Navigating the multifaceted landscape of culture and social work: A qualitative evidence synthesis of cultural competence and cultural sensitivity in practice

Faced with increased global migration, there is a growing concern that social workers need more training in- and knowledge of culture and ethnicity. These understandings have come to influence research, education, practice, codes of ethics and organizational policy, constituting a multicultural discourse within the field of social work. Social workers are expected to have cultural competence, and exercise cultural sensitivity in their practice. However, a clear and consistent understanding of what it means to be culturally competent or culturally sensitive is missing, and there seems to be little consensus in how to define and apply these concepts, both within research and practice. The aim of this qualitative evidence synthesis is to synthesize what previous empirical research reports about social workers’ understandings and experiences when operationalizing the concepts into practice. Through data-based and a manual journal search, 12 qualitative empirical studies were included in the synthesis. Our analysis describes four main challenges in the studies’ efforts to operationalize the cultural concepts in social work practice: 1) Who to define as culturally diverse service-users; 2) What aspects of culture to consider in the encounters with culturally diverse service-users; 3) How to consider and approach these aspects of culture, and 4) the capacity to work in a culturally appropriate manner within the organizational context where this work is undertaken. The literature acknowledges these challenges to varying degrees. We summarize the four challenges in a model, and argue that the model can be useful in further awareness-raising, development and integration of our understandings of cross-cultural social work. By depicting the essential questions of who, what, how and where to employ the concepts into practice, we aim to assist scholars, practitioners and educators to help navigate the multifaceted landscape of culture and social work.


Introduction
Over the last few decades, the multicultural discourse has gained increased significance within the field of social work. Researchers argue that the impact of globalization and migration poses new demands and challenges on social workers (Azzopardi & McNeill, 2016;Boyle & Springer, 2001;Green et al., 2016), with a growing body of research examining how social workers should provide culturally competent and sensitive services to diverse service-users. Culture is a complex and ambiguous concept. As early as the 1950s, Kroeber and Kluckhohn (1952) identified more than 100 anthropological definitions of culture. Adding the word 'competent' to culture unsurprisingly generated countless descriptions. By the millennium, 'literally hundreds of conceptual definitions' of cultural competence existed (Boyle & Springer, 2001, p. 55). Cultural competence is also just one of the concepts describing how social workers should work with service-users from culturally diverse backgrounds.
In this article, instead of providing a theoretical definition of cultural competence and cultural sensitivity, we do a qualitative evidence synthesis of previous empirical research and synthesize what they report about social workers' understandings and experiences when operationalizing the concepts into practice. In order to operationalize a concept, social workers have to both create a mental definition of the concept and turn these mental definitions into something applicable in their practice with specific clients (Volckmar-Eeg, 2020). In other words, we explore how social workers understand the concepts and make practical use of them, and the challenges they experience in this work.
It is beyond the scope of this article to list and define all the various concepts of cultural competence or sensitivity that exist. We note that the most frequently used concepts are cultural competence (Horevitz et al., 2013), cultural skills (Kandylaki, 2005) cultural sensitivity (Fernández-Borrero et al., 2016) and cultural awareness (Yan, 2005). The concepts of cultural competence and cultural sensitivity represent two main strands in the literature. One focuses on social workers' competence or skills to work with cultural issues, while the other emphasizes social workers' reflective processes, respect and humility toward cultural differences, as well as social workers' attention toand awareness of cultural aspects in their practice. We use the notion of cultural concepts as a collective term referring to cultural competence and cultural sensitivity.
Although some researchers engage with a broad understanding of culture, including sexuality (Charnley & Langley, 2007) and disability (Dupré, 2012), in most of the literature within the multicultural discourse of social work, culture is connected to ethnicity, race or religion. Researchers portray 'social work with ethnic minorities as an area that requires specific knowledge and competence' (Rugkåsa & Ylvisaker, 2019, p. 5). International and national guidelines outline social workers' responsibilities in working competently with culturally diverse people (IFSW, 2018;NASW, 2017). The rationale behind the cultural concepts is that if social workers employ practices described as culturally competent or culturally sensitive, the services to minority service-users will improve. However, several studies argue that social workers fail to work in a culturally appropriate way, by either overemphasizing (Anis, 2005;Rugkåsa & Ylvisaker, 2019) or underestimating (Ploesser & Mecheril, 2012) the significance of culture in their interaction with clients. Consequently, recommendations for practice diverge. Moreover, as the concepts are mostly theoretical descriptions of practice, they do not necessarily capture the empirical reality of social workers and the challenges they encounter in their cross-cultural work. Making sense of-and making use of these theoretical and somewhat ambiguous concepts in practice therefore pose potential challenges for the social workers, and it is difficult to know whether the concepts are applicable for social workers in practice. This is where our study makes a novel contribution.
Previous literature reviews within this field seem to a large extent to be focused on specific populations (Jackson & Hodge, 2010;Poon & Lee, 2019), specific interventions (Horevitz et al., 2013;Jackson & Samuels, 2011) or on defining or explaining the concepts (Henderson et al., 2018;Jackson & Samuels, 2011;Poon & Lee, 2019;Suh, 2004). Most of them are within the field of health science, and the social workers and their reality are not present.
In this qualitative evidence synthesis, we ask the following research question: What challenges do social workers experience in their efforts to operationalize the cultural concepts in practice? This will provide insight, not just into how the cultural concepts are understood by social workers, but also the applicability of the concepts in social work practice.
We acknowledge that the use of the terms 'service-user' and 'client' in social work are debated (Hübner, 2014). Because the data in our study consists of previous research, and because we want to stay true to their original intention and meaning, we will comply with the terms as used in our data. Additionally, since the studies differ in whether they use the term service-user or client, we will use the terms interchangeably.
After a presentation of our search strategy and data, we introduce our findings. Our synthesis shows that the studies report four main challenges in their efforts to operationalize the cultural concepts in social work practice. We summarize these challenges in a model, and discuss these findings in light of scholarly debates of cross-cultural social work.

