Nurse Education in Practice 71 (2023) 103729

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Association between proactive personality and professional identity of

nursing undergraduates: The mediating role of resilience and
irrational belief
Ya Shi a, b, *, Jing-xin Zhou b, Jiang-lin Shi b, Jo-Fan Pan a, Jia-yang Dai b, Qiang Gao b
a
School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
b
School of Nursing & School of Public Health, Yangzhou University, Yangzhou, Jiangsu province, China

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: To examine the relationship between proactive personality and professional identity of undergraduate
Proactive personality nursing students, including the role of psychological resilience and irrational belief as mediators.
Professional identity Background: Personality has been shown to play a crucial role in determining professional identity. However, the
Psychological resilience
influence of proactive personality on professional identity in the nursing field is poorly understood and requires
Irrational belief
Nursing undergraduate
further investigation.
Design: We conducted a cross-sectional study in China. Between July and December of 2021, 860 nursing un­
dergraduates participated in an online questionnaire survey.
Methods: Four main variables (proactive personality, psychological resilience, irrational belief and professional
identity) and two covariates (willingness to choose nursing profession and family attitude towards nursing) were
assessed. The assessment tools chosen are both valid and reliable. To test the proposed multi-mediation model,
linear regression analysis by Hayes’s SPSS macro-PROCESS was used.
Results: The results revealed that PP, PR and PI were positively connected with one another, but negatively with
IB. PP positively predicted PI through direct and indirect paths, after controlling for two covariates. The per­
centage of indirect path (78.72%) outweighed the direct path (21.28%). The indirect effect of PR (72.51%) was
higher than that of PR and IB (6.21%). PI was also positively predicted by students’ "Yes" willingness and
families’ "supportive" attitude towards nursing.
Conclusion: This study stated that nursing educators should take nursing students’ PP seriously, which would
allow for activities to be taken to improve their PR and decrease their IB, hence continuously enhancing their PI.
In addition, respecting students’ professional aspirations and improving family support may also be valuable
ways to boost their PI.

1. Introduction
1.1. Background
Nurses play a central role in achieving universal health coverage,
while the severe shortage of nursing workforce is an essential issue that
must be solved urgently. The World Health Organization recently re­
ported that the global professional nurses are 19.3 million (WHO, 2020),
but there will be a significant shortage of 9 million nurses by 2030 (ICN,
2019), notably in low-income and middle-income countries (Xie et al.,
2021). Even though China had the highest number of registered nurses
(over 4.71 million) in 2020, the ratio of nurses to population was only
3.3 (NBSC, 2021). The primary cause of the severe shortage was an
imbalance between the supply and demand of qualified nurses (Zhou
et al., 2018). More importantly, the resignation rate of nurses was high
in China due to regular overwork, high work pressure, strained
nurse-patient relationships, burnout and low pay (Zhou et al., 2018;
Chen et al., 2021). Several previous studies have already shown that
positive professional identity would reduce the burnout levels of nurses
and nursing students (Wang et al., 2019b; Sabanciogullari and Dogan,
2015) and decrease their intention leaving the profession (Zhang et al.,
2017).

* Correspondence to: School of Health Sciences, The University of Manchester, Manchester M13 9PL, UK.
E-mail addresses: ya.shi@postgrad.manchester.ac.uk (Y. Shi), zjx854819136@163.com (J.-x. Zhou), S18252770132@163.com (J.-l. Shi), jo-fan.pan@postgrad.
manchester.ac.uk (J.-F. Pan), DjyYzu@163.com (J.-y. Dai), qgao@yzu.edu.cn (Q. Gao).

