INTRODUCTION

The cause of the pneumonia cases, which first appeared in Wuhan, China towards the end of 2019, was identified as the new type coronavirus disease 2019 (COVID-19) on January 7, 2020. COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020, due to a dramatic increase in the rate of cross-country spread, morbidity, and mortality (3.4%) across countries. Turkey’s first case was announced on the same date. As a result of restrictions at the national level, the higher education board suspended education for 3 weeks as of March 16, 2020, and education on digital platforms was resumed in all universities with distance education as of March 23, 2020.

As in many countries of the world, the pandemic in our country caused an interruption that led to rapid and dramatic changes in the nature of midwifery education. In the short term, it has led to different approaches being adopted in order to reduce the impact on theoretical and clinical training of the current midwifery students and to seek the best approaches for both midwifery students and lecturers during the COVID-19 pandemic. In Turkey,¹ vocational courses in midwifery education are carried out simultaneously with theoretical and clinical practice. In this process, in which patient interaction was completely stopped, training suddenly started to be given in a digital environment. The training was carried out on digital platforms, either live or recorded. Midwifery education in Turkey has various graduation criteria. For instance, 4^th Grade midwifery student must have performed at least 40 normal vaginal births accompanied by a responsible instructor and a clinical midwife. Due to the closure of universities and the national restrictions imposed during the pandemic period and due to the fact that it is an “applied education”, especially the development of practical skills of the midwifery students who are candidates to graduate was interrupted. These practical skills are now often being developed on digital platforms through training videos and case discussions. In this process, the basic graduation criteria are based on the requirements set by the European Union directives and the time to be completed. Midwifery students who completed these criteria have entered the workforce.

The impact of social distancing, staying at home, or working with women who are likely to be infected, with some shortcomings, on graduate students is thought-provoking. Some researchers state that one in five students felt more anxious or depressed than they were in the period before COVID-19.² Digitization, currently a clear necessity, can result in a loss of experience, which has the potential to significantly damage education.³ In this context, Luyben et al.⁴ points out that while policymakers grapple with decisions that will affect all of us, we have only a limited overview of what students are going through and what directions the virus is taking us in. In spite of the pandemic, there is an important issue in this context that midwifery trainees continue their efforts to obtain the required competencies and skills at the same level as before the interruption.

Medical education has a different education structure than nursing and midwifery professions which has an education system coordinated with the clinic. This pandemic process has underlined the importance of nurses and midwives, who are an indispensable part of the team. It is imperative to acknowledge that our most valuable resource in fighting this pandemic is nurses. Also, midwives, who are an important part of preventive public health services, have continued their duty to maintain maternal and child health with optimum care despite all difficulties. During this challenging process, many pregnant women (especially women with previous loss) stated that they were really afraid of becoming COVID-19 positive, with feelings of insecurity, and anxiousness. This means that women need more support and reassurance by all healthcare professionals, during pregnancy, childbirth, and puerperium.⁵ For many midwives, the care given during labor and birth evokes images of a professional strengthening the first bonds of a new family, rubbing her back, dealing face to face with the woman, and holding her hand.⁶ However, it was not possible to provide care with this approach during the pandemic process. In this context, determining how the process affects the prospective graduate vocational school of health service students will allow us to make various predictions about these new groups who will join the workforce. Studies have been carried out during the COVID-19 period and past pandemics with students in the field of health (studies were conducted during the periods of SARS, Influenza, H1N1, MERS).^7-15 In those studies, issues such as stress, coping strategies, educational problems, and voluntary work were often investigated. There is only a limited number of studies evaluating professional belonging in the research findings, and no specific evaluated study was found.¹⁵ Professional belonging defines a person’s professional commitment as a psychological connection based on an affective response between the person and his or her profession.¹⁶ A midwife’s ownership of her profession, her willingness to take on her responsibilities towards her profession, her willingness to develop herself in the professional field, her belief in the values ​​of her profession and her determination to continue her profession show the midwifery affiliation. A midwife with high professional belonging feels safer and happier in her professional journey. A midwife who does not have a professional belonging can turn to jobs that are not their own duty, they can avoid the workload and act intolerantly towards the patients they serve. Considering Maslow’s hierarchy of needs, it can be seen that professional belonging has a very close relationship with the concepts of job satisfaction, and organizational and institutional commitment. In cases where there is job satisfaction or organizational and institutional commitment, professional belonging can also be considered high. In this context, factors affecting professional belonging can be summarized as follows; professional status, wage, teammates working together, working conditions, job security, public perception, the personality of the employee, conflict in the role, education, economic security, career opportunities, financial and moral rewards, participation in decisions, the work itself, the attitude of managers, and powers and responsibilities.¹⁷ Increasing workloads, and uncertainties and concerns in the field of work during the pandemic process are thought to cause a loss of motivation among our colleagues and affect professional belonging.

