The mediating role of professional identity between work environment and caring behavior: a cross-sectional survey among hospice nurses in China

Hospice care refers to care centered on end-of-life patients and their families, using a multidisciplinary collaborative model to provide physical, psychological, and humanistic care. This holistically involves alleviating their pain and discomfort, improving their quality of life, relieving psychological distress of family members, and helping patients transition with dignity and comfort [1]. Watson, a humanistic care theorist, believes that humanistic care is the essence and core of nursing. Caring behavior is the behavior that nurses actively support and care for patients in nursing practice, and it is the external manifestation of nurses’ professional humanistic care knowledge, attitude and ability[2]. According to the World Health Organization, approximately 56.8 million people worldwide require hospice care each year, but only 14% ultimately receive relevant care [3]. Given the aging population in China, the number of end-of-life patients is gradually increasing, and so is the demand for hospice care services. However, hospice care in China is still at an early stage of development, with a coverage rate of only 10% of the Chinese population [4]. Research has shown that at present, the number and service quality of domestic hospice care practitioners are unable to meet the needs of hospice services [5]. As core members of the hospice care team, the nurses’ ability to care for patients significantly impacts the quality of hospice services [6]. They spend 24-h days with patients, making them invaluable with regard to patient caring behavior [7]. For hospice nurses, a lack of humanistic care in clinical practice may hinder their effective communication with patients, leading to a lack of trust and an increase in conflicts. This will worsen patient clinical outcomes and reduce overall quality of life [8]. Although, some methods and efforts such as, “Healthy China 2030 Plan” [9] have been taken to improve caring services, complaints of dissatisfaction still remain, mainly due to inadequate humanistic care from nurses [10]. Therefore, it is of great importance to explore the factors that affect caring behavior of hospice nurses, in order to provide reference for nursing managers to formulate intervention plans to promote hospice care development in China.

The nursing work environment refers to organizational characteristics of the working environment that promote or prevent professional nursing practices [11]. A good working environment is characterized by harmonious colleague relationships, efficient teams, sufficient staffing, career advancement, and supportive leadership [12]. Multiple studies have suggested that the work environment is an important factor directly impacting hospice practice [13, 14]. The nurse’s caring ability is the core tenet of hospice practice. In a positive environment, nurses are fully engaged with their work and provide comprehensive care to patients [15]. However, in China, work environment problems such as insufficient staffing and resources [16], lead to overworked hospice nurses, who lack the time and energy to care for patients. Although the work environment has been proven to be an important factor influencing caring behavior [17], this relationship is unclear among hospice nurses.

The connotation of nurses’ professional identity is that nurses recognize the value of nursing profession and make corresponding behaviors accordingly[18]. Professional identity is an internal factor to foster career growth, and differences in nurses’ professional identity affect their behavior in clinical work [19]. Previous studies have shown that the higher levels of career satisfaction, were associated with lower turnover intention [20]. Nursing managers can use professional identity as an intrinsic motivation to stabilize nursing teams [21]. Hospice nurses face inevitable work challenges, which may lead to burnout and negative emotions, impacting work efficiency, personal development, and ultimately professional identity [22]. In addition, numerous surveys have demonstrated that professional identity can affect nurses’ caring behavior [23]. Specifically, the higher the nurses’ professional identity, the deeper their understanding of the essence of nursing care. However, few studies have focused on hospice nurses as research subjects, and it is essential to further clarify the relationship between professional identity and caring behavior of hospice nurses.

