Numerous studies have explored factors affecting nursing students' PI [38–40] though few have examined the role of mediators and moderating roles [41]. In the particular case of the COVID-19 pandemic, this study was conducted to mine the internal specific mechanism of interaction among the PSS, SE, PI and anxiety of nursing students. This study revealed that the total direct effect of PSS on PI was 72.629%. Self-efficacy explains part of the effect of PSS on PI, and SE acts as an important mediator between PSS and PI. The total indirect effect is 27.372% of the total effect. There is a moderating effect of anxiety on the relationship between PSS and SE. Therefore, the findings of the study are presented below: (a) Nursing students who have a higher sense of PI are those who had more PSS; (b) Nursing students with greater PSS show greater SE and a greater sense of PI; (c) PSS positively predicts self-efficacy, which would then positively predict PI; (d) The anxiety of nursing students plays a moderating role in the relationship between PSS and SE.
The findings indicate that PSS positively correlated with the related SE (Tables 2 and 3), validating hypothesis 2. Additionally, the research has found that PSS can directly affect PI. This finding further tests the theory of social support of Lin [42]. Based on the theory of social support, Sarason, Yue, and Yong argued that PSS plays a significant role in explaining the mechanism between the positive support system of PSS and PI [43–45]. The results of this study regarding the relationship between PSS and PI are consistent with previous studies. Sabatino's research pointed out that the optimistic and positive supportive atmosphere provided by departmental teachers has an extremely important impact on the professional values of nursing students [46]. Two studies have shown that the stronger social support, the greater the nursing student's perception of PI in the educational program [47, 48]. In addition, three studies focused on nursing students during their internship period and found a predictive effect of PSS on PI [49–51]. Overall, Hypothesis 1 is validated by this study.
The research indicated that SE was positively correlated with PI, verifying hypothesis 3, which indicated that nursing students' sense of SE could improve their PI. This finding was consistent with previous studies of college students [52–56].
Self-efficacy mediates the link between PSS and PI. According to the theory of social cognitive career theory, researcher has found that there is a positive correlation between social support, SE and PI [50]. Lent et al. developed social cognitive career theory (SCCT) in 1994 [57] which was originated from Bandura's 1986 social cognitive theory [58], which was the specific application of Bandura’s self-efficacy theory in the professional field. As with this study, Wu and Min found that higher PSS can enable nursing students to better improve their SE, thereby enhancing their sense of PI [50, 59]. An important finding of the present study was that SE played a partial moderating role between PSS and PI, and hypothesis 3 was verified. Self-efficacy plays a crucial mediating role in PSS and PI, which is reinforced the fact that using SE interventions to improve SE helps to improve PI, which in turn promotes the development of professional nurses and ultimately the nursing profession.
Anxiety was identified as a moderator between PSS and SE. The correlation between PSS and SE was weaker for internship nursing students with anxiety compared to students without anxiety. According to Bandura's Four Paths, anxiety is the enemy of self-efficacy, and as anxiety levels rise, self-efficacy levels decline [60]. Moreover, previous studies have shown that students' anxiety during the Covid 19 pandemic had a negative impact on their professional identity in nursing [61–63].
4.1 Implications For Clinical Practice
The current study has found that PSS could not only directly predict PI, but also indirectly predict PI by improving SE as a mediating variable. Therefore, in the clinical internship stage, nurse educators should be aware that focusing on improving PSS may be a path to improve PI, and more importantly, it may also be the path to improve SE. The current research findings have shown that the PSS, SE and PI of nursing students were at a moderate level, which is consistent with some previous studies [48, 50, 52, 55].
The pandemic has been shown to have a positive effect on the professional identity of nursing students [1, 5]. Understanding this pandemic and integrating relevant findings into educational programs has the promise to promote PI among nursing students and increase their engagement in staying in the nursing profession [8]. As for the intervention program strategies for PSS, nurse educators should support and promote the social network of nursing students through "group learning", "one-to-one teaching", "class psychological construction" and so on, and promote the establishment of mutual trust between teachers and students [47, 49]. Additionally, Sabatino et al. pointed out that an optimistic and positive supportive atmosphere provided by a clinical instructor had a significant impact on the professional values of nursing students [46]. Therefore, healthcare institutions should promote a staff teaching model, provide educational resources for nurses serving as clinical instructors, coordinate education programs in collaboration with nursing faculty at schools of nursing.
According to Bandura's self-efficacy theory, SE is mainly affected by substitute experiences, verbal persuasion, success or failure experiences, emotional states and other factors [21], which suggests that nurse educators should focus on the above four dimensions in teaching activities to promote clinical competence in the new nursing graduate. In the context of the current COVID-19 pandemic, nurse educators could strengthen PI by inviting front-line or senior nurses to serve as role models to promote nursing students’ SE and PI [64, 65].
Given the potential negative effects of covid-19 on nursing students inducing anxiety and other harmful mental health effects [63]. It has been shown that the flipped approach can work against anxiety-provoking components and increase nursing students' self-efficacy [66]. In addition, a systematic review has illustrated the effectiveness of anxiety interventions such as guided reflection, training using the Emotional Freedom Technique and mindfulness programs [63]. Researchers could implement measures to increase nursing students' self-efficacy and counteract the negative effects of anxiety.
In conclusion, this study bridged the gap in the literature on the relationship between PSS, SE, PI and anxiety which also set a theoretical foundation for future research.
4.2 Strength And Limitations
This is the first multi-center and large sample study to determine the mediating role and moderating role in the relationship among PSS, SE, PI and anxiety for nursing students in twenty-four provinces in China, in the broader perspective of the COVID-19 pandemic. This enhances the generalizability of findings to other provinces and possibly other countries in Asia. Several limitations need to be acknowledged. Firstly, this study used a cross-sectional survey, which can’t explain causality. Secondly, self-efficacy only provides part of the mediating effect, and there may be additional potential mediating effects that have not yet been identified. Therefore, longitudinal studies will be needed in the future to explore the true causal relationship and qualitative interviews could be considered to gather other data to explore potential mediating factors. This may also lead to interventions that promote PI of nursing students during their education programs and thus professional nurses in practice settings.