Research

Cultural models within general practice training: a scoping review

Lisa Collins, Helen Reid, Hinemoa Elder and Grainne P. Kearney
BJGP Open 30 June 2026; BJGPO.2025.0203. DOI: https://doi.org/10.3399/BJGPO.2025.0203

Abstract

Background Doctors training to become GPs (GPs-in-training) are increasingly working in cross-cultural consultations. Cultural models have been developed as frameworks to better equip medical professionals towards more culturally appropriate health care, with potential to improve equity in healthcare systems.

Aim To map evidence on models of cultural competence, cultural safety, cultural humility, and transcultural care within GP training worldwide.

Design & setting A scoping review was conducted using Arksey and O’Malley’s framework.

Method Searches were conducted across three databases, extending to grey literature such as curricula. Articles were extracted, reviewed, and analysed according to inclusion criteria.

Results Nineteen articles met inclusion criteria. Publications ranged from 2008–2024, with 10 articles from Australia, five from the US, two from Sweden, one from Canada, and one from The Netherlands. The following three themes were generated: unlearning; informal learning; and informed learning. The literature illustrates that there are gaps in knowledge of what the models are and how best to practise and teach them within GP education.

Conclusion Cultural models advocate for cultural awareness, examine power imbalances, and encourage self-reflexivity and learning. Integrating cultural models into health care can better serve all patients, with potential to reduce health inequities. There also needs to be an adaptation to learning in traditional GP consultations with a focus on how our own biases impact the care that we provide, and a more formal learning of cultural models best delivered by GP trainers in partnership with cultural mentors.

How this fits in

Presenting to general practice is often the first step that people take when seeking health care. GPs are increasingly working in cross-cultural consultations, so it is vital their care is culturally appropriate. A patient’s culture is intrinsic to who they are, the beliefs they hold, and decisions they make. As healthcare professionals, culture impacts the care delivered. Cultural model frameworks have emerged as a means of informing culturally appropriate healthcare systems. Cultural competence, cultural humility, cultural safety, and transcultural care are examples of these cultural models. These models provide medical professionals in training not only with the tools to move beyond the knowledge and skills necessary to deliver better patient care, but also the understanding to reflect on delivery of this care as individuals, in order to address power imbalances and potentially reduce health inequities.

Introduction

Doctors training to become GPs are increasingly working in cross-cultural consultations; the term ‘cross-cultural’ referring to when, ‘patients and doctors do not share language or culture’.1 Evidence shows that shared decision making regarding treatment and understanding between GPs and patients is more problematic in cross-cultural consultations.1–3 Language barriers, time constraints, interpreter use, and lack of familiarity with cultural belief systems have all been reported as examples of the challenges faced by GPs.4–6

Recognising and acknowledging how a person’s culture influences disease, health, and treatment has been identified as central to delivering effective health care.7 Acknowledging the role of cultural awareness and its potential impact on reducing health inequities is an ongoing area of research.8 Limitations in cultural literacy have been said to contribute to poorer communication and worse outcomes for marginalised groups.9 Recognising and reflecting on how our own beliefs and unconscious biases as healthcare providers might impact the care we provide is an area less researched.10 The intersectionality of systemic racism, health inequities, and cultural models is an area of ongoing research.11 A systematic review found that little is known about the extent of healthcare provider racism or how best to measure it.12 Systemic racism has a profound negative impact on health outcomes, with racism identified as a social determinant of health and a significant contributor to widening health inequities.8,13–15

Cultural model frameworks have emerged as a means of providing culturally specific care thus better serving all patients. Few studies have focused on training GPs in cultural models.10

We have elected to use the term ‘general practice’ to encompass general practice, family medicine, and primary care settings worldwide.

Cultural models

Cultural competency, which is perhaps the best-known concept, is a broad model16,17 that advocates for patient-centred care with skills, knowledge, and attitudes necessary to provide quality care that can reduce health inequities.18–25 Criticism of cultural competence has focused on its failure to examine inherent power dynamics between patients and doctors and how healthcare professionals can never be truly ‘competent’ in understanding another person’s culture.18,22,26–28 Cultural humility emerged in 1998 to address these perceived limitations,29 eliminating power imbalances in ‘a process of openness, self-awareness, being egoless and incorporating self-reflection and critique after willingly interacting with diverse individuals’.30 Cultural humility strives for self-reflexivity and a willingness to learn from patients about their experiences. A further model, cultural safety, originated in New Zealand in response to structural racism experienced by the Māori population.31,32 Coined by Māori nurse, Irahapeti Ramsden,33 cultural safety places a focus on the healthcare professional and the impact that their own cultural systems can have on the doctor–patient relationship. It acknowledges the inherent power imbalance between doctor and patient and ensures that healthcare professionals are both culturally and clinically safe.11,34

There are no studies that map the application of these cultural models, and attitudes towards them, within GP training schemes worldwide and any disparities that exist between different training schemes.

