The chain mediation effects of self-confidence and positive coping style on academic satisfaction and professional identity among Chinese medical students

Abstract

Due to the importance of medical students in the buildup of the health system and the influence of professional identity in their study, the aim of the study is to focus on the impact of academic satisfaction and professional identity on Chinese medical students during their career transformation, taking into consideration other factors that play a role in this relationship. 735 junior and senior medical university students from two training hospital were surveyed by using a cluster sampling method. The questionnaire included academic satisfaction scale, career transition psychological scale, simple coping style questionnaire and professional identity questionnaire. Pearson correlation and process plug-in model 6 were used for chain mediation analysis. The results show that in the career transition period, there is a direct relationship between academic satisfaction and career identity, and a chain intermediary relationship between academic satisfaction and self-confidence and coping style. In addition to our findings, we also assert that academic satisfaction has a direct impact on self-confidence and positive coping style in the transition period, and is a predictor of professional identity, whether directly or through the chain intermediary of self-confidence and coping style in the transition period. The results showed that academic satisfaction was sequentially associated with increased self-confidence, and then increased positive coping styles, which resulted in higher professional identity among medical students.

Introduction

With the continuous acceleration of Chinese development speed and the continuous optimization of the educational structure, many new industries and occupations have emerged. This has led to uncertainties in the career prospects of many occupations. Along with parents’ hope for their children to have stable jobs, the profession of doctor, which is never out of date, has become one of the top choices for many Chinese families when it comes to their children’s career choices.However, since the vast majority of families who choose medicine lack an understanding of the medical education system, they are unaware of the long—term training cycle, heavy academic pressure, and the difficult growth process of transforming theoretical knowledge into practical skills that medical students will face. They are not fully prepared for medical study. This has led to poor performance in medical studies as well as burnout of a significant number of students¹. According to a survey of Chinese public hospital doctors², 65.7% will choose to quit their jobs in the next year because they are dissatisfied with their current jobs, while 57.3% of them will opt for a different profession. The impact of such a situation on the Chinese health system will be unbearable. Therefore, to ensure that majority of medical students will be able to carry out their professional work in the future, it is not enough for them to complete just their studies. They will also be required to increase their level of professional identity by love their profession, identify with their work, and recognize the value of their work. They will also be the need to develop and stabilize in the future as a member of the healthcare team. It is therefore necessary to understand the level of medical students’ career identity, identify the factors that affect it, and explore on measures to improve it for the sake of the development and stability of the healthcare system’s reserve talent.

Professional identity is the personal positioning of one’s career that is formed during the process of personal experience and growth³. College period is a critical stage for the development of an individual’s professional identity. Professional identity is the core structure of career and life development⁴, and the construction of professional identity is of great significance to the successful career transition⁵. In the past, career construction was conducted by a certain organization, however, since individual’s career are no longer promoted by an organization, it gives full play to the individual’s subjective initiative⁶. Some studies have proved that individual development initiative and environment exploration related to career development can help predict their professional identity⁷. The university-to-work transition is an important link in the education of college students’ professional identity and an important development milestone in early adulthood⁸. Moreover, it is a fundamental step in the buildup of a professional identity for the graduates⁹. It is the most critical stage of all career transitions in a person’s life¹⁰, and it is the first major job adjustment that a young adult have to make in their careers. However, medical students’ professional identity is "an expression of self, which is realized in stages over time. During this period, the characteristics, values and norms of medical profession are internalized, resulting in individual thinking, behavior and feeling like a doctor"¹¹. At present, Chinese clinical medical students mostly adopt the "two-stage" training mode, that is, in the first stage, they mainly study basic theoretical knowledge in school, and in the second stage, they go to the hospital for theoretical study and clinical internship of professional courses. Junior and senior medical students are therefore in the transitional stage of their academics, and their understanding and inner feelings of clinical taking into consideration their future profession are more likely to change. At this stage, the professional identity of medical students has more research significance. Since the training of Chinese medical students has a longer duration when compared to other students, it becomes necessary to cultivate the spirit of medical students in universities to allow every medical student plays an important role in their medical profession³. In the future they will act as physicians, which will affects their relationships with colleagues, professional groups and patients¹². The degree to which professional identity affects medical students’ current attitudes and motivate can be associated with the stability and development of the health care team. Lydia de lasson¹³ believes that professional identity is very important for medical students in the transition stage of professional transformation. At the same time, some scholars strongly suggest paying attention to the cultivation of professional identity of medical personnel^14,15 to highlight the importance of professional identity. There is a correlation between the level of medical students’ professional identity and their degree; the higher the medical students’ degree, the lower the level of identity¹⁶. This implies that the situation of professional identity is not optimistic in terms of the long-term education of medical students. Since medical students will play a key role in health care in the future, it is important that they identify love their profession. The opportunity to reflect on their professional identity after their medical training is becomes difficult¹⁷. This leads to lack of professional identity when they start working in the hospital, evident by having difficulty communicating with patients and accepting the role of a physician¹⁸, developing vicious cycle eventually.

