Researcher characteristics.

Research Team Members. The research team comprised four members. The first author, a university faculty member with a master’s degree, was responsible for laboratory management and practical course instruction for third- and fourth-year students. She possessed comprehensive knowledge of the students’ academic and clinical curriculum and was directly involved in their laboratory teaching and management. In this study, she was responsible for study design, conducting all 14 core in-depth interviews, managing audio recordings, writing field notes, transcript verification, independent coding, and manuscript writing.

The second author, a second-year master’s student in nursing, was responsible for participant recruitment, literature review, transcript verification, independent coding, and thematic framework discussion. The third author, a university faculty member with a master’s degree, was responsible for laboratory management and practical course instruction for first- and second-year students in fundamental nursing courses, with nine years of teaching and geriatric nursing research experience. She was responsible for study design review, coding arbitration, and educational practice validation. The fourth author held a master’s degree in nursing and was a head nurse at a tertiary hospital in Beijing, with eight years of geriatric care research and clinical management experience. She was responsible for clinical relevance verification, thematic framework review, and long-term care setting validation.

All team members had nursing professional backgrounds and received qualitative research training. The first, third, and fourth authors completed dedicated training in qualitative research methods and in-depth interview techniques during their respective master’s degree studies. The second author received qualitative research training during undergraduate studies and ongoing master’s coursework. Only the first author had a teaching relationship with participants.

Positionality statement. The first author’s dual role as a faculty member and researcher may create several biases. First, power imbalance may lead participants to worry about academic evaluations, causing them to express overly positive career intentions or avoid sensitive topics like teaching evaluations. Second, relationship closeness may affect data quality. Familiar students might share more deeply due to trust, but could also participate just to save face. Unfamiliar students might feel nervous, avoidant, or give perfunctory responses. To mitigate these biases, we emphasized voluntary participation and grade independence in the consent form, used peer data collectors for supplementary conversations, conducted core interviews in neutral and private settings, had participants transcribe their own interviews, and maintained independent coding with team discussion of discrepancies.

Mitigation of interviewer bias. To minimize power-related bias from the interviewer’s dual role as instructor and researcher, the following strategies were implemented.

Data Collection Phase: (1) Recruitment. Conducted by the second author; the first author was not involved. Recruitment occurred after class meetings when the instructor had left, ensuring voluntary participation. (2) Timing. All interviews were scheduled after grades were finalized. Fourth-year students were interviewed in mid-May after graduation exam scores were entered; third-year students in early April after final grades were submitted, before clinical internships. (3) Power dynamics. Participants received written assurances that content was for research only, that the interviewer had no role in academic evaluation, and that all information was confidential. The consent form provided Ethics Committee and university complaint channels. The interviewer maintained neutrality, avoided judgment, and refrained from leading questions. (4) Peer supplementary conversations. Two trained peer data collectors conducted informal conversations on sensitive topics. These data were used solely for validation, not core thematic analysis.

Data Analysis Phase: (1) Independent coding. The first and second authors independently coded all 14 transcripts, discussed disagreements, reviewed original context, and reached consensus. The third author arbitrated unresolved codes; the fourth author reviewed the framework for clinical and long-term care relevance. (2) Member checking. Finalized transcripts were returned to participants for verification. (3) Reflexive practice. The interviewer wrote field notes within 24 hours, documenting emotional reactions, value judgments, and power dynamic perceptions. The team reviewed these weekly to identify interpretive bias.

Interview guide development.

A semi-structured interview guide was developed based on the study objectives. The guide was piloted with two eligible students and refined iteratively to enhance clarity and relevance. The final guide included the following core domains: (1) What motivated your choice to pursue the geriatric nursing track? (2) How important is the role of nurses in long-term care facility? Please describe their potential contributions. (3) Would you consider working as a nurse in long-term care facilities in the future? Please explain your reasons. (4) Do you believe most nursing undergraduates are willing to work in long-term care facilities? Why or why not? (5) What are the strengths and weaknesses of the current educational collaboration between the university and partner long-term care facilities? (6) What improvements could be made to attract more young nursing graduates to geriatric care?

Data collection.

