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Research into Work Life Experiences

Belongingness in the workplace: a study of Malaysian nurses’ experiences Z. Mohamed1,2 MN, RN, J.M. Newton3 L. McKenna4 RN, PhD, MEdSt, RM

RN, PhD, EdD, Grad Cert Sci, RM

&

1 PhD candidate, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia, 2 Lecturer, School of Nursing, Faculty of Medicine, Universiti Kebangsaan Malaysia, 3 Associate Professor Research, 4 Professor, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia

MOHAMED Z., NEWTON J.M. & MCKENNA L. (2014) Belongingness in the workplace: a study of Malaysian nurses’ experiences. International Nursing Review 61, 124–130 Background: The need to belong has been proposed as the most basic need for human psychological well-being. Lack of belongingness has been associated with stress, anxiety and lack of esteem. Social and psychological functioning in the workplace has been linked to nurses’ interconnection with others and their perceptions of belongingness. Aim: To explore factors contributing to Malaysian nurses’ sense of belonging in the workplace. Methods: A descriptive questionnaire survey of registered nurses (n = 437) working in two Malaysian hospitals was conducted in 2011. Previously validated questionnaires translated into the Malay language were used. Data were analysed using SPSS 19.0. Results: Nurses enhanced their sense of belonging through acceptance, ‘fitting in’, respect and group harmony. There were no specific demographic factors contributing to the nurses’ perceptions. The findings suggest that these priorities for belongingness were contextually influenced by factors such as elements of Malaysian culture, the nature of nurses’ teamwork and stereotypical values on the nursing profession. Limitations: Data were collected in only two hospitals. Experiences of nurses in other hospitals and areas of Malaysia may not be similar. The influence of Malaysian culture in this study raises issues about utilization of a measurement scale developed in Western cultures, which may not directly accord with cultural values of an Eastern ethnicity. Conclusions: Aspects of belongingness in Malaysian nurses reflect those of nurses elsewhere. However, there are specific cultural influences at play. Therefore, development of a measurement scale based on Eastern culture would help in increasing understanding of workplace practices among these groups. Implications for nursing and health policy: Workplaces that perpetuate an environment that is not conducive to generating a sense of belonging may have an untoward impact on care delivery. Healthcare policies need to ensure patient care has a focus on engaging practitioners within multidisciplinary teams. Keywords: Belongingness, Nurses, Nursing, Sense of Belonging, Workplace

Introduction Correspondence address: Zainah Mohamed, School of Nursing, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91456265; Fax: +603-91456683; E-mail: [email protected].

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One pervasive human concern is establishing and maintaining relatedness to others. The need to develop meaningful interpersonal relationships and experience sense of belonging in these relationships is important, as people will survive, develop and

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grow within this process (Hagerty et al. 1996). Sense of belonging has been identified as one specific process of relationships which promotes better social well-being (Hagerty et al. 1992). Belongingness has been defined as: . . . a deeply personal and contextually mediated experience that evolves in response to the degree to which an individual feels (a) secure, accepted, included, valued and respected by a defined group; (b) connected with or integral to the group; and (c) that their professional and/or personal values are in harmony with those of the group. (Levett-Jones & Lathlean 2009, p. 2872) Social integration in the work community should be experienced and acknowledged by colleagues and other members in the organization (Maslow 2000). In the workplace, people seek to find their place in formal and informal work groups. They seek pleasant working relationships with co-workers, peers and others in the organizational hierarchy (Maslow 2000). This helps them to experience feelings of belongingness and connectedness, integration into the work community, and acknowledgement by colleagues and other members in the organization (Ryan & Deci 2000). It has been suggested that, within nursing, several elements need to be in place for nurses to feel motivated and to progress to higher level functions (Chinnis et al. 2001). These include appropriate work schedules with adequate meal and rest breaks between shifts, safe nurse–patient ratios, job autonomy and decision-making abilities over their practice, and working within collaborative teams, all of which serve to enhance a degree of belongingness (Groff Paris & Terhaar 2010). Belongingness has been described as a prerequisite for nursing student clinical learning (Levett-Jones & Lathlean 2008; McKenna et al. 2013). Nurses’ positive belongingness experiences, including welcoming, encouraging and supportive behaviours, have been shown to help facilitate students’ perceptions of being valued and respected as members of the team (Levett-Jones et al. 2009). The experience of belongingness has also been found to play a role in motivating students to learn and influencing their future career decisions (Levett-Jones & Lathlean 2007). It is proposed that students’ progress to full competence requires the clinical education environment to offer physical and psychological security, belongingness experiences, and healthy self-concept, which includes the need to be appreciated, recognized and respected. The need to learn with freedom and to find professional role models must be met (Levett-Jones & Lathlean 2009). Belongingness in nurses’ working environments is considered challenging as the clinical workplace involves different disciplines with responsibility to work together as teams to deliver

