Cognitive changes in professional value and career development amid the COVID-19 pandemic: A qualitative study of nurses' experiences
Abstract
Aim
To explore cognitions in nurses' professional value and career development amid the COVID-19 pandemic and to analyse influencing factors.
Design
A qualitative descriptive study design was employed.
Methods
Thirty practising nurses from three general hospitals in Chengdu, China, were purposively recruited. Face-to-face semi-structured interviews were conducted. The content analysis was used for data analysis.
Results
After the outbreak of the COVID-19 pandemic, there were obvious cognitive changes in nurses' professional value, including improvement in the cognition of professional value, awareness of the broadening of the field of acting professional value, and realization of increasingly high requirements in careers. Approval and gratitude of patients, social recognition and attention, self-awareness of nurses were main influencing factors. For cognitive changes in career development, nurses became more motivated to develop their careers, had a clearer understanding of career development environment, and acquired a clearer understanding of what was needed to advance careers. Hospital support, social respect, family support, and team atmosphere were key influencing factors.
Conclusions
The contributions made by nurses in the prevention and control of the COVID-19 pandemic have prompted positive changes in their cognition of professional value and career development. To promote nurses' positive understanding and approach to career development, measures should be taken by hospitals. Further, social respect, family support and team cooperation can enhance nurses' enthusiasm for career development.
1 INTRODUCTION
Professional value is what a profession means to an individual and reflects the relationship between the attributes and functions of a profession and the satisfaction of the practitioner's needs (Odom-Forren, 2021). Career development is a process by which individuals explore and establish career paths and achieve success (Yarbrough et al., 2017). Professional value and career development are closely related, as nurses can establish clear career goals, develop workable career plans, and make real-time adjustments based on assessment of their own needs, ability, and situation (Lou et al., 2010; Sanford, 2020). The International Council of Nurses (ICN) has elucidated the unique and irreplaceable professional value of nurses and actively promoted their career development (International Council of Nurses [ICN], 2019, 2023a, 2023b). Nurses are critical to deliver on the promise of “leaving no one behind” and to achieve the Sustainable Development Goals (World Health Organization [WHO], 2020), and nurses also play a core role in protecting patient safety and shaping health policy (ICN, 2002, 2015a, 2015b, 2023b). On the other hand, the title of Nurse should be protected by law (ICN, 2012), and the professional abilities and development of nurses should be enhanced (ICN, 2013, 2017).
In China, legislation and ethical code recognized professional value and career development of nurses. The Nurse Regulation issued by the State Council in 2008 defines nurses as “health personnel who have obtained nurse practice certificate through practice registration, engage in nursing activities, and fulfill the responsibilities of protecting life, reducing pain, and promoting health.” and also stipulates the rights of nurses, including career development improvement (State Council of the People's Republic of China, 2008). Chinese Nursing Association released the Code of Ethics for Chinese Nurses in 2020 (Chinese Nursing Association & The Humanistic Nursing Professional Committee of Chinese Association for Life Care, 2020), which points out the professional value of nurses in providing nursing care, protecting patient rights, conducting health education, and coordinating social resources. Despite the recognition of roles of nurses by regulations and code of ethics, for a long time, due to social, cultural, professional development and other factors, the social status of nurses in China has always been low. The low social status of Chinese nurses has resulted in them not receiving the respect they deserve (Feng et al., 2017). Chinese nurses have also experienced workplace violence which has reduced their loyalty to the nursing profession and led to an increase in turnover rate (Liu et al., 2019).
The COVID-19 pandemic seems to be a turning point. Since 2020, the COVID-19 pandemic has had a profound impact on all aspects of society. It has posed huge challenges to the healthcare system. Under the pandemic, China responded quickly, valued scientific research, united all people and emphasized community participation (The Lancet, 2020). In the pandemic prevention and control, nurses played a prominent role, which underscored the value of nurses in protecting people's health (Anders & Lam, 2021). Nurses felt that they were duty-bound to work with other healthcare providers on the frontline to save lives (Xiaoxu et al., 2023). Nurses provided intensive care, assisted with patients' daily activities, supported patients emotionally, and kept explored the knowledge and experience to care for patients (Li et al., 2022). During the COVID-19 pandemic, studies showed that nurses experienced statistically significant traumas in the form of increased workloads, negative patient outcomes, and less social support system access (Riedel et al., 2021). They were at an increased risk for stress, burnout, and depression (Sriharan et al., 2021) and faced challenges including organization's inefficiency in supporting nurses, physical exhaustion, living with uncertainty and the psychological burden of the disease (Moradi et al., 2021). For Chinese nurses who fought against the COVID-19 pandemic in China, they were under great pressure and experienced anxiety, fatigue, and burnout (Mo et al., 2020; Wan et al., 2022; Zhan et al., 2020). Worth to note, attention has also been paid to changes in nurses' cognition of professional value under the COVID-19 pandemic (Aydın et al., 2022; Gassas & Salem, 2023; İlaslan et al., 2021), and emerging studies have pointed out that efforts should be made to affirm the value and professional recognition of nurses (Zhu et al., 2021). Furthermore, influencing factors of career development have been increasingly explored, such as support in the work place, clinical career development opportunities, work hours and access to further education (Cleary et al., 2013). The COVID-19 pandemic has unprecedently impacted how nurses view and change their professional value and career development.
