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Learn more: PMC Disclaimer | PMC Copyright Notice Nurs Open . 2026 Apr 10;13(4):e70543. doi: 10.1002/nop2.70543 Search in PMC Search in PubMed View in NLM Catalog Add to search The Mediating Effect of Teamwork Attitude Between Cultural Intelligence and Teamwork Cognition in Nursing Students Yanfen Gu Yanfen Gu 1 Nursing Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China Find articles by Yanfen Gu 1 , Yili Gao Yili Gao 1 Nursing Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China Find articles by Yili Gao 1 , Lin Zhou Lin Zhou 2 School of Public Health and Nursing, Shanghai Aurora College, Shanghai, China Find articles by Lin Zhou 2, ✉ , Haiping Yu Haiping Yu 3 Department of Nursing, Pudong Gongli Hospital, Shanghai University of Medicine & Health Sciences, Shanghai, China Find articles by Haiping Yu 3, ✉ , Danlei Yu Danlei Yu 1 Nursing Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China Find articles by Danlei Yu 1 , Yinyu Wang Yinyu Wang 1 Nursing Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China Find articles by Yinyu Wang 1 Author information Article notes Copyright and License information 1 Nursing Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China 2 School of Public Health and Nursing, Shanghai Aurora College, Shanghai, China 3 Department of Nursing, Pudong Gongli Hospital, Shanghai University of Medicine & Health Sciences, Shanghai, China * Correspondence: Lin Zhou ( [email protected] ), Haiping Yu ( [email protected] ) ✉ Corresponding author. Revised 2026 Mar 30; Received 2024 Sep 19; Accepted 2026 Apr 1; Collection date 2026 Apr. © 2026 The Author(s). Nursing Open published by John Wiley & Sons Ltd. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. PMC Copyright notice PMCID: PMC13069180 PMID: 41964286 ABSTRACT Aim This study aims to examine the relationships among cultural intelligence, teamwork cognition and teamwork attitude, which are deep‐seated factors influencing teamwork among nursing students. Design This was a cross‐sectional survey study. Methods Convenient sampling was used to select 301 nursing students from a nursing college in Shanghai for this investigation. The data collection utilized a self‐made general information questionnaire, cultural intelligence scale, teamwork attitude scale and teamwork cognition scale. Statistical methods such as t ‐tests, Pearson correlation analysis and structural equation modeling were employed for the analysis of the mediating effects. Results The scores for nursing students were (4.45 ± 0.79) for cultural intelligence, (3.84 ± 0.78) for teamwork attitude and (3.85 ± 0.63) for teamwork cognition. Cultural intelligence showed a positive correlation with both teamwork cognition and attitude ( r = 0.639, 0.507, both p < 0.01). Teamwork attitude partially mediated the association between cultural intelligence and teamwork cognition (β = 0.42, p < 0.01), with direct and indirect effects of 0.32 and 0.42, respectively. Conclusions Cultural intelligence was positively associated with teamwork cognition among nursing students, and teamwork attitude may partially mediate this association. These findings suggest that strengthening cultural intelligence and teamwork attitude may support teamwork cognition in nursing education. However, because of the cross‐sectional design, these findings should be interpreted as correlational rather than causal. No Patient or Public Contribution. Keywords: cultural intelligence, mediating effect, nursing students, teamwork attitude, teamwork cognition 1. Introduction The Institute of Medicine (IOM) in the United States explicitly stated in 1999, in its publication ‘To Err Is Human: Building a Safer Health System’, that the annual death toll due to medical errors reached a staggering 98,000 individuals. Shockingly, by 2016, this number further escalated, surpassing 400,000 deaths (Makary and Daniel 2016 ). Globally, healthcare safety concerns have intensified, with the ‘2021‐2030 Global Patient Safety Action Plan’ revealing millions of patients worldwide suffering harm or death due to unsafe healthcare. Low‐ and middle‐income countries alone witness 134 million adverse events annually, resulting in 2.6 million deaths. In high‐income countries, approximately one‐tenth of patients experience harm during hospital care, with almost half of these incidents being preventable. China is no exception, as medical quality research indicates that only 35% of technical errors by healthcare personnel contribute to adverse events, and 30%–50% of such incidents can be prevented through effective collaboration (Cao 2007 ). To ensure the efficient operation of healthcare services, global health organizations emphasize the need for healthcare professionals to enhance their teamwork capabilities. Research has demonstrated that effective teamwork can reduce hospital infection rates (Liu et al. 2019 ), shorten patient hospitalization times, decrease medical error rates and mortality (Boev and Xia 2015 ), improve nurse retention rates (Edwards et al. 2017 ) enhance healthcare quality and increase job satisfaction (Sames and Polt 2016 ). Harrison's study on hospital team cohesion suggests that over time (Harrison et al. 1998 ), the influence of surface‐level