Nursing Students Rate Spain’s Health System Differently Than Their Peers, Survey Study Finds

What do future nurses really think about the health system they are training to join? A new study from the University of Santiago de Compostela suggests their views are more complicated than a simple answer allows. In research published in BMC Nursing, María José Ferreira Díaz and María Carmen Agra Tuñas compared how third-year nursing students perceive the Spanish Health System with how young adults aged 18 to 25 view the same system, using data drawn from the 2024 Spanish Health Barometer, a national opinion survey administered by the Spanish Centre for Sociological Research. The results reveal a strikingly mixed picture: students gave the system a higher overall numerical score than their civilian peers, yet they were also more likely to demand fundamental changes to it. That apparent contradiction, the authors argue, is precisely what makes national health survey data such a promising, and so far underused, resource for nursing education.

The study’s design was straightforward but methodologically careful. The researchers collected responses from 97 third-year nursing students across two campuses of the University of Santiago de Compostela, in Santiago de Compostela and Lugo. They then administered a selection of items from the Spanish Health Barometer to this student group and compared the resulting answers with secondary data from 411 young adults aged 18 to 25 who had participated in the 2024 edition of the national survey. This created a natural comparison between two populations of similar age, one embedded in professional training and one drawn from the general public. The descriptive comparative design was applied across both sites of the single university, and ethical approval for the anonymised analysis of student responses was granted by the university’s Research Ethics Committee in January 2025, with all participants providing informed consent before completing the questionnaire.

The statistical treatment deserves attention because it reflects a growing trend toward rigor in educational research. Rather than relying on raw significance tests alone, the authors employed an omnibus chi-squared test for categorical comparisons and Welch’s t-tests for continuous measures, the latter being a variant that does not assume equal variances between groups and is therefore more robust when sample sizes and spreads differ. Crucially, they reported effect sizes using Hedges’ g, a measure that expresses the magnitude of a difference in standardized units, and they adjusted their p-values using the Benjamini–Hochberg procedure, which controls the false discovery rate when many comparisons are made simultaneously. This combination means the reported differences are not merely statistical artifacts of multiple testing; they survived a correction designed to filter out spurious findings.

The headline numerical result was that students rated the overall functioning of the health system at a mean of 7.00 on the survey’s scale, while young adults in the national dataset averaged 6.47. The difference was highly significant, with a p-value below 0.001 and an effect size of g = 0.326, which conventionally falls in the small-to-moderate range. On its face, this suggests that nursing students hold a somewhat more favorable view of the system’s overall performance than their peers outside health professional training. One plausible interpretation is that immersion in clinical placements and coursework gives students a more textured, less media-mediated picture of how the system operates day to day, including its successes as well as its strains.

Yet the categorical item told a different and more intriguing story. When asked to characterize how the system works in broader terms, only 4.1 percent of students judged that it worked quite well, compared with 11.0 percent of young adults in the national sample. Meanwhile, 40.2 percent of students said fundamental changes were required, against 31.1 percent of the general young adult population. In other words, the same students who awarded the system a higher average score were simultaneously more likely to call for deep structural reform. This divergence between a continuous rating and a categorical judgment is a textbook illustration of why survey methodology matters: the format of a question can shape, or at least reframe, the attitudes it captures, and researchers who read only one item risk drawing incomplete conclusions about public and professional sentiment.

The item-level comparisons deepened the pattern. Students rated hospital emergency services significantly higher than their young adult counterparts, with the difference again significant at p < 0.001 and an effect size of g = 0.312. This enthusiasm for emergency care may reflect direct exposure to hospital departments during clinical rotations, where students witness the machinery of acute medicine at close range. By contrast, students expressed significantly lower trust in primary care physicians, with an effect size of g = −0.318, and gave significantly lower ratings to the time that physicians dedicate to patients, at g = −0.423, the largest effect recorded in the study. Both findings remained significant after the Benjamini–Hochberg correction. One of the most notable null results concerned nursing itself: trust in nurses did not differ significantly between the two groups, suggesting that whatever professional socialization occurs during a nursing degree, it does not measurably inflate students’ confidence in their own future profession relative to the public’s view.

Why would nursing students be more critical of primary care than the general public? The study does not definitively answer this question, but the educational context offers reasonable hypotheses that the authors frame carefully. Students in their third year have typically completed rotations that include community and primary care settings, where they may observe time pressures, administrative burdens, and continuity-of-care challenges from an insider’s vantage point. Their lower ratings of the time physicians dedicate to patients could reflect an acute awareness of consultation length as a determinant of care quality, a theme heavily emphasized in nursing curricula that foreground holistic, patient-centered practice. At the same time, the authors are explicit that these are perceptions, not objective measures of system performance, and that the educational application arising from the study requires formal implementation and evaluation before any causal claims can be made.

The larger significance of the work lies in its proposal to treat national health surveys as pedagogical instruments. Surveys such as the Spanish Health Barometer, along with international counterparts like the European Health Interview Survey, the United States Behavioral Risk Factor Surveillance System, and national instruments in other countries, generate rich, publicly available datasets that policymakers rely on routinely. Yet, as the authors note, these resources remain underexplored in nursing education as tools for fostering critical thinking and systems-level awareness. The approach tested here inverts the usual classroom dynamic: instead of students merely answering survey questions, they compare their own answers against a nationally representative benchmark, forcing them to confront where their views align with the public and where they diverge, and to reason about why. That exercise sits at the intersection of survey methodology, health policy literacy, and professional identity formation, three competencies that modern nursing programs increasingly aim to cultivate together.

The study’s limitations are worth stating plainly, and the authors do so. The student sample came from a single university across two campuses, with 97 participants, which limits generalizability to nursing students in other regions or countries. The comparison group was restricted to young adults aged 18 to 25 within the national survey, so the findings speak to generational perceptions rather than the full population. The questionnaire had originally been administered as a voluntary and anonymous educational activity, and the research use involved secondary analysis of anonymised responses, a design that is ethically efficient but constrains the depth of data collection. And because the design is descriptive and comparative rather than experimental, it can document differences in perception but cannot explain their causes or test whether exposure to survey data actually improves educational outcomes.

Those caveats aside, the study opens a concrete agenda for future research. The authors call for intervention studies that formally evaluate whether the structured use of national survey data in nursing curricula supports critical thinking, systems literacy, and policy awareness. If such studies succeed, the implications could extend well beyond Spain. Health ministries and statistical agencies worldwide already invest heavily in opinion and health surveys; harnessing those same datasets as mirrors for health professional students would cost little and could reshape how the next generation of nurses understands the systems they will staff, defend, and reform. In an era when health systems everywhere face workforce shortages, aging populations, and eroding public trust, teaching future nurses to read the public’s verdict on their own institutions, and to compare it honestly with their own, may prove to be one of the most quietly consequential innovations in nursing education. This study, modest in size but rigorous in method, offers the first empirical foothold for that idea.

Subject of Research: Comparing nursing students' and young adults' perceptions of the Spanish health system using national survey data for nursing education

Article Title: National health survey data as a resource for nursing education: a comparative study of nursing students’ and young adults’ perceptions of the health system

Article References: Díaz, M. J. F., & Tuñas, M. C. A. (2026). National health survey data as a resource for nursing education: a comparative study of nursing students’ and young adults’ perceptions of the health system. BMC Nursing. https://doi.org/10.1186/s12912-026-05462-6

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05462-6

Keywords: nursing education, Spanish Health Barometer, health system perceptions, survey methodology, critical thinking, primary care, comparative study, health policy, nursing students, effect sizes, public trust, systems literacy