By the end of 2022, Chinese registered nurses reached 5.2 million (National Health Commission of the People's Republic of China, 2022). As the single largest group of healthcare professionals in China, Chinese nurses have been taking the role of primary caregiver like their counterparts in the rest of the world. Their cognitive changes in professional value and career development during the COVID-19 pandemic affect the safety of patients, development of nursing workforce, and steady operation of the medical system. However, this issue has not yet been paid attention by current studies. From the international perspective, comparative study before and after the COVID-19 pandemic in this field is limited, with studies mainly focusing on the middle and late stages of the pandemic (Fernández-Basanta et al., 2022; Rourke et al., 2024). Little was known about the impact of the COVID-19 pandemic on the trajectory of cognitive changes in the professional value and career development of nurses. This study aimed to understand the specific impact of the COVID-19 pandemic on nurses' cognition in professional value and career development and its influencing factors. The research question of this study is as follows: (a) Whether the COVID-19 pandemic has brought cognitive changes to nurses' professional value and career development? (b) If changes occur, what are the specific contents of cognitive changes in professional value and career development? (c) What are the positive and negative factors that affect nurses' cognitive changes in professional value and career development?
2 THE STUDY
2.1 Aims and objective
This study aimed to explore nurses' cognitions in their professional value and career development amid the COVID-19 pandemic.
3 METHODS
3.1 Design
This study employed a qualitative descriptive design (Doyle et al., 2020). Semi-structured in-depth interviews were conducted for data collection. We followed the COREQ guidelines in reporting the study (Tong et al., 2007).
3.2 Theoretical framework
This study used the Capability, Opportunity, and Motivation Behaviour (COM-B) model to facilitate exploring the cognitive changes of nurses in professional value and career development amid the COVID-19 pandemic. In the COM-B model, the capability, opportunity, and motivation interact to generate behaviours that in turn influences these components (Michie et al., 2011). The capability, opportunity, and motivation are complexly related and can be further explored at physical, psychological, environmental, and social levels. In this study, the COM-B model is helpful in understanding the complex cognitive changes as it provides a comprehensive framework that considers multi-faceted factors.
3.3 Participants and settings
Participants were purposively recruited from three general hospitals in Chengdu, China (Ames et al., 2019). These three hospitals are respectively tertiary hospital, secondary hospital and first-level hospital. Chengdu is the largest city in southwestern China with a population of 21.192 million. The inclusion criteria were as follows: (1) clinical nurse or nursing manager engaged in clinical nursing for more than two years; (2) participated in the COVID-19 pandemic prevention and control, including working in fever clinics, COVID-19 patient admission wards or nucleic acid sampling/testing, or epidemiological surveys; and (3) practised in departments closely related to the COVID-19 pandemic prevention and control, including department of emergency, respiratory medicine, cardiovascular medicine, thoracic surgery, infectious diseases, and ICUs.
3.4 Data collection
On the basis of literature research, open questions were drawn up according to the aims of this study, and pilot interviews were conducted using the preliminary interview guide. After interviewing two nurses, the interview guide was adjusted and finalized. The questions were as follows: 1. Since the outbreak of the COVID-19 pandemic, what changes have taken place in your cognition of professional value of nursing, and what may be the reasons for these changes? 2. Since the outbreak of the pandemic, do you think your professional value has been more fully reflected? If yes, where is it embodied? 3. Before and after the outbreak of the pandemic, did you have any changes in your work time and energy input? 4. Since the outbreak of the pandemic, did you have any changes in your identity and sense of pride in the nursing profession? 5. Since the outbreak of the pandemic, did you have any changes in your belief in choosing nursing as a lifelong career? If yes, what is the reason? 6. What do you think are the main factors affecting career development presently, and what support do you want? 7. What do you think are the pros and cons of the current practice environment for career development, and what aspects do you want to improve?
