Beyond the classroom: How hidden curriculum dynamics shape professional identity formation in nursing undergraduates-Evidence from structural equation model

Beyond the classroom: How hidden curriculum dynamics shape professional identity formation in nursing undergraduates-Evidence from structural equation model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond the classroom: How hidden curriculum dynamics shape professional identity formation in nursing undergraduates-Evidence from structural equation model Yangguang Chen, Zili Zhou, Guangxu Mao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6399320/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background In nursing education, the hidden curriculum is recognized as a crucial factor influencing professional outcomes and work ethics. While the formal curriculum in colleges and universities primarily focuses on imparting clinical knowledge, emerging evidence suggests that the hidden curriculum plays an equally critical yet underexplored role in shaping students' professional identity. Objectives This study aims to assess the current state of the hidden curriculum and professional identity among undergraduate nursing students. Additionally, it examines the correlation between these two factors. Methods This study employed a cross-sectional correlational design. Undergraduate nursing students from Guangxi Province were recruited through a convenience sampling method. Data were collected using a validated hidden curriculum assessment questionnaire and a professional identity questionnaire. Pearson’s correlation test was employed to analyze the relationship between the two variables, and a structural equation model was constructed to further explore the factors influencing professional identity. Results A total of 694 undergraduate nursing students participated in this study. The mean score for the hidden curriculum was 86.47 ± 23.27, while the mean score for professional identity was 59.50 ± 11.27, indicating moderate levels for both constructs. A strong positive correlation was found between hidden curriculum scores and professional identity scores ( r = 0.628, p < 0.001). Multiple linear regression analysis revealed that hidden curriculum scores, having family members with a medical background, class level, and experience as a student leader were significant predictors of professional identity. Furthermore, the structural equation model demonstrated a good fit, with a path coefficient of 0.42 ( p < 0.001) between the hidden curriculum and professional identity. Conclusion The hidden curriculum plays a significant role in shaping the professional identities of nursing students by socializing them into the norms of the profession. A hidden curriculum that fosters critical thinking and support within nursing education can help develop nurses who are not only clinically competent but also possess professional self-awareness and resilience. Hidden curriculum Professional identity Undergraduate nursing students Nursing education Structural equation model Figures Figure 1 Introduction Nursing education, as a strategic priority in the development of medical human resources, depends not only on the establishment of explicit knowledge systems but also on the seamless integration of implicit educational elements. Currently, medical education often faces a structural disconnect between explicit curricula focused on imparting professional knowledge and standardized skill training and the underlying hidden educational mechanisms[ 1 , 2 ]. According to the Future of Nursing 2020–2030, approximately 67% of nursing education institutions continue to adhere to the binary teaching model of "theoretical instruction and clinical training," systematically neglecting critical hidden educational factors such as the integration of organizational culture within healthcare settings and the dynamics of teacher‒student interactions[ 3 , 4 ]. The situation is corroborated by the "White Paper on the Current Development Status of the Nurse Group in China," which indicates that an analysis of a sample of practicing nurses reveals that approximately 52.5% of them lack clear objectives for their future career development. This finding underscores a significant deficiency in the mechanism through which explicit knowledge is translated into professional values. The hidden curriculum, as a structural counterpart to the explicit curriculum in higher education, operates through multidimensional mechanisms of subtle influence. Unlike traditional teaching frameworks, it shapes students' cognitive structures through diverse channels, such as campus spatial design, institutional disciplinary systems, academic community interactions, and organizational cultural symbols. Ultimately, this process facilitates the transformation of students' attitudes, knowledge, values, professional ethics, emotions, and behavioral norms[ 5 – 7 ]. A review from 2006–2018 demonstrated that scholars across different countries hold inconsistent interpretations of the hidden curriculum, sometimes conflating it with informal learning[ 8 ]. On the basis of these results, the writer suggested the use of the four areas identified by sociologist Hafferty (1998)—policies of institutions, decisions regarding resource distribution, institutional jargon, and assessment activities—as a basis for exploring the concealed curriculum in nursing education[ 9 ]. Curriculum designers not only systematically impart professional knowledge and skills through explicit curricula but also act as institutional agents who deeply engage in and shape students' professional socialization[ 10 ]. This process is intrinsically embedded within the operational logic of the hidden curriculum: through nonstructured cultural infiltration mechanisms, the organizational behaviors, discourse practices, and power dynamics of educational actors continuously transmit implicit professional norms, value judgments, and perceptions of authority, thereby fostering the internalization and construction of nursing professional identity[ 11 ]. Professional identity encompasses their emotional connection to and positive perception of both their current role as students and their future role as nurses. Professional identity functions both as a socialization process, through which nursing students progressively construct their professional selves via cognition, experience, and behavior, and as a dynamic, evolving mechanism that continues to develop throughout their careers. It begins with a preprofessional identity during the student phase and matures over time[ 12 ]. Factors such as population aging, regional infectious disease outbreaks (e.g., COVID-19), excessive workloads, and job burnout have exacerbated the global nursing shortage and contributed to high turnover rates among early-career nurses[ 13 ]. Studies indicate that nurse turnover rates in New Zealand, the United States, Canada, and Australia stand at 44.3%, 26.8%, 19.9%, and 15.1%, respectively[ 14 ]. In China, more than 50% of nurses report varying levels of intention to leave their positions, whereas 32.6% of newly hired nurses experience career uncertainty within three years (China's Medical and Health Development Report: 2020)[ 15 ]. Furthermore, the 2020 Global Nursing Situation Report highlights a global nursing workforce gap of 5.9 million[ 16 ]. These trends underscore the systemic challenges in cultivating resilient nurses with strong professional identities. This pressing reality has compelled nursing educators to reflect on why, despite undergoing standardized skills training within traditional explicit curricula, nurses continue to demonstrate high turnover rates and strong intentions to leave the profession. As a key predictor of nurse retention and work engagement, understanding the mechanisms underlying professional identity formation is critical for addressing these persistent challenges within the industry. Existing research has focused primarily on formal educational strategies to enhance professional identity, such as scenario simulations, clinical teaching practices[ 17 ], and ABC emotional theory[ 18 ]. However, it often neglects the pervasive and subtle influence of the hidden curriculum. A 2022 review by Hadi Abbaspour et al. highlighted that most studies were qualitative and context specific, particularly those focused on clinical internships[ 19 ]. Notably, there is a significant gap in quantitative research that systematically employs reliable measurement frameworks to model the complex relationship between the multidimensional structure of the hidden curriculum and the development of professional identity. This gap impedes evidence-based reforms in nursing pedagogy, as educators lack clear empirical guidance on which aspects of the hidden curriculum, such as institutional culture, interactions, and power dynamics, most significantly influence professional identity outcomes. This study seeks to address these limitations through two key innovations. First, the research team utilized a multidimensional assessment tool system developed and validated in China in 2024 to systematically evaluate the hidden curriculum. This tool introduces an innovative evaluation framework encompassing four dimensions: the physical campus environment, campus cultural life, institutional systems, and interpersonal interactions. Second, this study establishes a structural equation model (SEM) to illustrate the dynamic interaction mechanism between the hidden curriculum and professional identity. This educational innovation aligns with the initiative to build a stable nursing workforce, as outlined in the "Healthy China 2030" Planning Outline, and provides an empirically grounded model with ecological validity to advance nursing education reform in China. Methods Study design This study employed a cross-sectional