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The mediating effects of self-efficacy and study engagement on the relationship between specialty identity and career maturity of Chinese nursing students: a crosssectional study
自我效能感和学习参与对中国护理专业学生的专业认同与职业成熟度之间关系的中介效应：一项横断面研究

Yanjia Liu 1 , 2 1 , 2 ^(1,2){ }^{1,2}, Mei Chan Chong 2 2 ^(2){ }^{2}, Yanhong Han 1 1 ^(1){ }^{1}, Hui Wang 3 3 ^(3){ }^{3} and Lijuan Xiong 1 ∗ 1 ∗ ^(1**){ }^{1 *}

Abstract  摘要

Background Career maturity is a crucial indicator of career preparedness and unpreparedness can cause the turnover of new nurses. Considerable empirical work demonstrates the potential associations between specialty identity, self-efficacy, study engagement, and career maturity. This study aimed to explore the mediation role of selfefficacy and study engagement on the relationships between specialty identity and career maturity among Chinese nursing students. Methods Four hundred twenty-six Chinese nursing students were recruited between September 11 and October 30, 2022. The online survey was conducted following the CHERRIES checklist. Electronic questionnaires assessed their perceived specialty identity, self-efficacy, study engagement, and career maturity. The descriptive analysis, Harman single-factor analysis, Pearson correlation tests, structural equation modeling, and the bootstrap method were employed in data analysis. Results Bivariate correlation analysis identified a positive correlation between specialty identity, self-efficacy, study engagement, and career maturity ( r = 0.276 − 0.440 , P < 0.001 r = 0.276 − 0.440 , P < 0.001 r=0.276-0.440,P < 0.001r=0.276-0.440, P<0.001 ). Self-efficacy and study engagement partially mediated the relationship between specialty identity and career maturity. Self-efficacy and study engagement played a chain mediating role between specialty identity and career maturity. Conclusions The underlying mechanism can explain the relationships between specialty identity and career maturity: a direct predictor and an indirect effect through self-efficacy and study engagement. Policymakers and educators should emphasize the importance of specialty identity and provide tailored strategies for improving care maturity depending on nursing students’ specialty identity, self-efficacy, study engagement in the early stages of career development.
背景 职业成熟度是衡量职业准备程度的一个重要指标，准备不足会导致新护士的流失。大量实证研究表明，专科认同、自我效能感、学习参与度和职业成熟度之间存在潜在关联。本研究旨在探讨自我效能感和学习参与对中国护生的专业认同与职业成熟度之间关系的中介作用。方法 在 2022 年 9 月 11 日至 10 月 30 日期间招募了 426 名中国护理专业学生。在线调查按照 CHERRIES 核对表进行。电子问卷评估了他们的专业认同感、自我效能感、学习参与度和职业成熟度。数据分析采用了描述性分析、哈曼单因素分析、皮尔逊相关检验、结构方程模型和引导法。结果 双变量相关分析表明，专业认同、自我效能感、学习投入度和职业成熟度之间存在正相关（ r = 0.276 − 0.440 , P < 0.001 r = 0.276 − 0.440 , P < 0.001 r=0.276-0.440,P < 0.001r=0.276-0.440, P<0.001 ）。自我效能感和学习参与在一定程度上调节了专业认同与职业成熟度之间的关系。自我效能感和学习参与在专业认同和职业成熟度之间起到连锁中介作用。结论 专业认同和职业成熟度之间的内在机制可以解释两者之间的关系：直接预测和通过自我效能感和学习参与的间接影响。 政策制定者和教育者应强调专科身份的重要性，并根据护理专业学生在职业发展早期阶段的专科身份、自我效能感和学习参与度，提供量身定制的策略，以提高护理成熟度。

Keywords Nursing students, Self-efficacy, Study engagement, Specialty identity, Career maturity, Mediating effect
关键词 护理学生 自我效能感 学习投入 专业认同 职业成熟度 中介效应
2 2 ^(2){ }^{2} Department of Nursing Science, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
2 2 ^(2){ }^{2} 马来西亚吉隆坡马来亚大学医学院护理科学系
3 3 ^(3){ }^{3} Department of Medicine, Jingchu University of Technology, Jingmen, Hubei, China
3 3 ^(3){ }^{3} 中国湖北荆门荆楚理工学院医学系

Introduction  导言

The media visibility obtained by nursing during the COVID-19 pandemic has made the public aware of nurses’ role in promoting and maintaining health [1]. As the social environment becomes more conducive to nursing career development, adequate awareness and preparedness for nursing careers are driving nursing students to adapt to and be satisfied with their careers [2, 3].
在 COVID-19 大流行期间，护理工作在媒体上的曝光率使公众认识到护士在促进和维护健康方面的作用[1]。随着社会环境越来越有利于护理职业的发展，对护理职业的充分认识和准备促使护理专业学生适应并满意自己的职业[2, 3]。
Career maturity is a crucial indicator of career preparedness [4], which is defined as the readiness to make age-appropriate career decisions with adequate information and accomplish career development-related tasks [5]. Unpreparedness and difficulties in taking on the nurse’s role were the main reasons newly graduated nursing students left nursing in their first years [6]. The turnover rate for new nurses in their first year of employment can reach as high as 69 % 69 % 69%69 \%, with a range of 12.10 − 69 % 12.10 − 69 % 12.10-69%12.10-69 \% [6-9]. In addition, new nurses who experienced higher levels of career maturity were also less likely to leave the profession [10]. Therefore, more research focusing on career maturity should re-engage nursing educators and managers and support the development of customized programs in the early stage of career development.
职业成熟度是职业准备度的一个重要指标[4]，职业准备度被定义为在掌握充分信息的情况下做出与年龄相适应的职业决定并完成职业发展相关任务的准备程度[5]。准备不足和难以胜任护士角色是刚毕业的护生在第一年离开护理岗位的主要原因[6]。新护士入职第一年的离职率高达 69 % 69 % 69%69 \% ，范围为 12.10 − 69 % 12.10 − 69 % 12.10-69%12.10-69 \% [6-9]。此外，职业成熟度较高的新护士离职的可能性也较小[10]。因此，更多关注职业成熟度的研究应重新吸引护理教育者和管理者的关注，并支持在职业发展的早期阶段制定个性化的计划。