differences such as gender and age diminishes, while the impact of deep‐level differences such as culture, attitudes, cognition and perception asymmetry intensifies (Gu et al. 2022 ; Yu et al. 2020 , 2018 ). Attitude, being a complex mix of an individual's personality, beliefs, values, behaviour and motivation, can positively influence behaviour. In the context of ongoing global economic development and integration, there is a growing need for more healthcare professionals to provide necessary support and services in a collaborative team format, necessitating a positive teamwork attitude among healthcare personnel. However, Laura's research indicates that nurses tend to have lower teamwork attitude scores compared to other healthcare professionals (Muñoz De Morales‐Romero et al. 2021 ). The attitudes of healthcare professionals play a crucial role in influencing team cognition and behaviour, making achieving equal access to healthcare a challenge and affecting the quality and safety of nursing care (Ballangrud et al. 2020 ; Kalisch and Lee 2010 ). Particularly, the biases, attitudes and behaviours of healthcare professionals can negatively impact the health outcomes of marginalized and stigmatized populations (Richard‐Eaglin 2021 ). The 2021 Patient Safety Goals released by the American Medical Association emphasize the need for both safe healthcare professionals and safe patients. One suggested approach to enhance healthcare professionals' abilities is through education, particularly focusing on improving their cultural communication skills. The Special Action Plan for Patient Safety in China (2023–2025) explicitly emphasizes the pivotal role of cultural construction in guiding patient safety management. Cultural intelligence, as an ability related to culture, reflects individuals' capacity to collect, process information, make judgements and take effective measures to adapt to a new cultural context (Ang et al. 2006 ). People from different cultural backgrounds may interpret diverse cultures using their own thinking patterns and address issues through their own behavioural approaches, leading to cognitive and behavioural misalignment that can impact teamwork and influence both short‐term and long‐term patient outcomes (Gu et al. 2021 ). Therefore, it will bring great medical safety hazards and huge economic losses. High cultural intelligence has been proven to facilitate better cross‐cultural respect, recognition, or adaptation (Brislin 2006 ), with individuals displaying this ability being more attuned to the similarities and differences between their own culture and others. This competency reduces the likelihood of conflicts and positively influences job satisfaction and teamwork capabilities.(Bücker et al. 2014 ; Gu et al. 2022 ). Despite the increasing importance of teamwork, most research on healthcare teamwork focuses on emergency and perioperative teams (Kalisch and Lee 2010 ), with limited attention given to nursing students. This gap is important because nursing students represent the future nursing workforce, and their teamwork‐related attitudes and cognitions may influence both learning outcomes and later collaborative practice. In addition, recent nursing evidence continues to show that teamwork is closely tied to care quality and missed nursing care, further highlighting the importance of understanding how teamwork‐related capabilities develop early in nursing education (Kohanová et al. 2024 ). From a psychological and educational perspective, teamwork attitude may function as a proximal mechanism linking individual capability to cognition‐related outcomes. Students with higher cultural intelligence may be more open to diversity, more respectful of others' perspectives and more willing to collaborate with peers from different backgrounds. These tendencies may foster a more positive teamwork attitude. In turn, teamwork attitude may shape how students perceive, evaluate and understand teamwork processes, and may therefore contribute to teamwork cognition (Ang et al. 2006 ; Ballangrud et al. 2020 ; Richard‐Eaglin 2021 ; Ahmadi Forg et al. 2025 ). Therefore, teamwork attitude was hypothesized to mediate the relationship between cultural intelligence and teamwork cognition. 2. Methods 2.1. Participants and Procedure Study Participants: Convenience sampling was employed, selecting nursing students from a nursing college in Shanghai in November 2023. Inclusion criteria: (1) Full‐time undergraduate nursing students aged ≥ 18; (2) No reading or comprehension impediments; (3) Informed consent and voluntary participation. Exclusion criteria: Those unable to complete the questionnaire for various reasons. Data collection was conducted using the ‘Wen juan xing’ platform, ensuring all questions were mandatory. Participants independently completed and submitted the questionnaire within 30 min. Sample size was calculated based on 5–10 times (Wu 2000 ) the number of questionnaire items, resulting in 325 clinical nursing students participating, with 301 valid responses (92.62% response rate). All participants signed an informed consent form. 2.2. Measures 2.2.1. General Information Questionnaire A self‐designed questionnaire including demographics, language proficiency, living arrangements, leadership roles, international experiences, volunteering, internship history and foreign language proficiency. 