Professional Identity During the COVID-19 Pandemic: A Cross-Sectional Survey of Nurses in China

This was a self-reported, cross-sectional study conducted from February 17 to March 2, 2020. The study was approved by the Biomedical Ethics Review Committee of West China Hospital, Sichuan University. The survey measure was first uploaded to an online questionnaire system (Wenjuanxing, https://www.wjx.cn/) and the questionnaire link was then posted on a large Chinese social media platform (WeChat, https://weixin.qq.com/). Nurses currently working in an emergency department or ICU were invited to participate in the electronic survey. Participation was anonymous, and completion of the survey was considered consent to participate. Internet protocol (IP) address restriction technology was adopted to ensure that users with the same IP address could complete the questionnaire only once.

The Professional Identity Scale for Nurses (PIS) is a 30-item survey developed by Liu et al²⁴  to evaluate the PI of Chinese nurses. The instrument is a 5-point Likert scale comprising 5 dimensions:

• Professional identity evaluation: 9 items assessing nurses’ views on the significance and value of nursing, their beliefs and feelings about the nursing profession, and their perceptions of person-job matching

• Professional social support: 6 items referring to recognition and support from patients, nursing and medical colleagues, managers, and significant others like family members

• Professional social proficiency: 6 items referring to sense of control in interpersonal communication and cooperation in adapting to the complex professional working environment

• Dealing with professional frustration: 6 items assessing the cognitive style and action mode adopted while encountering professional frustrations, reflecting the effectiveness and tenacity of coping with occupational stress

• Professional self-reflection: 3 items referring to self-exploration, self-correction, and critical judgment in work, a process of in-depth cognition and understanding of self and occupation

Total PIS scores range from 30 to 150, with higher scores indicating a higher PI level. Total scores of 60 or less are designated as a poor level of PI; greater than 60 through 90, a low level; greater than 90 through 120, a medium level; and greater than 120, a high level.²⁴  Confirmatory factor analysis showed that PIS has good structural validity. The internal consistency Cronbach α was 0.938 for the total scale and 0.720 to 0.911 for the 5 dimensions.²⁴  Liu et al^14,25  also established a PI norm based on a survey of 524 clinical nurses recruited by stratified cluster sampling from 9 hospitals of different levels in Shanghai, China.

Demographic and professional data included sex, age, marital status, education level, years of nursing experience, job title, position, and work on the front line of COVID-19. We added 2 open-ended questions at the end of the questionnaire to collect a richer and more vivid description of participants’ feelings and perspectives under the COVID-19 pandemic. The first question asked how each respondent felt as a nurse when witnessing the COVID-19 pandemic; the second asked how each respondent felt if participating in frontline work.

Demographic and professional data and responses to open-ended questions were summarized with descriptive statistics. Analysis of variance and t tests were used to examine differences in PIS dimensions and total mean scores among participants with different demographic and professional characteristics. These tests were also used to analyze the differences between the results of this study and the PI norm established by Liu et al.¹⁴  The Pearson χ² test was used to analyze the total mean score distribution differences between the results of this study and Liu’s PI norm.²⁵  Data from the open-ended questions were analyzed with viewpoint extraction and coding, theme generation, and rechecking. The text was analyzed by 2 investigators independently and checked by a third investigator. Disagreements were resolved by discussion. Statistical analyses were performed using SPSS, version 22.0 (IBM), and statistical significance was set at P less than .05. All tests were 2-sided.

Among the 1323 complete responses, most participants were female and had a bachelor’s degree or higher. The mean (SD) age was 30.2 (6.2) years (mode, 30 years; range, 16-59 years) and the mean (SD) years of nursing experience was 8.67 (7.09) years (mode, 10 years; range, 0.5-40 years). More than half of the participants worked on the front line of the COVID-19 response (Table 1).

The total mean (SD) score for PI was 113.68 (23.92), at the medium level of PI according to the interpretation of Liu et al²⁴  (Table 1). In total, 1093 participants (82.6%) scored at the medium level or higher, with 537 (40.6%) scoring at the high level (see Figure). The item mean scores for the 5 PIS dimensions ranged from 3.57 to 3.96, all at an above-medium level (Table 1). In the subgroup analyses, significant differences were identified among nurses in different age groups (P < .05) and with or without a management position (P < .01) (Table 1).

The total mean score and item mean scores for all 5 dimensions of PI in this study were significantly higher than Liu’s PI norm¹⁴  (P < .001; Table 2). Of the 5 dimensions, the greatest difference in the item mean score was in PI evaluation (3.57 in this study vs 2.88 in Liu’s study; Table 2). The difference in the PI level distribution between participants in this study and Liu’s study²⁵  was significant (P < .001), and the percentage of participants in the high-level group was significantly higher in this study (40.6%) than in Liu’s study (4%) (see Figure).

