Nursing Assistant Students’ Digital Cultural Intelligence and Clinical Adaptability in a North African Health College: A Cross-Sectional Study
Abstract
Purpose of the study: This study examined the predictive relationship between digital cultural intelligence and clinical adaptability among nursing assistant students at a health sciences college in Morocco.
Methodology: A cross-sectional design was employed with 287 students who had completed at least one clinical placement. Data were analysed using partial leas squares structural equation modellingi (PLS-SEM) to test a theory-driven conceptual framework. Measurement model evaluation confirmed satisfactory reliability and validity (CR > 0.90; AVE > 0.50; HTMT < 0.85). Structural analysis revealed that digital cultural intelligence significantly predicted clinical adaptability (β = 0.64, p < 0.001), explaining 41% of the variance (R² = 0.41). Predictive relevance was supported (Q² = 0.29), and robustness checks using covariance-based SEM confirmed acceptable model fit indices.
Main Findings: The findings indicate that the capacity to navigate culturally diverse interactions within digitally mediated healthcare environments is a substantial determinant of adaptive clinical reasoning, flexible communication, and ethical responsiveness. By empirically validating digital cultural intelligence as a multidimensional construct in vocational nursing education, this study advances theoretical integration between intercultural competence and adaptive expertise frameworks.
Novelty/Originality of this study: This study contributes Global South evidence to international nursing education research and provides a predictive model for curriculum innovation in digitally transitioning healthcare contexts.
References
M. J. Hossain, M. Al‐Mamun, and M. R. Islam, “Diabetes mellitus, the fastest growing global public health concern: Early detection should be focused,” Heal. Sci. Reports, vol. 7, no. 3, Mar. 2024, doi: 10.1002/hsr2.2004.
N. N. S. P. Verawati and W. Wahyudi, “Raising the issue of local wisdom in science learning and its impact on increasing students’ scientific literacy,” Int. J. Ethnoscience Technol. Educ., vol. 1, no. 1, p. 42, 2024, doi: 10.33394/ijete.v1i1.10881.
M. A. Durand, M. Bannier, M. A. Aim, and J. Mancini, “Adaptation and implementation of pictorial conversation aids for early-stage breast cancer surgery and reconstruction: A quality improvement study,” Patient Prefer. Adherence, vol. 17, no. 11, pp. 2463–2474, 2023, doi: 10.2147/PPA.S421695.
R. M. Merchant et al., “The american heart association emergency cardiovascular care 2030 impact goals and call to action to improve cardiac arrest outcomes: A scientific statement from the american heart association,” Circulation, vol. 149, no. 8, pp. 914–933, 2024, doi: 10.1161/CIR.0000000000001196.
F. B. Hosseini, S. Ghorbani, and R. Rezaeeshirazi, “Effects of perceived autonomy support in the physical education on basic psychological needs satisfaction, intrinsic motivation and intention to perform physical activity in high school students,” Int. J. Sch. Heal., vol. 7, no. 4, pp. 39–46, 2020, doi: 10.30476/intjsh.2020.88171.1106.
M. K. Budiarto, Asrowi, Gunarhadi, R. Karsidi, and A. Rahman, “E-learning platform for enhancing 21st century skills for vocational school students: A systematic literature review,” Electron. J. e-Learning, vol. 22, no. 5, pp. 76–90, 2024, doi: 10.34190/ejel.22.5.3417.
A. A. Firoozi, “Navigating the complex landscape of healthcare innovation: Strategies for overcoming design and implementation challenges BT - transformative design in healthcare: infection control and patient well-being through architectural innovation,” Eds., Cham: Springer Nature Switzerland, pp. 379–439, 2026. doi: 10.1007/978-3-032-08019-6_9.
M. Weber and C. Harzer, “Relations between character strengths, school satisfaction, enjoyment of learning, academic self-efficacy, and school achievement: An examination of various aspects of positive schooling,” Front. Psychol., vol. 13, no. 10, pp. 1–15, 2022, doi: 10.3389/fpsyg.2022.826960.
A. S. Fathi and W. O’Brien, “A simulation-based approach for evaluating indoor environmental quality at the early design stage,” Sci. Technol. Built Environ., vol. 29, no. 4, pp. 457–471, 2023, doi: 10.1080/23744731.2023.2187611.
