Hui-Ping Wang,Chang-De Jin

1Graduate College,Tianjin University of Traditional Chinese Medicine,Tianjin,301608,China;2 School of Nursing,Tianjin University Traditional Chinese Medicine,Tianjin,301608,China.

Abstract This paper reviews the published literature according to the Arksey and O’Malley’framework in order to determine the factors that influencing factors of nursing interns' belongingness in clinical nursing.Five influencing factors were extracted from 11 included studies:nursing students themselves,clinical teacher,clinical placement environment,relationships with patients and their families.

Keywords:Nursing students,Clinical placement,Belongingness,Scoping review

Introduction

Clinical belongingness refers to the experience in which medical personnel are accepted and an individual's profession and values are in harmony with the group[1].Clinical practice promotes the development of experiential learning[2-3]and provides nursing students with opportunities to apply knowledge theory to clinical practice[4-6].Clinical practice period is important for students to be professional nurses[7].In nursing,belongingness has been proved to be a key factor affecting the quality of clinical practice[8].It has been confirmed that students with higher belongingness attach more importance to learning,and have stronger motivation for learning and stronger desire for success[9].However,the lack of belongingness will hinder students' motivation to learn and affect their willingness to practice in clinical practice which makes it impossible for them to maintain critical thinking and reflective attitude towards medical practice[10-11].

Nowadays,domestic and foreign research shows that the belongingness plays an important role in the nursing students in clinical nursing,and the improvement of the clinical internship of nursing students needs to be resolved.Therefore,we reviewed literatures on the belongingness of nursing students in clinical nursing and summarized the factors influencing the nursing belongingness.And further puts forward some suggestions to improve the belongingness of nursing students in clinical practice.

Materials and methods

Arksey and O’Malley(2005)'s scope review method framework was adopted,which was divided into five steps.In the first stage,research problems should be clarified.The second stage was to determine the relevant research.In the third stage,the target literatures were selected.The fourth stage was data extraction.In the fifth stage,the results were juxtaposed,summarized and presented[12].

Identification of research question

This review focuses on the factors influencing the belongingness of nursing students.The guideline for research question was "what factors are involved for belongingness of nursing students in clinical nursing in the study?”In this paper,the sense of belonging was defined as a kind of experience in which nursing students were accepted and respected by the group in the clinical environment,and their personal expertise and value were in harmony with the group.

Searching strategies

The data were searched in PubMed,EMbase,The Cochrane Library,Web of Science,CINAHL,Wanfang Database,China Knowledge Network(CNKI),VIP database.The retrieval time was from the establishment of the database to October 25,2018.The retrieval method combined subject words with free words.Search the foreign database with the keywords"pupil nurse*OR nursing student*OR nursing education*" AND "belonging*OR belongingness*OR perception of affiliation"AND "clinical placement OR clinical*OR internship*OR practice*OR exercitation*";The Chinese database used "nursing student"AND“belongingness" as search terms.In the end,a total of 339 literatures were retrieved,and 40 duplicates were removed,resulting in 299 literatures.

Literature Selection

Inclusion criteria:(1)language was limited to Chinese and English;(2)all studies were included that related to the influencing factors of belongingness of nursing students in clinical nursing.

Exclusion criteria:(1)duplicate publication;(2)a summary of the meeting or literatures not available in full;(3)general review.

Two researchers independently screened the literatures according to inclusion and exclusion criteria.If the two researchers disagree,consult the third researcher.By reading the titles and abstracts of the articles,irrelevant researches which were not involved in the belongingness of nursing students in clinical nursing were removed.There were 23 articles met the initial inclusion criteria.The full texts were browsed and a variety of articles which had no records or measures of the belongingness of nursing students were eliminated,and the number of articles was reduced to 10.The references of all the included articles were also thoroughly explored to search for any additional papers discussing the belongingness of nursing students in clinical nursing.In the end,10 related articles were finally collected in this study[13-22].

Data extraction

Data were extracted by 2 researchers independently and collated later.If there was any disagreement,the third researcher was consulted to assist in judgment.The detailed items of data extraction were as follows:(1)the basic characteristics of qualitative data included first author,publication time,research object,country of study object,sample size and data collection method;(2)the basic characteristics of the quantitative data included the first author,publication time,research object,country,sample size,and research tools;(3)influencing factors:extracted from the research results.

