Sense of Belonging and Evidence Learning: A Focus Group Study

: A sense of belonging is a prerequisite for the professional and clinical success of nursing students. The objective of this study was to elucidate whether students’ participation in projects oriented toward translating knowledge into clinical practice promoted a sense of belonging and assisted with their integration into clinical practice services. Fifteen students were distributed into two focus groups, and the study was carried out by means of a semi-structured interview script using the research question as a starting point for directing the discussion toward more speciﬁc topics. Qualitative analysis followed a predeﬁned protocol. WebQDA ® software was used to organize and analyze the ﬁndings, as well as to increase their rigor. The study design was approved by an ethics committee. Three categories related to belongingness emerged from the data analysis: integration, participation, and collaborative work. Belongingness was a central element for integrating students into services, and it inﬂuenced their clinical education, their motivation, and the quality of their experience. It also allowed them to learn about evidence, communicate science, carry out evidence-based practice, and develop competencies. Concurrently, student integration was facilitated by the sharing of knowledge between professors and nurses, and the existence of ongoing work with clinical practice services.


Introduction
The literature suggests that the need to belong influences health and well-being, as well as the behavioral, emotional, and cognitive responses of nursing students [1]. In Portugal, 50% of the nursing course load is designated to internships. This educational modality is a key period for learning nursing care and improving students' knowledge, attitudes, and competencies in evidence-based practice [2,3]. Some authors have claimed that education about research and the use of scientific knowledge becomes more pronounced when incorporated into this type of instruction, allowing both integration of theoretical knowledge into practice and contact with research projects that originated in clinical contexts [4,5]. This motivates students to engage in relevant research activities so that high-quality health outcomes are guaranteed [6].
Belongingness is described as the need for, and perception of, being involved with other people at different interpersonal levels. It is a necessity for self-esteem, which contributes to each person's sense of connection. However, from the nursing students' perspective described in the literature, it is clear that they are often overwhelmed by the magnitude of the environment that surrounds them in the healthcare context. Despite this difficulty, they have to integrate and belong [7,8].
Developing scientific competency implies acquiring and consolidating a minimum set of characteristics, knowledge, skills, and attitudes, all evidence-related, that contribute toward safer, better, patient-centered care [4,9,10]. The results of previous studies have suggested that relationships that support learning are fundamental to nursing students feeling that they have a place in their teams; this includes not only supervisor-student relationships, but also a sense of belonging to groups within the clinical contexts in which their internships occur [1][2][3][4].
The literature indicates that students who are supported and received with a positive attitude by their service's teams will support one another and feel included, which decreases feelings of isolation. In addition, they have a lower chance of experiencing feelings of incompetence, they are more available to cooperate in proposed activities, and they show more initiative and autonomy [1][2][3][4].
Some studies have pointed out that a lack of meaningful interpersonal relationships often proves to result in a difficult experience that impacts the students' ability to become proficient. Consequently, it is an obstacle to the development of clinical skills during higher education [1,7,8]. Therefore, it is clear that a feeling of belonging is a prerequisite for the professional and clinical success of nursing students [1].
The issue of belongingness is important, not only for the students, but also for the health professionals. A Finnish study with frontline and middle managers who developed activities in social and health services identified six categories of factors that promote a sense of belonging (open interaction; effective conversation culture; support and encouragement; common values; shared views of work and its objectives; and leadership structure), and five categories of factors that hinder it (negative work atmosphere; lack of common time; structural solutions in organizations; organizational problems; and problems related to leadership and management) [11].
Similar to what happens with professionals, for students who cross the borders from school into clinical practice and go into the settings in which they will have their internships, it is important that this sense of belonging is available in order to facilitate their learning and their personal and professional development. However, this creates a requirement that both the professors and the nurses who act as their clinical supervisors promote environments in which students feel safe and can develop the emotional bonds that allow them to express their concerns, fears, and anxieties and seek the necessary support [12]. Consequently, the challenge for clinical nursing educators may not lie in enhancing the students' experience of belonging in the workplace, but in keeping a critical and reflective approach to healthcare practice [13].
The authors share the strong belief that belongingness is a prerequisite for clinical education, and that the reformulation of the clinical learning experiences of nursing students by means of a "belongingness lens" provides a new perspective and reveals perceptions that are yet to be explored [8]. However, ensuring students feel a sense of belonging to the teams where their internships take place, and providing them with varied and active learning experiences that allow them to learn about evidence in the clinical context, are challenging tasks.
The objective of the present study was to elucidate whether students' participation in projects oriented toward translating knowledge into clinical practice promoted a sense of belonging and assisted with their integration into clinical practice services.

