Resilience and Flexibility for Clinical Nurses: A Latent Class Analysis

Aim . To explore potential resilience and psychological fexibility patterns in nurses and analyze the efects of related factors such as growth mindset and professional recognition of categories. Background . Resilience and psychological fexibility can help nurses resist occupational pressure and play essential roles in promoting personal growth and professional development. Methods . A latent category approach was used to examine the patterns of heterogeneity in resilience and fexibility among 805 nurses. Diferences in the infuences related to resilience and fexibility were analyzed using univariate and multivariate logistic re-gressions, with demographic information, growth mindset, and career recognition as covariates. Results . Participants were divided into three potential categories: toughness-fexible (32.8%), power-defcit-emotional (23.1%), and toughness-rigid (44.1%). Te results of multivariate logistic regression analysis showed that monthly income, mode of employment, growth mindset, and professional identity were infuential factors in the potential categories of nurse resilience and fexibility. Conclusion . One cohort of nurses had high resilience and low fexibility, and psychological rigidity was related to the fact that the monthly income was less than RMB 5,000 and the contractual mode of employment. An excellent growth mindset and a high professional identity indicate that nurses are resilient and fexible. Implications for Nursing Management . Hospitals and nursing managers should pay attention to nurses’ diferent career development needs and implement appropriate safeguards.


Introduction
Tere is no single defnition of resilience or mental fexibility.An extensive review of the empirical literature summarizes resilience into fve themes: overcoming adversity, adaptation and adjustment, prevalence, good mental health, and positive personal responses to challenges [1].Psychological fexibility is the management of actions in a way that facilitates the pursuit of one's goals or values as appropriate to the situation's needs [2].In resilient shield theory [3], several indicators are interwoven to form a protective shield to help people withstand adversity.Tis clearly explains the theoretical system developed by many factors and fexibilities, in which the fexibility of the thinking layer allows for the transformation of cognition.Overall, resilience positively correlated with coping.Psychological fexibility, in contrast, is accompanied by goal orientation and action management.Both resilience and fexibility in terms of favorable outcomes mean beating the odds, but there may be diferences in the process involved and the result of the choices made.
Te nursing community is a high-pressure occupational group, and nurses' mental health in China and other countries has received particular attention [4].Work pressure, burnout, moral dilemmas, and vicarious trauma often lead to anxiety, depression, and other negative psychological aspects of this group [5][6][7], thus, laying hidden dangers to the quality of nursing services and even casting doubt on the value of the nursing profession [8].When nurses face stress and challenges over time, better resilience helps them cope and adapt to adversity.However, psychological fexibility serves as a guiding light, telling the nurse the direction or goal for which they should strive.Better resilience and fexibility with greater adaptability positively impacted nurses' psychological, physical, and occupational functioning.
Resilience is dynamically variable and multifactorial from resource-, outcome-, and process-based perspectives [9].Te process of coping with stress and challenges refects the underlying characteristics of individuals.Although many studies have demonstrated a signifcant positive correlation between resilience and psychological fexibility, it is unknown whether more resilient individuals possess better psychological fexibility.Latent class analysis can categorize the study population based on probability, signifcantly diferentiating between groups and allowing heterogeneous individuals to exhibit characteristics that difer from other categories [10].Tis is an excellent approach for exploring diferences in resilience and fexibility within the same group of nurses.Compared to clustering algorithms, latent class analysis reduces human-induced errors and can be used to test more complex variable relationships.Terefore, this study aimed to explore resilience and psychological fexibility patterns among clinical nurses.
Te second aim was to elucidate the factors infuencing nurses' resilience and psychological fexibility.Te growth mindset theory hypothesizes that belief in changing our intellect and mindset can infuence how we handle challenges and defne goals [11].Te motivation involved involves a complex interaction between goal orientation and mindset and has a wide range of applications in education.Michael reviewed 27 medical professional education articles on growth mindset.He noted that one of its potential benefts is that it provides people with emotional and psychological support, increased resilience, improved mental health, and selfconfdence [12].Professional identity is a positive perception and evaluation of the occupation in which you work [13].Afrmation of the profession likewise afects the psychological state of the nurses themselves, their personal career development, quality nursing care, and the advancement of the professional discipline [14].Nurses' resilience is signifcantly associated with their professional identity [15].Higher resilience corresponds to a more positive career perception [16].Figure 1 illustrates this study's portfolio framework.
Terefore, we propose the following hypotheses: (a) there is heterogeneity in patterns of resilience and psychological fexibility among clinical nurses, (b) a growth mindset can infuence nurses' patterns of resilience and psychological fexibility, and (c) professional identity can infuence nurses' patterns of resilience and psychological fexibility.Exploring models of nurse resilience, psychological fexibility, and related infuences can provide hospitals and nursing administrators with new perspectives and evidence for nurses' mental health management and career development.