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patient care. In becoming part of teams, nurses have been found to sometimes hide their insecurities behind masks of competence and self-confidence (Andersson & Edberg 2010). Complying with established practices and ward routines has been identified as the quickest way for newly graduated nurses to ‘fit in’ (Etheridge 2007; Maben et al. 2006). These nurses sometimes suppress their knowledge to some degree (Maben et al. 2006), even though they may know better, or observe other nurses’ unethical behaviours. They may choose to keep silent due to nurse-nurse domination and desire to maintain acceptance by colleagues (Daiski 2004; Yeh et al. 2010). Given that little is understood about sense of belonging for Malaysian nurses, this study sought to explore intrinsic and extrinsic factors contributing to Malaysian nurses’ sense of belonging in the clinical workplace. In doing so, it sought to answer the following research questions: 1 To what extent do Malaysian nurses experience belongingness in the workplace with colleagues, other healthcare team members and the organization? 2 What strategies do nurses use to fit in with colleagues and other healthcare team members?

Methods A quantitative descriptive approach using survey design was used to explore experiences of belongingness for Malaysian nurses. A previously validated questionnaire, the Belongingness Scale, was adapted from Levett-Jones (2007) who reported the tool’s Cronbach’s alpha as 0.92. Twenty questions were selected from the original tool to measure participants’ belongingness experiences with colleagues. Twelve similar questions were employed to measure participants’ belongingness experiences with other healthcare team members. Eight additional questions were developed through literature review from previous studies on nursing and the organization. Content validity of the final questionnaire was then tested and reviewed by a panel of nursing personnel from two different hospitals (n = 5, average years of experience = 15). The revised scale had a Cronbach’s alpha value of 0.93 with 20 questions relating to colleagues (0.89), 12 questions relating to other healthcare team members (0.83) and eight questions relating to the organization (0.80). Participants were asked to rate on a 4-point Likert scale, from strongly agree to strongly disagree, the extent to which criteria were present in their practice settings. Demographic data such as age, gender, nursing education level, and work experience within their unit and nursing generally were also collected. The questionnaire, first designed in English, was translated into Malay language, translations confirmed by an expert, then translated back to English to ensure meaning was unchanged. A

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pilot study was conducted with 20 Malaysian nurses resulting in some minor changes to Malay words. Setting and sample

The sample consisted of 437 Registered Staff Nurses from two hospitals located in the capital city, Kuala Lumpur. Hospital A was a public government hospital with over 2000 beds while Hospital B was a semi-government teaching hospital with just over 1000 beds. During the study period, the total population of nurses in these two hospitals was 3316. Allowing for a 95% confidence level and a confidence interval of 5, the estimated required sample size was at least 344. Graduate nurses working in clinical areas, providing continuous nursing care to inpatients, were invited to participate and recruited between July and October 2011. Nursing staff were introduced to the study and invited to participate during regular nursing education meetings. Posters containing information about the study were also displayed on noticeboards in each ward. Following an explanation about the project by the first author at ward handovers, questionnaires were given to potential participants together with an explanatory statement containing information about the research. Prelabelled sealed envelopes were attached to the questionnaire. Participants were asked to return the completed questionnaires in sealed envelopes through internal mail to a designated locked box in the nursing administration of each hospital. Ethical considerations