Study Design
The focus group (FG) method was chosen to answer the research question "What is nursing students' perception regarding influence of the sense of belonging on their learning experiences in projects oriented toward translating knowledge into clinical practice?" The justification for this choice was through the recommendations of authors who have observed that this method allows a mixture of perspectives and opinions by means of group interactions [14]. The FG method is indicated when the topic has been little explored in studies and/or the specificity of the group's experience can be used as a source of knowledge about a situation, due to its ability to promote discretion, attribution of meanings, and reflection on events [14][15][16].
A literature review allowed the identification of studies on the importance of a feeling of belonging for students' integration into clinical settings, learning, and development of competencies. It indicated that the specific matter of development of learning experiences and scientific skills for the incorporation of evidence into clinical practice has not been addressed. This fact justified the present study, the choice of its method, and the decision to employ two focus groups to deepen the discussion.

Participants
The eligibility criteria for the participants in the present study were: being senior students enrolled in nursing courses oriented toward training professionals to develop teaching activities, who did their last internship (fourth year, second term) in one of the institutions that had a partnership with the project entitled "Safe Transition: A Knowledge Translation Project"-which is a collaborative initiative that includes one hospital, one nursing school, and primary care units in the region of Lisbon and the Tagus Valley in Portugal. During their five-month internship, the students had the option to participate in the knowledge translation project as an extracurricular activity.
Sixteen students were selected, of whom 15 agreed to participate. These were divided into two focus groups (FG1: n = 8; and FG2: n = 7), in accordance with the recommendation that the total number of participants should be between 5 and 10 [16].

Data Collection
A script was written to enable semi-structured interviews, with the research question as a starting point. Its objective was to address specific questions [14,16] related to the experience of participating in the Safe Transition project, integration into teams, and learning about evidence. The script was evaluated by the research team [17].
When the term began, the students were informed that, after their internship grades were released, they would be invited to participate in an FG. Face-to-face contact was established 15 days before the day scheduled for the meeting, and e-mails were sent with information about the study objectives, the estimated duration of the interview (75 min), and the identity of the moderator and co-moderator [16].
The two FGs were carried out during the first week of August 2019 and were recorded. The room in which the discussions took place was prepared for the event, not only to guarantee ideal conditions for videoing, but also to create a warm environment and ensure the confidentiality of information [16].
In the e-mails and at the beginning of the FG meeting, the participants were informed of the study objectives and the rules for participation, including the estimated duration of the meeting (75 min), in order to avoid early withdrawals during the group discussion [17]. The students were reminded of the names of the moderator and co-moderator.

Analysis
The video was subsequently watched and transcribed by the moderator of the two FGs [14,17]. Qualitative analysis followed the steps for codification of category attribution, storage/retrieval, and interpretation [18]. Rigor, representativeness, completeness, homogeneity, and pertinence were guaranteed in the category definitions.
WebQDA ® software was used to organize and analyze the findings and increase rigor. Free codification was carried out by the researcher responsible for the transcription, and then validated by the other researchers.

Ethical Considerations
The ethical principles guiding this type of study were observed in all phases. The design was approved by a research ethics committee under report no. 09/2019 HVFX.
The researcher-in-charge managed all of the collected data, always ensuring participant anonymity and data confidentiality. Sociodemographic variables that could allow the participants to be identified were not used at any time. Anonymity was guaranteed by assigning a code to each participant (P1, P2, P3, . . . ).
The participants signed free and informed consent forms after receiving an e-mail describing the study objectives, an explanation of the purpose of their participation, and the average time that was expected to be spent during the meetings. The principles of autonomy, non-maleficence, beneficence, equity, and informed consent were met. Additionally, the participants could decide to withdraw from the study at any step in the process, with no need to justify their exit, no implied responsibility, and no losses of any kind.

Results
The average age of the 15 participants was 21.9 years (±2.1), and 12 were women. One student had completed their internship in primary health care, three in a medical service, three in an orthopedics service, four in intensive care, and four in emergency services.
Three categories related to belongingness emerged during the FG content analysis: integration (with 32 registration units), participation (with 38 registration units), and collaborative work (with 50 registration units).

