Professional identity development, self-efficacy and sense of coherence in Nursing Education

doi:10.21203/rs.3.rs-3107229/v1

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Professional identity development, self-efficacy and sense of coherence in Nursing Education

https://doi.org/10.21203/rs.3.rs-3107229/v1

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Background.

For nursing students, it is important to learn how to think as a nurse and have a professional identity development. Nursing students are required a safe learning environment and reflection time to enhance their professional identity. The purpose of this study was firstly to examine nursing students’ professional identity development during education. Secondly it was to investigate the predictive value of self-efficacy and Sence of Coherence (SOC) on the professional identity of nursing students also during the education.

Methods.

A longitudinal study design was used to explore this development during education time. The relationship between sense of coherence, self-efficacy and professional identity were explored. Data were collected through self-reported questionnaires, three times. Statistical software jamovi 1.2.9 was used for the data analysis. Repeated measures ANOVA, and a multiple linear regression analysis were performed.

Result.

Professional identity development increased over time, and changes from Time 1–Time 3 were statistically significant. The only statistically significant predictor was students’ self-efficacy.

Conclusion.

To integrate self-efficacy when preparing the curriculum for nursing students, can lead to more competent nurses, and further on professional nurses with a higher level of professional identity.

Nursing Education

Nursing student

professional identity

self-efficacy

sense of coherence

longitudinal study design

To be a nursing student and a professional nurse, one must meet the field’s standards of education, which means both theoretical and practical knowledge, caring, commitment, and autonomy. Nurses also need to possess necessary knowledge and competencies, social value and knew the code of ethics of their profession (1).

This study is based on Bronfenbrenner’s developmental bioecological model (2-4). Bronfenbrenner and Morris described human development from a holistic perspective, where the analytical premise is that the individual is always in process in an environment or a context. This is about both the microsystem (individual level), mesosystem (multiple settings), exosystem (program), and macrosystem (institutional culture) level. The microsystem level includes engagements in the classroom, or clinical placements, one to one meeting with faculty members and practise supervisors as role models. The mesosystem involves engagement outside the classroom and practise areas, and the mesosystem describes the learning activities. Finely the macrosystem is about supportive and encouraging environment (5). Development takes place parallelly in several different environments affecting each other.

Furthermore Fitzgerald’s description of professional identity is applied (6). Fitzgerald argue the importance of individual practical experiences and reflection, both theoretical and practical situations. An important focus is that those experiences are in an interaction with good role models, other students, and patients (6). It is essential to integrate the factors connected to professional identity and to cope with clinical judgement abilities. Tanner (7) has carried out studies and developed a research-based model of clinical judgement in nursing, which includes the acts of noticing, interpretating, responding and reflecting. The act of noticing includes expectations and the initial grasp affected by context, background and relationship. The act of interpreting is about reasoning patterns, intuition, narrative approaches and how to analyse the situation. Responding involves indirect and direct nursing acts and outcomes. Finally, reflecting, both thinking and talking aloud of what the case is about, when students and nurses are in- action- and -after actions, are elements of this model (7-9).

Vygotsky, a psychologist and founder of sociocultural learning theory, wrote about the zone of proximal development (10). For this to happen, nursing students need supervisors who can transfer their own knowledge, establish a safe learning environment, and allow reflection. Another theorist, Benner (11), claimed that there is a gap between what students learn theoretically and what they learn in practice (11). They argued for a transformation related to using evidence, showing that it is important for “fostering professional, attentiveness, responsible and excellent students, where students learn that they have the authority based on evidence based practice, not just responsibility, to practice” (11.p.16).

Mead presented the self and the mind in terms of a social process When one acts as a nurse student during the entire education period, they interact within learning groups, both on campus and in the practise fields. On campus, they work together with teachers, supervisors and other students and discuss nursing theories. When they are in the practice field, they care for patients and have reflections together with supervisors and other students. The aim of this cooperation is to make room for reflection on where learning takes place. Reflections in a safe environment based upon both theoretical and practical experience result in learning (12).

Antonovsky’s theory of coherence in life are also used in this study. He postulates that if we experience a sense of coherence (SOC), we have a higher score for function in life (13). It is about how to respond to stressful situations, and to view life as structured, manageable, and coherent. It is about how to think, how to be and act with an inner trust. This way of orientation can lead people to identify, benefit, use and reuse the resources at their disposal. SOC consists of three elements – comprehensibility, manageability, and meaningfulness.

The way education is organised, is a factor in professional identity development. Gibbons describe the importance of support and in addition the benefits of self- efficacy for students. (14). A systematic review done by Vabo et.al. (15) about professional identity development and nursing students, defined main themes – a caring practice–academic partnership and supporting learning environment. Finely several subcategories – clinical supervisors, ethical competence, preparation, self-confidence, security and predictability, structure, cooperation and reflective space was revealed (15).

