Psychometric properties and latent profile analysis of the Nursing Brand Image Scale: a methodological study in the Chinese context

The importance of nurses has not been well recognized by the public despite their essential contributions to human health [1]. Traditional stereotypical images of nurses as angels of mercy or subordinates of physicians with minimal education undermine the public image of nurses, reduce the allocation of resources to nursing research, and decrease nurses’ quality of life (Godsey JA, Kallmeyer R, Hayes T: Public Validation of Brand Image of Nursing Scales: Implications for Global Health, unpublished). The stereotypical image of nurses can be commonly seen in the mass media, including magazines, television, and the Internet. For example, prior to the outbreak of the COVID-19 pandemic, nurses in China were often characterized by the media as a group of caregivers who received little education and had no expertise, and therefore, were not highly valued by the Chinese society [2]. The stereotypical images were largely due to the public’s perception that nurses’ work was equivalent to caring and serving others, which did not require expertise or extensive education [3].

After the outbreak of the COVID-19 pandemic, the image of nurses began to be evolved into tireless healthcare providers fighting on the frontline against a pandemic. This heroic view of nurses became a common report in the media and had greatly influenced the previous stereotypical perceptions of nurses [4], thus offering a booster to nurses’ virtuous image [5]. However, the benefits of this media trope on the virtuous image of nurses are projected to be temporary unless an accurate and consistent brand image of the profession is promoted and managed [6]. Highlighting the most virtuous features of nurses but ignoring the intensive professional and intellectual requirements of nurses on their education and training is not only a disservice to the brand image of nursing, but also reducing the attractiveness of the nursing profession to future nurses [7].

Branding is a marketing tool that is used to communicate core values, identify products and services, and positively influence public perception [8]. Intentional efforts to identify and strengthen the nursing brand image are currently underway in the U.S., with the hope to stimulate professional cohesiveness and consistency, enhance the profession's image, and eliminate role ambiguity [9]. The process of effective branding of the nursing profession could result in the conveyance of an image that is relevant, positive, accurate, distinctive, and research based [9]. The brand image could be most effectively communicated through consistent messages and actions over time [10]. A consistent message that highlights the roles and contributions of nurse leaders, scientists, and practitioners is not only desirable for the nursing profession but could also serve as a foundation for institutional strategic plans and college curricula to support the advancement and influence of nurses [9].

A review of literature revealed 11 original scales developed between 1991 and 2021 to measure the image of nursing. Given the paucity of available instruments in the literature, articles that included measures of professional self-concept (or “how nurses feel about themselves as nurses”) were retained [11]. The final list of scales from this review included The Porter Nursing Image Scale (PNIS) [12], the Nursing Image Scale (NIS) [13], the Nursing Attitudes/image Questionnaire (NAQ/NIQ) [14], the BELgian Professional Self-IMAGE Instrument (BELIMAGE) [15], the Professional Self-Concept of Nurses Instrument (PSCNI) [16], the Nurses Self-Concept Instrument (NSCI) [17], the Nurses Self-Concept Questionnaire (NSCQ) [18], the Nurse Self-Description Form (NSDF) [19], the Nursing Brand Image Scale (NBIS), the Nursing's Current Brand Position Scale (NCPBS) and Nursing's Desired Brand Position Scale (NDBPS) [9].

Among all scales examined in this review, the NBIS was the only instrument that incorporated the concept of the brand image of nursing and measured a more comprehensive nursing image. The internal consistency and reliability of the scale were good to excellent in a sample of 286 American Registered Nurses [9].

The importance of the nursing profession has often been overlooked due to inaccurate societal views and outdated stereotypes that negatively influenced nurses’ images. To correct the inaccurate views and stereotypes, nurses and relevant practitioners need to understand the current nursing brand image. However, empirical instruments that measure the comprehensive brand image of nursing are sparse in the literature. And psychometric properties of NBIS Chinese version remain unclear. Moreover, no study has thus far targeted latent profile analysis (LPA) on the brand nursing image. The aims of this study were to translate the U.S. version of the NBIS into Chinese (following the process of the Consensus-Based Standards for the Selection of Health Measurement Instruments [COSMIN] checklist) [20, 21], to evaluate its psychometric properties when administered to a national sample of Chinese nurses, and to identify nursing brand image profiles in Chinese nurses.