Integration
The students indicated that their participation in the project oriented toward translating knowledge into clinical practice favored their integration into the services in which their internships occurred. The existence and scope of the project-introduction of the results of clinical research into clinical practice-promoted coordination between the nursing school and the services, with the professors and nurses being involved in different activities in which the students engaged. The close relationships and joint definition of what was expected from the students facilitated their integration, as shown in the excerpt below: I think my colleagues have already mentioned that the nurses quite often asked what we were doing, which was an opportunity to start a conversation and also talk a little about other things, including the internship, and even have a chat, which helps us feel good in the workplace, ( . . . ) my colleagues and I had more contact with the whole team, which would not have happened if we were not involved in the project. (FG2, P1) By comparing their participation in this project with their other clinical experiences, they perceived differences in how they were integrated into the former, for a number of reasons.
They made us comfortable, offered help, the team heads themselves came to talk to us, and we could integrate more quickly. Yeah, this effect also happened for medical students. The fact that there are usually students developing activities made people accept us more quickly. It seems that there was another level of interest in us, like if we were more than just students, who are a handful and take more time to do stuff. (FG2, P5) In comparison with other services, I have never communicated with team heads or head nurses as much as I do here, as in this internship, and this is because of the project, because most of our conversations focused on this subject. (FG2, P6) In addition, it was always a topic of conversation at the beginning of the relationship, especially because the people at the service already knew what we would do in the context of the project. They repeatedly asked how the research was progressing, what results we had. Even at the beginning, when we were still were very reserved ( . . . ), and I think it was, I think it at least helped create some relationships so that awkward silence, which occurs sometimes, did not exist. It is embarrassing and makes us feel uncomfortable. (FG1, P6) Being available to answer our questions and clarify some points, sempre OK, always explaining how it works and how they do things here. We also shared our own ideas, what we thought could be done, we could share these ideas. They were available to talk and share things with us. I think this is also very important. (FG1, P1) The advisors are not always involved in the tasks in which we are engaged in the project, but they seem prepared to make us move on. (FG1, P4) My nurse advisor was keeping up with the project, he knew what the main objective was, but was not very aware of the details. He was always available if I had a question or needed anything. If he did not have good knowledge about the topic, he would resort to other nurses that could help. For instance, you mentioned evidence. I had a question about levels of evidence, and my nurse advisor did not know the answer to it. He immediately asked the specialist at the service, who had taken a course not long ago. And he always tried to help, even if it was just this way, by asking who could help me with some things. (FG2, P7) The integration process was facilitated by the existence of parallel topics of conversation within the project itself, which caused the students to work side by side with the professionals, easing any power relationships in the professional-student pairs, which became a success factor for the adaptation of the students into the teams. Support from professionals promotes the development of self-confidence, and is the basis for a feeling of well-being. It emerged as the first step toward the development of a sense of belonging.

Participation
The close relationships established during the process of integration seemed to be the driving force behind successful integration, which increased the opportunities for the students' greater participation in activities, meetings, and decisions related to the project, as well as in the activities required for the fulfillment of their internships.
Participation in the project was described by the students in the two FGs as follows: We had to take the initiative of speaking, asking questions, asking for help and guidance.
(FG2, P3) Quite often we were the ones to inform the nurses and other students about what was going on in the projects, we were approached about this several times. (FG2, P1) We often had to talk to the other members of the team to ask for things, but it improved our relationship with them, even with the medical team. (FG1, P3) The active role of the students in both the execution of the activities and the need to negotiate the decision-making for the tasks in progress blurred the usually well-defined student-health team barrier: We had to meet with them with a specific purpose, we had to make a presentation about the project to the physicians, the medical team, and I don't know . . . I think that they ended up seeing us more like part of the nursing team rather than students specifically. (FG2, P5) I think so, I for one feel so. Thinking about my internship, I can say that my nurse advisor was on many shifts in her team, but she was also on many shifts with other teams, and I also felt that the other team heads approached us to find out which information was available and which was not, or what had not been done. Even in the same team, there were some students more involved in the project than others. Still, they wanted to bring in a little bit of their experience, contribute, and evaluate the situation, and this allowed a close relationship and special work with the teams, even with the head nurses, who usually do not even know the students in their service. I had to talk to the head nurse several times because of the project, and she herself would come to us to get informed and ask questions, which also creates a more comfortable environment. (FG1, P6) And being part of the solution, and this is different. In the other internships, we are the problem, not the solution. It is not that we are really a problem, but we mean a lot of work, the nurses spend time with us, some people even say that they do not know why they accept EE since it is harder work, and here we actually come up with solutions. As someone just said, we were part of the team, not the students that get in the way!. (FG2, P4) The opportunities for greater involvement in the services, the dynamics, and the decision-making promoted other learning opportunities for the students and increased their sense of usefulness: Even because of the fact that we are students, there are a lot of things in which we do not participate in the service, and we end up having the possibility of participating in certain activities. I do not know what your experience was, but we had the opportunity to participate in an active life appointment, and at the end the nurse even asked our opinion about things that maybe we could remember and they could not, maybe they would not remember them, until we were involved and they counted on us in the service. (FG1, P3) But the question of them involving us in the making of the videos was actually very good, it was a way for us to feel useful, even other things in the service, not just, for instance, what we can do such as the flyers and stuff, which they asked, me at least, and it was very good, it was a way for us to see ourselves involved in the team, in the project, to feel that we were useful. (FG1, P1) The nurses had to have this willingness so we could participate, and my nurse encouraged me and gave me feedback . . . I also got feedback from my advisor, and it was important for me to know that I was doing a good job. There was a concern about not losing time, being able to be part of the project, and fulfilling the internship goals. (FG1, P7) According to the perception of the students, the participation opportunities were directly related to the project and the need to meet its necessary demands in order to achieve the goals for a certain step. Other opportunities came as a result of that. Active participation, and the challenge posed by other opportunities, motivated the students to learn, and created in them the notion of their usefulness and ability to contribute to the development of care practices within the service.