Nursing students gain knowledge and skills during the education period. This process of learning affects students’ development of professional identity (16). These elements lead to a separation from lay people to professional healthcare workers (17, 18). When nursing students experience both positive and negative situations as students, it is important with a safe environment to move forward to implement and internalise professional confidence (18). It is also important for students that teachers on campus and supervisors in clinical placements focus on their situation with a high level of authenticity (15, 19).

Another study showed how self-efficacy is a factor in the relationship between professional identity and competence to some extent (20). For students, it is important to feel the power of mastering what they are doing in their studies (21). Bandura stated,” Beliefs of personal efficacy constitute the key factor of human agency. If people believe they have no power to produce results, they will not attempt to make things happened” (21.p.3) Thus, self-efficacy is constrained by a particular task at hand (22).This self-efficacy appears to be a pervasive phenomenon, accounting for motivation and achievement in people, and it represents an optimistic sense of personal competence.

Previous studies and literature provide information about what is important for professional nursing identity. This led into a need for filling a “gap” within the literature. More information from the student perspective is warranted.

Aims of the study

The aim of this study was twofold. First to examine nursing students’ professional identity development during education. Second to investigate the predictive value of self-efficacy and SOC on the professional identity of nursing students also during the education.

In the present study, a survey-based quantitative research design was used. To meet each aim of the study a follow-up observational (years 1–3) and cross-sectional design (year 3), was employed.

Participants and procedure

Full-time bachelor nursing students from a Norwegian university were recruited as students in a cohort in 2014. During the three-year study programme, they were invited to participate in each academic year.

The students were informed that the first author would collect the delivered questionnaires at the end of the schedule. In the first data collection (T1, first study year), 148 of the possible 247 students completed the questionnaire. In the second data collection (T2, second study year). Of the 248 students present, 133 completed the questionnaire. Finally, in the last collection of data (T3, third study year), 112 of 226 students completed the questionnaire. Forty students (16.7%) completed the questionnaire every year during their education period. The response rates were 59.9% in 2014, 53.6% in 2015 and 49.5% in 2017, respectively.

The present study is performed in accordance with the Helsinki declaration, the Research Ethics Committee of the Faculty of Health and Sport Sciences at the University of Agder, and from the Norwegian Centre for Research Data; Sikt (Ref. No.39407).

Written informed consent was obtained from all participants. Moreover, the students were informed that their participation was voluntary and that they were free to withdraw at any time without giving any reasons that would not influence any result or grading during education. The first author was responsible for some educational activities, a teacher for a cohort of participants.

Instruments

Data were collected using a questionnaire composed of several scales with a focus on socialisation and coping in nursing education, together with a personal information form. In this study, data related to three of these scales were used. The professional identity scale, which had 9 items, was piloted by Adams et al. (16). The students had to answer a 5-point Likert scale, where 1 indicated totally disagree and 5 totally agree. The self-efficacy scale originally, which has been used in numerous studies (22, 23), consisted of 20 items but was reduced in 1981 to 10 items and subsequently adapted to 28 languages (24). The students had to choose a number between 1–4, where 1 indicated totally disagree and 4 exactly true.

The Sense of coherence (SOC) questionnaire (25, 26),which consisted of 13 itemswas used. The response keys (7) for all questions except no. 4, 7 and 11 were very often, often, sometimes, neither nor, seldom, very seldom and never. For no. 4, the participants could choose from (1) life with no aim to (7) transparent aims in life. No. 7 focused on daily life, from (7) a source of pleasure and satisfaction to (1) only pain and a boring life. No. 11 was about things that happen in life, with possible answers ranging from (1) overestimating or underestimating to (7) correct assessment (26).

Statistical analyses

The statistical software jamovi 2.3 (The jamovi project, 2022) was used to analyse the data. Based on the evaluation of skewness, kurtosis, mean–median differences and a visual inspection of Q–Q plots and histograms, all continuous variables except age were considered normally distributed. Thus, the mean and standard deviations were presented (apart for age, where the median and interquartile ranges were presented), and parametric inferential tests were performed for the main study analyses. Principal component analyses were performed to investigate the underlying factor structure of the included instruments. Moreover, Cronbach’s coefficient alpha was provided to assess internal consistency. Repeated measures ANOVA (with Bonferroni corrected post hoc tests) was performed when investigating the change in professional identity from year 1 to year 3. Moreover, to examine the relationship between self-efficacy, SOC and nursing professional identity at the end of education, a multiple linear regression analysis was performed with professional identity as the dependent variable.

Sample 1 consisted of 40 participants who responded to the professional identity measure at three time points. There were 6 (10%) males and 34 females. The median age was 20 years (interquartile range = 2, min = 18, max = 52).

