Contemporary Factors Influencing Professional Identity in Acute Care Nurses: An Integrative Review

ABSTRACT

Aim

To explore the current state of the science on influencing factors of acute care nursing professional identity.

Design

Integrative review.

Methods

Data were collected and screened using Covidence systematic review software, adhering to pre‐defined inclusion criteria. The Critical Appraisal Skills Programme checklist was used for critical appraisal, and content analysis was applied to analyse the data.

Data Sources

CINAHL, PsycINFO and PubMed were utilised to search literature published between 2018 and 2023.

Results

A total of 18 articles were included. Five themes were identified: (1) internal influences; (2) external influences; (3) externalisation of role; (4) early versus seasoned career experiences and (5) barriers to professional identity formation.

Conclusion

This review found evidence of multiple influencing factors, predominantly external, shaping acute care nurse professional identity. Research on the long‐term impacts on practice, management, policy and education remains limited.

Implications

Enablers to forming professional identity foster empowerment, confidence, belonging and job satisfaction. Barriers to formation lead to hesitation, performance impediments, stress and exhaustion. Development of nurse professional identity may be instrumental in tackling acute care workforce challenges.

Impact

Review findings on professional identity formation can guide initiatives for enhancing healthy work environments and workforce retention. This exploration has international contemporary relevance for the nursing profession with suggestions for future research.

Impact Statement

Existing literature underscores the significance of professional identity in nursing, yet the mechanisms underlying its integration and maintenance in the contemporary acute care workforce remain unclear. In the context of overwhelming workloads that adversely affect nurse mental health and retention, coupled with the escalating nursing shortage as we emerge from the pandemic, this examination of professional identity formation holds contemporary relevance for the evolving acute care landscape, offering implications for future research. The insights gleaned from this review may guide organisational leaders in developing new strategies addressing acute care nurse management, policy, education and retention.

Reporting Method

Reporting adheres to the EQUATOR network, ENTREQ guidelines.

Patient or Public Contribution

None.

Summary.

• What does this paper contribute to the wider global community?

  • ○
    Provides robust, synthesised evidence on professional identity, from a newly conceptualised definition in 2018.
  • ○
    Highlights the pandemic's influence on professional identity, emphasising its relevance to post‐pandemic nursing research.
  • ○
    Examines key influencing factors, offering insights for improving work environments and retention strategies.
• What is already known:

  • ○
    The global nursing shortage is projected to balloon to 13 million by 2030.
  • ○
    Nursing professional development and the exploration of new retention strategies must be a global priority.
  • ○
    In 2018, the concept of professional identity in nursing (PIN), which had traditionally lagged behind other fields, was redefined to highlight key professional guiding principles.
• What this paper adds:

  • ○
    18 sources published between 2018 to 2023 capture pandemic years and identify key influences of acute care professional identity.
  • ○
    The literature underscores how influences assist navigation of high‐pressure, acute care environments.
  • ○
    Findings predominantly emphasize external influences of professional identity.
• Implications for practice/policy:

  • ○
    Despite the significance of one's internal professional development, the acute care environment may be a primary driver of identity development.
  • ○
    This review holds contemporary relevance for the evolving acute care landscape.
  • ○
    Addressing themes and subthemes reported in this review can guide development of key acute care management, practice, and policy strategies for enhanced nursing retention.

1. Introduction

Nurses in healthcare systems continue to grapple with critical patient safety issues owing to workforce shortages. Following the COVID‐19 pandemic, over 100,000 nurses in the United States resigned, with more expected to leave the profession by 2027 due to stress, burnout or retirement (McKinsey and Company ²⁰²³). Despite attempts to attract and retain nurses, the national vacancy rate hovers near 10%, with over half of hospitals reporting in excess of this number (NSI ²⁰²⁴). In certain American work settings, turnover rates have surged from 101% to 119% over the past 5 years (Hooper 2023; National Council of State Boards of Nursing (NCSBN) ²⁰²³; NSI ²⁰²⁴). This alarming trend calls for concerted efforts to address the persistent shortage of nursing professionals.

Nurse turnover significantly disrupts health systems, healthy work environments and access to care, with numerous patient quality care gaps and adverse events attributed to the shortage (McCauley et al. ²⁰²³; Salvage et al. ²⁰¹⁹; Woodward and Willgerodt ²⁰²²). Approximately 58% of registered nurses in the United States are employed in acute care, where turnover rates and intent to leave are consistently higher compared to other nursing specialties (NCSBN ²⁰²³). Depending upon multiple factors such as geographic location, training duration, and specialty preparation, acute care turnover costs range between $10,000 and $88,000 per nurse, with annual losses between $3.6 million and $10.5 million within a single healthcare organisation (Alshawush et al. 2022; NSI ²⁰²³; Plescia ²⁰²¹). Moreover, the exodus of mid‐career nurses has led to a significant demographic shift, with leadership positions now occupied by professionals with less than 10 years of experience (McKinsey and Company ²⁰²³). This transformation has reduced the availability of bedside mentorship for a predominantly younger nursing workforce (McKinsey and Company ²⁰²³; NCSBN ²⁰²³). Consequently, the escalating levels of stress and fatigue are a contributing factor to increased rates of attrition among early‐career nurses. The turnover crisis extends worldwide, threatening the health and well‐being of all age groups and socioeconomic backgrounds. The global nursing shortage is projected to balloon to 13 million by 2030, which is almost 50% of the current 28 million nurses in practice (Buchan et al. 2022).

With a pressing need to replenish and retain nurses, the International Council of Nurses and the World Health Organisation declared that nursing professional development and the exploration of new retention strategies must be a global priority (Buchan et al. 2022; Howard ²⁰¹⁹; Salvage et al. ²⁰¹⁹). One promising approach to resetting the workforce trajectory is through the efforts of the International Society for Professional Identity in Nursing (ISPIN ²⁰¹⁹). The society's work focuses on organically strengthening nurse identity for long‐term career commitment and satisfaction.

Professional identity is a phenomenon that has been explored in sociology for decades, laying clear definitions and standards that guide various disciplines, such as medicine, pharmacy and physical therapy (Carr et al. 2019; Cruess et al. ²⁰¹⁴; Janke et al. ²⁰²¹; Jarvis‐Selinger et al. ²⁰¹²). Long recognised as fundamental to becoming a physician, core underpinnings for medical professional identity formation lie within individual, interactional and institutional aspects (Monrouxe 2010; Mount et al. ²⁰²²; Toubassi et al. ²⁰²³). A robust professional identity is linked to achievements within the work environment. Mount et al. (2022) describe strengthening medical professional identity through individualistic approaches, including seeking positive role models and using self‐reflection, or broader social‐contextual approaches such as implementing interprofessional team learning or patient partner programs. Allied health professional research emphasises that those possessing a strong sense of professional identity have a firmer understanding of the significance of social cohesion and teamwork needed for team success (Porter and Wilton 2020). Structurally, organisations with effective leadership who clearly communicate departmental and organisational objectives establish a foundation for fostering a sense of belonging, role fulfilment and enhancing retention, thereby facilitating a more robust sense of professional identity (Chandran et al. 2019; Sabanciogullari and Dogan ²⁰¹⁵; Shun ²⁰²¹).

Prior to the establishment of ISPIN in 2018, the term professional identity in nursing (PIN) was inconsistently defined in nursing literature. The objective of ISPIN was to clarify the concept, standardise the term, alleviate role confusion, and foster a sense of unity within the nursing community. ISPIN convened nursing scholars for concept analyses and think tanks, defining PIN as a “sense of oneself, and in relationship to others, that is influenced by the characteristics, norms, and values of the nursing discipline, resulting in the individual thinking, acting and feeling like a nurse” (Godfrey 2020). PIN encompasses four domains: values and ethics, knowledge, nurse as leader and professional comportment (Godfrey 2022). The values and ethics domain embraces a set of core beliefs that guide nursing conduct. This includes integrity, ethical awareness and actions, caring and empathy (Godfrey 2022). The knowledge domain includes evidence evaluation and recognising patterns and cues to inform care decisions (Godfrey 2022). The nurse as a leader is an umbrella concept for patient, self and peer advocacy, as well as a commitment to excellence and trustworthiness (Godfrey 2022). The concept of professional comportment refers to communication skills and demeanour, including respect for oneself and others, patient‐centred care and team engagement (Godfrey 2022).

