Professional Belongingness and Associated Factors among Iranian Undergraduate Nursing Students

Zahra Molazem¹, Shahnaz Rowshan² and Ladan Zarshenas^3*

^*Correspondence: Ladan Zarshenas, Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Iran, Email:

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Introduction

Belongingness means to be accepted by the group and is defined as a feeling of being valuable, needed and accepted [1,2]. Moreover, belongingness is a sense of involvement in a social system, such that the person feels like a necessary and integral part of the system [3].

Which as a significant aspect of nursing, would make the nurses feel professional, knowledgeable, competent and like they are a part of the healthcare team [4]. Belongingness is a pivotal concept for nursing students that would influence their acceptance in clinical environments [1]. Having a sense of belonging would lead to feeling good, cognitive growth [2] and reduced anxiety and stress [5]; this feeling is considered an influential key to positive clinical experiences [6]. Belongingness has a strong impact on mental, emotional and behavioral activities, as well as health, happiness and well-being [7-9]; this sense is also known to be a main factor in improving positive behavioral changes [10], professional identity [11], student satisfaction [12], self-esteem [13], academic achievement [14], interaction with instructors and clinical staff [15] and the students ’ capability for better care provision [16]. Nursing students who fail to attain a sense of belonging often face adverse outcomes [6], which result in a reduced motivation toward clinical learning, reduced self-esteem and general welfare, increased anxiety, stress and depression [7], disruption of synchrony and harmony [17], feelings of alienation, turmoil, anger and confusion, and a tendency to adapt their behavior in order to meet the expectations of the nursing staff [14].

So far, numerous studies have been done focusing on professional belongingness. However, no previous study has discussed and compared professional belongingness and its associated factors among students in all four college years. Thus, we decided to conduct a study on the subject in the Shiraz University of Medical Sciences.

Research Methodology

This is a descriptive-analytical study conducted at the School of Nursing and Midwifery, Shiraz, in 2017. Data collection was done using the Nursing Student Belongingness Scale (NSBS) presented by Dr. Zarshenas. Participants included 300 freshmen, sophomore, junior and senior nursing students at the School of Nursing, except the students in their first academic term.

Data collection

After receiving approval from the Research Department and Ethics Committee of the university (IR.SUMS.REC. 1395.S1222) and obtaining a letter of introduction, necessary arrangements were made with school officials; then, the researcher personally attended the classes and the clinic based on the predetermined schedule in order to conduct the research. After stating the objectives, ensuring the students of information confidentiality and obtaining written consents, the first questionnaire was distributed among students, which they completed while the researcher was present. For the purposes of data collection, we used the Nursing Student Belongingness Scale (NSBS) designed by Dr. Zarshenas et al. [18]. This questionnaire comprises 47 items in 5 areas. Dimensions include individual viewpoint (10 items), professional acceptance (11 items), educational background (11 items) interpersonal relationships (11 items) and perceived outcomes (4 items); all items are rated based on a Likert scale. The tool’s validity was evaluated using face validity, as well as qualitative and quantitative content validity, and its structural validity was determined based on convergent (r=0.6) and divergent (r=0.1) methods and factor analysis (58.31% variance). The tool ’ s reliability was verified through internal consistency (Cronbach’s alpha=97%) and a stability of 76%. In terms of scoring, positive and negative items are rated based on two 5-point Likert scales ranging from strongly agree to strongly disagree (1-5) and always to never (1-5), respectively. This questionnaire has a minimum score of 47 and a maximum score equaling 235. Belongingness scores fall under five categories; scores 47-58 indicate extremely poor belongingness, 86-122 poor belongingness, 123-160 average belongingness, 167-197 good belongingness and 168-235 suggest an excellent level of belongingness [18].

Data analysis

Data analysis was performed with the help of SPSS Statistics 16.

Results

Table 1 presents comparison of the mean scores for professional belongingness by demographic characteristics of the study sample.

Table 1: Comparison of the mean scores for professional belongingness by demographic characteristics of the study sample

Results showed a good level of professional belongingness in all college years. Table 2 provides comparison of the mean scores for professional belongingness and its dimensions stratified by college year.

