From motivation to meaning in medical humanities: a mixed-methods study of Chinese medical students’ value internalization

From motivation to meaning in medical humanities: a mixed-methods study of Chinese medical students’ value internalization | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From motivation to meaning in medical humanities: a mixed-methods study of Chinese medical students’ value internalization Min Wei, Yanhua Zhang, Fanglin Zhu, Daiqing Zhai, Chuanhe Zhu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7488873/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Jan, 2026 Read the published version in BMC Medical Education → Version 1 posted 14 You are reading this latest preprint version Abstract Background Medical humanities are expected to strengthen humanistic values in future physicians, yet how students internalize such values across learning contexts is not fully understood. This study examined how different types of motivation relate to engagement, and how emotions and clinical experiences may support value internalization. Methods We conducted a mixed-methods study at a Chinese medical university. Survey data from 161 students were analyzed with structural equation modeling (SEM), and semi-structured interviews with 30 students provided qualitative insights. Results Developmental motivation predicted both course satisfaction and professional identity (β = 0.47, p < 0.001). Avoidant motivation reduced affective satisfaction (β=-0.18, p = 0.021). Clinical internship appeared to strengthen the pathway from satisfaction to professional identity (Δβ=+0.14, p = 0.012). Qualitative themes highlighted emotional engagement as a turning point for reflection. Clinical settings appeared to act as catalysts, reinforcing or sometimes challenging how classroom knowledge was translated into professional practice. Conclusions Motivation alone does not fully explain how values are internalized. Our findings suggest that emotions and clinical context may serve as important bridges, supporting the translation of humanities learning into professional commitments. These results highlight the potential value of curricula that integrate experiential teaching with supportive clinical environments, although causal effects cannot be confirmed in this observational study. medical humanities motivation value internalization emotional engagement clinical training professional identity Figures Figure 1 Background Medical education has long faced the challenge of preparing doctors who are both technically skilled and humanistic in practice. Studies consistently show that empathy and compassion often decline as students progress through medical school [ 1 – 3 ]. Recent evidence confirms that this pattern persists in contemporary cohorts [ 4 ]. This trend undermines patient-centered care and has raised concerns worldwide [ 5 – 6 ]. In response, educators have introduced courses in ethics, narrative medicine, and medical humanities to restore a balance between science and humanism [ 7 – 9 ]. Evidence suggests that such programs can enhance empathy, cultural awareness, and reflective ability [ 10 , 18 ]. However, their role in medical curricula remains contested [ 8 ]. Humanities courses are often treated as optional or supplemental, and their connection to clinical training is weak [ 13 ]. This indicates that another key factor is motivation. Students approach humanities courses with different reasons: some are genuinely interested in personal and professional growth, while others participate mainly to meet credit requirements. Research grounded in Self-Determination Theory (SDT) shows that autonomous, developmental motivation promotes deeper engagement and value internalization [ 11 – 12 ], whereas controlled or avoidant motivation tends to result in superficial compliance. Recent work highlights the importance of aligning course design with students’ motivational needs [ 14 ]. In China, a new policy of Curriculum Ideological and Political Education (CIPE) emphasizes value education across all disciplines [ 15 ]. This reform has created opportunities for general education courses—beyond traditional medical ethics—to influence students’ professional identity. Studies have shown that such initiatives can enhance reflection, empathy, and a sense of social responsibility [ 13 , 16 , 18 ]. At the same time, approaches like e-learning have been used to make these courses more engaging and relevant to students [ 17 ]. Despite these efforts, important gaps remain. Most research has focused on professional or clinical training, while the contribution of general humanities education to the internalization of humanistic values has received little attention [ 19 – 20 ]. Moreover, few studies have examined how different forms of motivation interact with course design, emotional engagement, and clinical experience in shaping professional identity. This study seeks to answer a clear question: How do different types of motivation, within the context of Chinese medical education, lead to the internalization of humanistic values? More specifically, we ask how emotional engagement and clinical practice serve as bridges in this process. Addressing this question is important because it can inform the design of medical humanities courses that strengthen professional identity, and it speaks to the broader challenge of sustaining humanistic values in global medical education. Methods Study design and setting We employed a mixed-methods design to examine how medical students’ motivations are translated into meaningful engagement with humanities education. Mixed-methods approaches are widely used in medical education research because they integrate the generalizability of quantitative data with the depth of qualitative insights [ 29 ]. Our study drew on SDT and a push–pull framework of motivation. These frameworks distinguish between developmental motivation (autonomous, growth-oriented) and avoidant motivation (controlled, externally driven). They guided our selection of variables, the construction of survey items, and the framing of interview questions [ 11 , 14 ]. In particular, the survey measured students’ motivation type, course satisfaction, and professional identity indicators, while interview protocols encouraged students to describe how their motivations and attitudes evolved through course participation. The study was conducted between 2022 and 2024 at Shandong First Medical University, China. A required general education course, Tourism Culture , was chosen as the focal setting. This course was substantially redesigned to integrate cultural heritage, ethical reflection, and interdisciplinary case discussions, providing a unique opportunity to study value internalization outside traditional clinical or ethics courses. Participants The quantitative phase included 161 undergraduate students from the university. Of these, 62.7% were enrolled in clinical medicine, 24.2% in nursing, and 13.1% in public health. Both junior (Year 1–2) and senior (Year 3–5) students were represented (54.0% and 46.0%, respectively), allowing exploration of differences in clinical exposure. Female students accounted for 61.5% of the sample. Thirty students were purposively selected for follow-up interviews, ensuring diversity in gender, program background, and year of study. Data collection Data were collected in three waves, corresponding to the pre-reform (2022), mid-reform (2023), and post-reform (2024) iterations of the course. Survey : The survey instrument was adapted from validated SDT-based motivation scales [ 11 – 12 ]. Additional items were developed to address learning in humanities and cultural contexts. The final questionnaire covered three domains: motivation type (developmental vs. avoidant), course satisfaction, and professional identity indicators (e.g., empathy, sense of responsibility). All items were scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Reliability and validity were acceptable, with Cronbach’s alpha coefficients above 0.80 for all subscales. An English version of the survey is provided in Supplementary File 1. Interviews : Semi-structured interviews were conducted with 30 students (10 from each wave) selected via purposive sampling. The interview guide explored three main areas: reasons for course participation, emotional experiences during learning, and connections between the course and participants’ professional goals. Each interview lasted 45–60 minutes, was audio-recorded with consent, and transcribed verbatim. An