https://doi.org/10.1016/j.nepr.2023.103729
Received 20 December 2022; Received in revised form 10 July 2023; Accepted 16 July 2023
Available online 24 July 2023
1471-5953/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Y. Shi et al.
Professional identity (PI) is also known as career, occupational, or
vocational identity in the social sciences (Schwartz et al., 2011) and
refers to individual’s professional self-concept based on talents, attri­
butes, values, beliefs, motivation, interactions and experiences (Slay and
Smith, 2011). PI in the nursing field consists of subjective and objective
components, such as a person’s feelings and experiences as a nurse and
others’ perceptions of that person as a nurse (Öhlén and Segesten, 1998).
The construction of a nurse’s professional identity is an ongoing process
that occurs over the course of a nurse’s career, with education being the
crucial stage (Browne et al., 2018). During their education, nursing
students acquire a significant amount of professional information and
abilities that distinguish them as healthcare professionals from the
general population. These experiences help them increase professional
confidence and promote internalization of the values in nursing pro­
fession (Crooks et al., 2005). Studies have already confirmed that pos­
itive PI were closely associated with higher commitment to profession in
nursing area (Lu et al., 2019). Nursing PI has many influencing factors,
which could be grouped into personal, family, institutional and social
dimensions (Mao et al., 2020). Among them, individual personality is an
important factor affecting one’s occupational choice, professional
identity and job performance (Wang and Zhang, 2017; Huy et al., 2011).
Proactive personality might be one factor affecting nursing PI, but it
remains unknown until now.
Therefore, the present study will investigate the link and mediating
mechanism between proactive personality and professional identity
among undergraduate nursing students. It will contribute to the devel­
opment of appropriate theories and a research framework for future
investigations. Additionally, it can offer theoretical support for
enhancing the PI of nursing students, so as to reduce nursing personnel
turnover, increase job satisfaction, promote healthcare quality and
finally benefit patients.
1.2. Rationale of hypotheses
This study uses four main theories to formulate research hypotheses,
including Social Identity Theory, Self-determination Theory, Psycho­
logical Resilience Framework and Rational Emotive Behaviour Theory.
1.2.1. Personality traits and professional identity
Individuals’ PI has already been supported to be influenced by per­
sonality traits, with the Big Five personality traits having received more
attention. The Big Five personality traits include extroversion, openness,
agreeableness, conscientiousness and neuroticism (Goldberg, 1981),
which is the most widely accepted taxonomy of personality traits in
psychology (John et al., 2008). Individuals that score highly on the
extroversion personality trait are forceful, active, sociable (Guthrie
et al., 1998), as well as adept at driving their own professional devel­
opment by mapping their inner vocational demands (Seibert and
Kraimer, 2001) and subsequently deriving their personal meaning to
improve their PI (Mcardle et al., 2007). Similarly, individuals with high
score on openness personality trait are creative, intellectual, noncon­
formist and always receptive to new perspectives (Michel et al., 2011),
besides they could actively engage in numerous developmental activ­
ities, which increases their career decidedness (Lounsbury et al., 2005)
and enhances their PI (Van Rijn et al., 2013). In nursing field, a recent
study demonstrated that all of the Big Five personality traits except
neuroticism positively affected the engagement in nursing professionals
(Martos Martínez et al., 2021).
Proactive personality (PP) refers to an individual’s active endeavours
and behaviours to effectively change the current situation, identify op­
portunities, overcome difficulties and hurdles and achieve their goals
while shaping their external environment (Seibert et al., 1999; Zampe­
takis, 2008). One study examined the relationship between the Big Five
and PP and concluded that the Big Five personality traits of agreeable­
ness (altruism), extroversion (assertiveness and activity), openness
(actions, ideas and values) and conscientiousness (achievement striving)
2
Nurse Education in Practice 71 (2023) 103729
were significantly positively associated with PP (Major et al., 2006).
However, it should be noticed that PP cannot be equated with the Big
Five, but is only partially a composite of Big Five facets, which
accounted for 26% of its variance (Major et al., 2006). As outlined by
Crant and Bateman (2000), PP cannot be totally explained by the Big
Five personality traits due to some unique characteristics of the former
that are not accounted for by the latter.
The direct predictive relationship between PP and PI still remains
unknown, but evidence from the field of education indicates that PP has
a significant impact in college students’ career variables, as it increases
their academic self-efficacy, boosts their confidence in career decision-
making and job search and decreases their career hesitation (Park,
2015; Lin et al., 2014). In occupational stage, PP contributes to one’s
career success (Seibert et al., 1999). People with stronger PP were found
to have higher intrinsic motivation, perceived autonomy, career and
creative self-efficacy (Karimi et al., 2021), better job performance
(Thompson, 2005), more affective commitment and promotions in their
careers (Seibert et al., 1999) and higher job and career satisfaction
(Wang and Lei, 2021). As for nursing field, recent studies have
demonstrated that PP is negatively correlated with academic fatigue
among nursing students (Kong et al., 2021), but favourably associated
with their self-perceived employability (Ma et al., 2021), career adapt­
ability (Ma et al., 2020) and professional identity (Zhou et al., 2021).
Besides, it can help boost clinical nurse job performance (Hu et al.,
2021).
PI is an important part of career development. The contribution of
Social Identity Theory to the understanding of personal and social fac­
tors influencing PI has particular significance in the context of nursing
(Willetts and Clarke, 2014). In terms of personal factors, Social Identity
Theory espouses that individuals’ motivation to perform, sense of
self-worth, achievement of group goals or norms, professional efficacy
all have intertwined effects on their PI in group working environment
(Willetts and Clarke, 2014; Burford, 2012). From above reviews, we
already knew that PP was positively related to these factors affecting PI.
Furthermore, according to Self-determination Theory, controlled moti­
vation and autonomous motivation regulates the formation and main­
tenance of one’s PI (Mylrea et al., 2017). Evidences have supported that
PI and PP were both negatively correlated with controlled motivation
but positively correlated with autonomous motivation (Visser et al.,
2018). Hence, to verify the direct relation between PP and PI, we put
forward Hypothesis 1:
Hypothesis 1. (H1): PP can positively predict PI.
1.2.2. The mediating role of psychological resilience
The Resilience Framework for nursing and healthcare developed by
