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JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Understanding the influences on self-confidence among first-year


undergraduate nursing students in Ireland
Patricia A. Chesser-Smyth & Tony Long
Accepted for publication 3 March 2012

Correspondence to P.A. Chesser-Smyth:


e-mail: pchesser-smyth@wit.ie
Patricia A. Chesser-Smyth MSc RN RM
Course Leader in BSc Nursing
Waterford Institute of Technology,
Waterford, Ireland
Tony Long PhD RN
Professor of Child and Family Health
University of Salford, UK

C H E S S E R - S M Y T H P . A . & L O N G T . ( 2 0 1 3 ) Understanding the influences on selfconfidence among first-year undergraduate nursing students in Ireland. Journal of
Advanced Nursing 69(1), 145157. doi: 10.1111/j.1365-2648.2012.06001.x

Abstract
Aim. To report a mixed-methods study of the development of self-confidence in
Irish nursing students undertaking the first year of an undergraduate nursing programme.
Background. Self-confidence underpins nurses competence to carry out care
effectively, yet there is little empirical evidence of how this attribute is fostered in
pre-registration preparation. There is an assumption, however, that self-confidence
develops independently and spontaneously.
Design. A sequential, mixed methods three-phase design was used.
Method. The design involved pretest and posttest measurements of self-confidence,
focus group interviews, a student self-evaluation questionnaire and analysis of the
relevant curriculum content. Data were collected between September 2007April
2008 and sampling was from three cohorts of students at three different Institutes of
Technology in Ireland. Data collection matched the nature of the data, including
descriptive, non-inferential statistics and qualitative content analysis.
Results. There was considerable variation in the amount and nature of theoretical
preparation. Factors in clinical practice exerted the most influence. Self-confidence
fluctuated during the first clinical placement and as students self-confidence
developed, simultaneously, motivation towards academic achievement increased.
Conversely, self-confidence was quickly eroded by poor preceptor attitudes, lack of
communication, and feeling undervalued.
Conclusion. The development of self-confidence is complex and multi-factorial.
This study offers further understanding of facilitators and barriers that may be
relevant elsewhere in promoting student nurses developing self-confidence. The
development of self-confidence must be recognized as a central tenet for the design
and delivery of undergraduate programmes.
Keywords: clinical practice, nurse, nursing, self-confidence, self-efficacy, student,
undergraduate

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P.A. Chesser-Smyth and T. Long

Introduction
Self-confidence is the belief in ones abilities to accomplish a
goal or task (Potter & Perry 2001) and is crucial to effective
performance (Ferrand et al. 2006). Self-confidence underpins
nurses competence to carry out care effectively (Crookes
et al. 2005) and is an important aspect of learning to be a
nurse (Calman 2006). The purpose of an undergraduate
nurse education programme is to ensure that each nurse has
the knowledge and skills of critical-analysis, problem-solving, decision-making, reflective skills and abilities to
practice as a competent and professional nurse [An Bord
Altranais (ABA) 2005]. This study examined the extent to
which theoretical preparation and clinical practice influenced
self-confidence among first-year undergraduate nursing students in Ireland. However, no study to date has identified
specific factors that actively promote self-confidence from the
students perspectives or the impact of clinical practice on
self-confidence.

Background
Theoretical framework
Self-efficacy refers to a persons sense of confidence in his or
her ability to perform a defined behaviour in many situations
(Bandura 1977, 1986, 1997). Banduras Social Learning
Theory (Bandura 1977, 1982) explains human behaviour in
terms of the interaction among cognitive, behavioural, and
environmental influences. These theoretical elements are
imbedded in nursing where developing knowledge and skills
are based on cognitive, affective and psychomotor activities
which the student nurse must experience to develop both
competence and confidence.
Efficacy expectations are derived though four sources:
performance accomplishments (PA; carrying out behaviour),
vicarious experience (VE; observing another persons performance), verbal persuasion (VP; feedback), and emotional
arousal (EA; physiological and affective states such as
anxiety). A persons self-efficacy beliefs may vary on several
dimensions. The first is level that relates to the difficulty of
the task from simple to complex. The second dimension is
generality. Some experiences may instill self-efficacy beliefs
about specific tasks, while other experiences may carry a more
generalized self-efficacy. Strength, the third dimension,
relates to a persons perceived weakness or strength of selfefficacy towards a task. The sources of self-efficacy may have a
positive influence on the development of self-confidence
among undergraduate students and Bandura (1997) emphasized the importance of using all four sources to improve selfefficacy and provided the relevant framework for this study.
146

