Since 2011, Taiwan’s Accreditation of Task Indices for Medical Centers has mandated holistic medical education as a cornerstone of medical education [4]. Holistic medical education shifts the focus from traditional, medically centered approaches to human-centered care, enhancing clinical proficiency and reinforcing a commitment to patient-centered services [5]. The clinical setting serves as the primary venue for holistic medical education, supported by robust curriculum planning, teaching resources, and training programs, thereby nurturing a humanistic ethos among clinical educators and trainees [6].

The Theory of Planned Behavior (TPB) has been extensively validated across various disciplines, including healthcare research [7]. Relevant studies have explored barriers to incident reporting among nursing staff [8], interventions to improve breastfeeding outcomes [9], and factors influencing compliance with standard precautions among nursing students [10]. Additionally, studies have examined the role of attitudes, subjective norms, and perceived behavioral control (PBC) in healthcare professionals’ intentions regarding oral hygiene care [11], empirical management [12], and perioperative patient safety [13].

Despite these advances, existing studies on holistic medical education and clinical teacher training have several limitations. First, most prior research has primarily focused on preceptors or clinical educators, while the perspectives of nurses in their post-graduate year (NPGYs), who are key recipients and implementers of holistic medical education in clinical settings, have been largely overlooked. This single-perspective approach may limit a comprehensive understanding of how holistic medical education is perceived and enacted across different professional roles.

Second, although the Theory of Planned Behavior (TPB) has been widely applied in healthcare-related behavioral research, its use in the context of holistic medical education—particularly in comparing different professional groups within the same educational system—remains limited. Many studies have examined individual components of behavioral intention in isolation, without systematically comparing how attitudes, subjective norms, and perceived behavioral control may function differently between educators and trainees.

Finally, prior studies have rarely examined holistic medical education within real-world clinical training environments using an integrated analytical framework that simultaneously considers organizational context, educational roles, and behavioral intention. As a result, empirical evidence informing targeted strategies for improving holistic medical education practices in teaching hospitals remains insufficient.

The significance of nurses’ intentions in holistic care cannot be overstated, as evidenced by studies demonstrating the positive impact of intentions on patient care outcomes [14–16]. For instance, Zolfaghari et al. [14] found that nurses’ intentions to practice therapeutic touch improved patient outcomes. At the same time, Hsieh, Lee, and Wen [17] highlighted the influence of attitudes and self-efficacy on workplace safety practices among student nurses. Lin and Chuang [18] further demonstrated that self-efficacy and related psychological factors significantly influence behavioral intention among nursing staff. These findings underscore the importance of examining behavioral intentions as a key mechanism for promoting effective clinical practices.

To address the aforementioned limitations in prior research, this study integrates the perspectives of both preceptors and NPGYs in a teaching hospital in Taiwan. By applying the Theory of Planned Behavior, this study examines how attitudes, subjective norms, and perceived behavioral control influence behavioral intentions toward practicing holistic medical education. The findings aim to inform targeted improvement strategies for holistic medical education, thereby enhancing clinical competencies, patient care quality, and nursing education practices, and contributing to the cultivation of nursing staff capable of providing comprehensive and patient-centered care.

2. Methods
2.1 Study Objective
This study aimed to compare whether the intentions of preceptors and NPGYs toward holistic medical education differ and to further reflect on the hospital’s in-practice training course for clinical nursing teachers.

2.2 Study Subjects
This cross-sectional study used structured questionnaires to collect data between April 1 and May 31, 2020. The study participants consisted of all preceptors who were employees and nurses of the post-graduate year (NPGYs) in the nursing department of a teaching hospital in Taiwan. The inclusion and exclusion criteria were applied to ensure a consistent, reliable, and objective study population. The first page of each questionnaire included an informed consent statement and explanatory information, and participation was entirely voluntary.

According to data from the hospital’s human resource office, a total of 185 eligible preceptors and NPGYs were identified. Using purposive sampling, all eligible participants were invited to take part in the study, with particular attention to ensuring adequate representation of NPGYs. The researchers personally distributed paper-based questionnaires to potential participants, explained the study objectives and procedures, and obtained informed consent before participation. Completed questionnaires were collected on-site by the researchers to ensure data completeness and confidentiality.