survey design. Setting and sample of the study Kendall's approach to estimating sample sizes suggests that a minimum sample size should be between 5 and 10 times greater than the total number of variables, or the highest number of items present in the scale[ 20 ]. In this study, there are 15 variables (6 participant characteristics, 4 hidden curricula, and 5 professional identities), indicating that the minimum sample size should not be less than 150 cases. Furthermore, since the largest scale comprises 35 items, the sample size must also satisfy the requirement of being no fewer than 350 cases. To ensure adequate statistical power while accounting for potential invalid questionnaires, the sample size was increased by 20% over the minimum requirement derived from both methods. Consequently, the final sample size should be at least 420 cases (350×1.2). Ultimately, this study recruited 742 undergraduate nursing students through an online questionnaire administered between May and August 2024. A total of 694 valid responses were collected, resulting in an effective recovery rate of 93.50%, which meets the minimum sample size requirement. Data collection tools Personal information form A general information questionnaire was developed by the research team in alignment with the study's objectives to collect data on various demographic factors. This questionnaire includes participants' gender, residence, presence of family members with a medical background, class level, prior experience as student leaders, and whether they are only children. The Hidden Curriculum Assessment Scale in Nursing Education (HCAS-NE) : The HCAS-NE[ 7 ] represents a psychometrically validated instrument designed to quantify implicit pedagogical constructs within nursing education ecosystems. This 35-item multidimensional framework operationalizes four latent variables: 1) physical infrastructure and spatial design (HCAS1), 2) cultural ecosystem and symbolic practices (HCAS2), 3) organizational architecture and normative frameworks (HCAS3), and 4) relational dynamics and peer engagement (HCAS4). Using a quintile Likert-type response framework (1 = strongly disagree to 5 = strongly agree), composite scores demonstrate a possible range of 35–175, with elevated scores reflecting enhanced student perceptions of institutional hidden curriculum quality. The psychometric evaluation revealed strong scale reliability (Cronbach's α = 0.972 in the present sample, exceeding the original validation). Professional identity questionnaire for nursing students (PRQNS) : The Professional Identity Scale was developed by Chinese scholars [ 21 ]. Permission to utilize the pertinent scales was acquired from the original creators. Adapting Hao's (2011) vocational identity paradigm, our study implemented a 17-item measurement model containing five theoretically distinct components: 1) occupational identity formation (PIQNS1), 2) cost‒benefit calculus in career continuity (PIQNS2), 3) reflective positioning in social contexts (PIQNS3), 4) agency in occupational trajectory (PIQNS4), and 5) persuasion from members of the public (PIQNS5). The instrument employs a standardized 5-point metric (total range 17–85), incorporating one inverse-scored element to mitigate response bias. Empirical validation within Chinese academic populations has established robust psychometric properties (item-level reliability > 0.80). The current data demonstrated strong internal consistency (α = 0.906). Data collection A data investigation team was established, and the questionnaire was distributed to each group member through WeChat. It provided details about the study's purpose and informed consent. Nursing students were given the opportunity to decide whether to participate after understanding the study's objectives and the content of the questionnaire. They were also free to withdraw at any time. All items in the questionnaire were designated as mandatory, and each IP address was restricted to a single submission. The average time required to complete the surveys was approximately 15 min. Two researchers subsequently conducted data cleaning and logical verification of the collected questionnaires, eliminating invalid responses on the basis of predefined criteria: completion times of less than three minutes and answers exhibiting obvious patterns. To minimize potential risks associated with common method bias (CMB) and ensure the accuracy and reliability of the conclusions, this study implemented several procedural strategies[ 22 ]. First, respondent anonymity was strictly maintained to reduce the influence of subjective intentions and social desirability. Second, the order of the measurement tools was randomized to mitigate sequence effects. Finally, the data collection process was staggered across time and survey groups to avoid large-scale measurements within a short timeframe. Data analysis Data analysis was carried out with IBM SPSS (29.0) alongside AMOS (26.0). Normally distributed data are expressed as the means ± standard deviations. Independent samples t tests were used for comparisons between two independent groups, whereas one-way analysis of variance (ANOVA) was used for comparisons involving more than two independent groups. The relationship between the hidden curriculum and professional identity was examined via the Pearson correlation test. Furthermore, multiple linear regression analysis along with structural equation modelling (SEM) was used to determine how participant characteristics and the hidden curriculum predict professional identity. To evaluate the extent of collinearity among the variables, the variance inflation factor (VIF) and tolerance values are utilized. An acceptable range is defined as a VIF below 10 and a tolerance value exceeding 0.1[ 23 ]. All the statistical tests were two-sided, with a significance level set at α = 0.05. Results Participant characteristics In this study, 694 nursing students, including 72 males (10.4%) and 622 females (89.6%), participated. Among the participants, 144 (20.7%) were 1st year students, 158 (22.8%) were 2nd year students, 216 (31.1%) were 3rd year students, and 176 (26.4%) were 4th year students. Additionally, 191 participants (27.5%) reported having a family member with a medical background. Furthermore, 238 individuals (34.3%) resided in the city, whereas 113 participants (16.3%) held leadership positions as student leaders. Notably, 260 respondents (37.5%) identified as only children. Description of HCAS-NE and PIQNS The hidden curriculum assessment yielded a total score of 86.47 ± 23.27, with the highest item score observed in “Campus cultural life” (2.56 ± 0.83) and the lowest in “Interpersonal interaction” (2.37 ± 0.75). The professional identity assessment resulted in a total score of 59.50 ± 11.27, with the highest item score recorded for “Social persuasion” (3.62 ± 0.90) and the lowest for “Social comparison and self-reflection” (3.42 ± 0.78) (Table 1). Comparison of HCAS-NE and PIQNS with different characteristics Difference analysis revealed statistically significant differences in total hidden curriculum and professional identity scores among individuals from varying family backgrounds ( t = 2.409, 3.783, p = 0.017, < 0.001). Additionally, significant differences were observed across grade levels concerning the total hidden curriculum and professional identity scores ( F = 9.139, 18.410, p < 0.001). Furthermore, being an only child was significantly associated with perceptions of the hidden curriculum and professional identity ( t = 5.277, 7.881, p < 0.001). Pairwise comparisons between year groups indicated that higher-year nursing students (juniors and seniors) had significantly higher scores for hidden curriculum quality and professional identity than their lower-year counterparts (freshmen and sophomores) did ( p < 0.05) (Table 2). Relationships between HCAS-NE and PIQNS A significant positive relationship was identified between the hidden curriculum assessment scores of undergraduate nursing students and their sense of professional identity ( r = 0.628, p < 0.001). Additionally, the scores of each subdimension of the hidden curriculum were predominantly moderately correlated with those of the corresponding subdimensions of professional identity (0.4 < r < 0.6, p < 0.001). (Table 3). Predictors of PIQNS The class level was incorporated into the multiple linear regression analysis as a set of dummy variables, with the first year serving as the reference category. Three additional dummy variables were introduced to represent the other grades (“2nd --1st year”, “3rd --1st year”, and “4th --1st year”). Professional identity is influenced by various factors, including family medical background, involvement in student leadership roles, HCAS-NE scores, and class level (Table 4). SEM of the Association between Hidden Curriculum and Professional Identity On the basis of the findings from the preliminary analysis, SEM was created to investigate the connection between the hidden curriculum and professional identity. The univariate analysis indicated that factors such as grade level, having family members with a medical background, and holding leadership positions in student organizations significantly influenced both the hidden curriculum scores and professional identity. Given that these variables have been identified as critical influencing factors in prior studies, all the demographic characteristics were incorporated into the SEM for a comprehensive analysis. On the basis of the model fitting outcomes, the initial SEM was refined and adjusted to produce the final revised model. (1) Model fit: The revised model demonstrated an acceptable fit (Table 5). (2) As illustrated in Fig. 1, the established SEM revealed that the paths from general demographic characteristics to the hidden curriculum and from general demographic characteristics