Development and psychometric testing of the Belongingness Scale–Clinical Placement Experience: An international comparative study

Article Outline

• Summary
• Introduction
• Background
  • The literature on belongingness
  • Overview of the qualitative phase of the study
• The study
  • Aim
  • Method
    • Sample/participants
    • Instrument
    • Ethical considerations
    • Phase 1—pilot study
    • Phase 2—main study
    • Data preparation
  • Data analysis
• Results
  • Demographic characteristics of participants
  • Measuring and comparing BES–CPE scores
  • Demographic variables and BES–CPE
  • Psychometric testing
  • Reliability of the BES–CPE scale and Esteem, Connectedness and Efficacy subscales
• Discussion
  • Self-esteem, connectedness and efficacy subscales
  • Belongingness and English as a first language
  • The need for further testing of validity and reliability
  • Limitations
• Conclusion
• References
• Copyright

Summary 

Aim

This paper reports the development and psychometric testing of the Belongingness Scale–Clinical Placement Experience, an instrument designed to measure the extent to which nursing students experience belongingness related to their clinical placements.

Background

The need to belong is a global concept that exerts a powerful influence on cognitive processes, emotional patterns, behavioural responses, health and well-being. Diminished belongingness impedes students’ motivation to learn. Measuring belongingness specific to the clinical environment and comparing different cohorts requires valid and reliable instruments.

Method

Scales for measuring belongingness were identified following a critical review of the literature. From these a new 34-item instrument was developed. During 2006 the instrument was tested with students (n=362) from two Australian universities and one university in the south of England. Principal component analysis with varimax rotation was used to determine construct validity and Cronbach's coefficient alpha determined the scale's internal consistency reliability.

Results

Differences in belongingness scores were statistically significant, with the British cohort scoring higher than either of the Australian sites. The scale demonstrated high internal consistency (alpha 0.92). Principal component analysis yielded a three-component structure termed Esteem, Connectedness and Efficacy and each subscale demonstrated high internal consistency: 0.9; 0.82; 0.8 respectively.

Conclusion

The scale was reliable and valid for the three cohorts. Results indicated that the instrument is capable of differentiating between respondents and cohorts. Further research in different contexts would be valuable in taking this work forward.

Keywords: Belongingness, Nursing student, Instrument development, Clinical placement

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Introduction 

Clinical placements provide opportunities for professional socialisation and experiential learning; there is widespread agreement that they are of central importance to nursing education. There is evidence of a pivotal relationship between the extent to which students’ experience belongingness and their capacity and motivation to learn when undertaking placements (Levett-Jones & Lathlean, 2008). There needs to be a clear understanding of the extent to which students experience belongingness and the factors that influence this experience. This paper reports the development and testing of the Belongingness Scale–Clinical Placement Experience, designed to measure the degree to which British and Australian nursing students (n=362) from three universities experienced belongingness related to their clinical placements. Instrument development formed part of a mixed-methods international study.

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Background 

The literature on belongingness 

The evolution of the concept of belongingness over the last 60 years and its application in research has been discussed in a previously published review paper (Levett-Jones, Lathlean, Maguire, & McMillan, 2007). The nature and defining characteristics of belongingness were explored through a critical review of studies drawn from the psychological and social science literature. Belongingness is a fundamental, pervasive and universal human need. Links between belongingness and cognitive processes, emotional patterns, behavioural responses and health were identified, with evidence suggesting that people who are deprived of belongingness experience diminished self-esteem (Maslow, 1987), increased stress and anxiety (Anant, 1967), depression (Sargent, Williams, Hagerty, Lynch-Sauer, & Hoyle, 2002), and a decrease in general well-being and happiness (Lakin, 2003). At the behavioural level the absence of meaningful personal relationships appears to lead to an increase in affiliative behaviours such as unquestioning agreement with another person's decision, acquiescence, modification of behaviour or engaging in negative behaviours sanctioned by group members (Clark, 1992).