English version of the interview guide is available in Supplementary File 2. Data analysis Quantitative data were analyzed using SPSS and AMOS. Descriptive statistics summarized demographic characteristics and baseline motivational profiles. We used structural equation modeling (SEM) to test the hypothesized pathways between motivation, course satisfaction, and professional identity outcomes. SEM is commonly applied in medical education to examine latent constructs and complex relationships [ 32 ]. Model fit was evaluated using conventional criteria (e.g., χ²/df 0.90, RMSEA < 0.08). Qualitative data were analyzed following Braun and Clarke’s six-step thematic approach [ 33 ]. Two researchers independently coded the interview transcripts, then compared codes and resolved discrepancies through discussion. Themes were refined iteratively, paying special attention to contrasts between developmental and avoidant motivational orientations. Representative quotations were selected to illustrate each theme in the findings. We adopted a convergent mixed-methods integration strategy [ 29 ]. Quantitative and qualitative results were first analyzed separately, then compared to identify convergences and divergences. This approach allowed us to validate and enrich the quantitative findings with narrative insights, and vice versa, providing a more comprehensive understanding of the phenomena. Ethics The study protocol was approved by the Institutional Review Board of Shandong First Medical University (Approval No. PX-24242997). Participation was voluntary, and written informed consent was obtained from all students prior to surveys and interviews. Students were assured of anonymity and confidentiality, and they could withdraw from the study at any time without penalty. Results Participant characteristics A total of 161 students completed the survey across the three phases of the reformed course. Of these, 62.7% were in the clinical medicine program, 24.2% in nursing, and 13.1% in public health. Female students comprised 61.5% of the sample. Juniors (Year 1–2) and seniors (Year 3–5) made up 54.0% and 46.0% of participants, respectively. Thirty students participated in interviews, representing a range of genders, programs, and training stages (see Table 1 ). Table 1 Demographic characteristics of participants (n = 161) Characteristic n (%) Gender Male 62 (38.5) Female 99 (61.5) Program Clinical medicine 101 (62.7) Nursing 39 (24.2) Public health 21 (13.1) Year of study Junior (Years 1–2) 87 (54.0) Senior (Years 3–5) 74 (46.0) Quantitative results Structural equation modeling revealed significant relationships between motivation, course satisfaction, and professional identity outcomes (Table 2 ). In the final model, developmental motivation positively predicted course satisfaction (β = 0.47, p < 0.001) and professional identity (β = 0.35, p = 0.002). Avoidant motivation negatively affected course satisfaction (β = − 0.18, p = 0.021) and had no significant direct effect on professional identity (β = − 0.09, p = 0.18). Course satisfaction, in turn, significantly predicted professional identity (β = 0.39, p < 0.001), mediating the link between motivation and professional outcomes. The inclusion of an interaction term indicated that clinical experience moderated the satisfaction–identity relationship: for students who had entered clinical rotations, the impact of course satisfaction on professional identity was stronger (interaction Δβ ≈ +0.14, p = 0.012). The overall model showed good fit to the data (χ²/df = 2.41, CFI = 0.95, RMSEA = 0.06). Table 2 Structural equation modeling results Pathway β (standardized) p-value Developmental motivation → Satisfaction 0.47 < 0.001 Avoidant motivation → Satisfaction –0.18 0.021 Satisfaction → Professional identity 0.39 < 0.001 Developmental motivation → Professional identity 0.35 0.002 Avoidant motivation → Professional identity –0.09 0.18 Qualitative results Interview analysis identified three key themes that illustrated how students experienced the course(Table 3 ). Theme 1. Motivational contrasts: Students with developmental motivation saw the course as a chance for growth and exploration: “I too k it se riously because I wanted to understand culture and history better.” (Clinical medicine, junior) In contrast, avoidant-oriented students described compliance-driven reasons: “Honestly, I just needed the credits. I didn’t expect much from it.” (Nursing, senior) Theme 2. Emotional engagement as a turning point Many students highlighted moments of emotional resonance that transformed their views: “When we reenacted historical scenarios, I felt connected to the values, not just memorizing facts.” (Public health, junior) Theme 3. Clinical practice as reinforcement Students in clinical rotations reflected that the course provided meaning to patient interactions: “In the ward, I realized why respect and empathy matter. It wasn’t only about skills, but about treating the person.” (Clinical medicine, senior) Table 3 Themes and illustrative quotations from interviews Theme Illustrative quotation Motivational contrasts “I took it seriously because I wanted to understand culture and history better.” (Clinical medicine, junior) “Honestly, I just needed the credits.” (Nursing, senior) Emotional engagement “When we reenacted historical scenarios, I felt connected to the values, not just memorizing facts.” (Public health, junior) Clinical practice as reinforcement “In the ward, I realized why respect and empathy matter. It wasn’t only about skills, but about treating the person.” (Clinical medicine, senior) Integration of findings Comparison of quantitative and qualitative data showed strong convergence. Developmental motivation was consistently associated with higher satisfaction and stronger professional identity, both statistically and thematically. Avoidant motivation reduced satisfaction, yet interview narratives suggested that emotional engagement could sometimes shift avoidant learners toward more meaningful reflection. Clinical exposure amplified the pathway from satisfaction to professional identity, reinforcing the statistical evidence with students’ personal accounts. Notes : Standardized path coefficients (β) are derived from structural equation modeling (N = 161). ***p < 0.001, *p < 0.05, n.s. = not significant. Model fit indices: χ²/df = 2.41, CFI = 0.95, RMSEA = 0.06. Clinical practice significantly moderates the satisfaction-identity pathway (Δβ = +0.14, p = 0.012). Emotional engagement may support the motivation–satisfaction relationship, particularly for avoidant learners. Solid arrows represent significant paths; dashed arrow indicates non-significant relationship; dotted lines indicate moderating and catalytic effects. Figure 1 highlights the pathways through which motivation and context shape value internalization. Developmental motivation was associated with greater course satisfaction, which subsequently strengthened professional identity. In contrast, avoidant motivation reduced satisfaction and showed only a weak, non-significant direct link to professional identity. Clinical practice acted as a moderator, reinforcing the connection between satisfaction and professional outcomes. Emotional engagement emerged as a catalyst, enabling even initially avoidant learners to shift toward more meaningful reflection and value adoption. Discussion Rethinking value internalization: beyond motivation This study found that students’ motivational orientation, while important, was not sufficient to explain the internalization of humanistic values. Quantitative analysis confirmed that developmental motivation was positively related to both satisfaction and professional identity, but qualitative accounts highlighted the critical role of emotional resonance and clinical context. These results suggest that traditional models of value internalization—which focus mainly on autonomous vs. controlled motivation—capture only part of the picture. Similarly, recent perspectives have called for broadening professional identity formation frameworks beyond individual motivation, incorporating coaching and guided reflection to foster growth [ 21 ]. Earlier research by Williams and Deci demonstrated that autonomously motivated learning fosters deeper adoption of biopsychosocial values [ 12 ]. Our findings build on this by indicating that affective and situational factors may act as mediators, amplifying or constraining how motivation translates into meaning in practice [ 26 , 28 ]. In other words, even a well-motivated