Status of Professional Identity, Self-Directed Learning Competence, and Self-Efficacy Among Central Sterile Supply Department Nurses

Introduction

The “Central Sterile Supply Department” (CSSD), is the hospital department responsible for the obtaining, cleaning, disinfection, and sterilization of all reusable instruments, utensils, and other objects that have been involved in diagnosis and treatment. CSSD nurses work in a special environment, where they consistently engage in repeated high-intensity and high-workload tasks and are exposed to high temperature, high humidity, loud noise, and microorganisms for long time periods [1]. CSSD nurses do not have direct contact with patients. As a result of dealing only with instruments, utensils, and other objects, they often may not have a sense of accomplishment and vocation for patient care and treatment. This in turn results in CSSD nurses limiting their sense of self-value to the repetitive processes of cleaning, disinfection, packaging, and sterilization [2]. Compared with clinical nurses, CSSD nurses generally receive low wages, and it is difficult for CSSD nurses to get promoted at work. In addition, CSSD nursing is often considered to be a low-status profession, especially among people working in healthcare [3]. This distinctiveness of CSSD work determines a difference in professional identity between CSSD nurses and clinical nurses. CSSD nurses generally have a relatively low level of professional identity.

The CSSD is an important department with responsibility in nosocomial infection management, and is one of the key links to prevention and control of nosocomial infections [4]. In response to a call for high-quality hospital development, and considering the requirements for prevention and control of nosocomial infections towards the goals of healthcare quality and patient safety, the quality of CSSD work has attracted more and more scrutiny, leading to the setting of higher requirements for the professional and technical development of CSSD staff. These require CSSD nurses to have a strong self-directed learning competence in order to meet the demands of rapid professional development. Self-directed learning competence is considered a prerequisite for lifelong learning [5]. The results of Kaulback [6] have shown that self-directed learning competence in baccalaureate nursing students is correlated with a lifelong learning orientation.

Studies by Hwang et al [7] have shown that academic self-efficacy and self-regulated learning play a mediating role in self-directed learning and problem-solving ability among nursing students. The results of Zhan [8] and Moghadari-Koosha et al [9] show that students with high levels of self-efficacy are more willing to undertake challenging tasks and make more efforts to fulfill these tasks, along with self-efficacy having a significant promoting effect on college students’ self-directed learning competence. Self-efficacy is one of the internal factors that is associated with self-directed learning competence. The drive to engage in self-directed learning generally comes from recognition and love of the job. Previous studies have shown that CSSD nurses in China have different job expectations, which may lead to different degrees of recognition in professional situations.

The quantity of nursing personnel is closely associated with the quality of nursing care and healthcare safety. The global healthcare system is facing a shortage of nursing personnel [10]. The shortage of nurses is aggravated by an increasing demand for healthcare services. High nurse turnover rates are common in China and other countries, and can lead to a shortage of nurses and a decline in the quality of nursing care [11]. Studies by foreign scholars [12–16] have shown that age, gender, doctor-nurse relationship, and job burnout are the major factors associated with nurses’ resignation. Studies by Chinese scholars [17,18] have shown that poor professional identity, low educational attainment, suboptimal work environment, low wages, and a general lack of well-being are the major factors associated with nurses’ resignation.

The Plan of Healthy China 2030, released by the State Council of the People’s Republic of China, proposes that there shall be 4.7 registered nurses per 1000 population in China in 2030. This requires a sufficient number of nurses to fill these roles [19]. Under the circumstance of the current nursing shortage, it is necessary to solve the problems associated with nurses’ resignation, including poor professional identity and low educational attainment, to ensure a reduction in nurse turnover rate. Improving nurses’ professional identity and learning ability and achieving a higher level of educational attainment through continuing education are possible measures that can be taken to reduce nurse turnover rate.

We investigated the statuses of professional identity, self-directed learning competence, and self-efficacy among 318 CSSD nurses working in hospitals categorized as Secondary A or above in southwest China. We also offered suggestions for improvement of professional identity, self-directed learning competence, and self-efficacy, to provide nursing managers with talent training ideas, and to help nurses with different job expectations to build personalized career planning and formulate effective measures to stimulate learning motivation. The goal of this work is to achieve continuous development of CSSD nurses.

