Association between professional identity and humanistic caring ability in Chinese nursing students: a cross-sectional study in Changsha, Hunan, China

Abstract Humanistic caring (HC) is a key ability that nurses need. We aimed to explore factors related to humanistic caring ability (HCA) among Chinese nursing students and the association between professional identity (PI) and HCA. A cross-sectional survey was conducted. HCA of Nursing Undergraduates Assessment Scale (HCANU) and PI Scale for Nurse Students (PIQNS) were displayed. Linear regression analysis and Pearson correlation analysis were used. Education (β=-.161, P = .009), dimensions of professional self-image (β=.271, P = .028), career choice independence (β=.228, P < .001), and social comparison and self-reflection (β=-.102, P = .180) were independent predictors of HCA. PI (r = .578, P < .001) was associated with HCA. An association between PI and HCA has been found among nursing students. PI is an important consideration in the development, implementation, and evaluation of interventions for HCA.


Introduction
Caring, which is associated with humanistic care, is an essential core element of nursing. (Foth, 2013). Humanistic caring ability (HCA) is not only an external manifestation of the humanistic caring concept but also one of the core abilities that nurses have to possess (Li et al., 2017). Humanistic care emphasizes people-oriented care, which is the essence of nursing (Y. Z. Hao & Peng, 2016). Nursing humanistic care ability was a concrete embodiment of nurses' humanistic values in clinical practice (Watson, 2007). Humanistic nursing care addresses patients' expectations and places more emphasis on the relationship and interaction between nurses and patients. One study showed that nursing was the experience of interpersonal interaction, and nurses with good HCA were able to respond to the needs of others based on their awareness and empathy (Paterson & Zderad, 1988). However, the implementation of humanistic care in hospitals has been hindered by several factors, such as differences in workplaces, increasing workload of clinical nurses, shortage of nursing human resources, and low quality of nurses. To solve these problems, it is more important to improve the HCA of nurses in addition to reasonably increasing staffing and reforming the management mode.
The importance of humanistic care in modern medicine has been well-recognized worldwide. Nursing students are an important reserve force in the nursing field, and their HCA will directly affect the quality of nursing services and the overall quality of nursing teams in the future (Y. Wang et al., 2020). Therefore, the development of HCA is a big challenge (Y. Y. Chen et al., 2011). The cultivation of nursing students' humanistic care ability mainly depends on school education. In many developed countries, the cultivation of HCA has been incorporated into the curriculum of medical education (Qingbo et al., 2015;Song & Tang, 2017). However, educators in medical education in China have not paid much attention to the cultivation of humanistic ability. The implementation of humanistic care has been relatively backward (Tang, 2017). Therefore, we should consider cultivating nursing students' humanistic abilities.
Studies showed that humanistic care in nursing practice was related to professional satisfaction and achievement (Aiken et al., 2014;Buckley, 2014;Nelson, 2011). Nursing students' love for the nursing profession is also a positive professional identity (PI) that is the foundation and internal motivation for implementing humanistic care. PI is the self-concept of professionals, the recognition of the professional role given by the society, the heartfelt acceptance of the occupation, and the positive perception and evaluation of it (Guo et al., 2018). Nurse PI refers to nurses' selfaffirmation of the nursing profession, which represents the values and beliefs they hold for the nursing profession and guides their thinking, actions, and interactions with patients (Fagermoen, 1997). PI is a dynamic process of continuous change that mainly develops during the college period. (Ashby et al., 2016;Lydia et al., 2016). Some findings have shown that a strong sense of identity can influence an individual's thinking, emotions, and behaviors (Ashforth et al., 2008;Tian & Zhang, 2016). Incorporating caring into nursing education not only provides students with a deep understanding of the nursing profession and helps them establish professional values as early as possible, but also helps nursing students experience a sense of achievement by serving patients (Guo et al., 2018). PI can help to build harmonious relationships between patients and nurses. It may also positively impact nurses' job satisfaction and play an important role in improving their sense of humanistic caring abilities (Amendolair, 2012;Qiu, 2014;Xiaoli et al., 2021). However, the association between PI and HCA has not been clearly explained.
We speculated that understanding the role of PI in humanistic care ability and related factors that affect humanistic care ability may help teachers in both schools and hospitals learn how to cultivate nursing students' humanistic care ability. However, there is a lack of correlational studies between PI and humanistic care ability among nursing students, and little is known about how PI and humanistic care ability influence each other. Thus, this study aimed to explore the association between PI and humanistic care ability among Chinese nursing students and explore the factors related to HCA among nursing students. Our study offers novel approaches for educators to target problem areas that require specific interventions to improve Chinese nursing students' humanistic care ability.