Methods and data
This study is based on a synthesis of qualitative evidence Grant & Booth, 2009;Hannes & Macaitis, 2012;Noyes et al., 2019). A qualitative evidence synthesis is particularly good to explore why and how an intervention or policy works, the appropriateness and applicability of policies, and barriers and facilitators for the implementation of interventions or policies .
We conducted a systematic search of the research literature in order to identify qualitative studies that explore social workers' operationalization of the cultural concepts. Furthermore, we looked for '"themes" or "constructs" that lie in or across individual qualitative studies' (Grant & Booth, 2009, p. 94). The objective of the research synthesis is to obtain a holistic interpretation of a phenomenon by analysing qualitative studies that inform a specific research question Grant & Booth, 2009;Hannes & Macaitis, 2012;Noyes et al., 2019). The process from developing the search strategy, examination and sampling of studies, and analysis, has been done in collaboration between the authors. We argue that this strengthens the quality of the qualitative evidence synthesis, as well as reducing potential single-researcher bias. Nonetheless, we cannot exclude the fact that our background as ethnic Norwegian women, with an academic background within the field of social work and sociology, may have influenced our reading and interpretation of the articles.

Literature search strategy
The search strategy consisted of a combination of: (1) systematic and comprehensive literature searches in three databases, and (2) manual reviews of reference lists of the selected articles from step 1. We searched in three databases: SCOPUS, Academic Search Premier and SocIndex. A professional librarian within the field of social work also assisted us in developing the search strategy.
After initial searches in the databases, we identified terms used in scholarly discussions of multicultural social work. We defined specific terms as combinations of culture (culture, cultural, culturally, intercultural, interculturally, cross cultural, crosscultural, cross culturally, cross-culturally) and sensitivity, competence or corresponding terms (sensitive, sensitivity, aware, awareness, reflexive, reflexivity, responsive, responsiveness, humility, competence, competent, skill, skills, knowledge). This resulted in 127 specific terms that we implemented in our search string in quotation marks, combined with the Boolean operator OR. To help refine our search, we included 'social work', empiric* or qualitative or quantitative, and practice.
All the search terms had to appear in either abstract, title or as subject terms. To be included in this qualitative evidence synthesis, studies had to comply with four inclusion criteria: a) Published in English in scholarly, peer-reviewed journals from January 2000 to March 2020. As we have exclusively included studies published in English, our synthesis consists of studies predominantly from European and Anglo-American countries; b) Empirical contributions, investigating the operationalization of the concepts, not merely theoretical or methodological discussions of the concepts, c) The concepts comprise a key element to the study, in which the study takes one or more of the concepts as its point of departure. Studies exploring how social workers work with diversity in general, without linking it to the cultural concepts, have hence not been included in this qualitative evidence synthesis, and d) They explore the understandings and perspectives of professionals in their contact with service-users.
We have therefore excluded all studies in which the sample consists of students or teachers, or studies that only focus on the service-users' perspective. Since we focus on the operationalization of the concepts, we have excluded quantitative studies that merely measure the levels of cultural competence or sensitivity among social workers. Although we have done a systematic review of the literature, using 127 different cultural concepts, we cannot disregard that our search strategy might have left relevant studies undetected due to the myriad of existing concepts.

Search outcomes
Our searches were carried out in March 2020, and generated 462 articles. After removing duplicates, 431 remained. Both authors reviewed title and abstract, removing 401 articles that did not comply with our inclusion criteria. After a full text review of the 30 remaining articles, 20 were removed. Five of the articles reported findings from two studies. To prevent single study bias, we only included one article from a study. We performed a manual examination of the reference lists of the 10 remaining articles and added two articles to our sample. Our search strategy yielded

Study characteristics and quality appraisal
We used the criteria of Walsh and Downe (2006) to appraise the studies: scope and purpose, design, sample, analysis, interpretation, reflexivity, ethical considerations, relevance and transferability (context). No studies were excluded due to a lack of methodological soundness, with Table 1 providing an overview of the studies. The studies represent a broad range of geographical contexts. Several of the studies report findings from a specific social work setting, while others aim to provide more generalized accounts of social workers' interpretation of the concepts in their work with minority service-users. The studies take different concepts as their entry point, and some use several concepts. Most of the studies discuss cultural competence (Allain, 2007;Band-Winterstein & Freund, 2015;Davis, 2009;Graham et al., 2009;Hall & Rammell, 2017;Harrison & Turner, 2011;Hedlund & Moe, 2010;Käkelä, 2019;Kwok et al., 2018;Willis et al., 2017;Yan, 2005), or cultural sensitivity (Band-Winterstein & Freund, 2015;Graham et al., 2009;Hedlund & Moe, 2010;Testa, 2017). Some of the studies also argue that cultural sensitivity is part of cultural competence. Hence, all the studies take either cultural competence or cultural sensitivity, or both, as their point of departure.

Analytic approach
The 12 studies were analysed and synthesized in collaboration between the authors.
We conducted a thematic synthesis, inspired by Thomas and Harden (2008). Based on careful readings of the articles, we identified themes and patterns across studies.
Each of the authors individually read through every study and noted their initial ideas, before we jointly generated themes and codes. We then alternated between analysing the studies individually, and a collective interpretation of the findings. We started by coding the text and developing descriptive themes, such as 'client groups', 'organizational factors', and 'culture and cultural features'. We later created the two aggregate themes 'understandings of difference (making sense of)' and 'practical work (making use of)'. Through a constant comparison, both within and between studies (Cooper, 2015), we identified differences and nuances. Based on these initial stages, we developed analytical codes in which four challenges related to the operationalization of the concepts into practice emerged. We present these in the following.

Findings
Our analysis showed four challenges in social workers' efforts to operationalize the cultural concepts: 1) Who to define as culturally diverse service-users; 2) What aspects of culture to consider in encounters with culturally diverse service-users; 3) How to consider and approach these aspects of culture, and 4) the capacity to work in a culturally appropriate manner within the organizational context where the work is undertaken. The challenges are summarized in a model ( Figure 2). In the following, we describe the similarities and differences in-and between the studies in relation to these challenges.

