Perspectives of medicine, human biology, and nursing undergraduates on transversal skills learning: a mixed-methods study

RESEARCH Open Access © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 /. Fontana-Rosa et al. BMC Medical Education (2025) 25:162 https://doi.org/10.1186/s12909-025-06749-z BMC Medical Education *Correspondence: Luis González-de Paz [email protected] Full list of author information is available at the end of the article Abstract Background In health sciences practice, interpersonal skills, critical thinking, and learning-to-learn are crucial transversal skills. Effective teaching necessitates the understanding of undergraduates’ views. This study explored undergraduate experiences in human biology, medicine, and nursing degrees in learning transversal skills. Methods An exploratory sequential mixed method design with qualitative data collection and a subsequent online survey study. Three focus groups were conducted with thirdand fourth-year undergraduates, and data were analyzed with thematic analysis. The online survey targeted undergraduate students from all academic years to address inconclusive details. Analysis entailed descriptive statistics, and associations differences in responses by degrees were analyzed using chi-square tests or Fisher’s Exact Test. Results Thirteen undergraduates participated in focus groups and 159 in the online survey. Three thematic areas emerged: the training received and its perceived relevance, the evaluation, and the learning methods. Undergraduates expressed that transversal skills were necessary for self-personal growth and professional development; however 50.7% reported not receiving specific training. Human biology and medicine undergraduates reported less training in critical thinking compared to nursing (29.03% and 32.7% vs. 76%, p < 0.001) and in interpersonal and relational skills (16.1% and 16.3% vs. 57%, p < 0.001). Subjectivity is an issue compared to traditional testing, with 39.6% of undergraduates reporting knowing the assessment methods of transversal skills and 56% trusting the preparation of teaching staff. >80% of undegraduate students wanted more participatory methodologies —from classroom methodology to problem-based assessments and simulation, while plenary lectures and gamification were less preferred. Conclusion Health sciences undergraduates advocated for effectively integrating transversal skills in their programs. Nursing undergraduates showed higher satisfaction and expressed having experienced more transversal skills learning than human biology and medicine undergraduates. Undergraduates required educators to receive more support and training in adopting methodologies that facilitate transversal skill acquisition through changes in the assessment methods and substantive transformation of the program curricula. Perspectives of medicine, human biology, and nursing undergraduates on transversal skills learning: a mixed-methods study Nathalia SilvaFontana-Rosa1, LuisGonzález-de Paz2,3,4*, Ana C.Codina-Rodríguez5, MaríaPérez-Riart5 and María del MarCarrió-Llach6 Page 2 of 9Fontana-Rosa et al. BMC Medical Education (2025) 25:162 Background Higher educational authorities and international bodies have underscored the imperative shift toward educational strategies focused on developing Transversal Skills (TS) [1]. These skills are essential for handling changes in health sciences practice, like the increasing prevalence of a population having long-term conditions or the public health emergency for COVID-19 (2020–2023), which highlights the necessity of equipping health sciences professionals with skills to manage complex scenarios [2, 3]. Healthcare professionals must be able to analyze situations critically and creatively, adapt and manage large amounts of information, engage patients effectively, and demonstrate interpersonal and emotional skills [3, 4]. Interpersonal skills involve cognitive, emotional, and behavioral attitudes, including empathy and negotiation, that facilitates adaptive and prosocial interactions in various contexts [5, 6]. This group of skills are crucial in fostering collaborative efforts and addressing health inequities across diverse settings and networks [7, 8]. The critical thinking skill is the mental process of perceiving, analyzing, synthesizing, and evaluating information derived from observation, experience, reflection, and reasoning [9, 10]. Critical thinking links to learning-tolearn skills and is a key to generating new ideas, organizing one’s learning through efficient time and information management [11]. Critical thinking and learning to learn are crucial for developing knowledge to improve health sciences. Obstacles in integrating TS are not minor [12, 13] and include teachers’ motivation, resources, recognition, self-efficacy, and student-related elements like