A. Garneau and P. J, “Cultural competence: A constructivist definition,” J. Transcult. Nursing., vol. 26, no. 1, pp. 9–15, 2014, doi: 10.1177/1043659614541294.
E. Curtis, “Cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition,” Int. J. Equity Health, vol. 18, no. 1, pp. 1–17, 2019, doi:1 0.1186/s12939-019-1082-3.
Somnath Saha, M. C. Beach, and L. A. Cooper, “Patient centeredness, cultural competence and healthcare quality,” J. Natl. Med. Assoc., vol. 100, no. 11, pp. 1275–1285, 2008, doi: 10.1016/S0027-9684(15)31505-4.
M. C. Butter, E. M. Aguilera, M. G. B. Quintana, L. J. Pérez, and E. S. Valenzuela, “Quality assurance for postgraduate programs: Design of a model appilied on a university in Chile,” Int. Rev. Res. Open Distrib. Learn., vol. 18, no. 1, pp. 266–292, 2017, doi: 10.19173/irrodl.v18i1.2670.
S. Mystakidis, M. Fragkaki, and G. Filippousis, “Ready teacher one: Virtual and augmented reality online professional development for K-12 school teachers,” Computers, vol. 10, no. 10, pp. 1–16, 2021, doi: 10.3390/computers10100134.
B. Ban, T. Kanjanarach, and S. Chanaboon, “Awareness, intention to act and action in the exercising of patients’ rights: A case study of patients in khmer soviet friendship hospital, Phnom Penh, Cambodia,” Risk Manag. Healthc. Policy, vol. Volume 13, pp. 2365–2370, Nov. 2020, doi: 10.2147/RMHP.S265928.
A. Fedorov and G. Mikhaleva, “Current trends in media and information literacy in research and scientific publications of the early 21st century,” Int. J. Media Inf. Lit., vol. 5, no. 2, pp. 153–163, 2020, doi: 10.13187/IJMIL.2020.2.153.
Asmayawati, Yufiarti, and E. Yetti, “Pedagogical innovation and curricular adaptation in enhancing digital literacy: A local wisdom approaich for sustainable development in Indonesia context,” J. Open Innov. Technol. Mark. Complex., vol. 10, no. 1, pp. 100-112, 2024, doi: 10.1016/j.joitmc.2024.100233.
Masruddin, S. Hartina, M. Ahkam Arifin, and A. Langaji, “Flipped learning: Facilitating student engagement through repeated instruction and direct feedback,” Cogent Educ., vol. 11, no. 1, pp. 1–18, 2024, doi: 10.1080/2331186X.2024.2412500.
F. Tsandila-Kalakou, S. Wiig, and K. Aase, “Factors contributing to healthcare professionals’ adaptive capacity with hospital standardization: A scoping review,” BMC Health Serv. Res., vol. 23, no. 1, pp. 799-810, 2023, doi: 10.1186/s12913-023-09698-9.
I. Notarnicola, M. Lommi, D. Ivziku, S. Carrodano, G. Rocco, and A. Stievano, “The nursing theory of complex adaptive systems: A new paradigm for nursing,” Healtcare, vol. 19, no. 12, pp. 1-11, 2024. doi: 10.3390/healthcare12191997.
A. Hedqvist, G. Praetorius, M. Ekstedt, and C. Lindberg, “Entangled in complexity: An ethnographic study of organizational adaptabilitiy and safe care transitions for patients with complex care needs,” J. Adv. Nurs., vol. 81, no. 9, pp. 5528–5545, Sep. 2025, doi: 10.1111/jan.16203.
D. Bevere and N. Faccilongo, “Shaping the future of healthcare: Integrating ecology and digital innovation,” 2024. doi: 10.3390/su16093835.
A. H. Talal, E. M. Sofikitou, U. Jaanimägi, M. Zeremski, J. N. Tobin, and M. Markatou, “A framework for patient-centered telemedicine: Application and lessons learned from vulnerable populations,” J. Biomed. Inform., vol. 112, no. 2, p. 1036-1042, 2020, doi: https://doi.org/10.1016/j.jbi.2020.103622.