Purposive sampling method was used in this study (Ames et al., 2019). Nurses with different professional titles were selected based on the inclusion criteria. When the authors interviewed eight to nine nurses in each hospital and the total number of interviews reached 25, no new themes emerged and data saturation was achieved (Malterud et al., 2016). One to two nurses were further interviewed in each hospital for confirmation, and totally, 30 nurses were interviewed (Janice, 2015; Zhang, 2017). Face-to-face semi-structured interviews were conducted by two authors (YL, female; ZM, female). YL held a PhD degree in law and was a faculty member in nursing school. ZM held a bachelor's degree in nursing and had more than 30 years' experience in clinical practice and nursing management. Both interviewers had long-standing experience in the field of medical ethics and qualitative methods. Participants volunteered to participate in the study and oral informed consent was obtained before the interview. The interviews were conducted in a quiet and private room for about 35–45 min, and no one else was present. The interviews were recorded, interview data were deidentified, and identification codes range from N1 to N30 were used. Pilot interviews were conducted solely to test the questions and were not included in the data analysis.
3.5 Data analysis
The interview data and audio recordings were transcribed verbatim within 24 h. All transcripts were analysed by all authors using an inductive approach based on the content analysis method (Elo & Kyngäs, 2008). First, the transcripts were read independently by three authors (YL, QL, ZM) to gain an overall understanding of the interview content, in an approach that the transcripts were read through several times to make sense of the data. Second, important statements were identified and extracted from the data by the first author. Third, attention was given to potential meaning of important statements, its connotation was analysed, and the meaning units were refined and labelled as primary codes by the second and the third authors. Fourth, the meaning units were condensed into the of themes and sub-themes describing the meaning of the data by all authors. Fifth, available participants were asked to provide feedbacks. Feedbacks from 28 participants were obtained and discussed by all authors, and the themes and sub-themes were finally determined. No computer-aided qualitative data analysis tool was used, but Microsoft Excel software was used to facilitate data coding and analysis.
3.6 Ethical considerations
This study was approved by the Ethics Review Committee of West China Hospital, Sichuan University. This study followed the Declaration of Helsinki guidelines, and ethical principles about voluntariness, confidentiality and noninjury were emphasized before, during, and after data collection (World Medical Association, 2013). Before the interview, all participants were informed of the purpose and procedure of this study and expressed their agreement verbally. The verbal informed consent also included descriptions about the right to withdraw from the study at any time, and potential risks and benefits of participating in the study.
3.7 Rigour
The Consolidated Criteria for Reporting Qualitative Research (COREQ) recommendations were followed (Tong et al., 2007), and the following strategies were adopted to ensure the credibility, transferability, dependability and confirmability of the study (Lincoln & Guba, 1985). First, all interviews were conducted with an interview guide, ensuring relevancy to the research question. Second, member checking was performed to ensure credibility. The analysis findings were validated by the participants. Third, all interviews were audio-recorded, and field notes were made. The detailed documentation established the transferability. Fourth, data were analysed independently, and discussions were conducted among the research team until consensus was achieved, establishing confirmability. Fifth, all researchers have been experienced in qualitative research and conducted the study neutrally.
4 FINDINGS
4.1 Participants
Thirty participants completed the interviews, and the majority was female (93%). The mean age was 35.2 years (SD = 7.8), and the length of working experience ranged from 2 to 41 years. Eight participants had experience participating in anti-pandemic work in areas where medical staff were in great demand, and the other 22 participated in local anti-pandemic work. Participants' characteristics are shown in Table 1.