Background  背景介绍

Specialty identity as a predictor to career maturity
专业身份是职业成熟度的预测因素

Super’s theory emphasizes that career development is a lifelong activity closely related to individual maturity and experiences [11]. It encompasses the development of behaviors and professional identity [12]. Work values, including professional identity, are crucial for career development and can influence career maturity [13]. professional identity significantly correlates with high school students’ career maturity [14]. Additionally, specialty identity appears as a part of professional identity in studies worldwide [15]. To clarify this concept in student groups, specialty identity is defined as the emotional acceptance and recognition of learners based on their understanding of the specialty being studied, accompanied by positive external behaviors and an inner sense of satisfaction [15]. Therefore, this study proposes Hypothesis 1 : specialty identity significantly predicts career maturity among Chinese nursing students.
苏普的理论强调，职业发展是一项与个人成熟度和经历密切相关的终身活动[11]。它包括行为和职业认同的发展[12]。包括职业认同在内的工作价值观对职业发展至关重要，并能影响职业成熟度[13]。此外，在世界范围内的研究中，专业认同也是职业认同的一部分[15]。为了在学生群体中明确这一概念，专业认同被定义为学习者基于对所学专业的理解而产生的情感上的接受和认可，并伴随着积极的外部行为和内心的满足感[15]。因此，本研究提出假设 1：专业认同能显著预测中国护理专业学生的职业成熟度。

The mediating effect of self-efficacy between specialty identity and career maturity
自我效能感在专业认同与职业成熟度之间的中介效应

Self-efficacy and career maturity are positively related [16, 17]. According to social cognitive theory, self-efficacy is a belief in a person’s ability to achieve their goal [18]. Regarding career maturity, self-efficacy could be an internal driver for students to dedicate themselves to the fields they have chosen [16]. Students with high self-efficacy can improve their professionalism and self-confidence, thereby achieving high degrees of career maturity [16].
自我效能感与职业成熟度呈正相关[16, 17]。根据社会认知理论，自我效能感是一个人对自己实现目标的能力的信念[18]。关于职业成熟度，自我效能感可能是学生献身于自己所选领域的内在驱动力[16]。自我效能感高的学生可以提高自己的专业水平和自信心，从而达到较高的职业成熟度[16]。
Further, professional identity is found to be significantly correlated with self-efficacy [19, 20]. Yao et al. [21] found that self-efficacy mediated between professional identity and self-reported competence among nursing students. Thus, this study poses Hypothesis 2: Self-efficacy is the mediating variable affecting specialty identity and career maturity among Chinese nursing students.
此外，研究还发现专业认同与自我效能显著相关[19, 20]。Yao 等人[21]发现，自我效能感在护理专业学生的专业认同和自我报告能力之间起中介作用。因此，本研究提出假设 2：自我效能感是影响中国护生专业认同和职业成熟度的中介变量。

The mediating effect of study engagement between specialty identity and career maturity
学习参与在专业认同和职业成熟度之间的中介效应

Study engagement is a vital variable related to academic performance, achievement, persistence, and retention, which refers to a positive psychological process including attention, energy and effort in learning [22, 23]. Astin’s theory of student involvement emphasizes that the significant environmental factors that can influence their engagement entail students’ backgrounds, such as residence, experiences, and academic involvement [24]. A significant correlation exists between study engagement and career maturity [25]. Moreover, Liu et al. [26] report that professional identity is positively correlated with study engagement, and the mediating role of study engagement in professional identity and career adaptability is significant. Based on the above evidence, this study posits Hypothesis 3: study engagement is the mediating variable affecting specialty identity and career maturity among Chinese nursing students.
学习投入是一个与学习成绩、成就、坚持性和保持率相关的重要变量，指的是一种积极的心理过程，包括学习中的注意力、精力和努力[22, 23]。阿斯廷的学生参与理论强调，影响学生参与的重要环境因素包括学生的背景，如居住地、经历和学术参与等[24]。学习参与度与职业成熟度之间存在明显的相关性[25]。此外，Liu 等人[26] 的报告指出，职业认同与学习投入呈正相关，学习投入对职业认同和职业适应性的中介作用显著。基于以上证据，本研究提出假设 3：学习投入是影响中国护生专业认同和职业成熟度的中介变量。

The chain mediating effect of self-efficacy and study engagement between specialty identity and career maturity
自我效能感和学习参与在专业认同与职业成熟度之间的连锁中介效应

Based on the aforementioned information, self-efficacy and study engagement may play a single mediating role between specialty identity and career maturity. However, the relationship between self-efficacy and study engagement remains to be clarified. In addition, whether these variables play a chain mediating effect between specialty identity and career maturity must be explored. Previous research has shown that self-efficacy positively correlates with study engagement [27,28]. The relationship between specialty identity and career maturity may be influenced by self-efficacy in the first place and by study engagement in the second. Therefore, this study proposes Hypothesis 4: Chain mediation describes the relationship among the four variables.
根据上述信息，自我效能感和学习参与度可能在专业认同和职业成熟度之间起着单一的中介作用。然而，自我效能感与学习投入之间的关系仍有待澄清。此外，这些变量是否在专业认同和职业成熟度之间发挥连锁中介效应也有待探讨。以往的研究表明，自我效能感与学习投入度呈正相关[27,28]。专业认同与职业成熟度之间的关系可能首先受到自我效能感的影响，其次受到学习投入度的影响。因此，本研究提出假设 4：链式中介描述了四个变量之间的关系。
Overall, this study explores the relationship between specialty identity and career maturity. It also examines the potential mediation model of specialty identity, selfefficacy, and career maturity, the potential mediation model of specialty identity, study engagement, and career maturity, and the potential chain mediation of the four variables using mediation analysis.
总之，本研究探讨了专业认同与职业成熟度之间的关系。研究还探讨了专业认同、自我效能感和职业成熟度的潜在中介模型，专业认同、学习参与和职业成熟度的潜在中介模型，以及使用中介分析法对四个变量进行的潜在连锁中介。

Methods  方法

Design  设计

This cross-sectional online survey was conducted among nursing students between September 11 and October 30, 2022. This online survey was designed, disseminated and conducted following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [29] (see in the Supplement File 1). The online questionnaire entailed demographic sheet and four instruments with different question styles (single choice and Likert scales).
这项横断面在线调查于 2022 年 9 月 11 日至 10 月 30 日在护理专业学生中进行。该在线调查的设计、发布和实施均遵循《互联网电子调查结果报告核对表》（CHERRIES）[29]（见补充文件 1）。在线问卷包括人口统计表和四种不同提问方式（单选和李克特量表）的工具。