Table 2: Comparison of the mean scores for professional belongingness and its dimensions stratified by college year

According to the results, freshmen had the highest mean score for professional belongingness (189.20 ± 31.17) and the lowest mean score pertained to junior students (167.48 ± 23.98). Among the dimensions of professional belongingness, the highest mean score related to “individual viewpoint” and “perceived outcomes” got the lowest mean score. Furthermore, the highest mean scores for “ individual viewpoint ” , “ professional acceptance” and “perceived outcomes” were obtained by the freshmen. In the “ educational background ” dimension, the highest score related to freshmen and the lowest scores were attained by juniors and seniors. There were no significant differences between the students ’ professional belongingness in terms of gender, marital status and having or not having a nurse as a family member. Professional acceptance was significantly higher in students who lived with their families compared to those living in a dorm (p<0.05). Overall professional belongingness scores were not significantly different between students with experience working at healthcare centers and those without work experience; however, this difference was significant in the dimensions of “ educational background ” (p<0.05) and “ perceived outcomes ” (p<0.01). Thus, based on the mean differences, students with work experience had significantly lower scores in the “ educational background ” and “ perceived outcomes ” dimensions. According to ANOVA, statistical differences existed between the four age-groups in terms of individual viewpoint, inter-professional relationships, perceived outcomes, and overall professional belongingness (p<0.05)(Table 2). Based on Tukey’s post-hoc test, the scores for individual viewpoint and interpersonal relationships were lower in the 21 years-23 years agegroup compared to the age-group of 26 years and-over (p<0.05). Also, the 18 years-20 years age-group had higher “perceived outcomes” than the 21 years-23 years age-group (p<0.01). Moreover, there was a lower level of overall professional belongingness in the 21 years-23 years age-group comparing to student over 26 years (p<0.01)

Discussion

Findings of the present study revealed a good level of professional belongingness in all college years. Meanwhile, Honda et al. reported a low level of professional belongingness in Japanese students [19]. Furthermore, Dabirifard et al. in Yazd [20], Levett-Jones et al. [21] and Kim et al. [22] in South Korea found an average level of clinical belongingness among nursing students. These differences in belongingness levels could be attributed to the influences of personal and background factors [23]. In addition, this study used the Zarshenas et al. belongingness scale [18], while Honda et al. [19], Dabirifard et al. [20], and Levett-Jones et al. [21] all used the belongingness scale developed by Levett- Jones. Our findings showed that among all students in different college years, the highest score was given to the “individual viewpoint” dimension, and the dimensions of “ professional acceptance ” , “ educational background ” , “ inter-professional relationships ” and “ perceived outcomes” followed after that, in that order. Since this was the first time this questionnaire was being used in a research, we found no exactly similar studies in order to compare the dimensions of belongingness. Individual viewpoint had the highest score. In a study on the compatibility of nursing students ’ personalities for education and study and work in the profession, Dianati asserted that half the students are not mentally and personality-wise compatible with this discipline, a fact that would reduce their motivation [24]. In the current study, professional acceptance had the highest score following individual viewpoint. In this regard, Sedgwick et al. found that when students feel they are being treated like a nurse, it affects their sense of belonging to a great degree [25]. Educational background held the third rank among dimensions in terms of score. In this study, educational background consisted of educational methods, professor ’ s experience and motivation, educational content, facilities and opportunities, support from authorities and so on, all of which are influential in forming a student’s professional belongingness. In this relation, Messersmith introduced the professors working at nursing schools as being the first factor affecting professional socialization, which conveys the significance of this dimension [26]. Inter-professional relationships held the fourth rank in this study, while the subscale of connectivity could at least obtain the mean score in Dabirifard et al. article [20]. This difference could be due to the use of Ashktorab et al. [23] belongingness scale (an adapted version of Levett-Jones et al. questionnaire) by Dabirifard et al. [20]; in that scale, relationships included items such as free expression of feelings when upset with a colleague and being invited to lunch by a colleague, which are not consistent with our social criteria. What is known as inter-professional relationship in our society involves different interpersonal relationships with fellow nurses, classmates, patients and instructors within a familial framework [18]. Moreover, student-personnel relationships had the strongest impact on belongingness in the studies by Levett-Jones et al. and Andersson et al. [7,27]; also, Brodie et al. expressed that being comfortable with the medical personnel in the workplace would increase the students ’ ability to ask as many questions as required about the job [28].

