Abstract
Aim
Development and evaluation of the effectiveness of an online 5-week professional identity program among nursing students in clinical internship practice during the COVID-19 restrictions.
Background
Nurse professional identity is a strong predictor of career commitment. Clinical internship practice is a key stage when nursing students build and rebuild their professional identity. Meanwhile, the COVID-19 restrictions has strongly influenced the professional identity of nursing students as well as nursing education. A well-designed online professional identity program may contribute to nursing students who are in clinical internship practice developing positive professional identity during the COVID-19 restrictions.
Design
The study was a two-armed, randomised, controlled trial conducted and reported based on Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines.
Methods
A total of 111 nursing students undergoing clinical internship were randomised into an intervention group and a control group. The five-weekly session intervention was developed based on social identity theory and career self-efficacy theory. The primary outcomes were professional identity and professional self-efficacy and the second outcome was stress. Qualitative feedback was analysed by thematic analysis. Outcomes were assessed before and after the intervention and analysed using an intention-to-treat principle.
Results
The generalised linear model showed that group-by-time effects were significant for the total score of professional identity and three factors of professional self-image, social comparison and self-reflection and independence of career choice, with small effect sizes (Cohen’s d from 0.38 to 0.48). Only one factor of the capacity of information collection and planning in professional self-efficacy was significant (Wald χ2 =0.4.82, P < 0.01) with a medium effect size (Cohen d=0.73). The group effect, time effect and group-by-time effect of stress were not significant. Three themes were: ‘Gaining in professional identity, self-recognition and peer belonging’; ‘Content, self-motivation and intervenor as participation facilitators’; and ‘Combining offline and courses, setting group rules and building mutual trust as recommendations’.
Conclusions
The online 5-week professional identity program effectively promoted the development of professional identity and the capacity for information collection and career planning but did not significantly relieve pressure during the internship.
Keywords: Nursing student, Professional identity, Professional self-efficacy, Stress, COVID-19
1. Introduction
Professional identity is a strong predictor of job retention and is associated with professional commitment, professional activities and job satisfaction, which has been gaining attention in recent decades. (Chenevert et al., 2016, Hu et al., 2022, Niskala et al., 2020) Clinical internship practice is a key stage when nursing students transform theoretical knowledge into clinical practice and start to build or evolve their professional identity based on their experience. Meanwhile, since the outbreak of COVID-19 in 2019, the restrictions has strongly influenced the professional identity of nursing students as well as nursing education in both positive and negative ways. (Shun, 2021) In addition, the restrictions also challenged the delivery form of professional identity education, as many offline courses and lectures were cancelled, and some schools even launched online internship practices. Therefore, a structured, feasible and effective professional identity intervention program is necessary and important to help improve nursing students’ professional identity in clinical internship practice during the COVID-19 restrictions. This study built a structured online professional identity program and evaluated its acceptance and effectiveness from both qualitative and quantitative perspectives.
2. Background
Nurse professional identity refers to the process through which nurses recognise their professional roles and competency requirements and develop a clear professional commitment. (Ohlén and Segesten, 1998) Previous studies showed that a large number of nurse practitioners had a low level of work enthusiasm, (Shah et al., 2021) and the level of professional identity of nurses was significantly lower than that of other health-related professionals, (Yu et al., 2021) leading to job leaving that was counter to the current global shortage and need for nurses. (Chan et al., 2013) Nursing students with a high level of professional identity are more likely to complete nursing education and successfully become qualified nurses with professional ethics.(Cook et al., 2003; Furst, 2018).
COVID-19 has also influenced the level of professional identity in nursing students. On the one hand, due to the risk of becoming infected, physical and emotional stress and the heavy workload, some nursing students showed a low level of professional identity and tended to leave the profession after graduation. (Nie et al., 2021) On the other hand, social image improvement during the restrictions has promoted the professional identity level of students to some extent. (Lin et al., 2020, Zhang et al., 2021a, Zhang et al., 2021b) This phenomenon is particularly prominent in China. Data from 18 universities in mainland China implied that 86% of nursing students held a positive attitude towards nursing with a high level of professional identity during the restrictions. (Lin et al., 2020) Nursing educators should seize the positive influence of the restrictions on professional identity and take it as a valuable educational resource for professional identity education. Through a comprehensive literature review, previous identity interventions were mainly offline and rooted in related courses and practice, (Sarraf-Yazdi et al., 2021) and there was no online program aimed at enhancing the professional identity of nursing students during the COVID-19 restrictions.
