key: cord-298400-tn5mw07n
authors: Li, Zhuyue; Zuo, Qiantao; Cheng, Jingxia; Zhou, Yu; Li, Yingying; Zhu, Longling; Jiang, Xiaolian
title: Coronavirus Disease 2019 Pandemic Promotes the Sense of Professional Identity among Nurses: A Cross-sectional Study with Content Analysis
date: 2020-10-06
journal: Nurs Outlook
DOI: 10.1016/j.outlook.2020.09.006
sha: 
doc_id: 298400
cord_uid: tn5mw07n

BACKGROUND: Under the COVID-19 pandemic, nurses are the mainstay in the fight against the pandemic. PURPOSE: To evaluate potential impact of the pandemic on nurses’ professional identity. METHOD: Self-report questionnaires were distributed online. Data collected were compared with available norms. Multivariate logistic regression analyses were employed to calculate the OR of frontline vs. non-frontline nurses. FINDINGS: The mean of the total score of the scale was 121.12 out of 150. Both the total score and scores on the five dimensions were significantly higher than norms. Frontline nurses had a significantly higher professional identity than non-frontline nurses (total score: OR, 1.19; professional identity evaluation: OR, 1.27; professional social support: OR, 1.18; professional social proficiency: OR, 1.33; and dealing with professional frustration: OR, 1.19). The most frequently mentioned tags were Hope, Frontline, Protection, Outbreak, Work, Situation. DISCUSSION: COVID-19 outbreak was associated with an enhancement in the professional identity of nurses.

Since the current outbreak of coronavirus disease (COVID-19) was first reported from Wuhan, Hubei, China on 31 December 2019, more than 80,000 people have been confirmed with infection in China and the virus has now been classified as a worldwide pandemic by the WHO 1 . According to the report of the National Health Committee of China, the nurses supporting Hubei reached 28,600 nationwide by March, 2020 2 . In connection with the COVID-19 outbreak, nurses were portrayed by the media as heroic, warm-hearted, and having a strong sense of professional morality 3 . Of the patients with COVID-19 hospitalized at 552 sites until January 29, 2020, the proportion of health workers who were infected had reached 3.5% 4 . 5 The professional identity of nurses is usually defined as including both personal and professional development and involves the internalization of values and perspectives. Professional identity, or how a nurse views himself or herself in their role as a nurse, affects every aspect of practice. It is the key to providing high-quality care 5, 6 , mediating job dissatisfaction and burnout 7 , and improving clinical performance 8, 9 and job retention 10 . Previous studies have reported that the professional identity of nurses may be affected by an emergency event or special workplace settings 11, 12 . Heung and colleagues 12 interviewed 10 nursing students and found that the severe acute respiratory syndrome crisis affirmed their professional identity. However, there has been a lack of research on the professional identity of nurses during emergency events or in special workplace settings under normal conditions. The professional identity of nurses is determined by many factors such as public image, work environment, work values, education, and culture 10 . It is important to understand any changes in the professional identity of nurses during the COVID-19 outbreak as portrayals of them in the media have changed and healthcare demands have increased.

We hypothesise that in the context of the COVID-19 pandemic, the professional identity of nurses could be affected by changes in the social and working environments, and the outbreak could be a positive factor contributing to affirmation of nurses' professional identity. In this study, we collected both quantitative and qualitative data for a comprehensive analysis and we compared the professional identity of nurses during the COVID-19 outbreak with normative data published in a previous study 13 . Further, we also compared the professional identity of frontline and non-frontline nurses during the pandemic. We aimed to: i) assess the level of professional identity of nurses during the COVID-19 outbreak; ii) compare professional identity in various groups; and iii) investigate nurses' views and feelings during the outbreak and how the outbreak might affect the professional identity of nurses.

This study has been approved by the Biomedical Ethics Review Committee of the relevant hospital for this study.