In this study, the relationship between the professional belonging levels of midwifery students and the effects of COVID-19 on the social order and health system was evaluated. It is important to evaluate the factors that affect the feelings of professional competence of this group who participate in the workforce in extraordinary circumstances and their ability to cope with the forces that will be encountered in the health system in order to guide their education. In this process, to which we have not yet reached a solution, it is important to develop an awareness of professional belonging while adapting to the changes in education. It is a very unfamiliar issue to create this feeling in the students without them interacting with the patient or entering the care environment in the clinic. However, with a forward-looking point of view, it is possible to say that this has become a fundamental requirement for this occupation.

MATERIALS AND METHODS

Study Design and Sampling

This planned cross-sectional, correlational and descriptive study was conducted as a web-based research between June 15–20, 2020. In line with the aim of this study, a purposive sample was selected and only 4^th-grade students of the midwifery department studying at the undergraduate level were invited to take part in this study. The invitation to participate in this study was shared on the website of the student committee of the Anatolian Midwives Association, a national professional association. The target population of the study was 317 senior midwifery students who had enrolled in the student committee. It was aimed to reach the whole target population. The minimum sample size was calculated at a significance level of p<0.05 at a 95% confidence interval. The sample size was calculated using the sampling formula with a known population. Research data on the level of professional belonging of midwives reported in the study conducted by Baskaya et al.¹⁷ were used, and the sample size was identified as 151. The study was completed with 210 students who volunteered to participate.

Research Questions

What is the level of professional belonging of the student midwives?

Can health care policies in the pandemic process affect this sense professional of belonging?

Data Collection

The data collection phase was conducted in an online environment. All quantitative data were collected using a web-based online survey form within a specified time period. Individuals who headed to the link address given in the introduction of the information about the study first encountered an illuminated consent section. Individuals who approved the information participated in the study by completing the research form. The completion time of the online form was 5 minutes on average.

Data Collection Tools

The online survey form consisted of two parts. The first part includes introductory features, and the second includes the “Midwifery Belonging Scale (MBS)” developed to determine the levels of professional belonging.

Introductory Information Form

The introductory information form was originally prepared by the researchers in line with the related literature.^13,17 In the first part of the introductory information form, introductory features such as age, class, marital status, socioeconomic characteristics, and information about attitudes towards the preference of the midwifery profession were present.

In the second part, there were factors that may be related to occupational belonging, which examines the pandemic process and the effects of the pandemic on healthcare professionals and education. The questions related to education were prepared in line with the academic researchers’ own observations and experiences. Questions related to healthcare services were prepared in line with studies conducted in past pandemics and the news encountered in the media during this pandemic process.^8-12 The first draft of the form consisted of 32 questions. The questions were evaluated by an expert group and evaluated in terms of their similar meaning, understandability and expressions. The expert group consists of two faculty members from the midwifery department and an academic psychologist as an external observer. In line with the expert group reviews and suggestions, the form was finalized with 25 questions.

Midwifery Belonging Scale

To determine the level of professional belonging of midwives, a scale developed by Baskaya et al.¹⁷ was used. MBS, consisting of 22 articles with four sub-dimensions in total, namely: Emotional belonging, performance of professional roles and responsibilities, professional development and utilization of opportunities, and limits of duty and authority in the profession. The scale items consist of 22 items, all of which are positive, scaled between 1–5 (ranging from “Absolutely disagree” to “Absolutely agree”). The scores that can be obtained from this scale range between 22–110. The higher scores obtained from this scale are interpreted as meaning having high professional belonging. In the 2020 study of Baskaya et al.¹⁷, the Cronbach alpha () value of this scale was stated to be 0.905. The Cronbach alpha () value of this study was 0.902 and the item Cronbach alpha () values were between 0.892–0.910. This value is required to be at least 0.70.¹⁸ As a result of the Cronbach alpha values obtained, the scale was seen to be statistically reliable.

Statistical Analysis

The data were analyzed using descriptive and parametric statistical analysis methods via the Statistical Program for Social Science 20.0 (SPSS) (IBM, Chicago, IL, USA). The descriptive characteristics of the participants, their attitudes, beliefs, and the related factors towards sexuality during pregnancy, their comfort levels during counseling, and related factors were analyzed as frequency and percentage. In the comparison of dependent and independent variables, Student’s t-test was performed to determine the difference between two sets of data, and the One-Way ANOVA test was performed for the difference between three or sets of data. Multiple Linear Regression analysis was used to determine the relationship of dependent and independent variables with each other. Regression analysis results showed with regression coefficient (), coefficient of determination (R/R²), and goodness of fit of the model (F and p) values. The statistical significance level was taken as p<0.05.