The body of research on PIN is growing worldwide. Studies on PIN have demonstrated its crucial role in professional satisfaction, increased accountability, and providing high‐quality, safe patient care (Phillips and Priddy 2023; Rasmussen et al. ²⁰¹⁸; Sabanciogullari and Dogan ²⁰¹⁵). Hanum et al. (2023) found that a stronger sense of professional identity can lead to enhanced role congruence and improved abilities to solve complex patient and professional challenges. While this study was the first of its kind and should be interpreted accordingly, its findings reiterate the encouraging associations between PIN and job satisfaction observed in previous research, particularly under highly stressful conditions. Additionally, nurses who possess a strong sense of professional identity are also more likely to be empowered to initiate change (Johnson et al. 2012; Landis et al. ²⁰²⁰; Landis ²⁰²³), engage in shared decision‐making to drive high‐quality care, and enhance their well‐being (Phillips and Priddy 2023). Consequently, those who are empowered to effectively advocate for their patients and the nursing profession can steadily influence health policy, leading to improved healthcare systems and patient care standards worldwide (Phillips and Priddy 2023).

Considerable attention has been directed toward early PIN formation in academic nursing settings and pre‐licensure curricula. This concept is emphasised in United States professional nursing education throughout Domain 9 in the New AACN Essentials (American Association of Colleges of Nursing [AACN] ^{2021a, 2021b}). Correspondingly, the National Student Nurses' Association incorporates professional identity into its core values and mentoring practices to communicate standards, ethics, and practice to students (National Student Nurses' Association [NSNA] ²⁰²⁴). Early professional identity knowledge among nursing students assists with integration of reflection and integrity while strengthening competency throughout all stages of campus and clinical practice (Vabo et al. 2022).

Existing literature highlights the importance of PIN; however, the mechanisms underlying its integration and maintenance in the modern clinical workforce remain unclear. Research conducted before 2018 primarily utilised qualitative evidence, necessitating a thorough examination of literature to identify empirical studies undertaken since that time. Moreover, limited research and synthesised information capture the phenomenon of PIN within the context of the recent pandemic and acute care settings. These settings encompass hospital emergency departments, intensive care units, acute medical and surgical wards, immediate pre‐hospital settings, and long‐term care hospitals. Nurses, particularly those at the start of their careers, are predominantly employed in acute care settings (Smiley et al. 2023) that can facilitate the growth of PIN through learning in dynamic, specialised environments with experienced teams. However, the COVID‐19 pandemic significantly disrupted the already tenuous state of acute care nursing around the globe (Buchan et al. 2022; Smiley et al. ²⁰²³). Overwhelming workloads, rapidly changing role expectations and social distancing measures left acute care nurses little to no time for critical reflection, professional development or relationship building. Consequently, the psychological strain hindered both novice and experienced nurses from fully comprehending their professional identity (Broering et al. 2023). Considering the potential long‐term effects of this historical period on nursing amid a ballooning workforce crisis, it is crucial to advance our understanding of PIN in this essential demographic.

2. The Review

2.1. Aim

The aim of this integrative review is to examine the state of the science regarding what is known about nursing professional identity to identify and characterise the contemporary factors influencing the professional identity of registered clinical nurses situated in direct‐facing, acute care settings. The question guiding this integrative review was: “What does the existing literature from 2018 to 2023 reveal about the influencing factors contributing to the professional identity of acute care nurses?” By synthesising the recent literature from the inception of the newly conceptualised PIN definition, this review strives to strengthen our understanding of the phenomenon and offer new insights for this workforce.

2.2. Methodology

2.2.1. Design

Whittemore and Knafl's (2005) integrative review methodology was used to provide a wide understanding of professional identity in acute care nursing by identifying and synthesising a variety of studies. Integrative reviews seek to capture contextual elements and nuances by combining diverse scientific work that can be summarised and incorporated into best nursing practices (Whittemore and Knafl 2005). The integrative review process comprises five stages: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis and (5) presentation of findings (Whittemore and Knafl 2005). Having established the context and need for the review, the focus will shift to stage two of the integrative review process, the literature search.

2.2.2. Search Methods

A literature search was conducted across Cumulative Index to Nursing and Allied Health, PubMed and PsycINFO electronic databases. The basis for this search strategy includes the reconceptualization of PIN in 2018 and the onset of the 2020 pandemic. Thus, the search years were limited to studies performed and literature published between 2018 and 2023.

Main search terms include nurs*, professional identity and acute care. Additional terms and hierarchy tree derivatives include professional identity domains of knowledge, values, ethics, leader and professional comportment.

2.2.3. Inclusion and Exclusion Criteria

The search placed no limits on work experience, age, gender, ethnicity or country of origin. Exclusion criteria contain sources that were not peer‐reviewed research, nursing disciplines outside of acute care, advanced practice nursing roles, nurse leadership, nurse educators in academic settings or healthcare systems, nursing students and non‐English texts. Table S1 presents the full search strategy.

2.2.4. Search Outcome

The Covidence systematic review software was used to organise and screen the studies for this review. A PRISMA flow diagram in Table S2 identifies literature with screening and retrieval processes. One researcher identified 467 sources for screening and, after duplicate removal, screened all titles and abstracts for relevance to this integrative review's purpose (n = 384), leaving eligible sources for full‐text screening (n = 125). With subsequent evaluation of the full texts, 18 studies were selected and agreed upon by two researchers based on their congruence with the aim of this review.

Notably, one retrieved article (Wu et al. 2023) included four interrelated quantitative studies. Each study is described separately within the article, as they were performed at different time points with different participants. However, studies two through four implement follow‐up measures that aimed to answer questions resulting from the first study. Covidence retrieved this source as one article; thus, data extraction was kept under one retrieved article to maintain PRISMA diagram congruence.

2.2.5. Quality Appraisal

Stage three of Whittemore and Knafl's method, data evaluation, began with a high‐level appraisal summary, followed by a detailed critical appraisal of all included studies utilising the tools provided by the Critical Appraisal Skills Programme (CASP) Checklist (Critical Appraisal Skills Programme, ^{2018b, 2018c}). CASP supports reviewers with a systematic process to enhance consistency with quality appraisal decisions (Critical Appraisal Skills Programme ^2018a). Each section of the relevant checklist prompted two researchers to consider the strengths and issues in a structured manner.

Table S3 provides a high‐level appraisal summary of the reviewed literature, which comprises both quantitative (n = 7, 39%) and qualitative (n = 11, 61%) studies. The studies representing quantitative data from China (n = 6) and Italy (n = 1) recruited participants from China, Italy, the United Kingdom and the United States. Qualitative methods in this review originated from Australia (n = 1), Canada (n = 1), China (n = 1), Iran (n = 1), Italy (n = 1), New Zealand (n = 1), Norway (n = 1), Spain (n = 1) and the United States (n = 3). All study participants ranged from 21 to 64 years old and had between zero and over 30 years of nursing experience. Participants represented various acute care settings such as inpatient medical and surgical wards, adult and paediatric critical care units, and emergency services.

All quantitative studies had sample sizes greater than 100 participants, and all studies except one (Hu et al. 2023) employed surveys. Quantitative studies are Level III or IV evidence, as designated by LoBiondo‐Wood and Haber (2018). These included quasi‐experimental (n = 1), observational correlation (n = 1), longitudinal four‐wave crossed‐lagged panel (n = 1) and cross‐sectional, non‐experimental (n = 3) analyses. The four interrelated studies by Wu et al. (2023) included a 10‐wave prospective longitudinal study (n = 1), pre‐registered control group pre‐test/post‐test (n = 1), and quasi‐experimental pre‐ and post‐tests (n = 2). Among the quantitative sources, three studies (Dellafiore et al. 2021; Liu et al. ²⁰²⁰; Zhu et al. ²⁰²²) were conducted prior to the COVID‐19 outbreak, one study (Zhang et al. 2023) was COVID‐19 related, and four studies (Dellafiore et al. 2021; Hu et al. ²⁰²³; Su et al. ²⁰²³; Wu et al. ²⁰²³) were performed in a post‐COVID‐19 context. Table 1 presents the characteristics of the quantitative study.

TABLE 1.

Quantitative studies.