| Item | Frequency (%) |
|---|---|
| Age (years) | |
| 20–30 | 10 (33) |
| 31–40 | 11 (37) |
| 41–50 | 8 (27) |
| 51–60 | 1 (3) |
| Gender | |
| Male | 2 (7) |
| Female | 28 (93) |
| Education | |
| College diploma | 8 (27) |
| Bachelor's degree | 20 (67) |
| Master's degree | 2 (6) |
| Marital status | |
| Unmarried | 2 (7) |
| Married | 28 (93) |
| Professional title | |
| Junior | 10 (33) |
| Middle | 10 (33) |
| Senior | 10 (33) |
| Clinical department | |
| Emergency department | 12 (40) |
| ICU | 6 (20) |
| Respiratory department | 6 (20) |
| Cardiovascular department | 4 (13) |
| Thoracic surgery department | 1 (3) |
| Department of infectious disease | 1 (3) |
| Working years (year) | |
| 2–10 | 11 (37) |
| 11–20 | 12 (4) |
| 21–30 | 5 (17) |
| 31–40 | 1 (3) |
| 41–50 | 1 (3) |
4.2 Changes in nurses' cognition of professional value
As shown in Table 2, after the outbreak of the COVID-19 pandemic, participants' cognition of their professional value changed significantly, which was mainly reflected in three aspects: their cognition of the nursing professional value was significantly improved; they became more aware of the broad scope of the nursing field; and they realized a need to improve their abilities to play their value.
| Themes |
|---|
Change in cognition
|
|
Influencing factors
|
4.2.1 Theme 1: Dramatic improvement in the cognition of professional value
After the outbreak of the COVID-19 pandemic, participants' cognition of their professional value significantly improved, and participants who went to areas where the demand for anti-pandemic work was great reported particularly deep feelings in this regard.
I had deep feelings in the process of riding to the rescue of Jilin Province. The nursing team was the largest group on the medical team. There were 25 people in our hospital who rode to the rescue of Jilin, 17 of whom were nurses. By supporting the front line, I have felt more deeply the value of the nursing profession… Nurses shouldered the heavy responsibility in anti-pandemic work. (N3)
4.2.2 Theme 2: Awareness of the broadening of the field of acting nurses' professional value
I realize that nurses have a huge development space in the medical industry. Besides providing care, nurses play an increasingly important role in the promotion and education of popular science, risk management, and preventive health care, and we can provide views for decision-making based on our own experience. In addition, the role of nurses has gradually deepened to include in psychological intervention. (N5)
4.2.3 Theme 3: Realization of the increasingly high requirements in nurses' careers
In recent years, with the rapid development of the nursing discipline, nursing professional technology has become increasingly sophisticated. In the process of preventing and controlling the pandemic, many technical operations are completed by nurses, reflecting our professionalism. Due to the particularity of COVID-19, higher requirements have also been placed on nurses' professional ability, which makes me recognize the significance of improving my own ability. (N1)
4.3 Influencing factors of change in nurses' cognition on professional value
Changes in participants' cognition of their professional value are affected by many factors. Their self-awareness, social recognition and attention, approval and gratitude of patients are the main reasons mentioned by the participants as promoting their cognitive changes regarding professional value. Since the outbreak of the COVID-19 pandemic, not only nurses but also society and patients' views about the nursing profession have improved, indicating that the change in cognition of professional value is the result of multiple factors.
4.3.1 Theme 1: Approval and gratitude of patients
“In the anti-pandemic work, I obviously feel gratitude from patients.” She smiled brightly and said, “I hear patients say to us ‘Thank you for your hard work’ more often. Respect from patient's eyes, a smile, or a word of thanks let me realize my professional value.” (N21)
4.3.2 Theme 2: Social recognition and attention
I think there has been a big change in the emphasis on nurses. From the country to the hospital, increasing attention has been given to us. Hospitals have more training for nurses than before, especially pandemic prevention and control knowledge. The whole society also understands and respects us more, which makes me feel that nurses have increasingly important value. (N4)
4.3.3 Theme 3: Self-awareness of nurses
I feel that our professional value is becoming more intuitive and specific in this pandemic. I only performed basic nursing in the ward before. Although I gained a great sense of achievement in successfully rescuing patients in ordinary times, rushing to the front line made me feel that my occupation was of higher value. I can contribute to society and help people by using my professional knowledge. (N10)
4.4 Changes in nurses' cognition of career development
Participants' cognition of career development changed positively after the outbreak of the COVID-19 pandemic, which concretely embodied their perception of greater motivation for career development, clearer understanding of the career development environment and clearer understanding of the additional work needed (Table 3).
| Themes | Sub-themes |
|---|---|
| Change in cognition | |
| 1. Perception of greater motivation for career development | |
| 1.1 Improvement of identity and pride for the nursing profession | |
| 1.2 Firm belief in choosing nursing as a lifelong career | |
| 2. Clearer understanding of career development environment | |
| 3. Clearer understanding of more work input need | |
| Influencing factors | |
| 1. Hospital support for nurses | |
| 1.1 Basic working conditions | |
| 1.2 Development conditions | |
| 1.3 Hospital policy and culture | |
| 2. Social respect and support | |
| 3. Family support | |
| 4. Team atmosphere | |
4.4.1 Theme 1: Perception of greater motivation for career development
After the outbreak of COVID-19 pandemic, participants felt a greater driving force for career development, which was reflected in the improvement of their professional identity, pride in the nursing profession and a firm belief that the choice of nursing as a lifelong career was a good one.