Presentation of the results

The basic characteristics of the included studies are shown in Table 1;the literature quality evaluation is shown in Table 2 and Table 3;the influencing factors are shown in Table 4;explanations of the findings are presented in the discussion section.

Results

Search results

339 researches were obtained in the initial examination,and 40 duplicates were removed.After reading the titles and abstracts,276 researches were excluded and 23 were included.After carefully studying of the full texts,the final inclusion was 10 researches.As shown in Figure 1.

Basic characteristics of researches

10 researches were from five countries,including 4 from developed countries and 6 from developing countries.The most common data collection methods included interview and scale evaluation,and the most common used scale in quantitative research was Belongingness Scale-Clinical Placement Experience.The study included 844 participants,ranging from 10 to 389.The included literature types included 7 qualitative studies and 3 quantitative studies,as shown in Table 1.

Quality evaluation

Figure 1 Flowchart of literature search

Qualitative literature quality evaluation

This study included 7 qualitative research literatures,including 3 Chinese literatures and 4 English literatures.The results showed that only one of the included literatures had an inconsistent methodology and interpretation of the results,at the same time,its conclusion does not come from the analysis and interpretation of the data[13].Only one article explained the researcher's own situation from the perspective of cultural background and values[18](Table 2).

Qantitative literature quality evaluation

A total of three quantitative studies included in this study were all in Chinese.The results showed that all the research design elements were stated in the included literature.Only one document did not describe the study site,the specific site of data collection,and the time frame[20].Only one article explained the method of determining sample size[22](Table 2).

Factors influencing the belongingness of nursing students in clinical nursing

Table 1 Basic characteristics of researches

The literatures included in this study were summarized.The results showed that the factors influencing the belongingness of nursing students in clinical nursing mainly included the nursing students themselves,clinical nursing environments,managers and clinical teachers,Patients and their families.The detailed influencing factors of the summary of each article are shown in Table 4.

Discussion

Reasons for nursing students themselves

In this study,7 literatures pointed out that the characteristics of nursing students themselves were the internal influencing factors of their belongingness in clinical nursing[13-17,19,21].Yang's study found that nursing students with local residence had a higher belongingness in clinical nursing than nursing students from other places,analyzing the reason may be that interns from other places had to bear more loneliness,homesickness and the regional differences made it more difficult for them to integrate into the work environment[21].Therefore,we should pay more attention to the psychological needs of interns from other places.At the same time,we should give them enough care and help to relieve anxiety,in order to promote them better integrate into the clinical nursing.

The belongingness in clinical nursing of nursing students is positively correlated with their initiative and adaptability,however has a negatively correlated with their dependence[14].In clinical nursing,the initiative and adaptability of nursing students should be actively mobilized and more guidance should be given which can enable them to consciously learn nursing knowledge.Only with the improvement of enthusiasm and adaptability can nursing students be fully integrated into the study and work of clinical nursing.At the same time,through our analysis of the literature,it is not difficult to find that some interns do not like the nursing profession very much after entering the clinical practice,even full of boredom and resistance to the clinical nursing.Compared with the previous expectations of nursing profession in school,their mentalities are quite different.For a time,they may not fully accept the reality[23].As a result,the adaptation and transformation of nursing students'roles during the internship could not be carried out smoothly and it became very difficult for nursing students to integrate into clinical nursing[24].Therefore,educators and administrators should guide nursing students to establish a correct professional viewpoint.For example,before arranging nursing students to enter clinical practice,the school should guide nursing students to have a correct view of career value,so that they can clearly define their own position;nursing students should strengthen the cultivation of overall quality and constantly improve their ability to make adequate preparation for clinical practice.

Clinical nursing environments

Five literatures pointed out that clinical nursing environment plays a key role in the belongingness of nursing students[13,16-17,19-20].Many scholars suggested that a supportive and nurturing environment should be established for nursing students,so as to promote the compatibility between nursing students and clinical practice environment[25-26].The study found that the level and resources of the hospital were positively correlated with the belongingness of nursing students.In this case,the school should select excellent hospitals for nursing students.The superior hospitals should be the first choice,in order to lay a good foundation for the clinical nursing of nursing students.