The above review raised questions about the relevance of belongingness to nursing students, and led to a review of the nursing literature to establish the extent to which the existing body of knowledge addressed this issue. The domain of staff–student relationships has been researched for many years, yet problems related to student's clinical placement experiences continue to be encountered. Indeed, the last decade has seen a plethora of reports from Australia and the United Kingdome (UK) that provide evidence of the longstanding and multidimensional nature of the problems (Department of Health, 2000, Heath et al., 2002, Peach, 1999, Senate Report, 2002). Discussions related to the importance of creating nurturing, supportive and welcoming clinical environments are not new. However, the ways in which clinical environments engender and enhance belongingness are unclear, as are the short- and long-term consequences of this phenomenon, both for the individual, for patients and for the nursing profession. The review concluded that the concept of belongingness merits further investigation, particularly with respect to a need for appropriate instruments to measure the extent to which students’ experience belongingness within clinical contexts and that allow for comparisons between different groups.

Overview of the qualitative phase of the study 

In this mixed methods study qualitative and quantitative data from three sites (two in Australia, one in the United Kingdom) were collected sequentially. In the qualitative phase a total of 18 students were interviewed to explore the factors that impact upon students’ experience of belongingness when undertaking clinical placements and the consequences of that experience; the resultant data were thematically analysed. This phase of the study has been described in previous papers (Levett-Jones et al., 2007b, Levett-Jones et al., 2009). Through data analysis belongingness emerged as

A deeply personal and contextually mediated experience that evolves in response to the degree to which an individual feels (a) secure, accepted, included, valued and respected by a defined group, (b) connected with or integral to the group, and (c) that their professional and/or personal values are in harmony with those of the group. The experience of belongingness may evolve passively in response to the actions of the group to which one aspires to belong and/or actively through the actions initiated by the individual.

Students described placement experiences that spanned a continuum from those promoting a high degree of belongingness to those provoking intense feelings of alienation. It was the interpersonal relationships forged with the registered nurses that students worked with on a day-to-day basis that exerted the single most important influence on their sense of belonging. However, students’ sense of belonging was also influenced by a range of other individual, interpersonal, contextual and organisational factors.

A number of important consequences of belongingness were identified. These included affective consequences such as feeling safe, comfortable, satisfied and happy within the clinical environment. Belongingness was related to nursing students’ self-esteem, resilience, feelings of connectedness, confidence, degree of self-efficacy, the extent to which they were willing to question or conform to poor practice, and their future career decisions. The relationship between belongingness and students’ capacity and motivation for learning to nurse emerged as a critical and recurring theme (Levett-Jones & Lathlean, 2008).

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The study 

Aim 

The purpose of the quantitative phase of the study was to: (a) ascertain the validity and reliability of the Belongingness Scale–Clinical Placement Experience instrument; and (b) measure and compare the extent to which nursing students experience belongingness related to their clinical placements.

Method 

The study, conducted during 2006, was located within three universities. Each provided a three-year tertiary program as the requisite preparation for registration as a nurse, but differed in the duration and structure of the clinical placements, the clinical supervision model and the variables of environment, curriculum, cohort size and student demographics. Third-year students were seen as the best source for obtaining information about belongingness and clinical placements, as they had undertaken a range of clinical placements. Students were informed about the study by advertisements placed on Blackboard™, a web-based platform at each university.

The Belongingness Scale–Clinical Placement Experience (BES–CPE), an anonymous online 34-item self-report instrument, was developed to measure nursing students’ experience of belongingness specific to their clinical placement. This instrument was adapted from the Belongingness Scale (Somers, 1999), based on the work of Baumeister and Leary (1995) and framed in consideration of the social support, interpersonal attachment and self-esteem literature. The development and preliminary psychometric analysis of Somers’ Belongingness Scale was undertaken in the United States as part of a doctoral project. An examination of content relevance and representativeness of the scale was undertaken by an expert panel. A cross-sectional descriptive survey of belongingness was conducted and the preliminary psychometric properties of the scale were examined. The instrument measured belongingness specific to four environments: (a) family, (b) friends, (c) work/school, and (d) neighbourhood/community. The subscale of work/school had a Cronbach's alpha coefficient of 0.94 and was deemed to be an appropriate base for developing an instrument for the current study; it was used with Somers’ permission.

In the subscale of work/school the words “clinical placement” were substituted for “work/school”, and “colleagues” for “co-workers/classmates”, thereby ensuring that the instrument was more closely aligned with the language and experiences familiar to nursing students. The content of the BES–CPE and applicability of its language and terminology for an Australian and UK study were verified by two independent researchers. Further, a pilot study tested the clarity, readability and usefulness of the instrument to ensure that it was appropriate for its stated purpose.