Approval to conduct the study was granted by the relevant university ethics committee (CF11/1379-2011000763) and the two hospitals involved (NMRR-11-223-8561 and FF-282-2011). The first researcher contacted the Director and Head of Nursing Department of both hospitals to explain the study and seek permission to enter the hospital for the purpose of gathering data. Participation was voluntary and questionnaire was anonymously answered with no possibility of research participants being identified. Data analysis

Data were analysed using Statistical Package for the Social Sciences version 19.0 for Windows (SPSS Inc., Chicago, IL, USA). Descriptive analyses were performed on demographic data and respondents’ strategies were used to ‘fit in’ the workplace. Chisquare was used to explore relationships between respondents’ characteristics and their workplaces. Means and standard deviations were used to rank belongingness experiences from highest to lowest scores with colleagues, other healthcare team members and organization. Independent samples t-tests were used to ascertain any relationships between belongingness experience

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scores and place of work and gender. One-way between-groups analysis of variance was used to examine relationships between scores of belongingness experiences with age, years of experience since graduation and years of experience in clinical areas.

Results The majority of respondents (97%) were female. This mirrored the Malaysian nursing population where 99% are female (Kejururawatan 2012). Age distribution for Hospital B was dominated by respondents between the ages of 30 and 34, while at Hospital A this was more evenly spread across age groups. The different age distribution could have been due to years of establishment of the two hospitals: Hospital A commenced operation in 1870 and Hospital B in 1997 with the majority of nursing staff being new graduates aged 20–25 years. A 3-year nursing diploma, the most basic nursing qualification enabling practice as Registered Staff Nurse, was held by 96.6%. More than half (58.1%) of the respondents from both hospitals had over 5 years of post-graduation work experience, and 42.6% had been working in the same clinical area since graduation. Belongingness experience in the clinical workplace

Table 1 presents the analysis of respondents’ belongingness experiences with colleagues. ‘It is important to feel accepted by my colleagues’ was revealed as the highest scoring item (M = 3.52, SD = 0.514). The mean score of 3.52 indicates that almost all (99.3%) respondents agreed with this statement. As well as feeling accepted, maintaining acceptance was viewed by 98.6% as another important element of belongingness (M = 3.42, SD = 0.521). Belongingness experience with other healthcare team members: ‘It is important to feel accepted by other health care team members’ (M = 3.41, SD = 0.510) was similar with belongingness experiences with colleagues showing 99.0% agreement. Maintaining acceptance respondents received from other healthcare team members (M = 3.37, SD = 0.506) was the second most important element, with almost all (98.9%) agreeing with this statement (see Table 2). Table 3 presents the belongingness experiences within the organization. ‘I respect the administrative people (nursing and others) in my organisation’ scored highest (M = 3.23, SD = 0.465) with 98.6% of respondents agreeing. This may indicate the influence of Malay culture in the workplace setting where higher ranking or senior staff are highly respected by subordinates. The statement ‘I get adequate opportunities (e.g. promotion, study leave) from the organisation where I work’ scored lowest. A total of 118 (27.0%) respondents disagreed that they had adequate opportunities within their organizations (M = 2.79, SD = 0.681). Eighty-five (72.0%) respondents who

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Table 1 Belongingness experience with colleagues (n = 437)