To scientifically and systematically develop an online professional identity program for nursing students in clinical internship practice, two classic theories, Tajfel's social identity theory (SIT) (Tajfel et al., 1971) and career self-efficacy theory (CSET) (Lent and Hackett, 1987), were adopted and combined as the theoretical framework of this study. The programme was designed following three phases of how social identity was built and modified, which included social categorisation, social comparison and positive distinctiveness according to SIT. A favourable social comparison would lead to a positive distinctiveness (Tajfel et al., 1971), where in this study, the improvement of public recognition of the nursing profession could facilitate a favourable social comparison. Intervention elements embedded in three phases were derived from the CSET that consisted of direct experience, substituted experience, physio-psychological condition and social persuasion. Information and experience obtained from the above sources affect career self-efficacy through cognitive processing and then influence career behaviours as well as professional identity. (Lent and Hackett, 1987).
In summary, this study aimed to develop and evaluate the effectiveness of an online 5-week professional identity program among nursing students in clinical internship practice during the COVID-19 restrictions. We tested the primary hypothesis that this program would improve professional identity and self-efficacy and the secondary hypothesis that it would also mitigate stress among nursing students in clinical internship practice during the COVID-19 restrictions.
3. Method
3.1. Study design
The study was registered at https://register.clinicaltrials.gov (NCT04416074). This was a two-armed, randomised, controlled trial reported based on Consolidated Standards of Reporting Trials (CONSORT) guidelines.
This is a pragmatic intervention study and used both qualitative and quantitative data to reflect the outcomes of the intervention. Among several types of paradigms in dealing with quantitative and qualitative data, the paradigm of this study applied pragmatism. Pragmatism is outcome-oriented and focused on the product of the research. It is characterised by an emphasis on communication and shared meaning-making to create practical solutions to social problems (Shannon-Baker, 2016). This paradigm guided the development of the intervention program and analysis of qualitative and quantitative data, as later in this article.
3.2. Participants
Eligible students were recruited at the School of Nursing of Fudan University in Shanghai, China, in April 2020. The inclusion criteria were 1) full-time undergraduate nursing student, 2) undergoing clinical internship and 3) informed consent to participate. The exclusion criteria were 1) under poor mental or physical condition and thus not able to persist in intervention, 2) having experienced a major traumatic event in recent months that may affect participation and 3) having had other psychological therapy that may interact with the current intervention. The exclusion criteria were an attendance rate of fewer than three times.
The sample size was calculated by Gpower 3.0. The MANOVA approach (repeated means, within-between interaction) was chosen, and the parameters were set as follows: 2-tailed test, small effect size= 0.35, α = 0.05, power (1-β) = 0.9, number of groups= 2 and the number of measurements = 2. The minimum total sample size was calculated as 88. After the addition of an anticipated dropout rate of 20%, the total number of participants recruited at baseline was at least 110.
3.3. Ethical considerations
The study was approved by the Institutional Review Board at the researchers’ institute (20200504). The participants provided informed consent to participate and were free to withdraw from the study. Contact information for obtaining psychological assistance, if needed, was provided. The CG was on the waiting list and received the intervention after the study completion. All recordings and transcribed texts were numbered and securely stored by the researchers.
3.4. Procedure, randomisation and blinding
The researchers distributed the e-invitation and questionnaire link to online WeChat groups within their classes via the widely used investigation tool Wenjuanxing (http://www.wjx.cn). A total of 113 students from two classes were approached and 111 were willing to participate. The process of the trial is shown in Fig. 1.
Fig. 1.
CONSORT flow chart of recruitment, exclusion, and dropout of participants.
Students who were willing to participate were invited to respond to the questionnaire by scanning the QR code in the e-post. These recruited college-level students were in the middle of their 8 months of clinical internship, which was scheduled in the last academic year. This is compulsory for applying for a nurse practice licence. They would rotate among several affiliated hospitals to cover departments of internal medicine, surgery, obstetrics and gynaecology and paediatrics. The students who did internships in the same hospital may have interacted with each other; thus, we randomly allocated three hospitals into the intervention group (IG, n = 56) and the remaining three hospitals into the control group (CG, n = 55). These affiliated hospitals were all at the same tertiary level and the student’s choice of hospital was mainly out of interest, not academic performance. To allocate subjects by a hospital may not affect the study validity under this condition. The PI, who did not interact with the participants, independently generated the computerised random allocation and then communicated the results to the participants. Students finished the baseline measurement on the day of recruitment and immediately after the intervention via an e-questionnaire independently. The questionnaire used student ID as the identification number to match the pre- and post-evaluation. The students in the IG were asked to not communicate the content of the intervention with students in the CG and with those outside their facilitation group. The IG received the online 5-week professional identity program, while the CG received a booklet overviewing stress management and relaxation therapy at the beginning of the intervention.