to professional identity were not statistically significant ( p > 0.05). Nevertheless, the influence of the concealed curriculum on professional identity was significant, with a coefficient of 0.42 (p < 0.001) (Table 6). Discussion In this study, the findings indicated that nursing students had an overall professional identity score of 59.50 ± 11.27, placing it in the middle range (59.50/85). However, this score was lower than those reported in regions such as western Turkey[ 24 ], other parts of China[ 25 ], and Australia[ 26 ]. This inconsistency could be due to variations in regional cultures, along with the difficulties present in the current job market. Moreover, the low mean scores for the dimensions of retention benefits and separation risks (3.43 ± 0.76) suggest that nursing students may not fully recognize the advantages of a nursing career. They seem to believe that leaving the profession would not result in significant emotional consequences and do not appear to prioritize or reflect on alternative career options. In contrast, the "social persuasion" dimension received the highest mean score (3.62 ± 0.90), indicating that social persuasion is the primary influence on nursing students' professional identity. Given that these students have not yet formally entered the workforce, their understanding of the profession is predominantly shaped by their nursing education and clinical practice experiences and, significantly, by the influence of faculty and institutional personnel on their professional perceptions. The total hidden curriculum score (86.47 ± 23.27) was moderate (86.47 out of 175), indicating considerable variation in students' access to implicit learning opportunities. This finding underscores the need for institutions to reassess the equitable allocation of educational resources and improve the quality of clinical placements. Additionally, identifying key educational components, developing effective implementation strategies, and establishing rigorous evaluation methods are essential for successfully integrating the hidden curriculum into nursing education and promoting comprehensive reform of college teaching methodologies and ideologies. The HCAS-NE used in this study was developed by a research team in China[ 7 ]. Internationally, the HCES-N[ 27 ] serves a similar purpose and is considered one of the earliest tools. While both scales aim to evaluate the implicit curriculum among undergraduate nursing students, they differ significantly in their dimensional structures and scoring criteria, largely due to cultural differences. Specifically, the scale developed by our research team emphasizes quantifiable external factors, such as the campus physical environment, institutional management, and interpersonal interactions, reflecting a linear "environment-institution-behavior" conceptual framework. In contrast, the HCES-N by Akçakoca et al. focuses on students' subjective experiences, including professional identity development, perceptions of discrimination, power dynamics, and the internalization of institutional values. In this study, the highest subdimensional scores within the hidden curriculum were found for the "campus cultural environment" (2.56 ± 0.83) and the "campus material environment" (2.54 ± 0.71). These relatively high scores can likely be attributed to the characteristics of China’s current educational policies and systems. Given the considerable academic pressure from China's standardized college entrance examinations and structured high school curricula, students transition from exam-focused basic education to university education, where they encounter significant changes in both material and cultural aspects of life. The diverse university environment tends to inspire greater enthusiasm for their future careers among students. Given the increasing prevalence of artificial intelligence, nursing education institutions should consider integrating AI technologies to enhance the physical environment of campuses and strengthen the efficacy of the hidden curriculum. It is essential for these technologies to achieve a balance of "subtle integration" while avoiding excessive toolification, ensuring that the physical environment and technological applications synergistically align with and support the overarching goals of nursing education[ 28 ]. This research highlights the importance of family background as a key element that affects professional identity. The findings reveal that students with family members in medical professions exhibit stronger perceptions of both the hidden curriculum and professional identity ( t = 2.409, p = 0.017; t = 3.783, p < 0.001). This finding is consistent with previous research emphasizing how family influences career decisions and the formation of professional identity [ 29 ]. Students from medical backgrounds are likely to benefit from early and frequent exposure to healthcare values and norms, which aids their integration into the nursing profession[ 30 ]. Family members serve as vital role models, significantly contributing to the cultivation of professional values. The influence of these role models through observational learning frequently exceeds that of formal education[ 31 ]. Additionally, family members can help students critically evaluate both positive and negative behaviors exhibited by healthcare professionals through reflective practices[ 32 ]. This further supports the idea that professional identity is not only shaped by formal education but also deeply rooted in students' personal and social experiences. The results of the differentiation analysis also revealed that having family members in the medical field did not significantly impact students' ability to interpret "campus cultural life" and "school structure and regulation" ( p > 0.05). This finding suggests that preuniversity familial influence has limited effectiveness during students' transition to university life. Two factors may explain this limitation: the homogenizing effect of regional culture, which may overshadow familial educational influences, and the epistemological shock caused by the novelty of the university environment, which requires students to actively engage with and understand new experiences rather than passively inherit them. These observations are consistent with Bourdieu’s theory of habitus[ 33 ], which posits that through immersive socialization experiences, the institutional domain reshapes students' original cognition. The study also revealed that senior students and those who held leadership positions in student organizations exhibited heightened awareness of the hidden curriculum and a stronger sense of professional identity. This aligns with Raff and Wenger's "situated learning theory," which suggests that assuming leadership roles within the student body can serve as a platform for developing essential professional skills, such as communication, decision-making, and teamwork skills crucial to nursing practice[ 11 ]. Furthermore, participation in leadership roles may foster a deeper connection to the nursing profession, thereby enhancing students' professional identity. Additionally, students in leadership positions tend to show higher levels of self-efficacy, and research has indicated a significant positive correlation between self-efficacy and both professional identity and professional maturity [ 34 ]. A previous study revealed that as undergraduate nursing students advance through their academic years, their professional identity tends to decline[ 35 ]. This finding contrasts somewhat with the results of the current study. The observed data suggest that clinical practice plays a significant role in shaping vocational identity, as evidenced by an increase in vocational identity from the junior to senior stages ( p < 0.05). This enhancement can be attributed to students' increasing exposure to specialized professional knowledge and practical clinical experiences, fostering a deeper appreciation for the nursing profession. However, it is important to note that there was a slight decline in vocational identity among senior students approaching graduation; this change did not reach statistical significance ( p > 0.05). This minor reduction may be linked to stress related to impending graduation and concerns about employment prospects. In light of these findings, educational institutions should consider providing targeted psychological support and clear career guidance during the final academic year. Such initiatives could help students develop a positive outlook on their future careers while alleviating psychological pressures. Additionally, educational institutions could implement relevant programs aimed at enhancing nursing students' sense of life purpose, further strengthening their professional identity[ 36 ]. Previous qualitative research has indicated that while formal educational components, such as curriculum content and clinical training, are essential, informal processes within the implicit or hidden curriculum play an equally significant role in shaping nursing students' professional identities[ 37 ]. This study supports these findings, underscoring the considerable influence of informal learning processes on students' vocational socialization. Structural equation modelling (SEM) further corroborated this impact, revealing a notable path coefficient of 0.42. Pearson's correlation analyses revealed weak correlations between dimensions of the implicit curriculum and social persuasion ( r < 0.4, p < 0.001). The dimension of social persuasion primarily reflects advice and guidance from senior nursing professionals. This finding, coupled with relatively low scores in teacher‒student interactions (2.37 ± 0.75), suggests that educators should proactively offer positive guidance beyond explicit curricular activities. Collaborating with healthcare organizations