Material and Methods

ETHICS APPROVAL:

This study was approved by the medical ethics committee of the authors’ institution [2022 Medical Scientific Research for Ethical Approval No. (144)]. Verbal informed consent was obtained from all participants. The medical ethics committee of the authors’ institution approved the procedure of obtaining verbal informed consent.

STUDY DESIGN:

This was a cross-sectional study. Convenience sampling was applied in this study. CSSD nurses working in 45 hospitals categorized as Secondary A or above in southwest China were invited to participate in a questionnaire survey in August 2021. Respondents satisfied the following inclusion criteria: (1) were currently employed in frontline CSSD work; and (2) consented to voluntarily participate in this study. The exclusion criteria were as follows: (1) nurse interns; and (2) CSSD nurses who had been absent from duty for 3 months or more.

Power Analysis & Sample Size (PASS) 12 software was used to calculate the sample size. A minimum sample size of 189 was determined, with a test power level of 80% and a significance level of P<0.05. Considering factors such as incomplete responses in the questionnaire, a sample size of 318 was used in this study.

SURVEY TOOLS:

The survey comprised a general information questionnaire, a self-directed learning competence rating scale, a professional identity scale, and a general self-efficacy scale.

The general information questionnaire was used to collect information concerning gender, age, place of origin, educational attainment, marital status, hospital grade, working years, type of employee, nurse level, job title, monthly income, and reasons why the respondent had chosen to study nursing and work in the CSSD. The reliability of the questionnaire was tested using SPSS version 24.0; the Cronbach’s alpha coefficient was 0.683.

The self-directed learning competence rating scale for nurses, developed by Xiao [20], contains 4 components and 34 items (14 items addressing self-motivational beliefs, 6 items addressing task analysis, 10 items addressing self-monitoring and self-regulation, and 4 items addressing self-evaluation). All of the 34 items are single-choice questions. A 5-point Likert scale was used to rate the nurses’ responses. A score for each item, ranging from 5 to 1, was assigned to the response options ‘always’, ‘very often’, ‘sometimes’, ‘rarely’, and ‘never’. For positive items, 5 was assigned to ‘always’ and 1 was assigned to ‘never’. For the negative items, 5 was assigned to ‘never’ and 1 was assigned to ‘always’. The total scale scores ranged from 34 to 170. Cronbach’s alpha for this scale was 0.944, and Cronbach’s alpha for each of the components ranged from 0.701 to 0.887. Split half reliability of the scale was 0.894.

The professional identity scale for nurses, developed by Liu et al [21], contains 5 components (occupational cognition, occupational social skills, workplace social support, handling frustration at work, and occupational self-reflection) and 30 items. All of the 30 items are single-choice questions. A 5-point Likert scale was used to rate the nurses’ responses. The score range of 5 to 1 (‘always’, ‘very often’, ‘sometimes’, ‘rarely’, and ‘never’, respectively) was assigned to the response options. The maximum scale score was 150. The higher the scale score, the higher the level of professional identity. A score of 30–60 was considered ‘very low’; a score of 61–90 was considered ‘low’; a score of 91–120 was considered ‘medium’; and a score of 121–150 was considered ‘high’. Cronbach’s alpha and split half reliability for this scale were 0.938 and 0.88, respectively.

The general self-efficacy scale was developed by Scholz et al in 1981 [22], and a modified Chinese version was developed by Zhang et al [23]. This unidimensional scale contains 10 items, which are measured using a 4-point Likert scale. All 10 items are single-choice questions. A score range of 1–4 was assigned to the response options: ‘not at all true’, ‘barely true’, ‘moderately true’, and ‘exactly true’. Cronbach’s alpha, test-retest reliability, and split half reliability for this scale were 0.87, 0.83, and 0.90, respectively.

DATA COLLECTION:

The survey was created using Wenjuanxing, an online survey tool. The quick response survey code was shared in the WeChat group chats for CSSD nurses working in 45 hospitals categorized as Secondary A or above in southwest China. The CSSD nurses scanned the quick response survey code to open and complete the survey within a certain period of time. Information concerning informed consent was stated on the first page of the survey. Responses to the survey were voluntary and completely anonymous. The head nurse of the CSSD of each hospital was instructed to remind the frontline CSSD nurses under their charge to truthfully answer the questionnaires. All the questions in the questionnaire were set as mandatory questions. Any incomplete questionnaires, or those with repetitive answers to all questions, were classified as invalid. A total of 318 questionnaires were distributed, and 318 valid questionnaires were returned (valid recovery rate was 100%). Data were input by 2 researchers and randomly checked to ensure the accuracy and integrity of the data.