commitment and effort [14]. Effective development of learning activities aims at fostering skills transfer, particularly in interpersonal, critical thinking, and learning-to-learn skills, as it requires a comprehensive understanding of student characteristics [15, 16]. Interpersonal skills, critical thinking, and learning to learn effectively collectively form a robust foundation for achieving short and longterm educational goals in health sciences [5]. Although integrating these skills into academic curricula is a priority, there’s a gap in describing and understanding undergraduates’ experiential learning journey. Therefore, this study aimed to explore undergraduates experiences in human biology, medicine, and nursing degrees regarding interpersonal, critical thinking, and learning-to-learn TS. Materials and methods Context This study presents the results of the first stage of a European project aiming to integrate TS into health and social care [17]. The project sought pedagogical actions and learning activities to work on TS through a student-centered constructivist pedagogical approach [18, 19]. Setting The study site was a faculty of Health and Life Sciences at a major hospital in Barcelona [20, 21]. The faculty provides degree studies in human biology, medicine, and nursing [22]. At the end of 2021, the total number of enrolled undergraduate students was 260 in the human biology degree, 240 in the medicine degree, and 340 in the nursing degree [23]. Design We adopted an exploratory sequential mixed-method design with two phases [24, 25]. Initially, qualitative data collection with focus groups was conducted, followed by an analysis phase. This phase aimed to gain an in-depth understanding of undegraduates’ opinions, knowledge, perceptions, and concerns about interpersonal skills, critical thinking, and learning-to-learn TS. A subsequent quantitative phase involved the development of a survey design. The qualitative and quantitative results were integrated based on qualitative and quantitative approaches. Qualitative data collection with focus groups Participants and script design Participants in the focus groups were purposely selected from a population of undergraduates in the 3rd and 4th years of human biology, nursing, and 5th-year medicine. The selection was guided by recommendations from the university’s instructional staff; the criteria included participants’ communication proficiency, academic performance, active engagement in classroom activities, and a diverse representation of perspectives at different stages of their academic instruction. This sampling strategy aimed to capture comprehensively the range of insights and experiences related to TS. A comprehensive literature review and insights from a panel of experts in health and social sciences were gathered to formulate openended questions and themes on TS. The script and openended questions are in the online appendix. Focus groups We planned to conduct at least three focus groups to examine undergraduates views from the three-degree program separately (human biology, medicine, and nursing). The focus groups were conducted online and lasted from 90 to 100min. Each group had a maximum of six participants. The focus groups were conducted by the researchers involved in the study, who acted as Keywords Real-world outcomes, Critical thinking, Higher education, Assessment, Transversal skills Page 3 of 9Fontana-Rosa et al. BMC Medical Education (2025) 25:162 moderators and observers. The observers assisted by taking notes and managing the discussion flow. At the start, participants were informed about their roles and were aware of the observers; all concerns were answered. Participation norms were clearly outlined to ensure active participation, respect, and confidentiality. Measures to ensure confidentiality were emphasized and participants were reassured that their responses would remain anonymous and be used exclusively for research purposes [26, 27]. Information analysis We conducted a thematic analysis to explore the beliefs, perceptions, and experiences of health science undergraduate students related to transversal skills [28]. First, we transcribed data and reviewed the transcripts for accuracy. Researchers read the transcripts multiple times to familiarize themselves with the data and gain an indepth understanding. We then generated open codes by labelling text fragments with similar meanings. These codes were grouped into main themes that reflected undergraduates’ experiences with transversal skills. The themes were reviewed and refined to represent the participants’ perspectives accurately. The research team engaged in discussions to validate the themes. Quantitative data collection with a survey The results of focus group discussions were analyzed to identify areas where the qualitative data was inconclusive or