to create forums for sharing clinical experiences and facilitating emotional communication is recommended. Furthermore, nursing educators themselves should receive training in cognitive emotion regulation and positive emotional strategies to enhance their interactions with students[ 38 ]. Since the development of the HCES-N, there has been a notable increase in quantitative investigations into the hidden curriculum. Kaya (2022) determined that the hidden curriculum significantly influences the formation of professional identity in nursing students, the development of professional values, and the improvement of professional adaptability[ 39 ]. Despite the progress made in quantifying the dimensions of the hidden curriculum, research in this area is still in its early stages. Future studies should focus on clarifying and refining definitions related to the hidden curriculum, as well as improving the cultural adaptability and validity of assessment tools. Notably, there remains a scarcity of robust quantitative evidence regarding its role in shaping professional identity. This study aims to address this gap by providing empirical evidence that underscores the critical importance of integrating the hidden curriculum with formal curricula in nursing education. Such integration can enhance students' preparedness to meet the complex demands of the profession, thereby promoting both clinical competence and ethically grounded professional development. Limitations The research's cross-sectional design limits the ability to make causal inferences, indicating that a future longitudinal study would be beneficial for exploring how the effects of the hidden curriculum develop throughout various educational stages. Furthermore, the sample was obtained from only one regional educational institution, which could restrict the applicability of these results to the wider population of nursing students. Future research should explore variations in the hidden curriculum across different institutional settings and cultural contexts, as well as investigate how specific elements of the hidden curriculum may influence distinct dimensions of professional identity. Conclusion The hidden curriculum's quality and professional identity among the nursing students were observed to be moderate. Professional identity is influenced by various factors, including family medical background, involvement in student leadership roles, and academic class level. This study provides robust empirical evidence that the hidden curriculum within nursing education significantly impacts nursing students' professional identity, with structural equation modelling confirming a direct positive correlation. These findings deepen our understanding of how hidden institutional cultures and unspoken teaching practices contribute to the psychological internalization of the nursing role. They also offer practical insights for curricular reform and strategies to better support students. Additionally, it is essential for nursing educators to recognize and comprehend the evolution of the hidden curriculum while considering strategies to enhance students' views, ultimately promoting the growth of their professional identities. Declarations Acknowledgement s We would like to express our gratitude to all the faculty and nursing students who participated in this study. A uthor contribution s Yangguang Chen: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Zili Zhou: Conceptualization, Investigation, Methodology, Project administration. Guangxu Mao: Writing-review & editing, Methodology, Software, Supervision, Validation, Formal analysis, Conceptualization, Data curation. Funding This study was supported by the Education Department of Guangxi Zhuang Autonomous Region (Grant No. 2022ZJY466) Data availability All data generated and analyzed during this study are not publicly available but can be made available from the corresponding author upon request. Ethics approval and consent to participate All processes of the research were approved by the Ethics Committee of Guilin Medical University (Ethical Review Number: GLMC20211204). All nursing students participating in the study signed the informed consent form. The Declaration of Helsinki was followed throughout the research. Consent for publication Not applicable. Clinical trial number Not applicable. Competing interests The authors declare that they have no competing interests. References Boer C, Daelmans HEM. Team up with the hidden curriculum in medical teaching. Br J Anaesth. 2020;124:e52–4. Hosseini A, Ghasemi E, Nasrabadi AN, Sayadi L. 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Qiu L, Miao Q, Zhao Y, Zhu L, Wang Y. A study on the impact of life meaning on occupational identity of nursing students in China:a cross-sectional study. BMC Nurs. 2023;22:480. Karimi Z, Ashktorab T, Mohammadi E, Ali Abedi H. Using the Hidden Curriculum to Teach Professionalism in Nursing Students. Iran Red Crescent Med J. 2014;16. Liu J, Zhang H, Tao S, He J, Li S. Centrality and bridge connections between cognitive emotion regulation strategies and professional identity among Chinese undergraduate nursing students: A network analysis. Nurse Educ Pract. 2024;80:104151. Kaya SP, Özkan B, Çakmak B. The relationship between the hidden curriculum and fourth-year nursing students’ career plans, professional values, and professional readiness: A cross-sectional correlational study. Nurse Educ Pract. 2025;82:104235. Tables Tables 1 to 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6399320","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":452989070,"identity":"f5928e7c-b7e9-44b4-b9c7-6aaf625f43b0","order_by":0,"name":"Yangguang Chen","email":"","orcid":"","institution":"Guilin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yangguang","middleName":"","lastName":"Chen","suffix":""},{"id":452989071,"identity":"e0ccbd22-d241-4295-8275-ce3f54776757","order_by":1,"name":"Zili Zhou","email":"","orcid":"","institution":"Guilin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zili","middleName":"","lastName":"Zhou","suffix":""},{"id":452989072,"identity":"ac93125c-2d25-493c-988c-7c5d0c40e4b5","order_by":2,"name":"Guangxu Mao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArUlEQVRIiWNgGAWjYNACAxs5Nvb2A6RoqUgz5uM5k0CKljOHE+dJOBgQp1i3/fAxad62w+ltEgwJDD8qthHWYnYmLdmYty09t0268QBjz5nbRGg5kGP4mLfNOrdN5kACM2MbMVrOvzE4zNvGnM4mkWBApJYbQFt4zjgnkKLlWbLhnIo0wzZgIB8kzi/nk49JvDGwkZdvbz/44EcFEVpQwAES1Y+CUTAKRsEowAUAfiU7Y/6JxAsAAAAASUVORK5CYII=","orcid":"","institution":"Xinghua People's Hospital Affiliated to Yangzhou University","correspondingAuthor":true,"prefix":"","firstName":"Guangxu","middleName":"","lastName":"Mao","suffix":""}],"badges":[],"createdAt":"2025-04-08 05:08:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6399320/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6399320/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82384476,"identity":"d7c3ee8e-54bd-4a4c-99bd-566e5d2c09e9","added_by":"auto","created_at":"2025-05-09 16:10:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":128675,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation modelling results\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6399320/v1/6c898c98a1990d8590aebf00.png"},{"id":82384795,"identity":"ab460506-95dc-455b-895d-68d8d8b83b23","added_by":"auto","created_at":"2025-05-09 16:18:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":743427,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6399320/v1/e4747519-92ef-4df0-94f3-0ee54641c46e.pdf"},{"id":82384793,"identity":"a170584d-c6f0-446c-97f9-4c43dee9bf28","added_by":"auto","created_at":"2025-05-09 16:18:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40476,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6399320/v1/2cf190b52d13949b1dd3f2aa.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond the classroom: How hidden curriculum dynamics shape professional identity formation in nursing undergraduates-Evidence from structural equation model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNursing education, as a strategic priority in the development of medical human resources, depends not only on the establishment of explicit knowledge systems but also on the seamless integration of implicit educational elements. Currently, medical education often faces a structural disconnect between explicit curricula focused on imparting professional knowledge and standardized skill training and the underlying hidden educational mechanisms[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the Future of Nursing 2020\u0026ndash;2030, approximately 67% of nursing education institutions continue to adhere to the binary teaching model of \"theoretical instruction and clinical training,\" systematically neglecting critical hidden educational factors such as the integration of organizational culture within healthcare settings and the dynamics of teacher‒student interactions[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The situation is corroborated by the \"White Paper on the Current Development Status of the Nurse Group in China,\" which indicates that an analysis of a sample of practicing nurses reveals that approximately 52.5% of them lack clear objectives for their future career development. This finding underscores a significant deficiency in the mechanism through which explicit knowledge is translated into professional values.