Journal of Nursing Education

Major Article 

Student Interpersonal Connection in Nursing Education: A Concept Analysis

Amanda E. Cornine, MSN, RN, CNE

Abstract

Background:

A sense of connection is central to nursing education and is associated with positive student outcomes. The aim of this concept analysis was to clarify the meaning of student interpersonal connection in nursing education.

Method:

Walker's and Avant's method of concept analysis was used. GoogleTM and ancestry searches identified uses of “connection” across disciplines. PubMed® and ancestry searches identified 24 relevant manuscripts from nursing education, and two concept analyses related to connection in general nursing contexts; these informed the core of the analysis.

Results:

Across disciplines, connection had varied uses; these informed the analysis. Student interpersonal connection in nursing education was tentatively defined as a nursing student's evolving perception of mutually valuing, feeling close to, feeling comfortable with, and being cared about by others he or she encounters in education.

Conclusion:

The evolving nature and importance of this concept support the need for further scholarship in this area. [J Nurs Educ. 2020;59(1):15–21.]

Abstract

Background:

A sense of connection is central to nursing education and is associated with positive student outcomes. The aim of this concept analysis was to clarify the meaning of student interpersonal connection in nursing education.

Method:

Walker's and Avant's method of concept analysis was used. GoogleTM and ancestry searches identified uses of “connection” across disciplines. PubMed® and ancestry searches identified 24 relevant manuscripts from nursing education, and two concept analyses related to connection in general nursing contexts; these informed the core of the analysis.

Results:

Across disciplines, connection had varied uses; these informed the analysis. Student interpersonal connection in nursing education was tentatively defined as a nursing student's evolving perception of mutually valuing, feeling close to, feeling comfortable with, and being cared about by others he or she encounters in education.

Conclusion:

The evolving nature and importance of this concept support the need for further scholarship in this area. [J Nurs Educ. 2020;59(1):15–21.]

Connections are essential to everyone, as society is based on interactions with others and the environment (Lane & Serafica, 2014). In nursing, connections are part of routine practice (Lane & Serafica, 2014), both physically and psychologically. In education, a student's sense of connection has been linked to success in learning (Lizzio, 2006). Not surprisingly, Boyer (1989) described connections as central to nursing education, and Pesut (2003) identified interpersonal connection as a common element within the culture of nursing education. Clearly, connections are important to society at large, to nursing, and to nursing education.

Walker and Avant (2011) emphasized the importance of understanding concepts through analysis for creating theory, and Meleis (2012) pointed out that concept analysis can contribute to concepts being useful in research or practice. However, a search of PubMed®, Educational Resources Information Center (ERIC™), ProQuest® Education Database, and ProQuest® Education Collection revealed no published concept analysis on connection in education. Several concept analyses related to connection in general nursing contexts were identified (Lane & Serafica, 2014; Phillips-Salimi, Haase, & Kooken, 2012). Yet, these concept analyses are not focused on nursing education and the experience of connection is likely unique for nursing students (Lane & Serafica, 2014; Table 1 provides further differences between existing concept analyses and the current concept analysis). Without a clear definition of connection in nursing education, it may be difficult for nurse educators to recognize and promote connection.

Comparison of Concept Analyses of Connection in Nursing

Table 1:

Comparison of Concept Analyses of Connection in Nursing

The current analysis began with the aim of investigating connection within nursing education, but as the concept analysis evolved, the focus was narrowed to student interpersonal connection in nursing education. This article details the process of evolution, with the purpose of developing a concept analysis of student interpersonal connection in nursing education.

Method

Before a concept can be analyzed, it should first be appraised for its level of maturity (Morse, Mitcham, Hupcey, & Tasón, 1996). The literature on the concept of connection did not reveal a consistent definition, clearly defined characteristics, or well-defined boundaries, indicating that this concept is relatively immature (Morse et al., 1996). In this case, Morse et al. (1996) suggested Walker's and Avant's (2011) method of concept analysis, which was chosen for the current analysis. Their method includes eight steps:

  • Choose a concept.
  • Establish the reason for the concept analysis.
  • Determine all usages of the concept.
  • Ascertain the essential elements.
  • Distinguish a model case.
  • Delineate other types of cases.
  • Establish antecedents and consequences.
  • Describe observable referents.