Simplifed Version of the Psychological Resilience Scale.
Te original scale was the Connor-Davidson Resilience Scale [17].Te study was tested using the Chinese version of Laura Campbell-Sills [18], simplifying the 10-item entry [19].Te scale is based on a 5-point Likert scale with a positive scoring principle.It has shown good reliability and validity for testing mental health in the Chinese population.Te Cronbach's alpha coefcient for this scale in this study was 0.933.

Acceptance and Action Questionnaire Second Edition.
Te second version of the Acceptance and Action Questionnaire (AAQ II) was developed by Hayes et al. and later adapted by Bond et al. [20].Te study used the Chinese version of Cao et al. [21], with 7 entries.Currently, there are more satisfactory applications for diferent Chinese populations.Te scale measures acceptance and action on a 7-point Likert scale (from 1 � "never" to 7 � "always"), with higher total scores resulting in lower levels of psychological fexibility.Te Cronbach's alpha coefcient for this scale in the present study was 0.973.

Growth Mindset
Scale.Tis study uses the Growth Mindset Scale revised by Zhu et al. [22] in the context of Chinese culture, developed by Dweck et al., comprising three items.Te scale is based on a 6-point Likert scale, with scores of 1-6 indicating complete agreement with complete disagreement; the higher the score, the better the level of growth mindset.Te Cronbach's α for this study was 0.957.

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Journal of Nursing Management 2.2.5.Nurses' Professional Identity Rating Scale.Te original scale was obtained from the University of Tokyo, Japan, and a version translated by Fangli Deng from China was used in this study [23].Te scale was merged into fve dimensions based on Chinese cultural conventions: sense of self-efcacy and grasp, sense of congruence, sense of self-determination, sense of patient and organizational infuence, and sense of meaningfulness.Te entries totaled 21 items and were rated on a 5-point Likert scale, with 1 to 5 indicating strongly disagree ∼ strongly Agree, respectively.Te scores were positively related to professional identity.Tis scale is widely used in the Chinese population.Te Cronbach's alpha coefcient for the scale in this study was 0.969.

Data Collection.
Tis involved explaining the purpose and method of questionnaire distribution to the heads of the nursing management in each hospital.After obtaining consent, you can fll out the questionnaire using the Internet, and you will be limited to one response per IP address.Te questionnaire included an omission prompt to ensure the completeness of the information.Data in the web backend were exported if they were not updated for one consecutive week.Te two researchers jointly verifed and excluded invalid questionnaires; 805 valid questionnaires were returned, with a valid recovery rate of 94.15%.Te study used a rough estimation of the sample size, and with the addition of approximately 20% meaningless questionnaires, the maximum number was 252, which was sufcient for this study.

Ethical Considerations.
Te study was approved by the Ethics Committee of Bengbu Medical University, and all participants provided informed consent before the investigation.Te ethical approval number was Grant no.2023369.

Statistical Analysis.
Te CD-RISC-10 is scored on a 5-point scale.In particular, with a value < 3 as the lower responder.Te low responder group was estimated to be 0. Furthermore, a value ≥ 3 was the higher responder group, estimated as 1.AAQ II was scored on a 7-point scale, with ≥4 categorized as a low responder group and estimated as 0. In addition, a value < 4 was categorized as a higher responder group and estimated as 1.After the scores were standardized to dichotomous categories, potential category analysis was conducted using the Mplus 7.4 software.We used a range of test values to explore the most superior classifcation [24].Akaike's information criterion (AIC), Bayesian information criterion (BIC), and corrected Bayesian information criterion (aBIC) with lower values indicated a better ft.When the likelihood ratio (LMR) and bootstrap-based likelihood ratio test (BLRT) are signifcant (p < 0.05), the classifcation of the k-class model is better than that of the k-1 class.Regarding the classifcation accuracy, the closer the entropy value is to 1, the better.More importantly, the fnal choice of the model must be fully observed for its practical implications [25].Data were statistically analyzed using the SPSS software (version 26.0).Frequencies and percentages indicate qualitative data, while quantitative data obeying normal

Resilient
Power Adaptive

Psychological health Professional development
Figure 1: Combined framework of resilience and psychological fexibility models.In the face of stressful events, resilience and psychological fexibility comprise diferent psychological characteristics of a positive coping model with goal orientation.Resilience and psychological fexibility interact in the model and form a heterogeneous pattern by their diferent demographic characteristics.A growth mindset and professional identity had an infuential role in the model.In summary, the resilience and psychological fexibility model infuences mental health and professional development.
Journal of Nursing Management distribution are expressed as mean ± standard deviation (x ± s).Comparisons of scores between scales and modalities were performed using analysis of variance (ANOVA), and unordered categorical comparisons were performed using chi-square tests.Te Fisher-Freeman-Halton test was used to measure the underfrequency of a particular cell, and the Kruskal-Wallis test was used to measure diferences in continuous variables.Finally, multivariate logistic regression was used to analyze the factors infuencing nurses' resilience and fexibility categories, which were statistically signifcant at p < 0.05.

