size likely reduced the statistical power of our findings. Nevertheless, significant improvements in participants' self-rated ability to meet cross-cultural challenges, knowledge of legal aspects in health care, and capacity to respond appropriately to discrimination are particularly noteworthy. Future studies would benefit from complementing self-assessment tools with external evaluation methods, such as structured field observations, to yield more objective assessments of cultural competence development.

A substantial body of evidence confirms the effectiveness of cultural competence training in improving the knowledge, attitudes, and skills of health professionals (Beck et al., 2024; Chae et al., 2020). However, the vast majority of these studies focus on single professional groups. Our findings suggest that similar positive outcomes may be achievable through multiprofessional interventions, though further research is warranted to validate these preliminary insights.

The limited participation in our study is another important constraint. Only 17 participants enrolled, representing a small fraction of the hospital's total workforce. Several factors may explain this. The training consisted of four full-day sessions, which are difficult to accommodate within rotating shifts. Some participants had to be officially released from work, and two even attended during their personal vacation time. It is plausible that supervisors were not uniformly supportive of release time, and that only those staff with strong intrinsic motivation participated. The absence of physicians in the training further suggests systemic barriers, such as time constraints during clinical duties. Prior research has shown that physicians—particularly in high-pressure specialties like oncology—may show less interest in cultural competence training than other professional groups (Weber, Sulstarova, & Singy, 2016). To improve participation, institutions should consider offering protected time or designing more flexible training formats, such as modular or online sessions.

The strengths of this study include the preceding needs assessment, the participatory development process, and the inclusion of traditionally overlooked professional groups such as cleaning staff and service assistants. These individuals are frequently in contact with patients and often play informal roles, including ad-hoc interpreting (Jors, Tietgen, Xander, Momm, & Becker, 2017; Vance, Ackerman-Barger, Murray-García. & Cothran, 2022). Many of these staff members themselves have migration backgrounds (Mueller, 2022), further underscoring the importance of equipping them with cultural competence tools.

Recommendations

A general challenge in providing voluntary training for staff is the lack of participation (Ilvig et al., 2018), as seen in our pilot, in which only 17 out of more than 6,000 staff members attended the voluntary training. Thus, a sustainable goal is to strengthen those staff members who are interested in cultural sensitivity and enable them to become advocates for this topic within their units or departments.

In order to sustainably strengthen intercultural communication within a hospital, it is necessary to view intercultural openness as an organizational development process. Consequently, to empower participants of single cross-cultural training sessions in the long term, a sustainable training concept to become a cultural broker (Figure 1) was developed, following the same procedure as the pilot program described above. The education program for Ethnic Patient Coordinators at Odense University Hospital in Denmark served as a guiding framework (Nielsen, Korsholm, Mottelson, & Sodemann, 2019).

As part of a holistic training initiative for so-called “cultural brokers,” the pilot program will be expanded to include advanced training courses, a peer-group network, and a coordinating and counselling center. These components are intended to support long-term learning outcomes and emphasize the institution's responsibility in promoting intercultural competence.

Such structures have already proven successful in other fields where health care organizations needed to be empowered to manage complex challenges (Sampson, Vickerstaff, Lietz, & Orrell, 2017). Strengthened and sensitized by the pilot training, those interested in becoming cultural brokers will receive several days of further in-depth instruction. This will include, for example, a detailed study of intercultural communication, the relationship between migration, identity, and health, and quality management in intercultural and interprofessional contexts. After training, they will serve as contact persons for colleagues and patients on culturally sensitive issues, functioning in a mentoring role. They may also conduct short internal training sessions (e.g., on cross-cultural awareness) or initiate small projects within their units (e.g., designing a poster on different religions and their impact on health and illness concepts). In this way, they will act as an interface between employees and hospital management.

Cultural brokers will receive monthly supervision and attend additional training sessions (six times per year) to deepen their expertise and receive continuous support. Clinic-wide, they will benefit from peer networks, especially for cross-unit projects. Employees will be released on an hourly basis to accommodate the additional responsibilities involved in their work as cultural brokers. The program will be accessible to all professional groups involved in patient care.

Interdisciplinary teamwork is known to improve patient satisfaction (O’Leary, Sehgal, Terell, Williams, & High Performance Teams and the Hospital of the Future Project Team, 2012), and organizational cultural competence has been linked to better teamwork climate (Kumra et al., 2020). Therefore, offering cultural competence training to multiprofessional teams is not only equitable but essential for improving the overall quality of care.

After participation in the training, participants showed significant increases in their cross-cultural competencies. Furthermore, we assume that developing and implementing a sustainable mentoring program for cultural brokers will contribute to the long-term establishment of a culturally competent hospital. In the short term, we foresee three primary advantages: (1) a culturally competent workforce will improve patient satisfaction and reduce clinical risk (Govere & Govere, 2016); (2) enhancing cultural competence will improve staff safety, satisfaction, and team cohesion (Kumra et al., 2020); and (3) in response to increasing shortages of skilled workers and the effects of brain drain, providing accessible and supportive training programs may help retain qualified staff (de Vries et al., 2023; Mosadeghrad, Ferlie, & Rosenberg, 2011).

Acknowledgement Statement: The authors would like to thank Christian Hannig, Martina Simon, Dr. Christina Kayales, Insa Graefe, and Rabia Tayyeb for their participation in the conceptualization of the training and for conducting the training. Furthermore, the authors would like to thank the members of the international expert advisory board for their involvement in developing the training: Dr. Jens Friebe (German Institute for Adult Education), Dr. Sofie Bäärbhielm (Transcultural Centre of the St. Göran Hospital, Stockholm), Sylvania Gerlich (Self-help organization for migrants), Ms. Timpe (Training academy, Medical Chamber of Hamburg).

Conflicts of interest: The authors have no competing interests to declare that are relevant to the content of this article.

Authors' contribution statements: Heide Lindtner-Rudolph: Conceptualization, Project Administration, Methodology, Data Collection, Data Analysis, Writing – Original Draft, Writing – Review & Editing. Vera Mohwinkel: Data Analysis, Writing – Original Draft, Writing – Review & Editing. Mike Mösko: Conceptualization, Funding Acquisition, Methodology, Data Analysis, Writing – Original Draft, Writing – Review & Editing. The final manuscript has been read and approved by all authors..

Funding statements: This study was financially supported by the Robert Bosch Stiftung, Stuttgart, Germany.

Data availability statement: The datasets used and/or analysed during the current study are available from the corresponding author on request.

Ethics approval statement: According to the local Psychological Ethics Committee of the University Medical Centre Hamburg-Eppendorf, ethical approval was not required. No patient data has been collected within this study. All participants were informed about the purpose of the training evaluation, data privacy policy, voluntary participation, and the intention to publish and gave informed consent, according to the principles expressed in the Declaration of Helsinki.

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