Core Interviews (n = 14). Data were collected through face-to-face, in-depth, semi-structured individual interviews. Interviews were conducted in quiet, private study rooms to ensure confidentiality and minimize distractions. Only the interviewer and participant were present. Sessions were scheduled at times convenient for participants, avoiding meal breaks and rest periods. With prior consent, all interviews were audio-recorded. The interviewer also maintained handwritten field notes to document nonverbal cues and contextual observations. A neutral, non-judgmental stance was maintained throughout, and leading questions were avoided. Each interview lasted approximately 30–40 minutes.

Peer supplementary conversations (n = 9). To obtain candid feedback on sensitive topics (e.g., educational collaboration), a peer supplementary conversation mechanism was introduced. Two class officers (a class monitor and an academic representative) served as peer data collectors. In the Chinese higher education system, a class monitor assists with daily class management and monitors student well-being, while an academic representative serves as a liaison between students and course instructors regarding learning needs and difficulties.

The peer data collectors were in the same class as participants during the first two years. After third-year specialization, they shared core courses but had different minor tracks (operating room and critical care, respectively), thus not meeting the inclusion criteria. Their role was limited to data collection and transcription; they did not participate in coding or thematic analysis.

Before the conversations, researchers provided 3.5 hours of training on: (1) reviewing of qualitative research methods (1h); (2) ethics and confidentiality, including non-disclosure to faculty (1h); (3) non-leading questioning and audio equipment (0.5h); and (4) role-playing exercises (1h). Both signed ethical commitment forms after training.

The two peer data collectors conducted informal, open-ended conversations with nine additional third-year students (not among the 14 core participants) in informal settings (e.g., cafeterias, playgrounds). These exploratory dialogues used prompts such as “What do you think about the teaching collaboration?” and “What are the strengths and weaknesses of our current training model?”

Prior to each session, participants received a full explanation of the study’s purpose, were assured of anonymity and confidentiality, and provided written informed consent. They were also informed of their right to withdraw at any time without consequence. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure transparency in data collection and reporting [24].

Data analysis method.

Core data analysis (n = 14). Data collection and analysis occurred concurrently to allow for iterative refinement. Within 24 hours following each interview, a copy of the audio recording was provided to the research subject for verbatim transcription. The interviewer subsequently cross-referenced each transcript with observational notes taken during the interview to enhance data reliability.

Thematic analysis following the framework established by Braun and Clarke was applied to analyze the data [25]. Research team members independently coded the transcripts to identify salient statements and recurrent textual patterns, subsequently synthesizing the coded material. Divergences in thematic interpretation were resolved through structured team deliberation, comparative analysis, and iterative review until consensus on the final thematic framework was reached. Participant identifiers were replaced with anonymized codes throughout the analysis to ensure confidentiality.

Supplementary data processing (n = 9). The nine supplementary audio recordings were transcribed by two class officers (a class monitor and an academic representative). Supplementary participants were identified by anonymized codes (S1–S9). The second author then cross-checked all supplementary transcripts against the original audio recordings to ensure accuracy. After verification, the peer data collectors returned the transcripts to the nine supplementary participants to confirm that the written records accurately reflected their intended meanings. Supplementary data were not subjected to thematic analysis. They were used solely for triangulation and validation of the“school teaching” subtheme.

Rigor and trustworthiness.

To ensure the credibility and transferability of findings, several strategies were employed based on Lincoln and Guba’s trustworthiness framework [26]. Participants were purposively selected to represent diversity in academic performance, family socioeconomic status, and experience with elder care. Rapport was established prior to interviews to foster open communication. Interview duration and probing were adapted flexibly to elicit rich data. The researcher maintained reflexivity by avoiding assumptions and attentively observing paraverbal and nonverbal cues. Transcripts were returned to participants for verification to confirm that the interpretations reflected their intended meanings.

Ethical considerations.

This study received ethical approval from the Ethics Committee of the School of Nursing (WNMC20250103). Given the privacy implications for interviewees, the following ethical measures were implemented: (1) Prior to interviews, participants were informed of the study’s purpose, methodology, and significance, with assurances that participant identities and information would remain confidential (2) Participants were notified that interviews would be audio-recorded, with consent obtained before recording commenced; (3) Participants were informed of their right to withdraw from the interview at any time.

Theme 1: Nascent interest in geriatric care.