The field dynamic theory [24] proposed by Kurt Lewin holds that individual behavior is a result of the interaction between internal psychological and external environmental force fields. It is encompassed by the behavior formula; B = f(P*E), where B refers to the behavior, P refers to the individual, and E refers to the environment. Thus, individual behavior can be influenced by two factors: individual psychology (internal psychological factors) and external environment (external environmental factors). Caring behavior may also be explained by this theory, which means that individual caring behavior is affected by both interior psychological factors and exterior environmental factors. In addition, Mehrabianh and Russell’s Stimulus Organism Response (S–O-R) theoretical model [25] emphasizes that in the process from receiving an external stimulus to producing behavioral responses, individuals need to first act on their internal consciousness such as cognition and emotion, in order to produce and generate corresponding responses. In this study, hospice nurses were the subjects of behavioral responses (caring behavior); the effect of external stimuli (working environment) on their behavioral response (caring behavior) needs to be first mediated by internal awareness (professional identity).

Therefore, according to the field dynamics theory, S–O-R model, and previous research, we proposed the following hypotheses and the theoretical model is presented in Fig. 1:

First, our results showed that the caring behavior of hospice nurses was at a high level, slightly higher than other research reports [33]. In 2022, the National Health Commission released the “National Nursing Development Plan(2021–2025)”, one of the main tasks of which is to “promote the high-quality development of nursing and strengthen the humanistic care ability of nurses”. In addition, the policy also calls for accelerating the development of hospice care and training professionals engaged in hospice care services[34]. With the support of this policy, China Life Care Association actively organized humanistic care training for nurses, so that they have a deeper understanding of humanistic care[35]. A study on the humanistic care ability of Chinese healthcare workers showed that humanistic care training is the main influencing factor of nurses’ humanistic care ability[36]. In this study, 77.9% of hospice nurses participated in nursing humanistic care training, such as humanistic care case analysis and scenario simulation training, indicating that actively conducting training aids in improving nursing care. Interestingly, almost all participants in this survey (99%) were women suggesting that gender may significantly impact nursing behavior [37]. Furthermore, the level of care provided by responsible group leaders and associate senior nurses was higher, consistent with the research findings of Patiraki et al. [38]. When compared to younger nurses, senior staff tend to work longer, are more clinically experienced, and have a strong awareness of caring for patients. Therefore, it is suggested that nursing managers regularly organize senior nurses to share their experience of implementing humanistic care with younger nurses, so as to improve the level of humanistic care among young nurses. Besides, we also found that health condition significantly influenced caring behavior of hospice nurses. Nurses with excellent and good health were more likely to achieve the expected work performance [39]. Thus, there is a need for preventive interventions that focus on identifying or improving the physical and mental health of hospice nurses in order to enhance their caring behavior. On the one hand, nursing managers should attach importance to the construction of departmental sports culture, such as establishing activity rooms, which can not only promote physical activity but also create a harmonious working atmosphere. On the other hand, it is necessary to actively carry out group psychological counseling to help nurses learn emotional management skills, in order to strengthen the construction of positive psychological resources. Moreover, hospice nurses who earned more than 1,200 dollars a month had a higher level of care in our survey. However, these individuals only accounted for 32.1% of participants. Hospital administrators should establish a suitable salary system to ensure that hospice nurses’ welfare benefits are reasonable and fair, thereby promoting their care for patients.

Second, our results revealed that work environment has a direct and positive effect on hospice nurses’ caring behavior, which supports Hypothesis 1. To some extent, we can draw a conclusion that hospice nurses in a positive work environment are more willing to care for patients, corresponding with previous study by Norkaih et al.[17]. A healthy work environment helps hospice nurses access resources, which make them feel valued and supported by their leaders. This increases both their commitment to the organization and job satisfaction [40]. They then feel a strong sense of duty to the organization, promoting provision of high-quality care to patients [41]. Empirical evidence also suggested that a healthy working environment reduce worn out and profit for caring behavior, which were crucial to accomplish patient-centered care and efficient teamwork in hospices [42]. Therefore, creating a supportive nursing work environment is essential. Hospital managers can encourage hospice nurses to participate in organizational decision-making, provide clear organizational goals and career blueprints, and allocate resources reasonably [43]. Meanwhile, the empowering leadership of head nurses help to motivate junior nurses to work autonomously [44]. In addition, harmonious cooperation between doctors and nurses is very important, which fosters reciprocal feelings of trust and respect [45, 46].