STATISTICAL ANALYSIS:

The data were analyzed using SPSS version 24.0. The nurses’ demographic data were interpreted using frequency and component ratio. Professional identity, self-directed learning competence, and self-efficacy scores and their component scores were presented as (mean±standard deviation). Correlations between professional identity, self-directed learning competence, and self-efficacy were determined using Pearson correlation analysis; t-test and variance analyses were used to compare the mean values for factors associated with professional identity, self-directed learning competence, and self-efficacy.

Results

DEMOGRAPHIC DATA OF CSSD NURSES:

The CSSD nurses’ demographic data are presented in Table 1. Of the surveyed CSSD nurses, 185 (58.2%) possessed an undergraduate qualification or above; 199 (62.6%) had more than 10 years of work experience; 118 (37.1%) were aged 41 and older; and 197 (61.9%) received a monthly income ranging between 5001 Chinese Yuan (CNY) and 10 000 CNY.

REASONS WHY CSSD NURSES CHOSE TO STUDY NURSING AND WORK IN THE CSSD:

Of the surveyed CSSD nurses, 97 (30.5%) chose to study nursing due to their personal interest; 104 (32.7%) chose to work in the CSSD due to their personal interest; and 204 (64.1%) did not wish their children to become nurses, showing their low level of recognition in nursing (Table 2).

CORRELATIONS BETWEEN PROFESSIONAL IDENTITY, SELF-DIRECTED LEARNING COMPETENCE, AND SELF-EFFICACY:

The results of Pearson correlation analysis show positive correlations between professional identity, self-directed learning competence, and self-efficacy (P<0.01) (Table 3).

SCORES FOR PROFESSIONAL IDENTITY, SELF-DIRECTED LEARNING COMPETENCE, AND SELF-EFFICACY:

The 318 nurses’ professional identity scores ranged from 57 to 150, and their mean score was 109.92±17.161. Of the 5 components in the professional identity scale, occupational cognition received the highest score (31.53±6.20), and occupational self-reflection received the lowest score (11.53±1.88). For self-directed learning competence, the scores ranged from 69 to 170, with a mean score of 125.77±21.316. Of the 4 components in the self-directed learning competence rating scale, self-motivational beliefs received the highest score (53.84±8.768), and self-evaluation received the lowest score (13.92±2.792). The self-efficacy scores ranged from 10 to 40, with a mean score of 26.92±6.633. Details are presented in Table 4.

COMPARISON OF THE SCORES FOR PROFESSIONAL IDENTITY, SELF-DIRECTED LEARNING COMPETENCE, AND SELF-EFFICACY:

The 318 nurses’ scores for professional identity, self-directed learning competence, and self-efficacy were compared between groups. T-test or analysis of variance was performed for the measurement data. For professional identity scores, statistically significant differences (P≤0.05) were identified among the following factors: monthly income; reason for studying nursing; reason for choosing to work in the CSSD; whether or not they would study nursing and work in the CSSD if given a second chance; and desire for their own children to pursue a nursing career. For self-directed learning competence scores, statistically significant differences (P≤0.05) were identified among the following factors: age, hospital grade, type of employee, monthly income, and reason for choosing to work in the CSSD. For self-efficacy scores, statistically significant differences (P≤0.05) were identified among the following factors: age; reason for studying nursing; reason for choosing to work in the CSSD; whether or not they would study nursing and work in the CSSD if given a second chance; and desire for their own children to pursue a nursing career. Details are presented in Table 5.