Influence of Traditional “Filial Piety” Values. Traditional Chinese culture emphasizes reverence and care for the elderly, a principle that has evolved from a familial ethic into a state-governed system over centuries. Since the Qin and Han dynasties, “filial piety” has been codified into law, with disrespect toward elders classified among the “Ten Major Crimes” [27]. This dual reinforcement through morality and law has deeply ingrained traditional filial piety in societal consciousness. These values positively shape nursing students’ career intentions toward geriatric care. As participants noted:

N1: “My grandmother raised me, but she passed away when I was in first grade. I couldn’t be there for her in her old age—a lifelong regret. From that moment, I resolved to dedicate myself to supporting more elderly people.”

N3: “My grandfather once lived in a long-term care facility for a period. The caregivers there provided attentive care, and his life there was richer than at home. The humanistic care they offered during his treatment warmed my heart, and I want to pass on that warmth.”

N5: “The elderly have dedicated their entire lives to societal development. When they can no longer care for themselves, we younger generation have a duty to provide them with quality services, passing love down through the generations. Only then can we expect to be well cared for in our own old age, allowing us to peacefully navigate life’s final journey.”

These narratives reveal filial piety as a multidimensional moral-emotional anchor, transforming unresolved loss into redemptive purpose (N1), witnessed care quality into empathic commitment (N3), and cultural intergenerational responsibility into reciprocal obligation (N5). These pathways converge into positive social outcome expectations within the SCCT framework, operating through anticipated emotional fulfillment rather than instrumental calculation. This affective mode of expectation formation specifies how cultural values become internalized as career motives in collectivist settings, and suggests that geriatric care outcome expectations may carry stronger moral weight than in conventional domains.

The critical role of nursing in an aging society. As societies age, the prevalence of multimorbidity, functional disability, dementia, and advanced age increases. In this context, the basic daily assistance traditionally provided by care aides is no longer sufficient. The involvement of professionally trained nurses has become a societal necessity. N10: As the saying goes, “Treatment accounts for 30%, nursing for 70%.” Institutionalized seniors primarily rely on nursing for their physical well-being. Our four years of theoretical and practical training equip us not only to standardize daily care procedures but also to provide specialized nursing support in disease recovery and psychological care.

N11: Nurses deliver specialized care for elderly illnesses while serving as vital bridges between residents, families, and doctors. Though these communication roles may seem small, they are fundamental to helping seniors adapt swiftly and preserving their dignity.

These narratives reveal how students generate positive outcome expectations through professional identity. N10 emphasizes technical indispensability with the adage “Treatment accounts for 30%, nursing for 70%,” while N11 highlights relational coordination as a “communication bridge.” Together, they reframe geriatric nursing as skilled practice requiring professional training. This specifies a second source of outcome expectation formation alongside the emotion-driven pathway: students derive expectations from anticipated professional recognition and competence utilization.

Perceived promising future of geriatric care. Given the pronounced trend of population aging, the demand for nursing professionals in long-term care is rising steadily. Participants viewed market needs as a strong indicator of the field’s potential.

N4: I don’t have a particular passion for geriatrics, but with hospitals hiring fewer nurses, I believe elderly care will be in high demand in the future. I chose this minor in elderly care partly to gain more knowledge, and partly to have a backup plan in case I can’t find a suitable hospital in the future.

N7: Beyond our parents’ generation holding strong beliefs in “raising children for old age,” our generation of only children doesn’t expect our children to care for us. When we become frail, we’ll likely turn to long-term care facilities. Therefore, the future will require a large number of caregivers.

Even students without a strong personal passion for geriatric care are attracted by the considerable market demand and employment prospects. N4 frames geriatric care as a “backup plan” amid hospital hiring contraction, while N7 projects demographic inevitability onto personal future planning. These pragmatic considerations form a third source of positive outcome expectations, distinct from moral motivations and professional identity. Like those earlier sources, however, this market-informed interest only shapes students’ initial interest, remaining at the cognitive level and failing to translate into goal commitment when confronted with efficacy deficits and environmental barriers.

Theme 2: Perceived deficiencies in professional competence for geriatric care.

The imperative of compassion and patience. Long-term care facilities primarily serve older adults with advanced age, functional disabilities, or cognitive impairment. The gradual decline in physical function, coupled with deeply ingrained mindsets shaped by their life experiences, often results in communication difficulties. Participants emphasized that providing effective care in this context demands substantial compassion and patience.