The lowest belongingness score pertained to the dimension of “perceived outcomes”; meaning that in this research, students felt a level of discrimination between nursing and other disciplines, were dissatisfied with the clinical environment and believed that nurses had a negative attitude toward nursing. In this regard, Niknam et al. studied the environmental barriers to clinical education from the viewpoint of nursing students and instructors and reported the highest score as belonging to the discrimination between nursing students and other medical students [29], which can be said to be consistent with our study results. Considering the low score of perceived outcomes, creating a comfortable environment for students, provision of appropriate feedback by professors and lack of discrimination against the nursing discipline would increase the students’ sense of belongingness in the future.

Results from the present study revealed the mean score for professional belongingness to be significantly higher among freshmen compared with sophomores, juniors or seniors. The highest scores belonged to freshmen, sophomores, seniors and then juniors, in this order. In line with these findings, in Levett-Jones et al. study as well the majority of students reported a good experience at the beginning of the course and believed that being in a work environment would increase their self-esteem [21]. Moreover, in a longitudinal study, Braåten et al. determined that the interest and motivation of nursing students had decreased in the second college year compared to the first year, as well as in the third year comparing to the second year [30]. As the college years pass by and students age, their internal motivation (e.g. spiritual aspects of the profession) is reduced, and the reason for it is the students’ deeper knowledge of the issues in this profession and their negative attitudes toward the discipline, which manifest in later college years; in these stages, students put more emphasis on high salaries and occupational safety [31], which also can be a cause of lower belongingness scores in higher semesters. In contradiction to our findings, Dabirifard et al. reported a higher mean score for clinical belongingness experience among students in their 8^th semester [20]. This could be explained by the fact that their sample only included students in their 4^th, 6^th and 8^th semesters.

Our results showed no significant relationships between professional belongingness or any of its dimensions and gender, marital status, housing status or having a nurse family member. In line with these results, Dabirifard et al. didn ’ t find any significant relationships between belongingness and gender, marital status or housing status either [20]. Mirzaeyan et al. as well couldn’t find a significant relationship between professional socialization and marital status [32]. Furthermore, Abaszade et al. also stated that there is no relationship between gender and professional belongingness in nurses [33]. In contradiction to our findings, Mirzaeyan et al. revealed an association between professional belongingness and gender; in this relation, men showed higher belongingness [32].

In contradiction, Dabirifard et al. reported that professional belongingness was higher in individuals with work experience [20]. Moreover, in Mirzaeyan et al. study, professional socialization of nurses had a significant association with their clinical work experience during college years [32]. Levett-Jones et al. found that the duration and structure of clinical work experience was the most important factor affecting belongingness in nursing students [34]. These differences could have been resulted by the differences in work environments, which can be influential in the students’ sense of professional belongingness. Additionally, the different questionnaires used in these studies could as well be an effective factor in this regard.

The 21 years-23 years age-group got the lowest belongingness score among age-groups. Most subjects in the 21 years-23 years age-group were in their third or fourth college years, which can justify our results as belongingness is lower in the final years; it seems that this reduction in the sense of belongingness could be as a result of higher experience in clinical environments, organizational atmosphere and workplace discrimination against the nursing profession. However, in contradiction to these findings, Honda et al. reported a low level of belongingness in the age-group of 21 years-31 years [19]. According to Dabirifard et al., the 21 years-24 years agegroup received an average mean score for belongingness [20].

Conclusion and Recommendations

Considering the higher belongingness scores of freshmen comparing to other students in higher college years, we suggest the officials at the Department of Education plan for eliminating the obstacles and factors reducing the sense of professional belongingness in students and provide the necessary conditions to increase the students’ professional belongingness as college years go by. Nursing education officials can motivate the students and increase their sense of belongingness by creating a supportive educational environment, providing positive feedback, keeping the nursing knowledge up to date, creating consistency between the courses and students’ professional needs and using passionate professors.

Acknowledgments

The present article was extracted from the thesis written by Shahnaz Rowshan and financially supported by Shiraz University of Medical Sciences grants No. 13485 hereby; we thank the Deputy for research of Shiraz University of Medical Sciences for financial support. Profound gratitude and deep regards go to all students for their participation in this research.

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