Discussion

CORRELATIONS BETWEEN PROFESSIONAL IDENTITY, SELF-DIRECTED LEARNING COMPETENCE, AND SELF-EFFICACY:

The present study showed a pairwise positive correlation between professional identity, self-directed learning competence, and self-efficacy, indicating that the higher the level of professional identity possessed by the CSSD nurses, the stronger their self-directed competency and self-efficacy. This is similar to the results of Zhu et al [24] and Zhang et al [25]. Nurses with a high level of professional identity generally have positive cognition and evaluation regarding their profession, love their profession, and take pride in their work, thereby being more motivated to learn, seek solutions to problems, and overcome challenges. This is a positive factor in the generation of self-efficacy. Nurses can improve their professional knowledge and skills through active learning, thereby feeling a sense of accomplishment from work and improving their professional identity. Self-efficacy can positively affect professional identity [26]. Therefore, professional identity, self-directed learning competency, and self-efficacy are positively correlated.

CSSD NURSES NEED TO IMPROVE THEIR PROFESSIONAL IDENTITY, SELF-DIRECTED LEARNING COMPETENCE, AND SELF-EFFICACY:

The CSSD is a special nursing unit in the hospital. CSSD work is different from clinical nursing care. Whereas clinical nurses provide wholistic nursing care for patients and contribute to the rehabilitation of patients, CSSD nurses deal with reusable medical instruments. Having no contact with patients for a long time may cause a decrease in CSSD nurses’ competencies in planning, evaluation, and nursing. This can affect their work performance and feeling of accomplishment at work [27].

PROFESSIONAL IDENTITY SCORES:

This study shows that the CSSD nurses’ mean score for professional identity was 109.92±17.161, and the mean score for all items was 3.66±0.57, indicating a medium level of professional identity, which is similar to the results of Song et al [28] and Fang [29]. Among the 5 components, occupational cognition received the highest score (31.53±6.20) and occupational self-reflection received the lowest score (11.53±1.88). The survey results showed that 30.5% of the CSSD nurses chose to study nursing out of personal interest. Thus, most of them possessed knowledge of the general situation and development of the nursing profession, and bore a certain cognition of the purpose, significance, and value of the nursing profession. However, many of them were currently working in the CSSD due to random allocation around hospitals, and so were lacking in knowledge concerning the department upon arrival. Some of the nurses expressed uncertainty about their career development.

Occupational self-reflection is an important component of professional socialization, and is a hallmark of professional maturity in the nursing field. The term refers to a process of continuous self-exploration, self-correction, and judgment at work, as well as a process of in-depth cognition and understanding of self and career [30]. The low occupational self-reflection score may be indicative of the nurses’ lack of familiarity with CSSD work and the nature thereof. Most observers assume that CSSD work is simple and repetitive, and some medical practitioners consider such manual work beneath their station.

SELF-DIRECTED LEARNING COMPETENCE SCORES:

The present study shows that the CSSD nurses’ mean score for self-directed learning competence was 125.77±21.316, and the mean score for all items was 3.70±0.63, indicating a medium level of self-directed learning competence, which is similar to the results of Tan [31] and Wei et al [32], but lower than the scores reported by Sun et al [33] and Liu et al [34]. Xu [35] reported that the initial educational attainment levels of nurses in China are mainly technical secondary school and junior college, and that many of them greatly improved their level of educational attainment through adult higher education programs; however, they still experience pressure in relation to job promotion and career development, and so these nurses need to have developed self-directed learning competence. Our study shows that among many of the surveyed CSSD nurses there is substantial room for improvement in self-directed learning competence. Of the 4 components, self-motivational beliefs received the highest score (53.84±8.77), and self-evaluation received the lowest score (13.92±2.79). The high score of self-motivational beliefs might be associated with the nurses’ more utilitarian style of learning, in that they were concerned over whether the information they had acquired could help them solve the problems they encountered in daily work [36]. They were eager to acquire knowledge and skills which could help them at work. In particular, those lacking CSSD knowledge had an urgent need to this end. The respondents’ low score for self-evaluation might be associated with uncertainty about study planning and goals. CSSD knowledge, which is seldom covered in nursing training, includes cleaning, disinfection, sterilization, and techniques which are based on principles from chemistry, physics, and machinery fields. Compared with other nursing sub-branches and techniques, there is a lack of CSSD literature. CSSD nurses generally are left to themselves to improve their CSSD knowledge and skills, often via interactions with experts and via practice. There are no established criteria which enable CSSD nurses to evaluate the effectiveness of their learning; if CSSD nurses feel uncertain about study goals and planning, this may affect their self-reflection. Nursing managers and educators may develop training plans according to CSSD nurses’ learning needs and adopt innovative training methods so that their knowledge can solve practical problems and they can maintain learning enthusiasm.