Furthermore, the findings provided evidence that hospice nurses’ professional identity was positively associated with their caring behavior, supporting Hypothesis 2, which is consistent with a previous study on the relationship between professional identity and caring behavior of nurse leaders[2]. Wu et al. discovered that nurses possessing a strong sense of professional identity have greater work enthusiasm and engagement[18]. According to the field dynamics theory [24], individual internal factors such as cognition and attitude affect one’s behavior. When nurses recognize the value of their profession and derive a sense of happiness from it, they associate positive experiences and emotions with their work. This will promote an intrinsic motivation to actively engage in work, thereby changing caring behavior [47]. Not only that, professional identity can also increase psychological maturity of hospice nurses, enabling them to accept adverse phenomena in the profession with a calm outlook. They can then understand the special and psychological vulnerability of end-of-life patients, and actively integrate humanistic care into practice [48]. In summary, nursing managers should attach importance to the positive psychological construction of hospice nurses, help them establish professional resilience, and combine effective protection and incentive measures to enhance their professional identity.

Finally, professional identity is a mediator between work environment and hospice nurses’ caring behavior. Our results were consistent with the aforementioned hypothesis 3. Qi et al. highlighted that nurses had doubts about their professional perception within a non-supportive environment [49]. The lower the level of professional identity, the more likely nurses hold indifferent attitudes towards their work. They may view nursing as low-level cheap labor, which affects their caring behavior [50]. On the contrary, when nurses work in a positive environment, they are more likely to identify with their profession and increase their willingness to stay on the job [51]. Moreover, nurses with positive professional identity are more focused on their work and provide better patient care [47]. Therefore, nursing managers should pay attention to the interrelationship between the working environment of hospice nurses and their professional identity and caring behavior. They not only need to optimize the nursing working environment, but also intervene in the caring behavior of hospice nurses from the perspective of professional identity. Furthermore, the results of this study suggested that hospice nurses’ professional identity plays a partial mediating role between work environment and caring behavior, indicating that in addition to professional identity, there may be other variables that have a mediating effect between work environment and caring behavior, and the mechanisms of action still need to be further explored in the future.

Our research provides relevant implications for nursing management. By exploring the caring behavior of hospice nurses, a specialized group, we find that their working environment is positively correlated with caring behavior. Meanwhile, professional identity plays a mediating role between work environment and caring behavior. It suggests that hospital managers should attach importance to the construction of a healthy work environment as the long-term goal of organizational development. Proactive intervention measures should be taken to improve the working environment for hospice nurses, such as establishing a fair salary system, conducting end-of-life care training, and providing promotion opportunities. Furthermore, nursing managers should pay attention not only to hospice nurses’ work environment but also their professional identity. Nursing managers can organize Balint group activities and provide professional awareness training for hospice nurses to enhance their professional identity and thus promote their level of care.

In this study, we identified a significant relationship between work environment and caring behavior in hospice nurses, as well as the mediating influence of professional identity on this relationship. Nursing managers are supposed to have a correct understanding of relationship between the three variables, and then take targeted measures and coping strategies to improve hospice nurses’ work environments and enhance professional identity, so as to promote their caring behavior.

The study has several limitations. First, the cross-sectional design prevents establishing causal relationships between variables. Second, the limited sample size curtails the generalizability of our findings. Hence, large-scale longitudinal studies for hospice nurses can be considered in the future. Third, this study focuses on hospice nurses in some regions of China, which may have a certain impact on the external applicability of the result. Fourth, all data in this study were based on self-reporting, which increases the possibility of source bias. In the future, it is necessary to objectively measure the caring behavior of hospice nurses from the perspective of patients. Finally, the study investigated only professional identity of hospice nurses as a mediator between their work environment and caring behavior. Other mediators such as (psychological capital, job burnout, and emotional intelligence) should be explored in future studies.