In any nursing program, clinical experiences are essential in providing students with the opportunity to apply theoretical knowledge to the realities of clinical practice situations. As a result, effective clinical placements are vital for nursing students in ensuring they can develop the knowledge, skills, attitudes, and values of a registered nurse1.
Preceptorship has been a popular clinical teaching strategy since the 1960s in Canadian nursing programs because of its perceived benefits in socializing students to the nursing profession, improving student clinical competency, enhancing students' ability to apply theory to practice, and increasing their familiarity with health determinants. Preceptorships are also thought to support the development of teaching, collaboration, planning, and evaluation skills, as well as the leadership and interpersonal relations and communication skills necessary for professional nurse roles2. Preceptorship in these programs is typically described as a formal one-to-one relationship of a predetermined length of time between a nursing student and experienced registered nurse.
Many students in Alberta, Canada undertake a rural hospital preceptorship clinical practicum. Rural hospital preceptorship clinical practicums provide nursing students with an ideal opportunity to be immersed in the experience of rural nursing while under the supervision of experienced nurses. However, there is a potential for baccalaureate nursing students to have difficulty in becoming professionally socialized to the rural hospital nurse role, given the complex nature of the setting.
Although the nursing education literature is replete with reports describing successful student achievement of course objectives and nursing competencies during a preceptored clinical experience, there are significantly fewer articles that provide understanding about the sense of belonging as it pertains to clinical experiences, particularly in a rural hospital setting. By integrating excerpts from interviews with published literature, this article describes nursing students' experiences of belonging to the rural hospital team during a preceptored clinical experience.
Much of the research examining the student rural clinical experience is limited to the recruitment of students as a potential workforce3, or identifying factors that influence students who choose to undertake a rural clinical placement4-6. However, clinical placements, including rural preceptorships, are not without problems1. Healthcare settings whose focus is on workplace goals and outcomes rather than on student learning goals7 are not always ideal learning environments. This is often overlooked as a factor that impacts teaching and learning8. The scarcity of clinical placements, higher patient acuity levels, shorter patient hospital stays, staff shortages, increase staffing with casual positions, mandatory overtime, and the increased workload are factors that increase nursing staff stress and complicate the efforts of registered nurses to support student learning9-11. Understandably then, the presence of nursing students in the clinical setting is frequently perceived as a stressful burden12.
Given the tension between the short and long-term goals of the healthcare environment and the pressures on education programs to educate competent registered nurses who are work ready, developing a sense of belonging to ensure student success as well as to recruit and retain a future workforce is imperative. Yet a review of the literature on belongingness reveals that the concept of belongingness in the nursing education literature is scarce1,13 although professional socialization of nursing students, which includes being able to fit in or belong, represents a type of outcome that is critical to the education process14.
Given the current focus of accreditors and other evaluators of higher education on student outcomes15, the lack of knowledge regarding the sense of belonging for baccalaureate nursing students in the rural hospital setting represents a serious weakness for nurse educators relying on this type of clinical placement for their students. In light of the limited information regarding the 'belongingness' of nursing students while in a rural hospital setting, factors that influence their ability to develop a sense of belonging must be identified and described so that their meaning might be understood.
A sense of belonging defined
Belonging is a universal human characteristic and is a basic human need. Belonging may also offer a shared sense of socially constructed meaning that provides a sense of security or relatedness. Generally, people strive to be accepted by others because not being connected to others has cognitive, affective, and behavioral consequences16.
The experience of belonging, then, is unique to each individual and deeply personal. It is dependent on the context within which the experience occurs, and develops in response to the degree to which an individual feels secure, accepted, valued and respected by a defined group; connected with a group; and that their professional values and behaviors complement the group and facilitate group cohesion1,17.
Purpose of the study and study questions
The purpose of this study was to describe the experience of nursing students and preceptors during a rural hospital preceptorship clinical practicum. Specifically the focus was to identify and describe the norms, values, beliefs, and behaviors that influence baccalaureate senior nursing students' socialization during a rural hospital based preceptored clinical practicum. The broad research question that guided this study was: 'What are the experiences and perceptions of undergraduate nursing students and nurse preceptors during a rural hospital preceptored clinical practicum?'
A focused ethnography was completed. Through classroom presentations and receipt of an information letter, nursing students from a large western Canadian university and two colleges undertaking a rural hospital-based preceptored clinical practicum were invited to participate in the study. Registered nurse preceptors were invited to participate in the study by a written information letter provided to them by the student. All potential participants expressing interest received a follow-up telephone call prior to the first interview, and had to meet the following inclusion criteria: currently undertaking or having undertaken within the last 2 years a rural hospital preceptorship of 340 hours; able to reflect on and discuss his or her experience; and able to give consent to participate in the study by signing a consent form. Ethical approval was obtained from the health regions participating in the study as well as the health ethics review board of the relevant university.