3.5. Intervention
The Medical Research Council (MRC) framework for developing and evaluating complex interventions was adopted to guide the development. (Medical Research Council Guidance, 2008, Hardeman et al., 2005) Three steps were taken successively: 1) identifying evidence through a literature review, 2) choosing the appropriate social identity theory (Tajfel et al., 1971) and career self-efficacy theory and 3) modelling the process and outcome of the intervention. After finishing step 2, a theoretical framework and its corresponding modules were formulated. Thus, we summarised influential social factors of professional identity and classified them into corresponding modules. The sessions were built following the line of creating practical solutions to social problems (Shannon-Baker, 2016), which was professional identity in this study context. Then, referencing previous or similar programs cited in the literature as obtained in step 1 and combining group discussion, the topic and activities in each session were developed. As guided by pragmatism again, the group-based activities involved much experience sharing and group discussion, which reflected the emphasis on communication and shared meaning-making to create practical solutions in the pragmatism ( Shannon-Baker, 2016). The quantitative outcomes were set accordingly based on pragmatism, which was outcome-oriented and focused on the product of the research. This is in accordance with the primary aim of this trial, which was to test the effectiveness of the current intervention based on outcomes, not to verify the framework for the theoretical mechanism. Additionally, qualitative feedback was collected and analysed based on the goal of detecting whether the intervention was effective and what influenced its effectiveness during implementation. The open-ended questions used in the qualitative interviews are shown in the later measurement section. The intervention programme was revised and finalised based on the input of several experts in nursing and psychology who were invited to give comments. Because of time and energy limits, the pilot test was conducted among only five students to test the feasibility, not effectiveness.
The online 5-week professional identity program was designed as a group-based program and the students in the same hospital were grouped (20, 16, 20 in each group). The program included five weekly sessions and each session lasted approximately 1.5 h. We designed the sessions to be administered on a weekend day when the students were not on duty. The facilitator was the PI, who is a qualified psychological nurse. She sent each online meeting link (similar to Zoom) to the three intervention groups before each session. In each session, the PI started with a video greeting to increase familiarity with each other, a review of the last session and an explanation of today’s activities. Then, experience-sharing lecturers from invited guests in Sessions 2 and 4 or participants’ homework sharing in Sessions 1, 3 and 5 were conducted by opening their screen windows. After that, the facilitator invited participants to ask questions and express their opinions interactively. Finally, homework was then disseminated. The PI built a cell phone chatting group (similar to Whatsapp) per facilitating group, where the participants could post their homework shown to each other. Throughout the intervention, the facilitator acted as an organiser, group discussion guide, encourager to ensure that every participant had a chance to voice out their own experience and a prompter to remind about homework. The theoretical framework, modules and contents of the intervention were modelled and are shown in Fig. 2.
Fig. 2.
Theoretical framework, modules and contents of program.
3.6. Measures
The quantitative data were collected by sending the QR code in the e-post to the participants. This enabled the participants to complete it after online intervention and made the data collection independent.
3.7. Sociodemographic characteristics
Several sociodemographic characteristics of students were collected at baseline, including age, gender, only child status, family residence, per capita family income, part-time job experience, whether nursing was the first major choice and whether they had family members who worked in the health profession. The last question was added based on career self-efficacy theory, which postulated that social persuasion might be an important influencing factor of career self-efficacy.
3.7.1. Quantitative measurements
3.7.1.1. The Professional Identity Questionnaire for Nurse Students (PIQNS)
is an original Chinese version of the questionnaire developed in 2011. (Hao, 2007) It is widely used in China to measure professional identity among Chinese nursing students, with higher scores reflecting a higher professional identity. This 17-item scale applies 5 points (1−5) and includes 5 factors: professional self-image, the benefit of retention and risk of turnover, social comparison and self-reflection, independence of career choice and social modelling. The Cronbach's alpha coefficient (ἀ) was 0.82 in the original developed version and 0.96 in this study.
3.7.1.2. The professional self-efficacy questionnaire for nursing students (PSQNS)
was also an original Chinese version questionnaire developed in 2011, (Y.H, 2011) with a higher score reflecting greater professional self-efficacy. This 27-item scale applies 5 points (1−5) and includes 6 factors: professional attitude and belief, problem-solving ability, professional information collection and professional planning capacity, professional cognition, professional value and professional choice. The Cronbach's alpha coefficient (ἀ) was 0.84 in the original developed version and 0.97 in this study.
3.7.1.3. The depression anxiety stress scale (DASS)
was developed in 1995 and the simplified version contained 21 items and was translated into Simplified Chinese in 2010. (Gong et al., 2010) The Likert scale applies 4 points (0−3) and is divided into three subscales: depression (DASS-D), anxiety (DASS-A) and stress (DASS-S). The DASS-S was used to measure the stress level of students, with a cut-off score of 14. The Cronbach’s α coefficient of the stress subscale was 0.76 in the previous simplified Chinese version and in this study, it was 0.92.