Variables and data collection instruments Sociodemographic variables
变量和数据收集工具 社会人口变量

Sex (female, male), Higher education institution type (university, college), and Degree (diploma, bachelor’s).
性别（女性、男性）、高等教育机构类型（大学、学院）和学位（文凭、学士学位）。

Specialty identity  特殊身份

The College Student Specialty Identity Scale (CSSIS) developed by Qin [15], was used to measure medical students’ specialty identity [30]. It is a 23 -item scale with four subscales (cognitive, emotional, behavioral, and appropriateness). Students scored each item on a five-point Likert scale (1-5: strongly disagree to strongly agree). In Qin’s study, it had good reliability ( α = 0.955 α = 0.955 alpha=0.955\alpha=0.955 ) [15]. In the present study, Cronbach’s α α alpha\alpha was 0.949 .
Qin[15]编制的大学生专业认同量表（CSSIS）用于测量医学生的专业认同[30]。该量表共有 23 个项目，包含四个分量表（认知、情感、行为和适当性）。学生对每个项目采用李克特五点量表（1-5：非常不同意到非常同意）打分。在 Qin 的研究中，该量表具有良好的信度（ α = 0.955 α = 0.955 alpha=0.955\alpha=0.955 ）[15]。在本研究中，Cronbach's α α alpha\alpha 为 0.949。

Study engagement  学习参与

Study engagement was assessed using the Utrecht Work Engagement Scale-Student (UWES-S) [31]. Schaufeli et al. [32] developed the UWES and revised its items to measure students’ study engagement. Li & Huang [31] introduced UWES-S, translated it into Chinese, and validated it among undergraduate students. The UWES-S comprises 17 items grouped into three subscales (vigor, dedication, and absorption) and uses a 7 -point scale ( 0 = 0 = 0=0= never, to 7 = 7 = 7=7= always ). The cumulative scores range from 0 to 102, with higher scores indicating greater study engagement. The internal consistency using Cronbach’s alpha was 0.919 [31]. In this study, Cronbach’s α = 0.956 α = 0.956 alpha=0.956\alpha=0.956.
学习投入度采用乌特勒支学生工作投入度量表（UWES-S）[31]进行评估。Schaufeli 等人[32] 开发了 UWES，并对其项目进行了修订，以测量学生的学习投入程度。李和黄[31]介绍了 UWES-S，并将其翻译成中文，在本科生中进行了验证。UWES-S 包括 17 个项目，分为三个分量表（活力、投入和吸收），采用 7 点量表（ 0 = 0 = 0=0= 从不，到 7 = 7 = 7=7= 总是）。累计分数范围为 0-102 分，分数越高，表明学习投入程度越高。用 Cronbach's alpha 表示的内部一致性为 0.919 [31]。在本研究中，Cronbach's α = 0.956 α = 0.956 alpha=0.956\alpha=0.956 .

Self-efficacy  自我效能感

This study used the Chinese version of the General SelfEfficacy Scale to assess self-efficacy [33]. Schwarzer et al. [34] developed the original version. It was adapted to the context of China and validated by Wang et al. [33]. It is a 10-item scale with a 4-point Likert scale (from completely incorrect to completely correct). Cronbach’s alpha was 0.871 in Wang et al.'s study [33]. In this study, Cronbach’s α = 0.899 α = 0.899 alpha=0.899\alpha=0.899.
本研究使用中文版的一般自我效能感量表来评估自我效能感[33]。Schwarzer 等人[34]开发了该量表的原始版本。该量表根据中国国情进行了调整，并由 Wang 等人[33]进行了验证。该量表共有 10 个项目，采用李克特 4 点量表（从完全不正确到完全正确）。在 Wang 等人的研究[33]中，Cronbach's alpha 为 0.871。在本研究中，Cronbach's α = 0.899 α = 0.899 alpha=0.899\alpha=0.899 .

Career maturity  职业成熟度

Career maturity was measured using the validated Chinese version of the career maturity scale [35]. The original version developed by Lee [36] was translated into
职业成熟度采用经过验证的中文版职业成熟度量表进行测量[35]。由 Lee [36]开发的原始版本被翻译成了
Chinese by Zhang et al. [35]. The instrument entails 34 items broken down into six subscales: career decisiveness (CD), career confidence (CC), career independence (CI), career value (CV), relational dependence (RD), and career reference (CR). A 5-point Likert scale, ranging from strongly disagree to strongly agree, was adopted. The range of total scores was 34-170, with higher values indicating higher levels of career maturity. Its reliability coefficient was 0.86, as measured using Cronbach’s alpha [35]. In this sample, Cronbach’s α = 0.900 α = 0.900 alpha=0.900\alpha=0.900.
中文版由 Zhang 等人设计[35]。该工具包含 34 个项目，分为六个分量表：职业果断性（CD）、职业自信心（CC）、职业独立性（CI）、职业价值（CV）、关系依赖（RD）和职业参照（CR）。采用李克特 5 点量表，从 "非常不同意 "到 "非常同意"。总分范围为 34-170，分值越高，表明职业成熟度越高。根据 Cronbach's alpha [35]，其信度系数为 0.86。在本样本中，Cronbach's α = 0.900 α = 0.900 alpha=0.900\alpha=0.900 .