2.2.2. Cultural Intelligence Scale (CQS) Developed by P. Christopher Early and Soon Ang, this is a Likert 7‐level continuous scale that contains 20 entries including metacognitive (4 entries), cognitive (6 entries), motivational (5 entries) and behavioural (5 entries) cultural intelligence (Earley and Ang 2003 ). It ranges from ‘totally disagree’ to ‘totally agree’. The score varies from 20 to 140, indicating that higher scores signify better cultural intelligence. I know the legal and economic systems of other cultures. I know the rules (e.g., vocabulary, grammar) of other languages. The alpha coefficients of the subscales range from 0.747 to 0.838 and are 0.859 on the total scale. In this study, the Cronbach alpha is from 0.628 to 0.898 in subscales and is α = 0.923 in the overall scale. 2.2.3. TeamSTEPPS Teamwork Perceptions and Attitudes Questionnaires (T‐TPQ and T‐TAQ) Developed by the U.S. Department of Defence and AHRQ, these questionnaires evaluate individual perceptions and attitudes toward teamwork. These two scales are medical team collaboration assessment tools developed based on the ALONSO team theory model. They all contain 5 dimensions, including team structure, leadership, communication, mutual support and situation monitoring. It is a Likert 5‐level continuous scale ranging from ‘totally disagree’ to ‘totally agree’. T‐TPQ contains 35 entries (Ballangrud et al. 2017 ), with Cronbach's α of 0.96 and the construct validity is 0.681. Example items include: ‘Team members exchange available relevant information with each other’. T‐TAQ contains 30 entries, with Cronbach's α of 0.91 and the construct validity is 0.63 (Baker et al. 2010 ). Example items include: ‘Leaders should create various opportunities for members to share information’. In this study, the Cronbach alpha is 0.976 and 0.923 in the overall scale. 2.3. Data Analysis The formal survey was conducted from September 13 to September 14, 2023, using an electronic questionnaire distributed via QR codes. Prior approval was obtained from the college's authorities, and teachers explained the survey's purpose and significance. Data were exported to Excel for cleaning and then imported into SPSS 20 for statistical processing. Descriptive statistics, Pearson correlation analysis and AMOS 23.0 for mediation analysis were employed. Bootstrap method with bias‐corrected non‐parametric percentiles was used to determine the significance of effects. 2.4. Ethical Considerations The study has been approved by Shanghai East Hospital Medical Ethics Board (Number: 2024.148). The students who agreed to take part in the study were either unpaid or had no reporting relationship with the researchers. 3. Results 3.1. Demographic Information A total of 301 undergraduate nursing students participated in the study. The participants' ages ranged from 18 to 23 years, with a mean age of 19.44 ± 0.70. Among the participants, 120 (39.9%) were male and 181 (60.1%) were female. The majority of students resided outside Shanghai (68.8%), with 94 (31.2%) residing in Shanghai. Regarding sibling status, 148 (49.2%) were only children, while 153 (50.8%) had siblings. Regarding living arrangements, the vast majority of participants resided with their parents (278, 92.4%), while 23 participants (7.6%) had non‐parental living arrangements. Additionally, 26 students (8.6%) reported having a religious belief, while 275 (91.4%) did not. The majority (81.7%) were proficient in two or fewer languages and 55 (18.3%) were proficient in more than two languages. In terms of foreign language level, 123 participants (40.9%) had attained CET (College English Test) or equivalent qualifications and 178 participants (59.1%) held other foreign language qualifications. The ethnic composition included 293 Han Chinese (97.3%) and 8 (2.7%) from ethnic minorities. Among the participants, 184 (61.1%) had served as class cadres, 204 (67.8%) had volunteered, 25 (8.3%) had a history of living abroad and 27 (9%) had undergone hospital internships or clinical rotations. Detailed information is presented in Table 1 . TABLE 1. General information of nursing students and comparison of teamwork cognition scores based on different characteristics ( N = 301). Variables n (%) Teamwork cognition M ± SD t p Age 19.44 ± 0.70 Gender Male 120 (39.9) 3.66 ± 0.68 −4.30 < 0.001 Female 181 (60.1) 3.97 ± 0.57 Residence Shanghai 94 (31.2) 3.87 ± 0.66 0.40 0.686 Outside Shanghai 207 (68.8) 3.84 ± 0.62 Ethnicity Han Chinese 293 (97.3) 3.86 ± 0.63 0.96 0.341 Minority 8 (2.7) 3.64 ± 0.61 Only child Yes 148 (49.2) 3.86 ± 0.67 0.24 0.812 No 153 (50.8) 3.84 ± 0.60 Living arrangements With parents 278 (92.4) 3.85 ± 0.64 −0.74 0.462 Non‐parental 23 (7.6) 3.98 ± 0.56 Religious beliefs Yes 26 (8.6) 3.85 ± 0.69 0.02 0.984 No 275 (91.4) 3.85 ± 0.63 Languages proficiency ≤ 2 246 (81.7) 3.83 ± 0.61 −1.28 0.202 > 3 55 (18.3) 3.95 ± 0.75 Foreign language level CET or equivalent 123 (40.9) 3.86 ± 0.66 0.19 0.853 Others 178 (59.1) 3.84 ± 0.61 Class cadre experience Yes 184 (61.1) 3.89 ± 0.66 1.36 0.176 No 117 (38.9) 3.79 ± 0.59 Volunteer experience Yes 204 (67.8) 3.88 ± 0.66 1.33 0.186 No 97 (32.2) 3.78 ± 0.56 Hospital internship or clinical rotation Yes 27 (9.0) 3.89 ± 0.83 0.33 0.742 No 274 (91.0) 3.85 ± 0.61 International living experience Yes 25 (8.3) 3.92 ± 0.69 0.54 0.587 No 276 (91.7) 3.84 ± 0.63 Open in a new tab Abbreviations: M, mean; SD, standard deviation. 