Abstract
This study evaluates the sense of belonging and its determinants among standardized training nurses in China. A survey of 133 nurses was conducted using convenience sampling, incorporating the Belongingness Scale-Clinical Placement Experience, Turnover Intention Scale, and Self-Rating Anxiety Scale. Data were analyzed with t-tests, ANOVA, Pearson correlation, and multiple linear regression. The average belongingness score was 3.47 ± 0.43, indicating moderate levels. Alarmingly, 94.0% reported high turnover intentions, and 42.9% experienced anxiety. Significant variations in belongingness were linked to health status, work stress, colleague relationships, preceptor satisfaction, and training benefits (p<0.05). Negative correlations were found between belongingness and turnover intention (rs=−0.195, p<0.05) and anxiety (rs=−0.412, p<0.01). Moderate belonging levels were observed, with recommendations for enhanced preceptorship and psychological support.
Keywords: Standardized training nurses, Clinical sense of belonging, Turnover intention, Anxiety, The Job Demands-Resources Model
Introduction
The “Training Outline for Newly-Employed Nurses (Trial)”1), released in 2016 for China, mandates that new graduate nurses undergo a comprehensive two-year standardized training program. During this period, they are identified as standardized training nurses and are expected to rotate through different departments to gain practical experience. The two-year program includes systematic rotations through major hospital departments such as internal medicine, surgery, emergency, ICU, and pediatrics. Each rotation typically lasts 2–3 months and is supervised by trained preceptors. Nurses are evaluated through regular theoretical and practical assessments, with an emphasis on clinical skill development, teamwork, and communication. A sense of belonging is the experience of actively engaging in a system or environment, feeling integral to it, and being recognized and accepted by the group, which is a fundamental human need2). Clinical belongingness, in the context of healthcare, is the experience of feeling accepted, included, and respected within the clinical environment, with one’s professional identity and values harmonizing with the group3).
Newly employed nurses often encounter challenges such as role transitions, adapting to new work environments, and building interpersonal relationships during their training rotations. These challenges can lead to feelings of insecurity and instability4), potentially resulting in low clinical belongingness. Nurses with a low sense of clinical belonging may be more susceptible to stress, anxiety, depression, and issues with self-esteem, and they may even consider leaving their jobs5,6,7).
Research on the clinical belongingness of nursing students is prevalent, but studies on the belongingness of training nurses are scarce, and the influencing factors are not well-defined. Investigating the sense of belonging and its determinants among training nurses is essential for addressing their anxiety and depression and for enhancing their clinical belongingness. Therefore, this study aims to assess the current status of clinical belongingness among training nurses and to identify its influencing factors, with the objective of developing targeted interventions to improve their sense of clinical belonging.
Participants and Methods
Participants
In March 2019, we selected a convenience sample of all the standardized training nurses newly recruited in 2018 at a third-class public hospital of Guangzhou, China. Inclusion criteria: (1) All participating nurses graduated and worked for at least 1 yr with a nursing license, currently undergoing standardized rotational training; (2) All nurses voluntarily participated in the study and sign informed consent forms; (3) All nurses were registered for duty. Exclusion criteria: (1) Those on leave during the training period; (2) Those who recently experienced major events (e.g., bereavement, emotional upheaval). A total of 149 questionnaires were distributed and collected, with 16 questionnaires containing missing values and thus excluded. The final valid sample size was 133, with an effective recovery rate of 89.26%. According to the requirements of multiple linear regression for sample size, the sample size should be at least 5–10 times the number of independent variables8). This study included 17 independent variables, considering 10–20% invalid questionnaires, requiring at least 95 samples. Thus, the sample size was adequate. Approval for the study was obtained from the Ethics Committee of Nanfang Hospital, Southern Medical University (No. NFEC-2019-005).