Ethical Considerations

Ethics committee permission was taken from the Near East University Hospital Scientific Research Evaluation Ethics Committee before the research started (approval number: 2020/78-1054). The voluntary nature, the option to terminate at any time and anonymous quality of the study were stated to the participants in the illuminated consent section.

RESULTS

The average age of the students was 22.48±1.76 years. The majority of the students, almost all of whom (95.2%) are single, are members of a nuclear family, and approximately two-thirds stated that their income level is moderate. The rate of those who willingly choose to receive midwifery education is 66.2%, and the rate of satisfaction with their preference over the years is 87.6% (Table 1).

The findings regarding the situations of the students encountering a COVID-19 positive case, their concerns about healthcare workers in this process, their feelings of educational competence, and their feelings and thoughts about working conditions during the pandemic period are shown in Table 2. It seems that the students tend to think positively about volunteer work or being called to duty in cases of shortages of healthcare staff. 37.6% of them stated that the COVID-19 positive patient can be denied care, while 17.1% of them think that they should be punished in cases of refusal to care for a COVID-19 patient. The vast majority of the group stated that they could quit school if they were in the first year of their education, but for now, there were only three students who stated that they could quit the profession (Table 1).

The MBS total scores of students was 98.42±10.24 (minimum–maximum: 43–110). The mean scores of the subscales were as follows; 31.83±3.76 for emotional belonging, 31.82±3.74 for performance of professional roles and responsibilities, 16.95±2.48 for professional development and utilization of opportunities and 13.31±2.24 for limits of duty and authority in the profession (Table 2).

The factors associated with professional belonging levels and the Multiple Linear Regression Analysis Model were examined in three groups: namely, introductory features, health policy, and educational. Age, home, and family type are descriptive characteristics; they are meaningful predictors of the sense of professional belonging (p<0.05). The factors relating to volunteering, denial of care, and colleagues were included in the model under the heading of health policies. Of these factors, the fact that there is a system of punishment for being called to duty and refusing to work only in the event of incompetence are meaningful predictors of the level of professional belonging. Not finding it appropriate to invite students for duty in cases of shortages of healthcare workers is associated with a high level of professional belonging (p<0.05). Similarly, the belonging of those who find it inappropriate to be punished for rejection of care work increases. The high level of relationship factors between these factors relating to education and the sense of belonging to other groups is striking. The feeling of inadequacy to be able to graduate, adequate professionalism, concerns about starting the profession, and satisfaction with this profession are significant predictors to the sense of professional belonging (Table 3).

DISCUSSION

In this study, factors affecting students’ perspectives on their profession and their level of professional belonging due to the COVID-19 pandemic were researched. It was observed that the urgent change process emerging, especially in the form of education, was a factor affecting the level of professional belonging of the students. However, it was determined that positive attitudes towards health policies were positive predictors that affected the sense of professional belonging.

The average age of the students participating in this study was found to be 22.48±1.76 years, 66.2% of the students stated that they wanted to receive a midwifery education (Table 1). In the study conducted by Görgen and Bingöl¹⁹ on nursing and midwifery students, 61.3% of the students stated that they chose this department willingly. Again, in a similar study conducted by Söğüt et al.¹³, it was stated that the average age of the students was 21 years. These studies are in line with our findings. Research has shown that diseases such as coronavirus, which cause great devastation in societies, increase the rate of anxiety in people.^20,21 According to research conducted by the Mental Health Association in our country, 50% of the population stated that they were afraid of getting coronavirus; 59% of them stated that their worries about their health increased; 61% of them stated that their worries about their future increased; and 48% of them stated that their feeling of uneasiness increased.²² These situations such as the students’ stress levels, difficulties with accessing education, and COVID-19 positive cases around them were associated with an increase in the students’ anxiety and difficulty in coping mechanisms.^13,15,23 It was observed that the students participating in the study have a tendency to think positively about volunteering or being invited to work in cases of shortages of health care staff. 37.6% of them stated that they can refuse care to a COVID-19 positive patient, while 17.1% of them think that they should be punished in such cases of refusal. The majority of the group stated that if they were in their first year of education, they could drop out of school (Table 2). Although stress levels and associated emotional changes were not examined in this study, we think that these variables may be related to professional belonging levels.