required further elaboration. Based on this, an online survey was designed, estimated to take five minutes to complete, and collected information on: socio-demographics (gender, academic degree, and year of study); awareness of TS, using a predefined list of TS based on their opinions as mentioned in the focus groups; training in TS during their degree program, and specific training in the three investigated TS, both rated from 0 (no training) to 3 (High amount of training); perceived importance of TS, assessed through two items using a 4-point Likert scale ranging from “Not important” to “Very important”; methods facilitating TS acquisition, with participants rating three items on a 4-point Likert scale from “Never” to “Always”; and opinions on learning and assessment methods, measured by seven items rated on a 4-point Likert scale from “Disagree/Never” to “Agree/Always.” The final survey is available in the online appendix. Data collection, participants, and sampling The survey was edited with the Google Education suite (Google Forms®). Eligible participants were undergraduate students enrolled in human biology, medicine, or nursing programs for all academic years. A web link with the survey form and objectives of the study was sent to all participants using the academic web to maximize participation. Three reminders encouraging participation were sent for two weeks. We expected at least 150 participants, corresponding to 1/3 of the undergraduates at the faculty, to ensure external validity and generalization. Data collection started in November 2021 and ended in December 2021. Statistical analysis The three questionnaires from human biology, medicine, and nursing were merged, the date of birth was computed to age. All items scored using rating and Likert scales were dichotomized into a lower category (ratings 0–1) and a higher category (ratings 2–3). This was implemented to facilitate subsequent statistical analyses and ensure clarity in the interpretation of the data. Categorical variables were expressed as %, frequency, and continuous with means and standard deviation. Results were expressed as totals and by degree. Opinions on which TS and methodologies promoting Interpersonal skills, critical thinking, and learning-to-learn TS were represented graphically. Analysis of items of knowledge and self-understanding of TS were calculated for all participants, and differences in proportions across groups of degrees were analyzed with chi-square tests or Fisher’s Exact Test. The level of statistical significance was set at α = 0.05. All analyses used the R v.4.1.2 statistical package [29]. Integration of information and reporting We used joint displays to integrate information and construct a narrative based on quantitative and qualitative findings [30]. Findings were described in a single report with joint displays of quantitative results and qualitative findings side-by-side. Joint displays show empirical evidence while facilitating the derivation of meta-inferences and new insights [31]. Ethics The study’s protocol was authorized by a credited ethics committee. All procedures followed the established ethical guidelines. For focus groups, all participants provided informed consent before their involvement. For the survey study, participation was entirely voluntary and anonymous. Results Participants Thirteen undergraduate students (seven males and six women) participated in three distinct focus groups, each representing to a specific academic program: human biology (n = 5), medicine (n = 4) and nursing (n = 4). In the survey study, 163 undergraduate students from all academic years accessed the online survey, and 159 (98%) completed it. They had a mean age of 20.4 years Page 4 of 9Fontana-Rosa et al. BMC Medical Education (2025) 25:162 (SD = 3.6), the majority (73%) were females, and 70% were studying in the first to third academic year. Table1 shows the survey participants’ characteristics. Three thematic categories emerged from the qualitative study: (i) the training received and its perceived relevance, (ii) the evaluation, and (iii) the learning methods. These thematic areas guided the formulation of the survey questions. The training received and its perceived relevance Undergraduates expressed in the focus groups that TS were necessary for personal self-personal growth, professional development, and finding a job. The survey results on the upper right quadrant of the joint display 1 confirmed this perception, with importance given to these three issues being > 80%. Statistically significant differences (p < 0.05) across degrees (human biology, medicine, and nursing) were because of the uniform opinion of biology undergraduate students. Participants in the focus groups did not give a clear definition of TS. In the survey, most undergraduates (> 80%) reported self-understanding of