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Received: 26 March 2022    Revised: 25 October 2022    Accepted: 10 December 2022

DOI: 10.1002/nop2.1561

RESEARCH ARTICLE

Exploring the relationship between lateral violence and nursing

professionalism through the mediating effect of professional
identity: A cross-­sectional questionnaire study

Huiwen Xu1,2  | Mengxin Xue1 | En Takashi2 | Akio Kitayama2 | Pingting Zhu1  |

Yongbing Liu1

1
School of Nursing & Public Health,
Yangzhou University, Yangzhou, China Abstract
Aim: This study aimed to investigate the prevalence of lateral violence (LV) experi-
2
Faculty of Nursing, Nagano College of
Nursing, Nagano, Japan
enced by nursing students during their internship, explore the difference between
Correspondence professional identity and professionalism among nursing students who had or had
Pingting Zhu and Yongbing Liu, No.136,
Jiangyang Middle Road, Hanjiang District,
not experienced LV and analyse the mediating effect of professional identity on the
Yangzhou, Jiangsu Province, China. relationship between LV and professionalism.
Email: ptzhu@yzu.edu.cn and
bingbing19950806@163.com
Design: A cross-­sectional survey was used.
Methods: An online anonymous survey was distributed to nursing students (N = 298)
Funding information
The 2020 Medical Education Research
in Jiangsu province, China from June to July 2021. The questionnaire consisted of sec-
Project of the Medical Education Branch tions on lateral violence, professional identity and nursing professionalism.
of the Chinese Medical Association
and Medical Education Professional
Results: Approximately 49.7% of the nursing students experienced LV behaviour
Committee of the Chinese Society during the internship period. Students who experienced LV had lower professional
of Higher Education, Grant/Award
Number: 20A0576; The Interdisciplinary
identity and professionalism than those who did not. Among the students, LV was
Research Project of Chinese Language negatively correlated with professional identity (r  =  −0.333, p < 0.001) and profes-
and Literature Special Zone of Yangzhou
University, Grant/Award Number:
sionalism (r = −0.418, p < 0.001). The relationship effect of LV on nursing professional-
yzuxk202019; The Jiangsu Graduate ism was partly mediated by professional identity.
Research and Innovation Program, Grant/
Award Number: KYCX21_3298; “Huxin
Conclusion: Nearly half of the nursing students suffered from LV in the workplace,
Fund” project of Jiangsu Key Laboratory and this condition remarkably influenced nursing professionalism through profes-
of Zoonotic Diseases, Grant/Award
Number: HX2005; Educational Reform
sional identity. Both quantitative and qualitative studies are needed to investigate the
Project of Yangzhou University, Grant/ factors that influence LV development in detail.
Award Number: YZUJX2022—­D29

KEYWORDS
internship, lateral violence, mediating effect, nursing students, professional identity,
professionalism

Huiwen Xu and Mengxin Xue contributed equally to this work.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
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© 2022 The Authors. Nursing Open published by John Wiley & Sons Ltd.