Current knowledge
Positive links between self-efficacy, academic motivation, and
achievement in the primary, secondary, and higher education
contexts has been firmly established (Zimmerman 2000, Lane
& Lane 2001, Pajares & Schunk 2002) and contemporary
international research continues to lend support to the role of
self-efficacy in learning environments (van Dinther et al.
2010, Brady-Amoon & Fuertes 2011, Kleitman & Gibson
2011).
In nursing, the development of self-confidence is central to
better patient outcomes, effective performance (Hayes 2003)
and the learning process (Chesser-Smyth 2005, Epp 2008).
Reflection and self-evaluation are important sources of selfconfidence for personal and professional development and
innovative practice (Crookes et al. 2005). Research in
Sweden, Canada, the USA and Iran has explored the
meaning of self-confidence and ways to promote its development (Lofmark & Wikblad 2001, Frieburger 2002,
Brown et al. 2003, Sharif & Masoumi 2005, Lundberg
2008). Other studies have shown that simulation strategies
for clinical skills may enhance self-confidence (Messmer
et al. 2004, Jeffries 2005; McConville & Lane 2006,
Sinclair & Ferguson 2009, Smith & Roehrs 2009, Blum
et al. 2010, Pike & ODonnell 2010, Shepherd et al. 2010;
Hope et al. 2011).
Conversely, exposure to excessive anxiety can inhibit
students academic achievement (Jones 2007). Nursing environments can exert detrimental effects on students wellbeing and self-confidence (Randle 2003, Suliman & Halabi
2006). Yet, when students qualify they lack the competence
to implement care effectively (Last & Fulbrook 2003).
However, research in Scotland suggests that students may
be competent, but lack the confidence to make decisions
(Lauder et al. 2008). Self-confidence is integral to effective
decision-making (Bakalis & Watson 2005, Bakalis 2006,
Gillespie & Paterson 2009, Hegarty et al. 2009, KitsonReynolds 2009, Taylor et al. 2010). Yet, Jahanpour et al.
(2010) indicated that new graduates were unable to demonstrate clinical decision-making skills due to low levels of selfconfidence.
Other concerns about inadequate clinical skills development have been expressed (Gerrish 2000, Duchscher 2009).
Recent studies demonstrate such shortcomings in Ireland, too
(Mooney 2006, OShea & Kelly 2007). There are consistent
calls for qualified nurses to develop the attributes of selfconfidence and assertiveness, suggesting that this is often not
achieved during education (Crookes et al. 2005, Timmins &
McCabe 2005). The evidence suggests that there is enormous
scope for enhancing self-confidence and it was important,
then, to understand how self-confidence was developed by
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JAN: ORIGINAL RESEARCH

Irish undergraduate student nurses in their first year of


nursing.

The study
Aim
The aim of this study was to establish the effects of
theoretical preparation and clinical practice on the development of self-confidence amongst first-year undergraduate
nursing students in Ireland.

Design
This sequential mixed-methods three-phase design involved
pretest and posttest measurements of self-confidence, focus
group interviews, a student self-evaluation questionnaire
(SSEQ), and analysis of the relevant curriculum content.
Demographic data were not sought from the participants of
the pretest sample at the six Institutes of Technology, but was
delayed until the posttest point when paired data were
available. Demographic details at time 2 would not be
different from time 1 and collection of redundant data was
avoided. As research had never been conducted in this area,
all six institutes of technology were selected initially to elicit
an initial indication of self-confidence among first-year
nursing. These observations served to inform the selection
of three institutes of technology that were typical and
representative of nursing students in Ireland. This was a
more manageable sample for the remaining aspects of the
study.

Sample
The pretest sample for self-confidence measurements consisted of 435 students from a potential of 555 participants
from the general, psychiatry, and intellectual disability
disciplines at all six Institutes of Technology (ITs) in Ireland
that provided nursing programmes (78% response rate). This
allowed informed sampling of three ITs for Time 2 posttest
measurements, curriculum analysis and eliciting of student
perception. There were 251 general nursing students, 118
psychiatry students, and 66 intellectual disability students. A
total of 120 were not included in the study due to absence on
the day (n = 89), omission of identifier code on responses
(n = 30), and expressed preference not to participate (n = 1).
The students in the ITs were typical of age, gender, and
nationality of nursing students in Ireland (ABA 2005),
including both rural and urban populations (Central Statistics
Office 2007). The students were exposed to 9 weeks of
 2012 Blackwell Publishing Ltd