Morse et al. (2021) points out when individuals experience adversity,
the psychological resilience (PR) factors including protecting, compen­
sating and challenging will protect them to achieve equanimity out­
comes, such as self-possession, composure, mental acuity, self-restraint,
self-assurance and equilibrium. Equanimity enables optimism, the
establishment of realistic goals, the pursuit of these goals and resilience.
Similarly, PI is the internal acceptance and self-affirmation of one’s
work, which enables them to overcome pressure in their working envi­
ronment to improve self-efficacy. Recent research has demonstrated a
strong positive correlation between PR and PI (Shu et al., 2021) and PR
served as a mediator in the negotiation of PI tensions, which means that
people with higher PR are more likely to resolve identity tensions and
integrate their PI (Yang et al., 2021). Apart from this, PR possesses the
same proactive characteristics to tackle setbacks as PP, including
hardiness as the capacity to withstand unpleasant occurrences and
adaptability as the capacity to adjust in response to varying circum­
stances. Another new research result demonstrated that PP could facil­
itate individuals’ PR (Zhu and Li, 2021). Consequently, we submit
Hypothesis 2:
Hypothesis 2. (H2): PR serves as a mediator between PP and PI.
Y. Shi et al.
1.2.3. The mediating role of irrational belief
Irrational Belief (IB) is the main reason causing negative psycho­
logical issues. A systematic review reported that the stress levels of
undergraduate nursing students in different cultural settings were high
(Li and Hasson, 2020), specifically in China, it was significantly greater
than western nursing students (Smith and Yang, 2017). Academic
learning, clinical practise, personal connections, a sense of values, reli­
gion, prospects and the future all contribute to the stress of nursing
students (Li et al., 2018). Because of these, nursing students face many
kinds of mental disorders. Approximately 34% of nursing students
experience mild to severe depressive symptoms (Tung et al., 2018) and
anxiety affects 67% of depressed students (Mahmoud et al., 2012). Ac­
cording to the Rational Emotive Behaviour Theory, Albert Ellis (1958)
suggested that irrational beliefs were the primary cause of emotional
problems. Irrational beliefs are evaluative notions that are rigid,
inconsistent with reality, illogical and have dysfunctional consequences
(Dryden, 2013). IB was consistently associated with poor mental health
outcomes (Collard and Fuller-Tyskiewicz, 2020).
Although there is no evidence that directly shows the relation be­
tween IB and PI, a cross-sectional study carried out in China has found
that poor mental health was significantly and negatively correlated with
PI (Wang et al., 2019a). Moreover, there is also no evidence being found
to clearly clarify the association between PP and IB, but personality
traits were already supported to effectively predict rational and irra­
tional beliefs. One study has demonstrated that the Big Five personality,
including high scores on neuroticism and low scores on openness,
significantly predicted low rationality and high irrationality (Samar
et al., 2013). Major et al. (2006) discovered the link between PP and the
Big Five, which showed that PP only accounted for 26% of the variance
of the Big Five and was positively related to its two facets, extroversion
and openness. Besides, PP and the two facets could both predict in­
dividuals’ motivation to learn. On the contrary, findings indicated that
decreasing irrational beliefs could increase self-determined motivation
(Turner and Davis, 2018). Overall, we propose Hypotheses 3, 4 and 5:
Hypothesis 3. (H3): IB is negatively related to PI.
Hypothesis 4. (H4): IB is negatively related to PP.
Hypothesis 5. (H5): IB plays a mediating role between PP and PI.
1.2.4. The chain-mediating effect of psychological resilience and irrational
belief
Recent research examined the effect of the Cognitive-Behavioural
Group Psycho-Education Program on the psychological resilience and
irrational beliefs of students. Students who embraced cognitive behav­
ioural therapy showed a rise in PR levels and a drop in IB levels, ac­
cording to the findings (Sahin and Turk, 2021). Combined with previous
analysis of several theories, we believe that when encounter activating
events in life, individuals with higher resilience will take proactive at­
titudes and actions to reduce their irrational beliefs about these adverse
events, so as to protect themselves from suffering negative emotions and
mental illnesses. Lastly, we propose Hypothesis 6:
Hypothesis 6. (H6): PR and IB play chain-mediated roles between PP and
PI.
1.3. Aims
Based on the hypotheses, this study developed a multi-mediation
model (Fig. 1). The primary aim of this study was to investigate the
association between PP and PI among undergraduate nursing students,
as well as the roles of two mediators (PR and IB) and two covariates
(willingness to choose nursing profession and family attitude towards
nursing).
3
Nurse Education in Practice 71 (2023) 103729
Fig. 1. The Hypothesized model. Note: This figure describes the operationali­
zation of the multi-mediation model in the current investigation. “+ ” repre­
sents a positively predictive relationship between two variables, while “-”
represents a negatively predictive relationship.
2. Methods
2.1. Design and setting
Cross-sectional research design was conducted with undergraduate
nursing students in ten higher universities and colleges in Jiangsu
Province in China.
2.2. Participants and data collection
Nursing undergraduates were invited and recruited using the
approach of convenience sampling from July to December 2021. In­
clusion criteria: 1) Current undergraduate nursing students; and 2) a
willingness to voluntarily participate in this study. Exclusion criteria: 1)
those who participated in similar studies; and 2) those who transferred
from nursing to other majors.
To recruit nursing undergraduates to participate in this survey, an
online questionnaire and a brief introduction were created and sent via
WeChat, QQ, or email to nursing teachers or students in different uni­
versities and colleges who were familiar with the researchers or had met
them at academic conferences. They further assisted researchers in
distributing the e-questionnaire to each nursing class via WeChat or QQ.
Interested participants were invited to answer a series of self-reported e-
questionnaire, which took approximately 10 min to complete on their
mobile phones or laptops. The return of a completed e-questionnaire
was regarded as implied consent. Due to participant identities (names
and universities) were not obtained, the returned e-questionnaires were
unidentifiable.
924 participants initially completed the e-questionnaire, which was
administered via a link from Questionnaire Star, an electronic platform
for questionnaire data collection in China. The purpose of the ques­
tionnaire was to collect data on demographic characteristics, PP, PR, IB
and PI. This study excluded questionnaires which response time was less
than 180 s (n = 41) and which crucial information was missing or
incorrect (n = 23). In the end, 860 participant records were evaluated
for this study.
2.3. Measures
2.3.1. Demographic characteristics
Demographic characteristics involved age, gender (Female/Male),