\u003c/p\u003e \u003cp\u003eThe hidden curriculum, as a structural counterpart to the explicit curriculum in higher education, operates through multidimensional mechanisms of subtle influence. Unlike traditional teaching frameworks, it shapes students' cognitive structures through diverse channels, such as campus spatial design, institutional disciplinary systems, academic community interactions, and organizational cultural symbols. Ultimately, this process facilitates the transformation of students' attitudes, knowledge, values, professional ethics, emotions, and behavioral norms[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A review from 2006\u0026ndash;2018 demonstrated that scholars across different countries hold inconsistent interpretations of the hidden curriculum, sometimes conflating it with informal learning[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. On the basis of these results, the writer suggested the use of the four areas identified by sociologist Hafferty (1998)\u0026mdash;policies of institutions, decisions regarding resource distribution, institutional jargon, and assessment activities\u0026mdash;as a basis for exploring the concealed curriculum in nursing education[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Curriculum designers not only systematically impart professional knowledge and skills through explicit curricula but also act as institutional agents who deeply engage in and shape students' professional socialization[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This process is intrinsically embedded within the operational logic of the hidden curriculum: through nonstructured cultural infiltration mechanisms, the organizational behaviors, discourse practices, and power dynamics of educational actors continuously transmit implicit professional norms, value judgments, and perceptions of authority, thereby fostering the internalization and construction of nursing professional identity[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProfessional identity encompasses their emotional connection to and positive perception of both their current role as students and their future role as nurses. Professional identity functions both as a socialization process, through which nursing students progressively construct their professional selves via cognition, experience, and behavior, and as a dynamic, evolving mechanism that continues to develop throughout their careers. It begins with a preprofessional identity during the student phase and matures over time[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Factors such as population aging, regional infectious disease outbreaks (e.g., COVID-19), excessive workloads, and job burnout have exacerbated the global nursing shortage and contributed to high turnover rates among early-career nurses[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Studies indicate that nurse turnover rates in New Zealand, the United States, Canada, and Australia stand at 44.3%, 26.8%, 19.9%, and 15.1%, respectively[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In China, more than 50% of nurses report varying levels of intention to leave their positions, whereas 32.6% of newly hired nurses experience career uncertainty within three years (China's Medical and Health Development Report: 2020)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, the 2020 Global Nursing Situation Report highlights a global nursing workforce gap of 5.9 million[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These trends underscore the systemic challenges in cultivating resilient nurses with strong professional identities. This pressing reality has compelled nursing educators to reflect on why, despite undergoing standardized skills training within traditional explicit curricula, nurses continue to demonstrate high turnover rates and strong intentions to leave the profession. As a key predictor of nurse retention and work engagement, understanding the mechanisms underlying professional identity formation is critical for addressing these persistent challenges within the industry.\u003c/p\u003e \u003cp\u003eExisting research has focused primarily on formal educational strategies to enhance professional identity, such as scenario simulations, clinical teaching practices[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and ABC emotional theory[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, it often neglects the pervasive and subtle influence of the hidden curriculum. A 2022 review by Hadi Abbaspour et al. highlighted that most studies were qualitative and context specific, particularly those focused on clinical internships[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Notably, there is a significant gap in quantitative research that systematically employs reliable measurement frameworks to model the complex relationship between the multidimensional structure of the hidden curriculum and the development of professional identity. This gap impedes evidence-based reforms in nursing pedagogy, as educators lack clear empirical guidance on which aspects of the hidden curriculum, such as institutional culture, interactions, and power dynamics, most significantly influence professional identity outcomes.\u003c/p\u003e \u003cp\u003eThis study seeks to address these limitations through two key innovations. First, the research team utilized a multidimensional assessment tool system developed and validated in China in 2024 to systematically evaluate the hidden curriculum. This tool introduces an innovative evaluation framework encompassing four dimensions: the physical campus environment, campus cultural life, institutional systems, and interpersonal interactions. Second, this study establishes a structural equation model (SEM) to illustrate the dynamic interaction mechanism between the hidden curriculum and professional identity. This educational innovation aligns with the initiative to build a stable nursing workforce, as outlined in the \"Healthy China 2030\" Planning Outline, and provides an empirically grounded model with ecological validity to advance nursing education reform in China.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study employed a cross-sectional survey design.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and sample of the study\u003c/h3\u003e\n\u003cp\u003eKendall's approach to estimating sample sizes suggests that a minimum sample size should be between 5 and 10 times greater than the total number of variables, or the highest number of items present in the scale[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In this study, there are 15 variables (6 participant characteristics, 4 hidden curricula, and 5 professional identities), indicating that the minimum sample size should not be less than 150 cases. Furthermore, since the largest scale comprises 35 items, the sample size must also satisfy the requirement of being no fewer than 350 cases. To ensure adequate statistical power while accounting for potential invalid questionnaires, the sample size was increased by 20% over the minimum requirement derived from both methods. Consequently, the final sample size should be at least 420 cases (350\u0026times;1.2). Ultimately, this study recruited 742 undergraduate nursing students through an online questionnaire administered between May and August 2024. A total of 694 valid responses were collected, resulting in an effective recovery rate of 93.50%, which meets the minimum sample size requirement.\u003c/p\u003e\n\u003ch3\u003eData collection tools\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003ePersonal information form\u003c/strong\u003e \u003cp\u003eA general information questionnaire was developed by the research team in alignment with the study's objectives to collect data on various demographic factors. This questionnaire includes participants' gender, residence, presence of family members with a medical background, class level, prior experience as student leaders, and whether they are only children.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eThe Hidden Curriculum Assessment Scale in Nursing Education (HCAS-NE)\u003c/em\u003e: The HCAS-NE[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] represents a psychometrically validated instrument designed to quantify implicit pedagogical constructs within nursing education ecosystems. This 35-item multidimensional framework operationalizes four latent variables: 1) physical infrastructure and spatial design (HCAS1), 2) cultural ecosystem and symbolic practices (HCAS2), 3) organizational architecture and normative frameworks (HCAS3), and 4) relational dynamics and peer engagement (HCAS4). Using a quintile Likert-type response framework (1\u0026thinsp;=\u0026thinsp;strongly disagree to 5\u0026thinsp;=\u0026thinsp;strongly agree), composite scores demonstrate a possible range of 35\u0026ndash;175, with elevated scores reflecting enhanced student perceptions of institutional hidden curriculum quality. The psychometric evaluation revealed strong scale reliability (Cronbach's α\u0026thinsp;=\u0026thinsp;0.972 in the present sample, exceeding the original validation).\u003c/p\u003e \u003cp\u003e \u003cem\u003eProfessional identity questionnaire for nursing students (PRQNS)\u003c/em\u003e: The Professional Identity Scale was developed by Chinese scholars [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Permission to utilize the pertinent scales was acquired from the original creators. Adapting Hao's (2011) vocational identity paradigm, our study implemented a 17-item measurement model containing five theoretically distinct components: 1) occupational identity formation (PIQNS1), 2) cost‒benefit calculus in career continuity (PIQNS2), 3) reflective positioning in social contexts (PIQNS3), 4) agency in occupational trajectory (PIQNS4), and 5) persuasion from members of the public (PIQNS5). The instrument employs a standardized 5-point metric (total range 17\u0026ndash;85), incorporating one inverse-scored element to mitigate response bias. Empirical validation within Chinese academic populations has established robust psychometric properties (item-level reliability\u0026thinsp;\u0026gt;\u0026thinsp;0.80). The current data demonstrated strong internal consistency (α\u0026thinsp;=\u0026thinsp;0.906).