According to Erikson’s theory of psychosocial development, in the adolescent period, when an individual faces the changes of psychological and social roles, the problem of self-identity becomes particularly prominent¹⁹. In recent years, studies have indicated that the transition from adolescence to adulthood is significantly longer²⁰. The extended phase of adolescence, i.e., emerging adulthood²¹, runs from 18 to 29 years of age²², and is precisely when medical students learn, graduate, and are employed. So, their experience of graduation and employment still involves self-identity. When medical students experience career transition, their personal social roles will also change, so they can better develop themselves only if they have identified their new role.

In past studies, academic satisfaction is often studied as a dependent variable, and a direct relationship between academic satisfaction and professional identity²³ and academic satisfaction has also been shown to positively predict professional identity ²⁴. Academic satisfaction includes not only students’ cognition of the current situation of their own learning, but also the overall evaluation of whether they have received teaching experience and enjoyed teaching while in school²⁵. It reflects a student’s level of satisfaction with all aspects of his or her studies and life while in school. Academic satisfaction can also indirectly affect professional identity by influencing career transition, in which self-confidence, as one of the two core resources in career transition^26,27, shows an important role. Shrauger pointed out that self-confidence refers to a person’s feeling of his own ability or skills, and is a subjective evaluation of his ability to effectively cope with various environments²⁸. Self-confidence as a positive psychological resource is extremely important in facing the stress and challenges of job transition and in building professional identity²³. Research suggests that understanding people’s career adaptability, confidence, and readiness can enhance action by all stakeholders to address challenges associated with career transitions and may help identify needed counseling and interventions⁵. Meanwhile, good academic satisfaction promotes positive coping styles and better outcomes for students. Coping styles are the ways in which individuals cope with stress, and positive coping styles can reduce the negative effects of stress and bring about psychological well-being. Studies of undergraduate nursing students have shown that professional identity is positively correlated with problem-solving, help seeking and bring about positive coping styles, while negatively correlated with avoidance, expectation and brings negative coping styles²⁹. At the same time, career transitions require varying degrees of coping skills which in turn are influenced by individual coping styles³⁰. The coping process is central in a transition stage, making a successful transition associated with effective coping style³¹. This is why employers have always favored young doctors who can do the job independently and are self-motivated, who can easily adapt to change, bring value and create their own future³². Research has shown that positive proactivity is a good predictor of job adaption outcomes, such as professional identity and well-being. The students who take a positive coping style have better adaptability and will consume less emotional cost in their future work³², thus increasing their job involvement. From this, we hypothesized that a positive coping approach would predict higher occupational identity.

Although many literatures has already highlighted the issues presented, during our review, we found only one work that analyze the relationship between academic satisfaction and professional identity, and verify the mediating role of psychological resources.According to Mark L. Savickas’ theory of occupational adaptation, occupational adaptation is a continuous process that includes a confidence dimension in the four-dimensional dimensions of occupational adaptation, in order to explore individuals’ beliefs about their ability to successfully cope with occupational challenges, therefore, our study will attempt to explore the role of confidence and coping style in this relationship. From the previous literature, we know that a successful career transition involves several factors: such as psychological resources and specific skills. Readiness and confidence were considered the core components of psychological resources, we focused on confidence in the present study. According to the EDP perspective, we acquire some individual antecedents of the students’ satisfaction in university³³.