Nursing Open. 2023;10:3113–3121.  |

wileyonlinelibrary.com/journal/nop2     3113
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3114      XU et al.
1  |  I NTRO D U C TI O N
The shortage of nurses is currently a widespread problem both in
China and all over the world (Wang et al., 2019). This shortage can be
attributed to negative work environment, workplace violence, low job
satisfaction, job burnout and other reasons leading to resignation (Liu
et al., 2018). Among these factors, workplace violence is an important
factor for the high turnover rate of nurses (Duan et al., 2019). Lateral
violence (LV) is a form of workplace violence. It refers to bullying and
aggression involving inter-­group conflict (Curtis et al.,  2007). It is a
vital issue confronting the whole nursing profession (Taylor,  2001).
However, nursing managers in clinical practice in China do not pay
much attention to the education and management of workplace LV
(Tian et al., 2019), thus affecting the organisation and job retention in
the nursing profession (Tian et al., 2019).
2  |  BAC KG RO U N D
A negative idiom, “nurses eat their young”, is used to describe LV in
the nursing environment (Tian et al.,  2019). Duffy  (1995) describes
LV among nurses as overt and covert non-­physical hostility. As a
kind of workplace violence, LV is manifested as overt violence (e.g.,
abuse, threat, intimidation, scapegoat and quarrel) and covert violence
(e.g., contempt, strike, cold shoulder) (Fu et al., 2008). LV prevalence
varies in different countries, with an incidence of 1%–­87.4% (Bambi
et al.,  2018). A survey of seven hospitals in China's Hubei Province
showed that 59.1% of nurses experienced LV at least once in the past
6 months, and this phenomenon is common in clinical nursing work
(Peng et al.,  2021). Nursing students are particularly susceptible to
LV. Curtis et al.  (2007) found that nearly 60% of nursing students
experienced or witnessed LV at least once during clinical practice.
Negative clinical experience will affect their future career or employ-
ment choices, thus further aggravating the problem of nurse shortage
(Curtis et al., 2007). Victims of LV suffer from varying degrees of fear,
anxiety, depression and other negative psychology, as well as weight
loss, sleep disorders, headaches and other physical discomfort. Nursing
professionals are thus affected by the low job satisfaction, turnover
intention and nursing quality decline (Hopkinson et al., 2020). Clinical
nursing practice has become an important part of professional skill
learning and socialisation in nursing education programs. However,
nursing students are marginalised in the hospital hierarchy because of
various reasons, such as unfamiliarity with the work view, operation
process and lack of clinical nursing skills (Yang et al., 2021).
Negative experiences of nursing students in clinical practice en-
vironment are associated with professional identity, such as LV and
hospital violence (Furst, 2018; Wang, 2016). Professional identity is a
self-­perception of an occupation based on attitudes, beliefs, feelings,
values, motivations and experiences (Johnson et al., 2012). In short,
it is an individual's view of the goals, social values and other factors
of the profession (Hu et al., 2009). For nursing students, professional
identity is typically acquired and enhanced through theoretical and
practical learning during nursing education and interactions with
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advanced healthcare providers (Johnson et al., 2012). However, the
lack of professional identity is an important factor in the choice of
nursing students to leave the profession and pursue other careers
(Deppoliti, 2008). A higher level of professional identity can adjust
the role pressure of nursing students, alleviate the negative effect of
nurses' work pressure (Sun, Gao, Yang, Zang, & Wang, 2016), improve
clinical performance and reduce the turnover rate (Hao et al., 2020).
Therefore, the development of professional identity of nursing stu-
dents is very important. In addition, professional identity has a sig-
nificant positive effect on professionalism. With the improvement of
professional identity level of nursing students, professionalism also
increases (Shen et al., 2021).
Professionalism refers to the value orientation and standards
of practicing nurse, which reflects the work attitude and concepts
of nursing (Duphily,  2014). Professional identity has a moderately
strong positive relationship with both commitment to the organisa-
tion and job satisfaction (Mainous 3rd et al., 2018). However, profes-
sionalism level is correlated with nursing students' career intention
and professional recognition (Zhang et al.,  2020) and may affect
nurses' job satisfaction and retention intention (Hwang et al., 2009;
Shin & Kim,  2021). Although limited studies have focused on the
relationship between professional identity and professionalism,
career choice motivation and professional values are considered
as part of the evaluation of professional identity (Hao et al., 2014;
Parida·Muhammata et al.,  2016), and these factors are positively
correlated with professionalism (Cui et al.,  2021). De Santa and
Podder (2016) found that clinical practice is the best way to cultivate
and educate nursing students' professionalism. Therefore, maintain-
ing a high level of professionalism during clinical practice may im-
prove the job satisfaction of nursing students and their continued
engagement in the profession.
Most researchers focus on LV experienced by staff nurses. The
same issue is also experienced by nursing students prior to gradua-
tion, but only a few studies have considered this issue. Hence, we fo-
cused on studying nursing students who have just completed clinical
internship, because they may be vulnerable to LV considering their
weak status and the high levels of stress associated with role adjust-
ment. This study aimed to investigate the prevalence of LV experi-
enced by nursing students during their internship period. Moreover,
the relationship between LV and professionalism of nursing students
was examined, and the mediating effect of professional identity on
LV and professionalism was investigated.
2.1  |  Study aim and hypotheses
This study aimed to determine the prevalence of LV experienced
by nursing students during their internship period, explore the dif-
ference between professional identity and professionalism among
nursing students who had or had not experienced LV and analyse
the mediating effect of professional identity on the relationship
between LV and professionalism. The following hypotheses were
confirmed:

XU et al.
H1 . The professional identity level and nursing profession-
alism level of the nursing students who experienced LV were
lower than those who have not.
H2 . Higher levels of LV are associated with lower levels of
professional identity and nursing professionalism.
H3 . Professional identity would partially mediate the rela-
tionship between LV and nursing professionalism.
3  |   M E TH O D S
3.1  |  Design and participants
In the present study, a descriptive, cross-­sectional design was ap-
plied via convenience sampling. Nursing students who experienced
a one-­year internship were recruited as respondents. The study was
conducted from June 1 to July 1 2021 in Jiangsu Province, China.
The inclusion criteria were as follows: (a) nursing students who have
just completed 1  year of hospital practice; (b) engaged in clinical
nursing work and (c) voluntary participation in the study and sign-
ing of informed consent. G*Power 3.1.9.6 (University of Dusseldorf,
Germany) was used to calculate the sample size. For the variables
to be analysed, the sample size required for 13 predictive variables
was determined, with a significance level of 0.05, median effect size
of 0.15 and power of 0.95. Based on a 20% elimination rate, 227
samples were estimated.
3.2  |  Measures
We disseminated the recruitment information to the teachers of
different nursing schools in Jiangsu Province. Then, the teachers
announced the instructions for eligible nursing students to partici-
pate in the investigation. Upon agreement, each individual student
was invited to participate in the study. The survey was carried out
online through the “Questionnaire Star” platform (Wenjuanxing,
http://www.wjx.cn), relying on WeChat and QQ (social software).
The questionnaires consisted of Demographic information sheet,
Lateral Violence Inventory, Professional Identity Scale and Nursing
Professionalism Inventory. An illustration at the top of the question-
naire included an introduction to the participants, the aim of the
study and notes for filling it. Participants were ensured of confi-
dentiality of their information, and that all the data will be used for
research purpose only. Students were free to decline if they were
reluctant to participant. All items were set as required to avoid miss-
ing details. Data were received online once the questionnaire was
completed and submitted.
3.3  |  Demographic information sheet
A demographic information sheet with four variables (e.g., age, gen-
der and education level) was created.
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      3115
3.4  |  Lateral violence inventory
Bullying behaviour was measured using the Lateral Violence
Inventory, which was developed by Li (2011). The scale consists of
19 items that describe different types of behaviours that may be
perceived as bullying. The respondents were asked to answer “Yes”
or “No” based on the LV behaviour that they have suffered before.
LV was divided into covert LV (11 items) and overt LV (8 items).
The scale has a high internal reliability of 0.95 as measured by the
Cronbach α and a split-­reliability of 0.93. Bullying was considered if
an individual has been subjected to at least one negative act.
3.5  |  Professional identity scale
Professional identity was measured by the Chinese version of the
Professional Identity Scale for nursing students, as developed by
Parida·Muhammata et al.  (2016). It consists of five dimensions, in-
cluding professional attitude, professional devotion will, sense of
benefit, motivation of professional choice and professional values
with a total of 23 items. The Cronbach's α coefficient for all items
was 0.94, the split reliability was 0.88, and the retest reliability was
0.74 (Parida·Muhammata et al.,  2016). Each item was rated on a
seven-­point Likert-­scale (1 = strongly disagree to 7 = strongly agree).
Higher scores indicates higher level of professional identity.
3.6  |  Nursing professionalism inventory
Nursing professionalism was assessed using the Chinese version of
Hall's Professionalism Inventory. The inventory was originally de-
signed to determine suitable criteria and measure a person's profes-
sional standing by Professor Richard Hall (1968) in 1968. Wu (2019)
translated and revised the scale into Chinese in 2019. This version
had good reliability and validity, and was applied to nursing students
in China. The Chinese inventory consisted of six subscales, including
professional organisation, public service, self-­discipline, autonomy,
sense of mission and job satisfaction with a total of 20 items. Each
item was rated on a five-­point Likert-­scale (1  =  totally disagree to
5  =  totally agree). Higher scores indicate a higher level of nursing
professionalism. The Cronbach's α coefficient was 0.75, and the
test–­retest reliability was 0.84.
3.7  |  Data analysis
IBM SPSS Statistics version 24.0. (IBM Corporation) was used for
descriptive and correlation analysis. Mean and standard deviation
were used to analyse continuous variables, whereas the number and
percentages were used to analyse categorical variables. Two-­sample
t-­test was used to compare group differences in professional iden-
tity and professionalism. The relationships among the variables were
estimated by Pearson's correlation analysis. Mediation analysis was
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3116      XU et al.