The BES–CPE assesses feelings, cognition and behaviours. The items reflect the major components of belongingness: Esteem (feeling secure, included, valued and respected by others) and Connectedness (feeling part of or integral to the group, being accepted, and fitting in). Items also reflect active and passive interactions, that is, what the individual receives or perceives that they receive from others, as well as the efficacious actions they engage in to either enhance belongingness or in response to belongingness.

Answer choices were based on frequency responses on a five-point rating scale, with 1=never true, 2=rarely true, 3=sometimes true, 4=often true and 5=always true. Items were written in both positive and negative terms to reduce response bias. Negatively worded items were reverse-scored. Demographic questions were included as the first section of the BES–CPE survey and covered university, academic program, age, gender, previous nursing experience, family members with nursing experience, native language and country of origin.

Ethics approval for the study was obtained from each of the participating educational institutions. An information statement explained the nature of the project and offered a guarantee of anonymity and confidentiality. Completion and electronic submission of the questionnaire were taken as implied consent.

The first stage of the instrument testing process was a pilot study conducted by sampling one data set (n=60) from site 1 (New South Wales). Forty-one students completed the questionnaire giving a response rate of 68 per cent. The purpose of the pilot study was to:

Reliability analysis revealed a Cronbach's alpha of 0.9. Although the size of the pilot study sample (n=41) limited the strength of reliability testing, there was no indication that the instrument was not rigorous and would not be appropriate for the main study.

For the main study 362 students were recruited. After responding to the advertisement on Blackboard™ and viewing the electronic survey information statement, potential participants were given the option of either exiting the system or proceeding to the anonymous questionnaire which required approximately 10min to complete.

A total of 368 online questionnaires were submitted. Six questionnaires were excluded from analysis based on a conservative criterion of having 20 per cent or more missing data. There was no discernable pattern to the missing data nor did it appear to relate to the nature of the questions.

Data analysis 

The Statistical Package for the Social Sciences (SPSS) (Version 14) was used to facilitate analysis. The psychometric properties of the instrument were analysed using principal component analysis with varimax rotation to determine construct validity and Cronbach's coefficient alpha to determine the scale's internal consistency reliability.

Analysis also allowed characteristics of the study population to be summarised through measures of central tendency (means, median and mode) and indicated how widely individuals differ through analysis of standard deviation. Data were analysed for the effect of each variable using t-test and analysis of variance (ANOVA).

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Results 

Demographic characteristics of participants 

Of the total population of third-year students across the three sites (N=844), 362 completed the survey giving a response rate of 43 per cent. Comparison of the demographic characteristics of the sample with those of the overall population using a one-sample chi-square test indicated that the participants were a representative sample.

The three universities were labelled site 1 (New South Wales), site 2 (Queensland) and site 3 (UK). The majority, or 90 per cent, of participants were women (n=322). The participants’ ages ranged from 20 to 60 years. School leavers aged 19–22 years comprised 41 per cent of participants (n=144). Mature-age students, 23 years and above, comprised 58 per cent (n=203). The majority of the participants identified Australia (47 per cent, n=162) or the UK as their country of birth (41 per cent, n=141). The remainder of the participants were from a wide range of other countries. For 8 per cent of participants, English was not their first language (n=29). The award of Bachelor of Nursing is the only nomenclature offered to Australian nursing students whereas in the UK Bachelor of Nursing, Advanced Diploma in Nursing and Diploma in Nursing are offered. The majority of the participants, 68 per cent, were enrolled in a Bachelor of Nursing program (n=244). Full details are presented in Table 1.

Table 1. Demographic characteristics of participants.

	Sample	Percenta
Sample composition (n=362)
Site 1	160	44.2
Site 2	61	16.9
Site 3	141	39.0
Academic program (n=357)
Bachelor of Nursing	244	68.3
Advanced Diploma in Nursing	82	23.0
Diploma in Nursing	31	8.7
Age (n=347)
19–22	144	41.5
23–25	44	12.7
26–30	47	13.0
31–40	67	18.5
41–50	42	11.6
51–60	3	0.8
Gender (n=356)
Women	322	90.4
Men	34	9.6
Previous or concurrent nursing experience (n=314)
Yes	189	60.2
No	125	39.8
Family members with nursing experience (n=317)
Yes	85	26.8
No	232	73.2
English as first language (n=356)
Yes	327	91.9
No	29	8.1
Country of birth (n=344)
Australia	162	47.1
UK	141	41.0
Asiab	24	7.0
Otherc	17	4.9

Measuring and comparing BES–CPE scores 

To determine the extent to which nursing students from different sites experience belongingness the mean BES–CPE scores for each item and for each site were computed and compared. Ranked mean scores and standard deviation for BES–CPE are demonstrated in Table 2.