3.2. Cultural Intelligence, Teamwork Attitude and Teamwork Cognition Scores of Nursing Students In this study, the cultural intelligence score of nursing students was (4.45 ± 0.79), the teamwork attitude score was (3.84 ± 0.78) and the teamwork cognition score was (3.85 ± 0.63). 3.3. Correlation Analysis of Cultural Intelligence, Teamwork Attitude and Teamwork Cognition in Nursing Students The statistical results of this survey indicate a positive correlation between cultural intelligence and teamwork cognition ( r = 0.639, p < 0.01). There is also a positive correlation between cultural intelligence and teamwork attitude ( r = 0.507, p < 0.01). Additionally, there is a positive correlation between nursing students' teamwork attitude and teamwork cognition ( r = 0.821, p < 0.01). Detailed correlation coefficients are presented in Table 2 . TABLE 2. Correlation analysis of cultural intelligence, teamwork attitude and teamwork cognition in nursing students ( N = 301). Variables M ± SD 1 2 3 1. Cultural intelligence 4.45 ± 0.79 1 2. Teamwork cognition 3.85 ± 0.63 0.639 ** 1 3. Teamwork attitude 3.84 ± 0.78 0.507 ** 0.821 ** 1 Open in a new tab Abbreviations: M, mean; SD, standard deviation. ** p < 0.01. 3.4. Analysis of the Mediating Effect of Nursing Students' Teamwork Attitude Between Cultural Intelligence and Teamwork Cognition Using the Harman single‐factor method, a factor analysis with no rotation was conducted on all items of cultural intelligence, teamwork cognition and teamwork attitude. The results revealed that there were 10 common factors with eigenvalues > 1. The first common factor explained 49.3871% of the total variance, which is below the critical standard of 50% (Williams and Brown 1994 ). Therefore, there is no common method bias in the data of this study. A structural equation model was constructed with cultural intelligence as the independent variable, teamwork cognition as the dependent variable and teamwork attitude as the mediating variable. The maximum likelihood method was employed for the mediation effect test. After adjustment using Bollen and Stine ( 1993 ), the fit indices of the model were as follows: the chi‐square‐to‐degrees‐of‐freedom ratio ( χ 2 /df) was 1.43, goodness of fit index (GFI) was 0.98, normed fit index (NFI) was 0.98, Tucker‐Lewis index (TLI) was 0.99, comparative fit index (CFI) was 0.99 and root mean square error of approximation (RMSEA) was 0.04. The values indicated a good fit for the model, as χ 2 /df < 5, and GFI, NFI, TLI, CFI > 0.9 and RMSEA < 0.8. Refer to Figure 1 for the model diagram. FIGURE 1. Open in a new tab Depicts the standardized mediation model of nursing students' teamwork attitude in the relationship between cultural intelligence and teamwork cognition. The model indicated that cultural intelligence has a direct positive predictive effect on teamwork cognition (β = 0.32, p < 0.01). Cultural intelligence also has a direct positive predictive effect on teamwork attitude (β = 0.59, p < 0.01). Teamwork attitude has a direct positive predictive effect on teamwork cognition (β = 0.71, p < 0.01). Teamwork attitude partially mediates between cultural intelligence and teamwork cognition. Furthermore, using the Bootstrap method with 5000 samples for the mediation effect test, the results showed that the 95% confidence interval (CI) for the mediation effect value of teamwork attitude between cultural intelligence and teamwork cognition was (0.380–0.650), which does not include 0, indicating a significant mediation effect. The specific mediation effect value is 0.59 × 0.71 = 0.42, and the total effect value is 0.32 + 0.42 = 0.74. The mediation effect accounts for 56.75% of the total effect, while the direct effect accounts for 43.25%. Refer to Table 3 for details. TABLE 3. Effects of the mediation model (standardized). Independent variable Dependent variable Direct effect Indirect effect Total effect Culture intelligence Teamwork cognition 0.32 0.42 0.74 Culture intelligence Teamwork attitude 0.59 — 0.59 Teamwork attitude Teamwork cognition 0.71 — 0.71 Open in a new tab 4. Discussion The results of this study indicate that the teamwork attitude scores of Chinese nursing students are lower than those of American nursing students falling into the lower end of the moderate level (Greene and Doss 2021 ). Moreover, teamwork attitude has a direct impact on teamwork cognition. Paying attention to the teamwork attitude of nursing students has a positive impact on their own professional development, creating a safe nursing work environment, and ensuring patient safety (Jones and Treiber 2018 ). Studies on nurses in Turkey and China found that the teamwork attitude and teamwork cognition levels of nurses are at a moderate level (Meng et al. 2021 ). Therefore, training in teamwork attitude and cognition for nurses is necessary. Research by Zhou et al. ( 2025 ) found that students participating in new teaching reforms can enhance their enthusiasm and fundamentally improve the quality of medical care. In this study, the scores for