This study employed an explanatory sequential mixed-methods design to explore nursing undergraduates’ perceived value, experiences, and behavioral intentions regarding TCM nursing (Figure 1). Firstly, quantitative data were gathered using a questionnaire. Subsequently, based on the results of quantitative analysis, in-depth interviews were conducted with students to further explain the preliminary quantitative findings (21). The study followed the Guidelines for Reporting on Mixed Methods Studies (GRAMMS) (22) and was approved by the Ethics Committee of Zhengzhou University Life Sciences (Approval No.: ZZUIRB 2025-01). The conceptual framework was informed by Perceived Value Theory and Cultural Competence Theory, which supported the investigation of cultural beliefs and educational experiences in TCM nursing education.

The survey instrument was developed by integrating items from multiple published studies (15, 25–31) to ensure comprehensive coverage of the research domains. To ensure content validity, the initial draft was reviewed by a panel of experts (e.g., TCM nursing specialists and educators) to confirm its clinical and cultural relevance. A pilot test was subsequently conducted with 15 nursing undergraduates to assess the clarity and readability of the questions; minor adjustments were made to the phrasing based on their feedback. The structured questionnaire consists of five main sections: (1) general demographics; (2) TCM cultural background; (3) cognition of TCM nursing; (4) knowledge of TCM nursing; (5) behavior of applying TCM nursing; (6) awareness of TCM-related policies (see Appendix A). The survey was delivered both online and offline. Trained research assistants provided consistent instructions. Questionnaires were reviewed and validated on-site to reduce missing data.

Interviews were employed face-to-face in private classrooms after obtaining informed consent, and conducted by the first author. Main questions were regarding their view on TCM nursing, perceptions, experiences, and practice behaviors. Each interview lasted 30–40 min, guided by the perceived-value framework, followed an interview protocol covering five domains: (1) perceptions of TCM nursing; (2) learning experiences and emotional responses; (3) CHANGES in cultural understanding and attitudes; (4) impact on personal life, family, and academic growth; (5) suggestions for improving TCM nursing education. The specific interview outline was shown in Appendix B.

Quantitative data were processed using SPSS 25.0 for descriptive statistics and consistency checks. Comparisons of the proportion of correct responses between the two universities were performed using the chi-square test or Fisher’s exact test. Data were independently entered by two coders and cross-verified to ensure accuracy. The significance level for all tests was set at p-value <0.05.

Interviews were audio-recorded, supplemented with notes, and transcribed verbatim within 24 h. The researchers performed a comprehensive thematic immersion by repeatedly reviewing the data and notes, analyzing participants’ behavioral and emotional expressions. Colaizzi’s (32) seven-step phenomenological approach was used to analyze qualitative data, including: (1) familiarization: The researchers carefully read all the data; (2) extraction of significant statements; (3) formulation the researchers formulated/coded meanings for recurring viewpoints; (4) clustering of coded viewpoints; (5) writing a detailed and comprehensive description with no omissions; (6) identification of similar viewpoints; (7) verification through return visits to the participants. Two researchers who had undergone training in qualitative research courses and forums performed data coding, acquiring expertise in qualitative research methods and interview skills, coupled with experience of leading qualitative research interviews. The study employed investigator triangulation with independent coding to minimize bias (33). Any coding discrepancies were resolved through team consensus.

Data integration and interpretation were achieved through the construction of a joint display, aimed at generating meta-inferences through cross-validation and complementary elaboration of the findings. Following a contiguous approach, the quantitative and qualitative results are presented side-by-side within the text to facilitate a synergistic weaving of data (34). During this integrative stage, both datasets were systematically merged to assess for confirmation, expansion, or discordance. Confirmation was identified when the qualitative insights reinforced the statistical trends, leading to convergent conclusions (35). Expansion occurred when the qualitative narratives further elucidated the quantitative results by providing additional, non-overlapping interpretations that enriched the overall findings. Conversely, any discordance—where quantitative and qualitative results diverged or led to conflicting interpretations—was critically examined to reveal underlying complexities. This systemic integration provides a comprehensive explanation for the participants’ cognitive characteristics, the underlying factors, and the resulting educational implications.

Initial quantitative results indicated that nursing undergraduates from both TCM and Western medicine universities maintained high levels of recognition and positive attitudes toward TCM nursing. However, Western medicine students exhibited significant deficits in TCM knowledge, clinical application, and awareness of relevant policies. To further elucidate the factors contributing to this phenomenon and to explore specific barriers within their educational environment, a subsequent qualitative phase was conducted. A total of 14 undergraduate nursing students from a Western-medicine-oriented university participated in semi-structured interviews. Among them, 12 were female, and 10 were in their junior year. Detailed demographic information is presented in Table 2. The qualitative study identified three major themes and eight sub-themes, as illustrated in Figure 2.

The qualitative findings provided a complementary perspective, offering a nuanced validation of the prior quantitative results. As summarized in the joint display (Table 3), the merging of these datasets facilitates a deeper understanding of the findings, where qualitative narratives elucidate the statistical patterns observed in the initial phase.

