The overview of the included articles
There were two literature reviews (12, 13) and the other 51 articles were non-experimental descriptive studies. Forty-two (80%) of the 53 articles were survey studies conducted either in nursing schools or/and in hospitals, with the number of participants ranging from 200-1983. Only seven surveys applied random sampling. Studies conducted with clinical nurses all happened in large- or middle- sized hospitals in metropolitans or the regional capital cities. Despite no publication time imposed, the articles were published from 2006-2018, with more articles published in the last four years. The overview of the articles was shown in Table 1.
Table1 Basic information of the included studies (N=53)
Categories
|
N
|
(%)
|
Study design
|
|
|
Survey
Random sampling
Convenience sampling
|
7
35
|
13.2
66.0
|
Qualitative research
Personal interview
Focus group
|
3
1
|
5.7
1.9
|
Mixed design
Survey +personal interview
Survey +literature review
Survey +case study
|
3
1
1
|
5.7
1.9
1.9
|
(general) literature review
|
2
|
3.8
|
Academic background of the first author
|
|
|
Nursing
Nursing schools (including adult students in masters or doctorate programs)
Hospitals
|
38
14
|
71.7
26.4
|
Management
|
1
|
1.9
|
Participants of the studies
|
|
|
Nursing students
|
28
|
52.8
|
Clinical nurses
Tertiary hospitals*
Other hospitals in metropolitan or capital cities
|
12
10
|
22.6
18.9
|
Mixed participants (nursing students and clinical nurses)
|
3
|
5.7
|
Publication sources
|
|
|
Academic journals
|
|
|
Nursing journals
|
29
|
54.7
|
Other journal
|
|
|
University /college journals
|
5
|
9.4
|
Other medical journals
|
6
|
11.3
|
Master’s degree thesis
|
13
|
24.5
|
Publication time ( 2006 -2018)
|
|
|
2014 and onwards
|
31
|
58.5
|
2009-2013
|
17
|
32.1
|
2008 and before
|
5
|
9.4
|
*There are different hospital rankings in China and the biggest and best are called “tertiary hospital”.
Influencing factors to PI development
All the included survey studies applied at least one instrument to explore PI related elements. We focused on the studies with the instruments specifically identifying PI levels and influencing factors based on our research questions. Researchers in the included studies applied nine PI instruments targeting nursing students and clinical nurses, among which seven were developed by the nursing scholars in China with the other two being translated and modified from the instruments outside China. Items in the PI instruments were different but generally embraced such elements as self-identity, perceived professional autonomy, perceived professional competency, feelings to profession, professional expectations, etc. The number of the dimensions with the instruments were 6-7, with the total number of items ranging from 17-44. Likert rating scale was used to measure the PI levels of the student and/or nurse participants. The higher score the participants got, the higher PI level they had.
While the individual survey studies explored only some of influencing factors to nursing PI, combination of the findings from the studies can provide a whole map. The factors can be grouped into three levels of dimensions: micro, medium and macro. The different dimensions of the factors are interplayed, exerting a combining force to shape the construction of PI (Figure 2).
Personal factors affecting nursing PI development
Personal factors were mentioned by all the included articles. The most frequently examined factors were basic information, such as age, gender, motivations to join nursing, year of stud or year of work, and type of program joining in. Gender differences in PI development were reported by those studies with mixed gender participants. Nursing was traditionally regarded as the care work carried out by females and male nursing students and male nurses had lower level of PI. Motivations to join nursing was another definite contributor to PI, with those who were fond of nursing and willingly joined the profession showing higher PI in both nursing students and clinical nurses.
One of the common findings was the declined PI levels among the students with their increased length of academic study. The fresh students had the highest level while the senior students had the lowest. This was because the fresh students held ideal image on nursing and nurses while the seniors experienced the gap between the ideals and realities. Studies with participants from different programs got the finding that the students in lower degree of programs had higher level of PI. Those students in higher degree programs tended to hold higher expectations of themselves and might experience the gap between the expectations and the reality. One positive factor to PI reported unanimously by the studies was holding a position. The nursing students who held a leader’s position or the nurses who held a management or expert position had higher PI, because holding a position would enhance the overall self-confidence of the individuals.
The studies examined marital status and age but reported mixed results. Two studies examined the influence of being the single child of the family to nursing PI (14, 15). China relaxed it’s One-Child Policy in 2015 and a large proportion of the current youths and adolescents are the singletons as the result of 35 years of implementation of the policy. The studies found that the singletons suffered lower level of PI because of the tough nature of nursing job. Nurses usually worked at busy and stressful scenarios. This working environment was the sharp contrast to the cosiness enjoyed at home by the singletons.
Familier factors affecting nursing PI development
All the included studies sent a strong message that family support was significantly associated with higher PI. Specially, the nursing students who had family members working in health care showed higher PI (16-18). There are controversial findings over whether the family economic conditions have impacts on PI of nurses The comfort in the affluent household would be contrary to the stressful working conditions of nursing, resulting in nurses’ dissatisfaction with their job, which would in turn result in lower PI among nurses from richer families (19). On the other hand, nurses from richer family were found to be more committed to nursing job because they had chosen nursing out of fondness(17). Several studies found that nightshift was an influencing factor to lower PI levels (20-22). Qualitative studies provided nurses’ own explanations that working on nightshift somehow limited their time to take care of family (20, 23).