situation monitoring in teamwork attitude were the highest, while mutual support scores were the lowest. This is consistent with the results of Karlsen et al. ( 2022 ), where mutual support refers to the ability of team members to understand and communicate with each other, accurately grasp each other's responsibilities and workload and provide support and assistance when needed. Creating an environment for students to develop these abilities in the classroom is essential, as experiential teaching has been shown to be more effective (Kirste and Holtbrügge 2019 ), with higher student engagement. Situation monitoring involves actively examining and evaluating work situations, collecting information from various sources, understanding work situations and maintaining awareness to sustain team functionality. With the adjustment of China's family planning policy, more than half of the nursing students in this study are not only children, indicating a positive impact of the policy on family structure. Children in multi‐child families may have more opportunities to learn through sibling interaction, and positive sibling relationships may support the development of social skills, prosocial behaviour and constructive problem‐solving (Morgan and Rogers 2025 ). This educational approach is conducive to improving the overall quality of children, enabling them to cooperate in teams and adapt to future society. In nursing textbooks and curriculum design, personalized teaching for students is needed to encourage their participation in lectures, enhance their reflective and teamwork abilities and provide specialized training for dimensions lacking in teamwork. This study found that the teamwork cognition scores of male nursing students are slightly higher than those of Korean male nurses (Hwang and Ahn 2015 ), but lower than those of female nursing students and the difference is statistically significant. The proportion of male nursing students in this study is close to 40%, significantly improving the representativeness of the results. With the continuous change in social attitudes, bias against men in nursing in Chinese society has gradually decreased. However, compared to females, males may have a weaker perception of conflict and lower enthusiasm for work (Satake and Arao 2019 ), often failing to perceive potential conflicts in the team, which can affect teamwork cognition. Studies have shown that communication models such as SBAR and AIDET (Msosa et al. 2021 ; Register et al. 2020 ) can improve the communication skills of male nursing students. Therefore, clinical managers need to pay attention to the cognitive deviation of teamwork in male nurses and conduct effective communication training to reduce teamwork cognitive differences. While encouraging men to engage in nursing work, attention should also be paid to addressing the new issues that may arise and finding solutions. The cultural intelligence of nursing students in this study was at a moderate level, consistent with the findings of Hong et al. ( 2021 ). However, the metacognition scores are the lowest. Metacognition is the ability of individuals to have their own views and ideas about different cultures through perception and analysis, demonstrating the ability to understand different cultures. Recent meta‐analytic evidence suggests that cultural intelligence has meaningful and incremental associations with work‐related outcomes, supporting its relevance for effective functioning in culturally diverse contexts (Schlaegel et al. 2021 ). Learning cultural intelligence has been proven to follow a spiral development curve (Hong et al. 2021 ), and improvement can be achieved through deliberate practice. Therefore, cultural intelligence training should be integrated throughout the entire learning cycle of nursing students, requiring continuous attention. In formulating cultural intelligence training programs, grouping should be done according to the different grades of nursing students, tracking the training effects of cultural intelligence for each nursing student longitudinally, and adjusting the training programs based on changes. Through the mediation analysis, the direct and indirect effects of cultural intelligence on teamwork cognition of nursing students were verified. Cultural intelligence has a direct positive predictive effect on teamwork cognition, with a direct effect accounting for 43.25%. This suggests that enhancing the cultural intelligence level of nursing students helps strengthen their teamwork cognition abilities, better adapting to the demands of nursing work. Cultural intelligence can also have an indirect effect on teamwork cognition through teamwork attitude, with the mediating effect accounting for 56.75%. This implies that nursing students with positive teamwork attitudes can better translate their advantages in cultural intelligence into tangible teamwork outcomes. In summary, this study reveals the direct and indirect effects of cultural intelligence on the teamwork cognition of nursing students. The cultural intelligence level and teamwork attitude of nursing students play crucial roles in teamwork cognition, providing valuable insights for nursing educators and managers. To improve the teamwork cognition abilities of nursing students, attention should be paid to enhancing their cultural intelligence level, enabling nursing students to better understand and respect classmates from different cultural backgrounds and enhancing teamwork cognition. Cultivating a positive teamwork attitude and guiding nursing students to establish correct teamwork concepts are important. Strengthening training in teamwork skills is also necessary for nursing students. Creating a good team atmosphere is crucial, and nursing educators should focus on creating a learning environment that is mutually respectful and fair. Through these measures, it is hoped that the teamwork cognition abilities of nursing students can be improved, injecting new vitality into the nursing profession. 