Participants and data collection procedure
参与者和数据收集程序

This study was conducted at five higher education institutions in Hubei province, China. The target population, full-time nursing students, were surveyed using convenience sampling. The suggested minimum sample size based on Monte Carlo simulations studies was adopted [37], and the minimum and maximum sample sizes for structural equation models were 200 and 460 respectively [38]. The final sample size in the design stage was 250575 , accommodating a possible dropout rate of 20 % 20 % 20%20 \%.
本研究在中国湖北省的五所高等院校进行。目标人群为全日制护理专业学生，采用方便抽样法进行调查。采用了基于蒙特卡罗模拟研究的建议最小样本量[37]，结构方程模型的最小和最大样本量分别为 200 和 460 [38]。设计阶段的最终样本量为 250575 个，考虑到可能的辍学率 20 % 20 % 20%20 \% 。
For data collection, we uploaded the integrated questionnaires on Wenjuanxing (https://www.wjx.cn/, Acquired NO. 168 , 902 , 709 168 , 902 , 709 168,902,709168,902,709 ). This website offers the most popular and convenient tool for anonymous data collection and collecting data anonymously extraction. One investigator from each university or college was invited to collect the data. All investigators held master’s degrees and understood the critical points for questionnaire collection well. Simple training was conducted before questionnaire distribution. Each nursing student can review and change their answers if necessary, but they were provided only one chance to submit the online questionnaires. The individual IP address can be yielded after submissions and provided for verification. Finally, 560 questionnaires were administered. After double-checking and eliminating invalid questionnaires, 426 valid questionnaires were extracted, yielding an effective response rate of 76.07 % 76.07 % 76.07%76.07 \%.
为了收集数据，我们将综合问卷上传到文娟星（https://www.wjx.cn/，获取编号： 168 , 902 , 709 168 , 902 , 709 168,902,709168,902,709 ）。该网站为匿名数据收集和匿名提取数据提供了最流行、最方便的工具。每所大学或学院邀请一名调查员收集数据。所有调查员都拥有硕士学位，并且非常了解问卷收集的关键点。问卷发放前进行了简单培训。每个护理专业学生都可以在必要时查看和修改自己的答案，但他们只有一次在线提交问卷的机会。个人 IP 地址可在提交问卷后被提取出来，以备核查。最后，共发放了 560 份问卷。经过重复检查和剔除无效问卷后，提取了 426 份有效问卷，有效答卷率为 76.07 % 76.07 % 76.07%76.07 \% 。

Data analysis  数据分析

After completing the descriptive analysis, Harman sin-gle-factor analysis was performed to assess the common method bias, and Pearson correlations were calculated in SPSS Version 26.0. Subsequently, structural equation modeling was validated, and the chain-mediation effect was examined using the bootstrap method in AMOS Version 23.0 with 5000 samples. The significance level was set at 0.05 .
在完成描述性分析后，进行了哈曼单因素分析以评估常用方法的偏差，并在 SPSS 26.0 版中计算了皮尔逊相关性。随后，对结构方程模型进行了验证，并在 AMOS 23.0 版中使用 Bootstrap 方法对 5000 个样本进行了链中介效应检验。显著性水平设定为 0.05。

Ethical considerations  伦理方面的考虑

This study was approved by the Ethics Committee of Jingmen No. 2 People’s Hospital, affiliated to Jingchu University of Technology (Approval No.2020002-1). All students
本研究经荆楚理工学院附属荆门市第二人民医院伦理委员会批准（批准号：2020002-1）。所有学生
Table 1 Nursing students’ characteristics ( n = 426 n = 426 n=426n=426 )
表 1 护理专业学生的特征 ( n = 426 n = 426 n=426n=426 )
Variables  变量 n ( % / / m e a n ± S D n ( % / / m e a n ± S D n(%////mean+-SD\boldsymbol{n} \boldsymbol{(} \mathbf{\%} \boldsymbol{/} \mathbf{/ m e a n} \boldsymbol{\pm} \mathbf{S D}
Age  年龄 19.89 ± 1.27 19.89 ± 1.27 19.89+-1.2719.89 \pm 1.27
Gender  性别
Male  男 56 (13.15)
Female  女性 370 (86.85)
School  学校
University  大学 322 (75.59)
College  学院 104 (24.41)
Grade  等级
Grade 1 (freshmen)  一年级（新生） 101 (23.71)
Grade 2 (sophomores)  二年级（高二） 166 (38.97)
Grade 3 (juniors)  3 年级（初三） 127 (29.81)
Grade 4 (seniors)  四年级（高年级） 32 (7.51)
Home location  主页位置
Urban areas  城市地区 151 (35.45)
Rural areas  农村地区 275 (64.55)
Variables n(%////mean+-SD Age 19.89+-1.27 Gender Male 56 (13.15) Female 370 (86.85) School University 322 (75.59) College 104 (24.41) Grade Grade 1 (freshmen) 101 (23.71) Grade 2 (sophomores) 166 (38.97) Grade 3 (juniors) 127 (29.81) Grade 4 (seniors) 32 (7.51) Home location Urban areas 151 (35.45) Rural areas 275 (64.55)| Variables | $\boldsymbol{n} \boldsymbol{(} \mathbf{\%} \boldsymbol{/} \mathbf{/ m e a n} \boldsymbol{\pm} \mathbf{S D}$ | | :--- | :--- | | Age | $19.89 \pm 1.27$ | | Gender | | | Male | 56 (13.15) | | Female | 370 (86.85) | | School | | | University | 322 (75.59) | | College | 104 (24.41) | | Grade | | | Grade 1 (freshmen) | 101 (23.71) | | Grade 2 (sophomores) | 166 (38.97) | | Grade 3 (juniors) | 127 (29.81) | | Grade 4 (seniors) | 32 (7.51) | | Home location | | | Urban areas | 151 (35.45) | | Rural areas | 275 (64.55) |
provided verbal consent to participate in the study and voluntarily completed and submitted the questionnaire.
口头同意参与研究，并自愿填写和提交问卷。

Results  成果

Harman single-factor analysis
哈曼单因素分析

The self-reported nature of the data meant the possibility of common method bias [39]. The Harman single-factor analysis showed that the eigenvalues of the five common factors were greater than 1 . The first common factor explained 35.50 % 35.50 % 35.50%35.50 \% of the variance, which is lower than the recommended threshold of 50% [40]. Therefore, no common method bias was detected.
数据的自我报告性质意味着可能存在共同方法偏差 [39]。哈曼单因素分析表明，五个共同因素的特征值均大于 1。第一个共同因子解释了 35.50 % 35.50 % 35.50%35.50 \% 的方差，低于建议的 50%阈值[40]。因此，没有发现共同方法偏差。