N3: Older adults often have fixed mindsets. Coming from different generations, communicating with them can be very challenging. Before my grandfather entered long-term care facilities, he had dementia and a difficult personality. My family couldn’t manage his care at home. Caring for residents like him requires caregivers to have immense patience and compassion; otherwise, they can easily become emotionally depleted over time.

N6: Caring for residents in long-term care facilities is different from treating patients in a hospital. It involves less acute medical intervention but demands greater compassion, patience, and personal responsibility. While a hospital is a temporary treatment site, a long-term care facility becomes their final home. Witnessing their emotional struggles makes me doubt my own ability to provide adequate emotional support.

N8: During my long-term care facility practicum, I found communicating with residents quite challenging. I often had to speak very loudly and repeat myself multiple times for them to understand. This aspect of the work is difficult, and I don’t think someone without considerable patience could sustain it.

These narratives converge on a critical insight: students perceive emotional labor not merely as a professional requirement but as a finite personal resource at risk of depletion. The convergence of N3’s exhaustion fear, N6’s self-doubt, and N8’s patience demands reveals low self-efficacy for emotional sustainability as the first dimension of Theme 2, undermining their confidence in pursuing geriatric care careers.

Insufficiency of specialized geriatric knowledge. Nursing education in China primarily focuses on general medical knowledge, nursing theory, and clinical skills. However, older adults living in long-term care facilities face not only physical challenges but also psychological issues that require immediate attention upon admission.

N10: Although our university offer geriatric nursing minor, the curriculum remains largely disconnected from the actual needs of elderly residents in long term care facilities. The relatively relevant course “Geriatric Nursing” provides insufficient coverage of geriatric knowledge. The learning objective for many students, including myself, is merely to achieve a passing grade. I won’t need this knowledge if I work in a hospital or pursue graduate studies later. Unless I apply to a geriatric hospital or long-term care facility, last-minute exam cramming seems more useful than our current curriculum.

N12: After interning at a long-term care facility, I realized we don’t truly understand the residents there. Even our instructors may have limited practical experience in this setting. Despite our geriatric care education, we still don’t know how to properly care for older adults living in long-term care facilities. Most residents suffer from multiple chronic conditions. Ensuring medication adherence is a major challenge; some even hide their pills. I believe we need to supplement our studies with geriatric care psychology to understand the underlying psychological needs behind their unusual behaviors.

N10’s critique of curricular insufficiency and N12’s recognition of instructor-practice gaps expose a structural lag between classroom learning and institutional realities. This specifies the second dimension of Theme 2’s low self-efficacy: the perceived knowledge gap undermines students’ confidence that their acute-care training can address the multimorbidity and psychosocial complexity of long-term care.

Need for an inquisitive and pioneering spirit. Participants perceived professional geriatric care in China as a field still in development, requiring caregivers who are not only knowledgeable but also willing to engage in exploration and knowledge creation to address existing gaps in practice and theory.

N9: Residents may spend their entire later years in long-term care facilities, even passing away there. Yet our textbooks offer minimal guidance on death education and end-of-life care—a critical component that should be standard practice for facility staff.

N11: There are very few comprehensive books on geriatric care. I searched the library but couldn’t find systematic, in-depth knowledge. The existing knowledge we are currently learning is too limited to adequately address the care needs in elderly care facilities. The future requires not only knowledge disseminators but also knowledge creators. Care providers must cultivate intellectual curiosity to identify and solve emerging problems in geriatric practice, thereby providing higher-quality care. This represents a significant challenge for the profession.

N9’s concern about the absence of death education and N11‘s critique of the lack of systematic geriatric knowledge reveal students’ aspiration to be “knowledge creators” rather than mere “knowledge users.” This perceived absence of a pioneering spirit adds a third dimension to Theme 2‘s low self-efficacy. Beyond concerns about emotional sustainability and specialized knowledge gaps, students feel unprepared to contribute to knowledge development in this emerging field, further undermining their confidence in pursuing long-term care careers.

Theme 3: The “government-society-family” collaborative geriatric care ecosystem remains underdeveloped.

