Exploring Cultural and Technological Gaps: A Qualitative Study of Spanish and Colombian Nursing Students’ Views on Digital Health Leadership

Study Design

This study utilized a qualitative-descriptive design with a deductive-inductive approach. While qualitative description is traditionally used to provide a detailed account of events “without extensive interpretation or theorization” (Sandelowski, 2000), in this study, the design was adapted to operationalize Leininger’s Theory of Culture Care Diversity and Universality (Leininger, 1991). This approach was selected over other methodologies because the objective was not to generate a new theory or explore the essence of lived experience, but to comprehensively describe the specific facilitators and barriers to digital leadership within a pre-existing cultural framework (Kim et al., 2017). This design allowed us to capture the richness of the phenomenon (Moser & Korstjens, 2017) while using Leininger’s Sunrise Model as a structural lens to organize the data without forcing the students’ narratives into abstract categories. The research followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).

Participants and Setting

This study employed a playful-reflective workshop methodology. This approach utilizes participatory group workspaces organized through structured work-play-reflection sessions (Geilfus, 2009) that integrate specific group dynamics centered around a primary objective (Peña-Cuanda & Esteban-Guitart, 2013). Students in their first and second years of nursing programs in Spain and Colombia participated in the research. We intentionally recruited an unusually large qualitative sample of 208 participants. This comprehensive inclusion was a deliberate methodological choice because the interactive digital platforms yielded relatively brief individual inputs; accumulating a larger volume of data was essential to ensure diverse representation and achieve data saturation. While integrated into regular class schedules, attendance remained strictly voluntary and independent of formal academic assessment. To maximize engagement, students were divided into smaller cohorts, with each group completing a single 4-hour in-person workshop.

During these workshops, participants engaged with the facilitator through interactive activities and answered questions using mobile devices and QR codes. The implementation of audience response platforms, specifically Slido, Mentimeter, and Miro, enabled anonymous input that was displayed to all attendees in real time. The facilitator then leveraged this live data to provide immediate feedback and stimulate deeper group discussion. Utilizing such audience response systems actively promotes learning and significantly increases student engagement within synchronous educational environments (Lee et al., 2024; Tarazi & Ortega-Martín, 2023). These tools have been utilized to collect opinions and stimulate debate among health care professionals, students, and patients (Barragán Núñez et al., 2023; Bontje et al., 2022; Dinkler et al., 2023; Montero-Vilchez et al., 2024; Rataj et al., 2021; Schimmer et al., 2019). Miro has been shown to foster collaboration, creative thinking, and a meaningful, participatory learning experience (Chan et al., 2024; Skubik-Peplaski et al., 2022). Table 1 shows the questions used in the session and the tools implemented in each of them.

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Table 1.

Questions and Tools Used.

Question	Tool & activity
1. In short, what could nursing technology be useful for?	Mentimeter Word cloud activity
2. What is nurse-led digital transformation for you?	Slido Open-ended activity
3. I would say that I manage (on a scale of 5 points, with 1 being the worst mark and 5 being the best mark) on:  • Social networks  • Searching for quality information  • In content creation: videos, blogs  • Safety issues in the network	Mentimeter Visual scale activity (Likert scale)
4. Are nurses prepared to take care by means of technology?	Mentimeter Multiple choice activity
5. What possible uses could we make of technology in hospitals or health centers?	Miro Brainstorming activity
6. What barriers or limitations do we have to apply to technology at a collective/individual level?	Slido Open-ended activity

Data Collection and Analysis

Data collection occurred during face-to-face university sessions in Spain and Colombia between November 2022 and November 2023. The principal investigator and another faculty member, both female scholars with doctoral degrees, facilitated the groups. Prior to participation, students received comprehensive written and verbal information and provided informed consent. To mitigate potential power imbalances and social desirability bias, the researchers had no prior academic relationships with or evaluative authority over the participants. No financial compensation was provided. Furthermore, utilizing anonymous digital response platforms ensured uninhibited feedback and protected participant identities. The study achieved full participation with zero refusals or dropouts. Digital responses were exported to a spreadsheet database for systematic evaluation. The analytical process followed the thematic analysis phases outlined by Braun and Clarke (2012) while utilizing Sunrise Model (Leininger, 1991) as a guiding theoretical framework.