student may fail to internalize humanistic values if the learning context lacks emotional impact or if clinical experiences do not reinforce what was taught. Conversely, a student initially taking the course “just for the credits” might still internalize its lessons if something in the course sparks an emotional connection, or if later clinical encounters make those lessons salient. This aligns with Self-Determination Theory and related work. Kusurkar et al. noted that education strategies should attend to students’ motivational profiles [ 14 ]. Our study extends that idea by showing how educational design and context can interact with motivation. A supportive learning environment—rich with narrative, reflection, and empathetic role models—can help convert a sense of obligation into genuine commitment. Conversely, an unsupportive environment may dampen even well-intentioned motivation. This dynamic interplay highlights why purely intrinsic motivation, by itself, was not a “magic bullet” for developing professional identity in our cohort. Motivation must be coupled with meaningful experiences. Emotional engagement and experiential learning The importance of emotional engagement emerged strongly. Students described how immersive activities (such as storytelling, historical reenactments, and group reflections) made abstract values tangible. This supports theories that emotion is central to deep learning and value formation, consistent with affective neuroscience insights [ 26 ]. Through emotional resonance, students moved beyond rote learning to personal connection—what was initially an academic exercise became “real” and memorable. Even students who initially disengaged from the course often recalled a specific moment when a story or exercise affected them, prompting a shift in perspective. Our qualitative findings suggest that emotional engagement can sometimes redirect avoidant learners. That is, students who enrolled reluctantly could still derive meaning from the course once something touched them personally. This is encouraging: it implies that well-designed humanities curricula have the potential to reach even skeptical students. It also reinforces the idea that humanities teaching should aim to engage , not just inform. Techniques like reflective writing, patient narratives, drama, or art may be powerful precisely because they invoke empathy and self-reflection, bridging the gap between intellectual understanding and emotional insight [ 8 ]. The clinical context as a catalyst We also found that experiences in the clinical environment significantly reinforced the internalization of values. Quantitatively, clinical exposure strengthened the link between course satisfaction and professional identity outcomes. Qualitatively, students in internships or rotations often drew direct connections between the course content and their patient care experiences. In their words, the humanities course “clicked” during clinical practice—they realized, for example, why concepts of respect, empathy, and cultural understanding truly matter when interacting with patients. This finding echoes the notion of “situated learning,” where context and community shape the learning process [ 27 ]. The clinical setting provided authentic reinforcement of classroom lessons. However, it can be a double-edged sword: a supportive clinical culture with positive role models can amplify the course’s impact, whereas a countervailing hidden curriculum could negate it [ 28 ]. Our study underscores the need for alignment between what is taught in humanities classrooms and what students see and do in the clinical world. Bridging this gap may involve faculty development, mentorship programs, or integrated activities that span classroom and clinic. Limitations and future directions This study has several limitations. First, it was conducted at a single medical university with one specific general education course; thus, generalizability to other institutions, courses, or cultural contexts may be limited. Second, the quantitative data were cross-sectional and relied on self-report measures, which are subject to common method variance and social desirability bias. We did not include objective behavioral outcomes to corroborate the self-reported changes. Third, several survey items were adapted or newly developed for this context; although internal consistency was acceptable, further validation of these measures (e.g., confirming factor structure, test–retest reliability) is warranted. Fourth, the moderation analysis of clinical internship experience was exploratory and based on subgroup comparisons; replication with a priori hypotheses and longitudinal designs is needed to confirm this moderating effect. Fifth, the qualitative sample size was modest and purposively selected; while appropriate for thematic exploration, it may not capture the full diversity of student experiences. Sixth, we did not specifically examine the possibility of student resistance or disengagement; some students may be reluctant to embrace humanistic content, as prior work on narrative-based training suggests [ 34 ]. Nonetheless, by using a mixed-methods approach, we were able to obtain a richer picture than either method alone could provide. Future research should extend this work across multiple institutions and cultural settings, ideally using longitudinal designs that follow students through their training. Ethnographic and action research could further illuminate how classroom and clinical environments interact to influence professional identity formation [ 29 – 31 ]. It may also be valuable to evaluate specific pedagogical strategies (e.g., reflective writing programs, cross-disciplinary projects) and to explore alternative theoretical frameworks (such as moral development or cultural humility) for fostering value internalization. Our findings provide preliminary evidence that motivation, emotion, and context interact in shaping students’ professional identity. These insights point to new directions for both theory and practice in medical education, emphasizing the need for integrated, experience-rich curricula. Conclusions This study clarifies how medical students move from initial motivation to meaningful professional commitment, revealing key pathways of value internalization. Three central findings emerge. First, motivation is complex: while developmental (autonomous) motivation supports deeper engagement, even students with avoidant motivation may be guided toward reflection through effective teaching. Second, emotional engagement functions as a bridge, transforming classroom exposure into personal resonance and insight. Third, the clinical environment serves as a catalyst, reinforcing—or undermining—humanistic values depending on the culture and role models that students encounter. In our mixed-methods analysis, developmental motivation was associated with greater course satisfaction and stronger professional identity indicators, whereas avoidant motivation related to lower satisfaction. However, emotional engagement and supportive clinical contexts appeared to help translate classroom learning into professional meaning. Educational interventions that intentionally integrate emotionally resonant activities with aligned clinical experiences could be especially impactful. Of course, we cannot make causal claims from this observational study; determining causation would require longitudinal or experimental research designs [ 34 ]. By tracing how motivation, affect, and context interact to shape value internalization, this study contributes to both theory and practice in medical education. It calls for a more integrated approach that bridges the classroom and the clinic, and it offers practical insights for developing humanistic training models in diverse cultural settings. Abbreviations CIPE Curriculum Ideological and Political Education SEM Structural Equation Modeling Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of Shandong First Medical University. Written informed consent was obtained from all participants. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Consent for publication Not applicable, as the study did not include individual patient data or identifiable personal information. Availability of data and materials The datasets generated and analyzed during the current study are available in the Harvard Dataverse repository, https://doi.org/10.7910/DVN/JSBBMR (V1). Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Curriculum Ideological and Political Education (CIPE) Teaching Reform Project (Grant No. PX-24242997), Shandong First Medical University. No additional funding was received from commercial, pharmaceutical, or biotechnology sectors. Authors’ contributions Min Wei: Conceptualization, Investigation, Writing – original draft Yanhua Zhang: Methodology, Validation Fanglin Zhu: Data curation Daiqing Zhai: Formal analysis Chuanhe Zhu: Data curation and Supervision Ying Zhao: Supervision, Language polishing All authors contributed to manuscript revisions and approved the final version. Acknowledgements We sincerely thank the students who participated in this study and the faculty members who supported the course reform and research process. Clinical trial number Not applicable. References Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine . 2009;84(9):1182–1191. https://doi.org/10.1097/ACM.0b013e3181b17e55 Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: A systematic review of studies with medical students and residents. 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Supplementary Files SurveyInstrumentfile1.docx InterviewGuidefile2.docx Cite Share Download PDF Status: Published Journal Publication published 05 Jan, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 04 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviews received at journal 03 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviews received at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 01 Dec, 2025 Reviewers agreed at journal 01 Dec, 2025 Reviewers invited by journal 01 Dec, 2025 Editor invited by journal 28 Nov, 2025 Editor assigned by journal 15 Sep, 2025 Submission checks completed at journal 12 Sep, 2025 First submitted to journal 12 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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University","correspondingAuthor":false,"prefix":"","firstName":"Chuanhe","middleName":"","lastName":"Zhu","suffix":""},{"id":554136654,"identity":"f9b737a1-45a4-4ba7-bad2-3e3296481118","order_by":5,"name":"Ying Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAu0lEQVRIiWNgGAWjYJCCAx8YmPnBLB5itRycwcAs2UCSFmYekrTozkg+eNjmj7WE7owExgdv2xjkzQlpMbuRlnA4ty1dwuxGArPh3DYGw50NhLTczjE4nNtwuA6ohU2at40hweAAQS35Hw5b/DkMsoX9N5FachgOM7CBtbAxE6fl/jODg70gv5x52Cw555yE4QaCWs4cfvzhBzDEzI4nH/zwpsxGnqAtSICxAUhIEK9+FIyCUTAKRgFuAAAwCUM7jSrvWAAAAABJRU5ErkJggg==","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":true,"prefix":"","firstName":"Ying","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2025-08-29 13:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7488873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7488873/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08504-w","type":"published","date":"2026-01-05T15:57:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97664664,"identity":"57fdfe77-813c-4796-9c09-57aa4e3c89ad","added_by":"auto","created_at":"2025-12-08 09:12:25","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":155130,"visible":true,"origin":"","legend":"","description":"","filename":"FrommotivationtomeaninginmedicalhumanitiesamixedmethodsstudyofChinesemedicalstudentsvalueinternalization.docx","url":"https://assets-eu.researchsquare.com/files/rs-7488873/v1/c3bc35a51055b295aae5ecaa.docx"},{"id":97665392,"identity":"f5df1f42-1c82-4cee-bfd4-c274484bda60","added_by":"auto","created_at":"2025-12-08 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1","display":"","copyAsset":false,"role":"figure","size":96647,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual model of motivation, satisfaction, and professional identity formation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNotes:\u003c/strong\u003e Standardized path coefficients (β) are derived from structural equation modeling (N = 161). ***p \u0026lt; 0.001, *p \u0026lt; 0.05, n.s. = not significant. Model fit indices: χ²/df = 2.41, CFI = 0.95, RMSEA = 0.06. Clinical practice significantly moderates the satisfaction-identity pathway (Δβ = +0.14, p = 0.012). Emotional engagement may support the motivation–satisfaction relationship, particularly for avoidant learners. Solid arrows represent significant paths; dashed arrow indicates non-significant relationship; dotted lines indicate moderating and catalytic effects.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7488873/v1/4d3c99164c890af5a9f8fa2b.png"},{"id":100069473,"identity":"519e338a-c1fb-48df-80d8-eb1ad2e584ff","added_by":"auto","created_at":"2026-01-12 16:14:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":863315,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7488873/v1/8b264f80-a9df-4fec-8e8e-640726f03e15.pdf"},{"id":97664859,"identity":"17ef3570-6940-4525-857e-7dc6a2dbad99","added_by":"auto","created_at":"2025-12-08 09:15:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":32355,"visible":true,"origin":"","legend":"","description":"","filename":"SurveyInstrumentfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7488873/v1/d9d7845ae098923404559b8f.docx"},{"id":97387759,"identity":"a67ebcb4-3ebc-4e6c-86ff-7d1b51f2a67d","added_by":"auto","created_at":"2025-12-03 21:05:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":29107,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuidefile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7488873/v1/c81b063c3d2a7f55c362395d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"From motivation to meaning in medical humanities: a mixed-methods study of Chinese medical students’ value internalization","fulltext":[{"header":"Background","content":"\u003cp\u003eMedical education has long faced the challenge of preparing doctors who are both technically skilled and humanistic in practice. Studies consistently show that empathy and compassion often decline as students progress through medical school [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recent evidence confirms that this pattern persists in contemporary cohorts [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This trend undermines patient-centered care and has raised concerns worldwide [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn response, educators have introduced courses in ethics, narrative medicine, and medical humanities to restore a balance between science and humanism [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Evidence suggests that such programs can enhance empathy, cultural awareness, and reflective ability [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, their role in medical curricula remains contested [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Humanities courses are often treated as optional or supplemental, and their connection to clinical training is weak [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis indicates that another key factor is motivation. Students approach humanities courses with different reasons: some are genuinely interested in personal and professional growth, while others participate mainly to meet credit requirements. Research grounded in Self-Determination Theory (SDT) shows that autonomous, developmental motivation promotes deeper engagement and value internalization [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], whereas controlled or avoidant motivation tends to result in superficial compliance. Recent work highlights the importance of aligning course design with students\u0026rsquo; motivational needs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn China, a new policy of Curriculum Ideological and Political Education (CIPE) emphasizes value education across all disciplines [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This reform has created opportunities for general education courses\u0026mdash;beyond traditional medical ethics\u0026mdash;to influence students\u0026rsquo; professional identity. Studies have shown that such initiatives can enhance reflection, empathy, and a sense of social responsibility [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. At the same time, approaches like e-learning have been used to make these courses more engaging and relevant to students [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these efforts, important gaps remain. Most research has focused on professional or clinical training, while the contribution of general humanities education to the internalization of humanistic values has received little attention [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Moreover, few studies have examined how different forms of motivation interact with course design, emotional engagement, and clinical experience in shaping professional identity.