willingness to choose nursing profession (No/Yes), family attitude to­
wards nursing (Opponent/ Neutrality/Support), grade (Freshman/
Sophomore/Junior/Senior), residence (Rural area/Urban area), one-
child family (Yes/No), monthly living expenses (0–500/501 − 1000/
1001–1500/1501–2000/2001–2500/2501–3000/>3000 RMB). Among
them, we specifically chosen two factors as covariates, willingness to
choose nursing profession and family attitude towards nursing, to
explore their effects on the multi-mediation model in this study, which
were closely related to the cultural and social context of China.
2.3.2. Proactive personality
This was measured using the Proactive Personality Scale made by
Bateman and Crant (1993) and revised by Shang and Gan (2009) from
Y. Shi et al.
psychology department of Peking University in China. This scale was
chosen primarily because it was originally intended for undergraduates
and exhibited strong reliability and validity among not only Chinese
undergraduate students (Shang and Gan, 2009) but also Chinese nursing
undergraduates (Kong et al., 2021). There are 11 items in this scale
without subscale, for example: “I excel at identifying opportunities”.
Likert 7-point scoring is adopted, ranging from 1 = "totally disagree" to
7 = "totally agree". The higher the score is, the higher the PP level is.
Confirmatory factor analysis showed that χ 2/df = 7.770, GFI= 0.950,
AGFI= 0.950, CFI= 0.940, RMSEA= 0.050. The Chinese version of the
whole scale had a Cronbach alpha coefficient of 0.860.
2.3.3. Psychological resilience
This was assessed using the Connor-Davidson Resilience scale
(Connor and Davidson, 2003), which was revised by Yu and Zhang
(2007), the City University of Hong Kong in China. This scale was
selected primarily because it displayed strong reliability and validity
among different Chinese groups (Yu and Zhang, 2007), as well as among
Chinese nursing students (Li et al., 2021). The Chinese version scale
contains 25 items in three domains, including tenacity (13 items, e.g.
prefer to take the lead in problem solving), strength (8 items, e.g. tend to
bounce back after illness or hardship) and optimism (4 items, e.g. see the
humorous side of things). Likert 5-point scoring is adopted, ranging from
1 = "not true at all" to 5 = "true all the time". The higher the score is, the
stronger the psychological resilience is. Confirmatory factor analysis
showed that χ 2/df = 1.878, GFI= 0.844, AGFI= 0.881, CFI= 0.892,
RMSEA= 0.063. In the Chinese edition, the Cronbach’s alpha coefficient
for the overall scale was 0.910.
2.3.4. Irrational belief
This was measured using the Irrational Belief Scale developed by Liu
and Cheng (2009), the development and educational psychology of
Fujian Normal University, China. This measure was chosen since it was
designed exclusively for Chinese college students and has demonstrated
good reliability and validity among Chinese nursing undergraduates
(Shi, 2020). There are 18 items in the simplified version of this scale,
including two sub-scales of absolutist desire (10 items, exhibiting un­
realistic and absolute demands on oneself, others and the environment)
and depressive self-concept (8 items, characterized by low
self-evaluation and low self- efficacy). Likert 5-point scoring is used,
ranging from 1 = "totally disagree" to 5 = "totally agree". The greater
the score, the greater the extent of irrational belief. Confirmatory factor
analysis showed that χ 2/df = 3.250, GFI= 0.937, AGFI= 0.872,
TLI= 0.913, RMSEA= 0.054. Cronbach’s alpha coefficient of the total
scale was 0.749.
2.3.5. Professional identity
This was assessed using the Professional Identity Questionnaire of
Nursing Students designed by Hao (2011), the Second Military Medical
University, China. This questionnaire was chosen as it was specific to
nursing students, had high reliability and validity and was suggested for
evaluating the PI level of Chinese nursing students (Chen et al., 2020).
This questionnaire has 17 items and includes five dimensions: profes­
sional self-concept (6 items, e.g. I’m proud to be in the nursing field),
benefits of staying and risks of quitting (4 items, e.g. Nursing enables me
to showcase my skills and capabilities), social comparison and
self-reflection (3 items, e.g. I have tried to learn about various career
fields to strengthen my career belief), professional autonomy and
selectivity (2 items, e.g. What I understood about a career came entirely
from what my parents, teachers, or other authorities had told me and I
hadn’t given it much thought) and social persuasion (2 items, e.g. I love
learning the coming-of-age stories of nursing professionals who have
achieved success). Likert 5-point scoring was adopted, ranging from
1 = "very inconsistent" to 5 = "very consistent". The higher the score,
the higher level of nursing students’ PI. Confirmatory factor analysis
showed that χ 2/df = 1.638, GFI= 0.894, AGFI= 0.852, RMSEA= 0.058.
4
Nurse Education in Practice 71 (2023) 103729
Cronbach’s alpha coefficient of the total scale was 0.841.
2.4. Ethical considerations
At the beginning of the e-questionnaire, there is a special part of
declaring the content and significance of the study for informed consent.
Participants can give up filling in the questionnaire at any time if they
don’t want to continue with any reasons. The protocol for the study was
authorised by the Research Ethics Committee.
2.5. Statistical analysis
All data were analysed using the SPSS v 22.0 statistical software tool
(IBM Corp, Armonk, NY). Common method biases were evaluated using
Harman’s single factor test. Using the independent sample t-test,
Kruskal-Wallis H test and Pearson’s correlation coefficients, descriptive
statistics were analysed. Using regression analysis, the link between PP
and PI was examined. To test our hypotheses, all continuous variables
were standardised within the regression equation. Model 6 (as depicted
in Fig. 2) of Hayes’s SPSS macro-PROCESS (Hayes, 2012) was used to
explore the sequential mediating influence of PR and IB on the
connection between PP and PI. The effect of mediation was evaluated
using a sampling estimate of 5000. P < 0.05 was statistically significant.
The indirect effect was deemed statistically significant if the 95% con­
fidence interval did not contain zero.
3. Results
3.1. Demographic characteristics
The age of undergraduate nursing students was between 17 and 23
years old (n = 860, MEAN=19.30, SD=1.21). Among the participants,
female was 764(88.80%) and male was 96(11.20%). As for willingness
to choose nursing profession, the number of students choosing Yes and
No was 418(48.60%) and 442 (51.40%) respectively. In terms of family
attitude towards nursing, support was 563(65.50%), neutrality was 212
(24.70%) and opponent was 85(9.90%). With respect to grade, the
number of participants of grade one to four was 261(30.30%), 252
(29.30%), 171(19.90%) and 176(20.50%) respectively. In addition, 555
(64.50%) of the undergraduate nursing students were from rural areas,
whereas 305 (35.50%) were from urban areas. There were 444 (51.60%)
one-child families and 416 (48.40%) multi-child families. 10(1.20%),
143(16.60%), 434(50.50%), 185(21.50%), 39(4.50%), 20(2.30%) and
29(3.40%) undergraduate nursing students had 0–500, 501–1000,
1001–1500, 1501–2000, 2501–3000, > 3000 RMB of average monthly
Fig. 2. Model 6 of the SPSS macro-PROCESS (Hayes, 2012).
Y. Shi et al. Nurse Education in Practice 71 (2023) 103729