3.7.1.4. Qualitative feedback
Immediately after the intervention, one-fourth of the students in the IG were randomly selected based on student ID to additionally conduct an online interview. The sample size was determined by data saturation and 12 students were interviewed. The interviews were conducted separately in Chinese by the PI. Semistructured open-ended questions were used and developed by the research team based on their understanding. The illustrative questions were ‘Can you describe your feelings in this program?’, ‘What have you gained in this program?’, ‘What was the factor that influenced your participation?’ and ‘What further suggestions do you have for this program? Which nursing course do you think this program can be integrated into?’ Each interview was audio recorded and lasted 30 min.
3.8. Treatment fidelity and feasibility
To ensure the homogeneity of the intervention, the facilitator for every group was the first author. The students in the IG were also asked to report their degree of participation in the program using a 5-point scale (1–5, from “not at all” to “very much”). The dropout rate and homework participation rate were also recorded, representing how acceptable the intervention was to participants. The appraisal of the program was measured by several self-designed questions from IG, including overall ‘What is your overall evaluation of this program’ and specific ‘What is your evaluation of session 1′, using a 5-point scale (1–5, from “not satisfactory at all” to “very satisfactory”). The delivery method and group members were also applied to gather feedback.
3.9. Statistical analysis
Quantitative data were input and analysed using SPSS 20.0. The chi-square test and ANOVA were used to compare sociodemographic differences in variable scores between the two groups. We conducted a generalised linear model (GLM) analysis to examine the outcome variables and interaction of time×group among the 2 groups, with sociodemographic variables as covariates. Missing data were handled using the last observation carried forwards method, according to the ‘intention to treat’ (ITT) principle and a per-protocol (PP) analysis of complete data was undertaken as a sensitivity analysis. Cohen’s d represented the effect size, with 0.2 indicating a small effect size, 0.5 indicating a medium effect size and 0.8 indicating a large effect size. (Cohen, 1988).
Qualitative data were managed by NVivo 11.0 software and thematic analysis was used to analyse the data. Rigour in qualitative research of credibility, dependability, transferability and confirmability (Lincoln and Guna, 1986) was ensured. In the qualitative part, interviewees were randomly recruited and interviews were conducted based on the interview guide by the same interviewer to ensure authenticity throughout. The data were audio-recorded, verbatim transcribed, cross-checked and returned to participants for correction. Each transcript was independently coded by two researchers and the final codes and supporting quotes were gathered by group discussion.
4. Results
4.1. Study flow, treatment feasibility and overall appraisal
A total of 111 participants were randomly assigned to the IG and CG. At baseline, there was no significant difference in sociodemographic and outcome variables within the two groups, as shown in Table 1 and the sociodemographic variables of interviewed participants are shown in Table 2. No adverse events were reported during the study. The mean degree of participation in the IG was 3.69 ± 0.88, indicating relatively positive participation. The dropout rate was only 3.5% for 2 participants in the IG. The rate of homework participation in each session ranged from 55.6% to 66.7%.
Table 1.
Sociodemographic variables and baseline outcomes between two groups.
| IG (n = 56) | CG (n = 55) | χ2 /t | P | |
|---|---|---|---|---|
| Gender | ||||
| Male | 3 | 5 | 0.58 | 0.48 |
| Female | 53 | 50 | ||
| Only-child in core family | ||||
| Yes | 51 | 43 | 3.55 | 0.59 |
| No | 5 | 12 | ||
| Per capita monthly income (¥)* | ||||
| ≤ 1000 | 2 | 2 | 1.74 | 0.62 |
| 1001–2000 | 2 | 3 | ||
| 2001–3000 | 5 | 9 | ||
| ≥ 3000 | 47 | 41 | ||
| Residence place* | ||||
| Urban | 42 | 41 | 1.17 | 0.55 |
| Township | 11 | 13 | ||
| Rural | 3 | 1 | ||
| Part-time job experience related to nursing* | ||||
| Yes | 2 | 3 | 0.29 | 0.67 |
| No | 54 | 52 | ||
| Nursing as first major choice | ||||
| Yes | 39 | 42 | 0.63 | 0.42 |
| No | 17 | 13 | ||
| Family members working in health profession | ||||
| Yes | 11 | 13 | 0.26 | 0.65 |
| No | 45 | 42 | ||
| Age (year) | 21.30 ± 0.87 | 21.29 ± 1.43 | 0.60 | 0.43 |
| Professional identity | 54.46 ± 9.96 | 56.16 ± 10.77 | -0.85 | 0.39 |
| Professional self-efficacy | 91.56 ± 14.93 | 95.38 ± 16.99 | -1.24 | 0.21 |
| Stress | 7.50 ± 4.08 | 7.18 ± 4.75 | -0.375 | 0.71 |
Note: Income is valued in Chinese currency unit, with ¥2000 RMB≈ $314 USD. *The number of grids with theoretical number less than 5 exceeds 1/5, Fisher exact probability was applied.
Table 2.
