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keshmiri F, Bahramnezhad F. Belonging is an influential factor in the process of professional identity of nursing students: A qualitative study. JMED 2022; 15 (46) :1-7
URL: http://edujournal.zums.ac.ir/article-1-1626-en.html
1- Shahid Sadoghi University of Science , keshmiri1395@gmail.com
2- Tehran University of Science
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Abstract
Background & Objective: The professional identity of nursing students was defined as the primary trend in becoming a profession. The present study aimed to explore the factors affecting students' professional identity as nurses.
Materials & Methods: This Study is a qualitative content analysis from May 2019 to October 2020. The participants were contributed through purposefully sampling. Data were collected through in-depth semi-structured interviews. The duration of each interview was between 30 and 60 minutes. Interviews continued until data saturation. Data analysis was performed simultaneously with Graneheim and Lundman approach.
Results: 123 open codes with five subcategories and two categories were extracted. In the present study, "belongingness" was explained as the central theme. Two categories, "positive role model in the education process" and "The perception of the society towards the nursing profession," were explored.
Conclusion: The present results showed that the identification of nursing students is influenced by belonging influenced by the nursing community and the general community. In addition, the community’s appreciation of the nursing profession and the approval and respect for the nursing profession among the community members have been considered crucial factors for nursing students to become good nurses. Due to the importance of growing a belonging and better understanding of professional identity by nursing students in the educational period, the development of teachers’ abilities as a model and creating a platform for recognizing the professional identity of nursing among community and medical science students is recommended.

Introduction
In recent decades, professional identification has been introduced as an essential predictor of acceptance, success, and sustainability in nursing (1-3). Professional identity formation happens in professional socialization (4, 5) when students learn the required skills, knowledge, values , and attitudes to play a professional role during education (6). The socialization led to the intended or unintended outcomes of the educational process and work environment experiences (6, 7). Learners' professional identity is formed and promoted through their relationships with others, interaction in society, and interpretation of their experiences as a nurse (8, 9). In addition, socialization as a primary factor was recognized to strengthen a learner's identity to promote a professional identity. Socialization begins with the entry of people into the school and continues with the completion of the education and entry into the working environment. Through socialization, learners learn to adapt to the values, skills, views, norms, and knowledge needed.
to belong to a society, group, or organization (10, 11). Additionally, socialization facilitates the formation of learners' cognitive, emotional, and psychomotor dimensions. The socialization process shows the external image of the profession and internal recognition of professional identity (12). In other words, socialization is an approach to developing professional identity (12). Professional socialization is a complex process described by the characteristics of learning, interaction, evolution, and adaptation (13, 14). The socialization process formed learners' professional identity through training programs, role models, and constructive feedback during training and working environments (13).
Professional socialization is affected by personal, organizational, and situational factors (7). The appropriate socialization process leads to acquiring an identity compatible with professional roles, professional and organizational commitment, job satisfaction, and improving the quality of care
 (10-12). The inappropriate socialization process leads to negative consequences such as leaving the job and burnout, role conflict, loss or reduction of motivation, and satisfaction of nurses in the future (17-15). Professional identification is a process of dynamic change over time, formed by the interactions of internal factors such as emotions and motivation and external factors regarding society, recognition of the profession, and social position (18, 19). Therefore, various factors affect the identification process, including prominent and planned factors of educational curricula or hidden and unplanned factors that occur during training courses or professional work (20). Nursing concepts changed seriously during the 20th century, and nurses were not recognized as doctor’s assistants. Therefore, exploring the influential factors in identity formation and promotion among nurses is essential (9, 13, 21). Considering that professional identification is an issue depending on society's context and cultural-social factors, and educational systems, explaining this issue in different societies can help better describe the phenomenon (9). This study aimed to explore influential factors in the process of identification of undergraduate nursing students.

Material & Methods
The current study is a qualitative content analysis suitable for explaining new phenomena or perspectives. This study was conducted from May 2018 to October 2019. The present study is a part of a large study that was conducted using grounded theory qualitative research to explain the hidden curriculum influence on the socialization process of undergraduate nursing students.
Participant
The participants included 20 undergraduate nursing students in universities affiliated with the Ministry of Health and Medical Education (four universities in Tehran). Sampling was done purposefully. In order to achieve maximum diversity, students from all four universities in Tehran and different years (students from the 3 to 8 semesters of nursing) were included in the study.
Collecting data
In-depth semi-structured interviews collected data. The interviews began with open-ended questions and continued with probing questions. (Table 1). The first author conducted all interviews at the teaching hospital and college where students study. The location and time of the interviews were chosen based on the participants' suggestions.