Who to define as culturally diverse service-users?
The studies diverged in who they focused on as 'culturally diverse' service-users. In some of the studies, it was evident that cross-cultural social work was understood as including service-users of specific ethnicities, religions, language and/or experiences.
In these studies, the researchers predefined which service-users required a culturally competent or sensitive approach. Hedlund and Moe (2010) emphasized the demand for reflective practices when working with indigenous people, and argued that social workers need to engage with indigenous worldviews. Kwok et al. (2018) focused on social workers' responses to the needs of South Asian migrants in Hong Kong, and questioned the appropriateness of applying Western-based approaches and practice models within this context. In Allain's (2007) study, the service-users were described as black and minority-ethnic children. Two of the studies focused on how social workers ensured and expressed cultural sensitivity in their encounters with serviceusers from specific religious groups, namely Jewish Ultra-Orthodox (Band- Winterstein & Freund, 2015) and Muslims (Graham et al., 2009). Käkelä (2019) focused her study on social work practices with service-users who had specific experiences; refugees who were simultaneously experiencing the compounding effects of displacement and immigration control. Willis et al. (2017) explicated that their study focused on social care staff working across differences of culture, ethnicity, religion and language.
Whereas some studies, to varying degrees, demonstrably defined the specific (minority) groups that required the social workers to perform cultural competence or sensitivity, others highlighted cross-cultural social work as conditioned by the difference between the service-users' and the social workers' cultural or ethnic background. Hall and Rammell (2017) asserted that while white social workers constitute more than half of the social workers in the US, most of the people receiving social work services are people of colour. Based on this, they argued the need for practitioners to recognize how their cultural make-up influences their responses. Testa (2017) also emphasized the cultural difference between users and helpers, and focused on social workers' encounters with services-users from cultures different from the social worker's own.
A few of the studies did not define who the culturally diverse clients were, or which instances called for the use of cultural competence or cultural sensitivity by the social workers. These used broader descriptions of these service-users, such as 'clients from diverse backgrounds' (Harrison & Turner, 2011), 'culturally different clients' (Yan, 2005), and 'culturally diverse families and children' (Davis, 2009). In these studies, the social workers had to define who to categorize as culturally diverse clients who needed something other than conventional social work methods and measures. We will come back to this in the next section. The large variation in focus, and the definition of culturally diverse service-users in our rather small sample of studies, creates a backdrop for the studies' findings concerning social workers' understanding and operationalization of cultural competence and cultural sensitivity in practice.

What aspects of culture to consider in encounters with culturally diverse service-users?
When describing what aspects of culture they considered relevant in their work, the social workers in the studies of Band-Winterstein and Freund (2015), Graham et al. (2009), Hedlund andMoe (2010) and Kwok et al. (2018) emphasized specific traits they needed to be attentive to-or competent with when working with culturally diverse clients. However, as described above, these studies concerned pre-defined groups of service-users; Jewish Ultra-Orthodox, Muslims, the Samí people or South Asian migrants.
Yet, in most of the studies the social workers had to define what aspects of culture they had to be competent at-or sensitive to. In their general understanding of the concepts, the social workers acknowledged that the work with minority service-users might entail challenges that differed from those of other service-users. The social workers described how they must be attentive to potential prejudice and discrimination (Davis, 2009), and were aware of potentially simplistic understandings of culture (Allain, 2007). They highlighted how cultural diversity and service-users of a minority background called for an awareness of cultural values and beliefs (Käkelä, 2019). Some of the understandings of difference and cultural diversity the social workers employed still reflected essentialist interpretations of culture (Käkelä, 2019;Kwok et al., 2018), and a homogenization of cultural needs (Testa, 2017). Thus, the social workers, as expected, portrayed culture as an ambiguous concept.
Although attentive to culture and different minority groups in a specific case, the social workers in the studies expressed uncertainty about what aspects of culture they should be sensitive towards or competent about. Allain (2007) described how social workers were unsure about which culture to consider in their interaction with children of dual heritage. One social worker explained how a child that is half Asian might still identify mostly as white, thereby complicating their efforts to implement culturally appropriate measures (Allain, 2007, p. 135). Another social worker emphasized how their work is complex because 'there are many different cultures within countries' (ibid.). Similarly, the social workers in the study of Harrison and Turner (2011, p. 340) reported that everything a person says or does might be an expression of culture, as culture might refer to identity, community traditions and norms. The social workers in their study understood culture as 'something that applies to everyonebut it equally evoked particular ideas about difference and indeterminacy' (Harrison & Turner, 2011, p. 341).
Across the studies, the social workers also debated whether they should focus on the service-users' affiliation with a cultural group, or on their individual identity (Allain, 2007;Band-Winterstein & Freund, 2015;Davis, 2009;Harrison & Turner, 2011;Willis et al., 2017). The social workers in the study by Hall and Rammell (2017) categorized cultural diversity on different levels. Some spoke of humanity as one entity, others described racial, cultural or familial groups, while others again highlighted each service-user's individual uniqueness. The social workers in the study by Harrison and Turner (2011) acknowledged that 'individuals do not always think and act in ways that are consistent with their cultural background and may contest or resist cultural practices' (Harrison & Turner, 2011, p. 340). The social workers were concerned that an excessive focus on culture 'may detract from the importance of individual experience' (ibid.), and highlighted the importance of taking a person-centred approach (Harrison & Turner, 2011;Willis et al., 2017).