Monforte-Royo and Fuster²⁴ stated that in the year celebrating Florence Nightingale’s 200^th birthday and designated as “the International Year of Nurses and Midwives” by the WHO, all students who graduated as midwifery nurses during the COVID-19 epidemic could be called ‘coronial’.²⁴ This coronial group was deprived of the intensive clinical experience and responsibility for further practice, especially in the final 3 months of their training. The transition from student to qualified professional life is a complex phenomenon. Various studies mention that the first year of work is difficult for new graduates. It has been stated that they experience stress as a result of their expectations and the team’s expectations from them, with the struggle to make the right decisions, and to adapt to a high workload.^25,26 These students have never seen such high rates of patient death, and have never had to work in a health system and its chaotic conditions where treatment protocols are constantly updated. In addition, they have not had experiences such as a fear of being infected, feeling unprepared to work in the midst of a pandemic, pressure to provide care, and isolation from their families to avoid exposing them to the risk of infection. All these are factors that can affect the level of professional belonging and the feelings, thoughts, and attitudes associated with starting their profession. Among the students participating in this study, the fact that there is only a punishment system for recruitment and refusal of care is one of the significant predictors of the level of occupational affiliation, and in cases of a shortage of healthcare workers, it was found that this was associated with a high level of occupational belonging (p<0.05). Similarly, the belonging of those who find it inappropriate to be punished for refusal to care for COVID-19 patients increases. The relationship between the factors relating to education and the sense of belonging to other groups is striking. The inability to graduate, the feeling of adequate professionalism, concerns about starting the profession and satisfaction with this profession are significant predictors of the sense of professional belonging (Table 3). Dos Santos²⁷ stated in his qualitative study that financial factors are effective in the sense of belonging and career plans of student nurses who will graduate during the pandemic process. Contrary to this data, our study findings showed that the perception of the economic level was not a meaningful predictor of a sense of professional belonging. As noted in many studies in the literature, unwillingness to enter a profession is associated with a low sense of belonging.^28-31 Hence, the findings of this study are in line with this.

According to these findings, midwifery students were mostly willing to work voluntarily and believed that this was a professional responsibility. However, these are not significant predictors of professional belonging. On the other hand, the sense of belonging of those who stated that it would be appropriate to be invited in case of staff shortages was approximately 3 times higher. Herman et al.⁷, in their study during the influenza epidemic, mentioned an increase in the risk of contracting the disease, although it was encouraging that healthcare students believed that they had an obligation to volunteer during a pandemic. In a study with midwives on Ebola, a previous regional epidemic, it stated that in addition to the fear of being infected with the virus, the public had to deal with the fear of this infectious disease. They stated that the fear of being a risk to their families, which they coped with in different ways, was another important source of stress.³² The fact that all participants stated that they would not hesitate to provide care in the event of encountering a COVID-19 positive pregnant woman and the fact that there were few concerns about starting their profession suggests that they ignore some risks in this process, which they are still alien to. This is an extremely positive reflection of their high sense of professional belonging.

It was an interesting and impressive result of this study that those who did not feel competent to graduate had higher levels of professional belonging. In applied professions, the patient-healthcare professional relationship is an emotional one. Although the system continues theoretically, the lack of practice in the clinic reinforces a sense of inadequacy for students with a high sense of belonging. In such extraordinary times, there is little specific information about treatment and care, especially in the initial phase. Current protocols cannot provide clear guidance on many of the practical and ethical dilemmas they will face. Infection control procedures are often restrictive, strict and leave limited opportunities to improve the level of care of pregnant women during pandemic times, especially for midwives, who inherently involve cooperation and touch with pregnant woman as part of their duties. These limitations might help develop professional creative skills, as noted by Erland and Dahl.³² This pandemic is a process in which changes and rapid adaptation to this change is occurring in many areas. We think that these difficult conditions will lead individuals with a high awareness of professional belonging to think more analytically and practically.

CONCLUSION

The level of professional belonging of student midwives is quite high.

More studies are needed on how we can consolidate this consciousness and emotion in the digital environment. In addition to this, we recommend conducting online meetings, symposiums or social activities to improve students’ sense of occupational belonging, as well as conducting studies that evaluate this group, who joined the workforce under extraordinary conditions, in terms of concepts such as burnout, post-traumatic stress, professional satisfaction and professional adaptation.

MAIN POINTS

• Socio-demographic factors such as age and family type are predictors of a sense of belonging.

• Health care policies in the pandemic process can affect the sense of belonging.

• Especially the processes of change, failures and adaptation in education are important in terms of professional belonging.

The reason for having a high sense of belonging of senior students can be because we do many stages of education in a face-to-face environment.

ETHICS

Ethics Committee Approval: Ethics committee approval was obtained from the Near East University Hospital Scientific Research Evaluation Ethics Committee (approval number: 2020/78-1054).

Informed Consent: Written informed consent was obtained from the  who participated in this study.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: F.Y, B.A.V., Design: F.Y., B.A.V., Supervi­sion: F.Y., B.A.V., Data Collection and/or Processing: F.Y., B.A.V., Analysis and/or Interpretation: F.Y., B.A.V., Literature Search: F.Y. B.A.V., Writing: F.Y. B.A.V., Critical Reviews: F.Y. B.A.V.

DISCLOSURES

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The author declared that this study had received no financial support.