Then, considering that satisfaction is a significant predictor of positive outcomes in several spheres of life²³, we hypothesize that there is a direct effect between academic satisfaction and professional identity and that confidence and coping style mediate the effect of this relationship (indirect effects). Thus, we proposed the following hypothesis.

Hypothesis

Hypothesis 1: The perceived academic satisfaction will be positively related to professional identity.

Hypothesis 2: Self-confidence and coping styles will mediate the relationship between academic satisfaction and professional identity.

Methods

Participants

In this study, 735 junior and senior students from two training hospital were recruited by using a cluster sampling method, After sorting out the questionnaires and excluding the unqualified questionnaires with missing items, the final remaining valid questionnaires were 696, with a valid percentage of 94.69%. Among the participants, there were 294 males (42.4%) and 402 females (57.8%). The mean age was (21.07 ± 0.79) years old. The study was approved by the Ethics Committee of Harbin Medical University, and the survey method used complies with relevant guidelines and laws and regulations. All students provided informed consent forms.

Measures

The first section is a self-made general population questionnaire, which mainly includes the basic information of participants, such as gender, grade, nationality, type of registered residence, their wishes for college, family economic status, whether it is their own wish to study medicine, as well as their views on the current status of doctor-patient relationship and income wages in China.

The second to fifth sections were measured by academic satisfaction scale, career transition psychological scale, simple coping style questionnaire and professional identity questionnaire.

The occupational satisfaction scale uses the academic satisfaction scale (ASS) compiled by Li Hongyu and Wang Rui to measure the academic satisfaction of medical students. It consists of a 12-items scale with three dimensions. The three dimensions include: learning satisfaction (items 1, 4, 7 and 10), teaching satisfaction (items 2, 5, 8 and 11) and school hardware satisfaction (items 3, 6, 9 and 12). The Cronbach’s coefficients is 0.847.

The occupational transition psychological scale (CTPs) is the occupational transition psychological scale compiled by Han Kaicheng. The scale has 18 items and is divided into four dimensions: expected practice (items 1–5), self-confidence (items 6–10), control (items 11–14) and trust (items 15–18). The project was assessed using Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), The Cronbach’s coefficients is 0.976.

The simple coping style questionnaire (SCSQ) adopts the simple coping style questionnaire that was compiled by Xie Yaning. There are 20 items in the questionnaire, which consists of two subscales: positive coping styles (items 1 to 12) and negative coping styles (items 13 to 20). The questionnaire is a self-assessment scale. Items were assessed using the Likert scale, ranging from 0 (no use) to 3 (frequent use). The reliability coefficients of the total scale and each subscale are high. The Cronbach’s coefficients is 0.853.

The professional identity questionnaire (PIQ) adopts the professional identity questionnaire prepared by Zhang Lili. There are 38 items in the questionnaire, which are divided into six dimensions: career cognition (items 1–7), career emotion (items 8–12), career commitment (items 13–17), career behavior (items 18–25), career expectation (items 26–30) and career values (items 31–38). Items 5, 6, 15 and 35 are reverse scoring items. The project was assessed using Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The higher the score, the higher the level of professional identity. The Cronbach’s coefficients is 0.939.

Statistical analysis

SPSS software was used to analyze the data. Pearson correlation coefficient was used to verify the correlation between academic satisfaction, professional identity, self-confidence and coping style, and process plug-in model 6 was used to explore the relationship between independent variable(academic satisfaction) and dependent variable (professional identity),which may be affected by mediator variable (self-confidence) and mediator variable (coping style).

Patient and public involvement

We sent the results to the medical students by email after we got the results.And students will receive relevant credits as compensation for their participation.

