The Relationship between Metacognitive Beliefs with Clinical Belongingness and Resilience among Novice Nurses in Neonatal Intensive Care Units

Background The neonatal intensive care unit (NICU) is a sensitive ward for nurses. However, the low nurse-to-patient ratio has led to the hiring of novice nurses into the critical areas such as NICUs. These nurses are in need of help in the clinical environment as they have no much experience caring the neonates in the real clinical setting. Therefore, it is necessary to address the individual and psychological capacities with the help of which a person can overcome the difficult situations. This study aimed to investigate the relationship between metacognitions, clinical belongingness, and resilience of novice nursing staff in NICU wards. Method This study is a descriptive-analytical study, and the research samples were composed of 78 novice nursing staff of Neonatal Intensive Care Units from teaching hospitals. Samples were selected via a purposive sampling method. Research tools included demographic, Wells and Hatton metacognitive beliefs, Jones Levitt belonging, and Connor–Davidson resilience questionnaires. SPSS 22 software was used for data analysis. Results The mean score of metacognitive beliefs in novice nursing staff was 92.67 ± 13.69, and it was 116.69 ± 19.11 for belongingness and 78.78 ± 14.73 for resilience. There is positive and significant relationship between metacognitive beliefs and belongingness (p < 0.019, r = 0.265). In addition, the relationship between metacognitive beliefs and resilience in novice nursing staff was positive and significant (p < 0.001, r = 0.359). Conclusion There is a positive relationship between metacognitive beliefs with belongingness and resilience of novice nurses; nursing managers can consider educational metacognition workshops to enhance the sense of belongingness and resilience of novice nursing staff leading to improve their clinical performance in neonatal care.


Introduction
Nurses are the frst to recognize the risks and critical situations of infants and take action to address them in the Neonatal Intensive Care Units [1]. Nurses are one of the largest health care providers [2], but nursing shortage has led to the use of novice nurses in the health care system, who often enter real situations early, and caused job and environmental stress and reduced their satisfaction [1,3]. In one study, the average ratio of nurses to infants in the Neonatal Intensive Care Unit in Tehran, the capital of Iran, one nurse for more than 4 babies, was reported [1]. Novice nurses have many problems in context, including having difculty in concentrating, lacking focused attention, and failing to maintain moment-to-moment awareness. Novice nurses in clinical settings need help and do not know what is expected of them in real settings [4,5]. In this way, they are not able to understand their situation and solve problems efectively [6]. However, novice nurses, in order to creatively solve problems, need skills that can help them in the proper and correct use of their information [7]. Te novice nurses' past experiences acquired through their academic studies include factors to enhance them, and one factor is metacognition or having the talent or skill of metacognitive ability, which helps novice nurses use these experiences in new situations [8]. Metacognition is a multifaceted concept that includes beliefs (knowledge), processes, and strategies that evaluate, monitor, or control cognition [9]. Tis knowledge is beliefs and theories held by people about their thinking, such as beliefs about the meaning of certain types of thoughts, the efciency of memory, and cognitive control, and they are responsible for controlling healthy and unhealthy thoughts [10]. Te results of some studies have shown that metacognitions are efective factors in the state of mental health. We can improve the situation by changing the metacognitions that increase the maladaptive ways of negative thoughts or increase the general negative beliefs [11,12]. Tus, we can help people to structure their thinking and prepare themselves to accept their future roles [13]. Moreover, maintaining meaningful relationships with others is a permanent desire in humans, and people tend to communicate with each other for optimal performance [14].
Te sense of belonging is one of the basic human needs that creates a sense of security and comfort. In general, people are trying to be accepted by others because the lack of communication with others has many cognitive, emotional, and behavioral consequences [15]. One nursing concept analysis defnes the sense of belonging as the experience of a person's involvement in a system or environment so that a person feels that she is an integral part of that system or environment [16]. Te absence of a sense of belonging can lead to problems such as low self-esteem and satisfaction, anxiety, depression, high level of stress, and increased tension in clinical practice [17,18]. Belongingness is an important efect factor in workplace satisfaction, and this type of satisfaction is one of the main factors that determine nurses' resilience in difcult situation [19].
Resilience is one of the main abilities of humans enabling them to resist difcult conditions and mental pressures through efective adaptation to changes and stressful factors [20]. Warelo and Edward stated that 21st-century nurses need to skillfully develop their resilience to face professional challenges and ensure their mental health because resilience and resilient behaviors potentially help individuals to overcome negative experiences and turn these experiences into positive experiences [21].
Considering the annual employment of a large number of novice nursing staf in the medical care system and their predefned problems, it is necessary to provide solutions to improve their skills. Te role of metacognition in solving problems, attitude towards problems, resilience against them, and clinical relevance in the path of gaining experiences and lack of research on the role of metacognition necessitates determining the role of each of these variables and in case of the presence of efective role to design programs to improve them. Te lack of research studies that has investigated the relationship between metacognitive beliefs, belongingness, and resilience, especially in novice nurses, caused that this study was conducted to investigate the relationship between metacognition, belongingness, and resilience in novice nursing staf in Neonatal Intensive Care Units (NICUs).