Understanding the influences on self-confidence

clinical practice during the first year of study with access to


clinical practice coordinator support.
Inclusion criteria required students to be registered for a
BSc (Hons) Nursing undergraduate course in any of the three
degree programmes: general, psychiatry, or intellectual disability nursing, at the ITs in Ireland. Students admitted to the
course after September 2007 as a late registrant or as a
transfer from another programme were excluded. A power
analysis of 08 was selected for the study. Cohen (1992) has
made some widely used suggestions about what constitutes a
small, medium, and large affect. The guidelines for detecting
a medium effect or difference in this study required a
minimum sample size of 85 subjects (Pallant 2007, Field
2009).
Posttest sample
A total of 146 paired results from a potential 323 participants
represented a response rate of 45%. The distribution of the
sample among the disciplines was general nursing n = 80
(55%), psychiatry nursing n = 35 (24%), and intellectual
disability nursing n = 31 (21%) who were present on the day.
The remaining 177 non-respondents did not have corresponding pretest and posttest measurements due to absenteeism at Time 1 (n = 26) or Time 2 (n = 151) due to
sickness, self-directed study, or unknown reasons. The same
students completed the SSEQ to elicit perception of selfconfidence.
Phase 2 focus groups
A purposive sample of 20 students from each discipline from
the three ITs was selected. Each participant was given the
opportunity to take part in the focus groups. The number of
participants per group ranged from 68, consisting of male
and female representation as illustrated in Table 1. Schoolleavers and mature participants with different degrees of
experiential learning or previous employment ensured varied
perspectives in the discussions.

Data collection
Phase 1 pretest posttest questionnaire
Pretest data took place in the third week of the programme in
September 2007 at all six centres. Data were collected using
the Personal Evaluation Inventory (PEI) (Shrauger & Schohn
1995) to measure self-confidence. The posttest data collection
took place in 2008 at three ITs. This 54-item instrument has
eight domain-specific subscales: Academic performance,
Physical appearance, Athletics, Romantic relationships,
Social interactions, Speaking before others, General
confidence, and Mood state. All the subscales have seven
147

P.A. Chesser-Smyth and T. Long

Table 1 Focus group composition of participants at each centre.


Focus groups

General

Psychiatry

Intellectual disability

Gender

Centre 1 (n = 8)

1822 years (2)


30 years+ (1)
1822 years (2)
2330 years (1)
30 years+ (1)
1822 years (2)

1822 years (1)


2330 years (2)
2330 years (2)

1822 years (2)


No course on offer

Female (6)
Male (2)
Female (4)
Male (2)

1822 years (1)

2330 years (3)

Centre 2 (n = 6)

Centre 3 (n = 6)

items except Athletics with five. All items were presented as


Likert scales that scored 14 (negative items reversed), with 4
indicating strong agreement with items reflecting selfconfidence. Possible scores ranged from 728 (520 for
Athletics). High scores indicated high self-confidence.
Validity and reliability of the questionnaire (PEI). Face and
content validity was assessed by three experts. Construct
validity was established as the PEI scores were significantly
correlated in expected directions with other independent
measures of anxiety, hopelessness, depression, and optimism
(Shrauger & Schohn 1995). Cronbachs alpha was used to
assess reliability of each of the subscales and a significance
level was set at P = 005. Shrauger and Schohn (1995)
reported Cronbachs alpha for the PEI instrument in the
original development of this questionnaire, which ranged
from 077 (Academic) 0905 (Athletics), indicating acceptable-to-good internal consistencies. One-month testretest
reliabilities ranged from 0730 (Academic)090 (Athletics),
which demonstrated good stability over this period. This
tool was deemed to be a well-validated construct for use and
subsequent permission was sought from the authors.
Cronbachs alpha was calculated in this study and the PEI
content scales ranged from 0762 (Academic) 0860 (Speaking before others). These results were comparable to the
reliability of the original instrument (Shrauger & Schohn
1995).
Pilot study. A pilot study was conducted with a convenience
sample of 30 2nd year nursing students to test the feasibility
of both the PEI and the SSEQ. Five American terms were
removed from the PEI and replaced with the equivalent
English terms. Revisions were made to some of the wording
of the SSEQ and the overall layout.
Phase 2 focus groups and student self-evaluation
questionnaire
The focus group interviews, conducted within 8 weeks of
completion of the Time 2 questionnaires, were aimed at
148