GoogleTM and ancestry searches were used to identify uses of the concept of connection across many disciplines. Because the relevant literature was abundant, a targeted search strategy was then used to identify the sources most relevant to student interpersonal connection in nursing education. There were no date limits placed on these searches. PubMed was searched for English language publications using the search terms education, nursing [MeSH] and connect* [Title]; ancestry searching was also used. Twenty-four relevant nursing education publications and two concept analyses related to connection in general nursing contexts were used to inform the definition, antecedents, and consequences in this concept analysis. Figure 1 further details this literature search and evaluation process.

Flowchart of literature search and evaluation.

Figure 1.

Flowchart of literature search and evaluation.

Results

The steps of Walker's and Avant's (2011) concept analysis were used in an iterative fashion, although they are listed systematically in this article. In particular, I moved among the first three steps (concept selection, aim of analysis, and identification of uses) several times while clarifying the focus of this analysis.

Concept Selection

Connection within nursing education was the initial topic selected for this concept analysis; however, given that a broad literature search revealed that the uses of connection were highly varied even within nursing education, the concept analysis was then narrowed to student interpersonal connection within nursing education. The topic of this concept analysis is relevant to nurse educators, in keeping with Walker's and Avant's (2011) suggestion that a concept selected should be relevant to a researcher's area of curiosity.

Aim of Analysis

The literature search revealed many uses of the concept of connection within nursing education without a clear and unified definition. Therefore, the aim of this concept analysis was to clarify the meaning of student interpersonal connection in nursing education. By having a clear definition of this concept, nurse educators will be better prepared to recognize and promote students' interpersonal connection.

Identification of Uses

Walker and Avant (2011) stated that this step-in concept analysis should discover as many usages of the concept as possible, and Schiller (2018) described it as an immersion. Weaver and Mitcham (2008) suggested that it is impossible to identify all the information related to a concept. However, to cast a wide net, a variety of sources were consulted to identify the uses of connection (Schiller, 2018).

First, the most general sources for defining connection were consulted. Merriam Webster's (2019) dictionary definition includes five different senses of connection:

the act of connecting: the state of being connected…something that connects…a person connected with another…a political, social, professional, or commercial relationship…[and] a set of persons associated together

Another definition indicates:

The word connection has roots to the fourteenth century and emerged from words meaning “together” and “to bind, tie.”

The concept of connection is used in many fields. In mathematics, connection is an important concept in differential geometry with a highly technical definition (Freeman, 2011). Connection is important in both mathematical graph theory and business, referring to links (Lane & Serafica, 2014; Oxera, 2010). In business, connection is also an outcome of being fully present during communication (Youssef, 2017). In management, connection between leaders and workers is important for success (Lane & Serafica, 2014). In fine arts, no novel entitled “connection” was identified, but numerous poems with this title were found, often focusing on interpersonal connection between two people (Hello Poetry, n.d.). A Google image search for “connection artwork” did not reveal visual art entitled “connection,” but it did identify many pieces of art as relevant to this concept. Connections between humans and nature, and between humans themselves, are linked to increased longevity, enhanced immunity, and improved mental health (Capaldi, Dopko, & Zelenski, 2014; Seppala, 2014). Connection is also described as an outcome of the use of modern technology (Skiba, 2014).

Many theories also have connection as an integral concept. The learning theory of Connectivism posits that understanding is concentrated on making connections (Siemens, 2005). In neuroscience, the theory of connectivity posits that brain cells have set assemblies that lead to specific neuronal connections (Li, Liu, & Tsien, 2016). When these neural connections are halted early in development, autism may result, according to the connectivity theory of autism (Coben & Myers, 2008). The connectivity theory of metaphor interpretation describes the analysis of metaphor as based on association with prior knowledge (Ritchie, 2009). In the field of transportation, the theory of international connectivity defines connectivity as “the availability of transport that enables people and goods to reach a range of destinations” in a cost-efficient manner (Oxera, 2010, p. 3). Hagerty, Lynch-Sauer, Patusky, and Bouwsema (1993) listed connectedness as a stage within the theory of human relatedness. Clearly, connection is used in a broad range of theories, in many ways.

Within the nursing education literature, a number of (mostly interpersonal) connections are described. These connections include faculty links with communities (Canales & Bowers, 2001), clients, and other health care workers (Grigsby & Megel, 1995). Connection is also described as being central to mentoring relationships (Rand & Pajarillo, 2015). Many student connections are discussed within nursing education as well. These include connections between students and educators (Diekelmann & Mikol, 2003), the community (Petrozella, 2004), clients and/or families (Raudonis, McLean, & Caubel, 2012), student organizations (Petrozella, 2004), and other nursing students (Beck, 2001). Technology's ability to facilitate connection is often discussed in nursing education literature (e.g., Chandler & Hanrahan, 2000; Rieck & Crouch, 2007; Teel & Shaw, 2005). Although a theory of connection was not evident in the nursing education literature, this concept is essential (as a teaching strategy and outcome of teaching) to a theory of teaching practice based on the views of Latina nurse educators (Canales & Bowers, 2001).