To ensure anonymity and confidentiality, participant names were removed from all data sources and were replaced by pseudonyms. In addition, events were modified in such a way as to protect the anonymity of those people living and working in the rural communities in which the preceptored clinical practicum was undertaken.
The setting for this project was central and northern Alberta and Yukon, Canada. The term 'rural' is frequently described using population parameters18 and/or as those areas where access to health care services is limited because of distance and the lack of qualified health professionals19,20. However, the rural setting also has unique characteristics that include social, economical, and political factors that influences one's perception of 'being rural'. In this study, the participants who identified themselves as 'going rural' were located in 11 communities with populations ranging from 1800 to 15 000 people that were geographically dispersed over a 640 000 km2 rural area. Communities were located 1.5 hours to 16 hours driving time from large urban centers.
The rural hospitals within these communities were generally able to offer only a limited number of clinical placements for nursing students. Only three hospitals were able to host more than one student at a time for a preceptored clinical practicum. There were several reasons for the limited number of available clinical placements, including a small number of registered nurses willing and/or able to take on the preceptor role, physically smaller patient care units and fewer patients and, at times, more limited learning experiences. In this study, the smallest hospital had 20 inpatient beds and the largest had 72 beds. Most of the hospitals had between 20 and 30 inpatient beds.
Over the course of an 8 month period, semistructured ethnographic interviews21 were conducted. A total of 24 interviews were conducted at a mutually convenient time and place outside the participants scheduled work time. Because of travel considerations and weather conditions, some interviews were conducted by telephone or videoconferencing. Twelve nursing students and six preceptors were interviewed once. Five of the 12 students and one preceptor participated in a second interview. Interview questions for these interviews were guided by emerging categories.
Other data sources included student journals and field notes. Student journals that made up part of the course assignments were electronically sent to the principle investigator. Although we had hoped to engage in participant observation, all of the preceptors and some of the nursing students expressed unease and anxiety at being observed. To capture more fully the culture of the rural hospital setting, a focus group interview with a hospital manager and other staff members was conducted in lieu of engaging in participant observation.
Data collection and analysis occurred simultaneously beginning with the first interview. To uncover a system of cultural meaning, students and preceptors used during the preceptorship four kinds of ethnographic analysis: domain analysis; taxonomic analysis; componential analysis; and theme analysis21. Constantly comparing codes and theoretical sampling helped to ensure the students' experience of a rural hospital preceptored clinical placement was represented22. Verification strategies23 that included investigator responsiveness, methodological coherence, sample appropriateness, concurrent data generation and analysis, theoretical thinking and theory development established reliability and validity. Through inductive analysis the cultural theme 'a sense of belonging' was generated.
The students described diverse clinical experiences that fostered for them a sense of belonging to the hospital team. It was apparent from their stories that belongingness was influenced by such factors as: individual characteristics, interpersonal relationships, and unit climate1. It was especially evident that interactions with all of the staff with whom they worked with on a daily basis significantly influenced their sense of belonging. Consequently, students who felt they belonged reported feeling safe and comfortable with interacting not only with their preceptor but with the majority of the hospital team. Some students were also able to describe clinical experiences that prohibited them from developing a sense of belonging. Conversely, the absence of feeling they belonged resulted in feelings of anger and confusion, and ultimately resulted in being ostracized from the team. In the end, these students were left to feel uncertain about themselves as nurses, as well as the nursing profession in general.
Given that preceptored clinical practicums are designed to provide students with 'real life' nursing experiences that facilitate the transition from the student to graduate role, these findings are significant. In describing factors that influence students' sense of belongingness, the effectiveness of this model of clinical education can be enhanced.
Bridges to 'a sense of belonging'
Rural nursing at its core is different from practicing nursing in a rural setting24. To describe the nature of their practice, nurses in this study used words like 'we're it'25, 'we work as a team'24, 'we're family' and 'we have community ties26'. For students in this study to feel they belonged and were accepted as members of the hospital team, preceptors needed to build bridges between them and the hospital staff. As a result, there were countless times students and preceptors described instances where the preceptor:
...would go down and talk to the girls in emerg and say, 'My student wants to come down here and do a NG [nasogastric tube insertion], so when you have one, phone me and I'll send my student'. (Angie)
The preceptored clinical experience then is a 'joint effort' reflective of the nature of rural hospital nursing practice which is grounded in team work. However, becoming part of the team was dependent on how well the preceptor was accepted into the practice community. In fact, if the preceptors' relationships with other team members were strained, the students' relationships with the team would also be strained.