Descriptive statistics and correlation analysis
描述性统计和相关分析

The sociodemographic variables were as follows: female ( n = 370 , 86.85 % n = 370 , 86.85 % n=370,86.85%n=370,86.85 \% ), male ( n = 56 , 13.15 % n = 56 , 13.15 % n=56,13.15%n=56,13.15 \% ); university ( n = 322 , 75.59 % n = 322 , 75.59 % n=322,75.59%n=322,75.59 \% ), college ( n = 104 , 24.41 % n = 104 , 24.41 % n=104,24.41%n=104,24.41 \% ); freshmen ( n = 101 , 23.71 % n = 101 , 23.71 % n=101,23.71%n=101,23.71 \% ), sophomores ( n = 166 , 38.97 % n = 166 , 38.97 % n=166,38.97%n=166,38.97 \% ), juniors ( n = 127 , 29.81 % n = 127 , 29.81 % n=127,29.81%n=127,29.81 \% ), seniors ( n = 32 , 7.51 % n = 32 , 7.51 % n=32,7.51%n=32,7.51 \% ); Urban areas ( n = 151 , 35.45 % n = 151 , 35.45 % n=151,35.45%n=151,35.45 \% ), Rural areas ( n = 275 , 64.55 % n = 275 , 64.55 % n=275,64.55%n=275,64.55 \% ). The age of nursing students range from 18 to 25 (mean = 19.89 = 19.89 =19.89=19.89, SD = 1.27 SD = 1.27 SD=1.27\mathrm{SD}=1.27 ) (see Table 1).
社会人口学变量如下：女生（ n = 370 , 86.85 % n = 370 , 86.85 % n=370,86.85%n=370,86.85 \% ），男生（ n = 56 , 13.15 % n = 56 , 13.15 % n=56,13.15%n=56,13.15 \% ）；大学（ n = 322 , 75.59 % n = 322 , 75.59 % n=322,75.59%n=322,75.59 \% ），大专（ n = 104 , 24.41 % n = 104 , 24.41 % n=104,24.41%n=104,24.41 \% ）；大一（ n = 101 , 23.71 % n = 101 , 23.71 % n=101,23.71%n=101,23.71 \% ），大二（ n = 166 , 38.97 % n = 166 , 38.97 % n=166,38.97%n=166,38.97 \% ），大三（ n = 127 , 29.81 % n = 127 , 29.81 % n=127,29.81%n=127,29.81 \% ），大四（ n = 32 , 7.51 % n = 32 , 7.51 % n=32,7.51%n=32,7.51 \% ）；城市地区（ n = 151 , 35.45 % n = 151 , 35.45 % n=151,35.45%n=151,35.45 \% ），农村地区（ n = 275 , 64.55 % n = 275 , 64.55 % n=275,64.55%n=275,64.55 \% ）。护生的年龄在 18 至 25 岁之间（平均 = 19.89 = 19.89 =19.89=19.89 ， SD = 1.27 SD = 1.27 SD=1.27\mathrm{SD}=1.27 ）（见表 1）。
Table 2 shows the mean scores of the four key variables were 80.40 ± 21.66 , 57.56 ± 16.04 , 26.23 ± 9.37 80.40 ± 21.66 , 57.56 ± 16.04 , 26.23 ± 9.37 80.40+-21.66,57.56+-16.04,26.23+-9.3780.40 \pm 21.66,57.56 \pm 16.04,26.23 \pm 9.37, and 113.42 ± 31.61 113.42 ± 31.61 113.42+-31.61113.42 \pm 31.61. Positive correlations were found between the key variables: specialty identity and study engagement ( r = 0.276 r = 0.276 r=0.276r=0.276 ), specialty identity and self-efficacy ( r = 0.319 r = 0.319 r=0.319r=0.319 ),
表 2 显示，四个关键变量的平均得分分别为 80.40 ± 21.66 , 57.56 ± 16.04 , 26.23 ± 9.37 80.40 ± 21.66 , 57.56 ± 16.04 , 26.23 ± 9.37 80.40+-21.66,57.56+-16.04,26.23+-9.3780.40 \pm 21.66,57.56 \pm 16.04,26.23 \pm 9.37 和 113.42 ± 31.61 113.42 ± 31.61 113.42+-31.61113.42 \pm 31.61 。发现关键变量之间存在正相关：专业认同与学习参与度（ r = 0.276 r = 0.276 r=0.276r=0.276 ）、专业认同与自我效能感（ r = 0.319 r = 0.319 r=0.319r=0.319 ）、
specialty identity and career maturity ( r = 0.300 r = 0.300 r=0.300r=0.300 ), study engagement and self-efficacy ( r = 0.420 r = 0.420 r=0.420r=0.420 ), study engagement and career maturity ( r = 0.319 r = 0.319 r=0.319r=0.319 ), and self-efficacy and career maturity ( r = 0.440 r = 0.440 r=0.440r=0.440 ) (each p < 0.001 p < 0.001 p < 0.001p<0.001 ).
专业认同与职业成熟度（ r = 0.300 r = 0.300 r=0.300r=0.300 ）、学习参与度与自我效能感（ r = 0.420 r = 0.420 r=0.420r=0.420 ）、学习参与度与职业成熟度（ r = 0.319 r = 0.319 r=0.319r=0.319 ）、自我效能感与职业成熟度（ r = 0.440 r = 0.440 r=0.440r=0.440 ）（各 p < 0.001 p < 0.001 p < 0.001p<0.001 ）。

The chain-mediation effect analysis
连锁中介效应分析

A chain-mediation structural model was constructed with specialty identity as the independent variable, career maturity as the dependent variable, and self-efficacy and study engagement as the mediating variables. The model fitting results showed that χ 2 / d f = 2.965 χ 2 / d f = 2.965 chi^(2)//df=2.965\chi^{2} / d f=2.965, the comparative fit index = 0.963 = 0.963 =0.963=0.963, the Tucker-Lewis index = 0.958 = 0.958 =0.958=0.958, and the root mean square error of approximation = 0.068 = 0.068 =0.068=0.068, indicating good model fit. The chain-mediation effect model diagram of specialty identity, self-efficacy, study engagement, and career maturity of nursing students is shown in Fig. 1.
以专业认同为自变量，以职业成熟度为因变量，以自我效能感和学习投入度为中介变量，构建了一个链式中介结构模型。模型拟合结果显示， χ 2 / d f = 2.965 χ 2 / d f = 2.965 chi^(2)//df=2.965\chi^{2} / d f=2.965 、比较拟合指数 = 0.963 = 0.963 =0.963=0.963 、塔克-刘易斯指数 = 0.958 = 0.958 =0.958=0.958 、近似均方根误差 = 0.068 = 0.068 =0.068=0.068 ，表明模型拟合效果良好。护生专业认同、自我效能感、学习参与度、职业成熟度的链中介效应模型图见图 1。
The bootstrapping method found that the 95 % 95 % 95%95 \% confidence interval ( 95 % CI ) ( 95 % CI ) (95%CI)(95 \% \mathrm{CI}) of the chain-mediation path from specialty identity to career maturity was [0.002, 0.054], which did not include 0 , indicating significance. Thus, two possible mediation effects were detected: the mediating roles of self-efficacy in the relationship between specialty identity and career maturity and of study engagement in the relationship between specialty identity and career maturity, both of which were significant with a 95% CI (see Table 3).
自举法发现，从专业认同到职业成熟度的链式中介路径的 95 % 95 % 95%95 \% 置信区间 ( 95 % CI ) ( 95 % CI ) (95%CI)(95 \% \mathrm{CI}) 为[0.002, 0.054]，不包含 0 ，表示显著。因此，我们发现了两个可能的中介效应：自我效能感在专业认同与职业成熟度之间的中介作用，以及学习参与在专业认同与职业成熟度之间的中介作用，这两个中介效应在 95% 置信区间内均显著（见表 3）。