living expenses, respectively (Table 1).

4.5

1
3.2. Correlation analysis

0.30 * *
The correlation study (Table 2) revealed that PP was significantly

4.4

1
positively correlated with PR, PI and their subscales, with correlation
coefficients ranging from 0.32 to 0.85 (all p < 0.01). In addition, PR and

0.32 * *
0.60 * *
its subsclaes were also positively linked with PI and its subscales, with

4.3
correlation coefficients during 0.22–0.62 (all p < 0.01). However, IB

1
and one of its subscale (depressive self-concept) were negatively asso­
ciated with PP, PR, PI and their subscales, with correlation coefficients

0.54 * *
0.14 * *
0.70 * *
between − 0.46 and − 0.19 (all p < 0.01). As for another subscale

4.2

1
(absolutist desire) of IB, it demonstrated positive correlations with PP
(r = 0.13, p < 0.01), PR (r = 0.07, p < 0.05) and one subscale (strength)

0.89 * *
0.61 * *
0.26 * *
0.77 * *
in PR (r = 0.09, p < 0.05), whereas its correlations with the remaining

4.1
variables were not statistically significant (p > 0.05). The results of the

1
Harman single test indicated that for the four selected scales, there were

0.96 * *
0.91 * *
0.74 * *
0.39 * *
0.85 * *
12 factors with characteristic roots > 1, but the first factor explained
only 22.94% of the variance, which was significantly less than the cri­

1
terion of 40%. In this analysis, no significant common technique bias
was identified.