Research methods
Survey tools
1. General demographic data
The general demographic data contained age, gender, rural or urban household registration, et al. See Table 1 for details. Belongingness Scale: This includes three sub-scales—self-esteem (12 items, α=0.88), communication (10 items, α=0.86), and efficacy (9 items, α=0.85). Anxiety Scale: Example item—“I feel afraid for no reason at all”. Personality was self-reported (optimistic/uncertain/pessimistic); health status was self-evaluated (good/fair/poor); work stress was categorized into very high, high, and average; satisfaction with colleagues/preceptors was rated on a 5-point Likert scale; rotation helpfulness was assessed via a single item (helpful/uncertain/not helpful).
Table 1. Scores of clinical belongingness of standardized training nurses with different demographic characteristics.
| Characteristic | Number | Clinical belongingness | t/F value | p-value | |
|---|---|---|---|---|---|
| Gender | 0.251 | 0.802 | |||
| Male | 12 | 108.82 ± 12.30 | |||
| Female | 121 | 107.39 ± 13.61 | |||
| Household registration | −0.495 | 0.624 | |||
| Rural | 105 | 107.13 ± 12.63 | |||
| Urban | 28 | 108.79 ± 16.41 | |||
| Only child | −1.258 | 0.211 | |||
| Yes | 20 | 104.00 ± 14.00 | |||
| No | 113 | 108.10 ± 13.33 | |||
| Marital status | 0.287 | 0.751 | |||
| Single | 99 | 107.94 ± 13.55 | |||
| In a relationship | 32 | 105.94 ± 12.31 | |||
| Other | 2 | 109.50 ± 33.23 | |||
| Education | 1.315 | 0.254 | |||
| Associate degree | 82 | 106.43 ± 13.75 | |||
| Bachelor’s degree | 51 | 109.18 ± 12.93 | |||
| Personality | 2.817 | 0.063 | |||
| Pessimistic | 10 | 101.90 ± 16.54 | |||
| Uncertain | 25 | 103.36 ± 13.13 | |||
| Optimistic | 98 | 109.10 ± 12.97 | |||
| Health status | 5.747 | <0.001 | |||
| Poor | 4 | 93.25 ± 10.56 | |||
| Fair | 59 | 105.56 ± 11.97 | |||
| Good | 58 | 107.90 ± 13.95 | |||
| Very good | 12 | 119.67 ± 11.11 | |||
| Work Stress | 4.126 | 0.018 | |||
| Very high | 13 | 97.62 ± 12.82 | |||
| High | 84 | 108.25 ± 12.34 | |||
| Average | 36 | 109.25 ± 14.90 | |||
| Colleague relationship satisfaction | 3.077 | 0.049 | |||
| Average | 52 | 104.62 ± 13.81 | |||
| Good | 72 | 108.56 ± 12.27 | |||
| Very good | 9 | 115.44 ± 17.41 | |||
| Preceptor satisfaction | 18.343 | <0.001 | |||
| Not satisfied | 7 | 102.57 ± 8.38 | |||
| Average | 40 | 97.18 ± 11.72 | |||
| Satisfied | 68 | 111.54 ± 10.68 | |||
| Very satisfied | 18 | 116.94 ± 14.01 | |||
| Rotation helpfulness | 11.859 | <0.001 | |||
| Not helpful | 48 | 105.98 ± 12.20 | |||
| Uncertain | 11 | 91.64 ± 9.66 | |||
| Helpful | 74 | 110.81 ± 12.98 | |||
2. Clinical belongingness scale
This scale is used to evaluate the sense of belonging of nursing students in clinical internship environments3, 9). This study used the scale to measure the overall belongingness of standardized training nurses in all departments they rotated through. The scale includes self-esteem, communication, and efficacy dimensions, with a total of 34 items. However, items 6, 12, and 22 had low factor loadings in the original scale9), so this study used only 31 items. Each item is scored on a 5-point scale (1=completely disagree; 3=unsure; 5=completely agree). Items 10 and 14 are reverse scored, with a total score ranging from 31 to 155, with higher scores indicating higher levels of clinical belongingness. The Cronbach’s α coefficient of the scale is 0.83–0.92, indicating good reliability and validity3). The Cronbach’s α coefficient in this study was 0.90.