Results

Common method deviation test

According to the Harman single factor test method, the statistical results show that 11 factors with eigenvalues greater than 1 were obtained without rotation. The variation explained by the first factor is 24.93%, which is less than the critical threshold of 40%. Therefore, it can be concluded that there is no common method bias in the research data.

Socio-demographic information of participants

The frequency and composition ratios of general demographic conditions are detailed in Table 1.

Table 1.

General situation analysis of medical students.

Demographic Variables	Group	N	Composition ratio (%)
Gender	Male	294	42.2
	Female	402	57.8
Grade	Junior	493	70.8
	Senior	203	29.2
Whether as a student cadre	Yes	258	37.1
	No	438	62.9
Household registration type	Rural area	227	32.6
	Town	469	67.4
Whether they are the only child	Yes	467	67.1
	No	229	32.9
Family economic conditions	Good	53	7.6
	Mid	522	75.0
	Bad	121	17.4
Is it your will to study medicine	Yes	596	85.6
	No	100	14.4

Description of the current research state on factors influencing medical students’ professional identity

Through descriptive statistical analysis, the mean total score of professional identity was (3.76 ± 0.48), and the specific scores of each dimension are shown in Table 2, where the highest score was the career emotion dimension with (3.93 ± 0.67), while the lowest score was the career perception dimension with (3.54 ± 0.47).

Table 2.

Scores for each dimension of professional identity (n = 696).

Professional recognition	Professional affection	Professional commitment	Professional behaviors	Professional expectations	Professional values	Total mean score
3.54 ± 0.47	3.93 ± 0.67	3.65 ± 0.54	3.73 ± 0.65	3.90 ± 0.67	3.87 ± 0.49	3.76 ± 0.48

Correlations between academic satisfaction, career transition psychology, coping styles, and professional identity

This study analyzed the correlations among the dimensions of professional identity, academic satisfaction, career transition psychology and coping style, and the results showed that all variables and dimensions were positively correlated with medical students’ professional identity. The details are shown in Table 3.

Table 3.

Correlations between academic satisfaction, self-confidence, positive coping styles and professional identity.

Variables	Professional identity	Academic satisfaction	Self-confidence	Positive coping styles
Professional identity	1
Academic satisfaction	0.600**	1
Self-confidence	0.172**	0.162**	1
Positive coping styles	0.423**	0.288**	0.161**	1
M	143.04	47.65	14.65	25.07
SD	18.29	6.22	5.25	5.92

Note: **p < 0.01.

Mediation analyses

In this study, academic satisfaction was set as the independent variable X, professional identity as the dependent variable Y, self-confidence of career transition psychology and positive coping styles as the mediating variables M1 and M2, respectively, to conduct the mediating effect analysis. The results showed that self-confidence and positive coping style played a chain mediating role between academic satisfaction and professional identity, and the effect path was shown in Fig. 1.

Fig. 1.

The mediating path of professional identity.

Total effect (c = 1.7661, SE = 0.0893, p < 0.001) of academic satisfaction on professional identity was found to be significant. In addition, academic satisfaction had a positive direct effect on self-confidence (B = 0.1369, SE = 0.0316, p < 0.001) and a positive direct effect on positive coping styles (B = 0.2566, SE = 0.0348, p < 0.001). The direct effect of self-confidence as the first mediating variable on the second mediating variable of positive coping styles (B = 0.1319, SE = 0.0413, p < 0.01) was also found to be significant. A review of the direct effects of mediating variables on professional identity showed that the effects of self-confidence (B = 0.1576, SE = 0.1020, p > 0.05) and positive coping styles (B = 0.8232, SE = 0.0932, p < 0.001) were significant. When academic satisfaction and the two mediating variables were simultaneously entered into the model, the direct effect of academic satisfaction on professional identity was also found to be significant (c’ = 1.5184, SE = 0.0888, p < 0.001). Overall, these results revealed that serial-multiple mediation had occurred.