Author, year	Aim	Level of evidence/methods	Measures	Sample	Factors, evidence themes	Results/other key findings	Implications	LIMITATIONS
Dellafiore et al. (2021)	Identify relationship between nurse professional values and self‐efficacy, influence on PI	Level IV Observational correlational Survey—convenience sample	Measures Nursing professional values Self‐efficacy Instruments Italian Nursing Professional Values Scale‐3 (I‐NPVS‐3) Nursing Professional Self‐Efficacy Scale (NPSES)	N = 532 Ages 22–65 year (M = 42) Experience M = 15 year	Factors Caring (main element) Activism Responsibility Loyalty Ethical, quality care Caring Situations Professional Situations Themes External influences Externalisation of role	There was a significant positive correlation between caring and activism on PI and self‐efficacy (p < 0.001) Higher perception of RN values is related to higher self‐efficacy Age, experience related to higher self‐efficacy of caring, PI	Targeted interventions could increase NPV and SE, enhancing nursing actions Further studies should be done on org. value of elements, administrative and policy Investigation into how these elements affect RN‐patient relationships, pt. satisfaction needed	Self‐reporting bias Analytics issues Reporting issues Unable to generalise findings
Hu et al. (2023)	To investigate the effect of a transition program and cognitive‐behaviour‐based preceptorship intervention on ICU NGRN PI and intent to stay.	Level IV Quasi‐exp; pretest/ post‐test/ follow‐up TI: baseline T2: 1 month T3: 6 month Intervention: 4 90‐min trainings, 1 × week. conducted by RN psychology experts	Measures PI Intent to stay Instruments Chinese version of Professional Identity Scale for Nurses Adapted Intention to Quit Scale Job Search Behaviour Scale	N = 112 NGRNs n = 53 Preceptors n = 59 NGRNs Ages 21–24 year (M = 22.11) Experience 0–6 month Preceptors Ages 24–35 year (M = 29.75) Experience: M = 7.21 year	Factors Self‐reflection techniques Recognising role value Positive role models Professional social support Recognition by others Themes Internal influences External influences Early career vs. seasoned nurses	Statistical sig btwn time, PI, professional social support, self‐reflection and dealing with professional frustration Total scores (p = 0.004) PI (p = 0.026) Social support (p = 0.017) Dealing with professional frustration: (p < 0.001) Self‐reflection: (p < 0.001) No changes observed in social skill score (p = 0.142)	Increased PI failed to maintain after 6 months, suggesting continued support may enhance or maintain factors Further longitudinal research should study expectations and attitudes of NGRNs and preceptors	Self‐selection bias Self‐reporting bias Reporting issues Unable to generalise findings
Liu et al. (2020)	Examine reciprocal relationships of emotional labor strategies with emotional exhaustion and PI of NGRNs	Level IV Longitudinal Survey Four‐wave cross‐lagged panel, two consecutive time points: T1/T2/T3 Time interval 1 month	Measures/Instruments (translated to Chinese) Deep acting Emotional exhaustion PI Surface acting	N = 171 Ages M = 22.7 year Experience < 12 month	Factors Strong fostering of PI motivates further identity development Themes Internal influences Externalisation of role Early career vs. seasoned nurses	Surface acting, deep acting had no impact on nurse PI, but more developed PI motivates NGRNs to employ deep acting strategies over surface acting strategies T1 PI positively predicted T2 deep acting strategies (β = 0.19, p < 0.01)	Deep acting can alleviate emotional exhaustion RNs w > PI more likely to regulate emotions to decrease emotional exhaustion Orgs may utilise PI measurements for recruiting, workshops, training, development to promote concept	Reporting issues Common method bias PI scale not specific to nursing context Sampling incongruencies
Su et al. (2023)	Explore mediating role of clinical teaching behaviour in the relationship between transition shock and career/PI in NGRNs	Level IV Cross‐Sectional Survey Multi‐stage Purposive Sampling	Measures Transition Shock Career Identity Clinical Teaching Instruments (Chinese versions) Clinical Teaching Behaviour Inventory (CTBI‐23) Transition Shock of NGRNs Scale (TSNGNS) Nurses Career Identity Scale (NCIS)	N = 1684 Ages (in %) < 25: 36 25–30: 61.1 > 30: 2.9 Experience ≤ 12 month: 38.8% 12 month to 2 year: 24.9% 2–3 year: 36.4%	Factors Preceptor caring/support Clinical teaching behaviours Level of transition shock Themes External influences Early career vs. seasoned nurses	Clinical teaching behaviours: Positively related to career/PI: (β = 0.52, p < 0.01) Transition shock: Indirect negative effect on career/PI mediated by clinical teaching behaviour: (β = 0.05, p = 0.01) Effective clinical teaching behaviour contributes to PI attributes ➔ increased adaptability rates	Clinical teaching behaviours partially mediates the effects of PI, transition shock Effective clinical teaching behaviours enhance sense of consistency, competence, sense of value Teaching strategies, feedback, assessments of role socialisation can improve career/PI	Self‐report bias Sample differences Limited generalisation of findings
Wu et al. (2023)	Study 1: Whether professional‐spotlighting events influence NGRN PI development Study 2: Whether work meaning‐fulness mediates PI Study 3A/3B: Study 1 replication, testing hypotheses Study 4: Assess the influence of moral elevation during professional spotlighting events and influence on PI	1: Level IV 2: Level IV 3A: Level IV 3B: Level IV Study 1: 10‐wave Prospective Longitudinal Survey –monthly intervals: T1—T5 prior to COVID outbreak T6—T10 after COVID outbreak Study 2: Pre‐registered Control Group Pre‐test/Post‐test Survey Random selection Studies 3A and 3B: Quasi‐experimental Pre‐test/Post‐test Survey	Study 1: Measurements (Chinese version) Professional Identity Study 2: Measurements: (Chinese versions) Professional Identity Work Meaningfulness Studies 3A/3B: Quasi‐experimental Pre‐test/post‐test Measurements No additional	Study 1: N = 322 Ages M = 21.8 year Experience Newly hired—Start: 0 month End 10 month Study 2: n = 241 Ages M = 35.81 year Experience < 2 year M = 7.69 month Study 3A: n = 90 Ages M = 28.91 year Experience < 2 year M = 12.6 month Study 3B: n = 131 Ages M = 29.83 year Experience < 2 year M = 12.1 month	Factors Study 1: Spotlighting event Study 2: Internalising meaning of work Study 3A: High sense giving Study 3B: Moral elevation during a profession‐spotlighting event Themes Internal influences External influences Externalisation of role Early career vs. seasoned nurses	Study 1: PI fell gradually before COVID, increased dramatically after outbreak: PRE: (β = −0.04, p < 0.001) COVID: (β = 0.19, p < 0.001) Sense giving sig related to PI: (p < 0.001) PI fell after initial increase Study 2: Strongest mediator of PI = work meaningfulness (Mpretest = 4.24, Mposttest = 4.52, F (1, 219) = 11.08, p = 0.001) Study 3A: High sense giving increases PI: (Mpretest = 4.25, Mposttest = 4.55, F (1, 88) = 11.33, p = 0.001) Study 3B: High moral elevation increases PI: (Mpretest = 4.48, Mposttest = 4.87, F (1, 129) = 14.78, p < 0.001)	Profession‐spotlighting events led to increases in NGRN PI can affect frontline workers in essential professions Sense giving and moral elevation lead to an increase in NGRN PI Further research is needed on relationship between PI and work meaningfulness Sense giving is essential to foster employees' PI during critical events and should be well managed by leadership	Sample differences Self‐reporting bias Omission of certain variables information Study 1 cannot discern causality (Studies 2—3B designed to address) COVID “spotlighting” event may be different than other positive professional spotlighting events No consideration of COVID as a “negative” professional spotlighting event
Zhang et al. (2023)	To determine the associated factors of PI among ICU nurses during the COVID‐19 pandemic in China.	Level IV Cross‐sectional Survey Convenience Sampling	Measures Doctor recognition level Perceived professional benefits Professional Identity Instruments (Chinese version) Perceived Professional Benefits Professional Identity Scale for Nurses	N = 348 Ages (%) < 25: 17.24 25–34: 63.79 ≥ 35: 18.97 (M = 29.71 year) Experience ≤ 5year: 45.4% 6–10: 28.74% ≥ 11: 25.86%	Factors Perceived benefits (growth, honour, financial reward, social image) Provider recognition Family support Themes Internal influences Early career vs. seasoned nurses	PI score M = 102.38 Low: 23% Mod: 65.8% High: 11.2% Perceived benefits: strongest predictor of PI (p < 0.001) Doctor recognition level (p < 0.001) Family support (p < 0.001) Provider recognition directly or indirectly affects PI Family support = direct effect on perceived benefits, indirect effect on PI	Policy makers and nurse leaders should create targeted interventions to better facilitate PI development	Sample bias Self‐reporting bias Subjectivity/personal response to COVID phenomenon Limited generalise‐ability
Zhu et al. (2022)	To explore and compare stress, coping, PI and work locus of control in NGRNs	Level IV Cross‐sectional survey Shanghai: Cluster random sampling Hong Kong: Convenience sampling Taipei: Purposive Sample	Measurements/Instruments Occupational Stress Scale for NGRNs Chinese Trait Coping Style Questionnaire PI Work Locus of Control Scale	N = 591 Shanghai: n = 430 Hong Kong: n = 107 Taipei: n = 54 Ages Not reported Experience < 12 month	Factors Support Resources Leadership presence Surrounding environment Themes External influences Early career vs. seasoned nurses	PI, work locus of control related to degree type, teaching style on unit, transition program, NGRN mgmt of stress training: Degree type: p < 0.0360 Teaching style: p < 0.001 Training: p = 0.0013	Proper leadership, mentoring, emotional and stress mgmt during transition programs is suggested	Sampling bias, Self‐reporting bias Study location differences Sample differences