Methods
Te present study was a descriptive correlational study. Te samples included 78 novice nursing staf working in Neonatal Intensive Care Units of three hospitals afliated to Shiraz University of Medical Sciences. After obtaining permission from the Ethics Committee and Vice Chancellor for Research of Shiraz University of Medical Sciences, the researcher referred to the mentioned hospitals and selected the novice nursing staf who were eligible to enter the study by the purposive sampling method. It was decided that nurses with less than one year of work experience in NICU wards through the purposive sampling method entered the study. Other inclusion criteria for this study were as follows: having at least a bachelor's or master's degree in nursing or midwifery, working in the Neonatal Intensive Care Units of mentioned hospitals, and signing the informed consent form.
After obtaining informed consent from the samples, researcher provided the relevant questionnaires to novice nurses to complete. Te ethics code of this research (IR.SUMS.REC.1400.217) was obtained from the Ethics Committee of Shiraz University of Medical Sciences.
In order to achieve the objectives of this study, demographic characteristic questionnaires, Wells and Hatton metacognitive beliefs, Jones Levitt belonging, and Connor-Davidson resilience questionnaires were used: (1) Demographic Information Questionnaire. Tis questionnaire contains questions such as age, sex, marital status, feld of study, and type of ward; the face validity of which has been approved by several professors and experts in neonatal nursing feld.

(2) Wells and Cartwright-Hatton Metacognitive Beliefs
Questionnaire. Tis questionnaire was designed in 2004 and has 30 questions in which each person answers four-choice questions (disagree, slightly agree, relatively agree, and strongly agree). Tese options are scored 1, 2, 3, and 4, respectively. Tis questionnaire has 5 subscales: cognitive confict measures positive beliefs, cognitive self-awareness, uncontrollability, and the danger of thoughts and the need to control thoughts. A high score on this scale indicates a strong level of metacognition in the individual. A score between 30 and 60 indicates a weak level of metacognition, a score between 60 and 90 indicates an average level of metacognition, and a score between 90 and 120 indicates a strong level of metacognition in a person. Hatton and Wells have reported the Cronbach's alpha coefcient of this questionnaire and its components in the range of 0.72 to 0.93 and its retest reliability coefcient (with an interval of one month) of 0.73 [22]. Osoli [28]. Javadian and Fathi reported the reliability of the resilience scale using Cronbach's alpha method as 0.86 [29]. Regarding its validity, using the factor analysis method, the calculation of each score with the total score showed that, except for the three questions that were higher, the coefcients of the other questions were between 0.51 and 0.61 [30].

Ethical Considerations.
Ethical approval was obtained from the Local Research Ethics Committee of Shiraz University of Medical Sciences, Iran (Approval No. IR.SUMS.REC.1400.217). In the beginning, a verbal description of the study objectives was provided for novice staf and after the assurance of the confdentiality of their information, the written informed consent was obtained from participants.