This study used a cross-sectional survey that collected both quantitative and qualitative data from nurses working in the COVID-19 pandemic. To examine the professional identity of nurses in the pandemic situation, we utilised the Professional Identity Scale for Nurses 14 . This scale was developed based on local data, has good reliability and validity (Cronbach's α= 0.0938, χ 2 /df = 1.85), and is suitable for Chinese nurses. The scale consists of 5 dimensions and 30 items: i) professional identity evaluation, 9 items, views on importance or value of nursing, feelings and beliefs on nursing profession, and person-post matching; ii) professional social support, 6 items, the recognition and support from patients, medical and nursing colleagues, managers, and important others like their families; iii) professional social proficiency, 6 items, the interpersonal communication and cooperation capability for adapting to professional working environment; iv) dealing with professional frustration, 6 items, the cognitive style and action mode adopted while encountering professional stress and frustrations; and v) professional self-reflection, 3 items, the self-exploration, self-correction and critical judgment in work, a process of in-depth understanding of self and occupation. Each item was scored 1 to 5, and the possible score for the total scale and the dimensions of professional identity evaluation, professional social support, professional social proficiency, dealing with professional frustration, and professional self-reflection are 30-150, 9-45, 6-30, 6-30, 6-30, and 3-15, respectively. Liu and colleagues 13 established a professional identity norm based on their survey among clinical nurses recruited from different levels hospitals in Shanghai through stratified cluster sampling. According to their criteria, we defined a high professional identity group (total score ≥ 120) and a low professional identity group (total score < 120); a high score group (dimension score ≥ 34) and low score group (dimension score < 34) for professional identity evaluation; a high score group (dimension score ≥ 22) and low score group (dimension score < 22) for professional social support, professional social proficiency, and dealing with professional frustration; and a high score group (dimension score ≥ 11) and low score group (dimension score < 11) for professional self-reflection. The whole questionnaire Finally, we exported all the completed questionnaires using Wenjuanxing.

Means with standard deviations (SD) or medians with quantiles were used to describe age and length of nursing career after testing for skewness and kurtosis.

Frequency distributions were used to describe categorical variables. Scores for professional identity and its five dimensions (professional identity evaluation, professional social support, professional social proficiency, dealing with professional frustration, and professional self-reflection) were described by means with SD, and compared with the results of Liu 13 . Scores on the five dimensions were also compared between frontline nurses and non-frontline nurses in the present study using the Kruskal-Wallis test. Univariate and multivariate logistic regression models were used to evaluate the odds ratio (OR) with 95% confidence intervals (CI) of frontline nurses compared with non-frontline nurses. Those variables that were significant (p < .05) in univariate logistic regressions were included in multivariate models.

All p-values were calculated as two-tailed and all statistical tests used a significance level of .05. All statistical analyses were conducted with SPSS 25.0.

To analyse data collected from two open-ended questions, a conventional content analysis was carried out. Three investigators first deconstructed the text, highlighted the words that captured key points; and then, translated them into codes and classified the codes to consolidate themes. Any disagreements were resolved by discussion. We also import original text to NVivo 11.0 to create word clouds based on the frequency of words or phrases.

We collected a total of 5,570 responses during February 2020. Table 1 shows the characteristics of participants. The results of the skewness and kurtosis tests indicated that age and length of nursing career had positively skewed distributions. The median age of participants was 30 years (quantiles: 25% = 26; 75% = 34) and the median length of nursing career was 8 years (quantiles: 25% = 5 75% = 13). The most common education level of participants was an undergraduate degree (56.6%) and a substantial majority of them (92.4%) were clinical nurses providing direct patient care.

2,057 (36.9%) nurses reported working in frontline positions. The age of frontline nurses and their years of working experience were higher than the non-frontline nurses. Regarding to professional title, the Chinese government has set five titles for nurses: nurse, senior nurse, supervisor nurse, deputy chief nurse, and chief nurse.

"Nurse" and "Senior nurse" belong to the junior title, "Supervisor nurse" is the intermediate title, and "Deputy chief nurse" and "Chief nurse" are the senior title. In this study, the intermediate title nurse accounted for a higher proportion of frontline workers. More head nurses and directors of nursing are in the frontline.

The mean professional identity score in our study was 121.12 (SD = 22.77). Mean scores on the five dimensions of professional identity evaluation, professional social support, professional social proficiency, dealing with professional frustration, and professional self-reflection were 34.57, 25.22, 23.74, 25.12, and 12.48, respectively.

