The Effectiveness of Group Counseling with Emphasis on Communication Skills on Midwifery Students’ Sense of Belonging in Clinical Settings


Mahnaz Saadatbakht 1 , Atefeh Ahmadi 2 , * , Ali Mehdizadeh Zare Ansari 3 , Mansooreh Azizzade Forouzi 4 , Yunes Jahani ORCID 5

1 Student Research Committee, Kerman University of Medical Sciences, Kerman, Iran

2 Nursing Research Center, Razi Nursing and Midwifery Faculty, Kerman University of Medical Sciences, Kerman, Iran

3 Neuroscience Research Center, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran

4 Department of Medical Surgical Nursing, Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran

5 Department of Biostatistics and Epidemiology, Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

How to Cite: Saadatbakht M, Ahmadi A, Mehdizadeh Zare Ansari A, Azizzade Forouzi M, Jahani Y. The Effectiveness of Group Counseling with Emphasis on Communication Skills on Midwifery Students’ Sense of Belonging in Clinical Settings, Strides Dev Med Educ. Online ahead of Print ; 16(1):e90362. doi: 10.5812/sdme.90362.


Strides in Development of Medical Education: 16 (1); e90362
Published Online: December 30, 2019
Article Type: Research Article
Received: February 6, 2019
Revised: September 4, 2019
Accepted: September 7, 2019


Objectives: This study aimed to investigate the effect of group counseling with emphasis on communication skills on midwifery students’ sense of belonging in clinical settings.

Methods: This interventional study with the pre-test - post-test control group design was conducted on 78 midwifery students of Kerman Medical University, who were selected using the census method. Of the total study population, sixty students with low level of mental health were screened using Goldberg’s General Health Questionnaire and randomly included in an intervention and a control group. They filled out Belongingness Scale-Clinical Placement Experience (BES-CPE) as the pre-test. The intervention consisted of eight group counseling sessions (two 2-hour sessions per week) with emphasis on communication skills that were held in their faculty. The final sample included fifty-two students filling out the post-test instruments. Data were analyzed using SPSS 22.

Results: There was a significant difference between the groups in terms of total score (P < 0.0001) as well as the self-esteem and self-efficacy subscales (P < 0.05).

Conclusions: Sense of belonging in clinical settings is required for midwifery students so that they can improve their communicaton skills in such settings. Therefore, it is recommended to include programs in midwifery curricula in order to improve students’ sense of belonging with enhancing their communication skills.

Copyright © 2019, Strides in Development of Medical Education. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Midwifery is a medical profession and also a combination of art and science. It requires complex capabilities such as social intelligence, knowledge, creativity, experience, logical perception and critical thinking (1). Clinical training is among the main and vital components of midwifery curriculum. It is considered as the heart of midwifery education, which encompasses about half of the list of courses on midwifery. Clinical experience is essential to learn certain knowledge or skills in practice. Similarly, students’ trust in their own professional capabilities is highly important. The main goal in this regard is that students reach the highest level of learning, which is professional qualification (2). A highly fruitful clinical training program aims to graduate highly efficient students (3). A clinical setting and/or curriculum should have sufficient self-efficacy to transfer knowledge and skills to midwifery students. It is a key factor in improving midwifery students’ skills in clinical settings (4). Students’ compatibility and adaptation with appropriate clinical context as well as efficient interactions between the students with the patients, fellows and colleagues provide a suitable ground for their compliance in clinical settings. In this way, students’ sense of belonging in practice is promoted (5) as a major requirement to work reliably in clinical settings (6).

Sense of belonging has been recognized as the basic psychological requirement of human beings, and is a prerequisite for clinical training of students (7). It is also considered as the basic concept of mental health as well as a shared social sense that provides the ground for security and communication (8). Belonging is defined as the sense of being existent and the perception of being valuable for others at different interpersonal levels (9). Among the advantages of belonging are increased self-esteem, self-self-efficacy, and resilience; positive clinical experiences; motivated self-learning; and academic achievement (6, 7, 10). Low self-esteem and job satisfaction along with a high level of anxiety and stress in clinical practice in case of poor general health can be related to the lack of sense of belonging in clinical settings (11-13). It is obvious that sense of belonging leads to enthusiastic concentration on learning for better comprehension as well as to high quality communication with staffs and perception of their supports (14). Students unable to secure belonging learn in clinical settings as outsiders, unfamiliar with the nursing environment (15).

