Factors Affecting the Belongingness Sense of Undergraduate Nursing Students towards Clinical Setting: A Qualitative Study

"I Will Be a nurse:" Identity and Belongingness in Nursing School

A nursing shortage is anticipated within the next decade. Knowing what factors draw individuals to the field of nursing and help them finish their degree is important for recruitment to nursing school, but what is equally important is knowing how individuals connect and see themselves in the field of nursing. One of the contributions of health communication is examining the processes of identity formation in nursing school to determine how they construct their years of nursing school. Using Qualitative Longitudinal Research (QLR) and the model of communication and identity, the research presented in this article examines the experiences of nursing students (n = 32) at one university. The research summarizes the phases of identity that can be characterized as three distinct stages of getting in, scrubbing in, and fitting in. The research also highlights what helps students stay with nursing, feel like they belong to the field, and how this can be translated into communicating what potential nurses need to succeed.

Adapting to change: Undergraduate nursing students' sense of belonging transitioning from online to in-person learning environments

AIM

To examine undergraduate nursing students' sense of belonging as they transitioned from online to in-person learning.

DESIGN

A mixed-method design employing a Sense of Belonging Survey and three open-ended questions.

METHODS

Participants were first-year undergraduate nursing students who were back to in-person learning after 3 years of online learning during the pandemic. The survey was administered online in April 2023 using Qualtrics survey software. The survey data were analysed using descriptive statistics, and the open-ended questions were analysed by deductive thematic analysis.

RESULTS

Seventy-five (48%) of the 155 potential participants responded to the survey. The mean score on the Sense of Belonging Survey was 74%, a positive finding suggesting that many participants feel that they 'belong' in the classroom. Three overarching themes were identified in response to the open-ended questions: factors supporting students' sense of belonging, factors hindering students' sense of belonging and strategies for faculty, administrators and students to increase a sense of belonging.

CONCLUSION

Understanding the factors that contribute to or hinder nursing students' sense of belonging during this transition will assist in developing strategies to mitigate challenges, foster a positive learning environment and enhance the overall sense of belonging among nursing students.

IMPACT

The first year of a nursing programme is crucial for student retention as students require tailored programmes and strategies to support their success. Examining and analysing the transition from online to in-person classroom settings is crucial to identifying strategies to enhance and support first-year students' sense of belonging and academic success. Exploring nursing students' experiences of belonging during transitions contributes to a more inclusive and equitable educational experience, fostering an environment where all students can thrive and succeed.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Student nurse retention. Lived experience of mature female students on a UK Bachelor of Nursing (Adult) programme: An interpretative phenomenological analysis

AIMS

To explore the lived experiences of mature female students undertaking a Bachelor of Nursing (Adult) programme in the UK, to gain insight into the challenges and barriers faced by students and investigate the factors that support students who have considered leaving, to stay and continue with their studies.

BACKGROUND

There is a global shortage of nurses and challenges exist in ensuring that enough nurses are available to provide care in the complex and rapidly changing care environments. Initiatives introduced to increase the number of Registered Nurses (RN), include increasing the number of students enrolled on pre-registration nursing programmes. However, the success of this intervention is contingent on the number of students who go on to complete their course.

DESIGN

This qualitative study employed Interpretative Phenomenological Analysis (IPA), which provided a methodological framework and analytical approach to enable an exploration of participants' individual and shared lived experiences.

METHODS

Eight female, mature students at the end of their second year of a Bachelor of Nursing (Adult) programme at a Higher Education Institution in South Wales participated in semi-structured, face-to-face interviews, which were analysed idiographically before group-level analysis was undertaken.

FINDINGS

The analysis revealed three superordinate themes: 'Ambition to become a Registered Nurse'; 'Jugging Roles' and 'Particular Support Needs for a Particular Student'.

CONCLUSION

Each student had a unique history, their past and present social and psychological experiences were multifaceted and complex. These differences resulted in varying degrees of resilience and motivations to continue their studies. These findings are important for ensuring that services develop and provide effective support to maximize retention and, ultimately, increase the number of students entering the RN workforce.