Abbreviations: NGRN = New Graduate Registered Nurse; PI = Professional Identity.

Qualitative studies used sample sizes ranging from 5 to 9 participants (n = 2), 11 to 15 participants (n = 4) and 16 to 31 participants (n = 5). Qualitative studies are Level VI evidence (LoBiondo‐Wood and Haber ²⁰¹⁸). Phenomenology (n = 6), integrated ethnographic case context (n = 1), qualitative descriptive (n = 3) and evidence‐based quality improvement project (n = 1) methods were employed. Of the qualitative sources, seven studies (Dames 2019; Heldal et al. ²⁰¹⁹; Hunter and Cook ²⁰¹⁸; Karanikola et al. ²⁰¹⁸; Mousazadeh et al. ²⁰¹⁹; Ni et al. ²⁰²²; Willetts and Garvey ²⁰²⁰) were conducted prior to the pandemic, one study (Watson 2023) is COVID‐19 related, and three studies (Hoppe and Clukey 2021; Landis et al. ²⁰²⁰; Mateo‐Martínez et al. ²⁰²¹) were not COVID‐19 specific studies but were published during the height of the pandemic. Table 2 captures qualitative study characteristics.

TABLE 2.

Qualitative studies.

Authors, year	Aim	Methods	Sample	Factors, evidence themes	Results/other key findings	Implications	Limitations
Dames (2019)	Impact of interplay between workplace and developmental factors that enable and disable thriving within the 1st year of practice	Reported as Basic qualitative	N = 8 Ages 25–37 year (M = 28.75) Experience 9–12 mo.	Factors Stable environment with “home unit” Schedule and promotion of rest Mentorship Self‐compassion Themes Internal influences External influences Early career vs. seasoned nurses	Participants with trusted mentors felt more congruent in role Self‐compassion allowed mgmt of feelings, improving ability to stay engaged in work and progress	NGRNs who lack developmental assets may need more leadership and org support Self‐compassion should be emphasised in organisations	Self‐selection bias Self‐reporting bias
Heldal et al. (2019)	To study how implementing a national patient safety program affects nursing PI	EBQI Project Purposive Sampling Interviews, focus groups, observations over 4 months	N = 13 (RN managers not included in extraction, n = 3) Ages Not reported Experience Not reported	Factors Transparency System safeguards Workload visibility Interdisciplinary support and recognition Increases in visibility of patient safety Themes External influences	Increased visibility had a motivational effect overall Traditional PI emphasis on “care” is challenged ➔ “high quality” focused on measurable, standardised, system‐based emphasis of “cure”	Suggestive of trusting the system over trusting the professionals Future research should examine org changes and effects on PI, how it relates to RN‐patient relationships	Sample size Self‐reporting bias Study implemented after EBQI in place
Hoppe and Clukey (2021)	To explore lived experiences of NGRNs within critical access hospitals (CAH)	Descriptive Phenomenological Purposive Sampling	N = 13 Ages 22–49 year (M = 30.7) Experience 2–10 month (M = 7.5 month)	Factors Constant professional behaviour in/out of work Personal connections Accountability Community perspectives Lifelong learning Debriefing Belonging/valued Cross‐training Themes Internal influences External influences Externalisation of role Early career vs. seasoned nurses	Each participant felt valued/belonging Variety/cross‐training facilitates autonomy around 6 months CAH > team support, connection, satisfaction	Suggestive of CAH nurse progression through transition stages and identity development more quickly	Self‐selection bias Self‐reporting bias Sample bias Limited transferability of findings
Hunter and Cook (2018)	Explore NGRN's experiences of socialisation into profession from intentional or unintentional role modelling	Descriptive Phenomenological Purposive/Network Sampling	N = 5 Ages 21–24 year (M = not reported) Experience < 6 month	Factors Positive role models (biggest factor) Continued learning/dev Patient‐centred Frequent, constructive feedback Exposure to nuances Themes Internal influences External influences Externalisation of role Early career vs. seasoned nurses	NGRNs recognised own attributes of PI at 6 months mark “Fitting in” may be prioritised over own ideals Personality differences are non‐modifiable factors in team processes, which may affect PI NGRNs can navigate ethical sensitivities with internal moral compass, contributing to PI	Proactive learning style is key during transition stage—education should be offered on processes Despite heavy reliance on seasoned RNs, NGRNs are not naïve and recognise breaches of professional boundaries Undergraduate education should include comprehensive role identity inventory	Sample size Self‐selection bias Self‐reporting bias Limited transferability of findings
Karanikola et al. (2018)	To explore the lived experience of professional role perception and feelings of personal and professional self‐concept in Greek nurses.	Interpretive Phenomenological Purposive sampling	N = 16 Ages M = 34.8 year Experience M = 12.1 year	Factors Self‐worth assessment Problem solving Contributions to patient care Themes Internal influences Externalisation of role	Positive self‐perception RNs with increased self‐perception ➔ greater autonomy, more consistent, greater coping skills, higher job satisfaction	RNs who relied on others' perception of them = more self‐critical, delayed overcoming of external adverse events Org interventions aimed at psychological empowerment could impact self‐ and role perception, coping skills, job distress, burnout	Sampling bias Self‐reporting bias Potential translation issues Limited transferability of findings
Landis et al. (2020)	To describe the lived experience of nurses working with patients in the hospital environment and the meaning as it relates to their PI	Interpretive Phenomenological Purposive sampling	N = 12 Ages Not reported Experience Not reported	Themes Validation of expertise by others Critical thinking and actions Group collaboration Patient advocacy and spending time rapport building Connection to patients, others Factors Internal influences External influences Externalisation of role	Valuing the humanness of patients is sometimes doing “invisible work” that reflects holistic care and fundamental to the work of a nurse Interprofessional training helps build skills to develop stronger sense of PI	Nursing practice should continue to stress nursing presence and patient rapport building, as this also impacts patient satisfaction with care Nurses need to be involved in decisions about patient care to validate nursing identity Interprofessional and team training and education could benefit interdisciplinary communication, patient advocacy processes	Sampling bias Self‐reporting bias Limited transferability of findings
Mateo‐Martinez et al. (2021)	To explore the contemporary narrative of nursing identity in Spain	Hermeneutic Phenomenological Purposive sampling	N = 11 Ages 23–64 (M = 36.3)	Factors Training Knowledge Significant experiences Co‐worker acceptance Self‐esteem Prioritisation Value by others Self‐care Themes Internal influences External influences Externalisation of role	PI is manifested as variable, diverse, and transmutable as it gains voice and visibility	Nursing PI is evolving within a new culture, from prescriptive feminine repression toward newer philosophy of nursing care Reflective practice in academic and healthcare settings can promote paradigm shift	Sample bias Self‐reporting bias Limited transferability of findings
Mousazadeh et al. (2019)	To investigate the impediments to forming positive PI in nurses working in intensive care unit.	Qualitative Description – Exploratory Purposive sampling	N = 24 Ages 25–42 year (M = not reported)	Factors—Catalysts Respect of professional values Use of (and recognition of use by others) scientific knowledge Critical thinking Providing spiritual care services Factors ‐ Detractors Poor understanding of profession/distrust of nursing knowledge, subsequent poor societal image Physician disrespect, workplace discrimination Overall tea unit disregard for ethical considerations Poor professional/family/patient interactions, leads to negative attitudes Lack of any hospital authority or autonomy Low income with high workload Themes External influences Externalisation of role	Many nursing graduates are not willing to work in intensive care due to lack of autonomy Heavy workload, inappropriate staffing ratios, increased documentation, working overtime all contribute to increased job dissatisfaction Poor workplace justice in the form of unfair facility usage and practices between physicians and nurses is a big cause of dissatisfaction Unhealthy work environment is top cause for dissatisfaction, burnout, and leaving	Iranian nursing needs detailed role descriptions of area practices and responsibilities Scientific knowledge and verbiage must be incorporated into practice norms Efforts to educate public of nursing attributes can increase societal image of nursing, increase attraction to profession	Limited transferability of findings Small study
Ni et al. (2022)	To explore nurses' experiences and perceptions of career identity on growth and its influencing factors	Qualitative Description Purposive sampling	N = 31 Ages 22–51 year (M = 33.4 year) Experience 1–33 year (M = 11.4 year)	Factors Individual level: Self‐reflection/appraisal Personal traits Abilities Intrinsic motivation Affection toward career choice Organisational: Culture/support/resources/opportunities Social: Social support Family support Societal support of discipline Themes Internal influences External influences Externalisation of role Early career vs. seasoned nurses	The nurse‐specific symbol of perceptions of career growth was how characteristics of professional identity development evolved	When nurses perceive social and organisational support, their socio‐emotional needs are fulfilled and can affect career outcomes Longitudinal quantitative and qualitative investigations should further explore the process of career growth and influencing factors	Self‐selection bias Self‐reporting bias Limited transferability of findings
Watson (2023)	To explore the meaning behind ICU RN PI for those who cared for patients with COVID‐19	Hermeneutic Phenomenological Snowball sampling	N = 20 Ages Not reported Experience 5–30 year	Factors Compassion Connection Resilience Knowledge Role importance Committing to quality care Self‐care Themes Internal influences External influences Externalisation of role Early career vs. seasoned nurses	Extreme circumstances redefine purpose Knowledge empowers pride In the face of patient death, identity changes ➔ compassion and healing become compassion and comfort	Themes contribute to greater understanding of purpose, meaning, fulfilment in post‐pandemic context Organisational investment in strategies and tools that support nurse PI should be studied to assess how it fosters work engagement and commitment	Sampling bias Recall bias Limited transferability of findings
Willetts and Garvey (2020)	To examine PI through the group performances of nurses within a specific work environment	Integrated methodology: Ethnographic case context study Convenience sample	N = 23 Ages Not reported Experience Not reported	Factors Handoff reports Collective nurse identity Themes External influences Externalisation of role	Group efficacy helps to promote belongingness and commitment	To construct and advance PI, organisations need to have opportunities for nurse‐to‐nurse communication and social connection	Sampling bias Reporting issues Limited transferability of findings