Table 1. Interview Questions

Open-ended questions

Probing questions

  • Tell us about how you entered nursing.

  • Did you choose this field with interest?

  • How did you feel when you started this discipline?

  • Did you accept yourself as a nurse? What

  • made you recognize yourself as a nurse?

  • What factors helped you become a nurse?

  • What factors made you not like being a nurse?

  • Have you ever regretted entering this field? Why?

  • How did you feel when you entered clinical education?

  • Has a behavior made your instructor or the nurses hate nursing?

     - Why did this happen?

  • Has it ever happened that the clinical environment gave you

     - self-esteem or reduced your self-confidence? Explain

  • When you go to an internship with your clinical instructor,

      - what behaviors of your instructor annoy you? Why?

  • Can you explain more about it?

  • What do you mean when you say...?

  • Can you give an example based on your experience?

  • Is there anything else you want to talk to me

The interview lasted about 45 - 60 minutes. The interviews were recorded with a tape recorder. Data saturation is determined through the exchange of data with codes, categories, and themes formed in the research process. Sampling should continue until new data has emerged. (22). In the present study, data collection continued until a new code has not appeared.

Data analysis
The data were analyzed by the conventional content analysis method introduced by Granheim and Lundman (23). Interviews were transcribed and analyzed immediately after each interview. Data analysis was done simultaneously and continuously with data collection. The data analysis process included transcribing the interviews, extracting the semantic unit and classifying them under the compact unit, summarizing and classifying the compact unit and selecting the appropriate label for them, and sorting subcategories based on comparing the similarities and differences between them. Meaningful segments of data were identified and labeled as open code. The explored codes were compared according to differences and similarities. Then, the categories and subcategories emerged by sorting the extracted codes. The theme was extracted by comparing the explored categories.

Trustworthiness
The purpose of trustworthiness is to represent the experiences of participants. Guba and Lincoln's criteria were used for trustworthiness (24). We used various techniques to increase trustworthiness in the current study. Interviewing in-depth, peer checking by the researchers, and member checking by the participants to validate the findings were performed. Moreover, the faculty members checked the encoding process and forming of the categories (external checks). The confirmability was achieved by enrolling the participants from different professions according to maximum variation sampling. We consulted with some health profession education and social sciences experts about the accuracy of interpretations and coding process (expert checking). We precisely recorded all steps of the interview and analysis process. The initial codes were merged by constant data comparison, and we explored the subcategories and categories of the participant's experiences of the phenomena.

Results
Most of the participants in this study were 63% female students. The mean age of the participants was 11.3 years ± 3.21. 18% were married, and the participants' mean academic achievement scores were 17.21±3.1. A total of 22 interviews were conducted with 20 participants. In sum, 123 codes were extracted from five subcategories and two categories. (Table 2).
Table 2. Explained experiences of the participants
Subcategory Category Theme
Advocacy Positive role model Belongingness
Professional enthusiasm
Multidimensional capability
The general belief about the value of nursing The perception of society toward
the nursing profession
Professional dignity in society