Sub-theme 1: Improvement of identity and pride for the nursing profession
I used to do nursing work in obscurity. After the outbreak of this pandemic, I felt that my work was of great significance and that I was needed. I'm proud to be able to exert my efforts in such a significant affair. (N16)
Sub-theme 2: Firm belief in choosing nursing as a lifelong career
At first, I chose nursing as my job mostly due to my parents' wishes. However, throughout this pandemic, I have realized the lofty nature of the nursing profession and strengthened my belief in choosing nursing as a lifelong career. (N25)
4.4.2 Theme 2: Clearer understanding of career development environment
An obvious feeling is that I am more aware of the advantages and disadvantages of the career development environment. After the outbreak of the pandemic, the career development environment of nurses improved. For example, we have received more support from the hospital, the treatment has improved to a certain extent, and there are more learning and training opportunities, which makes me feel that the path for career development is brighter. But in the whole social environment, we need more protection. (N22)
4.4.3 Theme 3: Clearer understanding of more work input need
Now we need to care for patients and undertake pandemic prevention work. We are putting more time into pandemic prevention work, such as nucleic acid testing. The work requirements of pandemic prevention and control for nurses are increasingly higher, and the quality of work should be strictly controlled. Therefore, I will devote more energy to study and think about how to complete the work better. (N27)
4.5 Influencing factors of change in nurses' cognition of career development
4.5.1 Theme 1: Hospital support for nurses
All participants emphasized the importance of hospital support for their career development, and they mentioned the impact of basic working conditions, development opportunities, hospital policy, and culture.
Sub-theme 1: Basic working conditions
The primary influencing factor is salary. Nurses are treated well in our hospital. Since the outbreak of the pandemic, we have been paid corresponding allowances for anti-pandemic work, but there is still a certain gap between us and doctors. Hospitals owe nurses more respect and need to make rewards proportional to our efforts. Since the pandemic, we have needed to balance clinical nursing and anti-pandemic work, and the work intensity has increased. (N4)
Sub-theme 2: Development conditions
We had few opportunities for learning and training before. Since the outbreak of the pandemic, with increased work, we have received more professional knowledge training, especially in pandemic prevention and control, and our hospital has also encouraged us to improve education levels. I realize that the professionalism of the nursing profession is increasingly valued. However, in the current manpower situation, we cannot make full use of these opportunities. (N28)
Sub-theme 3: Hospital policy and culture
From the perspective of cultural atmosphere, our hospital attaches great importance to the nursing team. Leaders emphasize fostering nursing talent, nursing discipline development and echelon construction, and they also implemented many incentives to improve our status, which makes us feel our importance. However, there is still room for improvement compared with doctors. I hope that the hospital could recognize the value of nurses and give more support to the nursing team. (N7)
4.5.2 Theme 2: Social respect and support
Our country is becoming an older society. The society is paying more attention to nurses and nursing work and vigorously advocating the development of nursing, and the role of nurses in aged care, health care and other fields, in which we can see good career prospects. After the outbreak of the pandemic, patients have more respect for us. However, different patients have different perceptions of nurses, and some patients still don't respect us. I hope that the society will give more recognition to nurses, nurses and patients will improve mutual trust and respect and our personal safety will be better protected. (N10)
4.5.3 Theme 3: Family support
My family has always supported me in nursing work. Since the outbreak of the pandemic, our work has become busier. At the early stage of the pandemic, I worked until 22 o'clock. My family has no complaints; they are very supportive of my work both psychologically and physically. They are proud of my contribution to the hospital and the country. My son regards me as his hero. (N14)
4.5.4 Theme 4: Team atmosphere
As a manager, I hope the nursing team remains stable, but nurses receive less attention than doctors at present. Although the situation has improved since the outbreak of the pandemic, the emphasis on nurses is still insufficient. A poor team atmosphere will lead to difficulties in team development. Management strategy could have a great impact. The old-fashioned management mode will lead to the loss of nursing talent. (N11)
5 DISCUSSION
Nurses' cognition of career development affects the stability and vitality of the nursing team. Since the COVID-19 pandemic, the positive changes in nurses' perception of their professional worth have given them a clearer understanding of career development, including motivation for career development, awareness of the work needed and the value of the career development environment. Motivation for career development mainly involves identity and pride for the nursing profession and occupational belief. Zeng et al. (2022) pointed out in their study that intrinsic motivation of nurses has a significant positive effect on work engagement. The transformation from regarding nursing as work to regarding nursing as a lifelong career is a crucial change in the nursing field (Sanford, 2020). This study showed that participants strengthened their belief in choosing nursing as a lifelong career, which showed that the value reflected in this major public health event and the respect and recognition by society can change nurses' original views, making them recognize the work as a profession and a lifelong career. From the aspect of work input, nurses became aware that they needed to concentrate more on the profession and spend more time and energy to improve the quality of their work. Meanwhile, nurses have a clearer and overall understanding of current career development environment. Nurses expressed that hospitals provide more support for nurses, especially the need for personal safety protection.