Clearly, connection has a wide variety of uses in many fields. Walker and Avant (2011) specified that after all usages of a concept have been discovered, a decision must be made regarding the focus of the concept analysis. Because the identified uses of connection were more varied than could be incorporated into a single concept analysis, the focus of the analysis moving forward is student interpersonal connection in nursing education. Student interpersonal connection was chosen as a focus because it was frequently discussed in nursing literature and linked to a variety of positive outcomes (Bryan, Weaver, Anderson-Johnson, & Lindo, 2013).

Defining Attributes

Identifying the defining characteristics of a concept is central to Walker's and Avant's (2011) method. The various uses of the concept of connection across disciplines informed this step, but publications from nursing education and concept analyses related to connection in nursing formed the core sources for defining attributes, as they are most relevant to student interpersonal connection in nursing education. During the process of identifying defining attributes, I followed Schiller's (2018) suggestions for clarifying attributes by reflecting on whether the literature supported each element, if each element was always present within the concept, and if any aspects were left out.

Gillespie (2002) described interpersonal connection between nurse educators and students as “evolving” (p. 569). Phillips-Salimi et al. (2012) also suggested that connection in nursing is something that develops. Other descriptions of connection in nursing education support the changing nature of this concept, by describing it as “a place of possibility” (Gillespie, 2005, p. 213), very collaborative, and involving give and take (Gillespie, 2002). This led to the inclusion of evolving in the defining attributes.

Lane and Serafica (2014) viewed respect as an important element of connection in nursing, whereas Gillespie's unpublished thesis finds respect to be important to connection in nursing education (as cited in Gillespie, 2005). Phillips-Salimi et al. (2012) further described such respect as “a sense of being valued and/or displaying value for others” (p. 6). This led to valuing others being included as a defining attributes of student interpersonal connection in nursing education.

Many authors imply that trust is an essential part of connection in nursing (Lane & Serafica, 2014; Phillips-Salimi et al., 2012) and in connections between nurse educators and students (Gillespie as cited in Gillespie, 2005; Pralle, 2016). As advised by Schiller (2018), I questioned whether student interpersonal connection in nursing education could be present without trust. A student could perceive connection without trust—for example, feeling connected to a client without trusting them. However, one important element of trust is feeling comfortable (Phillips-Salimi et al., 2012). Upon further reflection, comfort was seen as always present within the concept of student interpersonal connection in nursing education and therefore feeling comfortable was included in the defining attributes, rather than the broader attribute of trust.

Various authors also suggest a feeling of closeness as essential to student interpersonal connection in nursing education, such as when describing mutuality as being present (Gillespie, 2002; Gillespie as cited in Gillespie, 2005; Lane & Serafica, 2014). This sense of intimacy was further supported by Phillips-Salimi et al. (2012) when describing connection as a feeling of being bonded to, belonging with, or having compassion for others. Therefore, feeling close was included in the defining attributes.

Caring was another common theme in the literature. Grigsby and Megel (1995) defined caring as a connection, and Gillespie (2002) considered connection to be part of a caring relationship. The essential nature of caring to connection is reinforced by Phillips-Salimi et al. (2012), as they noted that connection is often measured through an awareness of being cared about by important others. This supports that being cared about is another defining attribute of student interpersonal connection in nursing education.

The literature also supports that there is a mutual aspect to connection, in which both parties sense their connection (Gillespie, 2002; Gillespie as cited in Gillespie, 2005; Lane & Serafica, 2014). Upon reflecting on mutuality in nursing education, it was clear that both parties involved do not necessarily feel the same strength of connection. For example, a patient could feel a strong, enduring connection with a nursing student, whereas the student's connection might be limited to the time in the clinical setting. Therefore, mutuality is part of the definition but does not imply that connection is perceived equally by all individuals.

These commonalities and core attributes of student interpersonal connection in nursing education formed the basis of a tentative definition of this concept. Student interpersonal connection in nursing education is defined as a nursing student's evolving perception of mutually valuing, feeling close to, feeling comfortable with, and being cared about by others he or she encounters in education, such as fellow students, educators, and clients. This definition incorporates carefully considered defining attributes drawn from various literature sources.