\u003c/p\u003e\u003cp\u003eThis study seeks to answer a clear question: How do different types of motivation, within the context of Chinese medical education, lead to the internalization of humanistic values? More specifically, we ask how emotional engagement and clinical practice serve as bridges in this process. Addressing this question is important because it can inform the design of medical humanities courses that strengthen professional identity, and it speaks to the broader challenge of sustaining humanistic values in global medical education.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eWe employed a mixed-methods design to examine how medical students\u0026rsquo; motivations are translated into meaningful engagement with humanities education. Mixed-methods approaches are widely used in medical education research because they integrate the generalizability of quantitative data with the depth of qualitative insights [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Our study drew on SDT and a push\u0026ndash;pull framework of motivation. These frameworks distinguish between developmental motivation (autonomous, growth-oriented) and avoidant motivation (controlled, externally driven). They guided our selection of variables, the construction of survey items, and the framing of interview questions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In particular, the survey measured students\u0026rsquo; motivation type, course satisfaction, and professional identity indicators, while interview protocols encouraged students to describe how their motivations and attitudes evolved through course participation.\u003c/p\u003e\u003cp\u003eThe study was conducted between 2022 and 2024 at Shandong First Medical University, China. A required general education course, \u003cem\u003eTourism Culture\u003c/em\u003e, was chosen as the focal setting. This course was substantially redesigned to integrate cultural heritage, ethical reflection, and interdisciplinary case discussions, providing a unique opportunity to study value internalization outside traditional clinical or ethics courses.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe quantitative phase included 161 undergraduate students from the university. Of these, 62.7% were enrolled in clinical medicine, 24.2% in nursing, and 13.1% in public health. Both junior (Year 1\u0026ndash;2) and senior (Year 3\u0026ndash;5) students were represented (54.0% and 46.0%, respectively), allowing exploration of differences in clinical exposure. Female students accounted for 61.5% of the sample. Thirty students were purposively selected for follow-up interviews, ensuring diversity in gender, program background, and year of study.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected in three waves, corresponding to the pre-reform (2022), mid-reform (2023), and post-reform (2024) iterations of the course.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurvey\u003c/b\u003e: The survey instrument was adapted from validated SDT-based motivation scales [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additional items were developed to address learning in humanities and cultural contexts. The final questionnaire covered three domains: motivation type (developmental vs. avoidant), course satisfaction, and professional identity indicators (e.g., empathy, sense of responsibility). All items were scored on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 5\u0026thinsp;=\u0026thinsp;strongly agree). Reliability and validity were acceptable, with Cronbach\u0026rsquo;s alpha coefficients above 0.80 for all subscales. An English version of the survey is provided in Supplementary File 1.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInterviews\u003c/b\u003e: Semi-structured interviews were conducted with 30 students (10 from each wave) selected via purposive sampling. The interview guide explored three main areas: reasons for course participation, emotional experiences during learning, and connections between the course and participants\u0026rsquo; professional goals. Each interview lasted 45\u0026ndash;60 minutes, was audio-recorded with consent, and transcribed verbatim. An English version of the interview guide is available in Supplementary File 2.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eQuantitative data were analyzed using SPSS and AMOS. Descriptive statistics summarized demographic characteristics and baseline motivational profiles. We used structural equation modeling (SEM) to test the hypothesized pathways between motivation, course satisfaction, and professional identity outcomes. SEM is commonly applied in medical education to examine latent constructs and complex relationships [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Model fit was evaluated using conventional criteria (e.g., χ\u0026sup2;/df\u0026thinsp;\u0026lt;\u0026thinsp;3.0, CFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90, RMSEA\u0026thinsp;\u0026lt;\u0026thinsp;0.08).\u003c/p\u003e\u003cp\u003eQualitative data were analyzed following Braun and Clarke\u0026rsquo;s six-step thematic approach [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Two researchers independently coded the interview transcripts, then compared codes and resolved discrepancies through discussion. Themes were refined iteratively, paying special attention to contrasts between developmental and avoidant motivational orientations. Representative quotations were selected to illustrate each theme in the findings.\u003c/p\u003e\u003cp\u003eWe adopted a convergent mixed-methods integration strategy [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Quantitative and qualitative results were first analyzed separately, then compared to identify convergences and divergences. This approach allowed us to validate and enrich the quantitative findings with narrative insights, and vice versa, providing a more comprehensive understanding of the phenomena.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e The study protocol was approved by the Institutional Review Board of Shandong First Medical University (Approval No. PX-24242997). Participation was voluntary, and written informed consent was obtained from all students prior to surveys and interviews. Students were assured of anonymity and confidentiality, and they could withdraw from the study at any time without penalty.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\u003cp\u003eA total of 161 students completed the survey across the three phases of the reformed course. Of these, 62.7% were in the clinical medicine program, 24.2% in nursing, and 13.1% in public health. Female students comprised 61.5% of the sample. Juniors (Year 1\u0026ndash;2) and seniors (Year 3\u0026ndash;5) made up 54.0% and 46.0% of participants, respectively. Thirty students participated in interviews, representing a range of genders, programs, and training stages (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of participants (n\u0026thinsp;=\u0026thinsp;161)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62 (38.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99 (61.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProgram\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e101 (62.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e39 (24.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21 (13.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYear of study\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior (Years 1\u0026ndash;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87 (54.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior (Years 3\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74 (46.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQuantitative results\u003c/h3\u003e\n\u003cp\u003eStructural equation modeling revealed significant relationships between motivation, course satisfaction, and professional identity outcomes (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the final model, developmental motivation positively predicted course satisfaction (β\u0026thinsp;=\u0026thinsp;0.47, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and professional identity (β\u0026thinsp;=\u0026thinsp;0.35, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Avoidant motivation negatively affected course satisfaction (β = \u0026minus;\u0026thinsp;0.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021) and had no significant direct effect on professional identity (β = \u0026minus;\u0026thinsp;0.