Results
From 78 novice nursing staf working in Neonatal Intensive Care Units (NICUs), 43.6% of the staf are working in internal wards of NICUs with 93.5% of the novice nursing staf aged less than 31 years. All novice nursing staf in NICUs were female (no male nurses have worked in the Neonatal Intensive Care Units during this study) and 55.1% of them are single. Te majority of these staf (97.4%) had a bachelor's degree (Table 1). Te lowest score recorded for metacognition in novice nursing staf was 63 and the highest score was 125 with an average of 92.67, which indicated the high score of metacognitions. Te lowest recorded score for the belongingness in novice nursing staf was 46 and the highest score was 141 with an average of 116.69, which indicated high belongingness in novice nursing staf. Te lowest score of resilience in novice nursing staf was 14 and the highest score was 95 with an average of 72.87, which indicated high resilience in novice nursing staf ( Table 2).
Given the quantitative nature of the two indicators, Pearson's correlation test was used to determine the relationship between metacognition and belongingness. Pearson correlation coefcient of 0.265 shows a positive relationship between metacognition and belongingness. Te signifcance level of Table 3 (p < 0.05) shows the signifcance of this correlation coefcient at the 5% error level. In general, the results show that there is a relationship between metacognition and the belongingness of novice nursing staf in NICUs. Also, given the quantitative nature of the two Nursing Research and Practice indicators, Pearson's correlation test was used to determine the relationship between metacognition and resilience. Pearson correlation coefcient of 0.359 shows a positive relationship between metacognition and resilience. Te signifcance level of the above table (p < 0.001) shows the signifcance of this correlation coefcient at the 5% error level. In general, the results show that there is a relationship between metacognition and the resilience of novice nursing staf in NICUs (Table 3).
According to the correlation coefcient (r � 0.265), the relationship between metacognition and belongingness is positive and signifcant (Figure 1).
According to the correlation coefcient (r � 0.359), the relationship between metacognition and resilience is positive and signifcant (Figure 2).

Discussion
Tis study examined the relationship between metacognition with belongingness and resilience in novice nursing staf in Neonatal Intensive Care Units in three hospitals. Te results showed that there was a signifcant relationship between metacognition and belongingness. Te results of this research are consistent with the study of Mousavi and Alvani [31] and Chamanabad et al. [32]. In fact, nurses involved in difcult issues and problems need to simultaneously use metacognition to understand concepts, fnd creative solutions, and make the decision, as well as belongingness to increase clinical skills. Both of the abovementioned variables will help nurses in difcult situations; thus, the two skills will help to solve problems more favorably. Some studies have shown that cognitive skills and knowledge enable people to understand concepts, solve problems, and make decisions [33,34]. In other words, through metacognition, novice nursing staf can solve their problems when problems arise and cause confusion. Tis power in solving problems and overcoming problems increases the sense of belonging as an important factor in clinical learning.
Te results showed that there was a signifcant relationship between metacognition with resilience. In a study by Han in Korea, a signifcant relationship was established among metacognition, shared leadership, and resilience [35]. Tis study was consistent with the results of Hasani's study [36] and the study of Yoosef and Karimipoor [37].    In explaining these fndings, it can be said that belief and awareness of individual abilities and inabilities, which are considered to be part of the characteristics of the metacognition system, strengthen motivation, and initiate a series of actions to win the task. Before a person chooses a job and starts his or her eforts, she/he frst collects and evaluates information about his or her capacities and abilities in that particular case. Doing this step allows him/her to consciously review themselves, whether she/he can adapt to perform a certain behavior in the face of problems or not. Also, it is also specifed that how much she/he will try despite the existing problems and how long she/he will continue eforts in the specifc feld. In these conditions, people will achieve sufcient self-efcacy (characteristic of resilience) and will be able to cope with unpleasant or complex events more efectively, and fnally, optimism and positive thinking will become active in the resilience process. By achieving resilience, people are more steadfast in their eforts, they have more confdence in their abilities, they do not drown in the waves of their doubts, they persevere in doing their tasks, and often the result of their performance is at a high level. Also, the activation of positive metacognition makes people less tense. It should be noted that the experience of tension in people causes them to engage in incompatible coping strategies (avoidance and suppression of thoughts) and the use of these strategies intensifes stress and negative emotions. Tis process makes people overestimate environmental threats and not have the ability to deal with problems, and this leads to a decrease in their resilience; therefore, it can be concluded that having metacognition knowledge can increase resilience. Te main limitation of this research is that the results cannot be generalized due to the small number of samples and hospitals.

Conclusion
Tis study showed that there is a signifcant relationship between metacognitive beliefs with clinical belongingness and resilience of novice nursing staf in NICU wards. In other words, the more metacognition a novice nurse has in the clinical environment, the better her/his belongingness and resilience. Tis also increases the belongingness to the clinical environment and increases the motivation of novice nursing staf to learn at the clinic. Terefore, it is suggested that health professionals improve the clinical belongingness and resilience of novice nursing staf in NICUs by developing training programs for novice nurses to increase the quality of care for neonates through the increasing of belongingness and resilience in nurses.

Data Availability
Data used and analyzed to support the fndings of this study are available from the corresponding author upon request.

Disclosure
Tis article was extracted from M.S. thesis of the second author.

Conflicts of Interest
Te authors declare that there are no conficts of interest.