If there wasn't anything positive going on in my relationship with the team, why would there be anything positive happening for her and the team? The team really associated the student with me so if they couldn't give a rats ass about me, I'm not sure her relationship with the team would have been positive for her. (Donna)
Conversely, if preceptors had good working relationships with their colleagues, acceptance of the students seemed to occur more readily and easily. 'I think it also has helped that I am with a preceptor who's really well respected and that reflects on me' (Katie). From these comments it can be concluded that for a preceptorship to be successful, the unit climate which encompasses the relationships among and between colleagues had to be positive and supportive.
To help create and support a hospitable learning climate on the unit8, specific strategies preceptors would engage in to bridge the gap between the student and staff were aimed at minimizing the disruption in the team's routine as a result of introducing someone unfamiliar to that team27. Based on their assessment of the student's knowledge and skill level, learning activities were carefully planned and negotiated with other staff members28. It was important then to review with the student their learning objectives and expectations, teach them psychomotor skills not yet mastered, as well as how to use pieces of unfamiliar equipment and, most of all, to provide students with 'those little idiosyncrasies of the unit and staff just to make the student's life simpler and so that he can be successful' (Donna). Knowing the routine of the facility became an important skill for students to master to fit in with the daily activities of the team.
Preceptors also engaged in observation and vigilance, in questioning the student and providing them with feedback to ensure the provision of safe patient care. Appropriate direction in emergent situations and balancing the student's learning needs with the needs of the unit were other strategies used by preceptors to protect the nursing team.
While all graduating students must learn to think like a nurse29, students who choose to complete their preceptorship in a rural hospital setting also had to learn to think like a rural nurse. For students, thinking like a rural hospital nurse meant they needed to recognize rural hospital nursing practice was rooted in team work. Preceptors would help students think like a rural nurse by incorporating the concepts of 'we're it', 'we're a team', and 'we're a family' in their discussion and practice. For example they would teach students these concepts by demonstrating how to establish and maintain professional relationships with staff members.
My preceptor tried to teach me not to get involved in kind of the political thing. A bunch of women all working together there's lots of chattering about different things that happen. In a smaller hospital when you don't have as much staff, my preceptor was good about not getting involved with it. (Laurie)
Preceptors also demonstrated how to work within a team and respect each team members' contribution to the care provided. Katie expresses what she has learned about team work this way:
The biggest thing is just knowing how to work as a team. Respecting the scope of practice and just each other. Becoming friends with people. Knowing them, knowing their limits, and not being condescending when they ask you a question. Everyone is a team member and no one is better than the other. That was the biggest thing I learned.
Although these strategies helped to protect the team, in some situations preceptors explicitly engaged in behaviors that protected the student's role as learner. In one instance the preceptor had to clearly articulate to the staff the student's role and associated functions and responsibilities.
Staffing is always an issue. There's always a shortage. I've seen more frequently than not that the student gets taken advantage of and that she's expected to play a role as a staff member on the floor because she gets separated from her preceptor. I just find in this facility that the drug cart is very much downplayed as an easy step, anybody can do that. The attitude is just let the student do that because you need to go do this. They separate the two of us so we have more staff. I don't see how separating us is a good learning experience. I try really hard to advocate for us so wherever I go, she goes. (Devon)
Being a student advocate also required preceptors to shelter30 students in certain situations. For example, preceptors in this study explained that because they knew their colleagues as well as they did, they were able to gauge their colleagues' receptivity to the student. As a result they did not 'put the student in a position where someone was going to chew her out' (Angie). In fact, preceptors in this study were very particular in choosing which staff members would help preceptor the student when they were not at work. They deliberately choose nurses who had similar teaching styles and approaches to nursing practice in order to provide the student with a consistent learning experience. Given the diversity of potential experiences in rural hospitals and the potential for students to feel overwhelmed, preceptors felt it was important that the students be provided with consistent exposure to one or two areas of nursing practice.
Preceptors also provided safe passage28 by setting, articulating, and supporting students in meeting expectations consistent with new graduate competencies31, thereby assisting them in building self-confidence.
I think it's important for these students to have someone that they feel comfortable with that they can go to with any concerns or just when you feel you need a safe place to be. So I think protecting him from the feeling that he doesn't know anything is important. I have seen other nurses where they have basically attacked the school program and they think these students at this level should be able to function as a full fledged RN and should be able to handle everything that is thrown their way even though they are in a new environment. I'd just rather build his self-esteem rather than knock it down. (Donna)
As a result, for all of the students in this study, the provision of emotional support by the preceptor was invaluable, thereby illustrating how overwhelming becoming part of the team could be and how nervous most of the students were about being successful32.