PATIENT OF PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT STATEMENT

This research expands on current literature regarding the needs of mature female students, a growing student nurse demographic. Every student had a dynamic set of circumstances and demonstrated that the identification of 'at-risk' students, purely based on demographics or information on a Curriculum Vitae, is problematic and potentially futile. This knowledge could be used to tailor University support systems and inform curriculum development and support systems for maximizing student retention. These findings are important for ensuring that services continue to develop and provide effective support to maximize retention and completion and, ultimately, increase the number of students entering the Nursing and Midwifery Council register.

Theory-Practice Gap During Clinical Learning: A Descriptive Qualitative Study of Nursing Students' Experiences and Perceptions

Introduction

One of the main areas that contributes to clarifying the significance of nursing students' performance in the clinical context is clinical learning. However, the theory-practice gap has long been an issue for clinical learning for nursing students. This study sought to explore the experiences and perceptions of nursing student when applying theory into practice during their clinical learning.

Methods

A descriptive qualitative study was conducted with 10 senior nursing students using face-to-face interviews. These interviews were audio-taped and transcribed verbatim and analyzed using a qualitative thematic analysis.

Results

Three themes emerged upon analysis: academic contribution to the theory-practice gap, clinical environment contribution to the theory-practice gap, and effects of the theory-practice gap. Seven sub-themes emerged including educator contribution to the theory-practice gap, student contribution to the theory-practice gap, supporting facility contribution to the theory-practice gap, clinical instructor contribution to the theory-practice gap, clinical field contribution to the theory-practice gap, effects of the theory-practice gap to the academic field and effect of the theory-practice gap to the clinical field.

Conclusion

This study provides an overview of experiences and perceptions of nursing students on theory-practice gaps during clinical learning. Further research using in-depth focus group interviews in a wider population may provide more explanatory and useful information for nursing education to better manage learning process.

The Relationship Between the Sense of Professional Belonging and Perceptions of Spirituality and Spiritual Care Among Turkish Midwifery Students

This study examined the relationship between the sense of professional belonging and perceptions of spirituality and spiritual care among midwifery students. This cross-sectional study's sample included 194 third- and fourth-year midwifery students associated with the Faculty of Health Sciences at two universities in western Turkey. Data were collected using web-based surveys. The results indicate a positive relationship between total scores on the Midwifery Belonging Scale and scores on the Spirituality and Spiritual Care Rating Scale. As the students' spirituality and spiritual care perceptions increased, their feelings of professional belonging as midwives also increased. Therefore, including the concepts of spirituality and belonging in the midwifery curriculum can increase students' spiritual perceptions and sense of professional belonging, thereby enhancing the quality of the care they ultimately provide.

Feelings and thoughts of midwifery students during their first birth suite placement: A qualitative study

This descriptive qualitative study aimed to understand the feelings and thoughts experienced by 4th year midwifery students during the first birth they attended during clinical practice. Focus group interviews were conducted with 22 final year midwifery students in Istanbul, Türkiye December 2020. The transcribed data were analyzed by the descriptive qualitative analysis method. The students experienced not only negative feelings such as fear, torment, anxiety but also positive feelings such as hope, excitement, and curiosity during the first birth practice. The situations that caused negative feelings and thoughts were not only the feelings of the students but also the conditions that negatively affected the care provided to the patient in the clinic. The clinical practice environment affects the feelings and thoughts of midwifery students about the birth process. For this reason, improving the clinical practice environment and supporting students throughout the education process may contribute to the development of positive feelings and thoughts when attending as a student for their first birth suite placement.

Third Year Veterinary Student Academic Encumbrances and Tenacity: Navigating Clinical Skills Curricula and Assessment

This study is a qualitative exploration of the student experience of stress at the University of Calgary Faculty of Veterinary Medicine (UCVM). Ten third-year students from the class of 2019 participated in a semi-structured interview designed to explore the student experience surrounding stress, resiliency, and their perception of mental health awareness initiatives. Transcripts were de-identified and analyzed using thematic analysis. Two central themes of academic encumbrances and academic tenacity were identified, and each theme was further delineated into three main sub-themes associated with the Objective Structured Clinical Examination assessment. Students described the clinical skills course OSCEs as a primary source of stress and fear. Academic encumbrances were delineated through the sub-themes of academic load, fear of failure, and low academic self-efficacy. Students navigated these encumbrances through their academic tenacity, rooted in their sense of belonging among peers, family, and friends, a growth mindset, and self-care practices. Study results exemplify the importance of attending to student needs beyond acquiring clinical knowledge and skills. As we continue to redefine veterinary curricula and assessment, our work highlights the need for curricular streamlining, attending to student well-being, and fostering an academically balanced lifestyle. Lastly, the findings will help inform student services about the mental health needs of the students specific to academic achievement.