SELF-EFFICACY SCORES:

The results of our study show that the CSSD nurses’ mean score on self-efficacy was 26.92±6.633, which is similar to the results of Wu et al [37], but lower than the national norm of 28.60 (t=−25.176, P<0.001) [38]. The CSSD nurses in our study tended to experience heavy workloads in a stressful and complex working environment, and also experienced relatively low social status and an attendant low sense of self-worth, as well as poor job promotion prospects, leading to lack of self-confidence. CSSD nurses do not have direct contact with patients, and so experience a lower sense of work achievement compared with clinical nurses. The heavy workloads combined with low social status translate into a low level of professional identity, leading to poor self-efficacy [39]. There is a need for nursing managers to create conditions for improving CSSD nurses’ work enthusiasm and self-confidence. Nursing managers should encourage nurses in their duties and provide more development opportunities for them. Activities designed to boost self-efficacy can be conducted to help nurses improve self-confidence.

DIFFERENT GROUPS OF NURSES HAD DIFFERENT LEVELS OF PROFESSIONAL IDENTITY SCORES, SELF-DIRECTED LEARNING COMPETENCE, AND SELF-EFFICACY:

The professional identity scores of the nurses with a high monthly income were higher than those with a low monthly income. The professional identity scores of the nurses who had a personal interest in nursing and working in the CSSD and who wished their own children to become nurses were higher than those of the nurses who made these choices for other reasons and who did not wish their own children to become nurses. It is widely recognized that the most basic physiological needs of human beings are food, clothing, and shelter [30]. Income can satisfy these needs. Newly recruited nurses have shorter employment histories and low-ranking job titles, are paid less, and are under greater pressure in meeting their living expenses. The nursing profession is generally characterized by heavy workloads, high risk, and great responsibility, and the value of nursing work may not be fully reflected in their labor remuneration. Yu et al [40] have shown in their results that unsatisfactory income is one of the main reasons for nurses’ poor sense of professional identity and the high numbers of nurses leaving the profession.

A significant link is found between the nurses’ motivations for choosing to work in the CSSD and their professional identity scores. An individual’s subjective intention determines the degree of passion and recognition [29]. Nurses who voluntarily chose to study nursing and work in the CSSD had higher professional identity scores, possibly because their choices were in line with their personal interest and career goals, and they had a higher cognitive evaluation of the nursing profession.

The self-directed learning competence of the CSSD nurses tended to increase with age, as evidenced by the 3 age groups in this study (26–30, 31–40 and 41–50 years), before peaking at around 50 years of age. The CSSD nurses aged below 25 and over 50 had low scores for self-directed learning competence, which is similar to the results of Chen et al [41]. Between their twenties and fifties, the performance of nurses generally improves with accumulating professional knowledge and experience, rendering them more capable of making appropriate plans for realizing goals, choosing appropriate learning strategies, and using learning resources effectively. However, nurses in their fifties in many cases will have accrued many years of physical and psychological stress, and will experience declining physical function, gradually lose interest in self-directed professional development, and exhibit declining self-directed learning competence.