How to consider and approach such cultural aspects?
The studies described cross-cultural social work as disparate and multifaceted. In the social workers' descriptions of how to provide culturally competent and sensitive services, they highlighted openness as both a necessity and a challenge. The social workers emphasized openness and self-reflection as a prerequisite when working cross-culturally, and how they had to 'be as open as possible' and 'put aside personal opinions and thoughts', even if they 'may not always agree' (Band-Winterstein & Freund, 2015). The ability to empathize and listen to the service-users was also highlighted by the social workers in the study by Band-Winterstein and Freund (2015). The social workers in the study by Harrison and Turner (2011) described experiential learning as an important part of cultural competence, in which the social workers learn from their experiences. Moreover, social workers accentuated being at ease with uncertainty, testing personal assumptions, asking questions in a respectful manner and recognizing personal fallibility as critical aspects of working across diversity (Harrison & Turner, 2011).
This openness was also a challenge, and emerged as an unattainable ideal to the social workers. Several studies addressed the potential conflict between professional ethics and cultural codes. Social workers in Testa's (2017) study expressed an experience of personal dissonance when their cultural values differed from serviceusers' values and beliefs, describing challenges in balancing personal or cultural beliefs of service-users with social work interventions in a respectful way. Several studies also emphasized the social workers' uncertainty about culturally appropriate behaviour, such as a fear of appearing ignorant (Willis et al., 2017). Social workers described culture as a potentially sensitive topic (Allain, 2007;Band-Winterstein & Freund, 2015), and experienced anxiety about getting it wrong or making mistakes (Allain, 2007). The social workers were also unsure about whether to prioritize clients' universal needs or their specific cultural needs (Allain, 2007). Although social workers admitted a fear of not asking the right questions, they also acknowledged that they needed to ask questions in order to do their job (Graham et al., 2009;Harrison & Turner, 2011). In this stance, the social workers in the studies differed in that some reported getting paralyzed by the uncertainty of how best to proceed, whereas others stressed that they could not dwell on the fear of unintentionally offending serviceusers. One social worker asserted: 'It's important to be OK with being uncomfortable, to know that working cross-culturally the ground is never going to be stable, it's always going to be shifting... And if you are not sure that there's nothing wrong with asking. So, there's that respectful inquiry. We are going to make mistakes' (Harrison & Turner, 2011, p. 341).