Regarding the open-ended questions, 607 participants responded to the first question (how they felt as nurses when witnessing the COVID-19 pandemic) and 523 responded to the second question (how they felt if they participated in frontline work). Of the respondents to the first and second questions, 68.9% and 83.9%, respectively, expressed viewpoints related to the formation of positive PI (Table 3). The major themes identified were a sense of professional and social responsibility and accountability, actively dealing with setbacks and frustrations, a sense of professional value and fulfillment, social support, concerns about the nursing profession, and emotional reactions. The first 4 of these themes were associated with positive PI changes (Table 3).

Overall, our results revealed that during the COVID-19 pandemic, the PI of emergency and ICU nurses was at a medium level. The PIS total mean score and the mean scores of the 5 dimensions were significantly higher than the norm reported by Liu et al,¹⁴  indicating that there were positive changes in all the aspects of PI. However, PI still did not reach an ideal level for emergency and ICU nurses with challenging professional responsibilities at the critical time of the COVID-19 pandemic outbreak. Targeted PI-promoting interventions to better prepare this group of nurses to cope with delivering care during crises such as future pandemics are indicated.

Subgroup analyses revealed no significant differences in PIS total mean scores or item mean scores of each dimension among participants of different sexes, years of nursing experience, marital status, educational levels, or job titles, a finding that is consistent with those of previous studies.^26,27  Most studies with participants of different sexes reported that male nurses had a lower level of PI.^28,29  The lack of any significant difference in PI between male and female nurses in our study might indicate that male nurses have not only a physical advantage over female nurses but a psychological advantage of being more valued and recognized in the ICU and emergency department, especially at the critical time of the pandemic outbreak. Although nurses generally become more professionally mature and competent with increasing years of nursing experience and with senior differences in PI among participants with different years of nursing experience and job titles. The reason for this finding might be that PI does not reflect only professional proficiency; rather, it is a set of traits shaped by personal, familial, social, and institutional factors.^29,31  Findings on the influence of marriage on nurses’ PI have not all agreed. Some researchers found that increased family burden may reduce nurses’ PI level,³²  and others reported that married nurses were more committed to their profession.²⁶ 

Results of some studies indicated that lower educational levels were associated with higher PI levels.^33,34  In our study, however, we found no significant differences among nurses of different educational levels. The reason might be that hospitals in China are paying much more attention to the cultivation and retention of highly educated nurses than ever before, making those nurses feel valued.³⁵  In our study, participants in the 25- to 34-year age group scored significantly lower in the dimensions of professional social support and PI evaluation than did those older than 35 years. The reason may be that 25- to 34-year-olds have comparatively higher life and work pressure because they are at the beginning or growing stages of their careers, establishing families, and having children. However, participants older than 35 years might be more mature in their professional life, and some may already be in management positions and have a relatively stable professional mindset.^25,36  Compared with nurses not in management positions, those in management positions reported a significantly higher level of PI, as in other studies.^25,37  Holding a management position might enhance the sense of fulfillment and overall self-confidence.²⁹  The interplay of these demographic and professional factors in shaping PI development warrants further exploration.

For a long time, the PI of Chinese nurses has been at medium and low levels³¹  and even lower for emergency and ICU nurses.^22,23  It is encouraging that our study participants’ mean total PI score was significantly higher than the norm established by Liu¹⁴  and by other studies^27,38,39  and that more than 40% of our participants had a high PI level. More importantly, the largest difference from Liu’s results in the item mean score was in the dimension of PI evaluation (3.57 vs 2.88), indicating a fundamentally positive PI change in emergency and ICU nurses during the COVID-19 pandemic. Several possible explanations are reflected in our participants’ responses to open-ended questions. As listed in Table 3, of the 6 major themes identified, the top 4 (sense of professional and social responsibility and accountability, actively dealing with setbacks and frustrations, sense of professional value and fulfillment, and social support) were helpful for positive PI formation.

During the COVID-19 pandemic, the public and media strongly affirmed nurses’ bravery, altruism, and value. Frontline nurses were called “the most beautiful heroes heading for danger,” which largely enhanced the public image of nurses. Studies have shown that nurses’ professional self-perception can influence their PI formation,^21,40  and a negative perception by the public can affect nurses’ self-perception.²¹  Praise from the public during the pandemic has brought nurses more respect and recognition, which might have prompted them to reexamine their profession and form a positive perception. Studies have shown that feelings of achievement and being valued contribute to self-esteem and confidence, which influence coping strategies.^41–43  Studies on the correlation between social support and PI also support this explanation: nurses’ PI is influenced more by the public than by their family members.⁴⁴ 

For both frontline nurses and nurses not on the front line, responses to open-ended questions indicated that they actively dealt with setbacks and frustrations. The most common comments from frontline nurses were “As professional nurse[s], we cannot flinch from the virus. Only by facing [the situation] bravely can we save those patients”; “The more difficult [the situation], the more [we move] forward”; and “We must learn to thrive on problems.” Nurses not on the front line emphasized that although they were not on the front line, they would try their best to stick to their posts and be ready to go to the front line at any time. Additionally, participants, especially frontline nurses, stated that they felt that they had become more mature not only in professional skills but also in their views on life and the nursing profession. They were also psychologically more resilient.