\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA data investigation team was established, and the questionnaire was distributed to each group member through WeChat. It provided details about the study's purpose and informed consent. Nursing students were given the opportunity to decide whether to participate after understanding the study's objectives and the content of the questionnaire. They were also free to withdraw at any time. All items in the questionnaire were designated as mandatory, and each IP address was restricted to a single submission. The average time required to complete the surveys was approximately 15 min. Two researchers subsequently conducted data cleaning and logical verification of the collected questionnaires, eliminating invalid responses on the basis of predefined criteria: completion times of less than three minutes and answers exhibiting obvious patterns. To minimize potential risks associated with common method bias (CMB) and ensure the accuracy and reliability of the conclusions, this study implemented several procedural strategies[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. First, respondent anonymity was strictly maintained to reduce the influence of subjective intentions and social desirability. Second, the order of the measurement tools was randomized to mitigate sequence effects. Finally, the data collection process was staggered across time and survey groups to avoid large-scale measurements within a short timeframe.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis was carried out with IBM SPSS (29.0) alongside AMOS (26.0). Normally distributed data are expressed as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations. Independent samples t tests were used for comparisons between two independent groups, whereas one-way analysis of variance (ANOVA) was used for comparisons involving more than two independent groups. The relationship between the hidden curriculum and professional identity was examined via the Pearson correlation test. Furthermore, multiple linear regression analysis along with structural equation modelling (SEM) was used to determine how participant characteristics and the hidden curriculum predict professional identity. To evaluate the extent of collinearity among the variables, the variance inflation factor (VIF) and tolerance values are utilized. An acceptable range is defined as a VIF below 10 and a tolerance value exceeding 0.1[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. All the statistical tests were two-sided, with a significance level set at α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, 694 nursing students, including 72 males (10.4%) and 622 females (89.6%), participated. Among the participants, 144 (20.7%) were 1st year students, 158 (22.8%) were 2nd year students, 216 (31.1%) were 3rd year students, and 176 (26.4%) were 4th year students. Additionally, 191 participants (27.5%) reported having a family member with a medical background. Furthermore, 238 individuals (34.3%) resided in the city, whereas 113 participants (16.3%) held leadership positions as student leaders. Notably, 260 respondents (37.5%) identified as only children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of HCAS-NE and PIQNS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe hidden curriculum assessment yielded a total score of 86.47\u0026thinsp;\u0026plusmn;\u0026thinsp;23.27, with the highest item score observed in \u0026ldquo;Campus cultural life\u0026rdquo; (2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83) and the lowest in \u0026ldquo;Interpersonal interaction\u0026rdquo; (2.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75). The professional identity assessment resulted in a total score of 59.50\u0026thinsp;\u0026plusmn;\u0026thinsp;11.27, with the highest item score recorded for \u0026ldquo;Social persuasion\u0026rdquo; (3.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90) and the lowest for \u0026ldquo;Social comparison and self-reflection\u0026rdquo; (3.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78) (Table\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of HCAS-NE and PIQNS with different characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDifference analysis revealed statistically significant differences in total hidden curriculum and professional identity scores among individuals from varying family backgrounds (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.409, 3.783, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017, \u0026lt;\u0026thinsp;0.001). Additionally, significant differences were observed across grade levels concerning the total hidden curriculum and professional identity scores (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9.139, 18.410, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, being an only child was significantly associated with perceptions of the hidden curriculum and professional identity (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.277, 7.881, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Pairwise comparisons between year groups indicated that higher-year nursing students (juniors and seniors) had significantly higher scores for hidden curriculum quality and professional identity than their lower-year counterparts (freshmen and sophomores) did (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelationships between HCAS-NE and PIQNS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA significant positive relationship was identified between the hidden curriculum assessment scores of undergraduate nursing students and their sense of professional identity (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.628, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, the scores of each subdimension of the hidden curriculum were predominantly moderately correlated with those of the corresponding subdimensions of professional identity (0.4\u0026thinsp;\u0026lt;\u0026thinsp;\u003cem\u003er\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.6, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of PIQNS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe class level was incorporated into the multiple linear regression analysis as a set of dummy variables, with the first year serving as the reference category. Three additional dummy variables were introduced to represent the other grades (\u0026ldquo;2nd --1st year\u0026rdquo;, \u0026ldquo;3rd --1st year\u0026rdquo;, and \u0026ldquo;4th --1st year\u0026rdquo;). Professional identity is influenced by various factors, including family medical background, involvement in student leadership roles, HCAS-NE scores, and class level (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSEM of the Association between Hidden Curriculum and Professional Identity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn the basis of the findings from the preliminary analysis, SEM was created to investigate the connection between the hidden curriculum and professional identity. The univariate analysis indicated that factors such as grade level, having family members with a medical background, and holding leadership positions in student organizations significantly influenced both the hidden curriculum scores and professional identity. Given that these variables have been identified as critical influencing factors in prior studies, all the demographic characteristics were incorporated into the SEM for a comprehensive analysis. On the basis of the model fitting outcomes, the initial SEM was refined and adjusted to produce the final revised model. (1) Model fit: The revised model demonstrated an acceptable fit (Table\u0026nbsp;5). (2) As illustrated in Fig.\u0026nbsp;1, the established SEM revealed that the paths from general demographic characteristics to the hidden curriculum and from general demographic characteristics to professional identity were not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Nevertheless, the influence of the concealed curriculum on professional identity was significant, with a coefficient of 0.42 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;6).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the findings indicated that nursing students had an overall professional identity score of 59.50\u0026thinsp;\u0026plusmn;\u0026thinsp;11.27, placing it in the middle range (59.50/85). However, this score was lower than those reported in regions such as western Turkey[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], other parts of China[\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e], and Australia[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. This inconsistency could be due to variations in regional cultures, along with the difficulties present in the current job market. Moreover, the low mean scores for the dimensions of retention benefits and separation risks (3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76) suggest that nursing students may not fully recognize the advantages of a nursing career. They seem to believe that leaving the profession would not result in significant emotional consequences and do not appear to prioritize or reflect on alternative career options. In contrast, the \u0026quot;social persuasion\u0026quot; dimension received the highest mean score (3.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90), indicating that social persuasion is the primary influence on nursing students\u0026apos; professional identity. Given that these students have not yet formally entered the workforce, their understanding of the profession is predominantly shaped by their nursing education and clinical practice experiences and, significantly, by the influence of faculty and institutional personnel on their professional perceptions.