Abbreviations: NGRN = New Graduate Registered Nurse; PI = Professional Identity.

2.2.6. Data Abstraction

Stage four of the integrative review, data analysis, was executed by creating tables to categorise study characteristics and interpret content. One researcher analysed the data, with each phase discussed among the research team until consensus was reached. Content analysis was used to analyse the data pertinent to the research purpose (Erlingsson and Brysiewicz 2017). Initial codes were derived from the data based on the research question and PIN definition, without any interpretation. Subsequent comparisons between codes helped determine their relationships and develop categories (Erlingsson and Brysiewicz 2017). Overarching themes emerged from the categories to convey the researchers' interpretations of the data consistent with content analysis procedures.

2.2.7. Synthesis

The data analysis resulted in five overarching themes of factors that influence acute care PIN: “internal influences,” “external influences,” “externalization of the role,” “early career versus seasoned experience” and “barriers to PIN formation.” Stage five of Whittemore and Knafl's integrative review process is the presentation of findings. Table 1 illustrates full data extraction, narrative summary of all quantitative sources, and categorisation of overarching themes. Table 2 includes extracted data with narratives of qualitative sources and theme categorizations. Table 3 illustrates how themes and subthemes map to PIN domains.

TABLE 3.

Cross walk of overarching themes and subthemes to alignment with PIN domains.

Theme	Subtheme	Authors	Pin domain
Internal Influences	Meaning of work	Dames (2019), Hu et al. (2023), Watson (2023), Wu et al. (2023), Zhang et al. (2023)	2,3,4
	Self‐compassion	Dames (2019), Heldal et al. (2019), Karanikola et al. (2018), Mateo‐Martínez et al. (2021), Ni et al. (2022), Watson (2023)	3,4
	Self‐reflection	Hu et al. (2023), Karanikola et al. (2018), Landis et al. (2020), Mateo‐Martínez et al. (2021), Ni et al. (2022), Watson (2023)	1,2
External Influences	Organisational Support	Dames (2019), Heldal et al. (2019), Ni et al. (2022), Willetts and Garvey (2020), Wu et al. (2023), Zhang et al. (2023), Zhu et al. (2022)	3
	Professional Support and Recognition by Others	Dellafiore et al. (2021), Landis et al. (2020), Mousazadeh et al. (2019), Zhang et al. (2023), Zhu et al. (2022)	2,4
	Role Modelling and Mentorship	Dames (2019), Hu et al. (2023), Hunter and Cook (2018), Ni et al. (2022), Su et al. (2023)	1,2,3,4
	Social Connection	Hoppe and Clukey (2021), Hu et al. (2023), Karanikola et al. (2018), Landis et al. (2020), Mateo‐Martínez et al. 2021, Watson 2023, Willetts and Garvey 2020, Zhang et al. 2023	4
Externalisation of Role		Dellafiore et al. (2021), Karanikola et al. (2018), Mousazadeh et al. (2019), Hoppe and Clukey (2021), Hunter and Cook (2018), Mateo‐Martínez et al. (2021), Landis et al. (2020), Liu et al. (2020), Watson (2023)	2,3,4
Early Career versus Seasoned Experience		Dames (2019), Hoppe and Clukey (2021), Hu et al. (2023), Hunter and Cook (2018), Landis et al. (2020), Liu et al. (2020), Mateo‐Martínez et al. (2021), Ni et al. (2022), Su et al. (2023), Wu et al. (2023), Zhang et al. (2023), Zhu et al. (2022)	1,2,3,4
Barriers to PIN Formation		Dames (2019), Liu et al. (2020), Su et al. (2023), Hoppe and Clukey (2021), Hunter and Cook (2018), Mousazadeh et al. (2019), Ni et al. (2022)	3,4

Note: Pin Domains (1 = Knowledge; 2 = Values/Ethics; 3 = Nurse As Leader; 4 = Professional Comportment).

3. Results

3.1. Internal Influences

The internal influence theme captures personal perceptions and values. As learned from the data, three subthemes further categorised these influences. Identified sub‐categories are “meaning of work,” “self‐compassion” and “self‐reflection.”

3.1.1. Meaning of Work

Recognition of role value is a present factor in several studies (Dames 2019; Hu et al. ²⁰²³; Watson ²⁰²³; Wu et al. ²⁰²³; Zhang et al. ²⁰²³). Understanding the importance of individual and joint roles is pivotal for acute care environment acclimation, moral elevation, and internalisation of PIN attributes (Hu et al. 2023; Wu et al. ²⁰²³). Within the COVID‐19 context, Wu et al. (2023) highlights work meaningfulness as the strongest mediator of PIN (p = 0.001). Zhang et al. (2023) echo this among intensive care (ICU) nurses (p < 0.001); perceived benefits aligning with work meaning include professional growth and honour of representing the role. These findings resonate with qualitative descriptions from ICU nurses internationally, where, when needs are met, extreme circumstances empower them to connect with their true professional worth, guiding authentic meaning and purpose (Dames 2019; Watson ²⁰²³).