Method

This scoping review followed the Arksey and O’Malley framework35 and was informed by updated guidance on scoping review methodology.36–38 A full scoping review protocol can be accessed elsewhere.39

Research aim

To map the literature around the use of cultural models in GP training.

Inclusion criteria

The main inclusion criteria (Table 1) included any study with a primary objective to define, discuss, or explore ‘cultural competence’, ‘cultural safety’, or ‘cultural humility’ within GP training worldwide. ‘Transcultural care’ was identified as an additional term after preliminary searches and incorporated into the next iteration of the search strategy. We included doctors in GP training and those who practise as ‘family medicine residents’, another term used for GPs.

View this table:
Table 1. Inclusion and exclusion criteria

Search strategy

Embase, MEDLINE, and Web of Science Core Collection were selected to identify articles. Search strategies combining key terms were developed with the aid of a subject librarian (Supplementary Appendix 1). We supplemented this search by hand searching reference lists of included articles and curricula.

Study selection

Titles and abstracts were screened against the inclusion criteria by two independent reviewers. Rayyan software was used to manage study selection.40 Differences in selection were resolved through discussion. An additional reviewer was available to resolve disputes, but this was not required. Non-English articles were translated using Google Translate.41

Data extraction, analysis, and presentation

As set out by the JBI (formerly known as the Joanna Briggs Institute),36 a modified data extraction table was developed for data collection and coding (Supplementary Table 1). This process involved repeatedly reading articles; identifying, characterising, and summarising key findings; and inductively generating codes related to the research question. Related codes were grouped to develop major themes. This iterative process was critically analysed by the research team with key findings and implications for future research discussed. In line with JBI methodology and the Arksey and O’Malley framework for scoping studies, our review did not seek to assess quality of evidence but rather provide a descriptive analysis of the evidence collated.35,38

Results

Descriptive results

Nineteen peer-reviewed articles were included. Figure 1 presents the publication selection process. Publications ranged from 2008–2024, with 10 articles from Australia10,42–50 five from the US7,51–54 two from Sweden55,56, one from Canada57, and one from The Netherlands18. Methodologies varied, including four mixed-methods reviews43–45,49, five quantitative reviews7,18,47,53,54, four qualitative studies46,48,50,55, three literature reviews10,56,57, and three commentaries including curriculum reviews.42,51,52 Seven studies represent two areas of work (Watt et al 10,46,47 and Brumpton et al 42–45), which is not uncommon in scoping reviews owing to their exploratory nature.

Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram
Figure 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram

Of the cultural models, cultural competency was explored most frequently (n = 15), followed by cultural safety (n = 5) and cultural humility (n = 3). Transcultural care was not covered by any of the identified articles. One study advocated for a new term, ‘cultural proficiency’ but this was not something reflected elsewhere in the studies retrieved.51

Thematic results

From our in-depth review, we generated the following themes: unlearning; informal learning; and informed learning (Figure 2).

A thematic framework of cultural models
Figure 2. A thematic framework of cultural models

Unlearning

One of the core skills developed throughout GP training worldwide is conducting effective consultations, which should incorporate the patient’s perspective.58,59 Within the literature, there is an acknowledgement that consulting with different cultures requires an adaptation to the traditional consultation that perhaps hasn’t been achieved, or even sought, within GP training.43,44 Deeper understanding of cultural models results in an awareness of the potentially silenced patient perspective.10 The very essence of cultural safety is that it is determined by the patient, yet our review highlighted that GPs-in-training didn’t always recognise this as fundamental.43 Brumpton et al (2024) state that GP registrars (a UK term for GPs-in-training) seemed to practise by the common adage of ‘treat others the way you want to be treated’ and failed to recognise that cultural safety should be determined by those being treated, that is, ‘treat others the way they want to be treated’. Brumpton et al suggest that, for this to happen, there needs to be a ‘critical unlearning’, a requirement to shift attitudes and to progress culturally safe treatment and care.43