Latent Classes of Resilience and Psychological Flexibility.
Exploratory latent class analyses were based on nurses' resilience and fexibility dichotomous scores.First, 1-5 models were established.Te values of AIC, BIC, and aBIC in the model tended to be minor, and the LMR of the fve classifcations was >0.05.Terefore, they were not considered.For the four categorical models, when both LMR and BLRT were signifcant, the curves of the four classifcations were more complex, somewhat ambiguous, and challenging to interpret in terms of their theoretical and practical signifcance.By observing the three-category model with an entropy of >0.8 and both LMR and BLRT of <0.05, the categorization is concise, and its functional relevance is more apparent.Te results are summarized in Table 1.Ultimately, the best latent class was determined to be three.

Characterization and Naming of Diferent Models.
Of the three classifcation schemes identifed, the frst group was named the "toughness-fexible group," which accounted for 32.8% of the total.In this group, the probability of scoring most items for resilience and mental fexibility was above 0.8, indicating that nurses in this group were more resilient and fexible.Te second group was categorized as the "power-defcit-emotional group," which accounted for 23.1%.Te perceived sense of strength against adversity was low, and the low-scoring entries in fexibility were emotional concerns and worries that led to stumbling.Te third group was categorized as the "toughness-rigid group," which accounted for 44.1% of the total.Tis group is characterized by a degree of resilience but generally poor mental fexibility as shown in Figure 2.

Results of One-Way Analysis of Latent Classes of Resilience
and Psychological Flexibility.Comparisons of nurses in the diferent resilience and psychological fexibility categories regarding monthly income, job title, and mode of employment revealed signifcant diferences.Te results are summarized in Table 3.

Comparison of Growth Mindset and Professional Identity
Scores for Nurses in Tree Latent Classes.A comparison of nurses in the three potential categories of resilience and psychological fexibility in terms of growth mindset and total professional identity scores revealed statistically signifcant diferences (p < 0.05), as shown in Table 4.

Multiple Logistic Regression Analysis of Factors Infuencing Latent Classes of Nurses' Resilience and Psychological
Flexibility.Unsorted multicategorical logistic regression analyses were conducted using the potential categories of nurse resilience and psychological fexibility as dependent variables (with the toughness-fexible group as the reference) and variables statistically signifcant in the univariate analyses as independent variables and covariates.Te results indicated that contract employment style was a predictor of the strength-defcit-emotional group; monthly income < RMB5,000, stafng agency, contract employment style, and growth mindset were predictors of the toughness-rigid group; and higher occupational identity and growth mindset together predicted the toughness-fexible group, as shown in Table 5.

Monthly Income Mode of Employment can Afect Nurses'
Resilience and Psychological Flexibility.Nurses earning less than RMB 5,000 per month were more likely to be in the rigid toughness group than in the fexible toughness group.In this group, nurses with families and children accounted for more than 2/3, and for their family consumption, a monthly income of less than 5,000 yuan was slightly constrained.An Australian study [26] states that lowincome families may be more likely to adopt a childfocused spending plan that allocates less to the adult budget and often requires careful budgeting to meet the family's needs.Te dual pressures generated by work and life lead to looking ahead and empirical avoidance when addressing other challenges.Psychological fexibility mediates perceived stress and negative emotions [27].Based on the family systems' theory, poorer parental psychological fexibility leads to poorer family functioning [28].
For nurses with families and children, the more negative emotions generated, the less family functioning and psychological fexibility.
Contractual hiring practices were an infuential factor in the strength-defcit-emotional group compared to the toughness-fexibility group.Contractual employment is one of the most common methods of recruiting nurses.However, this may make nurses feel more apprehensive.In certain cities in China, other modes of employment represent diferent jobs, hospital benefts, and professional statuses.In contrast, nurses employed on a contractual basis have relatively low educational qualifcations, monthly incomes, and retirement benefts.Dr Kate interviewed nurses working temporarily in the UK, who reported feelings of isolation, fewer training opportunities, and difculties in maintaining permanent jobs [29].According to the job demand resource model [30], when job resources are limited, demand fulfllment frustration occurs, and personal commitment to work decreases, which may ultimately lead to burnout or separation from service [31].
Personnel agencies and contractual hiring practices afected the toughness-rigidity group.Tis may have had a diferent infuence on the two outcomes of toughness and mental rigidity in this group.Te better fexibility in this group may have resulted from the personnel agency method of employment.A personnel agency is a new type of personnel management in which the Chinese government provides social services for talent.[32].Compared with other forms of employment, stafng agencies consider the advantages of legal protection, fexible employment, and reasonable distribution of performance pay, among others.Most contractors are highly educated and qualifed [33].Tis implies favorable future career development and confrms the protective role of the professional dimension in the shield layer of resilient shield theory.