Table 2. Mean and standard deviation for BES–CPE scores ranked highest to lowest.

r denotes that the item is reverse scored.

The highest scoring item was number 2: “It is important to feel accepted by my colleagues” (M=4.56, SD=0.62). A mean score of 4.56 indicates that the majority, or 92.3 per cent, of students selected either always true (61.6 per cent, n=223) or often true (30.7 per cent, n=111) as their response to this item. As acceptance is one of the major components of belongingness this demonstrates the relative importance of belongingness to the vast majority of students.

To item 6, “I view my placements as a place to experience a sense of belonging”, the majority of students, 61.1 per cent (n=221), indicated that they perceive their clinical placement to be an experience that should foster a sense of belonging. However, it should also be noted that a similar number of participants (n=223, 61.6 per cent), indicated by their responses to item 14r, “On placements I feel like an outsider”, that they do not experience a sense of belonging most of the time when on clinical placements. It can be surmised that although belonging is important to the majority of students, many do not experience belonging when on clinical placements and as a consequence often feel like outsiders. Noteworthy are the differences between the responses to question 14r by the participants from the three sites. At site 1 (NSW), 74.2 per cent of participants indicated that they always or often felt like an outsider; at site 2 (QLD), 62.5 per cent of participants indicated that they always or often felt like an outsider; whereas at site 3 (UK), 50.4 per cent of participants indicated that they always or often felt like an outsider.

BES–CPE scores for items 8, 12 and 26r were the lowest of the 34 items. For students who were in many respects short-term visitors to the clinical environment, it is perhaps not surprising that they kept “their personal lives to themselves” (item 26r) and were rarely “invited to social events outside of the placement” (item 8). Nor was it surprising that for many it was not “important that someone at the placement acknowledged their birthday” (item 12). While belonging was important to the students, for the most part their clinical placement experiences were limited in duration and they did not have the same expectations of clinical staff as they did of close friends or family members.

The BES–CPE scores for the three sites were analysed with a one-way analysis of variance (ANOVA), using alpha=0.05. ANOVA test assumptions were found to be satisfactory, and the result was statistically significant, F(2,355)=21.70, p≤0.001, partial eta squared=0.11. Post hoc comparisons using the Tukey HSD test revealed significant differences between site 3 (UK) and both of the other sites; with a higher BES–CPE score being achieved at site 3, for sites 1–2 p≤0.81, for sites 1–3 and for 2–3 p≤0.001.

Demographic variables and BES–CPE 

Of the demographic variables analysed in relation to students’ BES–CPE scores, gender, age, country of birth, nursing experience and family members with nursing experience were not a strong influence on students’ experience of belongingness. However, the effect of an English-speaking background was statistically significant. Independent t-tests were conducted and the mean BES–CPE score for participants for whom English was a first language (M=3.62, SD=0.42) was significantly different from that of participants for whom English was not a first language (M=3.34, SD=0.46). A statistically significant t value was found, t(354)=3.48, p≤0.001 (two-tailed). The 95 per cent confidence interval for the difference between the means was 0.12–0.44. It is also noteworthy that the mean score for item 10 (reverse scored), “I feel discriminated against on placements”, was higher for those participants for whom English was their first language (M=2.14, SD=0.93) than those for whom English was not their first language (M=2.66, SD=0.97). A statistically significant t value was identified, t(354)=2.88, p≤0.004 (two-tailed); the 95 per cent confidence interval for the difference between the means was 0.87–0.16. This indicates that participants for whom English was not their first language were more likely to feel discriminated against by the staff in clinical environments and that this discrimination has a negative impact on their experience of belonging.