The working atmosphere of the department also plays an important role in the internship process of nursing students[16].If the department atmosphere of the internship is good,nursing students will feel that they are in a harmonious "big family".This kind of harmonious and friendly department atmosphere will make them like their career very much.Therefore,managers should guide department staff to create agood working atmosphere and strengthen ideological education of department staff,so as to form the cohesion of their own department.

Table 2 Qualitative literature quality evaluation

Table 3 Qantitative literature quality evaluation

Table 4 Influencing factors

Managers and clinical teachers

In this study,8 literatures indicated that managers and clinical teachers had important influence on belongingness of nursing students in clinical nursing[14-19,21-22].The lack of emphasis on clinical nursing education and effective communication is an important reason for the low belongingness of nursing students during the clinical nursing[27].As a new clinical intern,facing unfamiliar environment and pressuring from department assessment and nurse-patient relationship,etc.,nursing students need to feel accepted,recognized,supported and loved particularly[16].The popularity of nursing students can increase their sense of identity,so that they will feel respected and put more effort into clinical nursing.

In clinical practice,nursing students encountered teachers who had a significant impact on their learning and future career decisions[28].Therefore,the choice of clinical teachers should be especially careful[29].Hospitals should educate and train clinical teachers so that they can better educate students in the clinical environment and convey the correct profession value[30].Nursing students expect clinical teachers not only have solid professional quality,pedagogical knowledge,organization and coordination ability,but also have good professional personality characteristics[31].Teachers should accept,tolerate,approve,appreciate and support nursing students to improve their belongingness in clinical nursing.If the teachers do not provide enough support and help,the clinical belongingness of nursing students will be seriously affected[32].At the same time,teachers should play a leading role.Walker et al.[33]believed that a good role model was crucial to the cultivation of nursing students' professional identity.After entering clinical practice,nursing students spend most of their time studying and working together with their teachers whose influence on nursing students is imperceptible.Therefore,clinical teachers should play an exemplary role in helping nursing students to establish a correct professional outlook for future clinical nursing.

Patients and their families

Two literatures pointed out that patients and their families were another important factor affecting the belongingness of nursing students in clinical nursing[14,17].The interaction between nursing students,patients and their families have a positive or negative impact on their belongingness.Good communication is the premise between nursing students and patients,and the empathy ability of nursing students is the breakthrough point to maintain a good nurse-patient relationship[34].When facing patients,nursing students should have empathy and think about something from the patient's perspective,which is an effective way to integrate clinical nursing work quickly for nursing students who just leave school and start to get involved in clinical practice.

Because of the pain and distrust of the interns,patients and their families may refuse the nursing students to operate or put forward more demanding requirements.Meanwhile,clinical teachers should actively reconcile the relationship between nursing students and patients.Clinical teachers should look for opportunities to help nursing students operate and encourage nursing students to avoid being discouraged.Nursing students should constantly improve their own clinical techniques and improve the success rate of nursing operations.

To sum up,the belongingness is not only an important clinical nursing education problem but also the key to solve the problem[35].The belongingness is an important factor affecting workplace satisfaction,and workplace satisfaction is a key determinant of career decision making,which is crucial to the future development of nursing students[36].We should pay attention to the improvement of nursing students'belongingness in clinical nursing.The increase of the belongingness can make nursing students have a good experience in clinical nursing.They will be more active and enthusiastic in their own practice,and have full confidence in their future development in nursing.Only when the belongingness of clinical practice of nursing students is improved,can they better integrate into nursing work and find problems in work.In this way,they can maintain their critical and reflective attitude towards medical practice,instead of mechanically repeating the daily work with the mentality of completing tasks.When nursing students are regarded as important stakeholders rather than consumers of clinical education in the clinical nursing,the nursing career can be better developed.

Abbreviations

CNKI,China Knowledge Network;BES-CPE,Belongingness Scale-Clinical Placement Experience;GBS,the General Belongingness Scale;SCS,Social Connectedness Scale;SES,Self-esteem Scale;SHS,Subjective Happiness Scale;SWLS,Satisfaction with Life Scale.

Acknowledgments

None.

Competing interests

The authors declare that there is no conflict of interests regarding the publication of this paper.