3.1.2. Self‐Compassion

Self‐compassion and self‐approval are significant driving factors for viewing work challenges with optimism, engaged motivation and thriving in the role (Dames 2019; Heldal et al. ²⁰¹⁹; Karanikola et al. ²⁰¹⁸; Ni et al. ²⁰²²; Watson ²⁰²³). Nurses with increased self‐perception show greater autonomy, problem‐solving consistency, better coping skills and higher job satisfaction than those who rely on others' opinions (Karanikola et al. 2018). A participant relays it clearly in the study by Karanikola et al. (2018) as “…to do this job you have to feel competent enough and fulfilled as a person, to be at peace with yourself, to have an inner balance…” (p. 8). A critical underscoring factor is consistent inward kindness. This depends on logistics, such as proper scheduling and rest, to enable resilience and self‐actualization (Dames 2019; Watson ²⁰²³). Further, baseline self‐care practices boost self‐esteem and encourage nurses to advance their collective nursing voice (Mateo‐Martínez et al. ²⁰²¹).

3.1.3. Self‐Reflection

Ni et al. (2022) emphasise that the professional growth process should encompass personal traits and intrinsic motivations alongside clinical abilities. By analysing individual work ethics and skills, nurses can identify areas for improvement. It is imperative to cultivate the skill of autonomous critical thinking, helping to facilitate a constructive exchange of diverse, yet respectful, opinions on effective patient interventions. Deliberate reflection on acute patient care contributes to navigating future complex situations by enhancing subsequent clinical and ethical reasoning and fostering the capacity to advocate safe practices (Karanikola et al. 2018; Landis et al. ²⁰²⁰; Watson ²⁰²³). To facilitate PIN maturation, it is crucial to reflect at various points throughout the day and upon reaching career milestones (Hu et al. 2023; Mateo‐Martínez et al. ²⁰²¹; Ni et al. ²⁰²²). In a study by Hu et al. (2023) on learned self‐reflection techniques, statistically significant increases in PIN were observed during and immediately post‐intervention (p < 0.001). To underscore this theme, a study participant in Mateo‐Martínez et al. (2021) reflects, “Every day is different…I think it is necessary to think ahead, as much as possible, reflecting on issues we know we will have to deal with the next day, to bring the most thought‐out ideas” (p. 5).

3.2. External Influences

External influences are non‐internal factors or situations that affect individuals. External factors influencing PIN span across individual, social, organisational and societal levels. Identified subthemes include “organisational support,” “professional support and recognition by others,” “role modelling and mentorship” and “social connection.”

3.2.1. Organisational Support

Organisational support may present as financial rewards, resources, leadership, and structural processes or norms. Financial rewards were positively correlated with ICU PIN during unprecedented times such as COVID‐19 (r = 0.771, p < 0.001) (Zhang et al. 2023) and help nurses to feel valued (Ni et al. 2022). In other words, compensation and benefits enhanced their perceived organisational value in caring for COVID‐19 patients, subsequently increasing their sense of PIN.

For many, the presence of solid leadership is a crucial influencing factor of PIN (Wu et al. 2023; Zhu et al. ²⁰²²). Wu et al. (2023) highlight the significance of leadership with the concept of sense‐giving, which refers to how leaders endorse and interpret roles within environmental situations. The findings of the study indicate that sense giving effectively supported the overall mission and goals of the work environment (Mpretest = 4.25, Mposttest = 4.55, F (1, 88) = 11.33, p = 0.001) (Wu et al. 2023).

Leadership‐initiated system safeguards in acute care, such as streamlined medication safety programs, efficacy in group reporting and electronic documentation, also play a pivotal role in PIN. These measures contribute not only to the external validity of patient care appropriateness but also to increased patient trust and subsequent nurse confidence (Heldal et al. 2019; Willetts and Garvey ²⁰²⁰). Consistent organisational support in the form of policies, guidelines, well‐allocated staffing and resources and leadership visibility addresses a substantial portion of nursing adaptive functioning needs and contributes to career development and self‐actualization (Dames 2019; Ni et al. ²⁰²²; Wu et al. ²⁰²³).

3.2.2. Professional Support and Recognition by Others

Professional support is expressed in the literature as recognition by coworkers, sustained collaborative team efforts, and tangible resources to perform the role. Recognition by others involves formal acknowledgment of the nursing profession. Some overlaps exist within these subcategories, and are discussed together.

Practice provider acknowledgment and high regard for intensive care unit (ICU) nurses contribute to enhancing nurses' perception of career status (Mousazadeh et al. 2019) and, during the pandemic, increased team collaboration (p < 0.001) (Zhang et al. 2023). Continued recognition beyond pandemic times may directly or indirectly empower ICU nurses' confidence and commitment (Dellafiore et al. 2021; Zhang et al. ²⁰²³; Zhu et al. ²⁰²²). Nurse competence is reported to be key to gaining provider respect, thereby amplifying nurse self‐assurance (Landis et al. 2020; Zhu et al. ²⁰²²). This aligns with internal factors such as reflection and knowledge to shape PIN.

Workload acknowledgment by others extends to other interdisciplinary team members, patients, and the public (Heldal et al. 2019; Hu et al. ²⁰²³; Landis et al. ²⁰²⁰; Mousazadeh et al. ²⁰¹⁹; Wu et al. ²⁰²³; Zhang et al. ²⁰²³). The reviewed literature correlates with similar descriptions tying the social image of the profession to nurses' perceptions of their role and professional intentions (Grinberg and Sela 2022; Takase et al. ²⁰⁰⁶). Hence, amidst demanding workloads, competing patient priorities and the perpetual pressure of time‐bound tasks, nurses find motivation in authentic affirmations. Importantly, collegiality and mutual respect among nursing colleagues, nursing managers, and nursing leadership foster PIN (Hoppe and Clukey 2021; Hu et al. ²⁰²³; Karanikola et al. ²⁰¹⁸; Landis et al. ²⁰²⁰; Mousazadeh et al. ²⁰¹⁹; Willetts and Garvey ²⁰²⁰). Respected nurses can traverse their individual identities to work in concert to strengthen team solidarity.

3.2.3. Role Modelling and Mentorship

Mentorship and positive role modelling are principal factors of PIN development (Dames 2019; Hu et al. ²⁰²³; Hunter and Cook ²⁰¹⁸). Demonstrating confidence, efficient time management, professionalism, approachability and empathy are well‐noted attributes of excellent role models (Hunter and Cook 2018). Frequent, useful feedback is also central to growth, empowerment and career planning (Ni et al. 2022) and has statistical significance in how nurses deal with professional frustration (p < 0.001) (Hu et al. 2023). Effective clinical teaching strategies by preceptors and mentors are vital for newer nurses' PIN (β = 0.52, p < 0.01) (Su et al. 2023).

3.2.4. Social Connection

Social connections among healthcare workers are meaningful for PIN construction (p = 0.017) (Hu et al. 2023) and evolution (Mateo‐Martínez et al. ²⁰²¹; Watson ²⁰²³; Willetts and Garvey ²⁰²⁰). Forming interpersonal relationships also provides significant health and work benefits. Cultivating purposeful environments that build community can mitigate emotionally, mentally and physically intense workloads in acute care environments (Watson 2023; Zhang et al. ²⁰²³).

Hoppe and Clukey (2021) suggest that smaller critical access hospitals enable the nurturing of teamwork and social enjoyment, possibly fostering a sense of belonging more rapidly than larger acute care settings. Any acute setting can be gravely serious and stressful. Finding humour in the milieu is an important source of social connection and collective identity (Willetts and Garvey 2020).

Nurses report strong associations between professional self‐concept, job satisfaction and building patient rapport (Hoppe and Clukey 2021; Karanikola et al. ²⁰¹⁸; Landis et al. ²⁰²⁰). Watson (2023) demonstrates this deeper patient link during the pandemic:

I am taking care of the patient, the same as I did, but I feel a connection with them more as human beings now. I think what sustains us as nurses is the human aspect of it. I think that having a human connection is healing for everyone. It's healing for the patient, and to be honest, I think it's healing for the nurses too (p. 4).