Psychometric testing 

In order to better understand the underlying dimensions of the BES–CPE and to ascertain its construct validity, principal components analysis with varimax rotation (and Kaiser Normalisation) was performed on the 34 belongingness variables. There were no missing data and no outliers. Six components with eigenvalues greater than one were extracted, accounting for 54.65 per cent of the variance. Although factor solutions from three to nine components were carefully examined, the three-factor solution was seen to be most appropriate. The rotated component loadings and percentages of variance for the three-factor model are shown in Table 3. Component loadings of less than 0.3 have been suppressed to aid interpretation.

Table 3. Rotated component loadings for belongingness variables.

r denotes that the item is reverse scored.

Twenty of the variables were pure, loading onto only one factor; eight onto factor 1, five onto factor 2, and seven onto factor 3. Three items (6, 12 and 22r) cross-loaded or were poorly correlated (see Table 4). Item 6, “I view my placements as a place to experience a sense of belonging”, cross-loaded equally onto the three factors of Esteem, Connectedness and Efficacy. This is to be expected, as the three factors are each integral to belongingness.

Table 4. Poorly fitting or cross-loading items removed from the scales.

1 denotes that the item is reverse scored.

Variables loading on factor 1 seemed to be concerned with being held in esteem by one's work colleagues, for example, item 3, “Colleagues see me as a competent person”, and item 27, “It seems that people I work with on placements like me”. Those loading on factor 2 were concerned with interpersonal connections, for example, item 13, “I invite colleagues to eat lunch/dinner with me”, and item 25, “There are people on placements with whom I have a strong bond”. Variables loading onto factor 3 were concerned with efficacious behaviours undertaken to enhance one's experience of belongingness, for example, item 11, “I offer to help my colleagues, even if they don’t ask for it”, and item 18, “I make an effort when on placements to be involved with my colleagues in some way”. Thus, the subscales were labelled Esteem, Connectedness and Efficacy respectively.

Reliability of the BES–CPE scale and Esteem, Connectedness and Efficacy subscales 

Cronbach's alpha was used to measure the internal consistency reliability of the BES–CPE and each subscale (after removal of the poorly fitting items). Reliability coefficients for the BES–CPE and for the subscales were high: BES–CPE 0.92, Esteem subscale 0.9; Connectedness subscale 0.82; and Efficacy subscale 0.8.

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Discussion 

This paper has presented selected results from the quantitative phase of a study designed to (a) measure the extent to which nursing students experience belongingness related to their clinical placements; and (b) test the psychometric properties of the BES–CPE instrument. An interesting finding was the identification of a statistically significant difference in mean BES–CPE, Esteem and Connectedness scores between students from the UK and Australia indicating that belongingness varies in response to certain situations and environments and that the instrument has the capacity to discriminate between respondents and groups. The development of an instrument with the capacity to measure the extent to which students experience belongingness when undertaking clinical placements, to compare differences between group means and to measure changes in belongingness scores over time is an important outcome of the study.

The reasons underlying the differences between groups appear to be primarily related to the mentorship models and the duration of clinical placements at the different universities. These issues have been discussed in previously published papers (Levett-Jones et al., 2008, Myall et al., 2008).

Self-esteem, connectedness and efficacy subscales 

Further data analysis revealed that the BES–CPE consisted of a three-component structure named the Esteem, Connectedness and Efficacy subscales; each demonstrated high internal consistency. This result aligns with the definition of belongingness that emerged from the qualitative phase of the study.

Maslow (1987) contended that a person must experience belongingness and acceptance as a necessary precursor to the development of self-esteem. Self-esteem is defined as a set of innate beliefs, values and attitudes learned and developed through transactions in an environment that creates a self-image (Bandura, 1997). Positive self-esteem includes self-respect, self-confidence and self-acceptance. Negative self-esteem is synonymous with inferiority and feelings of worthlessness and diminished self-acceptance (Burns, 1979). In this study students’ self-esteem was not static but evolved in response to the degree of belongingness they experienced in particular contexts. A poor placement experience – where students did not feel they were welcomed, valued or accepted – often resulted in a poor self-image as they internalised the views expressed by the nursing staff with whom they worked. It appears that changes in self-esteem can be used as a criterion to judge the capacity of a clinical milieu to engender a sense of belonging. For this reason valid and reliable instruments, such as the BES–CPE, which measure both self-esteem and belongingness, are required.