Q2 Q3 Q 17 Q 10 Q1 Q5 Q 15 Q6 Q 12 Q8 Q 16 Q 18 Q 19 Q7 Q 14 Q 20 Q9 Q4 Q 11 Q 13

Items

M

SD

It is important to feel accepted by my colleagues. It is important to maintain the acceptance I received from my colleagues. I like where I work in the clinical area. I like working with my colleagues. I feel like I fit in with my colleagues. Colleagues offer to help me when they sense I need it. I ask for my colleagues’ advice about patient care. I make an effort to help new students or staff feel welcome. I offer to help my colleagues, even if they don’t ask for it. I get support from colleagues when I need it. Feeling ‘a part of things’ is one of the things I like about working in the clinical area. It seems that my colleagues like to work with me. I feel free to share my disappointments with at least one of my colleagues. I view my clinical workplace as a place to experience a sense of belonging. Colleagues ask for my ideas or opinion about different matters concerning the workplace. When I come to work, I feel welcomed by all staff. I am invited to social events outside of my clinical workplace by colleagues. Colleagues see me as a competent person. I do not feel discriminated against by my colleagues at my clinical workplace. I invite colleagues to eat lunch or dinner with me.

3.52 3.42 3.38 3.36 3.35 3.34 3.34 3.32 3.32 3.31 3.22 3.21 3.19 3.19 3.16 3.12 3.09 3.05 3.03 2.99

0.514 0.521 0.548 0.513 0.531 0.542 0.498 0.476 0.490 0.536 0.493 0.490 0.567 0.595 0.474 0.462 0.600 0.504 0.733 0.577

Table 2 Belongingness experience with other healthcare team members (n = 437)

Q2 Q3 Q1 Q 10 Q7 Q8 Q6 Q4 Q 11 Q9 Q5 Q 12

Items

M

SD

It is important to feel accepted by other healthcare team members. It is important to maintain the acceptance I received from other healthcare team members. I feel I fit in with other healthcare team members where I work. I ask for advice about patient care from other healthcare team members. I get along well with other healthcare team members at my workplace. I have good teamwork with other healthcare team members. I feel respected by other healthcare team members where I practice. Other healthcare team members see me as a competent person. Other healthcare team members ask for my ideas or opinion about different matters concerning the workplace. I do not feel discriminated against by other healthcare team members at my clinical workplace. I am invited to social events outside of my clinical area by other healthcare team members whom I work with. I invite other healthcare team members to eat lunch or dinner with me.

3.41 3.37 3.20 3.17 3.16 3.13 3.01 3.00 2.97 2.92 2.68 2.52

0.510 0.506 0.462 0.431 0.473 0.475 0.481 0.520 0.497 0.662 0.685 0.686

felt they did not get adequate opportunities to be promoted or granted study leave were nurses who had over 5 years of experience after graduating from basic training. This may be attributed to development of satisfaction with their expertise and the need for something different. Analysis of the open-ended question found that respondents used a range of strategies to ‘fit in’ with colleagues, with 52 different strategies identified. Of these, ‘Practising teamwork in all

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tasks’ was the most common (n = 103, 23.6%). ‘Always willing to help in performing nursing care to their patients even if not requested’ was next most common with 95 (21.7%) stating they used this tactic. The third most frequently used strategy, ‘compromising with and tolerating colleagues to maintain a peaceful situation/environment’, was identified by 68 (15.6%) respondents. These three frequently used strategies suggest that these Malaysian nurses tried to maintain peaceful working

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Table 3 Belongingness experience with the organization (n = 437)

Q6 Q7 Q3 Q8 Q2 Q5 Q1 Q4

Items

M

SD

I respect the administrative people (nursing and others) in my organization. My organization recognizes nursing as a profession. I feel strongly that I belong to the organization where I work. My organization involves nurses in decision making. As a nurse, I am comfortable attending multidisciplinary social functions at the clinical workplace as I feel like nursing does belong. I get adequate support (e.g. preceptor ship, orientation) from the organization. Being a nurse in a multidisciplinary clinical area does not make me feel like an outsider. I get adequate opportunities (e.g. promotion, study leave) from the organization where I work.

