Psychometric evaluation of the Persian version of the Sense of Belonging in Nursing School (SBNS): a quantitative and cross-sectional design

Nurses constitute the largest cohort of healthcare professionals, serving as integral and indispensable contributors to the enhancement of individual and societal well-being [1]. One of the primary strategies for addressing the shortage of nursing staff involves prioritizing the retention of the current nursing workforce [2]. The pressing demand for nurses necessitates that nursing schools and clinical staff establish inclusive environments to enhance nursing students' sense of belonging, thereby fostering their retention and successful graduation [3].

Belonging refers to the experience of being accepted, included, and valued within a particular context or group [4]. According to Hagerty et al. (1992), a person's experience of involvement in a system or environment leads them to believe they are an essential component of that system or environment [5]. The sense of belonging within the context of clinical education is a profoundly personal encounter that is connected to an individual's subjective perception in three key aspects. These aspects include a) a sense of safety, acceptance, appreciation, and respect from a specific group, b) proficient communication with said group, and c) aligning one's values with the professional values upheld by the group [6]. Strayhorn (2012) defines the sense of belonging in education as the social support students perceive in the university environment, the feeling or experience of engagement, and the feeling of being essential or welcomed, respected, and valued [7].

The sense of belonging among students is positively correlated with several aspects of their university experiences. For instance, the sense of belonging enhances and facilitates favorable educational experiences [8‐11], student-faculty connections [12], self-worth [13], self-assurance, motivation [8, 14], job contentment [15‐18], proficiency [19], students' aspirations for career advancement in their chosen field, and student retention [15, 20‐22], all of which are generally associated with their academic advancement and overall success at the university [23]. Multiple research studies have demonstrated that students who possess a heightened sense of belonging exhibit a greater emphasis on the value of learning and display increased motivation toward achieving academic success [24]. Furthermore, it has been observed that nursing students who have positive learning experiences and are satisfied with their studies [14, 25] tend to develop a sense of belonging. This sense of belonging is also associated with higher self-esteem [14], effective interaction with colleagues [26], increased motivation to learn and stay in the nursing profession [27], and reduced likelihood of leaving the job [28]. Additionally, it is worth noting that a sense of belonging is inversely related to perceived stress [14] and the disrespect of nurses [29]. Therefore, fostering a sense of belonging is considered one of the most crucial needs for nursing students in the clinical environment [3].

To date, a range of tools has been developed to assess the sense of belonging. Two commonly used tools in this context are the Belongingness Scale-Clinical Placement Experience (BES-CPE) developed by Levett-Jones et al. [16] and the General Belonging Scale (GBS) developed by Malone et al. [30]. The GBS was the first tool developed to differentiate between the concept of belongingness and the need for belonging. This tool assesses various levels of belonging, encompassing familial, close friendships, and community connections, as well as a broader sense of belonging that extends beyond interpersonal relationships [30]. Levett-Jones et al. (2009) developed the BES-CPE tool to assess students' perception of their sense of belonging in the clinical work environment. This tool consists of three microscales: self-esteem, group cohesion, and efficiency [16]. However, these instruments primarily assess the perception of belongingness within the context of family, social groups, and work environments. Prior to the tools mentioned above, there was a lack of a comprehensive scale to assess the level of belonging experienced by nursing students in various settings such as the classroom, clinical environment, peer groups, and other environments that contribute to fostering a sense of belonging [12, 31].

To assess, quantify, and determine the factors contributing to the enhancement of nursing students' sense of belonging, it is crucial to utilize a well-defined and all-encompassing scale. The newest instrument to measure nursing students' sense of belonging is the Sense of Belonging in Nursing School (SBNS), developed by Patel et al. in the English language in 2022. The tool consists of 19 items and focuses on students' experiences in four distinct areas: the clinical environment with instructors, the clinical environment with nursing personnel, the classroom environment with professors, and interactions with other nursing students [32]. Given that there has been no psychometric testing of this instrument in other countries, and considering the absence of a valid scale to assess the sense of belonging, particularly among nursing students in Iran, it is essential to conduct a psychometric evaluation of this scale. Hence, the objective of this study was to assess the validity of the Persian version of the SBNS scale. The validation of this tool is anticipated to facilitate its utilization in future research endeavors aimed at assessing and identifying potential ways of improving the sense of belonging among nursing students, thereby effectively contributing to their overall growth and development.

A comprehensive sample size of 382 undergraduate nursing students was involved in the present study. Out of the total, 199 individuals (52.1%) were identified as women, 358 individuals (93.7%) were reported as single, and 187 individuals (49%) were recorded as residents of student dormitories. The demographic information of the participants is presented in Table 1.

Based on the findings of the current study, it has been determined that the SBNS scale is composed of three distinct factors: "classmates," "clinical staff," and "an inclusive educational environment." These 15 items within the scale predict a noteworthy percentage of the total variance. The SBNS scale originally had 19 items and a four-factor structure (1- Classmates/Cohort, 2- Classroom, 3- Clinical-Staff, and 4- Clinical-Instructors) [32]. The first factor identified in the Persian version of the SBNS was the "classmates" encompassing six items primarily associated with fostering a sense of belonging within the college educational environment through interactions with classmates. This element accounted for the highest proportion of sense of belonging and demonstrated its significance in nursing school sense of belonging. This factor consists of six items, each with a positive expression. Patel et al. (2022) recognized Classmates/Cohort as one of four factors in the psychometrics of the early edition of SBNS, which is equivalent to the present factor in the Persian version [32]. They are critical for instilling a strong sense of "being a part of the community" in classmates, which supports members' effect on one another, including mutual trust [54]. It is important to remember that the presence of classmates with whom a nursing student may readily converse about his education is a form of social support in the nursing school setting. In this regard, one of the components known to increase academic self-efficacy in nursing students is social support [55].