Psychometric evaluation of the Persian version of the Sense of Belonging in Nursing School (SBNS): a quantitative and cross-sectional design

BACKGROUND

This study aimed to evaluate the psychometric indicators of the Persian version of the Sense of Belonging in Nursing School scale (SBNS).

METHODS

The study conducted in Shahroud and Semnan schools of nursing and midwifery in Iran examined nursing students using a cross-sectional approach by convenience sampling method from 3/6/2023 to 24/8/2023. To assess the SBNS scale, the forward-backward procedure was used to translate it into Persian. Face and content validity were evaluated, and exploratory and confirmatory factor analyses were conducted with sample sizes of 200 and 182, respectively. Reliability was assessed using Cronbach's alpha coefficient, MacDonald's omega, and intra-class correlation coefficient.

RESULTS

The exploratory factor analysis resulted in the exclusion of four items, leaving a final selection of 15 items. These items were categorized into three factors: classmates, clinical staff, and inclusive educational environment, which accounted for 49.16% of the overall variance. The confirmatory factor analysis indicated that the model was a good fit for the observed data, and the subscales had high internal consistency (Cronbach's alpha coefficient was 0.752 to 0.880) and stability (intra-class correlation coefficient was 0.889 to 0.968).

CONCLUSION

According to the results, it can be concluded that the Persian version of the SBNS scale demonstrates sufficient validity and reliability in assessing students' sense of belonging to the nursing school.

DEVELOPMENT AND PSYCHOMETRIC TESTING OF THE SENSE OF BELONGING IN NURSING SCHOOL SCALE

Background and Purpose: While sense of belonging is essential for human motivation, impaired belonging among nurses can impact the care and safety of patients. This article reports the development and psychometric testing of the Sense of Belonging in Nursing School (SBNS) scale to assess nursing students' sense of belonging in three different environments: Clinical, classroom, and among the student cohort. Method: Principal component exploratory factor analysis with varimax rotation was used to determine the construct validity on the 36-item SBNS scale with a sample of 110 undergraduate nursing students. Cronbach's alpha was used to determine the scale's internal consistency. Results: The scale was reduced to 19-items with high internal consistency (α = 0.914). Principal component analysis then identified four factors (sub-scales) with high internal consistency: Clinical staff (α = 0.904), clinical instructor (α = 0.926), classroom (α = 0.902), and classmates/cohort (α = 0.952). Conclusion: The SBNS scale is a reliable and valid tool to measure sense of belonging across three environments among nursing students. Further research is needed to determine the scale's predictive validity.

Integrating Compassion and Theoretical Premises of Caring Science into Undergraduate Health Professions Education

Compassion and caring are critical foundational concepts for the education of health professions students. Yet many curricula emphasize skill-based learning and test-taking preparation, which often limits the opportunities for students to practice compassionately caring for themselves and others. In 2019, an elective wellness course was introduced into a School of Nursing and Health Professions curriculum to provide students with the knowledge, understanding, and practice of self-compassion and caring as the foundation for holistically caring for others. The goal of the course is to use ethics, values, and ontological competencies of self-compassion and Caritas literacy to awaken students to their being, not just doing, and how it evolves throughout their professional careers. Narrative feedback from students demonstrated a deeper understanding of the necessity for compassion and caring for self to provide compassionate care to others.

Comparison of the effectiveness of the electronic portfolio and online discussion forum methods in teaching professional belonging and ethical behaviors to nursing students: a randomized controlled trial

BACKGROUND

Nursing is a profession that has had many ethical aspects and understanding professional belonging and ethics as a deep and complex process is one of the basic concepts in this field. This study aimed to compare the effectiveness of training professional belonging and ethical behaviors in two methods: electronic portfolio and online discussion forum in nursing students.