Collaborative Work
The FGs confirmed that the methodology of involving students in the project oriented toward translation of knowledge into clinical practice created opportunities for collaborative work with the nurses and other members of the multidisciplinary team: Additionally, some nurses who would not come to talk to us because they belonged to other teams actually talked and established close relationships. There were these situations in which we even interacted with head nurses, who were truly interested in asking. And I believe that, in our case, the fact that the project was a pioneer initiative also opened doors to us, because we ended up working with some nurses and this provided some continuity, there were things the nurses did not know, there were other things they knew but they were not sure if it was the best evidence, especially because they were so used to doing things certain ways that they do not question. The fact that they saw us answering questions based on evidence made them consider us members they did not want to lose. (FG2, P6) Teamwork improved even among the students. At least that is my perception. For instance, sometimes we got together to talk and search for information about the subject, and sometimes the activities and shifts did not coincide. Consequently, during these meetings we also exchanged information and shared what we knew with one another. There was a lot we did not know, even regarding education for sick patients and families, we had to search and share information. There were many topics that would not have been as deepened as they were if it were not for the project. I also think that, without the project, we would have talked less with one another. (FG2, P4) We had an opportunity to participate in the first stages of what can be considered a more professional context. We hold meetings at the nursing school with professors, the student council, but it ends up being very different from the professor-student relationship. In this case, it was a more professional meeting, with health professionals who are actively living a work life, so to speak . . . And I also think that this networking thing is important, that the project gives us the opportunity to interact with other professionals in the area, all the time. (FG1, P7) Collaborative work also contributed to the development of other competencies, such as time and resource administration, conflict management, and interpersonal relationships, as pointed out in the following excerpts: This closeness also allowed us to learn other things beyond the project. (FG2, P1) So, as we devoted more time to this activity, we also got to note the several ways each person works, which caused us to get closer and facilitate the work process, because, as we became closer, we got to know how each of us developed the activities, and this hugely facilitated our work and the achievement of the goals we had set for ourselves. (FG2, P7) We had to make a presentation about the project to the head nurse and the other members of the team, and this made us know how to work to meet deadlines and deal with one another for a purpose other than the school, that is, our work was for the service. (FG2, P3) I learned how to work with different people, for different purposes, not theirs, but my work's, sometimes the internship, sometimes the project, which was an extracurricular activity, I had to sort myself out, manage work and time, it was hard!. (FG1, P4) The nurse herself talked to the head nurse and said that the students were better prepared to move forward with the project than some professionals. Sometimes we asked questions and she was surprised that we knew the way better than the nurses who were not involved in the project. They got a little surprised and even interested in learning more about the follow-up appointment project so they got at the same level as the students. But it was a pacific process. They did not get upset because we knew more. (FG1, P5) Talk to professionals other than nurses, talk to nurses from another institution, I felt that I was in charge of a few things. I had to plan meetings, prepare content, negotiate with the nurses in the team about what would be said during these meetings. It also implied searching more, exploring what existed in other institutions. I felt capable in so many activities that I worked side by side with the professionals. And I realized, above all, that there is work beyond what we usually do with sick patients in EC. It was really rewarding!. (FG1, P7) Integration, opportunities to participate, and collaborative work created a sense of belonging in the students: I did not feel like I was treated as a student, but as someone who belonged to that team. (FG2, P2)