S. Bhaskar, S. Bradley, V. K. Chattu, A. Adisesh, A. Nurtazina, S. Kyrykbayeva, S. Sakhamuri, S. Moguilner, S. Pandya, S. Schroeder, M. Banach and D. Ray, “Telemedicine as the new outpatient clinic gone digital: position paper from the pandemic health system resilience program (Reprogram) international consortium (Part 2),” Front. Public Heal., vol. 8, no. 410, pp. 1–16, 2020. doi: 10.3389/fpubh.2020.00410
S. Zhao et al., “Transition shock among nursing interns and its relationship with patient safety attitudes, professional identity and climate of caring: A cross-sectional study,” BMC Nurs., vol. 23, no. 1, pp. 64-77, 2024, doi: 10.1186/s12912-024-01722-5.
J. Balante, D. van den Broek, and K. White, “Hiow does culture influence work experience in a foreign country? An umbrella review of the cultural challenges faced by internationally educated nurses,” Int. J. Nurs. Stud., vol. 118, no. 5, pp. 1039-1040, 2021, doi: 10.1016/j.ijnurstu.2021.103930.
S. Kamau, M. Koskenranta, H. Kuivila, A. Oikarainen, M. Tomietto, J. Juntunen, A. M. Tuomikoski, K. Mikkonen, “Integration strategies and models to support transition and adaptation of culturally and linguistically diverse nursing staff into healthcare environments: An umbrella review,” Int. J. Nurs. Stud., vol. 136, no.12, pp. 1043-1077, 2022, doi: 10.1016/j.ijnurstu.2022.104377.
Chuleeporn Prompahakul and Elizabeth G Epstein, “Moral distress experienced by non-western nurses: An integrative review,” Nurs. Ethics, vol. 27, no. 3, pp. 778–795, 2019, doi: 10.1177/0969733019880241.
J. M. Velarde, M. F. Ghani, D. Adams, and J. Cheah, “Towards a healthy school climate: The mediating effect of transformational leadership on cultural intelligence and organisational health,” Educ. Manag. Adm. Leadersh., vol. 50, no. 1, pp. 163–184, 2020, doi: 10.1177/1741143220937311.
F. Sakamoto, “Global competence in Japan: What do students really need?,” Int. J. Intercult. Relations, vol. 91, pp. 216–228, 2022, doi: 10.1016/j.ijintrel.2022.10.006.
N. S. Argyres, A. De Massis, N. J. Foss, F. Frattini, G. Jones, and B. S. Silverman, “History‐informed strategy research: The promise of history and historical research methods in advancing strategy scholarship,” Strateg. Manag. J., vol. 41, no. 3, pp. 343–368, Mar. 2020, doi: 10.1002/smj.3118.
M. Salajegheh, J. Sandars, A. Mirzazaideh, and R. Gandomkar, “Understanding the capacity development of faculty development programs: a sequential explanatory mixed methods study,” BMC Med. Educ., vol. 24, no. 1, p. 744, 2024, doi: 10.1186/s12909-024-05715-5.
Y. M. Al-Worafi, “Nursing Education, Practice, and Research in South Africa BT - Handbook of Medical and Health Sciences in Developing Countries: Education, Practice, and Research,” Cham: Springer International Publishing, pp. 1–33, 2023, doi: 10.1007/978-3-030-74786-2_527-1.
K. Singh, A. M. A. Alomari, H. M. A. Sayed, K. Mannethodi, J. Kunjavara, G. V. Joy, N. Hassan, E. Martinez, B. A. Lenjawi, “Barriers and solutions to the gap between theory and practice In nursing services: A systematic review of qualitative evidence,” Nurs. Forum, vol. 2024, no. 1, pp. 752-784, 2024, doi: 10.1155/2024/7522900.
J. C. D. Gagne, E. Cho, P. S. Randa, H. Hwang, E. Wang, L. Yoo, S. Yamane, L. S. Ledbetter, and D. Jung, “Exploration of cyberethics in healtih professions education: A scoping review,” Int. J. Environ. Res. Public Health, vol. 20, no. 22, pp. 1–16, 2023, doi: 10.3390/ijerph20227048..