Female (5)
Male (1)

explaining the data and eliciting perceptions of how selfconfidence had developed. An interview schedule was developed as a guide (Redmond & Curtis 2009) as illustrated in
Table 2. The interviews were digitally recorded and transcribed and lasted 4560 minutes. A moderator was present
at each of the focus groups that captured the nuances,
interactions, and group dynamics, while the researcher
conducted the interviews.
The SSEQ was developed from an extensive review of the
literature and was administered at Time 2 to the same
sample. The aim of this tool was to gather demographic data
and the perceptions from the participants that may influence
self-confidence from the classroom context and the clinical
learning environment. The questionnaire was checked for
face and content validity, followed by pilot testing to
eliminate foreseeable problems. The first section explored
details of age, gender, nationality, previous work experience
and previous study. The second section evaluated factors that
influenced self-confidence in the classroom environment (four
questions). The third section (seven questions) explored
perceptions of the influence of theoretical preparation and
the clinical environment on development of self-confidence. A
blend of seventeen multiple-choice or free-text questions

Table 2 The interview schedule.


The preliminary results to be reported about the measurements of
self-confidence and SSEQ followed by a discussion
(General) I am interested in the topic of self-confidence and student
nurses and what happens to self-confidence from the
commencement of the course and at the end of the first year 1. What
are your views of self-confidence as a concept?
(General) Does self-confidence depend on your personality and can it
be built upon?
(Specific) From an academic perspective, are there any factors that
may explain these results?
(Specific) Thinking about clinical practice, are there any factors that
may explain these results?
Summary and debriefing
Close and thanks

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JAN: ORIGINAL RESEARCH

captured nuances of experience and responses to external


influences on development of self-confidence. Whilst the
investigator tool (SSEQ) was subject to face and content
validity testing, the purpose of this tool was not to measure,
but to gather demographic data and the participants
perceptions of the college and clinical environments to guide
the focus group discussions.

Ethical considerations
Approval was granted by the research ethics committees of all
the ITs and the University of Salford. The researcher was not
involved in any pre-registration roles or responsibilities in the
first-year programme at any of the centres. No risks were
identified to participants other than the potential for perceived coercion and breach of confidentiality. Information
letters advised participants about all aspects the study and
emphasized the voluntary nature of participation and consent
forms were completed on agreement to take part in each part
of the study. All data were treated as confidential and stored
securely, with access restricted to the immediate research
team. No individual could be identified from reports or
dissemination activities.

Data analysis
Phase 1 self-confidence measurements
Data analysis was undertaken using the Statistical Package
for the Social Sciences (SPSS Version 15.0: SPSS Inc., Chicago,
IL, USA). Descriptive analyses, cross-tabulations and chisquare tests were conducted on the categorical data. Paired
sample t-tests were used to detect differences in all sub-scales
over time at the three ITs. Independent-samples t-tests were
used to compare sub-scales across the categories defined by
gender, previous work experience and previous study
achievements. ANOVA and Bonferroni post hoc tests were
undertaken on all sub-scales to compare differences between
centres, disciplines, and three age groups. The age categories
were determined by the school-leaving age (1822) and the
ABA (2005) definition of mature as being 23 years and over
(2330). A third category reflected the rising age of mature
entrants into nursing (more than 30 years).
Phase 2 qualitative data analysis
The transcripts were read and analysed using an inductive
content analysis (Krippendorff 2004, Elo & Kyngas 2008).
The units of analysis were identified and broken down into
phrases and sentences (open-coding). The fieldnotes
reflected verbal intonation and non-verbal cues such as
head-nodding that indicated general agreement among the
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Understanding the influences on self-confidence

participants on issues. The sub-categories were condensed


into generic categories, and the final categories were
reached in the abstraction process. Two researchers independently undertook data analysis and then compared their
respective categories and sub-categories until agreement
was reached.
Phase 2 SSEQ
Descriptive statistical analysis was applied to the demographic data. This was followed by a series of cross tabulations, chi-squared analysis and ANOVA tests to determine if
there were any significant differences or associations between
the groups and self-confidence scores.
Phase 3 curriculum analysis
An audit approach was taken to analyse the curricula. In
Ireland, five domains of competence represent the criteria for
registration:
Professional and ethical practice;
Holistic approaches to care and integration of knowledge;
Interpersonal relationships;
Organization and management of care;
Personal and professional development (ABA 2005).
The last of these, personal and professional development,
was the focus of this study. The related curriculum content is
designed to enable students to learn and practise key elements
and evidence of achievement of this is provided through
placement assessment. Core and supplementary curriculum
documents were scrutinized and clarified with relevant
academic staff for currency, amendments and unwritten
processes. The nature of relevant content and the number of
hours prescribed for each element were compared with the
minimum required criteria, processes, and standards as laid
down by ABA (2005).