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.18). Course satisfaction, in turn, significantly predicted professional identity (β\u0026thinsp;=\u0026thinsp;0.39, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), mediating the link between motivation and professional outcomes. The inclusion of an interaction term indicated that clinical experience moderated the satisfaction\u0026ndash;identity relationship: for students who had entered clinical rotations, the impact of course satisfaction on professional identity was stronger (interaction Δβ \u0026asymp; +0.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012). The overall model showed good fit to the data (χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;2.41, CFI\u0026thinsp;=\u0026thinsp;0.95, RMSEA\u0026thinsp;=\u0026thinsp;0.06).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStructural equation modeling results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathway\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eβ (standardized)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDevelopmental motivation \u0026rarr; Satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAvoidant motivation \u0026rarr; Satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSatisfaction \u0026rarr; Professional identity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDevelopmental motivation \u0026rarr; Professional identity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAvoidant motivation \u0026rarr; Professional identity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQualitative results\u003c/h2\u003e\u003cp\u003eInterview analysis identified three key themes that illustrated how students experienced the course(Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTheme 1. Motivational contrasts:\u003c/p\u003e\u003cp\u003eStudents with developmental motivation saw the course as a chance for growth and exploration:\u003c/p\u003e\u003cp\u003e\u0026ldquo;I too\u003cem\u003ek it\u003c/em\u003e \u003cb\u003ese\u003c/b\u003e\u003cem\u003eriously because I wanted to understand culture and history better.\u0026rdquo;\u003c/em\u003e (Clinical medicine, junior)\u003c/p\u003e\u003cp\u003eIn contrast, avoidant-oriented students described compliance-driven reasons:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Honestly, I just needed the credits. I didn\u0026rsquo;t expect much from it.\u0026rdquo;\u003c/em\u003e (Nursing, senior)\u003c/p\u003e\u003cp\u003eTheme 2. Emotional engagement as a turning point\u003c/p\u003e\u003cp\u003eMany students highlighted moments of emotional resonance that transformed their views:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When we reenacted historical scenarios, I felt connected to the values, not just memorizing facts.\u0026rdquo;\u003c/em\u003e (Public health, junior)\u003c/p\u003e\u003cp\u003eTheme 3. Clinical practice as reinforcement\u003c/p\u003e\u003cp\u003eStudents in clinical rotations reflected that the course provided meaning to patient interactions:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In the ward, I realized why respect and empathy matter. It wasn\u0026rsquo;t only about skills, but about treating the person.\u0026rdquo;\u003c/em\u003e (Clinical medicine, senior)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and illustrative quotations from interviews\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIllustrative quotation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMotivational contrasts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I took it seriously because I wanted to understand culture and history better.\u0026rdquo;\u003c/em\u003e (Clinical medicine, junior)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Honestly, I just needed the credits.\u0026rdquo;\u003c/em\u003e (Nursing, senior)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional engagement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When we reenacted historical scenarios, I felt connected to the values, not just memorizing facts.\u0026rdquo;\u003c/em\u003e (Public health, junior)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical practice as reinforcement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In the ward, I realized why respect and empathy matter. It wasn\u0026rsquo;t only about skills, but about treating the person.\u0026rdquo;\u003c/em\u003e (Clinical medicine, senior)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eIntegration of findings\u003c/h2\u003e\u003cp\u003eComparison of quantitative and qualitative data showed strong convergence. Developmental motivation was consistently associated with higher satisfaction and stronger professional identity, both statistically and thematically. Avoidant motivation reduced satisfaction, yet interview narratives suggested that emotional engagement could sometimes shift avoidant learners toward more meaningful reflection. Clinical exposure amplified the pathway from satisfaction to professional identity, reinforcing the statistical evidence with students\u0026rsquo; personal accounts.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eNotes\u003c/b\u003e: Standardized path coefficients (β) are derived from structural equation modeling (N\u0026thinsp;=\u0026thinsp;161). ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, n.s. = not significant. Model fit indices: χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;2.41, CFI\u0026thinsp;=\u0026thinsp;0.95, RMSEA\u0026thinsp;=\u0026thinsp;0.06. Clinical practice significantly moderates the satisfaction-identity pathway (Δβ = +0.14, p\u0026thinsp;=\u0026thinsp;0.012). Emotional engagement may support the motivation\u0026ndash;satisfaction relationship, particularly for avoidant learners. Solid arrows represent significant paths; dashed arrow indicates non-significant relationship; dotted lines indicate moderating and catalytic effects.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e highlights the pathways through which motivation and context shape value internalization. Developmental motivation was associated with greater course satisfaction, which subsequently strengthened professional identity. In contrast, avoidant motivation reduced satisfaction and showed only a weak, non-significant direct link to professional identity. Clinical practice acted as a moderator, reinforcing the connection between satisfaction and professional outcomes. Emotional engagement emerged as a catalyst, enabling even initially avoidant learners to shift toward more meaningful reflection and value adoption.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eRethinking value internalization: beyond motivation\u003c/h2\u003e\u003cp\u003eThis study found that students\u0026rsquo; motivational orientation, while important, was not sufficient to explain the internalization of humanistic values. Quantitative analysis confirmed that developmental motivation was positively related to both satisfaction and professional identity, but qualitative accounts highlighted the critical role of emotional resonance and clinical context. These results suggest that traditional models of value internalization\u0026mdash;which focus mainly on autonomous vs. controlled motivation\u0026mdash;capture only part of the picture. Similarly, recent perspectives have called for broadening professional identity formation frameworks beyond individual motivation, incorporating coaching and guided reflection to foster growth [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEarlier research by Williams and Deci demonstrated that autonomously motivated learning fosters deeper adoption of biopsychosocial values [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our findings build on this by indicating that affective and situational factors may act as mediators, amplifying or constraining how motivation translates into meaning in practice [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In other words, even a well-motivated student may fail to internalize humanistic values if the learning context lacks emotional impact or if clinical experiences do not reinforce what was taught. Conversely, a student initially taking the course \u0026ldquo;just for the credits\u0026rdquo; might still internalize its lessons if something in the course sparks an emotional connection, or if later clinical encounters make those lessons salient.