Model Case

A model case includes each defining attribute of a concept and is clearly an example of the concept (Walker & Avant, 2011). The model case for student interpersonal connection in nursing education is a composite case of a student named Samantha. Samantha is in her junior year of a prelicensure baccalaureate nursing program. She is speaking with her older sister and describes being part of a peer group that includes other nursing students. Samantha tells her sister that she appreciates how these friends help her learning (valuing), that she feels close to the group members, that she feels comfortable sharing struggles with them, and that they care about her success in the nursing program. Samantha reflects that their relationship has continued to grow stronger (evolving) and that all the group members sense their connection (mutuality). On the basis of defining attributes, Samantha is experiencing student interpersonal connection in nursing education.

Additional Cases

A borderline case includes most of a concept's essential elements but is missing at least one defining attribute (Walker & Avant, 2011). The borderline case for student interpersonal connection in nursing education is a composite case of a student named Virginia, who has just matriculated into the same nursing program as Samantha. Virginia is meeting with her advisor, Professor Lee, for the first time. Virginia appreciates that Professor Lee answers her questions thoroughly (valuing) and asks about her life experiences outside the nursing program (being cared about); these aspects help Virginia to begin to feel comfortable with Professor Lee. However, Virginia does not feel close to Professor Lee, as she knows nothing about Professor Lee and does not take any of Professor Lee's classes yet. Professor Lee senses that she has not yet made a connection with Virginia but understands that their connection may evolve over time.

A contrary case is obviously not the concept of interest (Walker & Avant, 2011). The contrary case for student interpersonal connection in nursing education is a composite case of a student named Nadine. Nadine recently transferred into the same nursing program as Samantha and Virginia, after completing her prerequisite courses at another institution. Nadine does not interact with other students outside of required collaborative projects. She comes to class right on time and returns home immediately afterward. Besides being in school, she works as a nurse's aide and assists her mother, who has a disability; “making friends” is not a priority for her (valuing). Nadine does not feel close to her peers or that they care about her, especially given that most of them took their first-year courses together and already knew each other when Nadine joined the program in sophomore year. Nadine does not feel comfortable sharing information about her life with her peers as she perceives that they are very different from her. Nadine does not mutually value, feel close to, feel comfortable with, or feel cared about by peers in her nursing education program and is therefore not experiencing student interpersonal connection in nursing education.

Antecedents and Consequences

An antecedent is required to be present before the concept of interest can occur and is not a defining attribute (Walker & Avant, 2011). Several antecedents were gleaned from the literature on connection. These include having some commonality with the other person with whom one is connected (Gillespie, 2002; Phillips-Salimi et al., 2012) and being emotionally available (Gillespie, 1997, as cited in Gillespie, 2005; Gillespie, 2002; Pralle, 2016). Some authors suggest that physical availability is required for connection (Gillespie, 2002; Ironside, Diekelmann, & Hirschmann, 2005), but this is not always possible in a connection facilitated by technology, such as in online education. Instead, spending time in contact with another person (Lia-Hoagberg, Vellenga, Miller, & Li, 1999) is seen as an antecedent to connection. In order to achieve this time in contact, communication is necessary (Boyer, 1989; Gillespie, 2002; Rand & Pajarillo, 2015; Raudonis et al., 2012; Shellman, 2006; Stott & Mozer, 2016). Finally, at least one party in the interpersonal connection must know about the other (Gillespie, 2002); this is often accomplished through sharing of personal and/or professional information (Beck, 2001; Diekelmann & Mikol, 2003; Gillespie, 2002; Grigsby & Megel, 1995; Stott & Mozer, 2016). Student interpersonal connection in nursing education requires the antecedents of commonality, emotional availability, time in contact, and knowing.

Consequences are the possible outcomes of the concept (Walker & Avant, 2011). Many consequences of student interpersonal connection in nursing education are reported in the literature. Student interpersonal connection in nursing education may lead to effects on student learning, which are generally viewed positively (Bryan et al., 2013; Diekelmann & Mendias, 2005; Gillespie, 2002, 2005; Lia-Hoagberg et al., 1999; Phillips-Salimi et al., 2012). Supporting students' persistence in nursing and/or nursing school is also a consequence of this concept (Grigsby & Megel, 1995; Ironside et al., 2005; McGregor, 2005; Pralle, 2016). Another consequence of student interpersonal connection in nursing education is an enhanced understanding of others (Canales & Bowers, 2001; Grigsby & Megel, 1995; Ironside et al., 2005; Riner & Phillips, 2018; Shellman, 2006). Finally, this connection may be personally transforming (Gillespie, 2005; Kostovich & Thurn, 2006; Pesut, 2003; Riner & Phillips, 2018). The findings that student interpersonal connection in nursing education can affect student learning, encourage persistence, enhance understanding of others, and transform a student personally further support the importance of this concept to nursing education. Figure 2 provides a graphic representation of the concept of student interpersonal connection in nursing education.