Design
A cross-sectional study was conducted.

Settings and participants
Convenient sampling was conducted to select patients from 7 tertiary hospitals, 10 secondary hospitals and 15 primary healthcare services from June to July 2021 in Changsha, Hunan Province, China. In China, there are three levels of nursing students. Junior college nursing students refer to those who continue to study for three years after graduating from high school to cultivate professional nursing skills. Undergraduates refer to students who continue to study for a bachelor's degree for four years in nursing after graduation from high school. The purpose of undergraduate education is to cultivate specialized talents with basic theoretical knowledge and skills of nursing, and to be able to engage in clinical nursing, nursing management, nursing teaching, and so on in the nursing field. Postgraduate students refer to those who continue to study for a master's degree in nursing after graduation from the undergraduate course, in order to cultivate high-level, application-oriented and specialized nursing professionals with the ability to independently solve common nursing problems in the nursing field, stronger clinical analysis and thinking ability, scientific research ability and educational and teaching ability. All levels of nursing students were selected in this study. The inclusion criteria were as follows: (i) full-time nursing students, (ii) internship time of more than or equal to one month, and (iii) volunteering to participate in this study. The questionnaires were collected by uniformly trained researchers in a clinical setting. A total of 985 students met the inclusion criteria, and 981 students participated in the survey. Before the investigation, the researchers explained the purpose, significance, and investigation procedures, as well as the principle of study anonymity. Participants volunteered to participate in the study, and the investigator promised that their learning of nursing clinical practice would not be affected if they refused to complete the questionnaire. After signing an informed consent form, the researchers sent out paper-based questionnaires to the participants, collected the questionnaires on the spot, checked whether the questionnaire was complete, and filled in the missing items on time. A total of 981 valid questionnaires were collected, and the effective recovery rate was 100%.
The study had been approved by the Ethics committee of the Third Xiangya Hospital of Central South University (No: expedited review I 21,064).

Measures
Demographic questionnaire. The questionnaire was designed according to the purpose of the study, including gender; age; home place; annual household income; whether only child in family or not; education level; clinical practice time; experience in being a student leader; experience in school club and experience in organizing activities.