The capacity to work in a culturally appropriate manner within the organizational context
Several of the social workers in the studies emphasized organizational frames and contextual factors as important aspects of their practices. Although the social workers generally expressed an understanding of what cross-cultural social work entails, they also described how the organizational context might influence their efforts to work in a culturally competent or sensitive manner. Some of the social workers emphasized how this influence might be positive, as the organization has the authority to impose that social workers employ measures of cultural competence (Testa, 2017), or to increase social workers' sensitivity towards cultural diversity through courses or training (Willis et al., 2017).
The social workers highlighted how organizational constraints impeded their efforts to work effectively with diverse service-users. They described tensions between competing priorities (Allain, 2007), and how the mandate of the organization may encourage efforts other than working in a culturally competent or sensitive way (Band-Winterstein & Freund, 2015;Harrison & Turner, 2011). Although acknowledging the importance of making respectful inquiries, the social workers also described how big caseloads, high pressure, a close monitoring of services and a lack of time impacted the depth of their work (Allain, 2007;Harrison & Turner, 2011;Käkelä, 2019;Testa, 2017;Willis et al., 2017), and led to superficial explanations of culture, faith and ethnicity (Allain, 2007). Social workers described that they did not have the time or resources to explore the position and situation of their service-users, as 'it takes time to understand' (Willis et al., 2017). They reported how service specialization reduced their capacity to work flexibly and creatively when needed (Harrison & Turner, 2011;Kwok et al., 2018;Testa, 2017). The social workers may identify needs that they cannot help with because they are outside the scope of the agency in which they work (Harrison & Turner, 2011;Testa, 2017). Hence, service gaps and specialization may directly impact the ability to engage with service-users' needs. Although the social workers might have a clear understanding of the concepts of cultural sensitivity or competence in service delivery, organizational constraints and bureaucratic demands are 'sometimes thwarting social workers' attempts to respond appropriately to the needs of service-users from different backgrounds' (Harrison & Turner, 2011, p. 344).