First, the research team performed inductive open coding by systematically extracting raw, participant-driven concepts directly from the qualitative narratives. Next, a deductive analytical phase mapped these emergent codes onto the specific social structure factors and care modes of Leininger’s Sunrise Model, elevating the data from simple thematic categories to a structured transcultural analysis. To prevent cultural stereotyping, both cohorts were analyzed concurrently through a comparative transcultural lens. This approach successfully distinguished between universal professional concerns and diverse country-specific challenges rooted in distinct socioeconomic structures. Because the original data were collected in Spanish, the findings were translated into English for publication. Bilingual research team members reviewed the translations, and a native editor conducted back-translation to safeguard shared Hispanic meanings and preserve the unique linguistic nuances of both sociocultural realities.

Trustworthiness was established following the criteria of Guba and Lincoln (2005). Two independent qualitative and eHealth experts reviewed the codes and themes to ensure confirmability and facilitate correct triangulation (Carter et al., 2014). The broader research group then discussed the findings and applied critical reasoning until reaching a final consensus. Credibility and authenticity were further bolstered by directly integrating participant quotations. Finally, the predominantly female research team engaged in continuous reflexive discussions throughout the study to ensure their own clinical and technological expertise did not overshadow the undergraduate participants’ authentic voices.

Ethical Approval

This project was approved by the Ethics Committee of the Catholic University of Valencia with the code UCV/2022–2023/001.

Digital Empowerment as Culture Care Accommodation in Patient Data Management

Participants conceptualized the nurse-led digital transformation as a pivotal shift in health care information management. Representing Culture Care Accommodation, the nursing profession actively integrates new technological artifacts to revolutionize patient data handling. Students primarily view this transition from traditional paper-based kinship systems to modern electronic medical records as a strategic alignment with contemporary technological values. This modernization deliberately moves practice away from handwritten documents, ultimately offering enhanced data control and advanced management capabilities: “It would be useful to change the use of written documents into digital ones for greater data control” (Colombian participant).

A central aspect of this theme is the enhanced accessibility and processing agility provided by digital systems, reflecting a fundamental shift in the cultural lifeways of the health care environment. Conceptualizing technology as a vital assistive tool, students emphasized how online programs simplify complex data management. Crucially, participants linked this improved data organization directly to enhanced patient care and systemic decision-making:

NLDT is all the information we receive from patients put onto an online program that helps you or orders it for you to make it easier. (Spanish participant)

Better data could contribute to improving the quality and efficiency of nursing care by obtaining information and using it appropriately for decision-making at all levels of the healthcare system. (Colombian participant)

Nurses as Cultural Agents Negotiating Technology and Humanism

NLDT represents a substantive paradigm shift. It moves the nursing profession far beyond the simple adoption of new technologies. Nurses no longer act as passive recipients of digital tools. Instead, they operate as active cultural agents who dynamically shape and redefine the digital health care landscape. Participants emphasized that technology integration must deliberately align with professional values of empathetic and culturally sensitive care. This relationship highlights a profound desire for culture care preservation to ensure the human element remains central amid technological advancement. This delicate tension is clearly evident in the concern that “it is important to respect the humanization of the professional environment because, if there is a screen involved, there is already something digital that detracts from the human aspect” (Colombian participant).