TS. The graph in joint display 1 shows that critical thinking, troubleshooting, ability to adapt to new situations, and organizing and planning were considered TS (> 78% of all participants marked these options). Table 1 Survey participants characteristics. *: There were no undergraduates, as the degree spans four academic years All Human Biology Medicine Nursing n = 159 n = 31 n = 49 n = 79 Age, mean (SD) 20.4 (3.6) 19.3 (1.6) 20.1 (2.1) 21.1 (4.7) Gender Male 37 (23.3%) 8 (25.8%) 14 (28.6%) 15 (18.9%) Female 116 (72.9%) 22 (71.7%) 33 (67.3%) 61 (77.2%) No binary 3 (1.9%) 1 (3.2%) 1 (2.0%) 1 (1.3%) NA 3 (1.9%) - 1 (2.0%) 2 (2.5%) Course 1st year 48 (30.2%) 11 (35.5%) 13 (26.5%) 24 (30.4%) 2nd year 30 (18.9%) 5 (16.1%) 7 (14.2%) 18 (22.8%) 3rd year 35 (21.9%) 7 (22.6%) 7 (14.2%) 21 (26.6%) 4rd year 27 (16.9%) 8 (25.8%) 3 (6.1%) 16 (20.2%) 5th year 12 (7.5%) -* 12 (24.5%) -* 6th year 7 (4.4%) -* 7 (14.3%) -* Joint Display 1 Integrated results on perception of transversal skills training received and its relevance thematic area Page 5 of 9Fontana-Rosa et al. BMC Medical Education (2025) 25:162 The left side of joint display 1 shows verbatims expressing undergraduates experiences on the limited learning of TS, which were given in a few subjects without enough depth; they mentioned a lack of connection between the TS and the teaching–learning process. Nursing undergraduates stated that they had some training at the beginning of the degree (especially in the first year), which was then integrated into other subjects—but not with sufficient intensity, given the real nursing practice needs. Human biology undegraduates students said that critical and creative thinking is not adequately encouraged, with more value placed on reproducing the theory given in class. Perception of training received differed across degrees: Only 25.2% of pre-graduates were considered to have received training in the learning-to-learn skill, with no statistical differences across degree programs (p > 0.05). Pre-graduates from human biology and medicine degrees reported less training in critical thinking compared to nursing (29.0% and 32.6% vs. 76.0%, p < 0.001) and interpersonal and Interpersonal skills (16.1% and 16.3% vs. 57%, p < 0.001), but no statistical differences were sought on the learning-to-learn skill and the perceived importance in the degree in the three examined TS (p > 0.05). The evaluation In the focus groups, undergradautes expressed that evaluating TS was more subjective than assessing multiplechoice tests and that methodologies would require clear guidelines. The left side of joint display 2 shows verbatims with suggestions: nursing undergraduates advocated for combining different assessment strategies using appropriate rubrics; human biology undegraduates proposed tailoring assessments, and medical undergraduate students advocated for more group work in determining the grades. Undergraduates recognized the inherent difficulty in evaluating TS (with more subjective elements than grading multiple-choice tests). They acknowledged the necessity of assessment while advocating for revised methodologies with explicit guidelines. The survey showed differences across undergraduates’ opinions from the three disciplines; more than half of the participants from the nursing degree considered that their degree included assessments of TS, that the teaching guides of the subjects identified the indicators of evaluation of the TS, that the teaching staff to was trained to teach the TS, furthermore, nursing undergraduate students reported having carried out self and peer-assessments during the degree. They found a higher alignment on TS and not on knowledge. The table on the right side of the joint display 2 shows all survey results and opinions on the learning and assessment methods. The learning methods Undegraduate students advocated using a higher level of participatory methodologies—from classroom methodology to assessments—prioritizing differentiated elements. They claimed to be closer to teachers in class, using methods and forms of teaching that prioritize acquiring knowledge more critically, beyond role memorization of a large amount of content with traditional lectures with side slides characterized by monotony and simplicity. The left side of the joint display 3 shows verbatims from the focus groups. Nursing undergraduate students argued that simulation and gamification are necessary for effective learning of TS, and new methods are needed to transfer the complexity of real clinical cases effectively. Joint Display 2 Integrated results on the assessment of transversal skills thematic area Page 6 of 9Fontana-Rosa et al. BMC Medical Education (2025) 25:162 Human biology undergradautestudents suggested using more practical cases to apply theory, as in medical studies; they also mentioned needing more