The mediation effect test was further conducted using bootstrap method. The results showed that the 95% CI of the chain mediating effect of self-confidence and positive coping style did not contain 0, indicating a significant mediating effect. Academic satisfaction can directly influence the level of professional identity, and it can also affect the level of professional identity by influencing self-confidence and then positive coping styles.

As seen in Table 4, when taking into account all variables (including covariates) in the tested model, the path through single mediation of positive coping styles (effect value = 0.2113; 95% BC CI[0.1157, 0.3386]), and the path through both mediators (effect value = 0.0149; 95% BC CI [0.0042,0.0352]), were all statistically significant. However, the path through single mediation of self-confidence (effect value = 0.0216;95% BC CI [− 0.0070, − 0.0673]) was not statistically significant. The total indirect effect was also statistically significant (effect value = 0.2477; 95% BC CI [0.1496, 0.3758]). Thus, the path through both mediators was significant, moreover the indirect effect through positive coping styles was also significant, while the indirect effect through self-confidence was not significant.

Table 4.

Analysis of the mediating role of medical students’ professional identity.

Path	Effect value	SE	%	t	P	Bootstrapping 95% BC Confidence Interval (CI)
						BootLLCI	BootULCI
Effect	1.7761	0.0893		19.7818	< 0.001	1.5908	1.9414
Direct effect	1.5184	0.0888	85.49%	17.1004	< 0.001	1.3440	1.6927
Indirect effect	0.2477	0.0582	13.95%			0.1496	0.3758
X-M1-Y	0.0216	0.0185	–			-0.0070	0.0673
X-M1-M2-Y	0.0149	0.0074	0.84%			0.0042	0.0352
X-M2-Y	0.2113	0.0563	11.90%			0.1157	0.3386

M1 = self-confidence, M2 = positive coping styles.

Discussion

In this study, we investigated the relationship between academic satisfaction and professional identity of Chinese medical students. As far as we know, this study is the first to study the relationship between academic satisfaction and professional identity of Chinese medical students, while discusses self-confidence and positive coping style as intermediary variables.

The direct effect of academic satisfaction on the professional identity

Academic satisfaction has a significant positive impact on professional identity, that is, students with higher academic satisfaction are more likely to give full attention to their expertise and prefer their major, which is conducive to the development of professional identity²³; In addition, students with high academic satisfaction usually have high psychological capital, such as hope and optimism, which makes their turnover intention low³⁴; From another perspective, this seems to mean that they recognize their current job to a large extent. For medical students who are practicing in the hospitals, we can predict that even without a stable environment and effective income, those with higher academic satisfaction will have higher professional identity.

The chain-mediated role of confidence and positive coping style in the influence of academic satisfaction on professional identity

According to our research, academic satisfaction can affect professional identity through the chain mediation of self-confidence and positive coping style. This means that those students who are satisfied with their studies have a better understanding of their major, which makes these students perform better than others, and are more likely to be praised, thus enhancing their self-confidence. Confident students seldom think about what to do with failure. They will try their best to complete a task or overcome a difficulty with positive dedication and optimism. Therefore, medical students with high academic satisfaction are more likely to promote and establish good professional identity during the transition from university to society.

The mediating effect of confidence between academic satisfaction and career identity is not significant

Previous studies have shown that self-confidence can play a mediating role between academic satisfaction and professional identity. However, in this model, we found a very interesting result. Self-confidence cannot independently mediate between academic satisfaction and professional identity. Self-confidence must form a chain mediation with positive coping styles to have an impact on professional identity. This seems to be inconsistent with previous studies. This may be related to the fact that the research objects are located in Northeast China. The cultural environment in Northeast China as a whole shows a sense of self-confidence, which is due to regional culture. Therefore, self-confidence may not be a single mediating factor between academic satisfaction and professional identity. At the same time, positive coping styles help individuals better adapt to the professional environment and deal with the pressures and challenges at work, thereby promoting the formation of professional identity. In the process of career development, medical students will inevitably encounter various difficulties and setbacks. If individuals can respond in a positive way with confidence and continuously overcome difficulties, they will further strengthen their choice and identification of their profession.