Discussion  讨论

This study explored the relationships between specialty identity, self-efficacy, study engagement, and career maturity and demonstrated the mediation models in Chinese nursing students. The finding identified a positive correlation between specialty identity and career maturity, and specialty identity can influence career maturity in three ways: self-efficacy, study engagement, and self-efficacy → → rarr\rightarrow study engagement, supporting the four Hypotheses. Despite this study did not validate the potential confounders such as career resilience [20], career adaptability [26], and resource management [29], the findings may improve our understanding of the underlying mechanism of these four variables and provide meaningful ideas for taking measures to improve nursing students’ career maturity.
本研究以中国护理专业学生为研究对象，探讨了专业认同、自我效能感、学习参与和职业成熟度之间的关系，并建立了中介模型。研究结果表明，专科认同与职业成熟度之间存在正相关，专科认同可以从自我效能感、学习参与度和自我效能感 → → rarr\rightarrow 学习参与度三个方面影响职业成熟度，支持了四个假设。尽管本研究没有验证潜在的混杂因素，如职业弹性[20]、职业适应性[26]和资源管理[29]，但研究结果可能会提高我们对这四个变量内在机制的理解，并为采取措施提高护生的职业成熟度提供有意义的思路。
Table 2 Descriptive statistics and correlation analysis between key variables ( n = 426 n = 426 n=426n=426 )
表 2 关键变量之间的描述性统计和相关分析 ( n = 426 n = 426 n=426n=426 )
Correlations  相关性
Variables  变量 M D Specialty identity  特殊身份 Study engagement  学习参与 Self-efficacy  自我效能感 Career maturity  职业成熟度
Specialty identity  特殊身份 80.40 21.66 1
Study engagement  学习参与 57.56 16.04 0.276** 1
Self-efficacy  自我效能感 26.23 9.37 0.319** 0.420** 1
Career maturity  职业成熟度 113.42 31.61 0.300** 0.319** 0.440 ** 1
Correlations Variables M D Specialty identity Study engagement Self-efficacy Career maturity Specialty identity 80.40 21.66 1 Study engagement 57.56 16.04 0.276** 1 Self-efficacy 26.23 9.37 0.319** 0.420** 1 Career maturity 113.42 31.61 0.300** 0.319** 0.440 ** 1| | | | | Correlations | | | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | Variables | M | D | Specialty identity | Study engagement | Self-efficacy | Career maturity | | Specialty identity | 80.40 | 21.66 | 1 | | | | | Study engagement | 57.56 | 16.04 | 0.276** | 1 | | | | Self-efficacy | 26.23 | 9.37 | 0.319** | 0.420** | 1 | | | Career maturity | 113.42 | 31.61 | 0.300** | 0.319** | 0.440 ** | 1 |
Note. ** p < 0.001 p < 0.001 p < 0.001p<0.001  请注意。** p < 0.001 p < 0.001 p < 0.001p<0.001
Fig. 1 The chain mediation effect model diagram of specialty identity, self-efficacy, study engagement, and career maturity of nursing students
图 1 护理专业学生的专业认同、自我效能感、学习参与度和职业成熟度的链式中介效应模型图
Table 3 Bootstrap analysis of the significance test of mediation effects
表 3 对中介效应显著性检验的 Bootstrap 分析
Effect  效果 Pathway  途径 Effect value  效果值 Effect Ratio(%)  效果比率(%) 95% CI
Low  低 High  高
Indirect effect  间接影响 SI → → rarr\rightarrow self-efficacy → → rarr\rightarrow CM
SI → → rarr\rightarrow 自我效能 → → rarr\rightarrow CM		 0.155 35.38 0.101 0.233
SI → → rarr\rightarrow SE → → rarr\rightarrow CM 0.031 7.08 0.002 0.085
SI → → rarr\rightarrow self-efficacy → → rarr\rightarrow SE → → rarr\rightarrow CM
SI → → rarr\rightarrow 自我效能 → → rarr\rightarrow SE → → rarr\rightarrow CM		 0.023 5.25 0.002 0.054
Direct effect  直接影响 0.209 47.71 - -
Total effect  总效果 0.438 100 0.264 0.618
Effect Pathway Effect value Effect Ratio(%) 95% CI Low High Indirect effect SI rarr self-efficacy rarr CM 0.155 35.38 0.101 0.233 SI rarr SE rarr CM 0.031 7.08 0.002 0.085 SI rarr self-efficacy rarr SE rarr CM 0.023 5.25 0.002 0.054 Direct effect 0.209 47.71 - - Total effect 0.438 100 0.264 0.618| Effect | Pathway | Effect value | Effect Ratio(%) | 95% CI | | | :--- | :--- | :--- | :--- | :--- | :--- | | | | | | Low | High | | Indirect effect | SI $\rightarrow$ self-efficacy $\rightarrow$ CM | 0.155 | 35.38 | 0.101 | 0.233 | | | SI $\rightarrow$ SE $\rightarrow$ CM | 0.031 | 7.08 | 0.002 | 0.085 | | | SI $\rightarrow$ self-efficacy $\rightarrow$ SE $\rightarrow$ CM | 0.023 | 5.25 | 0.002 | 0.054 | | Direct effect | | 0.209 | 47.71 | - | - | | Total effect | | 0.438 | 100 | 0.264 | 0.618 |
Note. Cl=confidence interval, SI=specialty identity, SE=study engagement, CM=career maturity
注 Cl=置信区间，SI=专业认同，SE=学习参与度，CM=职业成熟度
In this study, the findings revealed a positive correlation between specialty identity and career maturity, indicating that specialty identity could significantly predict career maturity in nursing students, which is consistent with previous studies [14, 41]. However, most nursing students enrolled in nursing school with insufficient specialty identity owing to poor nursing image and a lack of acknowledgment of career growth [42], meaning their unpreparedness for learning nursing and career development. Specialty identity is an emotional foundation of
本研究结果显示，专科认同与职业成熟度呈正相关，表明专科认同可显著预测护生的职业成熟度，这与以往的研究结果一致[14，41]。然而，由于护理形象不佳和缺乏对职业成长的认识，大多数护生在入学时专业认同感不足[42]，这意味着他们对护理学习和职业发展缺乏准备。专科认同是护理专业发展的情感基础。
career maturity, and it can serve as a powerful psychological adjustment when it comes to nursing students’ specialty or job selection. Therefore, the importance of specialty identity on career maturity should be valued by nurse educators and clinical mentors, and further studies should specifically develop and conduct the education program to verify the roles of specialty identity in the early stage of career development. For example, an innovative course about the power of nursing including embracing the healer’s art course, seed talk and reflection
在护生的专业或工作选择中，它可以作为一种强有力的心理调节。因此，专科认同对职业成熟的重要性应得到护士教育者和临床导师的重视，进一步的研究应专门开发和开展教育项目，以验证专科认同在职业发展早期阶段的作用。例如，关于护理力量的创新课程，包括拥抱医者的艺术课程、种子谈话和反思
exercises was found to connect the nursing students’ values to their specialty identity, and facilitate their professional formation and the development of nursing practice [43].
研究发现，练习能将护生的价值观与其专业身份联系起来，促进其专业形成和护理实践的发展[43]。
The first pathway confirmed was the mediating role of self-efficacy in the relationship between specialty identity and career maturity, aligning with its mediating effect on professional identity and career maturity in a previous study [41]. When nursing students perceive higher levels of specialty identity, they may have a stronger sense of self-efficacy and achieve greater career maturity. This finding is consistent with the Knowledge-Attitude-Belief-Practice model [44]. For nursing students, specialty identity and self-efficacy can support attitudes and beliefs about learning nursing specialties [21] and play the role of internal driving strength in the chase for a feasible professional study plan and career plan. As a result, career maturity could be a feedback indicator for learning behaviors and career preparedness.