3. Turnover intention scale
Translated and revised by Taiwanese scholars, consisting of 6 items, scored on a 4-point scale (1=never; 2=seldom; 3=occasionally; 4=often), with a total score ranging from 6 to 24. Higher scores indicate stronger turnover intention. According to the classification of turnover intention levels, the total score of turnover intention was converted to an average score, representing different levels of turnover intention. An average score ≤1 indicates very low turnover intention; 1 <average score ≤2 indicates low turnover intention; 2< average score ≤3 indicates high turnover intention; and an average score >3 indicates very high turnover intention. The Cronbach’s α coefficient of the revised scale was 0.77, indicating good reliability and validity. The Cronbach’s α coefficient in this study was 0.69.
4. Self-Rating Anxiety Scale (SAS)
Designed by Zung10), widely used for anxiety screening in different populations, with good reliability and validity. The scale includes 20 items, with items 5, 9, 13, 17, and 19 reverse scored. Respondents rate their feelings over the past week on a 4-point scale: 1=none or very little (less than 1 day in the past week); 2=seldom (1–2 d in the past week); 3=often (3–4 d in the past week); 4=almost always (5–7 d in the past week). The total item score is multiplied by 1.25 to obtain the SAS standard score. A standard score ≥50 is defined as anxiety10). Higher SAS scores indicate more severe anxiety. The Cronbach’s α coefficient in this study was 0.84.
Data collection method
Before a centralized training session, the training supervisor read the instructions and confidentiality commitment. After obtaining the participants’ consent, questionnaires were distributed and collected on-site, checking for missing items.
Statistical methods
Data were entered by two individuals using epidata3.1 and analyzed with SPSS20.0. For general demographic data (e.g., gender, personality), t-tests and analysis of variance were used for comparisons, assuming homogeneity of variance and normality. Spearman correlation analysis was used to examine the relationship between turnover intention and clinical belongingness, and Pearson correlation analysis was used to examine the relationship between anxiety and clinical belongingness. Stepwise multiple linear regression analysis was employed to identify the predictors of clinical belongingness. All collected demographic, occupational, and psychological variables were initially included in the model. Categorical variables were converted into dummy variables where appropriate. The stepwise selection method (entry criterion: p<0.05; removal criterion: p>0.10) was applied to retain the most relevant predictors. To assess multicollinearity, variance inflation factors (VIF) were calculated, and all were below 2.0, indicating no significant multicollinearity. The significance level was set at α=0.05.
Results
General information of standardized training nurses
The average age of standardized training nurses was (22.51 ± 1.03) yr, with females accounting for 91.0%, rural household registration accounting for 78.9%, bachelor degree holders accounting for 38.3%, and singles accounting for 74.4%. Those experiencing high work stress accounted for 72.9%, those rating colleague relationships satisfactory as average or below accounted for 39.1%, and those rating satisfaction with preceptors as satisfied or above accounted for 64.6%. Significant differences in clinical belongingness were observed among nurses with different self-rated health statuses, work stress levels, colleague relationships, satisfaction with preceptors, and perceived helpfulness of standardized rotational training for future career development (p<0.05).
Clinical belongingness, turnover intention, and anxiety of standardized training nurses
The total score of clinical belongingness was (107.48 ± 13.46), with an average item score of (3.47 ± 0.43), indicating a moderate level. The total score of turnover intention was (16.01 ± 2.47), with 94.0% of nurses having high turnover intention. The total score of SAS was (39.50 ± 7.91), with an anxiety positive rate of 42.9%.
Correlation of clinical belongingness with turnover intention and anxiety
Clinical belongingness was negatively correlated with turnover intention (rs=−0.195, p<0.05) and moderately negatively correlated with anxiety (r=−0.412, p<0.01). In other words, the lower the clinical belongingness, the stronger the turnover intention and the higher the anxiety level.