According to Hagerty's et al's (1993) theory of human relatedness, connectedness occurs when a person is actively involved with another in a manner that produces a sense of comfort, well-being and anxiety reduction. An individual's experience of connectedness is dependent upon the extent to which they also experience belonging and shared commonalities in visions, goals, personal and professional values. In the present study students described how their sense of connectedness was heightened by registered nurses who willingly gave of their time to provide clinical teaching and support. Students interpreted this professional generosity and collegiality as confirmation that their student role was valid, valued and respected. They described the experience of having a legitimate role as a ‘safe place’, where they felt included, connected and secure.

The concept of self-efficacy has been discussed extensively in social psychology literature to explain motivation and learning theory. Self-efficacy is defined as a conscious awareness of one's ability to be effective in controlling actions or outcomes (Kear, 2000); and the perceived confidence for learning or performing specific tasks or skills necessary to achieve a particular goal (Jeffreys, 2004). People with high self-efficacy believe that they are capable of accomplishing their goals and are willing to pursue them in spite of the difficulties they may encounter. On the contrary, inefficacious beliefs, fostered by experiences of failure, hinder a person's willingness to persist (Bandura, 1997). Thus, self-efficacy is dynamic in nature—positively or negatively influenced by environmental experiences.

Self-efficacy is a concept that is of particular importance to nursing students. In this study the students’ accounts made it clear that their degree of self-efficacy was strongly influenced by personal traits, previous experiences and the degree of belongingness they experienced while on a placements. Like self-esteem, self-efficacy both influenced and was influenced by the extent to which students experienced belongingness. Students with a high degree of self-efficacy were more confident and capable both in engaging with the clinicians they worked with and in negotiating learning opportunities within placements.

Belongingness and English as a first language 

When examining the relationship between BES–CPE scores and demographic variables, English as a first language was the only one where there was statistically significant difference. This is an important finding as global trends in immigration have resulted in increased numbers of university students whose first language is not English (Devlin, 1996). While language is only one of the multidimensional factors that impact upon the belongingness experiences of immigrant, refugee or international students, it nevertheless acts as a useful unit of analysis.

In a study undertaken by Shakya and Horsdall (2000) that explored the experiences of international undergraduate nursing students for whom English was a second language, the strongest finding was that most of the participants experienced difficulties with various aspects of language. In particular, the participants reported problems with speaking and listening in clinical contexts. They reported negative reactions from both staff and patients, and described how this reduced their confidence and feelings of self-esteem and made them feel alienated and isolated. Local accents, shortened rapid speech, the use of colloquialisms and complex technical language can cause significant difficulties for students for whom English is not their first language and because of this they often describe feeling like an ‘outsider’ (Levett-Jones & Bourgeois, 2007).

The need for further testing of validity and reliability 

Instrument development is an iterative process requiring additional studies to support evidence of psychometric integrity. Further use of the instrument in different contexts and with diverse cohorts will provide additional evidence of validity and reliability of the BES–CPE.

Limitations 

Although representative of the student cohorts from whom the survey participants were drawn, they cannot be assumed to be necessarily representative of a larger population outside of the study contexts. Although students from a wide range of countries participated in the study, most were English-speaking women from Australia and the UK. Thus, generalisability to other countries and cultures may be limited. An additional limitation of the BES–CPE is that survey data were based on self-report. Thus, respondents may have answered in a way that they felt was more socially acceptable. However, it was anticipated that the anonymity offered by online submission of questionnaires would improve the likelihood of participants responding candidly to the survey.

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Conclusion 

The review of literature from the disciplines of social science and psychology supports the idea that human beings are social creatures and that the need to belong is fundamental, driving much of human pursuit, activity and thinking. In fact, the desire for interpersonal attachment may well be one of the most far-reaching and integrative constructs currently available to understand human behaviour (Baumeister & Leary, 1995). The study profiled in this paper has demonstrated the experience of belongingness to be a measurable construct and that the capacity to measure and compare belongingness is important in understanding the dimensions of clinical environments that are conducive to positive learning experiences for nursing students. The BES–CPE proved to be an effective data collection tool across the three sample groups and was demonstrated to be a usable, valid and reliable instrument for the study cohort. There is potential for replication studies with different contexts and cohorts and further research is required to take this work forward. Additionally, as a sense of belonging is a key indicator of success for first year university students (Leppel, 2002), future studies are planned to adapt the instrument for use with this cohort.

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