TA B L E 1  Bullying behaviours experienced by nursing students

performed using linear regression models. A valid mediation model
(N = 148)
was developed based on the following steps: Step 1, the regression
of the independent variable X (LV) on the dependent variable Y (nurs- Lateral violence forms N %

ing professionalism); Step 2, the regression of independent variable X Withholding information 69 46.6
(LV) on the mediator M (professional identity); and Step 3, the regres- Being humiliated or ridiculed 58 39.2
sion of the independent variable X (LV) and the mediator M (profes- Work below level of competence 73 49.3
sional identity) on the dependent variable Y (nursing professionalism). Responsibilities removed 90 60.8
Bootstrap resampling was used to validate our results with SPSS mac-
Gossip about you 34 23.0
ros program (PROCESS v3.3). The number of bootstrap samples for
Being ignored or excluded 38 25.7
bias corrected bootstrap confidence intervals was 5000. A p < 0.05
Insulting or offensive remarks 33 22.3
was considered statistically significant in all analyses.
Being shouted at 44 29.7
Hints that you should quit 43 29.1

3.8  |  Ethical considerations Reminders of errors or mistakes 50 33.8

Persistent criticism of your work 50 33.8

The study strictly followed the Declaration of Helsinki, and ethi- Ignored or facing hostility 57 38.5
cal approval was obtained from the Ethics Committee of School of Accusation against you 39 26.4
Nursing, Yangzhou University (Ethical number: YZUHL2021037). Excessive monitoring of work 51 34.5
Practical jokes against you 37 25.0
Pressure not to use earned job 57 38.5
4  |  R E S U LT S benefits
Excessive teasing and sarcasm 32 21.6
4.1  |  Sample characteristics Unmanageable workload 46 31.1
Treats of violence or abuse 9 6.1
We screened 425 individuals, and 354 participants met the in-
Sum of bullying behaviour 148 100
clusion criteria. However, 56 of the responses were invalid. As a
result, 298 nursing students were recruited in the final analysis
with an 84.2% (298/354) response rate. Among the participants, two scales between the two groups were also compared, and the
40 (13.4%) were males and 258 (86.5%) were females. The aver- results show that the total scores of professional identity and nursing
age age was (20.75 ± 1.50) years. In total, 161 (54.0%) respondents professionalism in group 2 were higher than those in group 1 (both
were from junior college, and 137 (46.0%) were from the university. p < 0.001).