Influencing factors of clinical belongingness of standardized training nurses
To comprehensively evaluate the predictors of clinical belongingness, we performed stepwise multiple linear regression analysis using all potential influencing variables, including demographic characteristics, work-related conditions, and psychological factors (Table 2). Categorical variables such as marital status and department type were transformed into dummy variables, and multicollinearity was assessed using variance inflation factors (VIF), all of which were below 2.0, indicating acceptable levels (Supplementary Table 1). The final model identified satisfaction with preceptors (β=0.337, p<0.001), anxiety score (β=−0.205, p=0.018), and colleague relationship satisfaction (β=0.179, p=0.046) as significant predictors of overall clinical belongingness, explaining 40.2% of the variance (adjusted R2=0.402). To further clarify how these factors influence specific components of belongingness, additional stepwise regression analyses were conducted using the three sub-dimensions of the Belongingness Scale—self-esteem, communication, and efficacy—as dependent variables. Satisfaction with preceptors significantly predicted both self-esteem (β=0.362, p=0.001) and communication (β=0.291, p=0.004), whereas anxiety score negatively predicted self-esteem (β=−0.187, p=0.038) and efficacy (β=−0.209, p=0.025). These findings suggest that supportive mentorship enhances trainees’ confidence and interpersonal integration, while psychological distress may undermine their perceived clinical competence and self-worth.
Table 2. Multiple linear regression analysis of influencing factors of clinical belongingness of standardized training nurses.
| Variable | B | SE | β | t | p-value |
|---|---|---|---|---|---|
| Constant | 44.316 | 33.648 | - | 1.317 | 0.191 |
| Preceptor satisfaction | 5.894 | 1.646 | 0.333 | 3.581 | 0.001 |
| Anxiety | −0.331 | 0.153 | −0.195 | −2.166 | 0.032 |
R2=0.402; Adjusted R2=0.289; F=3.559, p<0.01.
Discussion
The average item score of the clinical belongingness scale for standardized training nurses in this study was (3.47 ± 0.43), indicating a moderate level, consistent with the research results of nursing students11, 12). The efficacy dimension in the clinical belongingness scale, referring to confidence in one’s ability to achieve specific behavioral goals in a particular domain, had the highest average item score of (3.80 ± 0.48). This may be because standardized training nurses have completed several months of clinical internships, mastering certain nursing skills and being familiar with nursing work, giving them confidence to perform clinical work9); additionally, standardized training nurses are newly employed, full of hope for themselves and their future13). The lowest score was in the communication dimension, referring to the connections formed through interactions with others at work, consistent with the research results of nursing master’s students14). Standardized training nurses need to rotate through multiple different departments, and different work modes and environments increase their work stress15); unfamiliarity with colleagues leads to less communication, resulting in insufficient communication with colleagues and preceptors16). Moreover, junior nurses lack work experience and relevant training, not knowing how to communicate effectively with patients or their families, leading to the lowest score in the communication dimension. Department members need strengthen communication with standardized training nurses, proactively asking if they need help, and giving attention and appropriate encouragement. As the management team of the hospital, the nursing department director and supervising nurses should regularly conduct relevant training to improve the communication skills of standardized training nurses, create a harmonious departmental atmosphere, and enhance their clinical sense of belonging. Clinical nursing educators need to provide on-site guidance to standardized nurses at regular intervals based on their actual work situation. It can mainly carry out the following work: (1) Edit the daily work manual for nurses, distribute it to each nurse for learning, and regularly conduct assessments of related projects; (2) Provide on-site guidance on operational skills to these personnel to make their operations more standardized; (3) Provide answers to the relevant problems encountered in their actual work one by one to improve their confusion.