METHODS

This study is a single-blinded randomized-controlled trial (RCT) with two parallel intervention groups and a third control group. The sample size was 90 selected by block randomization method. The educational contents of professional belonging and ethical behaviors were presented to the participants in two ways: electronic portfolio and online discussion forum. Demographic information form, professional belonging questionnaire, and ethical behaviors questionnaire were applied to collect data. Data were analyzed using SPSS version 24 software. Respectively mean, standard deviation and repeated measured, analysis of variance tests was used in descriptive and analytic statistic. (P value < 0.05).

RESULTS

Comparison of the mean score of professional belonging and ethical behavior in the three stages of pretest, immediately after the test and four weeks after the test in all three groups was significant (P < 0.001). The control group had a higher mean score of professional belonging immediately after the test (108.18 ± 48.9) compared to the other two groups. Also, the online discussion forum group had a higher mean score on ethical behavior in four weeks after the test (104.2 ± 0.8) compared to the other two groups.

CONCLUSION

Training based on two methods of the electronic portfolio and online discussion forum increases and enhances the level of ethical behaviors in students. Therefore, the implementation of such methods of training can be useful in improving, promoting, and learning ethical behaviors in nursing students. On the other hand, training based on the two methods had a negative impact on professional belonging. Therefore, it is suggested that future studies be conducted with a greater focus on areas of professional belonging.

TRIAL REGISTRATION

This research has been registered in Iranian Clinical Trial Registration Center (IRCT) with registration number "IRCT20180612040063N1" and registration date "16/07/2018".

Sense of Belonging and Evidence Learning: A Focus Group Study

A sense of belonging is a prerequisite for the professional and clinical success of nursing students. The objective of this study was to elucidate whether students’ participation in projects oriented toward translating knowledge into clinical practice promoted a sense of belonging and assisted with their integration into clinical practice services. Fifteen students were distributed into two focus groups, and the study was carried out by means of a semi-structured interview script using the research question as a starting point for directing the discussion toward more specific topics. Qualitative analysis followed a predefined protocol. WebQDA® software was used to organize and analyze the findings, as well as to increase their rigor. The study design was approved by an ethics committee. Three categories related to belongingness emerged from the data analysis: integration, participation, and collaborative work. Belongingness was a central element for integrating students into services, and it influenced their clinical education, their motivation, and the quality of their experience. It also allowed them to learn about evidence, communicate science, carry out evidence-based practice, and develop competencies. Concurrently, student integration was facilitated by the sharing of knowledge between professors and nurses, and the existence of ongoing work with clinical practice services.

The Influence of Physical Distancing, Sense of Belonging, and Resilience of Nursing Students on Their Viral Anxiety During the COVID-19 Era

OBJECTIVE

We aimed to explore how nursing students' adherence to physical distancing, sense of belonging, or resilience may be associated with viral anxiety during the coronavirus disease (COVID-19) era in South Korea.

METHODS

We conducted an online survey among nursing students from December 8-10, 2021. The survey gathered participants' age, sex, grades, living area, and responses to questions on COVID-19. In addition, responses to Stress and Anxiety to Viral Epidemics-6 items (SAVE-6), adherence to physical distancing, Sense of Belonging Instrument, Calling and Vocation Questionnaire, Patient Health Questionnaire-9 items (PHQ-9), and Connor-Davidson Resilience Scale-2 (CD-RISC2) items were gathered.

RESULTS

The SAVE-6 score was significantly correlated with adherence to physical distancing (r=0.29), PHQ-9 (r=0.26), and CD-RISC2 (r=-0.34, all p<0.01) similar to partial correlation analysis adjusting participants' group (freshmen and sophomores vs. juniors and seniors). A linear regression analysis revealed that viral anxiety of nursing students was predicted by sex (female, β=0.20, p=0.001), adherence to physical distancing (β=0.25, p<0.001), sense of belonging (β=0.16, p=0.014), and CD-RISC2 score (β=-0.32, p<0.001) (adjusted R2=0.24, F=10.01, p<0.001).

CONCLUSION

We observed that adherence to physical distancing, sense of belonging, and their resilience influenced nursing student's viral anxiety. An appropriate support system to manage viral anxiety is needed for nursing students during the COVID-19 pandemic.