Overall, the strategies used by the preceptors helped bridge the distance between the student and staff. Without fail all of the students in this study indicated that, unlike the experiences of their colleagues in urban centers, they were not 'just a student' (Cassie), anonymous to the staff. Rather, they were known as people with names and aspirations and goals instead of simply being someone who could get the work done29. In rural hospitals students are not 'thrown to the wolves' (Katie) where there is minimal investment in the students' learning. Instead, their relationship with their preceptor and with the other nurses and staff in the hospital supports a mutual construction of knowledge33 that, in turn, facilitates their sense of belonging34. As a student stated:
You just get to develop that closer relationship with the staff. You get to develop close professional and personal bonds with everyone and get to see them on all sorts of levels. You get to interact and support each other and you get to work as a team. (Cassie)
The work of being accepted into the team: students need to learn how to fit in
Students believed the first day of the preceptorship had the potential to set the tone for the remainder of the experience. For this reason, initially, they focused principally on their relationship with their preceptor. However, they quickly identified the need to become more effective in relating to other team members to fit in. They actively engaged in getting to know the hospital team by learning what team work meant and how the team worked as a unit, seeking and incorporating staff members' feedback into their practice, and sharing personal information with them.
Although being perceived as being able to demonstrate initiative, confidence, interest, and enthusiasm impacted the degree to which students were accepted as a member of the hospital team, the following preceptor quote suggests that students' individual characteristics, such as friendliness, were equally important in determining group acceptance.
It doesn't matter if the student doesn't know how to start an IV. The team is still going to accept her if she's got a really good sense of humour and personality regardless of the professional tasks she thinks she needs to master to be accepted. It can be other things that determine if she will be accepted. (Devon)
Therefore, students learned that cohesive teams, such as rural hospital teams, have strong norms. To be accepted by the team, these norms needed to be upheld27. One such norm students quickly learned was to 'know your position' (Daniel) and to remember 'you're the new kid on the block' (Laurie). Students could not 'be a know it all' (Samantha), needed to 'respect people even if they're not a registered nurse' (Daniel), and were required to prove to the team 'whether or not [they] could handle it' (Elanor).
Furthermore, students knew if they did not conform to group norms, because their position within the group was tenuous and on the outer fringes of the group, especially at the beginning of the experience, the sanctions placed on them would be severe. So there were times they 'wouldn't even open [their] mouth' (Elanor) even though there were times 'that you wanted to jump in because everyone else is doing it and you had the same feelings as they did' (Elanor). Although it was tempting to engage in the same kind of behavior as other group members, because of their low status35 and so that they could be liked and subsequently be admitted to the group, it was wise not to become involved in the political activity of the facility.
Ultimately the students' desire for meaningful involvement35 noted in Linda's comment 'I wanted more to become part of the team' seems to indicate that students understood the need to belong in order to be successful in their experience. Admission into the group helps students gain confidence in themselves36 and serves to make them feel that they were an integral part of the team37. This is evident in Janie's comment, 'I played a more important role'.
Being ostracized: the consequence of not belonging
In this study, becoming a rural hospital nurse was as much about joining a community of practice represented by qualified rural nurses as it was about learning the technicalities of nursing. Consequently, for many students, feeling they were accepted by the staff was more important than the actual clinical nursing experience offered1. Indeed, the findings made it clear that the rural hospital setting was a social context in which the significance of becoming accepted into the culture of the workplace could not be overemphasized38. It was not uncommon to hear nursing students discuss their attempts to gain entry into the community of practice as can be seen in this comment:
During the day or night, I'm always asking everyone 'do you need some help? Can I do anything for you?' If people do need help then I'll do it. Like I said, through my trying to be more involved and always being a team member has helped a lot too. (Katie)
Underlying this comment is the notion that students are not automatically incorporated into the rural practice community, and that marginalization and isolation might result when they are rejected for whatever reason39. For Candace, the experience of marginalization occurred because she did not feel that she had been able to demonstrate competence in her nursing skills and so was not accepted as a legitimate member of the community.
Living under criticism where you think that you're being criticized and talked about. Like you walk into the room and you felt you were being talked about. I felt a little bit black-balled by my preceptor, and people were kind of wary about trusting me then. I was expecting some support from the staff but [it] wasn't there.
Although the inability to become part of the nursing team in any setting has potentially serious consequences, the importance of being a team member in the rural hospital setting where the nature of nursing practice is described as 'we work as a team', 'we're it', and 'we're family' is crucial.