HCA of nursing undergraduates assessment scale (HCANU)
Compiled by Yibing Huang (Y. B. Huang, 2014), the HCANU contains eight dimensions and 45 items: instillation of faith and wish (9 items), healthcare education (7 items), formation of humanisticaltruistic values (6 items), scientific solution of health problem (4 items), assistance with the fulfillment of essential needs (4 items), provision of a good environment (5 items), promotion of empathetic communication (5 items) and help to overcome difficulty (5 items). Instillation of faith and wish refers to nursing staff encouraging and supporting patients to build confidence, and is full of beautiful ideas and pursuits for curing diseases and promoting health; healthcare education refers to nurses providing patients and other people with the necessary information to promote their self-care and health. Formation of humanistic-altruistic values involves the ideological state of contentment that nurses obtain when they respect human value and individual independence and consider for the interests and conditions of patients in the process of caring; Scientific solution of health problem is linked to the nurses' application of the principle and concept of scientific problem-solving to the assessment, planning, implementation and evaluation stage of nursing procedures in order to make the best decision and help solve health problems; Assistance with the fulfillment of essential needs is related to the nurses' ability to understand and confirm the physical, psychological and social needs of patients, and take appropriate methods to timely meet their needs; Provision for good environment requires the nurses to provide a supportive, protective, or corrective environment for patients in physical, psychological, social, and spiritual terms; Promotion of empathetic communication ask to the nurses use communication skills to communicate thoughts, exchange views and share experiences with patients by accepting and expressing positive or negative emotions, so as to establish harmonious interpersonal relationship; Help for overcoming difficulty requires the nurses use phenomenological methods to understand patients' experiences, views and accept patients' behaviors of seeking spiritual sustenance and spiritual support, so as to establish a harmonious nurse-patient relationship. It was measured using a 5-point Likert scale. From "completely disagree" to "completely agree" is 0 ~ 4 points in order. Among them, items 5, 6, 7, 20, 22, 29, 31, 33, 37, and 39 are reverse scores. The higher the score, the stronger the HCA of nursing students. The ratio of the participants' score to the full score of the questionnaire was the scoring rate, and the level was evaluated based on it. The scoring rate was divided four groups: poor (＜60%), medium (60% ~ 79%), good (80% ~ 90%), and excellent (>90%). The Cronbach's α coefficient of the scale was .904, and the Cronbach's α coefficient of each dimension was .639 ~ .842.The half-fold reliability was .925 and the content validity was 0.60.

PI scale for nursing students
The scale was designed by Yufang Hao in China (Y. F. Hao, 2011). It was used to assess nursing students' professional identities. The scale contains 17 items and five dimensions: professional self-image (6 items), retention benefit and risk of turnover (4 items), social comparison and selfreflection (3 items), career choice dependence (2 items), and social modeling (2 items). Professional self-image refers to the understanding, belief and emotion of nursing students to the nursing profession. Retention benefit and risk of turnover refer to the fact that nursing students can clearly understand the benefits brought by retention to themselves and their related people, as well as the risks brought by resignation to their future. Social comparison and self-reflection mean that nursing students can promote the development of their PI through proper social comparison and serious self-reflection. Career choice dependence refers to the social and cultural background in our country influences nursing students' PI. Social modeling means that nursing students can promote the development of their PI through the experience of successful people. The response for each item is graded on a 5-point Likert scale: 1=strongly disagree to 5=strongly agree, higher scores indicate stronger PI. A previous research showed the reliability and validity of scale was acceptable, the Cronbach's α coefficient of the scale is .827, and the half-fold reliability is .842.

Data analysis
Two researches input the data into Epidata software simultaneously to ensure the accuracy of the data. Statistical analysis was conducted using SPSS 23. Descriptive statistics were used to describe the nursing students' baseline characteristics, and their level of HCA and PI. T-tests, analysis of variance and the Kruskal-Wallis H test were used for the univariate analysis. Multiple linear regression analysis was conducted to analyze the independent factors of HCA. Pearson correlation analysis was used to determine the correlation between PI and HCA. The statistical significance level of this study was set at .05.

General characteristics of surveyed clinical nursing students
A total of 981 Chinese nursing students participated in the study. There were 291 (29.7%) junior Chinese nursing students, 591 (60.2%) undergraduates and 99 (10.1%) post-graduates; 93 were male and 888 were female, with age (M = 20.86, SD = 2.17). The major characteristics of the 981 participants in the study are presented in Table 1.