Discussion
This qualitative evidence synthesis shows that the operationalization of cultural concepts generates four challenges. First, because there is not one consistent description of which instances are cross-cultural, the social workers had to decide who to define as culturally diverse, and which encounters with service-users required something more than conventional approaches. Second, even though the social workers might know which clients to consider as culturally diverse, they still had trouble defining what aspects of culture to take into consideration in their work with these clients. Third, after defining what to be sensitive to or competent at, the social workers nonetheless reported difficulties in how to be sensitive to-or show competence in relation to these aspects. Fourth, the social workers described that although they understood what the concepts entailed, they might not have the capacity within the organizational context to act in a culturally competent or sensitive manner. This challenge relates to where the work is undertaken. The first two challenges refer to the ambiguous notion of culture, whereas the last two relate to the practices emerging from the concepts. In the following, we will discuss these challenges in relation to each other, to the concepts and to the discourse of crosscultural social work.
The studies in this synthesis showed that social workers were aware of-and reflected upon both structural factors, including potential discrimination or prejudice, and the potential influence of social and cultural identities at both the individual and group level. The social workers thus seemed to neither culturalize the client's problems, as proposed by Anis (2005), nor neglect culture as a relevant factor (Ploesser & Mecheril, 2012). We cannot rule out that the studies in this synthesis might have an overrepresentation of social workers who are highly aware of the challenges of working cross-culturally. This may contribute to more nuanced descriptions than from social workers in general. Further empirical research with a broader sample of participants is therefore needed to explore the real-life practices of social workers. Moreover, previous research has shown the presence of bias in social workers' understanding of-and work with people with a minority background, resulting in discrimination and 'othering' (Ylvisaker et al., 2015). As the aim of our study has been to explore the challenges arising in the operationalization of cultural concepts into practice, our findings cannot confirm or rule out the influence of such unconscious bias in the literature or social workers' practice. It could be useful for future studies to include this perspective.
Across the studies, the social workers experienced difficulties operationalizing culture into an applicable concept in service delivery. In general, the studies described social work with culturally diverse groups as requiring something other than ordinary social work. The literature on cultural concepts tends to characterize cross-cultural social work as different (Miu, 2008), but seldom defines what this difference consists of.
This also presupposes a homogenous majority culture that includes all other clients.
In other words, some clients are characterized as 'cultural', whereas others are not.
However, the social workers in the studies had difficulties in pinpointing which clients  (Anis, 2005;Anthias, 2001;Jenkins, 1994;Kroeber & Kluckhohn, 1952), and what the cultural concepts entail (Boyle & Springer, 2001), this might not be surprising. In the studies that specifically defined religious or ethnic groups, the social workers were more specific in which cultural traits they deemed relevant in their work. Although these traits might be relevant in terms of the chosen focus for that specific research, there might be other aspects of these clients' social identity that could be relevant, or other clients that could require culturally competent or sensitive means.
Diversity exists on multiple levels (Garran & Werkmeister Rozas, 2013). Our findings show that social workers struggle to grasp this multifaceted phenomenon in their work, and that processes of identification and categorization 'operate at the individual, interactional and collective levels' (Jenkins, 1994, p. 219). Such processes might result in a simplification of complex cases, in which the service-user's migrant or ethnic background could be overemphasized (Elrick & Schwartzman, 2015). Garran and Werkmeister Rozas (2013) suggest implementing intersectionality in the notion of cultural competence in order to recognize a person's 'multiple identities and complex relations to power' (Garran & Werkmeister Rozas, 2013, p. 103). They emphasize social workers' flexibility and reflexivity as important features of cultural competence (ibid.).