4.1. Implications Cultural intelligence training should be incorporated into both academic and clinical nursing education. In academic settings, this may be achieved through case discussion, simulation, reflective learning and communication‐focused educational activities, which have been reported to support teamwork attitudes and collaborative learning (Greene and Doss 2021 ; Muñoz De Morales‐Romero et al. 2021 ). During clinical placements, mentor guidance, observation of teamwork in practice, timely feedback and reflective debriefing may further facilitate the development of cultural intelligence and teamwork‐related competencies (Richard‐Eaglin 2021 ). Future training programs may also consider adopting more targeted approaches according to students' different developmental needs. 4.2. Limitations This study has several limitations. First, participants were recruited through convenience sampling from only one university in Shanghai, which may limit the representativeness of the sample and reduce the generalizability of the findings to nursing students in other regions of China and in other countries. Institutional, regional and educational differences may influence cultural intelligence, teamwork attitude and teamwork cognition; therefore, the findings should be interpreted with caution. Second, because this study used a cross‐sectional design, causal relationships among cultural intelligence, teamwork attitude and teamwork cognition cannot be established. Accordingly, the observed associations should be interpreted as correlational rather than causal. Future studies should recruit participants from multiple universities and broader geographic areas and use longitudinal or interventional designs to improve external validity and further clarify the directionality of these relationships. 5. Conclusions The global shortage of nurses is a severe challenge, and nursing students, as the successors of nursing, have their attitudes and cognition toward teamwork directly and indirectly impacting patient outcomes. Cultural intelligence has been confirmed as an ability related to culture that can be improved through training. The cultural intelligence of nursing students is at a moderate level, and their cultural intelligence can directly influence teamwork cognition and teamwork attitude. Additionally, cultural intelligence can have an indirect effect on teamwork cognition through teamwork attitude. Therefore, nursing educators need to emphasize the training of cultural intelligence, conduct personalized and long‐term training, dynamically monitor changes in nursing students' cultural intelligence, and intervene and train in a timely manner. Author Contributions Yanfen Gu, Yili Gao and Haiping Yu conceived and designed the study. Lin zhou and Danlei Yu collected the data. Yanfen Gu, Yinyu Wang and Yili Gao performed the statistical analysis. Yanfen Gu, Yili Gao, Lin Zhou and Haiping Yu drafted the manuscript. Yanfen Gu and Haiping Yu critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Funding Tongji University School of Medicine Nursing School (Provisional) Three‐Year Action Plan for Discipline Construction (Grant No. JS2210305). Tongji University School of Medicine Nursing School (Provisional) Three‐Year Action Plan for Discipline Construction (Grant No. JS2210204). Shanghai Lifelong Education Research Association 2023–2024 Self‐funded Project (Grant No. SLERA202327). Academic Leaders Training Program of Pudong Health Bureau of Shanghai (Grant No. PWRd2022‐16). Construction and Multicenter Effect Verification of a Cultural Competence Training Program for ICU Nurses Based on the Transcultural Nursing Theory (Grant No. 2025SD‐B03). Think Tank Research Project of Shanghai University of Medicine & Health Sciences (ZKXM2501‐20). Ethics Statement This study was approved by the Ethics Committee of Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China (Approval No. 2024.148, approved on 2024.06.11). All responses were collected anonymously, and participant confidentiality was maintained throughout the study. The study was conducted in accordance with the Declaration of Helsinki. Consent Electronic informed consent was obtained from all participants before completion of the survey. Conflicts of Interest The authors declare no conflicts of interest. Acknowledgements The authors thank all participating students for filling out the questionnaire. Contributor Information Lin Zhou, Email: [email protected]. Haiping Yu, Email: [email protected]. Data Availability Statement De‐identified datasets supporting the findings of this study are available from the corresponding author upon reasonable request, subject to institutional and ethical approvals. References Ahmadi Forg, F. , Doosti P., Hasani H., et al. 2025. “Investigating the Relationship Between Cultural Intelligence and Cultural Competence Among Students in Nursing Faculties in Iran: An Analytical Cross‐Sectional Study.” BMC Nursing 24, no. 1: 890. 