第一个被证实的途径是自我效能感在专科认同与职业成熟度之间的中介作用，这与之前一项研究[41]中自我效能感对专业认同和职业成熟度的中介作用相一致。当护生感知到更高水平的专业认同时，他们可能会有更强的自我效能感，并获得更高的职业成熟度。这一发现与 "知识-态度-信念-实践 "模型[44]一致。对护生而言，专业认同和自我效能感可以支持其学习护理专业的态度和信念[21]，并在追逐可行的专业学习计划和职业规划的过程中发挥内驱力的作用。因此，职业成熟度可以作为学习行为和职业准备的反馈指标。
This study also verified the mediating effect of study engagement on specialty identity and career maturity. This finding is consistent with a mediation analysis confirming the mediating role of study engagement between professional identity and career maturity among pre-service kindergarten teachers [25]. This result also supports the predictive impact of study engagement on the beneficial development of careers [26,45]. The mediating effect of study engagement revealed that if nursing students perceive high levels of specialty identity, they might have greater study engagement, achieve more knowledge and skills related to the nursing specialty, and possess high degrees of career maturity to adapt to the nursing profession. However, this study identified the study engagement had a limited mediating effect with a low effect size. The possible reason is that nursing is a specialized and complex discipline, which requires lifelong learning as health needs change and medical technology advances. In a short period, study engagement can improve nursing knowledge and skills, which is conducive to career preparedness, but high levels of career maturity are the result of long-term study engagement especially since this career needs continued education or continued career development [46].
本研究还验证了学习参与对专业认同和职业成熟度的中介效应。这一结果与一项中介分析证实的学习投入在职前幼儿园教师的专业认同和职业成熟度之间的中介作用相一致[25]。这一结果也支持了学习投入对职业生涯有益发展的预测影响[26,45]。学习投入的中介效应表明，如果护理专业学生的专业认同水平高，他们可能会有更高的学习投入，获得更多与护理专业相关的知识和技能，并拥有较高的职业成熟度以适应护理专业。然而，本研究发现学习投入度的中介效应有限，效应大小较低。可能的原因是，护理是一门专业而复杂的学科，随着健康需求的变化和医疗技术的发展，需要终身学习。在短期内，学习参与可以提高护理知识和技能，有利于职业准备，但高水平的职业成熟度是长期学习参与的结果，特别是因为这一职业需要继续教育或持续的职业发展[46]。
Additionally, these findings supported the assertion that the chain relationship between self-efficacy and study engagement mediates the relationship between specialty identity and career maturity. The indirect effect of the pathway, including self-efficacy, was greater than that of the chain pathway and the pathway, including a single study engagement. Higher specialty identity could yield higher self-efficacy [19, 20], and higher self-efficacy is related to greater study engagement [27, 28]. Thus, nursing students with higher specialty identity might have higher self-efficacy and greater study engagement,
此外，这些发现支持了自我效能感与学习参与之间的连锁关系介导了专业认同与职业成熟度之间关系的论断。包括自我效能在内的路径的间接效应大于链式路径和包括单一学习参与在内的路径的间接效应。较高的专科认同可产生较高的自我效能感[19, 20]，而较高的自我效能感与较高的学习参与度有关[27, 28]。因此，具有较高专业认同的护生可能具有较高的自我效能感和更高的学习投入度、
which leads to higher career maturity. This model also revealed that increased self-efficacy might contribute to nursing students’ high study engagement levels. When nursing students have a sense of high self-efficacy, their learning behaviors become more effective. They are more willing to devote themselves to learning, thus producing higher study engagement. Despite some studies have demonstrated the effect of interventions such as career planning group counseling [47] and self-reflectionfocused career course [48] on nursing students’ career maturity, what we found in this study provide theoretical foundation for the development and implementation of multifaceted interventions to improve nursing students career maturity and career development. Furthermore, further attention should be given to the interdisciplinary collaborations, such as positive psychology and nursing education, that can be contribute to explore novel perspectives and approaches to studying career maturity.
从而提高职业成熟度。该模型还显示，自我效能感的提高可能有助于提高护理专业学生的学习参与度。当护生具有较高的自我效能感时，他们的学习行为会变得更加有效。他们更愿意全身心地投入学习，从而产生更高的学习参与度。尽管有研究表明职业生涯规划团体辅导[47]和以自我反思为重点的职业生涯课程[48]等干预措施对护生的职业成熟度有影响，但本研究的发现为制定和实施多方面的干预措施以提高护生的职业成熟度和职业发展提供了理论基础。此外，应进一步关注跨学科合作，如积极心理学和护理教育学，这有助于探索研究职业成熟度的新视角和新方法。
This study had some limitations. First, the crosssectional design without a longitudinal method fails to explore the changes in psychological variables over time, which might restrict the temporal and causal inference. Therefore, scholars should focus on exploring the trajectory changes of these variables, notably the mutability of these psychological features, in the further studies, and the longitudinal and sustained interventions like tutor systems and peer learning should be strongly encouraged. Second, the nursing students were selected from five schools in Hubei province, China, which might limit the generalizability to all Chinese nursing students. As there are disparities in the curriculum systems of different schools, the results could be impacted by cognitive errors caused by teaching philosophy and training purposes. Therefore, the potential influencing factors should be considered and other mediators excluding self-efficacy and study engagement also should be explored in further studies. Third, selection bias may arise from the application of convenience sampling. Therefore, scholars could employ probability sampling methods like random stratified sampling to recruit nursing students. Finally, since all instruments were self-reported, the true feelings of these nursing students were not captured or tracked. From this, the research designs to deepen the understanding of the mechanisms underlying nursing students’ career development, such as mixed-method study and qualitative study, should be considered.
这项研究存在一些局限性。首先，没有采用纵向方法的横断面设计无法探究心理变量随时间的变化，这可能会限制时间推断和因果推断。因此，学者们在进一步的研究中应重点探讨这些变量的轨迹变化，尤其是这些心理特征的可变性，并大力提倡导师制和同伴学习等纵向和持续的干预措施。其次，研究对象选自中国湖北省的五所学校的护理专业学生，这可能会限制对所有中国护理专业学生的普适性。由于不同学校的课程体系存在差异，研究结果可能会受到教学理念和培养目的造成的认知误差的影响。因此，应考虑潜在的影响因素，并在进一步研究中探讨除自我效能感和学习参与度之外的其他中介因素。第三，方便抽样可能会产生选择偏差。因此，学者们可以采用随机分层抽样等概率抽样方法来招募护生。最后，由于所有工具均为自我报告，因此无法捕捉或追踪这些护生的真实感受。因此，应考虑采用混合方法研究和定性研究等研究设计来加深对护生职业发展内在机制的理解。