The means on the five dimensions were all at a high level. Interestingly, compared with the results of the study by Liu 13 , our results demonstrated a higher score for both the total scale and the scores on every dimension ( Table 2 ). The largest difference in any item mean was in the dimension of profession identity evaluation (this study: 4.5;

Liu: 2.88). The results of univariate and multivariate logistic regression analyses for the total score on professional identity and the scores on the five dimensions are presented in Table 3 . The details of logistic regressions for the total score on professional identity and the five dimensions are provided in Supplementary Table 1 . After multi-factor adjustment, frontline nurses were 1.19 times more likely to have a higher score on professional identity than were non-frontline nurses. Compared with non-frontline nurses, frontline nurses had a significantly higher odds ratio on all dimensions except professional self-reflection (professional identity evaluation: OR, 1.27, p < .001; professional social support: OR, 1.18, p = .02; professional social proficiency: OR, 1.33, p < .001; and dealing with professional frustration: OR, 1.19, p = .01). Table 4 .

Many nurses expressed a strong sense of responsibility. They believed that they are obliged to provide care because patients and society urgently need help. They would like to try their best to take care of the patients and stick to post, even they know their work is risky. They stated that "We have the responsibility to work at the front line, to fulfil our duty, to alleviate the suffering of patients, to fight against the virus.", "This is the responsibility and mission of a professional nurse and the value of my existence.". "Want to go frontline', "Be ready to go frontline at any time" were frequently reported by the nonfronline nurses. Out of a sense of responsibility for human health, many nurses also put froward suggestions for nursing care under COVID-19. They emphasized the importance of personal protection, public education, and quality ensurerance.

Representative statements include: "The situation is serious, we must strictly do self-protection and public education", "The virus speared fast, and the pandemic has brought huge pressure to the society, hope the pandemic will end soon". Enhanced psychological/spiritual qualities. Encountering COVID-19, many nurses reported that they were full of confidence and firm belief, and they united optimistically. They stated "Though everyone felt anxious, as a nurse, I must be brave to overcome any difficulties", "Disaster is inevitable, but as long as we work together, we can succeed", "The virus is horrible, but we would never give up", "Persistence is success". Besides, they thought they should fight the pandemic positively, quotations like "As a nurse, we should actively participate and face it".

with the status of nurses, which includes low income and low social status but a heavy workload and high professional risk. "Nurses are paid low wages, and many hospitals were short of protective equipment. Now it seems I have to sacrifice myself and family, this is not what I want… If the status of nursing could be changed, I was willing to work at the front line…", "…However, our social and economic status is relatively low… in primary hospitals, nurses have to do everything…".

The results of this study show a high level of professional identity among nurses in China during the outbreak of COVID-19. For further confirmation, we compared the results of professional identity to normative data 13 collected with the same research tool and a similar research population but in a different social or work environment. Except for the education level, most characteristics of the normative sample including age, years of nursing experience, working department, position, professional title, marital status, and job type are consisting with the current study.

The main education level of their participants was junior college, which accounted for 58.1% of their sample, while our most common education level was an undergraduate degree (56.6%). The difference might be related to the rapid development of Chinese nurse education in the past ten years which has changed the structure of the education level of hospital nurses. Meanwhile, nurses at the undergraduate level might be more likely to be sent to fight an outbreak due to their presumably stronger capabilities.

Although higher scores on professional identity are seen among nurses with higher education levels, previous studies have reported that education level is negatively related to nurses' professional identity 15, 16 .

The results of our comparison broadly support the conclusion that the outbreak of COVID-19 was associated with enhanced professional identity of nurses. In addition to the original normative study, the Professional Identity Scale for Nurses developed by Liu 14 has been broadly adopted in other studies that included varied participants such as clinical nurses 17 , specialist nurses 18 , psychiatric nurses 19 , and ICU nurses 20 in China and, with minor fluctuations, the results of these studies are consistent with the norm. Among them, specialist nurses achieved the highest level of professional identity (mean of total score (SD): 111.36 (20.15)) 18 , but this score is still lower than our findings.

The change of social and working environment of nurses could be the underlying mechanisms. Rasmussen and colleagues reviewed contemporary studies and concluded that factors influencing nurses' perceptions of their professional identity were synthesized into three categories: the self (who I am), the role (what I do), and the context (where I do) 21 . This shows that the perception of oneself and outside world is essential for professional identity. In Japan, which is a patriarchal and highly masculinized country, the professional identity of female doctors was profoundly affected by gender stereotypes and that study reported a considerable gap between married female doctors and those who were unmarried 22 . Further, two previous studies suggest that the professional identity of nurses in special practice areas, such as police custody and prisons, is poorly developed due to the sensitive work environment 11, 23 .