Sociodemographic variables of interviewed participants.
| Age | Gender | Only-child | Residence place | Per capita monthly income | Part-time job experience | Nursing as first major choice | Family members in health profession | |
|---|---|---|---|---|---|---|---|---|
| 1 | 21 | Male | Yes | Urban | ≥ 3000 | No | Yes | No |
| 2 | 22 | Female | Yes | Rural | 1001–2000 | No | Yes | No |
| 3 | 21 | Female | Yes | Urban | ≥ 3000 | No | No | No |
| 4 | 21 | Female | Yes | Urban | ≥ 3000 | No | Yes | No |
| 5 | 22 | Female | Yes | Urban | ≥ 3000 | No | No | No |
| 6 | 23 | Female | No | Urban | 2001–3000 | No | Yes | No |
| 7 | 22 | Female | Yes | Township | ≥ 3000 | No | Yes | No |
| 8 | 21 | Female | Yes | Urban | ≥ 3000 | No | Yes | Yes |
| 9 | 21 | Female | Yes | Urban | ≥ 3000 | No | Yes | No |
| 10 | 21 | Female | Yes | Urban | ≥ 3000 | No | Yes | Yes |
| 11 | 21 | Female | Yes | Urban | ≥ 3000 | No | No | No |
| 12 | 21 | Female | Yes | Urban | ≥ 3000 | Yes | Yes | No |
Note: Income is valued in Chinese currency unit, with ¥2000 RMB≈ $314 USD.
Students in the IG reported that the participants were moderately and very satisfied with the intervention as well as each session, with the percentages of ‘not at all’ and ‘little’ being zero. They preferred the online delivery method (94.4%). The number in the facilitating group was rated as appropriate (96.3%).
4.2. Quantitative outcomes: professional identity and self-efficacy
The group effects, time effects and group-by-time effects obtained from the GLM are summarised in Table 3 and the effect sizes between and within groups are summarised in Table 4 based on the intention to treat principle. We performed GLM based on the per-protocol principle as a sensitivity analysis and the results showed no difference between those two since there were only two participants lost in the IG.
Table 3.
Group effect, time effect and group-by-time effect of qualitative outcomes.
| Variable | Group effect | Time effect | Group×Time effect | |||
|---|---|---|---|---|---|---|
| Wald χ2 | P | Wald χ2 | P | Wald χ2 | P | |
| Professional identity | 0.66 | 0.41 | 8.51 | 0.04 | 3.98 | 0.05 |
| Professional self-image | 1.48 | 0.22 | 19.12 | 0.00 | 3.89 | 0.05 |
| Benefit of retention and risk of turnover | 0.01 | 0.92 | 3.09 | 0.07 | 1.06 | 0.30 |
| Social comparison and self-reflection | 0.83 | 0.36 | 1.62 | 0.20 | 4.51 | 0.03 |
| Independence of career choice | 0.55 | 0.45 | 2.88 | 0.08 | 6.08 | 0.01 |
| Social modelling | 0.17 | 0.67 | 0.57 | 0.45 | 0.01 | 0.93 |
| Professional self-efficacy | 2.02 | 0.15 | 1.21 | 0.27 | 0.06 | 0.80 |
| Professional attitude and belief | 1.97 | 0.16 | 1.22 | 0.26 | 0.14 | 0.70 |
| Ability of problem-solving | 1.87 | 0.17 | 0.52 | 0.47 | 0.00 | 0.97 |
| Capacity of information collection and plan | 10.30 | 0.00 | 4.20 | 0.04 | 4.82 | 0.03 |
| Professional cognition | 2.28 | 0.13 | 0.86 | 0.35 | 0.01 | 0.94 |
| Professional value | 1.24 | 0.26 | 3.45 | 0.06 | 0.43 | 0.51 |
| Professional choose | 2.23 | 0.13 | 2.53 | 0.11 | 0.00 | 0.97 |
| Stress | 0.51 | 0.47 | 3.29 | 0.06 | 1.66 | 0.19 |
Table 4.
Changes and effect size between group comparisons for significant qualitative outcomes.