\u003c/p\u003e\n\u003cp\u003eThe total hidden curriculum score (86.47\u0026thinsp;\u0026plusmn;\u0026thinsp;23.27) was moderate (86.47 out of 175), indicating considerable variation in students\u0026apos; access to implicit learning opportunities. This finding underscores the need for institutions to reassess the equitable allocation of educational resources and improve the quality of clinical placements. Additionally, identifying key educational components, developing effective implementation strategies, and establishing rigorous evaluation methods are essential for successfully integrating the hidden curriculum into nursing education and promoting comprehensive reform of college teaching methodologies and ideologies. The HCAS-NE used in this study was developed by a research team in China[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. Internationally, the HCES-N[\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e] serves a similar purpose and is considered one of the earliest tools. While both scales aim to evaluate the implicit curriculum among undergraduate nursing students, they differ significantly in their dimensional structures and scoring criteria, largely due to cultural differences. Specifically, the scale developed by our research team emphasizes quantifiable external factors, such as the campus physical environment, institutional management, and interpersonal interactions, reflecting a linear \u0026quot;environment-institution-behavior\u0026quot; conceptual framework. In contrast, the HCES-N by Ak\u0026ccedil;akoca et al. focuses on students\u0026apos; subjective experiences, including professional identity development, perceptions of discrimination, power dynamics, and the internalization of institutional values. In this study, the highest subdimensional scores within the hidden curriculum were found for the \u0026quot;campus cultural environment\u0026quot; (2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83) and the \u0026quot;campus material environment\u0026quot; (2.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71). These relatively high scores can likely be attributed to the characteristics of China\u0026rsquo;s current educational policies and systems. Given the considerable academic pressure from China\u0026apos;s standardized college entrance examinations and structured high school curricula, students transition from exam-focused basic education to university education, where they encounter significant changes in both material and cultural aspects of life. The diverse university environment tends to inspire greater enthusiasm for their future careers among students. Given the increasing prevalence of artificial intelligence, nursing education institutions should consider integrating AI technologies to enhance the physical environment of campuses and strengthen the efficacy of the hidden curriculum. It is essential for these technologies to achieve a balance of \u0026quot;subtle integration\u0026quot; while avoiding excessive toolification, ensuring that the physical environment and technological applications synergistically align with and support the overarching goals of nursing education[\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThis research highlights the importance of family background as a key element that affects professional identity. The findings reveal that students with family members in medical professions exhibit stronger perceptions of both the hidden curriculum and professional identity (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.409, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017; \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.783, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding is consistent with previous research emphasizing how family influences career decisions and the formation of professional identity [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Students from medical backgrounds are likely to benefit from early and frequent exposure to healthcare values and norms, which aids their integration into the nursing profession[\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Family members serve as vital role models, significantly contributing to the cultivation of professional values. The influence of these role models through observational learning frequently exceeds that of formal education[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, family members can help students critically evaluate both positive and negative behaviors exhibited by healthcare professionals through reflective practices[\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. This further supports the idea that professional identity is not only shaped by formal education but also deeply rooted in students\u0026apos; personal and social experiences. The results of the differentiation analysis also revealed that having family members in the medical field did not significantly impact students\u0026apos; ability to interpret \u0026quot;campus cultural life\u0026quot; and \u0026quot;school structure and regulation\u0026quot; (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This finding suggests that preuniversity familial influence has limited effectiveness during students\u0026apos; transition to university life. Two factors may explain this limitation: the homogenizing effect of regional culture, which may overshadow familial educational influences, and the epistemological shock caused by the novelty of the university environment, which requires students to actively engage with and understand new experiences rather than passively inherit them. These observations are consistent with Bourdieu\u0026rsquo;s theory of habitus[\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e], which posits that through immersive socialization experiences, the institutional domain reshapes students\u0026apos; original cognition. The study also revealed that senior students and those who held leadership positions in student organizations exhibited heightened awareness of the hidden curriculum and a stronger sense of professional identity. This aligns with Raff and Wenger\u0026apos;s \u0026quot;situated learning theory,\u0026quot; which suggests that assuming leadership roles within the student body can serve as a platform for developing essential professional skills, such as communication, decision-making, and teamwork skills crucial to nursing practice[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, participation in leadership roles may foster a deeper connection to the nursing profession, thereby enhancing students\u0026apos; professional identity. Additionally, students in leadership positions tend to show higher levels of self-efficacy, and research has indicated a significant positive correlation between self-efficacy and both professional identity and professional maturity [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. A previous study revealed that as undergraduate nursing students advance through their academic years, their professional identity tends to decline[\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. This finding contrasts somewhat with the results of the current study. The observed data suggest that clinical practice plays a significant role in shaping vocational identity, as evidenced by an increase in vocational identity from the junior to senior stages (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This enhancement can be attributed to students\u0026apos; increasing exposure to specialized professional knowledge and practical clinical experiences, fostering a deeper appreciation for the nursing profession. However, it is important to note that there was a slight decline in vocational identity among senior students approaching graduation; this change did not reach statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This minor reduction may be linked to stress related to impending graduation and concerns about employment prospects. In light of these findings, educational institutions should consider providing targeted psychological support and clear career guidance during the final academic year. Such initiatives could help students develop a positive outlook on their future careers while alleviating psychological pressures. Additionally, educational institutions could implement relevant programs aimed at enhancing nursing students\u0026apos; sense of life purpose, further strengthening their professional identity[\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePrevious qualitative research has indicated that while formal educational components, such as curriculum content and clinical training, are essential, informal processes within the implicit or hidden curriculum play an equally significant role in shaping nursing students\u0026apos; professional identities[\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. This study supports these findings, underscoring the considerable influence of informal learning processes on students\u0026apos; vocational socialization. Structural equation modelling (SEM) further corroborated this impact, revealing a notable path coefficient of 0.42. Pearson\u0026apos;s correlation analyses revealed weak correlations between dimensions of the implicit curriculum and social persuasion (\u003cem\u003er\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The dimension of social persuasion primarily reflects advice and guidance from senior nursing professionals. This finding, coupled with relatively low scores in teacher‒student interactions (2.