Support from the hospital, social respect and support, family support, and team atmosphere are the main factors mentioned by nurses as affecting their cognitive changes about career development. Support from the hospital includes basic working conditions, developmental opportunities, hospital policies, and culture. The treatment of nurses and the difference between nurses and other medical workers are widely known and have become limiting factors in maintaining the stability of nursing teams (Wang et al., 2017). The incongruity between nursing needs and insufficient manpower makes it difficult to guarantee the rest hours of nurses, which is particularly problematic in China. Overwork is not only an important theme of career development barriers but also leads to nursing turnover (Cleary et al., 2013). The lack of learning and development opportunities had led to a reduction in nurses' expectations for career development (Bindon, 2017). In recent years, the basic working conditions and developmental opportunities have improved to a certain extent, and hospital policy and culture also reflect the trend of paying more attention to the nursing team, but the degree varies in different levels of hospitals. The results of this study reflected that social respect and support were positive factors that promote nurses' cognitive changes about career development. Nurses pay special attention to their personal safety and dignity maintenance, which is consistent with other research results, reflecting the frequency and profound impact of verbal and behavioural violence suffered by nurses at work (Lu et al., 2019). Research by Al-Qadi (2021) showed that violence and humiliation suffered by nurses in the workplace are obstacles to career development. Social respect and protection for nurses could encourage nurses to devote themselves to their work and let nurses see a better future. In terms of family support, nurses expressed its importance, and firm support from family members was a positive factor in promoting their career development (Aranya et al., 2021). In terms of team atmosphere, the work of nurses involves cooperation with doctors, nurse colleagues and other hospital staff, so a harmonious atmosphere helps nurses better integrate into the team and creates a positive working environment (Tucker et al., 2019). Respect and recognition from managers and colleagues is also an essential part of forming a good team atmosphere.
To improve nurses' recognition of professional value, it is necessary to emphasize the value of nurses, promote the development of nurses in clinical nursing, management, education and scientific research, and make them feel the importance of the nursing profession and society's need for them. At the same time, approval from society, managers, colleagues, and patients is essential. A correct understanding about the nursing profession should be established and show respect and approval of nurses.
Promoting nurses' positive understanding of career development is crucial to help them concentrate on their careers and maintain the stability and growth of the nursing team. Efforts should be made to achieve this goal. First, nurses' basic working conditions and development opportunities should be guaranteed. Salary and treatment are the material embodiment of the value of nursing. The improvement of professional requirements and the prominence of professionalism should be reflected in the salary and treatment of nurses, and attention should be given to narrowing the differences in salary and treatment between doctors and nurses. In the normalization period of the pandemic, it is essential to strengthen the guarantee of working hours and reasonable rest. Ensuring training and learning opportunities and promotion opportunities for nurses will encourage their self-improvement and promote their career development. Second, good team atmosphere should be formed. The cooperative nature of medical staff's work determines the influence of team atmosphere on nurses' career development (Prompahakul et al., 2021). Managers, doctors, and other staff should respect nurses, attach importance to them, and give full play to their initiative and positive role in the team. Third, hospitals should provide active support, emphasize the construction and development of the nurse team and nursing profession, enhance the voice of the nurse team in hospital management and development, actively improve the problem of manpower shortages, reduce the burden of nurses in undertaking non-nursing work, and return the time and energy of nurses to professional nursing and related work. Finally, social respect and support should be enhanced. Society should increase publicity about the nursing profession to allow the public to obtain a fresh understanding of nurses. More attention should be given to supporting and protecting nurses, safeguarding their personal safety, rights and interests, and ensuring their career development.