Inadequate policy safeguards for geriatric care professionals. Geriatric care is an emerging nursing specialty that has developed in response to population aging. Establishing a comprehensive support system that encompasses talent development, improved employment conditions, and structured career advancement is a protracted process. Participants highlighted that the current lack of robust, government-led policy frameworks directly impacts their career considerations, particularly regarding job stability and professional progression.

N1: From what I understand, long-term care facility positions offer low pay and unstable work with no sense of security. If the long-term care facility I work at closes down, I’d have to find a new job. At my age, it’s uncertain whether I could find suitable employment. So for high-risk long-term care facilities, I’d definitely prioritize stable hospital work.

N7: Currently, long-term care facilities with higher wages are privately run and self-financed, meaning income is unstable. Government-run public long-term care facilities have low caregiver-to-resident ratios, offering stable but very low wages with heavy workloads. Neither option is easy, and hospitals pay better.

N13: Working in a long-term care facility means a low income with no end in sight, no professional title advancement, and no promotions or raises. Other jobs at least offer room for advancement—if you work hard enough, you can earn more.

N1’s fear of facility closure, N7‘s comparison of unstable private versus low-paid public facilities, and N13’s frustration with the absence of title advancement collectively reveal students‘ rational actor orientation. They weigh job stability, income security, and promotion potential as quantifiable variables in their career decisions. These policy level deficiencies constitute material barriers, the first dimension of Theme 3‘s environmental obstacles, directly discouraging students from committing to geriatric care careers regardless of their level of interest or outcome expectations.

Persisting social stigma against geriatric care workers. Within China’s traditional social framework, caregiving labor has been historically gendered and socially constructed as “feminine” and “low-skilled” [28]. Geriatric care workers consequently face intersecting stigmas related to professional recognition, occupational identity, and social status, which impede their ability to gain deserved economic and social respect [29]. Participants expressed how this pervasive stigma personally affects their career decisions and social perceptions.

N6: I’m naturally sensitive and insecure. I worry about relatives and friends asking about my job if I become a care worker. I feel it would embarrass my parents.

N10: Nurses have low social status but decent pay. Care workers have even lower status and poor income—it’s like stacking disadvantages. Even if I wanted to be a care worker, societal pressures heavily influence career choices.

N14: Our neighbors, family, relatives, and friends are extremely competitive and love prying into private matters like income and occupation. Good news doesn’t travel far, but bad news spreads like wildfire. If I become a care worker, I’m terrified that acquaintances asking about my job will spread malicious rumors.

N6’s fear of embarrassing parents, N10’s perception of “stacking disadvantages” from low status and poor income, and N14’s terror of malicious gossip reveal how stigma operates across interpersonal, familial, and community levels. This specifies the second dimension of environmental barriers in Theme 3: symbolic barriers, operating via “face” and reputation concerns in collectivist contexts, prove no less influential than material barriers in deterring career commitment.

Insufficient family support for both supply and demand sides. China faces a severe shortage of geriatric care professionals, with most (50.5%) working 41–50 hours per week. Nearly half (48.9%) care for 10 or more residents daily, leading to immense work pressure and limited time for their own families [30]. Furthermore, some families of residents mistakenly equate paying fees with fulfilling filial piety after placing an elder in a facility. They may transfer core responsibilities of respect and care entirely onto professional staff, sometimes even imposing traditional expectations of“obedience”derived from filial piety culture.

N2: My parents don’t want me to become a care worker. It’s dirty and exhausting, but the main issue is the lack of respect. Few acknowledge the value of care workers.

N10: I’m not married yet. Who would dare marry me after I become a caregiver? Low income, low status, and no time to care for my own elderly parents or children.

N8: My parents hold quite traditional views. They believe it’s more important for women to find work that balances family responsibilities. After all, the idea that “men work outside the home while women manage the household” remains dominant. Women are still expected to find jobs that allow them to care for their families.

N2’s parental disrespect concerns, N10’s marriageability anxiety, and N8’s traditional gender role pressures demonstrate family opposition as a bidirectional force. These family-level barriers deter entry into geriatric care while reinforcing hospital preference through concerns about wages, status, and work-family balance. This specifies the third dimension of environmental barriers in Theme 3: family-level constraints on social support compound the material and symbolic barriers identified previously, completing the multi-level ecosystem that channels talent away from long-term care.