After the NBIS was translated into Chinese, its validity, reliability, and responsiveness were tested based on the COSMIN checklist in a national sample of Chinese Registered Nurses [20]. Results of this study demonstrated acceptable validity (Content validity, structural validity, and construct validity), reliability (internal consistency and test–retest reliability), responsiveness, and no floor/ceiling effect. In the study, we found five categories of the self-perceived brand image among Chinese nurses: Subordinate (category 1), Innovative (category 2), Leader (category 3), Traditional (category 4), and Integrated (category 5).

The reliability of the NBIS-C was found to be acceptable. The results of internal consistency evaluation showed the items of the instrument to be consistent between themselves and predictive of the same construct. Going further than Cronbach’s alpha by testing all McDonald’s omega values, the global results and McDonald’s hierarchical omega subscales confirmed the reliability. In addition, CR values indicated adequate reliability for all subscales. The test–retest stability evaluation showed moderate indices for the Strong Interpersonal Skills and Lack Authority/Professional Identity subscales. A review of the raw data revealed this was due to the variation in the advocate item in the Strong Interpersonal Skills dimension. In Chinese culture, it appears that advocates are rarely associated with interpersonal communication skills in nursing [39]. The items in the Lack Authority/Professional Identity dimension, on the other hand, are more likely to be influenced by self-perception and society [1].

The seven-factor model is different from NBIS in two factors indicated by the results in the EFA. One of the revisions is that the Influential Leaders/Interprofessional Partners subscale in the original NBIS was divided into the Influential Leaders subscale and Interdisciplinary Partners subscale in the NBIS-C. Other than the linguistic usage preference, previous studies found that Influential Leaders and Interprofessional Partners are two different constructs, although some of their features overlap [40]. The two are mutually influencing and independent of each other [41]. The Expert Health-Care Providers and Partners subscale and the items it contains were highly correlated with the dimension of being Valued by Society/Healthcare; therefore, the original NBIS was modified to merge the Expert Health-Care Providers and Partners subscale into Valued by Society/Healthcare subscale.

Overall, principal component factor analysis extracted a seven-factor model consisting of Strong Interpersonal Skills, Influential Leaders, Interdisciplinary Partners, Valued By Society/Healthcare, Advanced Nursing Practice, Qualified Caregivers, and Lack Authority/Professional Identity, which differs slightly in structure from the original study. Therefore, we confirmed the model fit the NBIS-C using confirmatory factor analysis. It is worth noting that the x²/df, CFI, TLI, SRMR and RMSEA statistics demonstrated that the seven-factor model offered an acceptable fit with the data collected, indicating that the scale has good structure validity [42, 43]. This changed structure may be more conducive to the cross-cultural adaptation of the scale [43] and enable the evaluation of different brand images in Chinese nurses. Although all items in the factor structure were retained, five items were reallocated in the NBIS-C (Table 2), as indicated by the results in both the EFA and CFA. The difference might result from Chinese cultural and social backgrounds in the development of nursing.

Although all items in the factor structure were retained, five items were reallocated in the NBIS-C (Table 2), as indicated by the results in both the EFA and CFA. The difference might result from Chinese cultural and social backgrounds in the development of nursing. The American Nurses Association (ANA) stated in 1995 that all advanced practice nurses (APN) can make independent or collaborative healthcare decisions [44]. Advanced Nursing Practice has been developed as a professional core curriculum for master's degree students in China [45]. In addition, the outbreak of severe acute respiratory syndrome (SARS) and the COVID-19 pandemic have elevated the value of nurses and demonstrated they are not only the person who gives injections and dispenses medications, but also healthcare providers (Godsey JA, Kallmeyer R, Hayes T: Public Validation of Brand Image of Nursing Scales: Implications for Global Health, unpublished). Thus, item15 (Health Care Providers) was considered by most participants to be an important component of advanced nursing practice competencies. The APN needs to assume and be competent in the roles of expert practitioner, educator, researcher, and consultant [46]. The reallocated Item 32 (Researchers) and item 38 (Teacher/Educator) demonstrated that Chinese nurses' perceptions of advanced nursing practice and their values for society/healthcare are still inconsistent [47]. Participants in this study generally corroborated the seven-factor structure of NBIS-C. Validity in the NBIS-C was found to be nearly identical to the original NBIS. To avoid a biased effect from item 8 (Diverse Career Options), future studies could rephrase the wordings in item 32 and item 38 and examine whether these two items can fall back to the original structure as proposed by the NBIS.