Changes in professional identity from T1 to T3 are illustrated in Figure 1. As can be seen, there was a trend of an increase in professional identity throughout the bachelor’s programme. The repeated measures ANOVA indicated an overall increase over time (F(df) = 4.05(2), p = .022, partial eta squared = 0.109). Post-hoc comparisons revealed that the change from T1 (M [95% CI] = 4.21[4.04, 4.39]) to T3 (M [95% CI] = 4.42[4.25, 4.60]) was statistically significant (t = -2.64, p_bonferroni = .031). T2 (M [95% CI] = 4.25[4.07, 4.42]), however, was not statistically significantly different from either T1 or T3.

Fig 1.

Sample 2 consisted of 112 participants (10% males), with a median age of 22 years (interquartile range = 2, min = 20, max = 44). The descriptive and bivariate correlations of the central variables are shown in Table 1. There was a low-to-moderate positive relationship between all study variables.

Table 1. Descriptive and bivariate correlations of major study variables (sample 2)

	M(SD)	Min	Max	Scale range	2	3
1. Prof.Id	4.33(0.521)	2.78	5.00	1-5	0.347**	0.223*
2. Self-Eff	3.03(0.480)	1.00	4.00	1-4	-	0.352**
3. SoC	66.6(10.80)	35	88	13-91		-

Note. Prof.Id = professional identity (year 3); Self-Eff = student self-efficacy (year 3); SoC = sense of coherence (year 3). Values are reported as means and standard deviations, minimum and maximum, and Pearson’s product-moment correlation coefficient. * p < .05; ** p < .01.

The results from the linear regression analysis with professional identity at T3 as the outcome and students’ self-efficacy and SOC at T3 as predictors are shown in Table 2. As shown, the total model accounted for 15% of the variation in professional identity, the only statistically significant predictor being students’ self-efficacy. In other words, higher levels of self-reported self-efficacy predicted higher levels of self-reported professional identity among nursing students at the end of their bachelor’s education.

Table 2. Predicting professional identity by students’ self-efficacy and sense of coherence.

	Coeff	95% CI	t	P
Constant	2.917**^¥		7.92	< .001
Self-Eff	.277**	.072 , .483	2.68	.009
SoC	.186	-.019 , .392	1.80	.075
Model summary: F(df₁,df₂) = 7.91(2,91), p < .001, R² = .15

Note. Multivariate linear regression analysis. Dependent variable: professional identity (time 3); Self-Eff = students’ self-efficacy (time 3); SoC = sense of coherence (time 3); Coeff = standardised regression coefficient beta; 95% CI = 95% confidence interval of the standardised regression coefficient, upper and lower bound. ^¥Coefficient of the constant is unstandardised. ** p < .01.

The aim of this study was twofold – (1) to examine nursing student’s professional identity development during their period of education and (2) to examine the relationship between self-efficacy, sense of coherence and nursing professional identity at the end of the bachelor’s degree.

First, we focused on the change in professional identity from T1 to T3 (Fig. 1), which was statistically significant. There was a trend towards an increase in professional identity throughout the bachelor’s programme. The nursing education in Norway is organised with 50% theoretical and practice periods. Hence, one assumption is that the students felt that both the time on campus and in the practice, areas provided them with knowledge, values, and skills relevant to the nursing-profession. As well teachers on campus and supervisors in hospitals and municipalities may have provided them with predictable and well-prepared learning situations and environments. A connection to and identification with the nursing group throughout the education, may make them gradually more connected to the profession (16).

Bronfenbrenner and Morris’s ecological model (3) focuses on a holistic perspective. Students exist in an environment or within a context, and they develop in multiple environments that affect each other (27). They need to manage on their own, and together with other students both on campus and in the practise areas. They need to manage to be with patients, and supervisors in hospitals and municipalities. All those situations influence each other (5).

Our findings are in line with other studies that have found an increase in professional identity development during education (28). The results in this study found self-confidence to be an important factor in this development. Another two studies found that ethical competences and practice, together with nurses and nurse–patient relationships, were essential factors (27, 29).

The findings of our study confirm the results of previous research projects (30–32). To be able to handle an ever-increasing demanding field in which nurses must face their work situations, it is important to have a high level of professional identity. A systematic review done by Vabo et al., showed that a caring practice–academic partnership is about receiving support from clinical supervisors with ethical competence and with the ability to prepare for the students to arrive and be in the practice areas as students (15). If they feel met, have predictability and structure, in addition, opportunities for collaboration, the opportunities for increased professional identity will be present.

Reflection on and in situations is also a part of this caring practice–academic partnership. These previously mentioned themes should be considered when teachers on campus and supervisors in the practice areas prepare students to enter this area (15).

Blikstad-Balas et al. are focusing on the importance of meeting the students where they are and not where they are going or where they should be going (19). They emphasise the importance of the teacher having to focus on the here and now. In this context, this can be used, and much of what is said to be essential elements for the development of the professional identity of nursing students coincides with meetings with the students (19), both socially, psychologically and pedagogically.