Institutional factors affecting nursing PI development
Studies exploring the institutional factors had no consensus findings. Some studies found higher PI among those nurses with higher salaries (6, 16, 20, 24, 25). This happened among the nurses in the same health institution because salaries were not comparable among nurses in different institutions. Being awarded more than colleagues meant higher professional recognition, which could be transferred into higher self-identity. Despite the good feelings with some nurses with higher salaries, nurses as a whole were unsatisfied with reimbursement in their institutions. The nurse participants in the included qualitative studies complained of much lower salaries with nurses than other professionals in the same working unit (20, 26).
Several studies found the impacts of nature of hospitals and employment on nursing PI (6, 16, 27, 28). With the market economy expansion in China in the past forty decades, there are increased private hospitals. However, public health institutions generally enjoy more resources than private ones. The nurses in the public hospitals work on two kinds of employment: formal employment and informal employment. The former is called bianzhi (編制) while the latter is called contract-based. The employees on bianzhi enjoy higher salaries, more secure position, and more promotion opportunities. The limited number of studies revealed that the nurses in public hospitals enjoyed higher PI than those in private hospitals and that the nurses on bianzhi enjoyed higher PI than those on contract-based (22, 27).
The hospital management manner was another influencing factor to nursing PI. As it was difficult to quantify management manner this factor was implicitly embedded in the participants’ accounts in the included qualitative studies (14, 20, 26). Nurses were unhappy with the nursing management manner. There were no boundaries of responsibilities for nurses and they ended up to doing everything left by other professionals. Nurses’ voice was dumb or weak in decision making in the multidisciplinary medical or management team and they were treated unfairly if something wrong happened. It would be the nurses who were to be blamed, not the physicians, if the latter made an order mistake, because the nurses did not find out the mistake.
Social factors affecting nursing PI development
None of the included quantitative studies explicitly explored social factors. However, the accounts of the participants in the included qualitative studies clearly showed the impact of social factors, which negatively affected the nursing PI development (14, 20, 26, 29). Senior nursing students and clinical nurses mentioned that nursing was not regarded as a decent job in China. Nurses were not respected by patients and other medical professionals. When patients discharged after they were cured they would thank the physicians with no mention of nurses’ contributions. Nursing currently still subordinated to medicine and the public regarded nurses as physicians’ assistants, doing trifles under the physicians’ orders.
Development process of nursing PI
Researchers have suggested that professional socialisation is a subtle process, unnoticeable to the participants (1, 2). In-depth analysis of the included studies with participants of various stages of professional development provided clues of development process of PI in nursing.
The review found the highest level of PI among the fresh students (29-32). This indicates that conceptions on nursing and nurses prior to formal nursing education shaped the PI of those beginners. However, an interesting and common finding across the studies was the declining PI levels as the students advanced professional studying. The increased professional knowledge and skills seemed not to elevate nursing students’ confidence in proving nursing care when they learned more about the practicing complexity.
The dynamic nature of PI development was also detected with clinical nurses. Despite contradictory findings, more studies supported higher PI among the nurses in the first five years of practices (16, 22, 33-36). Newly graduated nurses might experience dramatic role changes in the first years. They had to rotate in different wards, learning specific nursing skills and routines in different wards. It is supposed that after the first one or two years of transition time, the nurses came out more confident in their professional proficiency and better adapting to the environmental complexity. Also, as the new professionals they held expectations for career development. All these would have contributed to the higher PI among the new nurses.
After nurses had worked for several years they were more familiar with the practice routines and more competent in nursing care. However, their passion to the profession begun to fade. Also, they had to balance their professional and family roles, given that, at this time, the nurses usually had to take care their children. They were likely to become burnouts under the dual burden of work and family.
Senior nurses who had worked more than 20 years might have been promoted to management or expert positions. Those who did not get promoted might feel challenging to continue frontline nursing and had to move to other positions less physically demanding. One study exclusively explored 474 nurses who had worked for 20-35 years (37). It was found that all the nurses had middle or high-level professional qualifications and 32.1% of them were in management position. None of them intended to leave nursing. At the same time they felt physically unsuitable for the frontline nightshifts and were unhappy with the same professional role as the junior nurses. Some of them had no expectations of career development and looked forward retirement.
The included studies examined the nurses’ levels of PI using different instruments with different range of scores and it is impossible to compare the PI levels of nursing students and nurses in different studies. The researchers usually compared the participants’ PI levels with the medium score. For example, in a Likert rate of 1-5, 1-2 was regarded as very low score, with 2-3 as low, 3-4 as medium and 4-5 as high. The participants’ scores generally fell on 3-4 score range. The scores fluctuated around the medium level. The dynamic nature of PI development of nurses at different stages of career life can be demonstrated in figure 3.
Figure 3: The PI developmental levels in different stages of career life of Chinese nurses