-0.33 * *
-0.26 * *
-0.22 * *
-0.41 * *
-0.23 * *
-0.27 * *
3.2
3.3. Construction of sequential mediation model

1
-0.01
-0.02
-0.01
-0.03
0.04
-0.05
-0.05
To prevent multicollinearity, each variable was standardised. Hay­

3.1

1
es’s (2012) PROCESS plug-in for the SPSS macro was used to analyse the
data. After adjusting for willingness to choose nursing and family atti­

-0.27 * *
-0.21 * *
-0.19 * *
-0.30 * *
-0.21 * *
-0.24 * *
0.62 * *
0.78 * *
tude towards nursing, the mediating roles of PR and IB between PP and
PI of undergraduate nursing students were analysed. Regression ana­

1
lyses (Table 3) indicated that PP positively predicted PI (β = 0.47,
p < 0.001) and PR (β = 0.84, p < 0.001) independently. Moreover, PR

-0.32 * *

-0.45 * *
0.50 * *
0.42 * *
0.38 * *
0.57 * *
0.27 * *
0.42 * *
negatively predicted PI (β = − 0.35, p < 0.001). In addition, when PP,

0.06
2.3

PR and IB were integrated into the model simultaneously, all three

1
variables accurately predicted PI, while PP (β = 0.10, p < 0.05) and PR
(β = 0.41, p < 0.001) predictions were positive and IB (β = − 0.10,
-0.25 * *

-0.39 * *
0.77 * *

0.56 * *
0.50 * *
0.48 * *
0.59 * *
0.22 * *
0.44 * *
0.09 *
p < 0.001) prediction was negative.
2.2

As demonstrated in Table 4 and Fig. 3, the bootstrap 95% confidence

1

-0.31 * *

-0.44 * *
0.83 * *
0.72 * *

0.55 * *
0.47 * *
0.45 * *
0.58 * *
0.32 * *
0.46 * *
Table 1
0.06
2.1

Demographic characteristics of undergraduate nursing students.

1

Variables Frequency %
-0.32 * *

-0.46 * *
0.97 * *
0.93 * *
0.84 * *

0.59 * *
0.50 * *
0.48 * *
0.62 * *
0.30 * *
0.48 * *
Gender

Note: M=mean, SD= standard deviation, ** means p < 0.01, * means p < 0.05.
0.07 *

Female 764 11.20

2

Male 96 88.80
Willingness to choose nursing profession
-0.26 * *

-0.43 * *

No 442 48.60
0.85 * *
0.83 * *
0.78 * *
0.69 * *

0.13 * *

0.52 * *
0.43 * *
0.40 * *
0.58 * *
0.32 * *
0.44 * *

Yes 418 51.40

Family attitude towards nursing
1

Opponent 85 9.90
Neutrality 212 24.70
Descriptive statistics and correlation analysis coefficients.

0.83
0.56
0.61
0.54
0.66
0.42
0.48
0.75
0.72
0.87
0.88
0.76
0.79
0.96
SD

Support 563 65.50

Grade
Freshman 261 30.30
4.70
3.49
3.49
3.47
3.56
2.87
3.31
2.32
3.36
3.28
3.09
3.67
3.53
3.50

Sophomore 252 29.30

M

Junior 171 19.90

Senior 176 20.50
4.2 Benefits of staying and risks of quitting

4.4 Professional autonomy and selectivity

Residence
4.3 Social comparison and self-reflection

Rural area 555 64.50

Urban area 305 35.50
One-child family
Yes 444 51.60
4.1 Professional self-concept
3.2 Depressive self-concept
2. Psychological Resilience

No 416 48.40
1. Proactive Personality

Monthly living expenses RMB(USD)