Several studies identified that understanding and practice of cultural models first requires individuals to acknowledge their own biases and stereotypes, which may impact their ability to provide culturally appropriate care.10,43,46,51,52 Racism is a social determinant of health60 and how our own beliefs and biases can influence patient consultations was a recurring point of discussion. Brumpton et al (2024) propose that we need to ‘explore ways of awakening awareness of racism in registrars’ consciousness’.45 They state that GPs-in-training fail to acknowledge power dynamics in consultations and the impact of their own biases, potentially perpetuating health inequities; ‘the combined effects of colonisation, racism, marginalisation, and other social determinants of health continue to affect the health outcomes of Aboriginal and Torres Strait Islander people …. factors … remaining either invisible to registrars or dismissed.’45 Watt et al (2016) agreed that cultural competence development of GP registrars requires more focus, which should include ‘training in non-conscious bias, anti-racism training and cultural self-reflectiveness’.10 The practice of reflection and specifically, cultural self-reflection, which ‘reflects on the role of the clinician, their culture and place within society’ was identified as an essential element to practising the models effectively.46,59

Informal learning

Where cultural models are incorporated into GP training schemes, most learning occurs informally.10,46,47,53,55,56 The traditional belief has been that exposure to diverse consultations synergistically leads to more culturally competent practitioners. One study advocated for ‘cultural immersion’ as a means of improving cultural competency.52 However, this review also identified that to reinforce culturally competent practice, exposure to diverse populations needed to occur alongside formal teaching exploring the social, cultural, and economic factors that contribute to healthcare outcomes.47,53

A common theme identified was that with the informality of cultural model teaching within GP training, there was no clearly identified educator leading this learning.10,56 GP supervisors either didn’t perceive cultural model training as a priority, weren’t familiar with the terms, or lacked confidence to deliver training in cultural competency, cultural humility, or cultural safety.10,46,48 This review identified that more formal training of cultural models may assist in developing a deeper understanding and practice of these frameworks.45,46

The review identified that attitudes towards cultural models were often negative, viewing cultural competence as ‘unscientific’ with cultural education an ‘afterthought’ in medical training.49 In Australian GP training schemes, cultural competence training was found to be undervalued despite being a key stated aim of training.48 However, GPs-in-training were found to value cultural education perceiving cultural competency to be important but their training as inadequate.10,18,49,54

Informed learning

Knowledge of formal cultural models among GPs-in-training was found to be lacking with little focus placed within GP training curricula on what the models were and how they could be incorporated into professional life.10,18,43 Watt’s integrative review found that in Australia, Canada, UK, Sweden, Norway, and The Netherlands, training in cultural competence was underdeveloped but desired by GPs-in-training.10 Without a clear understanding of what the cultural models are, there is potential for hindering implementation and effective outcomes related to these frameworks. This review identified that knowledge and practice would be aided by a range of strategies, including more consistent definitions, workshops, curricular integration and facilitation by experienced mentors and educators.7,10,43 One study explored how virtual patients could be a useful tool for exploring cultural competence training in general practice.55 Considering assessment, knowledge and practice of cultural models could be assessed effectively within Objective Structured Clinical Examinations (OSCEs) and validated instruments.17,42

GP trainers play a central role in the development of GPs-in-training. GPs-in-training identified GP trainers as an appropriate person to teach them about cultural models.10,46,47 Additionally, a common theme was the key role that cultural mentors can have in GP training schemes.10,48,49 Cultural mentors, representatives from within a certain cultural group, can aid communication and bridge understanding between doctors and patients. Cultural mentors also tend to have expertise in cultural issues and have leadership roles in their communities.49 Perhaps even more important was that knowledge of the cultural frameworks needs to be accompanied by knowledge of the historical, cultural, social, medical, and system factors that impact on healthcare delivery, and cultural mentors can offer a unique perspective. There may be potential for cultural mentors to work in partnership with GP trainers, to inform the learning.

Discussion

Summary

This is the first scoping review mapping current evidence on cultural competence, cultural safety, cultural humility, and transcultural care within GP training schemes worldwide. Our main findings include that, for these models to be practised, there first needs to be an unlearning within our GP training schemes, which demands self-reflection and an acknowledgment of our own biases and stereotypes. Even where the models are practised, most learning occurs informally; moving to a more informed learning experience requires better knowledge and teaching of the models, which can be aided by cultural mentors.

Few studies have focused on the training of GPs in cultural models.26 The majority of articles were Australian based where culturally safe general practice is a national health priority.45 None of the articles originated in the UK, which is potentially because before 2025 cultural models did not appear in UK postgraduate GP curricula.61 That none of the articles originated in New Zealand was surprising, despite cultural safety being coined as a term in the country and the models considered integral to all medical disciplines. Several studies originating in New Zealand have explored the use of the models in disciplines outside general practice.31,62,63

GPs-in-training express a lack of knowledge in cultural models with most learning occurring informally, based on exposure or experiential learning, resulting in opportunistic learning beyond any formal teaching, which is echoed across other medical disciplines.64–67 GPs-in-training largely identified GP trainers as most appropriate to teach and demonstrate this learning. GP trainers, however, felt inadequately trained and uninformed to lead this training.