Chinese nursing students' HCA and PI
Details of HCA and PI for 981 Chinese nursing students are displayed in Table 2. The mean scores for HCA and PI were 125.94 ± 21.19 (the scoring rate: 69.97%), 62.32 ± 11.23, respectively. Table 3 shows the results of the association between HCA and PI. PI was positively correlated with HCA respectively (r = .578, P < .001), and the relationship was only moderate. Each dimension of PI was positively associated with HCA. In addition, the four dimensions of PI were not found to be significantly associated with the dimensions of provision of a good environment in HCA. And the four dimensions of PI Professional self-image, Retention benefit and risk of turnover, Independence of career choice and social modeling in PI were not found to be significantly associated with the dimensions of help for overcoming difficulties in HCA. Table 4 presents the results of univariate analysis of Chinese nursing students' HCA. Male Chinese nursing students (9.63 ± 2.87) scored higher in the dimension of provision of a good environment in HCA than did female nursing students (8.46 ± 2.52), P = 0.017. Within the annual household income variable, statistic significance can be found in in HCA and the dimension of healthcare education of HCA, P = 0.044, P = 0.049 respectively. The scores of junior nursing students were higher than those undergraduates and postgraduate students in the dimensions of instillation of faith and wish (27.71 ± 5.42, 26.32 ± 5.08, 24.50 ± 6.33 respectively, p = 0.003), the formation of humanisticaltruistic values (19.09 ± 3.65, 18.01 ± 3.84, 17.44 ± 3.87 respectively, p = 0.015) and assistance with the fulfillment of essential needs (11.62 ± 2.33, 10.82 ± 2.03, 10.41 ± 2.24 respectively, P = 0.06). Students with no experience in being a student leader (18.84 ± 3.76) had higher score compared with those experience (17.90 ± 3.78) in the dimension of formation of humanisticaltruistic values, p = 0.028. Students with no experience in school clubs had higher score (8.73 ± 2.55) than those experienced (8.00 ± 2.59), p = 0.033. Students with no experience in organizing activities (11.02 ± 2.58) scored higher than those experience (10.38 ± 2.63) in the dimension of scientific solutions to health problems, P = 0.034. Table 5 shows the results of multivariate stepwise regression analysis of Chinese nursing students' HCA. PI (β = 1.135, P = 0.001), dimensions of professional self-image (β = 0.271, P = 0.028), career choice independence (β = 0.228, P < 0.001), and social comparison and selfreflection (β = 0.865, P = 0.029) were positive influencing factors in HCA. Individuals with a better professional self-image, social comparison and self-reflection, and independence of career choice in PI were more likely to have better HCA. Education level (β=-.161, P = 0.011) and annual household income (β=-0.081, P = 0.048) correlated negatively with HCA. Those with lower education level or low annual household income were more likely to have better HCA.