The convergent validity presented suitable values for most of the factors, except for the Influential Leaders subscale and the Lack Authority/Professional Identity subscale, which showed levels below those recommended AVE. Future studies might examine if these two dimensions represent two different brand images of nursing, the traditional and the new. The inconsistency in perceptions of brand image is responsible for the low convergent validity of the two subscales [48, 49]. Regarding the discriminant validity evaluation, there was interpretable identity between Valued By Society subscale and Influential Leaders subscale, as well as Strong Interpersonal Skills and Advanced Nursing Practice. A leader ‘s confidence has a positive association with social identity, and their communication skills are essential for advanced nursing practice skills [50, 51]. Generally, the convergent and discriminant validity limitations can be explained due to the high correlations present between the items of the subscales, or due to the item cross‐loadings. Another explanation for these limitations may be related to possible flaws in the scale translation process. However, the cultural adaptation process of the NBIS to Chinese was carefully conducted, and the participants did not report difficulties in understanding any item during the pretest. The factor loadings in Valued By Society subscale were also the lowest in the original scale [9].

The main novelty of the research was to generate image profiles in a large Chinese nurse sample using nontheoretical techniques. The different brand images of nursing profiles were performed via LPA to identify subgroups. The LPA revealed five well-interpretable subgroups. These findings demonstrated that the NBIS-C can clearly distinguish between different Chinese nursing brand images. In addition, despite the new and evolving roles in the contemporary nursing practice, the brand image of Chinese nurses is underestimated and inconsistent.

To our knowledge, this study is the first one to examine the validity, reliability, and responsiveness of the NBIS. Moreover, by uncovering latent subtypes of nursing brand image this study can contribute to the refinement of the NBIS Model. However, some study limitations should be acknowledged. First, the study relied on self-reported data, therefore, it was subject to response biases including social desirability effects. More cross-cultural studies are needed to verify the factor structure of the NBIS-C. Second, for the CFA estimator, robust maximum likelihood (MLR) was conducted for analysis due to the generally less biased standard error estimates and good coverage of the correlations than diagonally weighted least squares (DWLS) [52]. But, DWLS was designed specifically for ordinal data. Thus, DWLS may perform uniformly better than MLR in factor loading estimates. Third, in terms of responsiveness, this study only measured concurrent validity and predictive validity. Finally, the measurement invariance results did not test across demographic characteristics as the sample size to test measurement invariance was small. Future researchers should recruit a larger sample size of nurses from a variety of practice and non-practice settings to evaluate profiles of the brand image of nursing, and explore the differences and relationships across culture and social demography characteristics.

Nurse managers can use the NBIS-C to assess the brand image of nurses in their unique context. Various strategies could be offered to improve nursing’s brand image or to determine if certain features of nursing’s brand image might be predictors of mental health or motivation to improve clinical performance and well-being. To become more influential in the healthcare arena, nurses need to create a more attractive and sustainable brand image that helps retain and energize the current and future workforce [53, 54]. Narrowing the gap between nurses’ current and desired images could be achieved through correcting inaccurate stereotypes, eliminating role ambiguity, and stimulating the professional cohesiveness of the evolving nurse leaders.

NBIS-C is a valid and reliable scale that can be used to evaluate the brand image of nursing among Chinese nurses. Addressing the gap between nurses’ current and desired images could be achieved through correcting inaccurate stereotypes, eliminating role ambiguity, and stimulating the professional cohesiveness of the evolving nurse leaders.