The depth and breadth of authentic connections nurses have with their own families also ties to PIN. Zhang et al. (2023) reported that acute care nurses who are bolstered by their own families have higher PIN scores (p = 0.015). This indirect effect on PIN may be credited to baseline emotional support systems that further mental well‐being.

3.3. Externalisation of Role

Morally, the central experience of professional growth and personal satisfaction centres on expressing care for others (Karanikola et al. 2018). A significant positive correlation exists between attributing more worth to professional values such as caring and self‐efficacy of activism on PIN (p < 0.001) (Dellafiore et al. 2021). This finding indicates that those who feel strongly about upholding traditional professional attributes tend to display heightened nursing actions. In turn, staying accountable to uphold codes of conduct and ethical practices for quality, patient‐centred care is essential to PIN (Dellafiore et al. 2021; Hoppe and Clukey ²⁰²¹; Hunter and Cook ²⁰¹⁸; Mateo‐Martínez et al. ²⁰²¹; Mousazadeh et al. ²⁰¹⁹).

Similarly, there are reciprocal relationships between PIN and emotional regulation. The frequent use of authentic behavioural strategies, such as deep acting, reduces emotional exhaustion, increases internal endurance resources, and enhances PIN (β = 0.19, p < 0.01) (Liu et al. 2020). Although aligning emotions with organisational and patient expectations initially demands extra effort, genuine emotions foster commitment.

Nurses also have a sense of pride when using scientific knowledge and intuition to take swift action (Landis et al. 2020; Mousazadeh et al. ²⁰¹⁹). While no acute care nurse works in total isolation, various aspects of the role require self‐sufficiency. Successful prioritisation and implementation of independent actions supplements nursing development (Mateo‐Martínez et al. ²⁰²¹). At organisational and societal levels, the transformative impact of PIN predicts the degree of advocacy for collective nursing needs (Watson 2023).

3.4. Early Career Versus Seasoned Experience

The reviewed literature demonstrates that nurses, both early in their career and with years of experience, are influenced by similar factors as they sculpt their PIN; however, they evolve with time. For new nurses with less than 3 years of experience, a steady and supported transition to acute care practice is vital. The achievement of this best occurs through exposure to daily nuances of complex patient cases and reliable mentorship with consistent, constructive feedback for an understanding of acute care practice and a sense of belonging (Hoppe and Clukey 2021; Hu et al. ²⁰²³; Hunter and Cook ²⁰¹⁸). Clinical teaching practices such as active learning strategies and debriefing are crucial for progress (Hoppe and Clukey 2021; Hunter and Cook ²⁰¹⁸; Su et al. ²⁰²³). In rural hospital settings, variety and cross‐training facilitate and strengthen independence (Hoppe and Clukey 2021). Nurses who do not receive effective support and resources to execute the role tend to rely on their internal moral compass to navigate ethical sensitivities; however, this is met with internal hesitation and impedes role thriving, particularly if reflecting alone on a frequent basis (Dames 2019; Hunter and Cook ²⁰¹⁸; Su et al. ²⁰²³).

While those in the early career stages develop PIN through new experiences and observations of others, seasoned career nurses augment these identity perspectives through internal growth and accumulation of experiences. Key growth factors hinge upon mastering the latest evidence‐based practices, independent thinking, and problem‐solving to enhance interprofessional communication skills, camaraderie and validation of expertise (Karanikola et al. 2018; Landis et al. ²⁰²⁰). Civility and societal support impact PIN of both the new and experienced, with seasoned nurses being less affected by non‐modifiable team personality differences (Hu et al. 2023; Hunter and Cook ²⁰¹⁸; Landis et al. ²⁰²⁰; Mateo‐Martínez et al. ²⁰²¹; Ni et al. ²⁰²²; Su et al. ²⁰²³; Zhang et al. ²⁰²³; Zhu et al. ²⁰²²). However, these differences influence team dynamics. Regardless of tenure, developing proficiency in reflection, mindfulness and coping techniques enhances job satisfaction amid team challenges (Dames 2019; Hu et al. ²⁰²³; Liu et al. ²⁰²⁰; Su et al. ²⁰²³; Wu et al. ²⁰²³; Zhu et al. ²⁰²²).

3.5. Barriers to PIN Formation

Within the reviewed literature, primary obstacles to forming PIN arise from inadequate relational, environmental, or individual challenges. From a relational perspective within teams and leadership, nurses who experience or observe negative or suboptimal interactions, inadequate mentors' teaching behaviours, or insufficient support with career goals perceive an absence of safe environments that threaten their professionalism (Dames 2019; Hunter and Cook ²⁰¹⁸; Liu et al. ²⁰²⁰; Mousazadeh et al. ²⁰¹⁹; Ni et al. ²⁰²²; Su et al. ²⁰²³). In the broader acute care environment, nurses who must “float” to unfamiliar areas where they are unaccustomed to specific unit protocols or team members can, despite operating within their practice scope, experience role incongruence that impedes a sense of professional identity. On an individual level, nurses who experience emotional dysregulation, poor mental health practices, or fail to prepare emotionally for a designated period of self‐reflection tend to have reduced patient and team connections, decreased professional self‐respect, and a diminished sense of identity (Hoppe and Clukey 2021; Liu et al. ²⁰²⁰; Ni et al. ²⁰²²; Su et al. ²⁰²³). These barriers to forming PIN lead to increased or chronic stress, emotional exhaustion and burnout (Dames 2019; Liu et al. ²⁰²⁰; Mousazadeh et al. ²⁰¹⁹), and underscore the critical need for full recognition and promotion of nursing values to enhance professional integrity at the systemic, unit and individual levels.

4. Discussion

This review synthesises key themes influencing acute care PIN from diverse experiences and tenure within various acute care environments, with ICU settings more commonly utilised. Qualitative and quantitative data were reported within this review and synthesised into five overarching themes influencing acute care PIN: (1) internal influences, (2) external influences, (3) externalisation of the role, (4) early career versus seasoned experience and (5) barriers to PIN formation. Each theme was consistently identified across the pre‐COVID‐19 literature, COVID studies and post‐COVID contexts. The literature reviewed also underscores the significance of internal influences and external influences in assisting navigation of high‐pressure situations to enhance PIN.

Internal factors are crucial in shaping professional identity, especially in high‐pressure, emotionally demanding acute care environments where rapid, high‐stakes decisions are common. Nurses develop their PIN through self‐reflection, evaluating their work's significance and aligning their values with professional responsibilities. These internal factors help manage acute care stressors and ethical dilemmas, enhancing emotional resilience and coping strategies.

The literature findings predominantly emphasise external influencing factors of PIN. External factors encompass individual, social, organisational and societal levels. This emphasis on external factors suggests that, despite the significant importance of one's internal development and role representation, the acute care environment and organisational influences may be primary drivers of PIN formation.

Regarding external factors influencing PIN, a notable shift in the literature during the pandemic era emphasised collaborative, team‐based care over individual accountability and responsibility. This shift underscores the importance of interprofessional dynamics and collective decision‐making as well as the imperative to create an environment where nurses feel supported, valued and recognised. The COVID‐19 pandemic intensified these influences, as the healthcare system strain posed PIN challenges and opportunities. Nurses had to adapt to new roles, collaborate innovatively, and show leadership and resilience under pressure. The review indicates that a team solidarity approach influenced PIN formation by boosting nurses' sense of belonging and connection to their profession, especially during crises. While these findings examine an unprecedented pandemic period within acute care environments and the resulting patient population, a comprehensive understanding of its ramifications and ensuing consequences is necessary to understand how these changes might influence future PIN development among acute care nurses.

Externalisation of the role is another critical theme that emerged from the literature and is especially salient in the post‐COVID healthcare environment. The pandemic highlighted the profession's systemic undervaluation, despite advocating for safe practices. This disparity may have caused role incongruence, particularly among novice nurses or those struggling to define a clear career path.

The progression of PIN is also illuminated through the lens of early career versus seasoned experiences. Novice nurses undergo a crucial transition in acute care settings where mentorship, guidance, and exposure to complex patient scenarios are essential for professional growth. As they gain expertise, their confidence in clinical decision‐making, interprofessional communication, and leadership increases. The literature revealed that experienced nurses reinforce their PIN through demonstrating mastery of evidence‐based practices, problem‐solving, and collaboration. Noteworthy similarities exist in the importance of social and societal support, which can validate or undermine their confidence and expertise, thereby affecting their PIN.