The "clinical staff" emerged as the second factor in the current version, encompassing five items. This factor primarily focuses on student engagement in meaningful scientific discussions about patient care, active involvement in patient care responsibilities, and the regard and dignity shown to nursing students by the clinical staff. One of the detected factors in the initial edition of this scale was clinical staff, which is the same factor observed in the Persian version [32]. In this regard, it should be noted that clinical staff support for students during their educational rounds is a protective factor to improve their sense of belonging, as demonstrated by the findings of a study conducted by Lopez et al. (2018) that clinical staff support nursing students is a protective factor to prevent the intention to drop out of nursing education [56]. Furthermore, it is conceivable that the clinical staff does not encourage students and displays violence or rudeness against them. In this regard, the findings of Patel et al. (2022) revealed that clinical staff rudeness toward students has a negative and significant link with nursing students' sense of belonging [29].

The last factor was also identified as the inclusive educational environment. The items associated with this factor pertain to the support provided by the nursing faculty by means of a conducive learning environment and academic staff members, such as academic counseling. This factor corresponds precisely to the classroom factor in the first iteration of SBNS [32]. Consequently, instructors' support and communication with nursing students are crucial factors that affect students' academic performance [57]. In addition, Tharani et al. (2017) discovered that nursing students believed that the quality of their "educational environment" had a significant impact on their mental health. In addition, they cited the role of professors, teaching methods, academic expectations, and the availability of learning resources as other important factors affecting students' psychological well-being and academic performance [58].

Based on the results of the current study, all the fit indices in the CFA were in the acceptable range, so the model fits well with the data. The original version of the SBNS scale and a similar instrument designed by Levett-Jones et al. (2009) to measure nursing students' sense of belonging were not evaluated using CFA [16, 32]. In contrast, Ashktorab et al. (2015) evaluated the Persian version of the Belongingness Scale—Clinical Placement Experience (BES-CPE) and demonstrated, using CFA, that the model is well-fitting [59]. In addition, the CFA results from the study conducted by Kim and Jung (2012) in conjunction with the validation of the Korean version of the BES-CPE demonstrated that the tool model is a good fit with three factors (self-esteem, connectedness, and efficacy) [60].

The present study shows that SBNS items in the final model have good convergent and discriminant validity. The original version of SBNS was not evaluated in this respect [32]. However, Kim and Jung (2012), in a similar study, measured the validity of the Korean version of the BES-CPE and found that SBNS has a positive and significant correlation with self-esteem and self-directed learning [60]. Also, Daniels et al.'s (2020) study showed that the original belongingness scale has acceptable convergent validity. The sense of belonging is correlated with students' overall satisfaction with the undergraduate course [61].

In this study, the Cronbach's alpha coefficients for all components of the Persian version of the SBNS were found to be acceptable, demonstrating strong internal consistency among the scale items. Additionally, the construct reliability (CR) of the scale was evaluated through confirmatory factor analysis (CFA), revealing a sufficient level of construct reliability. One of the benefits of CR measurement is that it is independent of the number of scale items and sample size [62]. In Patel et al.'s study (2022), Cronbach's alpha coefficients for the entire scale and its subscales, including classmates, classroom, clinical staff, and clinical instructors, all surpassed the 0.9 threshold, consistent with the findings observed in the present study [32]. Also, Cronbach's alpha values for the Persian version of the BES-CPE were calculated by Ashktorab et al. (2015); the total score was 0.92, and the subscales ranged from 0.80 to 0.85 [59]. In addition, Cronbach's alpha values for the original BES-CPE total score were reported to be 0.92 (subscales between 0.80 and 0.92) [16].

The assessment of SBNS measurement stability was conducted using test–retest analysis. The findings indicated a substantial association between the initial and subsequent assessments. These results supported the scale's excellent repeatability, demonstrating that the Persian version of the SBNS scale exhibits appropriate stability based on intra-class correlation (ICC). It's noteworthy that the stability of this scale was not reported in its original version [32]. In a similar study, Ashktorab et al. (2015) calculated the ICC value of the Persian version of the BES-CPE for the whole scale as 0.95 [59].

There are now just 15 items in the SBNS Persian translation, as items 1, 7, 8, and 17 have been eliminated. A higher overall score (between 15 and 75) indicates a stronger sense of belonging within the nursing school. The Persian version of the SBNS comprises three factors: classmates (scores of six to 30), clinical staff (scores of five to 25), and inclusive educational environment (scores of four to 20).

Since only two nursing institutions participated in the data collection, the generalizability of the study may be limited. Additionally, this scale must be adapted to the culture of other Persian-speaking nations. Additionally, as the SBNS scale relies on self-reported measures, there is a potential for response bias to impact the results.

The present study revealed that the SBNS scale consists of 15 items and three factors in Iranian nursing students, which predicts approximately 50% of the variance in nursing school belongingness. This scale has high levels of reliability, internal consistency, and construct validity for measuring the sense of belonging in nursing school. In addition, the SBNS scale can be utilized as a practical instrument in nursing education to solve nursing student problems.