\u003c/p\u003e\u003cp\u003eThis aligns with Self-Determination Theory and related work. Kusurkar et al. noted that education strategies should attend to students\u0026rsquo; motivational profiles [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our study extends that idea by showing how educational design and context can \u003cem\u003einteract\u003c/em\u003e with motivation. A supportive learning environment\u0026mdash;rich with narrative, reflection, and empathetic role models\u0026mdash;can help convert a sense of obligation into genuine commitment. Conversely, an unsupportive environment may dampen even well-intentioned motivation. This dynamic interplay highlights why purely intrinsic motivation, by itself, was not a \u0026ldquo;magic bullet\u0026rdquo; for developing professional identity in our cohort. Motivation must be coupled with meaningful experiences.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eEmotional engagement and experiential learning\u003c/h2\u003e\u003cp\u003eThe importance of emotional engagement emerged strongly. Students described how immersive activities (such as storytelling, historical reenactments, and group reflections) made abstract values tangible. This supports theories that emotion is central to deep learning and value formation, consistent with affective neuroscience insights [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Through emotional resonance, students moved beyond rote learning to personal connection\u0026mdash;what was initially an academic exercise became \u0026ldquo;real\u0026rdquo; and memorable. Even students who initially disengaged from the course often recalled a specific moment when a story or exercise affected them, prompting a shift in perspective.\u003c/p\u003e\u003cp\u003eOur qualitative findings suggest that emotional engagement can sometimes redirect avoidant learners. That is, students who enrolled reluctantly could still derive meaning from the course once something touched them personally. This is encouraging: it implies that well-designed humanities curricula have the potential to reach even skeptical students. It also reinforces the idea that humanities teaching should aim to \u003cem\u003eengage\u003c/em\u003e, not just inform. Techniques like reflective writing, patient narratives, drama, or art may be powerful precisely because they invoke empathy and self-reflection, bridging the gap between intellectual understanding and emotional insight [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eThe clinical context as a catalyst\u003c/h2\u003e\u003cp\u003eWe also found that experiences in the clinical environment significantly reinforced the internalization of values. Quantitatively, clinical exposure strengthened the link between course satisfaction and professional identity outcomes. Qualitatively, students in internships or rotations often drew direct connections between the course content and their patient care experiences. In their words, the humanities course \u0026ldquo;clicked\u0026rdquo; during clinical practice\u0026mdash;they realized, for example, why concepts of respect, empathy, and cultural understanding truly matter when interacting with patients.\u003c/p\u003e\u003cp\u003eThis finding echoes the notion of \u0026ldquo;situated learning,\u0026rdquo; where context and community shape the learning process [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The clinical setting provided authentic reinforcement of classroom lessons. However, it can be a double-edged sword: a supportive clinical culture with positive role models can amplify the course\u0026rsquo;s impact, whereas a countervailing hidden curriculum could negate it [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Our study underscores the need for alignment between what is taught in humanities classrooms and what students see and do in the clinical world. Bridging this gap may involve faculty development, mentorship programs, or integrated activities that span classroom and clinic.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and future directions\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, it was conducted at a single medical university with one specific general education course; thus, generalizability to other institutions, courses, or cultural contexts may be limited. Second, the quantitative data were cross-sectional and relied on self-report measures, which are subject to common method variance and social desirability bias. We did not include objective behavioral outcomes to corroborate the self-reported changes. Third, several survey items were adapted or newly developed for this context; although internal consistency was acceptable, further validation of these measures (e.g., confirming factor structure, test\u0026ndash;retest reliability) is warranted. Fourth, the moderation analysis of clinical internship experience was exploratory and based on subgroup comparisons; replication with a priori hypotheses and longitudinal designs is needed to confirm this moderating effect. Fifth, the qualitative sample size was modest and purposively selected; while appropriate for thematic exploration, it may not capture the full diversity of student experiences. Sixth, we did not specifically examine the possibility of student resistance or disengagement; some students may be reluctant to embrace humanistic content, as prior work on narrative-based training suggests [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Nonetheless, by using a mixed-methods approach, we were able to obtain a richer picture than either method alone could provide.\u003c/p\u003e\u003cp\u003eFuture research should extend this work across multiple institutions and cultural settings, ideally using longitudinal designs that follow students through their training. Ethnographic and action research could further illuminate how classroom and clinical environments interact to influence professional identity formation [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. It may also be valuable to evaluate specific pedagogical strategies (e.g., reflective writing programs, cross-disciplinary projects) and to explore alternative theoretical frameworks (such as moral development or cultural humility) for fostering value internalization. Our findings provide preliminary evidence that motivation, emotion, and context interact in shaping students\u0026rsquo; professional identity. These insights point to new directions for both theory and practice in medical education, emphasizing the need for integrated, experience-rich curricula.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study clarifies how medical students move from initial motivation to meaningful professional commitment, revealing key pathways of value internalization. Three central findings emerge. First, motivation is complex: while developmental (autonomous) motivation supports deeper engagement, even students with avoidant motivation may be guided toward reflection through effective teaching. Second, emotional engagement functions as a bridge, transforming classroom exposure into personal resonance and insight. Third, the clinical environment serves as a catalyst, reinforcing\u0026mdash;or undermining\u0026mdash;humanistic values depending on the culture and role models that students encounter.\u003c/p\u003e\u003cp\u003eIn our mixed-methods analysis, developmental motivation was associated with greater course satisfaction and stronger professional identity indicators, whereas avoidant motivation related to lower satisfaction. However, emotional engagement and supportive clinical contexts appeared to help translate classroom learning into professional meaning. Educational interventions that intentionally integrate emotionally resonant activities with aligned clinical experiences could be especially impactful. Of course, we cannot make causal claims from this observational study; determining causation would require longitudinal or experimental research designs [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBy tracing how motivation, affect, and context interact to shape value internalization, this study contributes to both theory and practice in medical education. It calls for a more integrated approach that bridges the classroom and the clinic, and it offers practical insights for developing humanistic training models in diverse cultural settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCIPE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCurriculum Ideological and Political Education\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSEM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStructural Equation Modeling\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of Shandong First Medical University. Written informed consent was obtained from all participants. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, as the study did not include individual patient data or identifiable personal information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available in the Harvard Dataverse repository, https://doi.org/10.7910/DVN/JSBBMR (V1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Curriculum Ideological and Political Education (CIPE) Teaching Reform Project (Grant No. PX-24242997), Shandong First Medical University. No additional funding was received from commercial, pharmaceutical, or biotechnology sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMin Wei: Conceptualization, Investigation, Writing \u0026ndash; original draft\u003c/p\u003e\n\u003cp\u003eYanhua Zhang: Methodology, Validation\u003c/p\u003e\n\u003cp\u003eFanglin Zhu: Data curation\u003c/p\u003e\n\u003cp\u003eDaiqing Zhai: Formal analysis\u003c/p\u003e\n\u003cp\u003eChuanhe Zhu: Data curation and Supervision\u003c/p\u003e\n\u003cp\u003eYing Zhao: Supervision, Language polishing\u003c/p\u003e\n\u003cp\u003eAll authors contributed to manuscript revisions and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank the students who participated in this study and the faculty members who supported the course reform and research process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHojat M, Vergare MJ, Maxwell K, et al. 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Twelve tips for designing medical humanities curricula to foster professional identity formation. \u003cem\u003eMedical Teacher\u003c/em\u003e. 2020;42(5):493\u0026ndash;498. https://doi.org/10.1080/0142159X.2019.1567909\u003c/li\u003e\n\u003cli\u003eKrzyżanowska M, Brezis M. The challenge of empathy in medical education\u0026mdash;lessons from narrative medicine. \u003cem\u003eMedical Humanities\u003c/em\u003e. 2021;47(3):299\u0026ndash;305. https://doi.org/10.1136/medhum-2020-012018\u003c/li\u003e\n\u003cli\u003eKleinman A. \u003cem\u003eThe Illness Narratives: Suffering, Healing, and the Human Condition\u003c/em\u003e. New York: Basic Books; 1988.\u003c/li\u003e\n\u003cli\u003eImmordino-Yang MH, Damasio A. We feel, therefore we learn: The relevance of affective and social neuroscience to education. \u003cem\u003eMind, Brain, and Education\u003c/em\u003e. 2007;1(1):3\u0026ndash;10. https://doi.org/10.1111/j.1751-228X.2007.00004.x\u003c/li\u003e\n\u003cli\u003eLave J, Wenger E. \u003cem\u003eSituated Learning: Legitimate Peripheral Participation\u003c/em\u003e. Cambridge: Cambridge University Press; 1991. https://doi.org/10.1017/CBO9780511815355\u003c/li\u003e\n\u003cli\u003eHafferty FW. Beyond curriculum reform: Confronting medicine\u0026rsquo;s hidden curriculum. \u003cem\u003eAcademic Medicine\u003c/em\u003e. 1998;73(4):403\u0026ndash;407. https://doi.org/10.1097/00001888-199804000-00013\u003c/li\u003e\n\u003cli\u003eCreswell JW, Plano Clark VL. \u003cem\u003eDesigning and Conducting Mixed Methods Research\u003c/em\u003e. 3rd ed. Thousand Oaks, CA: Sage; 2017.\u003c/li\u003e\n\u003cli\u003eFetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs: Principles and practices. \u003cem\u003eHealth Services Research\u003c/em\u003e. 2013;48(6 Pt 2):2134\u0026ndash;2156. https://doi.org/10.1111/1475-6773.12117\u003c/li\u003e\n\u003cli\u003ePatton MQ. \u003cem\u003eQualitative Research \u0026amp; Evaluation Methods\u003c/em\u003e. 4th ed. Thousand Oaks, CA: Sage; 2015.\u003c/li\u003e\n\u003cli\u003eKline RB. \u003cem\u003ePrinciples and Practice of Structural Equation Modeling\u003c/em\u003e. 4th ed. New York: Guilford Press; 2015.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. \u003cem\u003eQualitative Research in Psychology\u003c/em\u003e. 2006;3(2):77\u0026ndash;101. https://doi.org/10.1191/1478088706qp063oa\u003c/li\u003e\n\u003cli\u003eWear D, Aultman JM. The limits of narrative: Medical student resistance to confronting inequality and oppression in literature and beyond. \u003cem\u003eMedical Education\u003c/em\u003e. 2005;39(10):1056\u0026ndash;1065. https://doi.org/10.1111/j.1365-2929.2005.02269.x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"medical humanities, motivation, value internalization, emotional engagement, clinical training, professional identity","lastPublishedDoi":"10.21203/rs.3.rs-7488873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7488873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMedical humanities are expected to strengthen humanistic values in future physicians, yet how students internalize such values across learning contexts is not fully understood. This study examined how different types of motivation relate to engagement, and how emotions and clinical experiences may support value internalization.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a mixed-methods study at a Chinese medical university. Survey data from 161 students were analyzed with structural equation modeling (SEM), and semi-structured interviews with 30 students provided qualitative insights.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eDevelopmental motivation predicted both course satisfaction and professional identity (β\u0026thinsp;=\u0026thinsp;0.47, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Avoidant motivation reduced affective satisfaction (β=-0.18, p\u0026thinsp;=\u0026thinsp;0.021). Clinical internship appeared to strengthen the pathway from satisfaction to professional identity (Δβ=+0.14, p\u0026thinsp;=\u0026thinsp;0.012). Qualitative themes highlighted emotional engagement as a turning point for reflection. Clinical settings appeared to act as catalysts, reinforcing or sometimes challenging how classroom knowledge was translated into professional practice.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eMotivation alone does not fully explain how values are internalized. Our findings suggest that emotions and clinical context may serve as important bridges, supporting the translation of humanities learning into professional commitments. These results highlight the potential value of curricula that integrate experiential teaching with supportive clinical environments, although causal effects cannot be confirmed in this observational study.\u003c/p\u003e","manuscriptTitle":"From motivation to meaning in medical humanities: a mixed-methods study of Chinese medical students’ value internalization","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 21:05:17","doi":"10.21203/rs.3.rs-7488873/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-04T13:45:29+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"309841760691080042756739287835629037432","date":"2025-12-03T23:09:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T07:51:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309200274704144337520535514065344053962","date":"2025-12-02T14:28:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-02T07:57:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22105891335090037740600242102060526058","date":"2025-12-02T06:39:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64342205986161615540825625871158989752","date":"2025-12-02T05:24:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196921114426295712016634244519104482578","date":"2025-12-02T03:35:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24723451696436931795837670209248860710","date":"2025-12-02T03:07:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-01T22:48:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-28T13:17:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-15T09:23:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-12T18:24:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-09-12T18:22:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4e2817b2-234c-4ed6-90f4-4d21c6420ed4","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:07:27+00:00","versionOfRecord":{"articleIdentity":"rs-7488873","link":"https://doi.org/10.1186/s12909-025-08504-w","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-01-05 15:57:44","publishedOnDateReadable":"January 5th, 2026"},"versionCreatedAt":"2025-12-03 21:05:17","video":"","vorDoi":"10.1186/s12909-025-08504-w","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08504-w","workflowStages":[]},"version":"v1","identity":"rs-7488873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7488873","identity":"rs-7488873","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}