In the sample, CSSD nurses working in Tertiary A hospitals had the highest self-directed learning competence scores (127.24±22.688), and CSSD nurses working at Secondary B hospitals had the lowest self-directed learning competence scores (96.67±8.963). Hospitals in China are divided into 3 categories and 10 levels (Tertiary: A+, A, B, and C; Secondary: A, B, and C; Primary: A, B, and C) according to the medical services they provide. Hospitals at higher levels impose higher standards in terms of talent selection. Nurses applying to higher-level hospitals incur fierce competition, and once recruited face greater pressure in relation to career development. Therefore, nurses working in Tertiary A hospitals need to possess outstanding professional knowledge and skills, and must constantly improve themselves to cope with the rapid hospital development. They must possess excellent self-directed learning competence. Our study shows that the self-directed learning competence scores of the nurses who were permanent employees (127.23±20.92) were higher than those of the nurses who were contract employees (124.61±21.076), and that the self-directed learning competence scores of the nurses with high monthly income (126.95±20.677) were higher than those with low monthly income (108.83±11.856). The staff in most hospitals in China consist of permanent staff and contract employees. Compared with contract employees, the permanent staff enjoy greater job security and benefits. The offer of a stable job is one reward for good self-directed learning competence. Income is the basic guarantee for life and work, and high income is the external stimulus and external driving force for self-directed learning competence [42]. Self-directed learning competence leads to better educational attainment and job promotion opportunities; a higher-ranked job title and salary increase can stimulate nurses’ desire towards self-directed learning. Therefore, job stability, income, and desire towards self-directed learning are positively correlated. The self-directed learning competence scores of the nurses who had been personally motivated towards working in the CSSD were higher than those of the nurses who had specified other reasons for working there. To quote the adage “Interest is the best teacher”, the nurses who chose to work in the CSSD out of a personal interest generally possessed greater continuous learning enthusiasm.

The nurses aged 41–50 had the highest self-efficacy score (28.99±6.10), and the nurses aged 18–25 had the lowest self-efficacy score (23.55±5.30). Young CSSD nurses generally have much less work experience, and therefore possess less CSSD knowledge, and are lacking in coping strategies when encountering difficulties and setbacks, which altogether undermine their self-confidence. Nurses aged 41–50 have acquired a rich store of social and work experience, are more resilient to setbacks and difficulties, and possess a high level of self-confidence. Bandura, an American psychologist, states that people with a high degree of self-efficacy are fearless, more calm and confident when confronted with difficulties, and can put in more effort to complete their work [43]. Nursing managers should increase efforts towards improving young CSSD nurses’ self-efficacy by allocating work according to their personal strengths, which will enhance their self-confidence. As mentioned, the self-efficacy scores of the nurses who entered the nursing field and chose to work in the CSSD out of personal interest were higher than those of nurses who chose this route for other reasons. If a chosen occupation is in line with a person’s own career interest and expectations, they will have a higher level of professional identity. The CSSD working environment is generally simpler than that of the clinical departments. The results of Xiao et al [44] have shown that a good nursing working environment leads to higher self-efficacy among nurses. Therefore, the self-efficacy scores of nurses who chose to work in the CSSD out of personal interest tend to be higher than those of nurses with different motivations. Higher self-efficacy translates into better capacity for overcoming difficulties and higher quality of task completion [45]. The results in this study suggest that professional identity is positively correlated with self-efficacy. Nursing managers should pay particular attention to the nurses who practice in the CSSD premises for reasons other than a personal interest in nursing and CSSD, so as to improve their professional identity and self-efficacy.

LIMITATIONS:

This was a cross-sectional study with a convenience sample of 318 CSSD nurses. Convenience sampling is a simple and cost-effective way to collect data, but the accuracy of sampling might be affected. Our study was only conducted with CSSD nurses, leading to a lack of diversity in study samples. The representativeness of the study samples was not high, which may lead to bias in the results. Ideally, in further studies, the sample size needs to be enlarged and participants from multiple regions should be included. Similar research shall be conducted with healthcare staff working in different departments.

Conclusions

The present study investigated the status of professional identity, self-directed learning competence, and self-efficacy among CSSD nurses. The professional identity, self-directed learning competence, and self-efficacy of the CSSD nurses in this study are at the medium level. The results suggest that, among many of the surveyed CSSD nurses, there is substantial scope for improvement in terms of their professional identity, self-directed learning competence, and self-efficacy. The rapid development of the CSSD field requires nurses of this subspecialty to possess a high level of CSSD knowledge and advanced skills [42]. The majority of CSSD nurses in the survey had been randomly allocated by hospitals to CSSD, and only a minority of them chose to work at the department out of personal interest. Nursing managers should consider ways of strengthening publicity and improving public awareness of CSSD work [46] in an effort to improve CSSD nurses’ social status and professional identity, thereby increasing their confidence and improving their self-directed learning competence. Meanwhile, more attention should be paid to CSSD talent development. It is advised to explore new teaching models to establish a complete knowledge system for talent training, which may lead to improvements in CSSD nurses’ professional skills, thereby promoting the development of CSSD nursing.