Growth Mindset as an Infuence on Resilience and Flexibility of Nurses' Mindset.
A growth mindset is a factor infuencing the "tough-fexible" group and the "toughrigid" group.A similar characteristic of both groups was a high level of resilience.After several major public health events, the nursing community underwent signifcant changes in professionalism and psychological adaptation [34].Mental health and occupational psychology have received worldwide attention [35].To prevent and recover emotional resilience from burnout, Jay encourages cultivating a growth mindset that can be used to enhance emotional resilience through the lens of positive psychology [36].Raquel demonstrated signifcant correlations and predictions between psychological fexibility and resilience to minimize burnout and trauma among Spanish nurses during major public health events [37].Growth mindset and mental fexibility, while not practical in prediction, showed statistically signifcant diferences in growth mindset in at least two groups in one-way outcome analyses.In short, the predictive efect of a growth mindset in this study appears to be related to nurses' resilience, and its relationship with psychological fexibility needs to be further demonstrated.

Professional Identity Afects Nurses' Psychological Resilience and Flexibility.
Professional identity predicts toughness and fexibility.Zhou et al. concluded that nursing students with a high level of professional identity had positive perceptions and evaluations of the nursing profession, and their capacity for self-directed learning was higher [38].Research has also demonstrated that people with higher levels of self-directed learning also tend to be more personally resilient [39].Conversely, Chen further elucidated the critical role of resilience in work-family confict and career development in his study, explaining why occupational identity is a high resilience predictor [40].Chong et al. [41] conducted an online survey of 514 Hong Kong citizens whose sequential equation modeling showed that psychological fexibility directly afected prosocial behavior.Occupational identity includes how the wider society recognizes the work an individual does and is a way of demonstrating the individual's relationship with society [42].Professional identity includes a great deal of prosocial identity.

Limitations.
Our study had some limitations.First, our sample comes from only one province in Central China, and economic development and humanistic literacy difer across regions, which may result in a certain degree of bias.Second, there were more female nurses in the sample, which may have prevented comparisons from considering gender differences.Tird, the sample size of tertiary care hospitals was large, and diferences between diferent hospital levels may not have been available.Future studies should expand the sample to a national or multinational scale to extrapolate the results.Journal of Nursing Management

Conclusions
Tis is the frst study to simultaneously examine the relationship between nurses' resilience and psychological fexibility.Moreover, this study empirically demonstrates the efects of a growth mindset and professional identity on psychological resilience and fexibility.According to our study, higher career identity predicted the toughnessfexibility group, a better growth mindset predicted high fexibility, and the relationship with psychological fexibility needs further validation.Diferent modes of employment and income levels are equally important factors afecting the resilience and fexibility of nurses.With the current signifcant nursing shortage, fair and varied career development for the nursing community is a must for healthcare providers.
5.1.Implications for Nursing Management.Te percentage of poorly adapted groups in the diferent models explored in this study was 67.2%, indicating that more resilient nurses may experience poor psychological fexibility.By examining variables related to nurses' career development, we found that improving professional identity and a growth mindset contribute to the psychological resilience and fexibility of the nurse population.Tis also refects the fact that good personal growth and professional development are benefcial for nurses' adaptive mindsets.By synthesizing work-related characteristics, nursing administrators and related leaders can make the following attempts: frst, enhancing nurses' sense of professional identity and social recognition.Examples include education about the signifcance of the profession, a sense of respect, and the exploration of multiple channels to build career development paths and display platforms.Second, nurses need to develop a growth mindset, such as teaching practices and learning experiences that support personal development, competencybased medical education, matching vocational assessment programs to nurses' professional needs and purposes, and managers practicing encouraging language and building supportive interactions.Tird, employment mechanisms should be reformed, job security implemented, and equal pay for equal work.

Figure 2 :
Figure 2: Conditional probability distributions for latent classes of resilience and mental fexibility.
Shows that the Fisher-Freeman-Halton test was used.

Table 1 :
Potential category model ft indices for nurse resilience and psychological fexibility (n � 805).

Table 2 :
Demographic characteristics of participants.

Table 4 :
Comparison of growth mindset and professional identity scores for nurses in 3 latent classes (scores, x ± s).

Table 5 :
Multivariate logistic regression analysis of infuencing factors of diferent potential categories.