| M (SD) of IG | M (SD) of CG | CG-IG (95% CI) | Cohen d (95% CI) | |||
|---|---|---|---|---|---|---|
| Professional identity | T0 | 54.46 (9.96) | 56.16 (10.77) | 1.70 (−2.29, 5.69) | ||
| T1 | 61.54 (10.26)* * | 57.49 (10.85) | -4.05 (−9.36, −1.38)** | 0.38 (0.01,0.75) | ||
| Professional self-image | T0 | 17.56 (4.38) | 18.05 (4.10) | 0.50 (−1.33,2.33) | ||
| T1 | 21.74 (5.72)* * | 19.64 (5.27) | -2.10 (−3.93, 0.28)* | 0.38 (0.00,0.76) | ||
| Social comparison and self-reflection | T0 | 10.48 (1.77) | 10.82 (2.31) | 0.34 (−0.43,1.11) | ||
| T1 | 11.43 (2.15)* | 10.58 (2.00) | -0.84 (−1.61, −0.07)* | 0.41 (0.03, 0.79) | ||
| Independence of career choice | T0 | 6.78 (1.57) | 7.15 (1.52) | 0.37 (−0.22, 0.96) | ||
| T1 | 7.76 (1.79)* | 6.98 (1.45) | -0.68 (−1.28, −0.09)* | 0.48 (0.10,0.86) | ||
| Capacity of information collection and plan | T0 | 16.94 (2.77) | 16.56 (2.80) | -0.38 (−1.42, 0.66) | ||
| T1 | 18.54 (2.61)* | 16.51 (2.96) | -2.03 (−3.07, −0.99)* * | 0.73 (0.34, 1.11) | ||
Note: *P < 0.05, * *P < 0.01; * on MD indicates the significant difference within the group from T0 toT1.
For professional identity, the time effect and group-by-time effect were significant, and the three factors of professional self-image, social comparison and self-reflection and independence of career choice showed a significant group-by-time effect. After the intervention, the scores of overall professional identity and these three factors were significantly increased in the IG compared with the CG, with a small effect size from 0.38 to 0.48.
For professional self-efficacy, the group effect, time effect and group-by-time effect were not significant, except for one factor related to the capacity for information collection and planning. After the intervention, the capacity for information collection and planning was significantly increased in the IG compared with the CG, with a medium effect size of 0.73.
For stress, the group effect, time effect and group-by-time effect were not significant. The stress level was slightly decreased after the intervention in the IG (from 7.50 ± 4.08–5.78 ± 3.21) and in the CG (from 7.18 ± 4.75–6.89 ± 4.30), but the data were not statistically significant.
4.3. Qualitative findings
Twelve students in the IG were interviewed, covering different genders, places of residence, per capita monthly income, whether nursing was their first major choice and whether they had family members in the health profession.
4.3.1. Theme 1: Improvement in professional identity, self-recognition and peer belonging
Most students pointed out that the overall program was good, with an appropriate content design, feasible online form, time length and prepared facilitators. Sessions 2 and 3 of experience sharing were the most impressive, through which they gained mostly professional identity, self-recognition and a deeper sense of peer belonging.
The students stated that this program enhanced their professional identity and belief ‘after knowing how frontline nurses coped with daily stress and with the COVID-19 restrictions (P.1)’. Their professionalism prompted them to think more deeply about nursing as a career, particularly in ‘helping them for future career planning in a practical way that could be well planned’ (P.7). They could prepare in advance for the future following successful examples.
‘When choosing a career, it is important to know yourself (P. 9)’ and this program triggered ‘the motivation of re-examining ourselves (P.10)’. The intervention integrated social and alternative experiences to ‘prompt the students to look inside themselves to discover their own values’ (P.5). They learned from the invited senior students and peers and then practised. From a practical standpoint, during the clinical internship, they felt less stressed in adapting to the stressful atmosphere and some tried to ‘change the way of thinking to communicate better with the patients, which in turn promoted the self-affirmation of choosing nursing as a life career (P.8)’. This indicated a change from thinking to real practice.
The group intervention indeed promoted a deeper sense of peer belonging, especially in the context of the COVID-19 restrictions and the students were strictly required to commute only between hospitals and living dormitories. ‘I long for group belonging and normal social interaction. The first session reminded me of the importance of coming back to the group (P.5)’. The group sharing also promoted bonding among classmates, such as ‘some of us were shy, but this gave us an opportunity to get to know each other and to gain more courage from the positive feedback of others (P.1)’.
4.3.2. Theme 2: Content, self-motivation and intervention as participation facilitators
The students pointed out several important facilitating aspects of participation, including the content of the program, the motivation of the students themselves and the good performance of the intervenor.
The resonance of the topics in each session, the authenticity of the shared experience and the authority of the sharer were important when designing each activity. ‘The development trajectory of the successful intervenor has much in common with my situation, which made me feel connected (P.12)’. The vivid experiences of the frontline nurse were believable and thus, ‘it is easy to be drawn into that situation’ (P.6). Most students thought that ‘experience from a head nurse or senior nurse is reliable’ (P.7).
‘How much we were interested in the program and identified with a career in nursing influenced how much were devoted to the intervention (P.2)’. These factors greatly determined the extent of internal self-motivation that motivated them to participate in each activity and then internalise and retain the content of the program.
‘The group interaction is well organised by the intervenor, which is effective in handling session connections, group sharing and group discussions (P.4)’. The intervenor’s capability and qualifications were undoubtedly key factors in attracting students’ attention and maintaining retention. ‘Especially when participating online, it was more challenging for the intervenor to conduct one-on-one guidance and encourage mutual sharing (P.5).’ The trust between the intervenor and students increased, as ‘the degree of participation increased as the program progressed (P.12)’.