Levett Jones et al. (14) believed that reciprocal respect between staff and faculty members with students in a pleasant environment would promote sense of belonging, learning experiences, self-confidence, self-self-efficacy, motivation and proficiency in students (16). To create positive clinical experiences, it appears necessary to consider all types of reactions and behaviors facilitating or undermining students’ sense of belongingness (14).

With these testimonials, communication skills is one of the effective components on the level of clinical belongingness (17). Group counseling is confirmed to improve communication skills (18). Proper ways of listening and talking to colleagues, being assertive and participating in group works and discussions are some aspects of communication skills. Counseling groups help members to find out, evaluate and displace their incorrect behaviors through a mutual, respectful and trustable environment. This climate should remove fear of loneliness and rejection. Thus, individuals can be supported and remain emotionally close to each other (19). The ultimate goal is to train midwifery students as future workers in the healthcare system with a high sense of belonging so that better services could be offered to patients and women during their fertility period. A thorough review of the literature revealed that no interventional studies attempted to promote midwifery students’ sense of belonging in clinical settings (17, 20, 21).

2. Objectives

Therefore, the present research aimed to determine the effect of group counseling on midwifery students’ sense of belonging in clinical settings, with an emphasis on their communication skills, at the Faculty of Nursing and Midwifery, Kerman Medical University (KMU), Kerman, Iran, in 2016.

3. Methods

This educational-intervention study with the pre-test - post-test control group design aimed to determine the effect of group counseling on midwifery students’ sense of belonging in clinical settings with the focus on their communication skills at the Faculty of Nursing and Midwifery of KMU in 2016. After obtaining the ethical code (ir.kmu.rect.2015.556) from the ethics committee of KMU, the recommendation letter was submitted to the head of the faculty. The inclusion criteria were successfully passing at least one clinical course and having low general health based on Goldberg’s General Health Questionnaire. Therefore, using the census method, the researcher conducted a meeting with all the midwifery students at KMU. Accordingly, 78 students inexperienced in clinical fields were included in the study. First, the researcher introduced herself and explained the research goals. Then, she asked the participants to complete Goldberg’s General Health Questionnaire (22). The questionnaire was used as an inclusion criterion in a bigger research project that aimed to determine students’ general health status and enhance it through group counseling with the emphasis on communication skills. As mentioned in the problem statement section, poor general health can be related to the lack of sense of belonging (11-13). Therefore, students with a general health score above 23 (23 is considered as the cutoff score) were excluded from the study whereas those with a general health score of 23 and below were included in the study after obtaining written informed consent. Accordingly, 60 eligible students were randomly placed in an intervention (n = 30) and a control (n = 30) group using a random number table. The students became homogenous in the both groups in terms of year of admission. Moreover, the number of students from each academic admission year was equal in the both groups. Belongingness Scale-Clinical Placement Experience (BES-CPE) (23) was completed by the both groups in the pre-test phase. Figure 1 shows the flow diagram of the study based on CONSORT criteria.

The CONSORT flow diagram of the study
Figure 1. The CONSORT flow diagram of the study

The intervention group received a total of eight group counseling sessions (two two-hour sessions per week) at the faculty, while the control group received no intervention. It is noteworthy that the number of samples in each group was reduced to 26 during the completion of the questionnaire. Finally, 52 samples were evaluated.

The students in the intervention group were asked not to give the educational pamphlets of counseling sessions to the students in the control group until the post-test was conducted. However, the education pamphlets were given to the control group students after the post-test in order to consider moral principles. The schedule of the intervention group students was set by the Office of Education so that they could participate in the group counseling sessions. Accordingly, they participated in eight sessions of group counseling with the emphasis on communication skills in order to improve their sense of belonging in clinical settings.

3.1. Materials

1. Demographic variables included age, academic semester, marital status, birth place, place of residence, interest in the field of study and having at least one first-degree relatives in the clinical field.

2. Goldberg’s General Health Questionnaire was developed by Goldberg and Hiller in 1979 and consists of 28 items (22). The items 1 to 7 associate with subscale of physical signs, the items 8 - 14 refer to the subscale of anxiety and insomnia, the items 15 - 21 associate with social function disorder and the items 22 - 28 associate with the subscale of depression. The items are scored with 0 and 1 and thus each individual score varies between 0 - 28. To obtain the total score, scores of all the items should be added. The score of 23 and below shows normal general health whereas the score of above 23 shows poor general health. The questionnaire was validated by Taghavi (24) for use in psychological researches and clinical practices.