3.23 3.22 3.08 3.04 2.99 2.98 2.84 2.79

0.465 0.554 0.475 0.595 0.712 0.546 0.692 0.681

environments and harmony with colleagues as priority, aligning closely with their cultural distinctiveness. A similar pattern of responses was seen with fitting in with other healthcare team members. Thirty-eight different strategies were reportedly used to fit in with team members. The most identified was ‘working together as a team’ (n = 107, 24.5%). The second ranked strategy was ‘always willing to help/assist the other health care team members’ given by 94 (21.5%) participants. ‘Respect them as team members’ and ‘always follow instructions that have been given’ were ranked third with 78 (17.8%) such responses.

Discussion The concept of belongingness associated with colleagues and other healthcare team members centred on the notion of acceptance. It was important for respondents that this be maintained throughout their careers as nurses. This parallels earlier studies in Sweden and USA where acceptance from colleagues was found to be important among newly graduate nurses (Andersson & Edberg 2010; Fink & Krugman 2008). On the other hand, belongingness with people in the organization was demonstrated by respecting people in authority, either from nursing or other departments. The prevalence of respecting ‘superior people’ suggests a direct influence of culture in this study. Malaysia is a multicultural country dominated by Malay ethnicity. In Malay culture, high-ranking or senior staff are well respected by subordinates (Abdullah 1994). Cultural values, as part of Malaysian people’s sense of self, are often carried into the workplace and influence the way people relate to one another in performing their daily work (Asma & Low 2001). Acceptance from people in the organization was gained through respect and obedience that they gave to those in authority. It would appear that acceptance influenced the nurses’ sense of belonging. Research suggests that most people want to be accepted and respected by others once they engage in interpersonal interac-

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tions (Baumeister 1982). People want to be perceived as having appropriate like-minded attitudes and competency, and thus be liked and respected (Bergsieker et al. 2010). The personal goals of being accepted and respected are theorized to be most salient and aroused when a person feels threatened (Leary & Kowalski 1990), i.e. when the person perceives a risk of being disliked or disrespected. Such situations may cause the person to become worried and consciously preoccupied with being accepted and respected (Bergsieker et al. 2010). In addition, the nursing profession has struggled to be respected due to reasons such as historical influences (Taft & Nanna 2008), medical hierarchy (Gershon et al. 2007) and public perceptions (Fletcher 2007). Desire to be accepted might also be due to the nature of nurses’ roles. Nurses in this study relied heavily on teamwork from colleagues and other healthcare team members. A high level of teamwork is crucial in maintaining job satisfaction among nurses (Kalisch et al. 2010). Feeling threatened, disliked or disrespected might jeopardize future teamwork. A seminal study on belongingness by Coon (1946) found that, early in human life, if an individual cannot get along easily with group members, that person might be excluded from the group. Individuals excluded from a group are less likely to survive in life. Excluded group members face many problems including lack of support and help from other group members (Lancaster 1986), and become emotionally unstable due to stressful conditions (Orden et al. 2008). Therefore, belonging to a group can promote more effective functioning rather than individual action. Individuals who are cooperative and able to maintain harmonious relationships with other group members have an advantage and are more likely to continue to be included in their groups (Lakin 2003; Lakin & Chartrand 2005). In this study, respondents’ strategies to fit in were based upon maintaining group harmony. The notions of ‘practising teamwork in all tasks’ and ‘cooperating with each other’ were given priority in strategies to ‘fit in’ with colleagues, for both new