A theme is “belongingness affected by society”; with two categories of “positive Role model in education" (support, professional enthusiasm, and multidimensional competence) and “the perception of the society towards the nursing profession”; (understanding of professional dignity in society and public belief in the value of Nursing) explored.
Belongingness affected by society was explained as the theme, which emphasizes the influence of the nursing community and the public society in forming nursing students' identities. In the nursing community, implicit and explicit behavior of teachers and their role models have formed their identity. Also, society’s valuing the dignity of the nursing profession and honoring them has played an essential role in encouraging students to form the identity of a nurse among them.
1- Positive role model in education
The participants stated that in the socialization process, an influential factor in forming interest or lack of interest in nursing students is influenced by the teachers' behavior and appearance. The teachers' behaviors, especially during the clinical education process, played a fundamental role in forming students' professional identities. The students also stated that successful nursing teachers need more theoretical and clinical education and research abilities than other professions. Professional ethics must also be manifested in the teachers because the student learns the principles of respect for the patient’s independence, confidentiality, and privacy in the teachers' dealings with the patient. The interaction of teachers and patients, whether intended or not, can significantly impact the formation of students' professional identities in the future. The students believed that the teachers' communication skills motivated them. When nursing students understand their teachers' support, they feel comfortable and play a significant role in creating their interest in nursing. The wisdom of nurses in the department can also be effective in the socialization process of nursing students. When a nurse has up-to-date knowledge and takes care of the patient based on scientific principles, it will unconsciously create an interest among the student and facilitate their professional identity and socialization process.
1-1- Advocacy
“When the teacher advocates me, I had a good feeling, I calm down, I like my field, and I say, I am a great field.” (Participant 1).
1-2- Professional enthusiasm
“A stylish and well-groomed nurse is important. The appearance of some nurses increases my self-confidence in the profession.” (Participant 3)
“My clinical teacher is very cool and organized. She is continuously up to date. When we asked a question, she searched and found it. She assured us that our profession is a discipline, not a skilled field.” (Participant 12)
1-3- Multidimensional capability
“When I understand that my teacher is knowledgeable, polite, and friendly, he professionally treats the patients, nurses, and students, it makes me interested in staying in this field and trying.” (Participant 19).
“We have a nurse who knows seems as a doctor in the department, all trusted her and was involved in the decision-making process in different fields such as the nurse’s office, doctors, patients, and students, everyone consults with her.” (Participant 8)
2- The perception of society toward the nursing profession
The second category explored in this study explored the perception of society toward the nursing profession with two subcategories of “public belief about the value of nursing”; and “professional dignity in the society.” The participants in this study stated that the perception of society toward nursing affected their acceptance of the nursing profession. In fact, before entering the profession, the nursing student did not pay attention to the recognition of this profession by the counselor or other nurses and explore the nurse's role in society. The dignity of the profession, both in society and the clinical environment, has directly or indirectly affected the students’ socialization process. The participants stated that professional and unprofessional observations, interactions, and enthusiasm toward nursing among teachers had contributed significantly to nursing students' acceptance and socialization process.
2-1- General belief about the value of nursing
The third-year student stated, “I liked this profession because I found the respect for nurses. My neighbors spoke of our neighbor’s daughter, a nurse, and respected her.”
Nursing is a profession, and you always understand that people in the community and on TV are talking about it. I think that nursing has a significant role in the healthcare system. I realized that one of the main deputies in healthcare Ministers is the nursing deputy. This means that Nursing has a high professional prestige”. (Participant No. 11).
“A person should care about his career and improve his capabilities is very important in accepting others. When I see that my teacher cares about himself and that the field is important to him, or when I see a nurse updating herself, I subconsciously become interested in nursing.” (Participant 19)