If you're planning on staying in a rural community, being part of the team is more important because you don't have a lot of options. In an urban center if I really wasn't getting along with the team that I was working with or not feeling that I was accepted, I could move to another unit. You either become part of the team or you're kind of ostracized. (Samantha)
Students who indicated they felt uncertain of themselves and in their abilities 'second guess[ed] themselves' (Candace) and were unable to become part of the team. As a result, the ability to identify themselves as registered nurses, let alone rural hospital nurses, was impaired, causing them to reconsider joining the nursing profession. 'To be quite honest, I'd dread coming to work everyday. I even thought about quitting!' (Candace). Clearly, this type of experience is disastrous for the student attempting to transition into the graduate role.
From these accounts, it is clear that work group cohesion helps alleviate students' sense of helplessness and aloneness, and fosters a sense of connectedness40. The ability to identify oneself as a group member consolidates and enhances the student's self-worth and produces for the student a coherent sense of identity41. For Janie this meant that '[the staff] treated [me] as an RN. [I] played more of an important role and had a greater role on the team than previously'.
Although there exits only a beginning understanding of the relationship between belongingness and students learning, data generated in this study suggest the sense of belonging is central to the success of the preceptored clinical experience, and is foundational to rural hospital nursing practice. This has implications for how the context of rural hospital nursing practice is understood by nurse educators, preceptors and students. Moreover, understanding the significance of belonging is invaluable for hospital managers who are seeking to cultivate and retain a future workforce.
Strategies used by the preceptors and students support the development of a sense of belonging and are not dissimilar to those described and utilized by students in other clinical placements1. However, because the nature of rural hospital nursing practice is grounded in the concepts of 'we work as a team', 'we're it', and 'we're family' there is a need to identify, develop, and implement specific strategies that enhance students' sense of belonging while in a rural hospital-based preceptored clinical practicum.
We offer the following strategies to help preceptors, students, hospital administrators, and supervising faculty develop and support the sense of belonging during a rural hospital preceptored clinical practicum.
First, effective collaboration between nursing educational programs and health services must be established. Hospital administrators must identify the extent to which their organization is ready and able to support a preceptored clinical experience. Although the hospital manager participating in this study was extensively involved in the preceptored clinical experience, she indicated most of her administrative colleagues choose not be involved in the preceptoring experience. Because belonging is intuitively appealing, as a recruitment strategy administrators can enhance the feeling of welcome by helping students find living accommodation, providing information about activities they might become involved in when not working, and introducing them to community members who might share similar interests. At the beginning of the preceptorship administrators might also adjust the preceptor's patient workload so more time can be given to teaching about rural hospital practice. Administrators can also plan in advance with staff ways in which they can support the preceptor and student in their roles28.
Second, involvement of faculty members can include providing preceptors with an orientation to preceptorship that reflects the realities of rural hospital practice. Discussion of rural nursing theory42 as well as the concept of belonging would help preceptors facilitate the development of belongingness. Regular, visible, and continual presence during the preceptored clinical practicum would support the student, preceptor, and hosting facility and help ensure a successful and satisfying experience. Faculty members are encouraged to listen to preceptor concerns, clarify student performance expectations, assist preceptors to interpret student behaviors, and provide preceptors with reassurance that what they are doing is appropriate and will likely help students learn and feel they belong. Clearly, to have such involvement in the rural preceptorship experience, supervising faculty workloads must be adjusted. The benefits of having an increased presence by supervising faculty in rural hospitals during a preceptored clinical practicum is job satisfaction for both faculty and preceptors, and increased ability for students to link rural theory and practice.
Third, because students are not automatically incorporated into the rural hospital practice community, nurse educators should invite students to a discussion on how to prepare for the rural hospital experience43 so they can become part of the hospital team. The concepts of 'we're it', 'we're a team', and 'we're family' can provide the foundation for this discussion, as well as for the development of specific strategies to facilitate their acceptance as a member of the team. Such strategies might include seeking, incorporating, and giving feedback; learning and recognizing group norms; and learning how to work in a team.
The implications of a sense of belonging for students, rural hospital workplaces and administrators, and for nurse education programs and faculty are diverse and far reaching and should continue to be explored. The findings demonstrate the critical importance of a sense of belonging. This is not an abstract term but one that can be actualized through the use of deliberate strategies. The consequences for the student of not developing a sense of belonging impacts the preceptored clinical experience and future employment possibilities; for the preceptor it impacts on their satisfaction with being a preceptor and may deter them from volunteering to be a preceptor in the future.
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