4.2  |  Frequency of LV 4.4  |  Correlation analyses

Approximately half (50.3%) of the students reported that they did
not experience LV behaviour during their internship period, 49.7%
reported at least one LV behaviour and 33.6% reported both cov-
ert and overt LV. Among the students, 14.1% experienced covert LV
only, and 2.0% experienced overt LV only. Accordingly, the partici-
pants were classified into those who experienced LV (group 1) and
those who did not experience LV (group 2).
Univariate descriptive statistics for each bullying behaviour
are shown in Table  1. Among the students who experienced LV,
“Responsibilities removed”, “Work below level of competence” and
“Withholding information” are the most common bullying behaviours.
4.3  |  Descriptive statistics of professional
identity and professionalism
Table 2 demonstrates the scores of Professional Identity Scale and
Nursing Professionalism Inventory of the participants. Scores of the
Correlations among all the scales are shown in Table 3. As predicted,
LV was negatively correlated with professional identity (r  =  −0.333,
p < 0.001) and professionalism (r  =  −0.418, p < 0.001). Professional
identity was positively associated with professionalism (r  =  0.599,
p < 0.001).
4.5  |  Measurement model
To determine whether professional identity mediated the relation-
ship between LV and nursing professionalism, we carried out linear
regression analysis. Total scores were used in the calculation. The
first regression equation was used to evaluate whether the LV in-
dices (the independent variable) predicted nursing professionalism
(the dependent variable). The second regression equation tested the
relationship between LV and professional identity (the mediator). In
step 3, the professional identity was introduced in the regression
equation. The results are summarised in Table 4 and Figure 1. The
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XU et al.       3117

TA B L E 2  Scores of the professional

identity scale and nursing professionalism Scores( X ± s)
inventory of the nursing students
Group 2
(N = 298)
Variables Range Group 1 (N = 148) (N = 150) t p

Professional identify 5 ~ 35 23.05 ± 5.92 27.06 ± 5.10 6.280 <0.001

Sense of benefit 1 ~ 7 4.82 ± 1.34 5.76 ± 1.13 6.585 <0.001
Professional devotion 1 ~ 7 4.74 ± 1.30 5.58 ± 1.16 5.946 <0.001
will
Professional values 1 ~ 7 4.43 ± 1.34 5.39 ± 1.26 6.361 <0.001
Professional attitude 1 ~ 7 4.43 ± 1.33 5.31 ± 1.28 5.822 <0.001
Motivation of 1 ~ 7 4.63 ± 1.23 5.02 ± 1.16 2.802 0.005
Professional choice
Nursing professionalism 6 ~ 30 18.42 ± 1.97 20.57 ± 2.35 8.537 <0.001
Sense of mission 1 ~ 5 3.47 ± 0.87 3.89 ± 0.75 4.472 <0.001
Professional 1 ~ 5 3.28 ± 0.88 3.83 ± 0.78 5.773 <0.001
organisation
Job satisfaction 1 ~ 5 3.37 ± 0.87 3.76 ± 0.76 4.136 <0.001
Self-­discipline 1 ~ 5 2.53 ± 0.86 2.64 ± 0.82 1.148 0.252
Public service 1 ~ 5 3.03 ± 0.51 3.36 ± 0.56 5.475 <0.001
Autonomy 1 ~ 5 2.74 ± 0.93 3.07 ± 1.01 2.967 0.003

Note: Group 1, Students have experienced LV. Group 2: Students have not experienced LV.

TA B L E 3  Correlations between the

Nursing Professional
study variables (N = 298)
Lateral violence professionalism identity

Variables r (p) r (p) r (p)

Lateral violence 1 —­ —­
Nursing professionalism −0.418 (<0.001) 1 —­
Professional identity −0.333 (<0.001) 0.599 (<0.001) 1

TA B L E 4  Results of indirect effects of professional identity mediation models

Independent Standardised regression Adjusted

Step variable Dependent variable equation R2 R2 t p 95% CI

Step 1 Lateral Nursing Y = −0.418X 0.175 0.172 −7.912 <0.001 −0.276, −0.166
violence professionalism
Step 2 Lateral Professional identity M = −0.333X 0.111 0.108 −6.074 <0.001 −0.564,
violence −0.288
Step 3 Lateral Nursing Y = −0.246X + 0.517 M 0.412 0.408 −5.191 <0.001 −0.179, −0.081
violence professionalism
Professional 10.917 <0.001 0.175, 0.252
identity

Note: The change in R 2 was 0.238 when M was added; 5000 samples re-­extracted for bootstrap; X, Lateral violence, Y, Nursing professionalism, M,
Professional identity.