3. BES-CPE (23) includes 34 items and three subscales of self-esteem (13 items), continuity (10 items) and self-efficacy (8 items) based on Likert scale ranging from 1 (it is never true) to 5 (it is always true). Therefore, the range of scores is between 1 and 170. A higher score shows a higher sense of belonging (23). The validity and reliability of the scale were determined by Hassanvand et al. (7). Accordingly, the reliability of the scale was shown to be r = 0.70 using the pre- and post-test repeatability method. Moreover, the Cronbach alpha value was 0.90 for the total scale, while it was 0.88, 0.75 and 0.84 for the subscales of self-esteem, continuity and self-efficacy, respectively (7). In addition, the content validity of the scale was obtained quantitatively with the content validity ratio being 0.91 and the content validity index being 0.84.

The data were analyzed using SPSS 22. In this regard, a paired t-test was applied to compare the difference between the pre- and post-test mean scores of the two groups and an independent t-test was run to find the difference between the mean scores of the two groups, pre- and post- intervention.

4. Results

The final analysis was carried out on 52 students. Table 1 shows the socio-demographic variables of the final sample.

Table 1. The Socio-Demographic Variables of the Final Sample
VariableInterventionControlP Value
Age, y21.38 ± 1.1621.26 ± 10.63
Semester, No. (%)0.85
Third semester7 (26.9)8 (30.8)
Fifth semester13 (50)11 (42.3)
Seventh semester6 (23.1)7 (26.9)
Marital status, No. (%)0.18
Single22 (84.6)18 (69.2)
Married4 (15.4)8 (30.8)
Residency, No. (%)0.35
Native17 (65.4)9 (34.6)
Non-native20 (76.9)6 (23.1)
Residency status, No. (%)0.07
Dormitory21 (80.8)15 (57.7)
Non-dormitory5 (19.2)11 (42.3)
Being interested in the field of study, No. (%)0.63
Yes24 (92.3)23 (88.5)
No2 (7.7)3 (11.5)
First-degree relative with a clinical job, No. (%)0.99
Yes11 (42.3)11 (42.3)
No15 (57.7)15 (57.7)

Results showed that the mean and standard deviation of age were 21.38 ± 1.16 and 21.26 ± 1 in the intervention and control groups, respectively. Most of the participating students were single (the intervention group = 84.6% and the control group = 69.2%), native (the intervention group = 65.4% and the control group = 76.9%), living in dormitory (the intervention group = 80.8% and the control group = 57.7%), and interested in their fields of study (the intervention group = 92.3% and the control = 88.5%). Moreover, the both groups were homogenous in terms of distribution of background variables and their general health scores (P = 0.69). However, there was a significant difference between the intervention and control groups in terms of total instrument’s mean scores (P = 0.006). With regard to sense of belonging, the highest mean score was given to self-self-efficacy (the intervention group = 3.31 ± 0.74 and the control group = 3.85 ± 0.68) whereas the lowest mean score was given to continuity (the intervention group = 2.43 ± 0.61 and the control group = 2.74 ± 0.75) in the both groups.

Comparative results were obtained on the mean scores of the students in the both groups in terms of sense of belonging in clinical settings before and after counseling. Accordingly, it was shown that a significant increase of the score was observed in the intervention group after counseling, but not in the control group. Moreover, comparative results were obtained on the mean scores of the sub domains of sense of belonging in clinical settings before and after counseling in the both groups. It was revealed that all the domains of sense of belonging in clinical settings significantly increased in the intervention group (Table 2).

Table 2. Comparison of the Subscales of Sense of Belonging in Clinical Settings Before and After Counseling in the Both Groups
Sense of Belonging Intervention (Inter)Control (Con)Statistical Results
Pre-InterventionPost-InterventionPre-InterventionPost-InterventionT (Inter)PT (Con)P
Self-esteem3.07 ± 0.613.54 ± 0.443.51 ± 0.733.65 ± 0.514.80.00011.06< 0.29
Continuity2.43 ± 0.612.78 ± 0.652.74 ± 0.753.03 ±< 0.088
Self-efficacy3.31 ± 0.743.9 ± 0.443.85 ± 0.683.9 ± 0.45- 4.340.00010.54< 0.59
Total score2.88 ± 0.523.38 ± 0.483.34 ± 0.63.43 ± 0.426.460.00010.980.33

Since the intervention and control groups were not homogenous in terms of the mean score of sense of belonging prior to the intervention, “pre-post mean of paired difference” was used to compare the mean scores of the pre-post intervention total scores and subscales. Further, the comparison of “pre-post mean of difference” in the both groups showed that there was a significant difference between the groups in terms of total score as well as the self-esteem and self-efficacy subscales. However, there was no significant difference between the groups in terms of the continuity subscale (Table 3).