Still, our findings show that although social workers acknowledged flexibility and reflectiveness as important features of their work, they did not necessarily have access to the required resources or organizational prerequisites to carry out the work in an ideal way. The organizational context influenced whether the social workers were capable of working cross-culturally. Contextual factors may not have received sufficient attention in scholarly debates of culturally competent or sensitive practice.
As our findings show, the decontextualized descriptions of cross-cultural social work contribute to creating a normative ideal that social workers fall short of living up to in their practice.
Although the concepts contribute to important debates of cultural diversity and social work, and highlight differences in the experiences and values connected to cultural and social identity, they also tend to leave the practical operationalization of crosscultural social work to the individual social worker. The findings presented in this qualitative evidence synthesis portray social workers' practices with cultural minority service-users as complex and permeated by uncertainty. Researchers seem to engage with this complexity by continuing to develop new concepts with only subtle nuances that focus on, e.g., the inter-cultural rather than culture, or humility rather than awareness. We argue that the attempts to clarify such a multifaceted phenomenon as cross-cultural social work through the continuous introduction of new cultural concepts, further complicate practice. The solution is arguably not to create more theoretical concepts, or to attempt to provide a final definition of them, but instead to investigate how and if the concepts are useful for practical implementation.
'Without application to professional practice and service delivery, the academic formulations fail to make any difference in the lives of diverse groups of clients' (Boyle & Springer, 2001, p. 59).
We have developed a model (Figure 2) that attempts to capture the key challenges inherent in the operationalization of cultural concepts into social work practice. The model could be useful as a tool for social workers by depicting the essential questions of who, what, how and where to employ the concepts into practice. However, it is not possible, nor advisable, to provide a final answer to these questions. This work is dynamic, and requires continuous efforts from social workers in terms of asking, reflecting and debating. The model arises from empirical descriptions of social workers' efforts. We argue that it can be used to further analyse scholarly portrayals of specific cultural concepts, and whether they sufficiently address the real-life challenges of social workers. Hence, the model can be useful in the further development of cross-cultural social work.

Conclusion
It is evident from the studies included in this synthesis that cultural competence and cultural sensitivity in social work is a complex field on several levels. It is problematic in terms of who the culturally diverse groups or individuals are. It is further complicated by a lack of a clear understanding of what is expected from social workers in order to achieve cultural competence, and how this is best practiced with groups or individuals with diverse cultural needs. In addition, there are several contextual factors that may influence the possibilities of practicing cultural competence. The social workers reported being uncertain, uncomfortable, and ambiguous when working cross-culturally. This does not mean that they are culturally incompetent; rather, it may reflect a field that is constantly changing and with few clear answers. The complexity of this field is reflected, and maybe also reinforced, by the many concepts aimed at capturing its essence. Instead of trying to eliminate the uncertainty and complexity in this work, we argue that working cross-culturally requires continuous inquiries and reflexivity from social workers. By providing a model of the key challenges inherent in the cultural concepts, we hope to assist scholars, practitioners and educators to help navigate the multifaceted landscape of culture and social work.