A. Scheunemann, T. Schnettler, J. Bobe, S. Fries, and C. Grunschel, “A longitudinal analysis of the reciprocal relationship between academic procrastination, study satisfaction, and dropout intentions in higher education,” Eur. J. Psychol. Educ., vol. 37, no. 4, pp. 1141–1164, 2022, doi: 10.1007/s10212-021-00571-z.
T. W. Taris, S. R. Kessler, and E. K. Kelloway, “Strategies addressing the limitations of cross-sectional designs in occupational health psychology: What they are good for (And what not),” Work Stress, vol. 35, no. 1, pp. 1–5, 2021, doi: 10.1080/02678373.2021.1888561.
R. Karnia, “Importance of Reliability and Validity in Research,” Psychol. Behav. Sci., vol. 13, no. 6, pp. 137–141, 2024, doi: 10.11648/j.pbs.20241306.11.
Y. Y. and L. W. P. Richard P. Bagozzi, “Bogazzi_assesing construct validity in organiational research,” Adm. Sci. Q., vol. 36, no. 3, pp. 421–458, 2017, doi: jstor.org/stable/2393203
Almita, M. Tahir, and M. N. Hajjad, “Employee performance and the impact of workplace facilities and discipline,” J. Manaj. Bisnis, vol. 10, no. 2, pp. 417–425, 2023, doi: 10.33096/jmb.v10i2.616
Arunraju Chinnaraju, “Partial least squares structural equation modeling (PLS-SEM) in the AI era: Innovative methodological guide and framework for business research,” Magna Sci. Adv. Res. Rev., vol. 13, no. 2, pp. 062–108, Apr. 2025, doi: 10.30574/msarr.2025.13.2.0048.
S. Wang, J.-H. Cheah, C. Y. Wong, and T. Ramayah, “Progress in partial least squares structural equation modeling use in logistics and supply chain imanagement in the last decade: A structured literature review,” Int. J. Phys. Distrib. Logist. Manag., vol. 54, no. 7–8, pp. 673–704, 2023, doi: 10.1108/IJPDLM-06-2023-0200.
N. I. Liveris, C. Tsarbou, G. Papageorgiou, E. Tsepis, and S. A. Xergia, “Interdependent effect of intrinsic risk factors on non-contact lower limb injuries in male football players: A structural equation modeling approach,” Medicina (B. Aires)., vol. 62, no. 1, pp. 52–60, 2025, doi: 10.3390/medicina62010052.
S. Cantele, S. Landi, and S. Vernizzi, “Measuring corporate sustainability in its multidimensionality: A formative approach to integrate ESG and triple bottom line approaches,” Bus. Strateg. Environ., vol. 33, no. 7, pp. 7383–7408, 2024, doi: 10.1002/bse.3872.
R. G. O. Atento, L. F. Quinto, C. Ann, and M. H. Espelita, “Bridging global health workforce gaps 2050 : A multilevel analysis of global demand , philippine supply fragilities , and competency alignment,” Int. J. Heal. Bus. Anal., vol. 1, no. 2, pp. 1–30, 2024, doi: 10.65166/kgbpey79
L. Starkey, “Each discipline is different: Teacher capabilities for future-focussed digitally infused undergraduate programmes,” Educ. Technol. Res. Dev., vol. 71, no. 1, pp. 117–136, 2023, doi: 10.1007/s11423-023-10196-2.
R. K. Behera, P. K. Bala, N. P. Rana, and Z. Irani, “Empowering co-creation of services with artificial intelligence: An empirical analysis to examine adoption intention,” Mark. Intell. Plan., vol. 42, no. 6, pp. 941–975, 2024, doi: 10.1108/MIP-08-2023-0412.
A. A. Aminullah, A. Yusuf, F. L. Azizan, I. Salisu, and Z. Bin Mansor, “Linking academic self-initiated expatriate’s cultural intelligence to specific job outcomes: The enabling role of psychological capital,” Cogent Bus. Manag., vol. 9, no. 1, pp. 546-560, 2022, doi: 10.1080/23311975.2021.2017546.