Barriers to PIN formation are a significant concern in acute care settings. Nurses facing these barriers are prone to emotional dysregulation, lower self‐esteem and decreased professional fulfilment. Acute care environments are especially vulnerable to emotional exhaustion, stress and burnout due to high patient acuity and staffing shortages. Addressing these barriers is crucial to fostering a work environment that supports professional identity development.

The conceptual model by Joseph et al. (2023) promotes an interdependent systems thinking perspective on PIN. Systems thinking encourages viewing different connections as interconnected, emphasising feedback loops between influencing factors to facilitate overall improvements and progress (Arnold and Wade 2015). This stimulates a holistic approach to examine how the various themes emerging from this review interact to shape PIN. The theme of internal influences significantly contributes to the enhancement of confidence or self‐doubt in high stress, acute care environments. Values, coping mechanisms, engagement in self‐reflection and continual evaluation of the significance of the role establish a foundation for continued professional development and clarify positive role identity (Joseph et al. 2023). External influencing factors, including team and leadership dynamics, organisational support and culture within a rapidly evolving environment, and public perceptions, can reinforce or undermine this foundation. Consequently, this reinforcement or undermining can significantly impact nurses' efforts to externalise, continue advocating for, and advance the public‐facing role. By employing systems thinking and recognising interconnected, influential themes within the PIN domains, acute care environments can formulate more comprehensive strategies to address the multifaceted factors impacting PIN across these themes.

Additionally, this review highlights the alignment between ISPIN's conceptualization of professional identity, its associated domains of values and ethics, knowledge, nurse as leader and professional comportment, and the themes emerging from the literature. The four domains are crucial to acute care nursing practice due to high‐stakes decision‐making, frequent ethical considerations, rapid coordination of patient care, and the necessity for flexible adaptability in these settings. The knowledge domain, involving evidence analysis and application, encompasses themes and subthemes of early career versus seasoned experience, self‐reflection, role modelling, and mentorship. Values and ethics, reflecting core beliefs guiding the role, resonates with internal subthemes of meaning of work and self‐reflection, external influences of professional support/recognition and role modelling/mentorship, externalisation of the role, and early versus seasoned experience. The nurse as leader domain, emphasising advocacy and commitment to excellence, permeates all themes. Similarly, professional comportment, encompassing demonstrated mannerisms, manifests across all themes. The barriers to PIN formation were primarily associated with domains of nurse as leader and professional comportment. Nurses experiencing suboptimal mental health, poor emotional self‐control during high‐ stakes decision‐making processes in acute care settings, and ambiguous career objectives lacking appropriate mentoring and support may result in neglect of professional status or diminished self‐efficacy. Echoing the study by Rasmussen et al. (2018), our review found that factors within the overarching themes hinder or enhance nurses' sense of PIN.

5. Limitations

This review had several limitations that warrant consideration when interpreting the findings. Many of the included studies had lower evidence levels, potentially impacting the generalizability and robustness of the conclusions. Moreover, six of the seven quantitative sources (86%) originated from China, where healthcare systems and societal norms differ from those of many other countries. Regional, socioeconomic and cultural differences within and between countries are also poorly represented. Additionally, the reviewed studies often lacked sufficient detail regarding gender and sex, which are critical factors influencing professional identity, particularly in a predominantly female profession.

While this review purposefully focused on acute care settings, it did not examine the literature pertaining to nurses in immediate prehospital or long‐term acute care settings, which may exhibit different influences on PIN. Acute care settings were found to be of critical importance to PIN, though challenges persist in delineating specific acute care environments where domains and influences have the greatest significance. Methodologically, the absence of standardised measurement tools for assessing PIN is another limitation. The studies employed valid but diverse scales or non‐specific measures of professional identity, rendering it challenging to draw definitive conclusions. Further limitations include potential sampling and other biases, as noted in the tables within the Appendix.

Although this literature review specifically focused on the period in which a newly standardised definition for PIN exists, the evolving nature of PIN definitions across studies also presents a challenge, as inconsistent terminology may have affected the interpretation of findings. These evolving definitions may also have enabled differing perceptions of PIN among the research participants, limiting our review findings. Furthermore, the paucity of empirical data to validate this definition limits the substantiation of the evidence found in this review.

6. Conclusion

This review examined the current state of nursing professional identity in acute care settings, identifying factors that contribute to or hinder its formation, despite differences in tenure, geography, or specific acute work environment. Factors influencing acute care nurses' sense of professional identity were synthesised into categories of internal influences, external influences, externalisation of the role, early career versus seasoned experience and barriers to professional identity formation. A robust sense of PIN fosters empowerment, advocacy, confidence, belonging and job satisfaction, which may mitigate the intense demands of acute care workloads. Exposure to the negative influences identified in this review can result in increased hesitation, elevated stress and exhaustion, burnout and other role impediments. Because PIN may be instrumental in tackling acute care workforce challenges, distinguishing the positive contributing influences found in this review can facilitate strategic initiatives leading to more favourable, healthy work environments.

The identified knowledge gaps necessitate further investigation to advance our understanding of this phenomenon and its policy, practice, and research implications. Especially pertinent in the post‐COVID era, and in light of the critical acute care nursing shortage, researchers, nurse educators, leaders and healthcare systems need robust data to develop frameworks that emphasise and sustain PIN. Researchers need a standardised approach incorporating the definition and domains put forth by the International Society of Professional Identity in Nursing to unify and promote PIN in acute care. To balance predominantly qualitative PIN research, comparative analyses of observations and interventions across various acute care settings can reveal PIN variances, enabling targeted improvement strategies for nursing practice in knowledge, values/ethics, nurse as leader, and professional comportment. The application of ISPIN's measurement instrument, the PINS scale (Landis et al. 2024), can guide systematic and rigorous research approaches that advance the science.

Nursing students increasingly recognise the importance of early PIN formation. Yet, their empowerment and expectations clash with the realisation that PIN may not be well‐established or facilitated in their chosen setting, potentially contributing to early career attrition (Labrague and de Los Santos ²⁰²⁰; Lanahan et al. ²⁰²²). Existing research inadequately addresses PIN formation for new graduates in acute care settings, highlighting the need for further study to bridge the theory‐practice gap. Clinical nurse educators should seek opportunities to integrate the PIN definition and domains into their pedagogical approaches. Understanding influences within these domains aids in creating case studies, implementing active learning strategies to enhance critical thinking and reasoning, and conducting debriefing exercises for both novice and experienced nurses.

Recent findings by Hanum et al. (2023) underscored the significance of cultivating PIN for job satisfaction and professional longevity. However, a knowledge gap persists regarding the specific impact on career decisions. Longitudinal studies can significantly illuminate how factors are associated with long‐term career trajectories, unit productivity, and patient satisfaction and outcomes.

Organisational leadership and healthcare systems should also prioritise PIN research across generational groups, experience levels, and diverse environments as well as examine how the influences identified in this review contribute to policy formation to promote professional recognition, equitable compensation, and an overall healthy work environment. Future PIN research from the view of colleagues—as the “voice of other” – may also provide a more comprehensive view of where gaps exist in the acute care space. Investigating PIN among acute care leadership in nursing may yield additionally valuable insights.

Overcoming barriers to PIN formation, including emotional dysregulation and insufficient support, requires a multifaceted strategy. Healthcare organisations should dedicate resources to mental health services, emotional regulation training, and programs to improve team cohesion to nurture PIN development. These measures may reduce stress and burnout, allowing nurses to better manage challenges in acute care settings and maintain their professional growth.

Although the concept of PIN is not novel, its renewed focus and conceptualization within the nursing field have established a framework for contemporary research initiatives leading to new insights and implications. As the global nursing workforce becomes increasingly interconnected, a universal understanding of PIN may facilitate nurses' integration into diverse healthcare systems, thereby enhancing the delivery of high‐quality care across geographical boundaries.

Author Contributions

A.H.: made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data, and drafting the manuscript. A.H., G.C., D.R.: made critical revisions for important intellectual content. G.C., D.R.: final approval of the version to be published. A.H., G.C., D.R.: participated sufficiently in the work to take public responsibility for appropriate portions of the content. A.H., G.C., D.R.: agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of Interest

The authors declare no conflicts of interest.

Peer Review

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16755.

Supporting information

Data S1.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.