Entering a new department for rotational training, standardized training nurses are unfamiliar with department staff and the work environment. Preceptors are the first close contacts for standardized training nurses after entering the department, playing the role of a “guide”. They provide technical assistance for nursing work, develop the ability to handle complex clinical problems, increasing standardized training nurses’ professional identity. Additionally, they help standardized training nurses quickly complete role transitions, adapt to the department environment, and establish good interpersonal relationships, integrating them into the department. This study found that the higher the satisfaction with preceptors, the higher the clinical belongingness, consistent with the research results of Li et al.17) on nursing students. To improve standardized training nurses’ satisfaction with clinical preceptors, the nursing department director and supervising nurses need strengthen the quality training of clinical preceptors and standardize clinical preceptorship activities. Preceptors and clinical nursing educators need be approachable, proactively communicate with standardized training nurses, establish harmonious teacher-student relationships, provide care and help, and give encouragement and support, making standardized training nurses feel accepted and cared for, enhancing their clinical belongingness.
This study found the total score of turnover intention was (16.01 ± 2.47), with 94.0% of nurses having high turnover intention. The main reason is that because the 2 yr program included different specialties and in other countries nurses select one and train in one specialty. Anxiety would be high to start in new specialties several times. In 2 yr, these nurses never feel “grounded” and part of a team. At the same time, this study found an anxiety positive rate of 42.9% among standardized training nurses, slightly higher than the study by Ting et al18). Standardized training nurses face issues such as unfamiliarity with clinical nursing work, work processes, shift work systems, economic pressure, and interpersonal relationships during rotational training, along with frequent training assessments, leading to anxiety19, 20). Anxiety can cause restlessness, irritability, sleep disturbances, and even affect normal life and work21). This study showed a moderate negative correlation between anxiety and clinical belongingness (r=−0.412, p<0.01), indicating that higher anxiety experiences are associated with lower clinical belongingness. Therefore, the nursing department director and supervising nurses should regularly have in-depth conversations with standardized training nurses, understanding their thoughts, answering their questions and confusions, and timely improving deficiencies in standardized management. In clinical nursing education, clinical nursing educators need to develop and add more scientific mental health education courses during the training process to improve psychological quality and adaptability, thereby enhancing clinical sense of belonging.
When exploring the sub-scales of clinical belongingness separately, we found that satisfaction with preceptors significantly enhanced both self-esteem and communication, highlighting the importance of mentorship in building trainees’ confidence and facilitating team integration. This aligns with prior findings that supportive supervisory relationships are foundational to professional socialization. Interestingly, anxiety primarily impaired efficacy and self-esteem, suggesting that internal emotional states directly affect nurses’ belief in their own clinical capability. These results reinforce the need for differentiated intervention strategies: mentorship programs to promote interpersonal integration, and psychological support systems to maintain personal efficacy under stress.
This study’s findings highlight the critical role of clinical preceptors and anxiety levels in shaping nurses’ clinical belongingness. Interventions to improve mentor engagement and reduce anxiety may be pivotal in enhancing trainee nurse retention and integration. Overall, the balance between training demands and available support—particularly from preceptors and colleagues—plays a critical role in shaping the clinical belongingness of nurses in training.
There are three limitations to this study: (1) This study only investigated the clinical sense of belonging of standardized training nurses in a tertiary comprehensive hospital, so the selected and considered influencing factors are inevitably limited. (2) The sample size selected for this study is relatively small, so the results obtained are inevitably biased. (3) Due to regional and cultural differences among the participants in this study, the research results are also inevitably biased. Therefore, given the above limitations, in future research, we will conduct a multicenter survey and conduct in-depth research in conjunction with qualitative interviews.
Conclusion
In summary, this study found that the clinical belongingness of standardized training nurses was at a moderate level, with preceptor satisfaction and anxiety status being important influencing factors. Standardizing clinical preceptorship activities and improving preceptor satisfaction while paying attention to the emotional states of standardized training nurses and timely addressing negative emotions can improve their clinical belongingness.
Conflict of Interest
All authors declare no conflict of interest.
Supplementary
Data Availability
The individual participant data can be requested and accessed by contacting the study management teams of the studies on reasonable request.
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Associated Data
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Supplementary Materials
Data Availability Statement
The individual participant data can be requested and accessed by contacting the study management teams of the studies on reasonable request.