Many studies acknowledge that the relationship between cultural models and improving patient outcomes needs further exploration.10,53,57 Few studies also give voice to the patient’s perspective. Given the fundamental importance of the patient’s perspective within culturally safe care, this paucity demands further research.

Knowledge alone of different cultural backgrounds does not equate to culturally competent practice.19 Critical self-reflection and consultation skills, important aspects of these cultural models, appeared to be lacking among GP training schemes. Furthermore, that medical professionals poorly reflect on our own biases and stereotypes and how the dismantling of racism can address health inequalities is inferenced throughout. Research in other medical domains has found that even where cultural safety policies are in place, the impact of inherent racism among many healthcare professionals is so deeply embedded that there is a lack of understanding of what these models are and how they can be implemented.13 Ongoing critical reflection of all healthcare professionals’ attitudes, knowledge, and behaviours in healthcare delivery is an integral aspect of what it is to be a culturally competent and (culturally) safe practitioner.

There is an intrinsic link between clinical safety and cultural safety but understanding what characteristics define a culturally safe consultation, particularly as determined by the patient, is an evolving and developing area of research and discussion.59,66 Cultural mentors may provide a pivotal bridge between patient and GP-in-training in achieving better health outcomes.

Strengths and limitations

This review entailed a rigorous search for cultural models as relevant to GP training. Several researchers were involved in data collection and analysis, enhancing review rigour. A subject librarian supported the searches and no limitations were placed on year of publication.

Although we were open to including articles published in any language, our database searches were limited to the English terms of ‘cultural competence’, ‘cultural safety’, ‘cultural humility’, and ‘transcultural care’. This scoping review was also limited to GP training; we recognise that there is likely literature relevant to this group from the wider multidisciplinary primary care team.

Furthermore, owing to the nature of scoping reviews we did not assess the quality of evidence but offered an overview of this topic, mapping and identifying relevant studies that met our inclusion criteria.

Comparison with existing literature

Cultural competence, cultural humility, cultural safety, and transcultural care have developed as models to support culturally appropriate care. This scoping review set out to map and synthesise literature on their prevalence and use within GP training. For this learning to be incorporated into training there needs to be an improved knowledge about the models, an adaptation to the traditional GP consultation, an awareness of impacts of own biases on care, and a more formal learning of models that could be potentially delivered by GP trainers and cultural mentors.

Implications for research and practice

This scoping review places focus on how knowledge and use of cultural models can help GPs-in-training and their trainers advocate for cultural awareness, examine power imbalances, and encourage self-reflexivity and informed learning. Culture is not static but a changing system of beliefs and values. Learning is also never linear. Through generation of three overarching themes, this review has identified that first an unlearning is required in GP training. Where learning is occurring, this appears informal, with GPs-in-training expressing desire for more formal learning led by trainers, potentially in partnership and informed by cultural mentors. Where other countries, such as Australia, have historically embedded these models into their GP training curricula, only recently has the Royal College of General Practitioners in the UK updated the curricula to reflect this learning, demonstrating an ongoing commitment to this work.45,61,68 Integrating cultural models into health care and healthcare training can better serve patients, potentially reduce health inequities, and strive towards a care system of treating patients the way they wish to be treated rather than the way their health care professional assumes they should be treated. Moving forward, we hope to use the learning from this review to explore the roles of cultural models and cultural mentors in shaping perceptions of the Traveller community, a minority group in the UK and the Republic of Ireland with distinct cultural practices and beliefs.

Notes

Funding

Lisa Collins was funded by Northern Ireland Research and Development through their support of the General Practice Academic and Research Training Scheme.

Ethical approval

No ethical approval was required for this study.

Provenance

Freely submitted; externally peer reviewed.

Data

The dataset relied on in this article is available from the corresponding author on reasonable request.

Acknowledgements

The authors would like to thank Richard Fallis, Queen’s University Belfast librarian, for their support in devising the search strategy and running the searches.

Competing interests

The authors declare that no competing interests exist.

  • Received September 25, 2025.
  • Accepted November 11, 2025.

This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)

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Cultural models within general practice training: a scoping review
Lisa Collins, Helen Reid, Hinemoa Elder, Grainne P. Kearney
BJGP Open 30 June 2026; BJGPO.2025.0203. DOI: 10.3399/BJGPO.2025.0203
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British Journal of General Practice