results of the regression analysis showed that professional identity
partially mediated the relationship between LV and nursing profes-
sionalism. The significance of professional identity's mediating ef-
fect was verified with bootstrap.
The analysis of mediation models showed that the total ef-
fect of LV on nursing professionalism was −0.418 (p < 0.001). The
direct effect of LV was −0.246 (p < 0.001), while the indirect ef-
fect of professional identity was −0.172(−0.333 × 0.517 = −0.172,
p < 0.001). These results indicate the existence of a par-
tial mediation model in the students. The mediation model
accounted for 41.2% (0.172/0.418) of the variance in nursing
professionalism.
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3118      XU et al.
5  |  D I S C U S S I O N
In the present study, we investigated the incidence of LV encoun-
tered by nursing students in clinical practice, explored the rela-
tionship of LV with professional identity and professionalism and
investigated the partially mediating role of professional identity in
the relationship between LV and professionalism. The survey results
showed that nearly half of nursing students experienced LV during
their year-­long clinical internship, and this figure is lower than the
findings of Curtis et al. (2007). The difference in local culture may
have contributed to this variation in incidence (Bambi et al., 2018). In
China, most of the students appear to be tolerated and tend not to
disclose their LV experience because of Confucianism.
Nursing students who encountered overt LV only accounted
for 2.0%, and those who encountered covert LV only accounted for
14.1%. In comparison with overt LV, more nursing students experi-
enced covert LV. However, covert LV is likely to be ignored by nursing
managers, although it may exist for a long time. Therefore, managers
should be vigilant of the manifestation of covert and be able to rec-
ognise it for a timely and effective intervention. More than one third
of nursing students suffer from both overt and covert LV. The LV
experience of nursing students in the clinical practice environment is
worrying. Nursing managers, clinical teachers and charge nurses are
the main sources of LV, and these interpersonal conflicts will induce
pain among nursing students (Clarke et al.,  2012; Fu et al.,  2008).
Among the LV forms, “responsibilities removed”, “work below level
of competence” and “withholding information” were the most com-
mon LV behaviours encountered by nursing students in clinical prac-
tice, accounting for 60.8%, 49.3% and 46.6%, respectively. Some
students reported of being deprived of their primary job responsi-
bilities and were assigned to do trivial task, such as taking express
delivery, getting medicine from the dispensary and taking out the
trash. Some students were overestimated by their clinical teach-
ers and were arranged to do some work beyond their competence.
“Withholding information” was another miserable LV experienced by
the subjects. Students had low position in practice settings and less
opportunity to participate in decision-­making, while some of them
felt that they were excluded. Curtis et al. (2007) found that exposure
to LV would affect students' future career and their employment
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F I G U R E 1  Mediation model showing
professional identity mediating the
relationship between lateral violence
and nursing professionalism. Note: All
coefficient are significant (p < 0.001).
choices. Moreover, LV experience may enable nursing students to
imitate and continue this behaviour in their careers, resulting in a
vicious circle (Cheung et al., 2019). Therefore, identifying the preva-
lence of LV in the clinical practice environment and arousing hospital
managers' attention to LV may play a key role in shaping the nursing
practice culture of the next generation. In addition, nursing manag-
ers should value nursing students, allow them to participate in the
formulation of rules and consider their suggestions. Clinical teachers
should be trained to strictly comply with the regulations and hear
out nursing students' suggestions. In addition, students should be
trained to deal with LV effectively to break the vicious circle of LV.
Sanner-­Stiehr and Ward-­Smith (2017) suggested that the curricular
content should integrate LV content into simulation experiences and
facilitate this knowledge into clinical experiences.
By comparing the differences in professional identity and pro-
fessionalism between students with and without LV experience,
Hypothesis 1 was confirmed. Students who experienced LV re-
ported lower mean scores of professional identity and nursing pro-
fessionalism. LV experience led to decreased self-­confidence, which
is linked to impaired professional identity (Webster et al.,  2016).
Ayasreh and Khalaf (2020) reported that nursing students who had
not witnessed workplace violence had significantly better attitudes
toward the nursing profession than witnesses, suggesting that wit-
nessing workplace violence has a considerable negative effect on
how nursing students view nursing work. LV was found to result
in uncertainty about their career choice (Armmer & Ball,  2015;
Palaz, 2013). Furthermore, based on a survey among hospital nurses
(Olsen et al., 2017), workplace bullying can lead to a decrease in job
satisfaction among nurses, thus affecting their professionalism.
In fact, students are likely to leave the nursing profession be-
cause of negative affectivity rather than that the lack of compe-
tence. Consequently, education on LV and coping are necessary to
increase student retention and improve their professional identity
and professionalism. For example, a greater emphasis on debriefing
in a supportive university environment and teaching conflict resolu-
tion skills before an internship can help the nursing students in deal-
ing with adverse staff relationships and improving coping strategies.
The results obtained in the study on the relationship of LV
with professional identity and professionalism of nurses confirmed