Discussion
Medicine is not only a science, it can also be more humanistic and help people seek their own value in life. Modern medical professionals are not only expected to provide the traditional medical caring to treat the diseased conditions, they are also expected to provide patient-centered humanistic caring to achieve self-actualization and self-healing (Watson, 2003). In this crosssectional study, we described the status of humanistic care ability and PI, and explored possible influencing factors of HCA, so as to provide theoretical reference for the practice of humanistic care.
Our study showed that their HCA and PI were 125.94 ± 21.19, 62.32 ± 11.23, respectively. HCA score in our study was a little lower than Huang's study (126.74 ± 14.16) (H. Huang et al., 2021), but a little higher than Chen's study (125.39 ± 16.30) (G. Y. Chen et al., 2015). In the whole, the level of the HCA was medium. Therefore, nursing students' HCA still has room for further improvement. We  hope humanistic care education could be pay more and more attention by Chinese educators based on the results. Many colleges and universities will set up humanistic care courses to cultivate the humanistic quality of nursing students. The PI score was lower than the survey results of Chen et al (Y. Chen et al., 2020) which score was 83.22 ± 12.68.
In the current study, PI was found to be positively correlated with HCA in Chinese nursing students, as were the dimensions of PI. It indicated that the stronger a nursing student's PI, the greater his or her HCA, which was consistent with the findings of Li (Qiu, 2014)and Pu((Pu et al., 2018). In professional study and practice, self-interested orientation will affect students' emotional engagement in nursing. Various reasons for nursing students to choose nursing major lead to differences in their subjective initiative, so that they show diverseness in humanistic care awareness and behavior. This may explain the strong correlation between career choice independence and HCA (r = .584, P < .001) and the weak correlation of social comparison and self-reflection with HCA (r = .122, P < .001).
In the study, multivariate stepwise regression analysis showed that Chinese nursing students' PI was considered as a factor influencing humanistic care ability. The dimensions of professional selfimage, social comparison and self-reflection and career choice independence in PI were found to be independent predictors associated with HCA, which was consistent with Guo's findings (Guo et al., 2018). Professional self-image refers to the understanding, beliefs and emotions of members of the nursing profession (Y. F. Hao, 2011). Nursing students who love the nursing specialty and have confidence in their future will always treat patients with enthusiasm and actively care for them. However, if nursing students do not receive patient feedback, it will reduce their sense of identity as members of the nursing profession and will affect their HCA (X. X. Wang, 2018). Under the current social environment, nursing students are increasingly pursuing independence, freedom and self-realization. Most of the nursing students who independently choose the nursing major are based on their own preferences and willingness, and they have certain emotions for the nursing profession (Gou et al., 2019).This can mobilize nursing students' subjective initiative and help to cultivate their humanistic care from the heart (Y. F. Hao, 2011). Therefore, the cultivation and promotion of nursing students' PI needs to be actively guided during their education (Kantek et al., 2017;Wu et al., 2020). Nursing educators should increase social practice activities related to their majors. This helps the students to understand the connotation of the profession as early as possible. This is also helpful for the students to achieve a balance between career ideal and career reality, and to actively plan their future career development. In addition, hospital managers need to focus on creating a good internship environment and providing nursing students with positive emotional support.
The study also showed that education level and annual household income were independent predictors correlated with humanistic care ability. The result indicated the HCA of junior nursing students was higher than that of undergraduates and postgraduates, which was consistent with Chen's results (Y. Chen, 2017), but contrary to Wang's (Liu, 2014). Some studies suggested that the HCA was gradually internalized based on the individual's life and learning experience, and it needed to go through a long process (J. Wang et al., 2019;Kuo et al., 2021). It was not simply considered that the HCA of nursing students with different educational levels is better or worse (Liu & Shen, 2014). Therefore, the difference in educational background of HCA is only limited in this study, and further researches are needed. In addition, the total scores of HCA of nursing students with different family economic conditions were significantly different (P < .05). The Chinese nursing students whose family annual household income was more than 40,000 ¥ had higher scores in the HCA. This may be the parents of nursing students with better family economy pay more and more attention to the education and training of their abilities in all aspects.
In order to improve the humanistic care ability and PI of nursing students, joint efforts of medical educators and medical institutions are required. Medical educators should better design the medical educational programs and build targeted strategies, such as scenario simulation,   participatory teaching methods, and training sessions encouraging all medical professionals to enhance the awareness and capability in the practice of patient-center humanistic care. Meanwhile, the practice of humanistic care should also be considered as one of the contents of the evaluation systems in the medical professionals.

Limitations
This study was conducted in only one province of China, and the results can not represent the entire country. Therefore, it is necessary to expand the sample size for further research. Furthermore, the distribution of the gender in our study was unbalanced, this makes the comparison between males and females more difficult and may lead to statistic bias. In addition, the study was a quantitative research, it was impossible to report students' perceptions towards the HCA, so we should combine qualitative research with quantitative research to explore the underlying mechanism in more depth.

Conclusion
In this study, we found that there was a significant positive correlation between PI and HCA of Chinese nursing students, and the level of HCA of nursing students needs to be improved. The stable development of the nursing profession is inseparable from the cultivation of nursing students' HCA. It is suggested that nursing educators should internalize scientific information and caring into the education process, and pay more attention to the formation of nursing students' PI, so as to provide better holistic nursing for patients. Nurses' humanistic care ability and PI need continuous learning and school education. This study provides a preliminary reference for the development of an effective intervention program.