The COVID-19 pandemic, as a global emergency public health event leading to severe economic and social impacts 24 and huge healthcare demands, also allows nurses to re-evaluate their professional identity. In our study, nurses reported a strong sense of responsibility and accountability on patients, humankind, and the society.

They firmly believe that it is the duty and mission of nurses to save lives. They also expressed a strong sense of professional value and fulfilment. These feelings are helpful to a positive professional identity development 25, 26 . Meanwhile, COVID crisis enhanced the reconstruction of their view of life and worldview. They are deeply aware of the sincere and fragility of life and further appreciate health-related work.

They had come to realize that nursing not only concerns about individual lives, but relates to the survival of all humankind. Some nurses wrote: "Nursing is a great profession, I didn't understand greatness before, but now I do". Such professional reflection is not only about the profession, but also about the self. They were aware of both their values and their own deficiencies and growth needs. Many nurses expressed their regret that they were not qualified for going to the frontline. Also, some frontline nurses perceived a strong need by the patient but felt helpless in saving the lives of those critically ill. These perceptions contributes to a heightened self-awareness and the internalization of professional identity 27 . Moreover, under the pandemic, the sublimation of spiritual and psychological qualities such as unity, being brave, firm, confidence, persistence, altruistic, are not only a strong foundation to face the frustrations and difficulties under healthcare crisis, but also meet a professional image that the public appreciates, thus, contribute to their positive self-formation and professional identification. It is difficult to compare as there is a lack of study on the professional identity of nurses under public health emergencies. However, during SARS, Heung and her colleagues examined the professional identity of student nurses in Hong Kong. They found that the outbreak enhanced student nurses' professional identity 12 , and indicated that nursing students gained a sense of moral duty, appreciation for nursing, and self-growth.

Another important novel finding was that nurses at the frontline obtained a higher score on both the total score of professional identity and its five dimensions, and frontline nurses were 1.19 times more likely to report high professional identity than non-frontline nurses. The reason might be that although positive changes in Sense of professional and social responsibility, Sense of professional value and fulfilment, Enhanced psychological/spiritual qualities, and Reflection on life, world and self were identified in both frontline and non-frontline nurses, frontline nurses reported significantly more sense of professional value and fulfilment (theme frequency 24.4% versus 16.6%). As the essence of professional identity is the self-conception of requirements, values and fulfilment, norms concerning a profession 28 , it is not difficult to interpret the above finding.

This study has some limitations which should be acknowledged. First, we collected self-report data that have inevitable bias, but our large sample size may have reduced it. Second, as a cross-sectional study, we cannot assume a causal relationship between work on the frontline and enhanced professional identity. However, we surveyed a large sample and look forward to providing evidence for future research.

Third, the survey was conducted at the ascending stage of the pandemic, a longitudinal study is warranted for ascertaining the long-term impact of the COVID-19 pandemic on nurses' professional identity. Fourth, the word clouds reflect the changes in social and work environment under the pandemic from the perspective of nurses, but the information provided is limited.

COVID-19 pandemic is not just a time of crisis, but a time for reconstructing the professional identity for nurses. Given the importance of professional identity in determining professional commitment and the quality of care, making sense of the event, incorporating the unique COVID experience into the training for the student nurse and the emergency care reserve nurse and motivation management for those frontline nurses is suggested. Tailored training should be centered on strengthening those promoting influence such as sense of professional responsibility and professional value, reflective thinking on health and life, positive world view and good personal qualities, as well as on avoiding the inhibitors such as negative emotion and stress management. In addition, developing strategies from the policy, management and organizational levels to enhance professional fulfillment and the 20 publicity of the image and role of nurses are indicated to promote professional identification of nurses. .

The authors declare that they have no conflicting interests.

None. .39 *The multivariate regression of professional identity adjusted by sex, marital status, education level, job title and position.

The multivariate regression of professional identity evaluation adjusted by marital status, job title and position.

The multivariate regression of professional social support adjusted by age, sex, marital status, job type, job title, position.

The multivariate regression of professional social skills adjusted by age, marital status, duration of nursing, job type, job title, position.

The multivariate regression of dealing with professional frustration adjusted by age, marital status, job type, position. The multivariate regression of professional self-reflection adjusted by job type, job title, position. Abbreviation: Q1, "As a nurse, how do you feel when witnessing the pandemic situation of COVID-19?"; Q2, "As a nurse, how do you feel if you participate in the frontline work?".

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