4.3.3. Theme 3: Combining offline and online courses, setting group rules and building mutual trust as recommendations
Although well-designed, the students proposed several recommendations for future implementation. The online method was acceptable during the COVID-19 restrictions when it was not possible to communicate face-to-face, but combining online and offline methods were recommended. ‘Because face-to-face contact will increase intimacy and facilitate group sharing (P.5)’. Moreover, this program had the potential to be embedded into school courses, such as ‘Nursing Aesthetics or Introduction to Nursing, which also contained parts about the meaning of the nursing profession (P.4)’.
The program set up several group rules, such as a group slogan, signing up at each session, at least one group discussion or sharing in each session and weekly homework to ensure loyalty and participation. The students suggested ‘setting puckish punishment for arriving late (P.2)’, ‘assigning members homework sharing in advance (P.11)’ and ‘informing the participants of the session activity at least one day in advance (P.7)’. This may help to strengthen group rules, especially when conducting online interventions.
The trust among team members and between team members and interveners were determinants of group dynamics. ‘If the members are not familiar with each other, it is difficult to mobilise discussion (P.3)’. This study grouped the students based on the internship hospital, but ‘a minority were not familiar with other group members' (P.12)’. Moreover, the unfamiliarity between students and the intervenor ‘extended the awkward sharing time and decreased the effectiveness of the interactions (P.2)’. Thus, building mutual trust and familiarity was essential at the very beginning.
5. Discussion
In this study, an online 5-week group intervention program was developed and evaluated; it was based on a combined theoretical framework of SIT and CSET that aimed to improve professional identity and capacity for information collection and career planning among nursing students in clinical internship practice during the COVID-19 restrictions. In general, the results of this study indicated that the program was effective in promoting the professional identity and capacity of professional information collection and professional plans of nursing students. The findings of this study are consistent with previous studies targeting the professional identity improvement of nursing students. For example, Wang et al. developed a professional identity promotion strategy (PIPS) where the key intervention elements were new insights, knowledge and experiences of changes in attitudes towards the nursing profession by the public and society and evaluated the effectiveness among sophomore nursing students. (Wang et al., 2022) Xu et al. managed to improve the professional identity of nursing students in clinical internship practice through a 5-time cognitive intervention, which showed effectiveness in promoting professional identity and career self-efficacy. (Xu et al., 2019).
Although many efforts have been made to promote the professional identity of nursing students, the program we developed in this study still contributed to existing research and practice in the following aspects. In terms of intervention mechanisms, instead of focusing on changing the internal cognition of students by guiding positive professional cognition (Xu et al., 2019) or exploring the positive emotions and subjective experiences of happiness, (Ning et al., 2019) we emphasised the internalisation of external factors, for instance, the effect of experience, role modelling and social image of nursing through social comparison and encouraged students to show the change in their self-portraits and career planning. In terms of the intervention delivery approach, we adopted the online method, which proved to be highly effective and accepted by students. Online programs could overcome spatial constraints and be practical during the restrictions. (Brouzos et al., 2021, Zhang et al., 2021a, Zhang et al., 2021b) Some students proposed that online and offline approaches should be combined, which requires future work to modify the program and find a balance between online and offline approaches in our future implementations. In terms of intervention content, compared with traditional lectures and discussions, our programs were student-centred and group-based, involving more interaction activities between students, such as sharing current experiences about COVID-19, interviewing, showing self-portraits and mutual encouragement. Feedback from students also suggested that interaction activities were the key attraction to them and group sharing prompted internalising the intervention content.
Specifically, analysing the relationship between intervention elements and promoted outcomes, this study significantly improved ‘professional self-image’, ‘social comparison and self-reflection’, ‘independence of career choice’ of professional identity and ‘capacity of professional information collection and professional plan’ of career self-efficacy. The improvement in ‘professional self-image’ and ‘social comparison and self-reflection’ might be related to both direct experience (their own practice experience) and substituted experience (frontline COVID-19 experience sharing), as well as through qualitative feedback. Additionally, the outbreak of COVID-19 has put nursing in the spotlight more than ever. Many nurses have been dedicated to combatting the restrictions with professional knowledge and skill as well as noble moral standards, which has led society to reverse the stereotype of nurses and the nursing profession to some extent; for example, images of nurses being ‘doctors’ helpers’ and nursing as the ‘doing’ profession (ten Hoeve et al., 2014). Overall, the public's recognition of the value of the nursing profession has improved. (Wang et al., 2021) The improvement in ‘independence of career choice’ of professional identity and ‘capacity of profession information collection and professional plan’ of career self-efficacy could be partly due to our target population in this study. As they were all senior students, they were most concerned with the career choice that they would soon face. Additionally, both modules (‘role modelling’ in the second week and ‘mentor reflecting’ in the fourth week) included content related to career choices where senior nurses were invited to share their career map, which increased the confidence of students to make career choices.