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75), suggests that educators should proactively offer positive guidance beyond explicit curricular activities. Collaborating with healthcare organizations to create forums for sharing clinical experiences and facilitating emotional communication is recommended. Furthermore, nursing educators themselves should receive training in cognitive emotion regulation and positive emotional strategies to enhance their interactions with students[\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e]. Since the development of the HCES-N, there has been a notable increase in quantitative investigations into the hidden curriculum. Kaya (2022) determined that the hidden curriculum significantly influences the formation of professional identity in nursing students, the development of professional values, and the improvement of professional adaptability[\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]. Despite the progress made in quantifying the dimensions of the hidden curriculum, research in this area is still in its early stages. Future studies should focus on clarifying and refining definitions related to the hidden curriculum, as well as improving the cultural adaptability and validity of assessment tools. Notably, there remains a scarcity of robust quantitative evidence regarding its role in shaping professional identity. This study aims to address this gap by providing empirical evidence that underscores the critical importance of integrating the hidden curriculum with formal curricula in nursing education. Such integration can enhance students\u0026apos; preparedness to meet the complex demands of the profession, thereby promoting both clinical competence and ethically grounded professional development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research\u0026apos;s cross-sectional design limits the ability to make causal inferences, indicating that a future longitudinal study would be beneficial for exploring how the effects of the hidden curriculum develop throughout various educational stages. Furthermore, the sample was obtained from only one regional educational institution, which could restrict the applicability of these results to the wider population of nursing students. Future research should explore variations in the hidden curriculum across different institutional settings and cultural contexts, as well as investigate how specific elements of the hidden curriculum may influence distinct dimensions of professional identity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe hidden curriculum\u0026apos;s quality and professional identity among the nursing students were observed to be moderate. Professional identity is influenced by various factors, including family medical background, involvement in student leadership roles, and academic class level. This study provides robust empirical evidence that the hidden curriculum within nursing education significantly impacts nursing students\u0026apos; professional identity, with structural equation modelling confirming a direct positive correlation. These findings deepen our understanding of how hidden institutional cultures and unspoken teaching practices contribute to the psychological internalization of the nursing role. They also offer practical insights for curricular reform and strategies to better support students. Additionally, it is essential for nursing educators to recognize and comprehend the evolution of the hidden curriculum while considering strategies to enhance students\u0026apos; views, ultimately promoting the growth of their professional identities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to all the faculty and nursing students who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003euthor contribution\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYangguang Chen: Writing – review \u0026amp; editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Zili Zhou: Conceptualization, Investigation, Methodology, Project administration. Guangxu Mao: Writing-review \u0026amp; editing, Methodology, Software, Supervision, Validation, Formal analysis, Conceptualization, Data curation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Education Department of Guangxi Zhuang Autonomous Region (Grant No. 2022ZJY466)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated and analyzed during this study are not publicly available but can be made available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll processes of the research were approved by the Ethics Committee of Guilin Medical University (Ethical Review Number: GLMC20211204). All nursing students participating in the study signed the informed consent form. The Declaration of Helsinki was followed throughout the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoer C, Daelmans HEM. Team up with the hidden curriculum in medical teaching. Br J Anaesth. 2020;124:e52\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosseini A, Ghasemi E, Nasrabadi AN, Sayadi L. Strategies to improve hidden curriculum in nursing and medical education: a scoping review. 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A study on the impact of life meaning on occupational identity of nursing students in China:a cross-sectional study. BMC Nurs. 2023;22:480.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarimi Z, Ashktorab T, Mohammadi E, Ali Abedi H. Using the Hidden Curriculum to Teach Professionalism in Nursing Students. Iran Red Crescent Med J. 2014;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Zhang H, Tao S, He J, Li S. Centrality and bridge connections between cognitive emotion regulation strategies and professional identity among Chinese undergraduate nursing students: A network analysis. Nurse Educ Pract. 2024;80:104151.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaya SP, \u0026Ouml;zkan B, \u0026Ccedil;akmak B. The relationship between the hidden curriculum and fourth-year nursing students\u0026rsquo; career plans, professional values, and professional readiness: A cross-sectional correlational study. Nurse Educ Pract. 2025;82:104235.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hidden curriculum, Professional identity, Undergraduate nursing students, Nursing education, Structural equation model","lastPublishedDoi":"10.21203/rs.3.rs-6399320/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6399320/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn nursing education, the hidden curriculum is recognized as a crucial factor influencing professional outcomes and work ethics. While the formal curriculum in colleges and universities primarily focuses on imparting clinical knowledge, emerging evidence suggests that the hidden curriculum plays an equally critical yet underexplored role in shaping students' professional identity.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aims to assess the current state of the hidden curriculum and professional identity among undergraduate nursing students. Additionally, it examines the correlation between these two factors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study employed a cross-sectional correlational design. Undergraduate nursing students from Guangxi Province were recruited through a convenience sampling method. Data were collected using a validated hidden curriculum assessment questionnaire and a professional identity questionnaire. Pearson\u0026rsquo;s correlation test was employed to analyze the relationship between the two variables, and a structural equation model was constructed to further explore the factors influencing professional identity.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 694 undergraduate nursing students participated in this study. The mean score for the hidden curriculum was 86.47\u0026thinsp;\u0026plusmn;\u0026thinsp;23.27, while the mean score for professional identity was 59.50\u0026thinsp;\u0026plusmn;\u0026thinsp;11.27, indicating moderate levels for both constructs. A strong positive correlation was found between hidden curriculum scores and professional identity scores (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.628, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multiple linear regression analysis revealed that hidden curriculum scores, having family members with a medical background, class level, and experience as a student leader were significant predictors of professional identity. Furthermore, the structural equation model demonstrated a good fit, with a path coefficient of 0.42 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between the hidden curriculum and professional identity.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe hidden curriculum plays a significant role in shaping the professional identities of nursing students by socializing them into the norms of the profession. A hidden curriculum that fosters critical thinking and support within nursing education can help develop nurses who are not only clinically competent but also possess professional self-awareness and resilience.\u003c/p\u003e","manuscriptTitle":"Beyond the classroom: How hidden curriculum dynamics shape professional identity formation in nursing undergraduates-Evidence from structural equation model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 16:10:27","doi":"10.21203/rs.3.rs-6399320/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-13T14:05:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"135386873958345421163617438114339809779","date":"2025-08-13T11:57:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-06T12:08:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-06T12:07:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-25T12:14:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-25T04:58:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-04-25T04:57:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56695b64-dfaf-4c47-a48b-8897f599586a","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T16:10:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 16:10:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6399320","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6399320","identity":"rs-6399320","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}