Participants expressed strong optimism regarding the capacity of technology to reduce clinical mistakes, alleviate administrative workloads, and enhance overall care quality and safety. This emphasis on timesaving and efficiency reflects a profound desire to revert to the fundamental essence of nursing care rather than viewing technology merely as an instrumental tool for modernization. However, this optimism is tempered by an acute awareness of the diverse cultural, organizational, and institutional challenges inherent in this transition:

For me, [NLDT] is adapting to the modern world, making use of current resources, with the aim of facilitating nursing work and improving care by investing all our effort and time in patient care, eliminating the error factor and improving data agility. (Spanish participant)

Digital Technologies as Facilitators of Transcultural Communication and Professional Kinship

Participants viewed NLDT as a catalyst for effective interprofessional communication that bridges generational gaps and facilitates accessible health promotion. Applying the Sunrise Model, these digital tools serve as essential cultural artifacts for building professional kinship and expanding global communication networks: “NLDT is about having current tools to reach new generations and to teach our work in health promotion and education in an easier way as well as reaching more people” (Colombian participant).

Participants envisioned a future where digital tools enable the seamless exchange of experiences and facilitate collective knowledge within the profession. Furthermore, students perceived that this enhanced digital communication actively supports the development of nursing as a science, ultimately contributing to a more autonomous and independent role within the health system. Consequently, digital transformation serves as a pivotal catalyst for professional advancement and empowers increased nurse participation in critical decision-making processes:

It [digital communication] allows the knowledge of one nurse to be the knowledge of all nurses. (Spanish participant)

It is a new role in which we are mindful of digital transformation, where nurses are empowered to manage and use technology in the workplace to enable improvement. (Colombian participant)

Finally, participants acknowledged an intrinsic relationship between professional advancement and the effective adoption of nursing technology. They perceived digital transformation as a pivotal cultural catalyst that empowers nurses to fortify their leadership capabilities, particularly in care research and systemic decision-making. This evolution reinforces the notion that ongoing professional development within the educational dimension is imperative for comprehensive technological integration, a shift accurately described as “the evolution of nursing toward a more technologically advanced profession, which brings multiple improvements in organization, communication, learning” (Spanish participant).

Political, Economic, and Educational Dimensions as Barriers to Culture Care Repatterning

This theme highlights multifaceted challenges hindering the effective application of nursing technology. Utilizing Leininger’s dimensions of social structure, participants identified a profound knowledge gap in digital competencies that fuels a deep-seated professional apprehension toward technological change. This fear is rooted in the reality that “not all people are equally provided with ICT training, and another reason may be that many people are afraid of change” (Colombian participant). Within this context, a noteworthy cultural disparity emerged. Even though some frankly admitted that “we don’t know how to use digital tools correctly” (Spanish participant), Colombian students consistently rated their social media skills even lower than their Spanish counterparts. This discrepancy underscores how distinct sociocultural and educational contexts shape the perception of digital competencies.

Beyond educational disparities, economic limitations emerged as a substantial barrier to technological integration. Reflecting the economic factors of the Sunrise Model, participants pointed to a severe lack of financial resources and insufficient investment in health care technology. Notably, Colombian students uniquely highlighted corruption as a systemic issue exacerbating this resource scarcity, bluntly stating that “the main barrier is that we are in Colombia, where the health care system is bad and there is corruption” (Colombian participant). Compounding these structural deficits is a pronounced cultural generational gap in technological aptitude. Participants perceived older nurses as particularly resistant to change due to differing generational values, observing that “there are quite a few older nurses who either don’t see themselves as capable or don’t want to accept that the world is moving on” (Spanish participant).

Strengths and Limitations

While this study offers valuable insights, certain limitations exist. Relying exclusively on first- and second-year nursing students from Spain and Colombia may restrict the transferability of the findings and omit advanced professional perspectives. Furthermore, group workshops risk introducing social desirability bias, and self-reported metrics may not accurately reflect objective digital competencies. Despite these constraints, the study demonstrates significant methodological strengths. The playful-reflective workshops utilized interactive digital tools to foster high participant engagement and generate exceptionally rich qualitative data. In addition, the transcultural design provided essential comparative perspectives on how distinct environments shape digital transformation in nursing education. Addressing these limitations, future research should expand transcultural comparisons across broader geographic regions, advanced educational tiers, and active professional cohorts to further elucidate the cultural determinants of digital health leadership.