participatory spaces. Medicine undergradautes students agreed with the need for more participatory methodologies. They added internships deserved more value as they can develop many of the TS. Furthermore, they emphasized the need for work on TS in seminars, specifically with the PBL methodology (problem-based learning). Survey results on the right side of the joint display 3 showed preferred methodologies to learn Interpersonal skills, critical thinking, and learning-to-learn TS. Problem-based and simulation were always in the top three, with almost > 80% of pre-graduates, while plenary lectures and gamification are less preferred. Discussion Undegraduates pursuing health sciences degrees recognized TS as indispensable to their self-personal growth and prospective professional development. The development of TS requires collaborative work, institutional support, and the proficiency of teaching staff [17]. Undegradautes advocated for TS as a primary role rather than supplementary in academic programs, suggesting seamless integration with conventional knowledge learning. They contended that the current methods for assessing TS lacked refinement and urged the adoption of more effective evaluation techniques. Undergraduates expressed their understanding in their own words—an essential skill in knowledge elicitation. Their perspective stressed a perceived deficiency in professional curricula and training programs, emphasizing an excessive focus on knowledge transmission. In contrast, degree programs are crafted per workplace demands and regulatory standards, with clinical components as key issues [3]. They noted that instructional methods are fragmented and confined to subjects. Therefore, indicating a necessity for a more comprehensive approach to TS in the higher education framework. Fragmentation persists in health sciences practice, where interdisciplinarity and a patient-centered approach are not sufficiently implemented in daily routines [32]. TS might empower undergradaute students and professionals to manage the complexity of their roles, complementing occupation-specific skills and knowledge [32, 33]. Our findings highlight a discrepancy between the ideal undergraduate learning experience, emphasizing seamless integration of expertise and TS, and the current Joint Display 3 Integrated results on learning transversal skills according to the learning strategies thematic area Page 7 of 9Fontana-Rosa et al. BMC Medical Education (2025) 25:162 reality, predominantly centered on knowledge acquisition. This gap requires enhancing the implementation and assessment of TS more effectively within the academic curricula. Traditional assessment methods such as tests and rubrics persist in current learning assessments without systematically incorporating the assessment of the TS. Despite some efforts, such as implementing ProblemBased Learning [8, 34], the persistent reality is that the final grade does not adequately reflect the relevance and contribution of the TS. Perceived barriers to adequate assessments of TS rely on the general design of the degree’s curricula. The extensive syllabus and exams often lead to prioritize content that should be memorized, and transmissive teaching methods are the general approach, therefore lacking feedback when working with TS. Assessment is a critical facet of curricular design, crucial for ensuring the safety and proficiency of healthcare professionals [35]. As reported in our study, one-time high-stakes assessments (e.g., an examination) are context-dependent and fail to capture the dynamic development of TS for professional practice [32, 33]. The reliance on traditional, summative assessments poses challenges in accurately gauging student competence [33, 35]. The European Higher Education Area advocated a shift to learning-centered education with students playing a more active role [17]. However, the results of our study showed that despite the intention and regulations, traditional evaluation methods persist, and transforming the learning system necessitates profound structural changes. Results showed undergraduates preferences for active participation and peer interactions promoting methodologies (e.g., Problem-Based Learning, discussion, cooperation, or simulation). Nursing undergraduates reported higher self-perceived training in TS than their human biology and medicine peers. This finding may be attributed to the nursing curriculum’s strong emphasis on early and frequent clinical placements, which foster the acquisition and refinement of interpersonal and communication skills [36]. This finding might reflect that most programs have focused on a single academic degree; therefore, examining undergraduate students from multiple degree programs within the same research context might advance the understanding of TS development within health sciences. TS