Qualitative interviews revealed a profound interest in TCM nursing among students, which is highly congruent with the quantitative findings showing that 93.6% of participants expressed a willingness to learn and 89.5% endorsed its therapeutic efficacy. Paradoxically, this strong cultural identification has not effectively translated into practical behaviors. Quantitative data indicated that 32.6% of students had never purchased TCM nursing healthcare products, providing empirical evidence that aligns with the ‘limited clinical applicability’ frequently mentioned by students during the interviews. According to the Perceived Value Theory, individual behavioral choices depend on the subjective assessment of benefits and costs (36). Although students have a high perception of the emotional and cultural values of TCM culture, their behavioral willingness decreases when the actual benefits perceived during practice (e.g., clinical application effects, patient benefits) are insufficient, or when the perceived costs of learning and application (e.g., difficulty of TCM theories, disconnection between the classroom and the clinic, etc.) are too high. On the other hand, Cultural Competence Theory emphasizes the need for nursing staff to build intercultural nursing competence in multiple dimensions such as awareness, knowledge, skills, practical experience and intrinsic motivation (37). Ingram (38) states that cultural competence involves not only knowledge of multicultural values, beliefs, and practices, but also learning reinforced by actual exposure and practice. In this study, the nursing undergraduates had a strong identification with TCM culture, which indicates that they have a foundation of ‘cultural awareness’, but their cultural competence is still incomplete without sufficient exposure to and training in TCM practice (37). It suggests that providing culturally sensitive care in multicultural environments is the key to reducing health inequalities and improving the quality of care (37), and cultural competence is not enough to meet the requirements of nursing care if it is only a matter of identification but not actual action.

The phenomenon of students’ strong cultural identification with TCM but weak behavioral transformation may be caused by the following reasons: firstly, the content and structure of teaching are single. At present, many nursing colleges and universities treat TCM nursing as a separate elective or theoretical course, the curriculum lacks systematicity and depth, and theory and clinical practice are separated, making it difficult for students to apply what they have learnt in real-life situations (39). Secondly, knowledge translation barriers. The abstract concepts of TCM theories have a high threshold of understanding for nursing undergraduates, coupled with the fact that traditional TCM terminology is not the same as the language of modern medicine, which makes it difficult for students to flexibly apply what they have learnt about TCM to modern nursing practice. This quantitative evidence is further corroborated by the qualitative theme: while students demonstrated a high level of identification with fundamental concepts such as Yin-Yang and the Five Elements, a significantly smaller proportion possessed a deep understanding of more abstract cultural constructs. This cognitive discrepancy elucidates the sense of frustration regarding theoretical comprehension expressed by students during interviews, highlighting a critical gap between cultural identification and actual knowledge mastery. The lack of case studies and practice opportunities also prevents students from experiencing the actual efficacy of TCM nursing, thus reducing learning motivation (40). Finally, insufficient system support. The lack of platforms or incentives for TCM nursing practice in school and clinical settings, such as dedicated TCM nursing training bases, internship opportunities in TCM hospitals, and instructors, greatly limits students’ ability to translate classroom knowledge into nursing behaviors (41). Additionally, there is a lack of uniform clinical pathways and evidence-based guidelines for TCM’s nursing, leading students to be skeptical about the efficacy of TCM nursing (42, 43).

The concepts and knowledge of TCM nursing are integrated into the nursing curriculum to optimize the curriculum system and achieve the integration of theory and clinical practice. For example, combining TCM nursing cases with teaching in professional courses such as internal surgery, obstetrics and gynecology (44), using experiential teaching methods such as case discussion and scenario simulation can enhance students’ practical perceptions (45, 46). Lin et al. (39) demonstrated that a 32-credit hour TCM foundation course significantly enhanced students’ knowledge of TCM and willingness to integrate treatments, suggesting that a more systematic teaching program for TCM nursing.

Furthermore, by reinforcing the clinical evidence of TCM nursing and the analysis of medical records, students can intuitively feel the positive effects of TCM methods on patients’ health and enhance their perceived value of TCM (47). Experienced TCM nursing experts can be invited to give special lectures or demonstrations to show successful cases of TCM nursing and help students recognize the unique advantages of TCM nursing in holistic health management, thereby increasing their recognition of TCM’s practical value.

Additionally, focus on the development of students’ “Awareness-Knowledge-Skill-Encounter-Desire” is important to improve students’ cultural competence according to the Campinha-Bacote’s process of cultural competence model (48). For example, experiential activities such as role-playing, teacher-student exchange visits and cross-cultural exchanges are introduced to enable students to understand multicultural perspectives and develop cross-cultural communication skills and service awareness in real-life exchanges. Studies (49) have pointed out that multicultural curricula and practical activities can effectively enhance nursing students’ intercultural nursing competence.

Finally, to strengthen systematic support, schools should co-operate with TCM organizations to establish TCM nursing practice bases to provide authentic clinical observation and operation opportunities (50). Teaching teams with both Chinese and Western medicine backgrounds should be trained, and TCM nursing syllabi and guidelines should be compiled to form institutional support (47). Emphasis has also been placed on integrating traditional medicine education internationally, the World Health Organization has recognized the value of TCM by incorporating TCM diagnostic codes into the International Classification of Diseases in 2019 (51), and tertiary nursing education should also follow this trend and improve the corresponding educational policies and resource support.

This study still has some limitations. First, the single-institution design in Henan province may limit generalizability due to regional particularities in both cultural attitudes toward TCM and curriculum implementation. For instance, students with more than 3 years of residence in inland China demonstrated stronger confidence in TCM nursing development and a higher willingness to participate in TCM training programs. Second, the sample was confined to undergraduate nursing students through convenience sampling, which may introduce selection bias and limit the comprehensiveness and generalizability of the findings, as students with a pre-existing interest in TCM might have been more likely to participate. Third, social desirability bias cannot be entirely ruled out. Participants might have provided responses they perceived as professionally ‘correct’ or favorable to the researchers, particularly regarding the significance of TCM nursing, which may not fully reflect their private clinical skepticism. To effectively enhance the teaching quality of TCM nursing courses and to achieve the anticipated goal of cultivating nursing professionals with a high-quality international perspective, future nursing education needs to focus on how to better align teaching practices with the overarching objectives of nursing talent development.