J. Mahadevan and J. Steinmann, “Cultural intelligence and COVID-induced virtual teams: Towards a conceptual framework for cross-cultural management studies,” Int. J. Cross Cult. Manag., vol. 23, no. 2, pp. 317–337, Jul. 2023, doi: 10.1177/14705958231188621.
M. U. Shahzad, “Core competencies for digital leadership development: A perspective from the lens of paradox theory,” Bottom Line, vol. 37, no. 4, pp. 454–472, 2024, doi: 10.1108/BL-10-2023-0278.
H. Zhan, K. M. Cheng, L. Wijaya, and S. Zhang, “Investigating the mediating role of self-efficacy between digital leadership capability, intercultural competence, and employability among working undergraduates,” High. Educ. Ski. Work. Learn., vol. 14, no. 4, pp. 796–820, 2024, doi: 10.1108/HESWBL-02-2024-0032.
A. Al-Azawei, F. Serenelli, and K. Lundqvist, “Universal design for learning (UDL): A content analysis of peer reviewed journals from 2012 to 2015,” J. Scholarsh. Teach. Learn., vol. 16, no. 3, pp. 39–56, 2016, doi: 10.14434/josotl.v16i3.19295.
E. J. Kim and Y. S. Roh, “Competence‐based training needs assessment for basic life support instructors,” Nurs. Health Sci., vol. 21, no. 2, pp. 198–205, 2019, doi: 10.1111/nhs.12581.
N. Shokrpour, Z. Soleymani, and A. Farahmandi, “Investigating the relationship between electronic learning and emotional and cultural intelligence of 2021–2022 incoming nursing students at Shiraz University of medical sciences,” BMC Med. Educ., vol. 24, no. 1, pp. 133-142, 2024, doi: 10.1186/s12909-024-06328-8.
K. Rajaram, “Cultural Intelligence in Teaching and Learning BT - Learning Intelligence: Innovative and Digital Transformative Learning Strategies: Cultural and Social Engineering Perspectives,” Springer Nature: Singapore, pp. 57–118, 2023, doi: 10.1007/978-981-19-9201-8_2.
K. D. Lomis, G. C. Mejicano, K. J. Caverzagie, S. U. Monrad, M. Pusic, and K. E. Hauer, “The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education,” Med. Teach., vol. 43, no. 2, pp. 7–16, 2021, doi: 10.1080/0142159X.2021.1924364.
R. da S. Tiago and A. Mitchell, “Integrating Digital Transformation in Nursing Education: Best Practices and Challenges in Curriculum Development,” Emerald Publishing Limited, 2024, doi: 10.1108/978-1-83608-424-220241004.
K. Rajaram, “Future of learning: Teaching and Learning Strategies BT - Learning Intelligence: Innovative and Digital Transformative Learning Strategies: Cultural and Social Engineering Perspectives,” Springer Nature: Singapore, pp. 3–53. 2023, doi: 10.1007/978-981-19-9201-8_1.
J. Frerejean, J. J. G. van Merriënboer, C. Condron, U. Strauch, and W. Eppich, “Critical design choices in healthcare simulation education: A 4C/ID perspective on design that leads to transfer,” Adv. Simul., vol. 8, no. 1, p. 5, 2023, doi: 10.1186/s41077-023-00242-7.
D. Ko, A. Bal, and A. J. Artiles, “Racial equity by design: forming transformative agency to address the racialization of school discipline,” Urban Educ., vol. 59, no. 3, pp. 660–693, 2022, doi: 10.1177/00420859221081774.
T. C. Horrill, C. Varcoe, H. Brown, K. I. Stajduhar, and A. J. Browne, “Bringing an equity lens to participant observation in critical ethnographic health research,” Int. J. Qual. Methods, vol. 23, no. 5, p. 160-168, 2024, doi: 10.1177/16094069241270397.
Copyright (c) 2024 Ridouane Oulhiq, Shi ching W, Pichayapor Ratt, Maurizio Martin Cavani Brain
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and acknowledge that the Journal of Health Innovation and Environmental Education is the first publisher licensed under a Creative Commons Attribution 4.0 International License.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges and earlier and greater citation of published work.
.png)
.png)