A total of 164 questionnaires were returned, of which 162 were valid after excluding incomplete responses, resulting in a response rate of 87.5%. This study was approved by the Institutional Review Board of Show Chwan Memorial Hospital (Approval No. 1090203), and administrative permission to conduct the study was obtained from the hospital before data collection.​​​​​​

2.3 Measurement
The self-developed questionnaire used in this study included personal demographic data and scales measuring attitudes, subjective norms, PBC, and behavioral intention in medical education. Personal demographic data encompassed sex, age, education level, marital status, clinical teaching qualifications, professional title, and years of service. The questionnaire was developed based on previous studies and focused on four main constructs: attitude (e.g., ' I believe holistic medical education is valuable.'), subjective norms (e.g., ' International trends emphasizing the importance of holistic care would make me inclined to teach or learn courses in holistic medical education.'), PBC (e.g., ' I find teaching or learning courses in holistic medical education enjoyable.'), and behavioral intention (e.g., ' The Taiwanese government's promotion of holistic care would lead hospitals to arrange for me to teach or learn courses in holistic medical education.'). Each item was rated on a five-point Likert scale, where participants indicated their agreement levels from 1 (completely disagree) to 5 (completely agree).

For each construct, higher scores represented more positive attitudes toward holistic medical education, stronger perceived subjective norms, greater perceived behavioral control, and stronger behavioral intention to engage in holistic medical education practices. Lower scores indicated less favourable perceptions or weaker behavioral intention. Therefore, higher mean scores across the scales reflect stronger endorsement and readiness to participate in holistic medical education.

A panel of experts reviewed the initial questionnaire to ensure content validity, and items were revised accordingly. The average content validity index (CVI) was 0.908.

Exploratory factor analysis (EFA) was conducted to identify the underlying structure of the questionnaire and to classify items into constructs. Based on the EFA results, items were grouped into attitude (A1–A5, A6, A8, A9, A12), subjective norms (A10–A11), perceived behavioral control (A14–A20), and behavioral intention (B2–B7).

Internal consistency reliability was assessed using Cronbach’s α, with values greater than 0.7 indicating acceptable reliability [19].

Recent studies have also emphasized the importance of behavioral and educational factors in shaping nursing competencies and training outcomes in clinical settings [26]. In addition, the Theory of Planned Behavior has been widely applied in nursing education to explain behavioral intentions and professional development [27].

According to this study’s findings, perceived behavioral control (PBC) was the primary factor influencing the behavioral intentions of both preceptors and NPGYs in holistic medical education. Ajzen’s [28] theoretical assumption that PBC has both a direct effect on behavior and an indirect effect through behavioral intention was partially supported. In addition, attitude was found to influence behavioral intention among NPGYs, which is partially consistent with prior findings [29].

Previous studies have suggested that behavioral intention is jointly determined by attitude, subjective norms, and PBC [28, 30]. However, in the present study, subjective norm did not emerge as a significant predictor of behavioral intention. This finding should be interpreted with caution. The relatively low average variance extracted (AVE = 0.336) indicates limited convergent validity, suggesting that the construct may not have been adequately captured by the measurement items. As such, the non-significant result may reflect measurement limitations rather than a true absence of normative influence. Future research should refine the operationalization of subjective norm and explore its role using more robust measurement frameworks. Although a relatively high correlation was observed between attitude and subjective norms, these constructs remain conceptually distinct within the Theory of Planned Behavior, representing personal evaluation and perceived social influence, respectively.

In our study, the influencing factors with regard to PBC while executing holistic medical education were the ability to control resources in need and opportunities and other nonmotivational factors that cannot be controlled by individuals, such as time, skills, abilities, and policies. In terms of time, given that most nursing staff work in shifts, the holistic medical education courses provided by this hospital have a flexible schedule and are available online, which are conducive to learning. In terms of skills, Von [31] pointed out that medical staff–patient communication in holistic medical education contexts could be improved by several measures that focus on the process of reflection and feedback on students. These measures include the use of social interaction and scenarios by teachers, the use of a mentoring approach to help students establish their knowledge and skills, and the use of teacher–student dialogue to identify the cognitive problems in students [31]. Through the process of producing reflection and feedback, students can further improve their staff–patient communication ability within holistic medical education contexts. Moreover, Bradley and Postlethwaite [32] stated that, due to the information explosion and technological advancement, teaching methods of medical education have also changed, including various teaching theories, such as behaviourism, reflective practice, situated learning, activity theory, constructivism, and social constructivism [33]. Therefore, it is recommended that constructivism be used in the introduction of holistic medical education and that preceptors’ medical knowledge and skills be integrated to cultivate NPGYs’ staff–patient communication ability within holistic medical education contexts.