Improving nurses' cognition of professional value and career development is a shared proposition for the nursing industry in countries around the world. Although this study was conducted in China, it would inspire other countries to reflect on the great significance of nurses for the healthcare system and the health of people and take active measures at the levels of nursing managers, healthcare systems, society, and national policies to help nurse exert their professional value and develop their career.
5.1 Strengths and limitations of the work
The study was one of the few qualitative studies focusing on nurses' experiences with cognitive changes of professional value and career development amid the COVID-19 pandemic. The findings are helpful for nursing leaders, medical institutions, and policy-makers to give play to nurses' value and promote their career.
The study had several limitations. First, this study was conducted only in one city in China, and the generalizability of the study may be limited as the research context was healthcare settings in China. Second, only two male nurses were included in the study, and the findings were mainly derived from interviews with female nurses who might have different thoughts and experiences compared with male nurses. Third, only an inductive qualitative approach was employed during data analysis, though the theoretical framework of COM-B model was used for understanding the complexity of the phenomenon.
5.2 Recommendations for further research
The results of the present study showed that contribution of nurses in this major public health event has led to positive changes in nurses' cognition of their professional value. The WHO has emphasized the core role of nurses in achieving universal health coverage and advocated for the value of the nursing profession (WHO, 2020). However, it is not uncommon that the professional value and contribution of nurses are not given the attention they deserve (Aarathi, 2021). In China, although increasing attention has been paid to the role of nursing in recent years, it is still doubtful whether nurses' perception of their professional value has truly changed based on the long-standing traditional concept (Liu et al., 2019). The outbreak of the COVID-19 pandemic seems to have brought a great turning point. The recognition of nurses by the whole society has improved. The state advocates the professional value of nurses and appeals to the public to respect nurses. Nurses' understanding of their professional value significantly improved, and this understanding transcended sex, age, professional title, region, and other factors. Approval and gratitude from patients, social recognition and attention, and self-awareness of nurses have jointly promoted these cognitive changes. The contribution of nurses in the COVID-19 pandemic has shown that nurses can play an active and key role in protecting patients' safety through caring, risk assessment and prevention, participation in decision-making, publicity and education, nursing research and other activities. As McHugh et al. (2021) showed, nurses are the key resources to achieve patient safety.
Further study could be conducted among nurses in different cities from different provinces of China and in different countries, balancing the female participants and male participants so as to gain a deeper understanding of nurses' cognition of their professional value and career development. In addition, both inductive and deductive approaches could be used for qualitative data analysis when more evidence and theoretical frameworks are available in the field of nurses' professional value and career development.
6 CONCLUSIONS
This study showed that nurses' cognition of professional value and career development underwent overall positive changes amid the COVID-19 pandemic. Nurses have improved the depth and breadth of their understanding of professional value and realized the requirements for improving their ability to engage in nursing. They now have a clearer understanding of career development, show greater motivation for career development, a clear understanding of more work input need and the opportunities and challenges brought by the career development environment. The key to enhancing nurses' cognition of their professional value is to make them feel and practice their own value. The exertion of their professional role, social approval, respect from colleagues and patients, and social attention and protection are important aspects of enhancing the value of the nursing profession. To promote the career development of nurses, measures should be taken in team building, hospital support, social support, and protection to help nurses overcome obstacles to professional development and achieve the goal of promoting the healthy development of nurses.
AUTHOR CONTRIBUTIONS
Yawen Luo: Writing-original draft, Investigation, Formal analysis. Quanlei Li: Writing-review & editing, Formal analysis. Zhiqun Ma: Investigation, Formal analysis, Validation. Xiuying Hu: Conceptualization, Project administration, Funding acquisition, Formal analysis.
ACKNOWLEDGEMENTS
We are grateful for all participating nurses.
FUNDING INFORMATION
This work was supported by the Beijing Weiren Weiye International Medical Research Center [grant number 2021-HLYJ-013].
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ETHICS STATEMENT
This study was approved by the Ethics Review Committee of West China Hospital, Sichuan University (2022–1332).
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author XH upon reasonable request.
