A scoping review on the influencing factors and development process of professional identity among nursing students and nurses

Background Professional identity is related to individuals’ professional commitment. It has been a hot topic in the nursing science because of the common problem of nursing workforce shortage around the world. Professional identity is culturally shaped, but few scholars have systematically examined its developmental characteristics in a specific culture. The aim of the scoping review is to get comprehensive knowledge on the influencing factors and development process of the professional identity among nursing students and nurses in mainland China Methods A scoping review was conducted. The most common Chinese databases, China National Knowledge Infrastructure and Wanfang Data, were searched for publications in Chinese. The EBSCOhost and ProQuest dissertation and thesis global were searched for publications in English. After screening the title and abstract of the articles in the first round and the full-text in the second round, 53 articles were included for analysis. Results The influencing factors to professional identity development in nursing could be grouped into three dimensions: personal factors at micro dimension, familier factors and institutional factors at medium dimension, and social factors at macro dimension. The social factors tended to negatively affect professional identity while the factors at the other two dimensions exerted influence in different directions. A framework was established based on professional identity levels in different career stages of nurses to depict the continuum and dynamic nature of development process. Conclusions Development of professional identity in nursing is a dynamic process shaped by multidimensional factors. The biggest obstacles to the development lie in the social factors. Changes in policy should be made to reverse the nursing profession stereotype of being a passive role to medicine. As some obstacles and challenges faced by nursing are shared by nurses around the world, international cooperation is needed to address the


Abstract
Background Professional identity is related to individuals' professional commitment. It has been a hot topic in the nursing science because of the common problem of nursing workforce shortage around the world. Professional identity is culturally shaped, but few scholars have systematically examined its developmental characteristics in a specific culture. The aim of the scoping review is to get comprehensive knowledge on the influencing factors and development process of the professional identity among nursing students and nurses in mainland China Conclusions Development of professional identity in nursing is a dynamic process shaped by multidimensional factors. The biggest obstacles to the development lie in the social factors. Changes in policy should be made to reverse the nursing profession stereotype of being a passive role to medicine. As some obstacles and challenges faced by nursing are shared by nurses around the world, international cooperation is needed to address the 3 common obstacles and challenges. Keywords: China; development process; influencing factors; nurses; nursing students; professional identity; scoping review Background Formation of professional identity (PI) is the result of professional socialisation, a process in which the individuals learn and internalise profession related knowledge, skills, norms, and values (1,2). It is estimated that by 2030 there will be shortage of 18 million healthcare professionals, among whom 50% being the nurses (3).Nursing leaders worldwide have called for governments to pay immediate attention to the issue of retention, given the bitter fact that the current nurses are leaving their profession at a pace faster than ever (3). Studies have confirmed the correlation between PI and retention of nursing workforce. Higher levels of PI, sometimes called positive PI, are associated with higher commitment to profession (4-6). China hosts 3.8 million of registered nurses, the largest number in the world. However, compared with its huge population of 1.4 billion, China is among the countries with the lowest nurse/population ratio, with 2.74 nurses per thousand of population (7). In addition to increasing recruitment, cultivating positive PI among prospect and current nurses is essential in China to prevent turnover of nursing workforce.
There are research studies in China on the development of PI among nursing students and clinical nurses. For example, the study by Ren  This review will add cultural diversity of PI construction. It will answer two questions: 1) Which factors contribute to the construction of PI among Chinese nursing students and nurses? 2) What is the PI development process like? There are significant differences in respect to nursing education and practice in different regions of Greater China, which includes Hong Kong, Taiwan, Macau, and mainland China. Here we focus on the nursing students and nurses in mainland China, where the number of nurses largely outweighs the combined number of the nurses in the other three regions. "Mainland China" is usually simply called "China"; so these two words are used interchangeably in this article. ProQuest Dissertation and Thesis Global were searched for the literatures published outside China. There was no publication time limitation. The keywords <"professional socialization" or "professional identity" or "professional development" > combined with <"nurses" or "nursing students" or "nursing"> were used in literature search. Chinese synonyms were used to maximise the inclusion. There were 18 different combinations, resulting in 1605 articles identified. "Chinese or China"> were added to search the relevant publications in English databases and 341 articles were identified.