Stress has been proven to be negatively related to professional identity (Zhao et al., 2021). Our study found that the program was likely to decrease the stress level at the same time that professional identity was improved. However, no difference was observed in stress between the IG and CG. One reason might be that dealing with stress took up only one activity in the module on “Easy coping”. Another reason might be that the stressors of the target population in this study were multiple, including the role change from students to clinical intern nurses, career decisions, graduation thesis and, most importantly, the changes in learning and lifestyle caused by epidemic public control policies. (Wang and Wang, 2020) Several investigations reported that nursing students had been going through psychological issues during the restrictions, (Tanji and Kodama, 2021, Wang et al., 2020) which implies that more targeted measures, such as online cognitive intervention, should be included in the program as a stress mitigation effort.
5.1. Strengths and limitations
In this study, we used the MRC framework to guide the development of our program. The implementation process followed a rigorous methodology to ensure that the results were reliable. To the best of our knowledge, this is the first trial among nursing students during the COVID-19 restrictions. There are still several limitations. First, we included only nursing students who were undergoing clinical internships. Future studies should include students in other grades and test the effectiveness of the intervention. Second, we did not follow up on the outcome and future career choices after intervention could be considered an outcome indicator. Third, due to the relatively small sample size, we did not examine whether there were any differences between different subgroups, for example, by gender. Fourth, the intervention was delivered by a single, nonblinded qualified psychological nurse and the nurse’s experience may have influenced the effect sizes of the intervention. Future research should involve different facilitators to test the effectiveness of the intervention, which was indicated by qualitative feedback. Fifth, the quantitative outcomes were self-reported, which may produce self-reported bias. As an online questionnaire was used, this ensured independence in reporting data. Additionally, the professional identity emphasised to the students that the data were only for research analysis and whether it was positive was meaningful at each measurement point. This might help to decrease the bias. Finally, this study was conducted in one nursing school, which may limit its external validity. Future research should conduct a multicentre study.
5.2. Implications
Undergraduate nursing students are required to take at least 8 months of clinical internship practice before they can take the Nurse Qualification Certificate examination and become registered nurses. During this process, nursing students will face the gap between the ‘real world’ and the ‘textbook’ as well as their expectations, thus affecting their professional identity. If timely intervention can be made at this critical stage to improve the professional identity of nursing students, it will help them to make a firm determination to become nurses in their upcoming career choice to alleviate the current situation of nurse shortages to some extent. Therefore, we attempted to improve the professional identity of nursing students through an online structured support program. The findings provide evidence for clinical nursing tutors and other educators to integrate this program into clinical training for nursing students. In addition, we designed a structured program because we hoped it could be implemented and popularised in more schools to increase professional commitment and potentially fill the gap of nurse shortages. One concern is that the intervention was carried out in students' spare time in this study, which may not be feasible in some countries. Fortunately, this is an online program with a high degree of freedom in time and location. Nursing educators in other countries could retain the structure and content of the program and conduct it at appropriate timing based on the characteristics of their undergraduate nursing education programs.
6. Conclusion
In conclusion, we constructed a systematic and easily implemented 5-week online professional identity program for nursing students in clinical internship practice. We proved the effectiveness of this program for improving professional identity and the capacity for information collection and career planning and the target population showed a high level of acceptance. Nursing educators may take it as an auxiliary strategy to enhance professional identity in addition to class-based teaching and clinical practice during and after the COVID-19 restrictions.
Ethical approval
The study was approved by the Institutional Review Board, School of Nursing, Fudan University (20200504).
Funding statement
This work was supported by the Fudan University-Fuxing Nursing Research Fund (FNF202029) and the Educational Science Foundation of Fujian Province during the 14th Five-Year Plan Period (FJJKBK21-043).
Clinical trials registration number
https://register.clinicaltrials.gov; (NCT04416074).
Funding
Fudan University-Fuxing Nursing Research Fund (FNF202029), the Project of 2021 Supported By Educational Science Foundation of Fujian Province During the 14th Five-Year Plan Period (FJJKBK21–043).
CRediT authorship contribution statement
Anni Wang: design, implementation, paper drafting. Fulei Wu:data interpretation, paper drafting, commuting. Cen Lin:design, data interpretation. Ming Wu: design, intervention development. Shoumei Jia: design, intervention development. Yufang Guo: intervention development, funding preparationWen Zhang: design, intervention development, funding preparation Feifei Huang: design, intervention development, funding preparation.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We are very grateful to the participants who participated in the trial. We thank all the experts for offering their feedback during the development of the intervention.
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