XU et al.
Hypothesis 2, that is, LV is negatively correlated with professional
identity and professionalism of nursing students, and professional
identity is positively correlated with professionalism. Professional
identity is negatively correlated with workplace violence (Qiu
et al.,  2019). The formation of nursing students' professional iden-
tity is a dynamic process, which is susceptible to various factors.
Experiencing negative interpersonal relationships will cause frus-
tration and affect their professional value (Wei et al.,  2021). When
nursing students witness or experience LV, they will experience low
self-­esteem, shame and lack of respect, which will reduce their posi-
tive emotions and feelings at work and influence their nursing values
and future career choices, thus affecting their professional identity
(Curtis et al., 2007; Iacobucci et al., 2013). Furthermore, workplace vi-
olence is negatively correlated with job satisfaction (Tee et al., 2016).
It may affect students' attitudes toward the nursing profession and
their levels of job satisfaction. Lim and Jo  (2016) reported that the
most important factors that affect the professionalism of intern
nurses are clinical practice experience, including internship content,
satisfaction during clinical practice, nurses' self-­image and hospital
working environment. When nursing students experience LV, this
additional source of stress affects individual mental health and re-
duces their job satisfaction, thus affecting professionalism. The for-
mation of professional identity is correlated with the development of
professionalism, and the education aimed at cultivating professional
identity is an important factor for promoting the development of pro-
fessionalism in medical education (Forouzadeh et al., 2018).
Professional identity plays a partially mediating role in the cor-
relation between LV and professionalism of nursing students, thus
confirming Hypothesis 3 that LV can directly affect the profession-
alism of nursing students and indirectly affect the professionalism
through professional identity. This finding indicates that LV may re-
duce the professional identity level of nursing students, thus lead-
ing to the decline of professionalism level of nursing students. This
condition may be closely related to clinical practice environment,
that is, once nursing students experience work environments such
as violent behaviour or negative interpersonal relationships, it can
negatively affect nursing professional attitudes and professional val-
ues (Tee et al., 2016; Wei et al., 2021) and influence the development
of students' professional identity (Wang, 2016), resulting in a decline
in nursing job satisfaction and affecting the level of professional-
ism (Kong, 2016; Lim & Jo, 2016). The level of professional identity
moderates the negative effect of LV behaviour on the level of pro-
fessionalism. The possible explanation is that professional identity
as an internal driving force, and nursing students with a high level
of professional identity can adapt to the occurrence of LV by ac-
tively participating in work and improving themselves, thus reducing
the effect on their level of professionalism (Wang, 2016). Therefore,
nursing managers and educators should reduce the occurrence of
LV and improve the professional identity level of nursing students to
prevent the negative effects of LV behaviour on the professionalism
level of nursing students.
Therefore, the cultivation of professional identity of nursing
students is important. The empirical study shows that the level of
|
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      3119
professional identity can be effectively improved by implementing
measures, such as career planning and establishing a communication
platform between nursing students and nurses (Cao & Liu,  2010).
Nursing educators and clinical practice managers should implement
targeted interventions to improve the level of professional identity
among nursing students and thus prevent the professional attrition
of nursing students.
5.1  |  Limitations
First, this study is a cross-­sectional study. Therefore, it cannot deter-
mine the causal relationship between variables. Longitudinal studies
are needed to confirm that. Second, the results of this study may be