Stage 3: Screening the articles
After excluding the duplicates, we developed inclusion and exclusion criteria for the screening process. The inclusion criteria were: 1) studies on influencing factors of nursing PI development; 2) Studies on development process of nursing PI. The exclusion criteria were: 1) Studies only on PI of special groups, such as male nurses; 2) Studies only on nursing students of non-bachelorette degree, because bachelorette degree program is 5 becoming the most common program of nursing education in China. Associate diploma program is shrinking and the number of postgraduate program attendees is still very small; 3) Studies of poor quality. Scholars have argued that lack of quality assessment of the included studies may jeopardize the legitimacy of the review findings (11). Practically, we encountered a large number of studies identified and decided appraising the included studies as a necessary process.
We applied a two-round of screening process. The first round of screening was based on title and abstract of the included articles and the second round was based on the full-text of the articles left after the first round of screening. Three members of our research team did the screening independently. The four members of the team met again and got consensus on the final screening results.
Selection of the included articles from English databases was conducted after the screening of Chinese studies. Screening articles in English was challenging for some of the team members because of their poorer English. Given that the selecting standards had become stable after the articles from the Chinese databases had been screened, we decided to have one of the team members to do the English articles screening.
After the two rounds of screening of all articles from both Chinese databases and English databases, there were 47 articles included. A manual search was then undertaken to identify more eligible articles. Seven articles were added to the included list. Figure 1 is the flowchart of searching and screening of the relevant literatures described above.
This process involves sorting materials according to research questions. We utilized Nvivo, a qualitative research analytic software to facilitate the sorting process. We picked up the essential information from the included articles, such as type of the artilces, background of the authors, publishing time, the purpose of the study, research design, and research findings, etc.
Again this is a similar process to data analysis in qualitative research. We read through the full-text of the articles and used inductive and deductive techniques in data analysis.
There are two themes related to the research questions, "influencing factors to PI 6 development" and "development process of nursing PI".

Results
The overview of the included articles There were two literature reviews (12,13)    Familier factors affecting nursing PI development 9 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)(17)(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)(21)(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 ( ) 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)(30)(31)(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)(34)(35)(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   China to examine influencing factors in different dimensions and to measure the PI levels.
Our review has made further contribution by synthesizing the existing studies and provide a whole picture of the experiences of PI development among Chinese nursing students and nurses. The review found that, despite ups and downs of PI levels in the different stages of professional lifetime, the PI levels fluctuate around the medium levels of PI scores in different measurement tools. This indicated the overall low passion to nursing among nursing students and clinical nurses in China. A study compared the PI levels of the nursing students from Hong Kong and mainland China and found that students from Hong Kong enjoyed much higher PI levels than their mainland counterparts (38). The turnover rate among Chinese nurses is reported at 5.8% (7). Compared with 10-40% of turnover rates in other countries (39)(40)(41), China seems enjoying a relatively higher rate of retention. It is not enjoyable, however, that the higher retention is accompanied with nurses' low level of passion to nursing profession.   (46,47). Adequate knowledge about nursing will help the high school graduates to make informed decisions on joining nursing at their own will. While "reality shock" is the common phenomenon among the students of different professions when they enter the practice world from classroom (46,48), early exposure to the reality seems reasonable to reduce the shock. While clinical study consists of an important part in nursing curricula, the nursing schools in China have the clinical arrangement almost solely in the last year. Senior students may experience tremendous stress after they suddenly step into the reality, complicating their PI construction process. Chinese nursing scholars have suggested increased early exposure to clinical world for junior students (49). Decreased PI among nursing students also attributed to different teachings offered by school teachers and clinical teachers, with the former tending to teach ideal knowledge and the latter providing information on actual doings (50,51). The two groups should cooperate in teaching so as to provide nursing students coherent information.
Nurses as a whole have been marginalized in the hierarchical power system of the health 14 institutions (52,53). However, nursing managers, who represent nurses' interest, should raise their voice. They can provide evidence for need of recruitment of nursing workforce and for improvement of nurses' benefits. There have been discussions in China over equal pay in equal position, regardless of bianzhi or contract-based employment (54)(55)(56), and nursing managers should actively involve in such discussions. Older nurses have experiences in nursing care but in the heavy-burdened clinical environment their professional proficiency has been overlooked while their physical frailness is amplified.
Nursing managers, together with nursing researchers, should look for ways to make use of expertise of the older nurses as nursing is becoming more specialised. Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests The influencing factors contributing to PI development 25 Figure 3 The PI developmental levels in different stages of career life of Chinese nurses