Conclusion  结论

A correlational and mediation analysis was used to examine the relationships between four variables. Specialty identity could be a predictive factor for nursing students’ career maturity. Most importantly, specialty identity can indirectly influence career maturity among nursing students through the mediating effect of self-efficacy, study
研究采用了相关分析和中介分析来考察四个变量之间的关系。专业认同可能是护生职业成熟度的一个预测因素。最重要的是，专业认同可通过自我效能感、学习动机、学习兴趣和学习动机的中介效应间接影响护生的职业成熟度。
engagement, and the chain mediating effect of self-efficacy and study engagement, supporting career-related theories. Policymakers and educators should focus on the value of specialty identity to promote nursing students’ career development. Specialty identity may be conducive to stimulating students with a strong sense of self-efficacy and robust study engagement. Nursing students with high self-efficacy and study engagement may perceive greater career maturity. Thus, scholars and educators should be encouraged to provide tailored career guidance programs and practical interventions to enhance nursing students’ career maturity in the early stage of career development.
参与，以及自我效能感和学习参与的连锁中介效应，支持职业相关理论。政策制定者和教育者应重视专业认同对促进护理专业学生职业发展的价值。专业认同可能有利于激发学生强烈的自我效能感和旺盛的学习热情。自我效能感和学习参与度高的护生可能会认为自己的职业生涯更加成熟。因此，应鼓励学者和教育者提供有针对性的职业指导方案和实际干预措施，以提高护理专业学生在职业发展早期的职业成熟度。

Supplementary Information
补充信息

The online version contains supplementary material available at https://doi. org/10.1186/s12912-024-02002-y.
在线版本包含补充材料，可查阅 https://doi. org/10.1186/s12912-024-02002-y。

Supplementary Material 1
补充材料 1

Acknowledgements  致谢

We greatly appreciate the support of all nursing students from five schools in Hubei province for their voluntary participation in this study.
我们非常感谢湖北省五所学校的所有护理专业学生自愿参与本研究。

Author contributions  作者供稿

Study design: XLJ, CMC, HYH; Data collection and analysis: WH, LYJ; Manuscript preparation: LYJ, HYH. All authors reviewed the manuscript.
研究设计：XLJ、CMC、HYH；数据收集与分析：WH、LYJ；撰稿：LYJ、HYH。所有作者审阅了手稿。

Funding  资金筹措

Not applicable.  不适用。

Data availability  数据可用性

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
本研究中使用和/或分析的数据集可向通讯作者索取。

Declarations  声明

This study has been approved by the Ethical Review Committee of Jingmen No. 2 People’s Hospital, affiliated with Jingchu University of Technology (Approval No.2022002-1). All methods were performed in accordance with the relevant guidelines and regulations. Informed consent was obtained from all subjects involved in the study.
本研究已经荆楚理工学院附属荆门市第二人民医院伦理审查委员会批准（批准号：2022002-1）。所有方法均按照相关指南和规定执行。所有研究对象均已知情同意。
Not application.  不适用。

Competing interests  竞争利益

The authors declare no competing interests.
作者声明不存在利益冲突。
Received: 13 December 2023 / Accepted: 8 May 2024
收到：收到：2023 年 12 月 13 日 / 接受：2024 年 5 月 8 日 2024 年 5 月 8 日
Published online: 21 May 2024
在线出版：2024 年 5 月 21 日

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  1. *Correspondence:  *通信：
    Lijuan Xiong  熊丽娟
    xhxlj@hust.edu.cn
    1 1 ^(1){ }^{1} Department of Nursing, Wuhan Union Hospital, Tongji Medical College,
    1 1 ^(1){ }^{1} 同济医学院附属武汉协和医院护理部、
    Huazhong University of Science and Technology, Wuhan, China
    中国武汉，华中科技大学