Learning to use evidence at nursing undergraduation: a contribution to collective health

Abstract There is universal agreement that health professionals have not implementing evidence-based practice as would be desirable and recommended by science and international institutions with responsibility for the guidelines issued for health contexts. This focus group with eight participants aimed to understand the perspective of students from the undergraduate nursing course on their involvement in a project of knowledge transfer to the clinic. Qualitative analysis followed the coding steps; storage/retrieval and interpretation of the findings and it was carried out by using a software for qualitative data analysis. This study is authorized by an Ethics Committee and respected the principles inherent to the investigation. The four categories that emerged from the content analysis were: Belonging, Using Evidence, Improving Care and Developing Competencies. The analysis of categories, subcategories and verbatim transcripts allowed us to conclude that participation in transference projects for clinics, according to the students, generates learning opportunities about the implementation and communication of evidence, facilitates integration in the service, participation, collaborative work and the development of transversal skills.

Learning to use evidence at nursing undergraduation: a contribution to collective health

There is universal agreement that health professionals have not implementing evidence-based practice as would be desirable and recommended by science and international institutions with responsibility for the guidelines issued for health contexts. This focus group with eight participants aimed to understand the perspective of students from the undergraduate nursing course on their involvement in a project of knowledge transfer to the clinic. Qualitative analysis followed the coding steps; storage/retrieval and interpretation of the findings and it was carried out by using a software for qualitative data analysis. This study is authorized by an Ethics Committee and respected the principles inherent to the investigation. The four categories that emerged from the content analysis were: Belonging, Using Evidence, Improving Care and Developing Competencies. The analysis of categories, subcategories and verbatim transcripts allowed us to conclude that participation in transference projects for clinics, according to the students, generates learning opportunities about the implementation and communication of evidence, facilitates integration in the service, participation, collaborative work and the development of transversal skills.

Facilitators of professional socialisation of learners in the clinical learning areas: A qualitative systematic review

Background

Professional socialisation is significant in nursing as it involves immersing learners in the profession so that they adopt the ethical values and conduct of the profession. It is in the clinical learning areas where learners observe and practise those values. The objective of the review was to explore the factors that promote professional socialisation of learners in the clinical learning areas. The problem is the inadequate support for learner nurses in the clinical learning areas. The South African community has lost trust in nurses and that was even acknowledged in the national nursing summit in 2011.

Objectives

To present a review of the factors that facilitate professional socialisation among undergraduate nursing learners.

Method

A systematic review was conducted on literature from 2008 to 2018. The literature search focused on factors that facilitate professional socialisation of learner nurses. A search of databases was conducted in CINAHL, MEDLINE, Google Scholar and Science Direct. The search focused on literature on professional socialisation of learner nurses published from 2008 to 2018. The search resulted in 3035 articles which were further reduced to 13 after further synthesis. Critical appraisal skills programme was used to assess the quality of the studies.

Results

Three main themes emerged. Learner factors, factors in the clinical learning areas and interpersonal factors were identified as the factors that facilitate professional socialisation of learners.

Conclusion

Learners should have self-motivation and be supported and assisted to develop a positive professional identity. The clinical learning environment should have effective communication that fosters learning. Professional nurses should act as exemplary role models so that learners can emulate the conduct and practice. The review brought to light that the professional socialisation of learners is affected by the learner factors, clinical learning areas and personal factors.

Nursing students' experiences of applying problem-based learning to train the core competence teamwork and collaboration: An interview study

AIM

To explore nursing students' experiences of applying problem-based learning to train the core competence teamwork and collaboration.

DESIGN

The study used a qualitative descriptive design.

METHOD

The data were collected using individual interviews with a purposive sample of 11 students and analysed using inductive qualitative content analysis.

RESULTS

The students' experiences of applying problem-based learning to train the core competence teamwork and collaboration were described in two generic categories: prerequisites to train teamwork and collaboration and abilities practised in the base group. The generic category "prerequisites to train teamwork and collaboration" includes three subcategories: previous experience and education, composition of the base group, and common goals and values in the base group. The generic category "abilities practised in the base group" includes four subcategories: taking personal responsibility, practising role distribution and leadership, developing communication skills and creating togetherness in the base group.

Moral intelligence, clinical placement experience and professional behaviors among Iranian undergraduate nursing students in a baccalaureate nursing program: A descriptive correlational study

AIMS

This study was intended to examine the relationship of both moral intelligence (MI) and Clinical Placement Experience (CPE) with the level of nursing students' professional behaviors (PB).