learning methodologies can be embraced once undergraduates have acquired the selfregulated learning capacity; however, this is often not the case, and undergraduates require support to transition from traditional learning based on lectures [37, 38]. Another critical issue in promoting the teaching of TS is the pedagogical preparedness of undergraduates educators, who need support and training to adopt these methods [12]. Undergraduate students dissatisfaction with the monotony and simplicity of lectures may signal a deficiency in adapting European university pedagogy to an era where information is readily accessible elsewhere and where students seek instruction characterized by problem-solving approaches and a more humanistic teacherstudent relationship. Strengths and limitations The study was confined to undergraduate students exclusively from the nursing, medicine, and human biology programs, reflecting the university’s academic programs where the research was conducted. While this provided valuable insights, including students from other health disciplines, such as physiotherapy or psychology, could contribute diverse perspectives. Second, the focus groups were conducted online, which could hamper the dialogue and participation. However, all participants were active, and the duration of the groups was as expected without inconvenience. Third, voluntary participation in the survey may have influenced the results; however, a mandatory participation system is impractical, and the participation rate and the alignment of results with focus group findings ensures the study’s reliability. Conclusion Human biology, medicine and nursing undergraduate students advocated for an increased emphasis on transversal skills. Undergraduates in human biology and medicine expressed greater dissatisfaction with traditional, knowledge-focused instruction than nursing undergraduates; all described their curricula as predominantly focused on knowledge acquisition, with traditional assessment methods persisting and lacking evaluation of transversal skills. Integrating transversal skills into higher education goes beyond mere quality audits and demands a practical and meaningful transformation to a fundamental change of universities in the European Higher Education Area. Abbreviations TS Transversal Skills Supplementary Information The online version contains supplementary material available at h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 0 9 - 0 2 5 - 0 6 7 4 9 - z. Supplementary Material 1 Acknowledgements We thank the human biology, medicine, and nursing students of the University Pompeu Fabra and The Hospital del Mar Nursing School for their participation and time in this study. We want to express our gratitude to Dr. Marta Benet for the time to plan and design the initial project. Page 8 of 9Fontana-Rosa et al. BMC Medical Education (2025) 25:162 Author contributions Nathalia Silva Fontana-Rosa & Luis González-de Paz: Conceptualization; investigation; formal analysis; writing—original draft; methodology; data curation; supervision; writing—review and editing. Ana C. Codina-Rodríguez & María Pérez-Riart: Investigation; formal analysis; writing—review. María del Mar Carrió-Llach: Methodology; writing—review and editing; funding acquisition. Funding This research was funded by the Erasmus + program for Strategic Partnerships for Higher Education Cooperation for innovation and the exchange of good practices (grant no. KA203-46838294). Data availability Forms are available from the corresponding author upon reasonable request. Declarations Ethics approval and consent to participate Ethical approval was granted through the Pompeu Fabra University Ethical Review Board of Projects (CIREP-UPF). The study was carried out in accordance with the Declaration of Helsinki. In the qualitative research, all participants gave informed consent to participate. Completing the anonymous online questionnaire was considered implicit consent in the survey study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1Campus Docent Sant Joan de Déu, Universitat de Vic–Universitat Central de Catalunya (UVIC-UCC), Sant Boi de Llobregat, Spain 2Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain 3Primary Healthcare Transversal Research Group, Institut d’Investigacions Biomèdiques, August Pi i Sunyer (IDIBAPS), Barcelona, Spain 4Department of Public Health, Mental Health and Mother and Child Health, University of Barcelona, Barcelona, Spain 5Nursing Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain 6Institute of Educational Sciences, Universitat Politècnica de Catalunya (UPC), Barcelona, Spain Received: 12 April 2024 / Accepted: 23 January 2025 References 1. European Commission. European Skills Agenda for sustainable competitiveness, social fairness and resilience. 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