The second aim of the present study was to identify how the factors of self-efficacy and SOC predicted the professional identity of nursing students. As can be seen in Table 2, the model accounted for a small-to-moderate amount (i.e., 15%) of the variation in professional identity. The only statistically significant predictor was students’ self-efficacy. In other words, higher levels of self-reported self-efficacy predicted higher levels of self-reported professional identity among nursing students at the end of their bachelor’s education. As a unique factor, there was no predictive value of SOC on professional identity. Honicke & Broadbent explored in a previous study, the clinical learning environment as having an indirect effect on professional identity through the mediation of career self-efficacy (33, 34).

In line with recent studies (20, 34, 35), our results confirm the abovementioned findings. From a theoretical point of view, one may argue that an education that strengthen the students’ self-efficacy may be valuable for the professional identity. Students’ self-efficacy is suggested to impact behavioural, cognitive, and motivational engagement in an educational setting (36). As individuals with strong sense of self-efficacy tend to set challenging goals, persist in the face of obstacles and are more likely to reach their goals (37) perceptions of success in the professional domain seems a likely outcome. Additionally, individuals with a strong sense of self-efficacy may be likely to have a stronger purpose in their job, which can help to maintain a professional identity. Contrary, low sense of self-efficacy may lead to avoidance of challenging tasks and a lack of confidence in their own professional pursuit, possibly leading to lower levels of professional identity.

A study done by Bulfone et al., found that students’ self-efficacy did not change significantly over the three‐year period of their education (38). Students with scientific backgrounds reported higher self‐efficacy than other students. The conclusion was that the students’ self‐efficacy did not change over time, but from a theoretical perspective, self‐efficacy can be developed using several strategies, such as a well‐organized tutorial during the clinical learning phase and feedback or encouragement. Academic staff should monitor nursing students’ self‐efficacy over time, particularly in the case of male and younger students, students with a partner and students with a humanities background during the first 2 years of the course.

If the nurses who guide students in the practice fields and the teachers on campus are aware of how all the elements mentioned in this article affect the development of the student’s professional identity, they can meet the students more consciously. They can take responsibility for planning the situation with focus om predictability and be aware of preparing an optimal situation for professional identity development.

Limitations

All empirical work should be interpreted considering its strengths and limitations. In the present study, the number of nursing students answering the questionnaire all three times was limited. Thus, replicating the present findings in a bigger sample of nursing students seems warranted. Moreover, the present study would have benefitted from investigating the relationship between self-efficacy (and sense of coherence) and professional identity over time, not solely cross-sectionally at the end of the education. Future studies would do well to build on our preliminary findings in longitudinal designs. Moreover, an in-depth investigation of the professional identity-development throughout the education would be relevant, for example through qualitative studies, which will ensure an opportunity to better understand the complexity of the development process.

This longitudinal study showed that professional identity development increased significantly during education. They need a safe practice–academic partnership, where they have possibilities both for reflection on and in action and to feel confident with the others. Nurse education institutions worldwide should be aware of this because of the importance of ensuring that students have a high level of professional identity. We did not find a unique relationship between sense of coherence, self-efficacy and professional identity development in this study.

SOC: Sence of Coherence,

Sikt: The Norwegian Agency for Shared Services in Education and Research

Ethics approval and consent to participate

This study followed the ethical principles highlighted in the 2009, Declaration of Helsinki. Approval was obtained from The Research Ethics Committee of The Faculty of Health and Sport Sciences at the University of Agder and from The Norwegian Centre for Research Data; Sikt (Ref. No.39407).

Before human data were collected through self-reported questionnaires in the study, participants received information about the study, and signed a written informed consent form. Participants were informed about the opportunity to withdraw from the study at any time.

Consent for publication:

Availability of data and materials

The dataset used, and materials are avaible from the corresponding author on request

Competing interests

The authors declare no conflicts of interest

Funding

Not relevant in this study

Author contributions

The first author, Grete Vabo, was responsible for designing the study and the writing process. The second author, Tommy Haugen, was responsible for the statistical analyzes. Both authors together wrote the results and the discussion section, in addition to prepare the manuscript, and reviewed the manuscript.

Author details

Department of Health and Nursing Science, Faculty of Health and Sport Sciences, PO box 422, NO-4604 Kristiansand, Norway.
Department of Sport Science and Physical Education, Faculty of Health and Sport Sciences, PO box 422, NO-4604 Kristiansand, Norway.

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No competing interests reported.

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Professional identity development, self-efficacy and sense of coherence in Nursing Education

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Abstract

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Background

Aims of the study

Methods

Participants and procedure

Instruments

Statistical analyses

Results

Discussion

Conclusion

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