In the responses to open-ended questions, both frontline nurses and nurses not on the front line most often mentioned increased professional and social responsibility and accountability. Frontline participants wrote, “Fighting against the pandemic is the duty-bound responsibility of every nurse” and “[I would] sacrifice myself to contribute to society.” Although confronted with considerable challenges and uncertainties, especially the risk of being infected, participants in this study expressed a strong desire to work on the front line. “Ready to go at any time,” “I want to go on the front line to fight with my colleagues side by side,” and “Feel regret that I may have lost the only chance to go on the front line to do something in my nursing career” were frequently reported feelings for nurses who were not on the front line. Although their work brought hardship and uncertainty, most frontline nurses expressed feeling the meaningfulness of their work, a strong sense of pride and fulfillment, and gladness that they could play a role. They may serve as vivid examples for other nurses to inspire internal moral motivation, deepen their professional cognition, and contribute to positive PI formation.^45,46  People choose nursing as a profession because they want to help others.⁴⁷  The goal of wanting to help people defines how nurses view themselves and their work.⁴⁸  As a major force in fighting against the pandemic, nurses have played an irreplaceable role. From their innermost hearts, they realize the difference nurses can make and the value their work can bring to society and humankind. Moreover, positive evaluation and recognition from patients and the public and more care and support from family, colleagues, and managers may have contributed to the positive PI change, particularly in the professional social support dimension.

Overall, our survey findings suggest that the COVID-19 pandemic had a positive effect on the PI of emergency and ICU nurses. The changes and underlying mechanisms identified confirm that “professional identity emerges through a process of self-formation, in which social interaction and self-reflection are basic processes.”⁴⁹  Nevertheless, participants reported experiencing negative emotional reactions such as pain, distress, worry, fear, powerlessness, and helplessness. Some participants also expressed their concerns about the nursing profession: the lack of good recognition, respect, and value; the heavy workload, high work pressure, and shortage of nursing personnel; the risky, stressful working environment; and the need to expand the nurse’s role, such as being public health educators. These factors may also explain why the PI of our participants improved significantly but remained at a medium level. Additionally, participants suggested pandemic prevention and control measures and expressed wishes for overcoming the pandemic, the well-being of humankind, and their awe of life.

One of the unexpected findings of this study was that PI scores of frontline nurses did not differ significantly from PI scores of nurses who were not on the front line. This finding may be related to the nature of the work and environment of the emergency department and ICU. The emergency department has the highest risk for occupational exposure in the hospital, and the most severely ill patients are cared for in the ICU. The working environment is stressful, complex, and changeable, and nursing work is characterized by urgency, a heavy workload, high risk, and uncertainty.¹  Although some emergency and ICU nurses did not directly participate in caring for patients with confirmed COVID-19, they were still at the forefront of the health care system, bearing almost the same risks and physical and psychological stresses, and they also obtained increased public recognition during the COVID-19 pandemic. One other possible reason might be positive feedback from their frontline colleagues. The positive public response to nurses during the pandemic might have prompted them to think about the meaning of nursing and the value of nurses.

This study has several limitations. First, the survey was conducted as the pandemic was building, and the results do not reflect nurses’ PI at other stages of the pandemic. A longitudinal design would be required to explore the long-term impact of the COVID-19 pandemic on nurses’ PI. Second, to compensate for the insufficiency of the questionnaire survey we added 2 open-ended questions, but information mining was still limited compared with in-depth interviews. We suggest a well-designed qualitative study to more fully understand the implications, connotations, and changes in emergency and ICU nurses’ PI during a severe public health emergency. Third, the convenience sampling adopted in our online survey may have caused some bias, but our large sample size helped reduce this bias. Fourth, because PI is culturally shaped and influenced by multidimensional factors, generalization of our findings to emergency and ICU nurses with other sociocultural backgrounds needs to be done with caution.

To our knowledge, to date in China no relevant research has been conducted concerning the PI of emergency and ICU nurses during major public health emergencies. In addition, we innovatively included both frontline participants and participants who were not on the front line for comparison. Social evaluation and recognition and a sense of professional value and fulfillment are important to shaping nurses’ PI, as we found in our study. To reduce turnover and stabilize emergency and ICU nursing teams, we suggest designing and implementing targeted PI-promoting strategies such as improving nurses’ social status, enhancing the nursing profession’s public image, exploring new areas of practice and new professional roles, and optimizing the appropriate use of different levels of nurses.