Table 3. Comparison of the “Pre-Post Mean of Scores’ Difference”
Belongingness InterventionControlTP Value
Self-esteem0.46 ± 0.490.13 ± 0.642.060.04
Continuity0.36 ± 0.610.24 ± 0.680.620.53
Self-efficacy0.59 ± 0.690.05 ± 0.543.080.003
Total 0.49 ± 0.380.09 ± 0.463.390.001

The results also indicated that there was no significant relationship between the demographic variables and also no significant difference between the pretest with post-test mean scores. Moreover, the intervention was shown to have no significant effect on the sense of belonging in terms of demographic variables (P value was 0.92 for age, 0.58 for academic semester, 0.35 for marital status, 0.28 for living status and 0.53 for interest in the field of study).

5. Discussion

The present study aimed to determine the effect of group counseling on students’ sense of belonging in clinical settings with the focus on communication skills. The results indicated that the mean score of students’ sense of belonging in clinical settings was higher in the control group before counseling than in the intervention group. The mean of scores in the control group was similar to that in the study of Levett Jones et al. (11), McKenna et al. (25) and Dabirifard et al. (26). Data analysis showed that the sense of belonging score significantly increased in the intervention group after counseling, but not in the control group. In a similar vein, Levett‐Jones et al. (14) showed that the improvement of communication skills had a positive impact on nursing students’ sense of belonging. Moreover, in consistent with the current study, previous research applying different methods was successful to enhance sense of belonging (21, 27, 28).

This central concept should be considered by medical teams during their communication with students in clinical settings (14). Providing a suitable setting where midwifery students have a sense of belonging can facilitate effective clinical learning (29, 30) toward achieving professional qualifications required for employment. High quality clinical training, which enhances sense of belonging, provides a safe academic environment for nursing and midwifery students and staff (25, 31).

As shown in the study, prior to holding the counseling sessions, the highest and lowest mean scores respectively belonged to the domains of self-efficacy and continuity in the questionnaire. This was similar to the study of Dabirifard et al. (26), which evaluated sense of belonging in clinical settings among bachelor nursing students. The high score of self-efficacy shows that students intend to do efficient practices that improve their sense of belonging in clinical settings (26). Self-self-efficacy is the intermediary between individuals’ knowledge and behavior and it also associates with professional qualification. The strong sense of self-self-efficacy leads to more efforts in obtaining achievements and higher performance (32).

Some previous research showed a positive strong relationship between students’ communication skills with their self-esteem, sense of belonging and responsibility (28, 33). Mahdavi et al. (2008) reported that responsibility increased students’ self-esteem. They believed that increasing self-esteem could lead to the development of planning ability and occurrence of targeted behavior proportional to the problem (34). Douglas Coatsworth and Conroy (35) believed that empirical interventions (psychological education) could have the strongest effects on increasing self-esteem of youths (35).

The literature review revealed no similar study on the concept of sense of belonging in clinical settings. Only some studies with other interventional techniques and various sample size measured interventional effect on sense of belonging in the academic environment. Borzabadi and Araghieh (2015) in their study indicated that students’ sense of belonging in schools increased by encouraging and motivating them to have this sense (27). In the study of Abolqasemi et al. (36), the use of the Jigsaw collaborative learning method had a significant positive effect on increasing sense of belongingness among students and enhancing their social interactions. These studies focus on the influence of efficient interventions on sense of belonging.

Concerning the valuable role of clinical training in education of midwifery students and the necessity of its high quality, it is highly important to promote students’ sense of belonging in clinical settings.

5.1. Conclusions

Emphasizing communication skills in group counseling had an effective role in enhancement of students’ sense of belonging, especially in the subscales of self-esteem and self-efficacy. Therefore, running sessions and workshops before or during clinical practice can improve performance, basic skills and proficiency of students.

5.2. Limitation of the Study

Some of the students were reluctant to attend the counseling sessions, which led to the decreased number of participants receiving the intervention. Moreover, genetic, personality and individual differences had influences on the pre- and post-test results.




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