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graduates and senior nurses. This diverges from previously reported strategies, where including seeking acceptance and having respect for authority and seniority was more common among newly graduate nurses (Andersson & Edberg 2010; Fink & Krugman 2008; Paton 2010) and nursing students (Levett-Jones 2007), but not senior nurses. It is important to note that many previous studies on nurses’ belongingness have focused on experiences of new graduates and nursing students. The issue of senior nurses still being concerned with seeking and maintaining acceptance and respect, and with maintaining harmony, has not been previously reported. The importance of belongingness for senior nurses in this study is likely due to strong influence of collectivism: teamwork, cooperation, strong sense of belonging, according priority to group interests, deriving satisfaction from respect from colleagues, and giving respect for hierarchy, authority, senior and elderly people are important factors (Abdullah 1994). This influence appeared to be present where ‘respect them (the other health care team members) as team members’ and ‘always follow the instructions that have been given’ were among the priorities to fit in with other healthcare team members. To claim oneself to be more competent than others is seldom uttered in Malay culture (Mastor et al. 2000). Therefore, it might be that Malaysian nurses ‘play safe’ to avoid being social outcasts in their workplaces. For nurses who work with others in higher positions in multidisciplinary professions, these values may be associated with feelings of powerlessness among nurses. The findings suggest there were no specific demographic factors contributing to belongingness perceptions. Rather than factors such as age or work experience, nurses’ sense of belonging was influenced by environmental needs and staff relationships. This mirrored Levett-Jones et al.’s (2009) study among nursing students in Australia where demographic characteristics were not strong influences of sense of belonging. It was the clinical environment and attitudes of staff that had greater influence. This could inform nursing management that providing supportive workplace environment is crucial for nurses. There are some limitations to this study. The overall response rate was 13.2%, even though the sample size was large (n = 437). Hence, there could have been a difference between respondents and non-respondents’ perceptions of belongingness experiences that was not captured. Furthermore, only 1% of the male nursing workforce from both hospitals completed the questionnaire, hence their experiences are still not well understood. Data were collected from two different hospitals located in the capital city of Malaysia. Experiences of nurses in other hospitals and other areas of Malaysia may not be similar. Hence, overall results cannot be generalized to other populations. Despite this, the results offer new insights

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that should be examined further. The influence of Malaysian culture in this study raises issues about utilization of a measurement scale developed in Western cultures, which may not directly accord with cultural values of an Eastern ethnicity. For this reason, it may be important in future studies to develop another measurement scale based on Eastern cultural values, which could give a clearer picture of belongingness experiences in such workplace settings. Despite these limitations, the study sheds light on an aspect of Malaysian nursing that has not previously been explored.

Implications for nursing and health policy Being aware of how cultural norms may interplay within the workplace and how they might influence an individual’s engagement is important to ensure that any potential negative consequences are avoided. Collaborative teamwork is essential to ensure quality patient centred is maintained, yet teamwork requires a workplace that is conducive to nurses having a sense of belonging. Workplaces that perpetuate an environment that is not conducive to generating a sense of belonging may have an untoward impact on care delivery. Healthcare policies need to ensure patient care has a focus on engaging practitioners within multidisciplinary teams while acknowledging cultural diversity.

Conclusion This study adds to current knowledge related to how Malaysian nurses’ valuing of belongingness in the work setting influences their perceptions and consequently affects their actions in the workplace. As has been highlighted, sense of belonging appears to be influenced by cultural ethnicity, in particular the existence of a dichotomy between Western and Eastern values among senior nurses. Further research is required to examine this influence in more detail, given in particular the multicultural nature of the nursing workforce and how this might influence the way nurses gain their sense of belonging.

Acknowledgements The authors are grateful to the directors of the participating hospitals who allowed the study to be conducted and to the nurse who completed the questionnaires.

Author contributions ZM: Study design; data collection and analysis; drafting of manuscript. JMN: Critical revisions for important intellectual content; supervision. LM: Critical revisions for important intellectual content; supervision.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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Conflict of interest No conflict of interest has been declared by the authors.

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Belongingness in the workplace: a study of Malaysian nurses' experiences.

The need to belong has been proposed as the most basic need for human psychological well-being. Lack of belongingness has been associated with stress,...
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