4. Professional Identity

4.5 Social persuasion

3.1 Absolutist desire

0–500 (0–69.1) 10 1.20

3. Irrational Belief

501–1000 (69.2–138.2) 143 16.60

Index Variables

1001–1500 (138.3–207.3) 434 50.50

2.3 Optimism
2.1 Tenacity
2.2 Strength

1501–2000 (207.4–276.4) 185 21.50

2001–2500 (276.5–345.5) 39 4.50
Table 2

2501–3000 (345.6–414.6) 20 2.30

> 3000 (>414.6) 29 3.40

5
Y. Shi et al. Nurse Education in Practice 71 (2023) 103729

Table 3 3.4. The impact of covariates on primary variables

Regression analysis of variable relationships.
Regression Equation Fit Index Regression The independent sample t-test displayed that the PP (n = 860,
Coefficient t = − 3.81, p < 0.001), PR (n = 860, t = − 4.08, p < 0.001) and PI
Result Predictive R R2 F (df) B t (n = 860, t = − 9.25, p < 0.001) of students with “Yes” of willingness to
Variable Variable choose nursing were significantly higher than that of who choosing
PI 0.63 0.39 186.06 * **
“No”. The analysis outcomes of Kruskal-Wallis H test showed that there
Covariate 1 0.09 2.88 * * were significantly different in the PP (n = 860, H=32.83, p < 0.001), PR
Covariate 2 0.30 9.82 * ** (n = 860, H=44.76, p < 0.001), IB (n = 860, H=6.02, p < 0.05) and PI
PP 0.47 17.41 * ** (n = 860, H=156.85, p < 0.001) among three groups of family attitude
PR 0.85 0.73 764.64 * **
(Table 5). Moreover, regression analysis showed that covariate 1 posi­
Covariate 1 -0.01 -0.39
Covariate 2 0.07 3.62 * ** tively predicted students’ PI (B=0.10, p < 0.001) and IB (B=0.10,
PP 0.84 46.70 * ** p < 0.05) and covariate 2 positively predicted students’ PI (B=0.27,
IB 0.32 0.10 24.96 * ** p < 0.001) and PR (B=0.07, p < 0.001), which indicated that students
Covariate 1 0.08 2.08 * with “Yes” of willingness to choose nursing may have higher PI and IB
Covariate 2 -0.04 -1.14
PP 0.04 0.65
and students with supportive family attitude may have higher PI and PR
PR -0.35 -5.68 * ** (Table 3).
PI 0.68 0.46 143.74 * **
Covariate 1 0.10 3.41 * ** 4. Discussion
Covariate 2 0.27 9.00 * **
PP 0.10 2.02 *
PR 0.41 8.35 * ** Based on relevant theories, this study examined the influence of PP
IB -0.10 -3.62 * ** on PI among undergraduate nursing students and included two medi­
ating variables, reflecting the internal individual factors: PR and IB.
Note: Covariate 1 = “willingness to choose nursing”; Covariate 2 = “family
attitude towards nursing”;*** p < 0.001, ** p < 0.01, * p < 0.05.
Individuals with greater PP considerably improved supported their PR
and decreased their IB, hence increasing their PI. Meanwhile, we
explored the impacts of two specific covariates based on the Chinese
Table 4 cultural and social environment and discovered that the willingness and
Decomposition table of mediate effect. family support of nursing students were critical for their PI level. This
Path Effect Effect Size Boot SEa Boot 95% CI Effect study extends the research findings of PP and PI to Chinese nursing
Percentage students and highlights the significance of personality variables for PI,
LLb ULc
relative to the current literature. This study used solid theoretical un­
Total Effect 0.47 0.03 0.42 0.52 100.00% derpinnings to describe the unique mechanisms of PP that induce PI,
Direct Effect 0.10 0.05 0.01 0.19 21.28%
while contributing to the current body of knowledge. The study findings
Total Indirect 0.37 0.05 0.28 0.48 78.72%
Effect gave theoretical guidelines for enhancing the PI of nursing students,
Indirect Effect 1 0.35 0.05 0.25 0.45 72.51% which could have great practical significance. It was proposed that when
Indirect Effect 2 -0.01 0.01 -0.02 0.01 0.00% evaluating PI, medical educators should consider personal psychological
Indirect Effect 3 0.03 0.01 0.01 0.05 6.21% aspects such as the personality, resilience and beliefs of students, as well
Note: a Boot SE, b Boot LLCI, and c Boot ULCI refer to the standard error, lower as their cultural and social background.
limit, and upper limit of 95% confidence interval of the indirect effect estimated
by percentile bootstrap method through deviation correction, respectively. In­ 4.1. Mediating role of PR
direct Effect 1: PP→PR→PI; Indirect Effect 2: PP→IB→PI; Indirect Effect 3:
PP→PR→IB→PI. The current study revealed that PR, PP and PI were positively
correlated and that PR was a significant mediator of the influence of PP
on PI. Hypotheses 1 and 2 were valid. PP is one of the most predictive
personality characteristics (Wang and Lei, 2021) and studies have
already shown that it could predict many occupational variables, such as
job satisfaction (Wang and Lei, 2021), job performance (Wei et al.,
2021) and job reflective (Li et al., 2019). PI is also important one of
occupational variables. The findings in this study expanded the relevant
research field by demonstrating that PP not only had a positive rela­
tionship with PI, but also predicted PI via direct and indirect effects. It is
Fig. 3. The sequential mediation model. Note: Path values are the path co­
noteworthy that the proportion of indirect effect (78.72%) exceeded
efficients, ***p < 0.001.
that of direct effect (21.28%) and that the indirect effect of PR accounted
for a large amount (72.51%) of the total.
interval (CI) for the mediating impact of PR and IB did not encompass 0.
According to Social Identity Theory, Self-determination Theory and
Thus, PP predicted PI not only directly but also indirectly via the
current literatures, individuals with a higher PP could actively excel at
mediation effect of PR and IB. The direct effect (0.10) and mediation
using information and resources, develop better interpersonal compe­
effect (0.37%) contributed 21.28% and 78.72%, respectively, to the
tence, strengthen cooperation with others, obtain objective support,
total effect (0.47). In particular, the indirect effect comprised of the
initiate future-oriented plans, seize opportunities, create favourable
mediating impact generated by two paths: indirect effect 1 (0.35),
conditions, improve current circumstances, take decisive actions and
generated by the path “PP→PR→PI” and indirect effect 3, generated by
persevere until achieving goals (Li and Mao, 2014; Wang and Lei, 2021).
the path “PP→PR→IB→PI”. The indirect impact 3 obtained by the path
These personality characteristics could facilitate an individual’s PR
“PP→IB→PI” was, however, not statistically significant. The two indi­
development, so PP was supported to be positively related to PR and its
rect effects accounted for 72.51% and 6.21% of the total impacts
sub-dimensions including tenacity, strength and optimism, with rela­
(Table 4).
tively high correlation coefficients ranging from 0.69 to 0.85, which was
consistent with the findings of a new research (Zhu and Li, 2021). This