10.1186/s12912-025-03555-2. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Ang, S. , Dyne L. V., and Koh C.. 2006. “Personality Correlates of the Four‐Factor Model of Cultural Intelligence.” Group & Organization Management 31, no. 1: 100–123. 10.1177/1059601105275267. [ DOI ] [ Google Scholar ] Baker, D. P. , Amodeo A. M., Krokos K. J., Slonim A., and Herrera H.. 2010. “Assessing Teamwork Attitudes in Healthcare: Development of the TeamSTEPPS Teamwork Attitudes Questionnaire.” Quality & Safety in Health Care 19, no. 6: e49. 10.1136/qshc.2009.036129. [ DOI ] [ PubMed ] [ Google Scholar ] Ballangrud, R. , Husebo S. E., and Hall‐Lord M. L.. 2017. “Cross‐Cultural Validation and Psychometric Testing of the Norwegian Version of the TeamSTEPPS(R) Teamwork Perceptions Questionnaire.” BMC Health Services Research 17: 799. 10.1186/s12913-017-2733-y. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Ballangrud, R. , Husebø S. E., and Hall‐Lord M. L.. 2020. “Cross‐Cultural Validation and Psychometric Testing of the Norwegian Version of TeamSTEPPS Teamwork Attitude Questionnaire.” Journal of Interprofessional Care 34, no. 1: 116–123. 10.1080/13561820.2019.1638759. [ DOI ] [ PubMed ] [ Google Scholar ] Boev, C. , and Xia Y.. 2015. “Nurse‐Physician Collaboration and Hospital‐Acquired Infections in Critical Care.” Critical Care Nurse 35, no. 2: 66–72. 10.4037/ccn2015809. [ DOI ] [ PubMed ] [ Google Scholar ] Bollen, K. A. , and Stine R. A.. 1993. “Bootstrapping Goodness‐Of‐Fit Measures in Structural Equation Models.” Sociological Methods & Research 21, no. 2: 205–229. [ Google Scholar ] Brislin, R.
2006. “Cultural Intelligence: Understanding Behaviors That Serve People's Goals.” Group & Organization Management 31, no. 1: 40–55. 10.1177/1059601105275262. [ DOI ] [ Google Scholar ] Bücker, J. J. L. E. , Furrer O., Poutsma E., and Buyens D.. 2014. “The Impact of Cultural Intelligence on Communication Effectiveness, Job Satisfaction and Anxiety for Chinese Host Country Managers Working for Foreign Multinationals.” International Journal of Human Resource Management 25, no. 14: 2068–2087. 10.1080/09585192.2013.870293. [ DOI ] [ Google Scholar ] Cao, R. G.
2007. “China's Medical Quality and Patient Safety.” Chinese Hospitals 11, no. 11: 1–4. 10.3969/j.issn.1671-0592.2007.11.001. [ DOI ] [ Google Scholar ] Earley, P. C. , and Ang S.. 2003. Cultural Intelligence: Individual Interactions Across Cultures. Stanford University Press. [ Google Scholar ] Edwards, P. B. , Rea J. B., Oermann M. H., et al. 2017. “Effect of Peer‐To‐Peer Nurse‐Physician Collaboration on Attitudes Toward the Nurse‐Physician Relationship.” Journal for Nurses in Professional Development 33, no. 1: 13–18. 10.1097/NND.0000000000000310. [ DOI ] [ PubMed ] [ Google Scholar ] Greene, D. A. , and Doss J. L.. 2021. “Developing Teamwork Skills in Baccalaureate Nursing Students: Impact of TeamSTEPPS Training and Simulation.” International Journal of Nursing Education Scholarship 18, no. 1: 20200077. 10.1515/ijnes-2020-0077. [ DOI ] [ PubMed ] [ Google Scholar ] Gu, Y. , Yu H., Wang Y., and Zhou S.. 2021. “Hulituandui Chongtu Yanjiu Jinzhan [Research Progress on Nursing Team Conflict].” Huli Xue 36, no. 6: 109–112. 10.3870/j.issn.1001-4152.2021.06.109. [ DOI ] [ Google Scholar ] Gu, Y. , Yu H., Wang Y., and Zhou S.. 2022. “The Moderating Effect of Cultural Intelligence Between Nurses' Relationship Conflict and Teamwork.” Journal of Nursing Management 30, no. 7: 3313–3321. 10.1111/jonm.13772. [ DOI ] [ PubMed ] [ Google Scholar ] Harrison, D. , Price K. H., and Bell M. P.. 1998. “Beyond Relational Demography: Time and the Effects of Surface‐ and Deep‐Level Diversity on Work Group Cohesion.” Academy of Management Journal 41: 96–107. [ Google Scholar ] Hong, J. Y. , Ko H., Mesicek L., and Song M.. 2021. “Cultural Intelligence as Education Contents: Exploring the Pedagogical Aspects of Effective Functioning in Higher Education.” Concurrency and Computation: Practice and Experience 33, no. 2: e5489. 10.1002/cpe.5489. [ DOI ] [ Google Scholar ] Hwang, J. , and Ahn J.. 2015. “Teamwork and Clinical Error Reporting Among Nurses in Korean Hospitals.” Asian Nursing Research 9, no. 1: 14–20. 10.1016/j.anr.2014.09.002. [ DOI ] [ PubMed ] [ Google Scholar ] Jones, J. H. , and Treiber L. A.. 2018. “More Than 1 Million Potential Second Victims.” Nurse Educator 43, no. 3: 154–157. 10.1097/NNE.0000000000000437. [ DOI ] [ PubMed ] [ Google Scholar ] Kalisch, B. J. , and Lee K. H.. 2010. “The Impact of Teamwork on Missed Nursing Care.” Nursing Outlook 58, no. 5: 233–241. 10.1016/j.outlook.2010.06.004. [ DOI ] [ PubMed ] [ Google Scholar ] Karlsen, T. , Hall‐Lord M. L., Wangensteen S., and Ballangrud R.. 2022. “Bachelor of Nursing Students' Attitudes Toward Teamwork in Healthcare: The Impact of Implementing a TeamSTEPPS Team Training Program ‐ A Longitudinal, Quasi‐Experimental Study.” Nurse Education Today 108: 105180. 