In terms of ability, teaching hospitals are suitable places to apply constructivist teaching to holistic medical education because, besides NPGYs, there are also nursing students from different schools. However, due to the lack of interaction with real patients, even though students have received good medical knowledge and simulation exercises, it is difficult for them to acquire communication and interaction skills with patients in real clinical settings. Therefore, it is necessary to deliver courses alongside real cases in the clinical setting and add affective domain teaching and NPGY skills support to the course to enhance NPGYs’ learning ability. Therefore, the provision of an environment that is sufficient in terms of teaching resources for preceptors and NPGYs can promote their behavioral intentions to participate in holistic medical education. Furthermore, with regard to policy, an aspect of utmost importance, Lin et al. [6] reported that hospitals should provide enough incentives, such as funds and rewards, to support holistic medical education. Thus, the policy should be in Favor of making preceptors and NPGYs believe that the course contents are beneficial to patients and are supported by the hospital leaders and policies.

In addition, the educational beliefs of medical educators influence their teaching practices. Good teaching outcomes depend on the application of appropriate teaching models and multiple teaching strategies. Clinical nursing teaching in hospitals should eventually be evaluated based on the trustworthy practice of holistic medical education and through cross-field team cooperation to solve patients’ problems. This approach will truly show the result of holistic medical education and improvement of professional nursing ability and strengthen the practicality of training courses for clinical nursing teachers. It is beneficial to incorporate concrete examples or case studies that demonstrate successful implementation of these measures. For instance, case hospitals receive positive feedback on holistic medical education from clinical faculty and students through educational incentives and the design of learning frameworks. It is hoped that the results of this study can provide a reference for hospitals while planning training courses for their clinical nursing teachers.

Finally, these studies provide concrete examples that enhance our understanding  of  the  challenges  and  opportunities  in  nursing education, including compassionate care challenges [34], research on different teaching methods in nursing education [34], and barriers to utilizing research findings to improve nursing care [15]. By incorporating these real-life examples into the discussion, we can make the findings of this study more tangible and practically meaningful, while also providing valuable references to aid in future planning of clinical nursing teacher training courses.

Additionally, the influence of hospital culture and leadership on the adoption and effectiveness of holistic medical education practices warrants further investigation. Understanding how these factors shape preceptors’ and NPGYs’ perceptions and behaviours may provide valuable insights into fostering a supportive environment for holistic medical education. Such considerations may contribute to the development of more effective training programs and the overall improvement of nursing education.

5. Conclusion
The findings of this study highlight the critical importance of addressing key factors to facilitate the effective implementation of holistic medical education. Through an analysis of perspectives from both preceptors and NPGYs, several crucial elements have been identified, shedding light on areas for improvement and enhancement in nursing education.

Primarily, the significant impact of PBC on the intentions of both preceptors and NPGYs underscores the necessity of providing adequate resources and support systems. Recognizing the pivotal role of factors such as time, skills, abilities, and policies in shaping behavioral intentions emphasizes the imperative for institutions to ensure tailored resources and support mechanisms for educators and learners.

Furthermore, addressing the challenges posed by the qualitative implementation of holistic medical education emphasizes the need to foster a hospital culture conducive to the values and principles of holistic education. This involves not only ensuring alignment of institutional policies and incentives with the objectives of holistic education but also cultivating an environment that values continuous learning and collaboration among stakeholders. The findings underscore the importance of integrating innovative teaching methodologies and strategies into clinical nursing education to meet the learning needs of NPGYs in holistic medicine.
Specific teaching models and strategies that could be effective based on the study’s findings include:
1. Problem-Based Learning (PBL): This model encourages critical thinking and the application of knowledge in real-world scenarios, allowing NPGYs to develop problem-solving skills essential for holistic care.
2. Simulation-Based Education: Utilizing simulation training can provide hands-on experience in a controlled environment, enhancing clinical skills and preparedness for real patient interactions.
3. Mentorship Programs: Establishing mentorship programs where experienced preceptors guide NPGYs can foster professional development and continuous learning.
4. Constructivist Approaches: Incorporating constructivist teaching strategies, such as reflective practice and collaborative learning, can help NPGYs integrate theoretical knowledge with practical application.
5. Real-World Case Studies: Integrating case studies into the curriculum can make learning more relevant and practical, helping NPGYs understand the complexities of patient care in a holistic context.

In addition to these strategies, educators' beliefs in patient-centered care and interdisciplinary collaboration significantly shape curriculum design and teaching methodologies in holistic medical education. These beliefs may manifest in the integration of case-based learning methods that emphasize empathy and comprehensive patient assessment. Moreover, educators who prioritize lifelong learning and reflective practice create environments where NPGYs feel supported in developing holistic care skills through ongoing mentorship and feedback. By leveraging these approaches, educators can significantly enhance the practicality and effectiveness of holistic medical education, equipping NPGYs with the essential skills needed for comprehensive patient care.