6
Y. Shi et al.
Table 5
Analysis of the Impact of Covariates on Primary Variables.
Covariates N PP t/H
M SD
Willingness to choose nursing No 442 4.60 0.82 -3.81 * **
profession Yes 418 4.81 0.82
Family attitude towards nursing Opponent 85 4.68 0.74 32.83 * **
Neutrality 212 4.43 0.74
Support 563 4.81 0.85
Note: M=mean, SD= standard deviation, *** p < 0.001, **
p < 0.01, * p < 0.05.
study also demonstrated that PP could positively predict PR with path
coefficient of 0.84.
Moreover, according to the Resilience Framework and related
studies, PR is the capacity of individuals to respond to stressors and
adversities and to resist their negative and long-lasting psychological
impacts (Lutha and Cicchetti, 2000), which could serve as a mediator in
number of situations. For example, PR facilitated the negative associa­
tion between social capital and job burnout according to Khaksar et al.
(2019). Anasori et al. (2019) found that PR partially mediated the
relationship between workplace bullying and emotional tiredness. Be­
sides, Lorente et al. (2021) discovered that emotion-focused techniques
were directly and indirectly associated to nurses’ psychological distress
via PR. In this study, we further demonstrated that PR was a main
mediator promoting the positive relation between PP and PI, which was
in line with the actual situation. PI development process is continuous
and dynamic. Students with a higher PP would also have a higher PR,
which could provide them with more tenacity, strength and optimism,
so assisting them in overcoming these negative influences, discovering
the genuine self-concept in the nursing profession, identifying the ben­
efits of becoming a nurse, mining self-worth in the nursing industry,
promoting self-reflection in clinical work, identifying the outstanding
accomplishments of nursing colleagues and employing these to drive
themselves, thereby facilitating their PI development throughout their
career.
4.2. Sequential mediating role of PR and IB
The present study also indicated that IB was negatively correlated
with PR, PP and PI, in addition, PR and IB mediated the action of PP on
PI in a sequential manner. Hypotheses 3, 4, 6 were valid, but Hypothesis
5 was not valid. This means that nursing students with higher PP can
increase their PI by adjusting for a higher PR and a reduced IB, while IB
was directly predicted by PR. As indicated by Rational Emotive Behav­
iour Theory and pertinent studies, four types of IB, namely demand­
ingness, awfulizing, depreciation and limited frustration tolerance, are
hypothesised to result in dysfunctional emotions and maladaptive be­
haviours (Dryden and Branch, 2008). It is the opposite of the effects of
PR, which could promote positive psychology and actions, so PR was
confirmed again to have negative relationship with the total score of IB
(Sahin and Turk, 2021) and was also supported to negatively predict IB
in this study. Apart from this, as poor mental health outcomes would
reduce individuals’ PI (Wang et al., 2019a), individuals with a higher IB
are more likely to have a lower PI and this is the first study to directly
clarify their relationships. Hence, it is difficult for nursing students with
lower PP to take the initiative to discover professional advantages and
value during the process of learning. When they confront learning dif­
ficulties, their PR is also at a low level; consequently, they readily yield
to barriers and lack future confidence for their career, resulting in a
negative psychology. Gradually, they tend to develop an unfavourable
perception of nursing and exaggerate the negative aspects of profes­
sional development, resulting in a high degree of irrational beliefs and a
diminished sense of professional identity.
However, there are two points that deserve special mention in this
study. First, the sub-dimension of absolutist desire in IB was not
7
Nurse Education in Practice 71 (2023) 103729
PR t/H IB t/H PI t/H
M SD M SD M SD
3.42 0.53 -4.08 * ** 2.87 0.40 -0.38 3.15 0.63 -9.25 * **
3.57 0.57 2.88 0.45 3.58 0.73
3.40 0.50 44.76 * ** 2.92 0.42 6.02 * 2.82 0.54 156.85 * **
3.30 0.46 2.90 0.37 3.00 0.51
3.58 0.58 2.85 0.44 3.58 0.71
negatively associated with PP, PR and PI in the same way as depressive
self-concept was. This may be connected to what the contents of abso­
lutist desire represent in this scale, for example “I must be exceptional in
group settings”, “I have to do everything better than others”, “I want the
future to be in my expectation and control”, which exemplifies too
extreme but do positive demands and expectations that individuals set
on themselves. Hence, the absolutist desire showed marginally positive
correlations with PP (r = 0.13) and PR (r = 0.07). Second, although this
is the first study to demonstrate a negative connection between PP and
IB, regression analysis reveals that IB is not an independent mediator
between PP and PI. In other words, IB just mediated the action of PP on
PI through PR and the indirect effect of PR and IB comprised a tiny part
(6.21%) of the total effects. This could be due to the fact that the irra­
tional belief scale employed in this study is a generic instrument
designed for all Chinese college students. Nevertheless, there are various
forms of irrational belief when confronted with varying subjective and
objective factors. Until date, there was no formal scale for measuring
irrational beliefs among nursing students or nurses. Therefore, it is
difficult for the general scale to discover irrational ideas specific to the
nursing profession.
4.3. The impact of willingness and family attitude
The true willingness and family support are crucial social psycho­
logical aspects for nursing students to build their professional identity.
This study revealed that the levels of PP, PR and PI among nursing
students with “Yes” of willingness to choose nursing and supportive
family attitude were significantly higher than that with “No” of will­
ingness and opponent family attitude. The outcomes are heavily influ­
enced by the college admission rules and the social support environment
in China.
According to the college admission regulations in China, if a stu­
dent’s National College Entrance Examination score meets the uni­
versity’s minimum admission requirement but does not meet the
minimum score for the chosen major, the student will be switched to a
different major at the same university, which is likely to cause dissat­
isfaction. Owing to the immense pressure of re-studying additional year
in high school to re-take the college entrance exam, many students have
to continue to accept the transferred major, despite their dislike for it,
which is a very common phenomenon in nursing major. Several studies
investigated that the rate of freshmen transferring to nursing ranged
from 20.26% to 25.42% (Meng and Guo, 2015; Rong et al., 2022; Wang,
2018) and that the PI level of transferred nursing students was much
lower than that of students who chose nursing (Rong et al., 2022; Wang,
2018). This is consistent with the results of this study. Not being
accepted into the desired major is a traumatic event for transferred
nursing students, which may lead to psychological problems. Researches
showed that the suicide rate was as high as 18.77% among freshmen
who did not actively choose nursing (Meng and Guo, 2015), while poor
mental health would further reduce students’ PI (Wang et al., 2019a).
In addition, nursing has a poor social standing and lacks extensive
societal support in China. Due to the influence of traditional ideas, there
has been a bias of "valuing physicians more than nurses" in Chinese
society. People disregard the significance and social standing of nursing
Y. Shi et al.
personnel since it is viewed as a simple and minor service occupation
requiring little education and few abilities. Hence, some parents disap­
prove of their children to pursue a career in nursing. Research indicated
that only 22.67% of parents encouraged their children to choose nursing
major (Meng and Guo, 2015). However, this survey revealed that
65.47% of parents expressed support and 48.60% of students expressed
willingness for the nursing profession, which is a greater percentage
than the one previously examined. This may be due to the fact that this
study was conducted during Covid-19, when the selfless dedication of
Chinese medical professionals increased the social value of medical care.
Studies showed that the professional identity of Chinese nurses and
nursing students both improved during the epidemic (Li et al., 2022;
Yang et al., 2022). This social phenomena further demonstrates the
significance of social identity theory in driving the development of
nursing PI.
4.4. Practical implications
In the first place, nursing educators could capitalise on the direct
effect of PP on PI found in this study. Using appropriate scales to screen
out nursing students with higher PP and PI and then analysing their
proactive emotions and behaviours towards nursing profession.
Encourage them to share these effective techniques with other nursing
students with lower PP and PI. For example, one action research
investigated the implementation of the peer assisted study programme
and individual peer mentorship for first-year nursing undergraduates,
which revealed that peer support not only improved nursing students’
PI, but also strengthened their academic knowledge and skills and
increased their confidence in nursing sessions and that students had
appreciated the opportunity to meet other students in their chosen field
(Green, 2018). Burgess and Nestel (2014) summarised the peer assisted
learning program at Sydney Medical School and indicted that senior
medical students could aid in the development of their peers’ PI through
participating in training to be teachers, assessors, examiners of their
peers and even simulated patients.
Secondly, it is important to note that the evolution of an individual’s
PI is a constant and dynamic psychological process, whereas PP is a
rather stable personality attribute. Indeed, although while personality
traits are relatively stable, they can be changed over the course of a
lifetime (Roberts et al., 2006). A systematic review indicated that per­
sonality traits were amenable through interventions and that in­
terventions were associated with significant changes in personality trait
assessments over an average of 24 weeks (Roberts et al., 2017). There
were a variety of intervention types, including pharmaceutical, cogni­
tive behavioural, supportive, psychodynamic, hospital and mixed ther­
apy, however the type of therapy adopted was not significantly related
to the degree of change in personality traits (Roberts et al., 2017).
Hence, nursing educators can establish a long-term plan throughout the
university careers of nursing students to improve their PP by adopting
appropriate intervention strategies, so as to positively affect their PI.
In addition, nursing educators could also facilitate nursing students’
PI by addressing the indirect impacts of PR and IB. There were already a
variety of programmes that might be used as a resource to facilitate PR
and/or reduce IB. For instance, according to a prospective study, a three-
week military training programme could boost PR and decrease
depression symptoms among college freshmen (Guo et al., 2021). A
systematic qualitative review concluded that nursing educators may
assist the development of their students’ PR in five dimensions,
including demonstrating strong, supportive and caring interactions with
students; enhancing students’ awareness of their ability to bear adver­
sity; assisting students in recognising and coping with the ambiguity,
challenges and hurdles as they transition into their future roles;
encouraging students to turn adversity into opportunities; adjusting
appropriate frames for students’ learning (Amsrud et al., 2019). One
study indicated that the psycho-education program based on cognitive
behavioural approach could increase PR levels and decrease IB levels of
8
Nurse Education in Practice 71 (2023) 103729
students (Sahin and Turk, 2021). Another research revealed that a
rational emotive career education program could significantly reduce
irrational career beliefs among students (Ifeanyieze et al., 2021).
4.5. Limitations and future directions
There are still certain limitations in the current study, which will
need to be addressed in future investigations. Firstly, this study was
limited to undergraduate nursing students and was unable to investigate
the characteristics of individuals in other education levels or professions
or work positions. Future researchers can widen the target population
and increase the validity of the existing research conclusions by iden­
tifying these constructs in new populations. Secondly, due to financial
constraints, only an online survey questionnaire is available, which has
methodological limitations. For instance, sampling error could lead to
the exclusion of students in remote locations without internet access and
the survey area was limited to higher education institutions in a single
province in China. As the PI of nursing students may also be influenced
by societal factors in various regions, future research can expand its
geographical scope. In addition, it is difficult to guarantee the response
process validity of an online survey and self-reported questionnaires,
resulting in response bias; therefore, many methodologies, such as a
combination of questionnaire surveys, observations and interviews, can
be used to examine the response validity. Thirdly, this study employed a
cross-sectional study design and data collection was completed in a short
time frame, omitting the long-term interaction between PP, PI and the
environment. Future researchers can use longitudinal study design to
explore this relationship more deeply.
5. Conclusions
This research is useful for comprehending the functions of PP, PR and
IB in enhancing PI. Considering the dearth of empirical research
addressing this link in the Chinese population, the findings of this study
are especially valuable. This study revealed that PR and IB mediated the
influence of PP on PI via multiple pathways. Therefore, PR mediates the
relationship between PP and PI in an independent manner and in a
sequential manner with IB, indicating that enhancing PP, boosting PR
and weakening IB can assist individuals to improve their PI. In addition,
we cannot disregard the impact of social and cultural context on these
variables. The willingness of students to choose nursing and the sup­
portive attitude of their families may contribute to an increase in their PI
towards nursing.
Ethical approval
The study was approved by the Research Ethics Committee of
Yangzhou University (Ethical Review NO: YZU2019 0003).
Funding
This work was supported by The University of Manchester - China
Scholarship Council Joint Scholarship. The funder has had no involve­
ment in any aspect of the protocol or the decision to submit for publi­
cation and will not be involved in the study. Award Number:
202108320049.
Declaration of Competing Interest
All 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; therefore, there are no potential con­
flicts of interest to disclose.
Y. Shi et al.
Acknowledgements
The authors thank all the participants and research assistants
involved with this study. The authors would also like to thank Dr. Yihan
MO of King’s College London, for her assistance with suggestions on the
writing framework of this paper in the early stage. Additionally, all the
authors thank the students who generously gave of their time to com­
plete the questionnaires.
Author contributions
YS, JXZ, JLS, JYD and QG contributed to the conception or design of
the study. JXZ, JLS and JYD drafted the study protocol with suggestions
from YS. YS, JXZ, JLS, JYD and QG constructed the pilot study. YS, JYD
and QG carried out the final data collection. YS and JFP conducted the
data analysis. YS finished paper writing with suggestions from JFP and
QG. YS, JXZ, JLS, JYD, QG and JFP provided final approval of the
research paper.
Consent for publication
All individuals eligible for authorship are listed as authors. We also
confirm that the work is original and has not been previously published,
in whole or in part. Currently, the work is not being considered for
publication elsewhere.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.nepr.2023.103729.
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