BACKGROUND

The foundation of belief, belonging and ethical values develop PB as a meaningful attribute during the period students and caring for patients.

DESIGN

A descriptive correlational study was conducted.

METHODS

Descriptive data were derived from the Belongingness Scale-Clinical Placement Experience (BES-CPE), the Moral Intelligence Questionnaire (MIQ) and the Nursing Students Professional Behaviors Scale (NSPBS) including 200 students (response rate 94.5%).

RESULTS

We found a statistically strong positive correlation between NSPB, MI and CPE. The regression model accounted for 57.8% of the variance in NSPB; CPE and MI were significant explanatory variables of NSPB. Moreover, the non-employed dormitory students had a significant statistical difference in the scores of all three variables. Female students had significantly higher CPE and MI (p˂0.05).

CONCLUSIONS

According to our findings, preventive and mediation endeavors for nursing students can explicitly target their behavioral skills to reduce perceived rejection and improve morality. As a result, an optimal plan to improve the quality of professional training courses for students should be designed based on the comprehension of clinical belonging and moral intelligence.

The relationship between a disposition of gratitude, clinical stress, and clinical satisfaction in nursing students

PURPOSE

This study assessed a disposition of gratitude, and clinical practice stress and satisfaction in nursing students, to determine the relationship between them and provide some basic information towards improving their satisfaction with clinical practice.

DESIGN AND METHODS

This descriptive research was conducted on 171 nursing students from three universities in South Korea using a structured questionnaire.

FINDINGS

Students who had a stronger disposition of gratitude (t = 3.482; P < .001), lower clinical practice stress (t = -2.998; P < .003), and better health (t = 2.900; P < .004) were more satisfied with their Clinical practice (R² = 0.298; F = 13.853; P < .001).

PRACTICE IMPLICATIONS

The findings emphasized the development of programs to improve disposition of gratitude in curriculum or extracurricular activity to enhance Clinical practice satisfaction.

Wellness among nursing students: A qualitative study

Nursing students typically experience high levels of stress and anxiety in nursing schools, and this is often compounded by having to combine complex classroom theories with practice. Healthy behaviors are subsequently neglected, diminishing academic efficiency and personal wellbeing. Student nurses need to adopt healthy lifestyles since wellness has been shown to promote positive health outcomes. Nonetheless, studies on the perception of wellness, and descriptions of its facilitators and barriers in wellness promotion among nursing students remain limited. This qualitative descriptive study aimed to explore facilitators and barriers to promote wellness among nursing students in Thailand. Data was gathered using focus groups with 80 undergraduate third and fourth-year nursing students, comprising 64 females and 16 males. Four themes emerged from content analysis regarding the facilitators of promoting wellness: healthy living; belief in animism; self-optimism; and receiving support. Barriers to wellness were three themes of stressors involved in students' lives: pressure from instructors; behaviors of staff nurses; and being perceived as untrustworthy. It is vital to promote wellness among nursing students to encourage their health care choices and to support them through their studies.

Factors affecting professional ethics development in students: A qualitative study

BACKGROUND

Ethics development is one of the most important aspects of professional practice in health sciences students. Understanding factors affecting ethics development can enhance clinical and professional performance in students.

OBJECTIVE

This study was conducted to explore students' perceptions about factors affecting professional ethics development.

RESEARCH DESIGN

This study is a conventional content analysis. Data were collected through 20 semi-structured interviews and two focus group interviews (12 students) during 2017-2018. Data were analyzed concurrently with data gathering, using the conventional content analysis approach of Graneheim and Lundman.

PARTICIPANTS AND RESEARCH CONTEXT

In total, 8 students of nursing, 5 medical students, 4 students of anesthesia and 3 operating room students in individual interviews, and 12 students in two focus group interviews from one university in the south of Iran were selected through purposive sampling.

ETHICAL CONSIDERATIONS

The research was approved by the Ethics Committee of one university in the south of Iran.

FINDINGS

The findings revealed two themes: personal and background factors. Personal factors consisted of the two categories of individual motivation and tendencies and interpersonal interactions. Background factors consisted of the two categories of role and function of teachers and environmental agents.

DISCUSSION AND CONCLUSIONS

According to the findings, both background and individual factors affect development of professional ethics in students. Understanding these factors along with reinforcement of educational planning in this field can improve healthcare services.