biased because of the difference in LV recognition and judgement
among nursing students because of their education level or person-
ality characteristics. Additionally, although the response rate was
excellent, the students were all from Jiangsu province. Therefore,
the results are not automatically generalisable to other levels of
nursing students within a larger geographical context. In the future,
the definition of LV need to be standardised, and multi-­centre and
large-­sample surveys need to be conducted among nursing students
with different characteristics to fully explain the occurrence of LV
in nursing students. Finally, the use of self-­report questionnaires to
determine the LV experience of students may bring recall bias, which
is another limitation of the research.
6  |  CO N C LU S I O N
The study found that the incidence of LV in nursing students in clini-
cal practice environment is high, and the incidence mainly involved
covert LV. This experience will affect the professional identity and
professionalism of nursing students. Professional identity plays a par-
tial intermediary role between LV and professionalism. Accordingly,
hospital administrators and nursing educators should recognise and
acknowledge the existence of LV, understand how nursing students
define LV and timely solve LV through organisational and personal
intervention when it occurs. Hospital administrators and nursing
educators should focus on the cultivation of professional identity of
nursing students, which has a significant regulatory effect on LV oc-
currence and professionalism of nursing students. Both quantitative
and qualitative researches are recommended to further investigate
the factors that influence the development of LV and understand the
feelings of the students after exposure to LV and how to avoid these
behaviours in the future.
AU T H O R C O N T R I B U T I O N S
Huiwen Xu: conception and design of the study, writing the original
draft, analysis and interpretation of data. Mengxin Xue: writing the
original draft, analysis and interpretation of data. En Takashi: criti-
cally revising the article. Akio Kitayama: critically revising the arti-
cle. Pingting Zhu: critically revising the article, writing the review,
 |
3120      XU et al.
supervision. Yongbing Liu: critically revising the article, writing the
review, supervision.
AC K N O​W L E D
​ G E ​M E N T S
The authors express their gratitude to all nursing students who par-
ticipated in the study.
F U N D I N G I N FO R M AT I O N
This work was supported by the 2020 Medical Education Research
Project of the Medical Education Branch of the Chinese Medical
Association and Medical Education Professional Committee of the
Chinese Society of Higher Education [grant numbers 20A0576], the
Jiangsu Graduate Research and Innovation Program [grant numbers
KYCX21_3298], the Interdisciplinary Research Project of Chinese
Language and Literature Special Zone of Yangzhou University [grant
numbers yzuxk202019], the “Huxin Fund” project of Jiangsu Key
Laboratory of Zoonotic Disease [grant numbers HX2005] and the
Educational Reform Project of Yangzhou University [grant numbers
YZUJX2022—­D29].
C O N FL I C T O F I N T E R E S T
The authors declare no conflict of interest in this work.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on re-
quest from the corresponding author.
E T H I C A L A P P R OVA L
The Ethical Committee of School of Nursing, Yangzhou University
gave ethical approval for the study (Ethical number: YZUHL2021037).
All methods were performed in accordance with the guidelines of
the Declaration of Helsinki. Participation was voluntary, and all the
students were informed of the study purpose and were assured of
the confidentiality of their data.
ORCID
Huiwen Xu  https://orcid.org/0000-0002-1051-1037
Pingting Zhu  https://orcid.org/0000-0002-1826-2725
Yongbing Liu  https://orcid.org/0000-0002-3480-8249
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How to cite this article: Xu, H., Xue, M., Takashi, E.,
Kitayama, A., Zhu, P., & Liu, Y. (2023). Exploring the
relationship between lateral violence and nursing
professionalism through the mediating effect of professional
identity: A cross-­sectional questionnaire study. Nursing Open,
10, 3113–3121. https://doi.org/10.1002/nop2.1561