Discussion
The literature points to belongingness as a central element for the integration of students into services, with this factor influencing their clinical education, motivation, and the quality of their clinical experience [4,10]. King et al. emphasized that the need to belong impacts health and behavioral, emotional, and cognitive well-being [1]. However, it has been reported that many nursing students have had bad clinical experiences, lacking in the establishment of relationships with their teams, and that some have been disrespected [19,20]. These attitudes lead to isolation and impact the emotional aspects, as well as the student's learning, productivity, and performance, even negatively influencing their perceptions regarding nursing and health care [20].
The present study was limited to a specific experience of involving students in a project oriented toward translating knowledge into clinical practice. The results suggested that the initiatives undertaken by schools and services, and the continuous engagement of students, promoted integration and created opportunities for participation and collaborative work that increased their sense of belonging. This corroborates research suggesting that the creation of effective and well-structured learning opportunities, with close coordination in clinical contexts, helps build nursing knowledge [21,22] and allows students to learn about evidence and evidence-based practice, communicate science, and develop competencies [4,23]. This increases the chances that a student will use evidence-based practice in the future, strengthens their critical thinking, and increases their ability to provide health care [24].
The participants' accounts showed the importance they gave to belonging to teams, and how the extracurricular activity contributed to their integration and participation, not just in the initiatives in progress at their institution, but also in the organizational routine of the services. This sense of belonging is a universal characteristic of human beings and a basic human need [25]. According to Ashktorab, Hasanvand, Seyedfatemi, Salmani, and Hosseini, this is one of the most important needs of students, and its fulfillment allows them to develop more reliable work practices in clinical environments. These authors emphasized that understanding and recognizing this distinctive characteristic can reduce stress and tension [26], and promote learning [4,10].
Developing a sense of belonging to a community involves four elements: adherence; influence; integration and fulfillment of needs; and shared emotional connections [27]. King et al. designed and validated the "WANTED" framework (Welcome-legitimization of the student role; Attitude-compassion for self and students; Nurture-encouraging sociable exchange; Talk-involvement in wards and work discussions; Encourage-appropriate autonomy for completion of tasks; Delight-in supportive relationships and success) with the objective of creating belongingness experiences as a team approach for nursing students undertaking clinical internships [1]. These authors claimed that this approach allows students to continue their learning in daily life and promotes feedback, positive reinforcement, questioning/reflection, guidance, shared discussions, and problem-solving [1].
The accounts of the participants corroborated the interconnection of these elements and their importance for successful integration, participation, and potential collaborative work that resulted in other learning opportunities, parallel to their internships. The results showed that the students' integration was facilitated by the exchange of knowledge between professors and clinical nurses, and through their continued work with the services. The role of nurse advisors is crucial in helping students become members of teams and in fostering the development of the sense of belonging, bridging the gap between professionals and students [25].
Some excerpts from the interviews indicated that the project focus became a subject for communication between the professionals and the senior nursing students, helping them to exchange information, to engage in discussions, and to jointly carry out activities that allowed the introduction of both evidence and a sense of belonging into clinical practice. The latter contributed to students feeling safe and confident in challenging themselves to talk about these questions with professionals, and the students considered them to be important to the learning process in this phase of the undergraduate course. In a short time, these students will become nurses and will have to base their decision-making on evidence. Having a sense of belonging contributes to students being active in the search for evidence and knowledge transfer [25]. As their participation becomes more active, the sense of belonging is reinforced, and they consider themselves to be part of teams when they are recognized both personally and professionally.
Future studies should explore these findings and their relationship to changes in attitudes in view of evidence-based practice and the development of scientific competencies.

Conclusions
The involvement of the students in the Safe Transition project as an extracurricular activity promoted a sense of belonging to the services. Integration, participation, and collaborative work emerged as categories that supported this feeling.
Close and collaborative work between nurse educators and clinical nurses who devote their time to patient care strengthened the bonds of trust and closeness, and supported the integration of students into the services. Students felt that, when this process occurs early and is satisfactory, they have a chance to actively participate in the work and enjoy new learning opportunities that may involve collaborative work. Concomitantly, participation and collaborative work strengthened their sense of belonging.
The study limitation was related to the method used, and the possible influence of the group on individual accounts. It is recommended that future studies resort to in-depth individual interviews to obtain a better understanding of the dimensions that allow the development of a sense of belonging in the students. It is also important to carry out studies that help elucidate the nurses' perceptions of the contribution of collaborative work between nursing schools and clinical practice contexts toward the attitudes of professionals that can promote a sense of belonging in the students.