Discussion
Belongingness affected by society was explained as the theme. This central concept includes two categories, positive role models in the education process and society's perception of the nursing profession. The social factors, such as teacher and their role models and society's value viewpoints toward the nursing profession, influence their sense of belonging and are explored as the main factors in their socialization process.
In this study, belonging was explained as an influential factor in identifying nursing students. Belonging is a personal and context-dependent experience that forms in response to how much a person feels safe, accepted, respected, and valued by the group. Belongingness is defined as the need to be and the understanding of the importance of belonging to others at different interpersonal levels. The connection and integration with the group and the understanding of the harmony of personal values with the professional values of the group affected the belongingness of nursing students (25, 26). In line with the present results, Simmonds’ Study introduced belonging as an essential factor in the identification process in the nursing profession (27).
In line with the present results, Wang and colleague recognized clinical environment, atmosphere, organizational culture, and interpersonal relationships as the main factors affecting social belonging (28). In Jarvis-Selinger’s Study, professional identification was defined as an adaptive development process that coincides on two levels. The individual level includes individual psychological development, and the collective level comprises the socialization of people to play appropriate roles and the formation of their participation in society (29). The current results showed that the identification process of the participants was more dominant through societal valuation. The participants believed that society's perspectives on nursing as a valuable profession and the nurse’s professional dignity have led to the growth of their belonging to this profession and have encouraged them to be and stay as nurses. In our study, from the student's perspective, the social level is critical in their identification process, which can be caused by organizational culture and class distinction. Social communication was introduced as an influential factor in nursing students' belongingness (30). Alharbi et al. have addressed the role of social media in the professional identity of nursing students. This study showed that students used social media to learn about the nursing profession and develop a sense of belonging to the nursing profession. Students also used social media to share their experiences as nursing students and increase the community's understanding of the importance of the nursing profession. This study explained three main categories of learning, including learning related to the professional identity of nurses through social media, acceptance of nursing identity and sharing among students, and understanding of the professional identity of nursing through social media were explained. They believed that undergraduate nursing students should be encouraged to develop their professional identity through socialization, which impacts the development of society’s understanding of the nursing profession and better identification of students. Social media facilitated the process of socialization of undergraduate nursing students by connecting them with members of the nursing community (31). In the current study, the socialization of the learners was influenced by the society that values the nursing profession, and the community's awareness about the role of the nursing profession in the health system is essential in this process.
Teachers have been introduced as influential in accepting the profession, understanding professional responsibilities, and adhering to its principles (32). In line with the present study, the students believed that belonging to the nursing profession was more influenced by their teachers. Professional enthusiasm for the profession, scholarship perspective, and supportive behaviors as role models developed a sense of worth among them. Wang’s review also showed that teachers' behaviors as role models in the clinical education environment influence nurses’ belongingness (28). In this study, the training course in nursing has been introduced as a turning point in recognizing and creating belongingness in the nursing profession. In a grounded theory study, Baldwin and colleagues explored the role of teachers as role models in identifying nursing students. Three categories of creating a context for learning, creating a context for practice, and reflecting on identity were explored in their study. Their results indicated that the influence of role models in the interactions with nursing students who learn and imitate the behaviors of the role model is essential, and it affects their performance in the work environment and their intention to stay in the nursing profession (33). Role models and mentors influenced learners in two paths. Firstly, learners consciously acquire the necessary knowledge through observation, imitation, practice, and reflection. In the second path, learners learn indirectly from role models and teachers, which is recognized as learning tacit knowledge (34). Thus, teachers' implicit and unconscious behaviors significantly impact the identification of learners, which should be taken into account (34). The present results showed that the teacher's behavior and enthusiasm for the nursing profession affected students' identification process. Also, the teachers' scientific mastery and professional ability were explored as influential factors directing them to belong to the nursing profession. Levett-Jones's study showed that belongingness is influenced by various individual, interpersonal, contextual, and organizational factors. In this study, belongingness has been introduced as an individual and context-dependent experience, and interpersonal relationships between students and nurses are the most important factors affecting students’ sense of belonging (35), which is inconsistent with the present results. In the current study, the role of society and teachers were introduced as essential elements in the identification process.
The current study discussed the positive aspects of nursing students' professional identification. It is suggested to explore negative or inhibiting factors in future studies. It is also suggested to explore the experiences of the socialization process from the viewpoints of clinical nursing teachers and nurses with different working experiences.
Limitations
Since the researchers were faculty members, many students were afraid that their words would be told to the teacher and this would interfere with their educational process, so the researcher tried to talk to and assure them of the confidentiality of this information. Of course, some students have not expressed some of their experiences due to this fear or the common cultural compliments in the country.

Conclusion
The results showed that the identification of nursing students is influenced by the sense of belonging to the nursing community and the general society. The participants believed that implicit behaviors of teachers, such as professional enthusiasm and advocacy of teachers, as well as explicit behaviors, such as professional mastery and competencies, have led to better acceptance of the nursing profession. Moreover, society values the nursing profession, and the community's recognition and respect of the nursing profession are explored as essential factors for nursing students to be encouraged to become a nurse. Considering the importance of developing belongingness and a better understanding of professional identity by nursing students during their education, it is recommended to develop teachers' abilities as role models and create platforms for recognizing the professional identity of nursing among society and students in different professions in universities of medical sciences.

Ethical considerations
The ethics committee has approved the present research of the Tehran University of Medical Sciences (ID: IR.TUMS.VCR.REC.1397.852). The goals and methods used in the research were fully explained to the participants. The participants were assured of confidentiality and anonymity. In addition, the purpose of using the audio recorder was explained to the participants. They were assured that participation in the research is optional, and they have the option to withdraw from the study.
Conflict of Interests
The authors have no conflict of interest in any research stages.
Acknowledgment
This Study was supported by the Tehran University of Medical Sciences. (ID: 97-03-214-39337). The authors express their gratitude to this Education Development Center and the students participating in this study.

 

 

 

 

 
Article Type : Orginal Research | Subject: Medical Education
Received: 2022/06/12 | Accepted: 2022/09/5 | Published: 2022/09/16

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