The mediating role of positive coping style between academic satisfaction and professional identity

In addition, this study also found that coping style plays an intermediary role between academic satisfaction and professional identity. Coping style is an individual’s way to deal with stress. Positive coping style can reduce the negative impact of stress. There is a correlation between academic satisfaction and positive coping styles. The higher academic satisfaction, the more willing to use positive coping styles to solve problems. As for the relationship between positive coping style and professional identity, we believe that positive coping style means showing full preparation and better psychological development, which enables students to adapt to the complex working environment, quickly completing their social identity, reduce interference and pay attention to work, which will enhance their professional identity. As a previous study has found, students with positive coping styles become better when they encounter problems³⁵.

Professional identity is the key to self-directed career management based on personal values³, and it is expressed as an "internal career compass" that provides direction, mitigation factors, and helps to initiate into the social work market³⁶. It is also related to some positive career outcomes, such as job involvement, commitment and work satisfaction³⁷. Therefore, graduates who like to have a professional or positive coping style are more likely to succeed from university-to-work transition period, and successfully get a satisfactory work and achieve their potential.Future research could further explore the factors influencing vocational identity in different learning environments and life contexts.

Although the study provides a framework regarding the relationship between academic satisfaction, self-confidence, positive coping styles, and professional identity, we acknowledge that the study has certain limitations. First, the study design was cross-sectional, in which there were no clear conclusions about the direction of the causal relationship between academic satisfaction, self-confidence, positive coping styles, and professional identity, and also, they did not have a specific, career-specific occupation at the time they were surveyed, which may have had an impact on the professional identity scores. Secondly, the research population is only composed of medical students from a medical college in Heilongjiang, and cannot represent medical students nationwide. The generalizability of the research results is limited, and it can be sampled from medical colleges in multiple provinces and cities for future studies.. Finally, the questionnaires were all self-reported, and the authenticity may have been compromised.

Conclusions

Firstly, there is a positive correlation between academic satisfaction and professional identity of medical students in the period of career transformation, that is, the higher academic satisfaction, the higher professional identity. Secondly, academic satisfaction was sequentially associated with increased self-confidence, and then increased positive coping styles, which resulted in higher professional identity among medical students. The results of this study show thatmedical students better understand the impact path of their academic satisfaction on their professional identity. By enhancing self-confidence and cultivating positive coping strategies, medical students can promote the formation of their professional identity and have a clearer understanding of their future career direction. And try to guide medical students to attach importance to the cultivation of confidence and the improvement of coping strategies. When they encounter difficulties or pressure in their studies, they can consciously adjust their mentality, solve problems in a positive way, enhance their confidence, and thus improve their recognition of the medical profession, laying a good psychological foundation for becoming a qualified doctor in the future. At the same time, it provides a new perspective for undergraduate medical education, making it realize that in addition to imparting professional knowledge and skills, attention should also be paid to students’ academic satisfaction, confidence cultivation, and guidance on coping strategies.

Author contributions

Z. S writes the paper, Y.YJ writes the paper, H.D designs the plan, O.B questionnaire survey and article revision, A.N writes the paper, Z.Y data processing, X.YJ data processing, B.TY questionnaire survey, Z.JW questionnaire survey, H.XM questionnaire survey, K.SY consults materials, Q.ZX funding support and research direction confirmation, Y.YJ funding support.

Funding

This research was supported by the Natural Science Foundation of Heilongjiang Province, China (LH2021H005) to Zhengxue Qiao, National Natural Science Foundation of China (81773536) to Prof. Yanjie Yang, and the Humanities and Social Sciences Project of the Chinese Ministry of Education, (23YJC190033) to Jiarun Yang.

Data availability

Due to the inclusion of personal privacy information and policy requirements, the datasets generated and/or analysed in this study are not available to the public, but are available from the corresponding authors on request.

Declarations

Competing interests

The authors declare no competing interests.

Informed consent

The study was approved by the Ethics Committee of Harbin Medical University, and the survey method used complies with relevant guidelines and laws and regulations. All students provided informed consent forms.