Student interpersonal connection in nursing education: antecedents, defining attributes, and consequences.

Figure 2.

Student interpersonal connection in nursing education: antecedents, defining attributes, and consequences.

Empirical Referents

Empirical referents are actual phenomena that indicate that the concept is in existence (Walker & Avant, 2011). These can be challenging to identify, particularly when considering an abstract concept such as student interpersonal connection in nursing education (Boyd, 1985). No existing measure of student interpersonal connection in nursing education was identified. However, Bryan et al. (2013) described measuring student–teacher connection in nursing education using student ratings, and Rovai's (2002) Classroom Community Scale includes a 10-item connection subscale based primarily on how a student feels. As these instruments support, student interpersonal connection in nursing education is relatively subjective. Therefore, self-report was chosen for the empirical referents because of the difficulty of observing states that are perceived subjectively (Streiner, Norman, & Cairney, 2015).

Walker and Avant (2011) suggested Boyd (1985) as a strong example of empirical referents in concept analysis, and the empirical referents for student interpersonal connection in nursing education are constructed similarly. The empirical referents include all of the following:

  • Student statement of mutually valuing others encountered in education.
  • Student statement of mutually feeling close to others encountered in education.
  • Student statement of mutually feeling comfortable with others encountered in education.
  • Student statement of mutually feeling cared about by others encountered in education.

The development of a psychometrically sound measure of student interpersonal connection in nursing education is needed for future research.

Conclusion

Following the steps outlined by Walker and Avant (2011) has allowed an exploration of the concept of student interpersonal connection in nursing education with the aim of clarifying its meaning. Central attributes were identified and used to support the working definition of student interpersonal connection in nursing education as a nursing student's evolving perception of mutually valuing, feeling close to, feeling comfortable with, and being cared about by others he or she encounters in education. Having a clear definition of student interpersonal connection in nursing education can help educators recognize and promote such connection.

Concepts are continually evolving (Walker & Avant, 2011, p. 158). Thus, although this analysis has captured the concept of student interpersonal connection in nursing education currently, nursing scholars are encouraged to continue exploring this concept. In particular, further work might concentrate on using this definition to refine measurement of the concept; extending this analysis to include interpersonal connection in nursing staff professional development; purposefully examining connections in the context of technology such as social media or online education; creating, implementing, and evaluating interventions to enhance student interpersonal connection in nursing education; and linking this concept to other relevant concepts within a larger theory. The importance of student interpersonal connection in nursing education supports these future endeavors as worthwhile.

References

Comparison of Concept Analyses of Connection in Nursing

Concept AnalysisLane & Serafica (2014)Phillips-Salimi, Haase, & Kooken (2012)Current Analysis
Area of focusNursing in generalPatient–provider relationships in nursingStudent interpersonal connection in nursing education
Method of concept analysisNo established method of concept analysis clearly utilizedHybrid (combining established concept analysis strategies)Walker & Avant (2011)
Key findingsConnect in nursing includes respect, trust, and mutualitySeven central aspects of connectedness are intimacy, sense of belonging, caring, empathy, respect, trust, and reciprocityStudent interpersonal connection in nursing education includes student's evolving perception of mutually valuing, feeling close to, feeling comfortable with, and being cared about by others encountered in education
Applicability to nursing educationVery brief discussion of applicability of “connect” to interdisciplinary education in nursingBrief discussion of applicability of patient–provider connectedness staff educationCentral focus is a nursing education context
Authors

Ms. Cornine is PhD student, University of Massachusetts Medical School Graduate School of Nursing, and Instructor, Worcester State University, Worcester, Massachusetts.

The author has disclosed no potential conflicts of interest, financial or otherwise.

The author thanks Dr. Donna Perry, Dr. Susan Sullivan-Bolyai, and Dr. Carol Bova for their invaluable comments and advice during the manuscript preparation.

Address correspondence to Amanda E. Cornine, MSN, RN, CNE, Instructor, Worcester State University, 486 Chandler Street, Worcester, MA 01602; e-mail: amanda.cornine@umassmed.edu.

Received: May 17, 2019
Accepted: September 23, 2019

10.3928/01484834-20191223-04

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