10.1016/j.nedt.2021.105180. [ DOI ] [ PubMed ] [ Google Scholar ] Kirste, L. , and Holtbrügge D.. 2019. “Experiential Learning in the Digital Context: An Experimental Study of Online Cultural Intelligence Training.” Journal of Teaching in International Business 30, no. 2: 147–174. 10.1080/08975930.2019.1663775. [ DOI ] [ Google Scholar ] Kohanová, D. , Solgajová A., and Cubelo F.. 2024. “The Association of Teamwork and Missed Nursing Care in Acute Care Setting: A Mixed‐Methods Systematic Review.” Journal of Clinical Nursing 33, no. 9: 3399–3413. 10.1111/jocn.17182. [ DOI ] [ PubMed ] [ Google Scholar ] Liu, J. , Masiello I., Ponzer S., and Farrokhnia N.. 2019. “Interprofessional Teamwork Versus Fast Track Streaming in an Emergency Department ‐ An Observational Cohort Study of Two Strategies for Enhancing the Throughput of Orthopedic Patients Presenting Limb Injuries or Back Pain.” PLoS One 14, no. 7: e0220011. 10.1371/journal.pone.0220011. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Makary, M. A. , and Daniel M.. 2016. “Medical Error—The Third Leading Cause of Death in the US.” BMJ 353: i2139. 10.1136/bmj.i2139. [ DOI ] [ PubMed ] [ Google Scholar ] Meng, Q. , Huang J., and Sun Y.. 2021. “Hushi Tuandui Hezuo Ganzhi Yu Taidu Xianzhuang Ji Qi Yingxiang Yinsu [Status Survey of Nurses' Teamwork Perceptions and Attitudes and Its Influencing Factors].” Jiefangjun Yi Yuan Guan Li Za Zhi 28, no. 6: 525–527. 10.16770/j.cnki.1008-9985.2021.06.009. [ DOI ] [ Google Scholar ] Morgan, D. D. , and Rogers C. R.. 2025. “Sibling Problem‐Solving as a Mediator Between Sibling Closeness and Social Motivations.” Journal of Social and Personal Relationships 43, no. 5: 1545–1569. 10.1177/02654075251411351. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Msosa, A. , Bruce J., and Crouch R.. 2021. “Effect of a Formative Assessment Intervention on Nursing Skills Laboratory Learning in a Resource‐Constrained Country.” Nurse Education Today 97: 104677. 10.1016/j.nedt.2020.104677. [ DOI ] [ PubMed ] [ Google Scholar ] Muñoz De Morales‐Romero, L. , Bermejo‐Cantarero A., Martínez‐Arce A., et al. 2021. “Effectiveness of an Educational Intervention With High‐Fidelity Clinical Simulation to Improve Attitudes Toward Teamwork Among Health Professionals.” Journal of Continuing Education in Nursing 52, no. 10: 457–467. 10.3928/00220124-20210913-05. [ DOI ] [ PubMed ] [ Google Scholar ] Register, S. J. , Blanchard E., Belle A., Viles A., and White M. L.. 2020. “Using AIDET Education Simulations to Improve Patient Experience Scores.” Clinical Simulation in Nursing 38: 14–17. 10.1016/j.ecns.2019.09.005. [ DOI ] [ Google Scholar ] Richard‐Eaglin, A.
2021. “The Significance of Cultural Intelligence in Nurse Leadership.” Nurse Leader 19, no. 1: 90–94. 10.1016/j.mnl.2020.07.009. [ DOI ] [ Google Scholar ] Sames, D. , and Polt R.. 2016. “Einfluss von Teamarbeit auf Wohlbefinden und emotionale Erschöpfung von Mitarbeitern in der medizinischen Rehabilitation.” Das Gesundheitswesen 80, no. 3: 270–277. [ DOI ] [ PubMed ] [ Google Scholar ] Satake, Y. , and Arao H.. 2019. “Conflict Experienced by Nurses Providing End‐Of‐Life Care in Emergency Departments in Japan.” Journal of Trauma Nursing 26, no. 3: 154–163. 10.1097/JTN.0000000000000441. [ DOI ] [ PubMed ] [ Google Scholar ] Schlaegel, C. , Richter N. F., and Taras V.. 2021. “Cultural Intelligence and Work‐Related Outcomes: A Meta‐Analytic Examination of Joint Effects and Incremental Predictive Validity.” Journal of World Business 56, no. 4: 101209. 10.1016/j.jwb.2021.101209. [ DOI ] [ Google Scholar ] Williams, L. J. , and Brown B. K.. 1994. “Method Variance in Organizational Behavior and Human Resources Research: Effects on Correlations, Path Coefficients, and Hypothesis Testing.” Organizational Behavior and Human Decision Processes 57, no. 2: 185–209. 10.1006/obhd.1994.1011. [ DOI ] [ Google Scholar ] Wu, M. R.
2000. SPSS Tongji Yingyong Shijian [SPSS Statistical Application Practice]. China Railway Publishing House. [ Google Scholar ] Yu, H. , Peng Y., Hung Y., and Zhou L.. 2018. “Immigrant Nurses' Perceptions on Cultural Differences‐Based Job Concerns: A Phenomenological Study in Shanghai China.” Journal of Clinical Nursing 27, no. 17–18: 3418–3425. 10.1111/jocn.14217. [ DOI ] [ PubMed ] [ Google Scholar ] Yu, H.‐P. , Zhang W.‐Y., Peng Y.‐Q., et al. 2020. “Emergency Medical Staff's Perceptions on Cultural Value Difference‐Based Teamwork Issues: A Phenomenological Study in China.” Journal of Nursing Management 28, no. 1: 24–34. 10.1111/jonm.12854. [ DOI ] [ PubMed ] [ Google Scholar ] Zhou, Y. Q. , Yang Y. L., and Chen Y.. 2025. “Determining the Effectiveness of a Clinical Nursing Teaching Intervention in Improving Teamwork Ability: A Quasi‐Experimental Study.” Journal of Multidisciplinary Healthcare 18: 1023–1030. 10.2147/JMDH.S506373. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement De‐identified datasets supporting the findings of this study are available from the corresponding author upon reasonable request, subject to institutional and ethical approvals. Articles from Nursing Open are provided here courtesy of Wiley ACTIONS View on publisher site PDF (533.9 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top