Results
The rationale for employing mixed methods was to illuminate and provide a more complete view of the influences of
theoretical preparation and clinical practice on self-confidence. The results from the pretest and posttest measurements, the students perceptions, and the curriculum analysis
are presented separately. The discussion integrates findings
from all three phases as recommended by Cresswell and
Plano Clark (2007).

Sample characteristics
At Time 1, there were 435 participants: a 78% response rate,
consisting of general (n = 251), psychiatry (n = 118), and
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P.A. Chesser-Smyth and T. Long

intellectual disability (n = 66) students. At Time 2, the


participants ranged in age from 1845 years of age and
consisted of n = 129 (88%) female nursing students and
n = 17 (12%) male nursing students (Table 3).

Results: measurement of self-confidence


Time 1 results
The baseline scores of self-confidence were measured at six
centres. The General confidence subscale refers to a global
sense of capability and the mean scores ranged from 1645 (SD
350)1798 (SD 335).
Time 2 results
Changes in self-confidence over time at each centre. Paired
t-test showed significant differences in Centres 1 and 2, but
no significant differences in Centre 3. There was a significant increase in self-confidence in Physical appearance,
Speaking before others, Social interactions, and General
confidence at Centre 1. At Centre 2, there was significant
decrease in Academic performance, Physical appearance,
Mood state, and General confidence. This is illustrated
in Table 4.

Table 3 Characteristics of the Time 2 sample (n = 146).

Gender
Male
Female
Discipline
General
Psychiatry
Intellectual disability
Nationality
Irish
Nigerian
Zimbabwean
German
Polish
Lithuanian
Swedish
Age
1822 years
2330 years
More than 30 years
Previous study
Prenursing
Certificate unrelated to nursing
Degree in social sciences
Healthcare assistant course
None

150

17
129

116
884

80
35
31

548
239
211

139
2
1
1
1
1
1

957
10
06
06
06
06
06

82
33
31

560
230
210

26
18
11
3
42

180
120
70
20
610

Differences in self-confidence across centres over time. A


one-way ANOVA was conducted to explore if there were any
differences among the three centres. There were statistical
differences at the P < 005 level in the following selfconfidence sub-scale scores: Academic performance
F(2,143) = 529, P = 0006, Physical appearance F(2,143) =
411, P = 0018, Social interactions F(2,143) = 384, P =
0024, Speaking before others F(2,143) = 334, P = 0038,
General confidence F(2,143) = 895, P = 0001, and
Mood state F(2,143) = 642, P = 0002. The change
over time on all scales except Athletics and Romantic
relationships was significantly better in Centre 1 than in
Centre 2. The improvement over time on Academic
performance, General confidence and Mood state subscales were significantly better in Centre 3 compared with
Centre 2. Centres 1 and 3 did not differ significantly on any
scale.
Changes in self-confidence among disciplines, age groups,
and genders. Further ANOVA analyses were conducted
to explore differences amongst the disciplines, age groups
and genders. No statistical differences were detected in
the self-confidence subscales among the three disciplines.
There was a statistically significant increase in Social
interactions in the 1822 age groups, but no significant
difference was found for other age groups. At Time 1,
there was a statistically significant difference (P = 0040)
in the baseline score at the commencement of nursing
for Romantic relationships between female students
(mean = 2013 SD 491) and males (mean = 1753 SD =
441). However, at Time 2, males demonstrated a significantly higher score (P = 0025) in Speaking before others
(mean = 2058 SD 406) compared with females (mean =
1775 SD 493). There were no differences in the other
sub-scales.
Effect of previous study. Fifty-eight participants (40%) had
undertaken previous study prior to nursing and, of these, 26
had undertaken a prenursing course. An independent samples t-test was conducted to compare self-confidence scores
and the effect of previous study at Time 1. There was a
statistically significant increase in Academic performance
sub-scale score (mean = 1860 SD 356) compared with no
study, [mean = 1714 SD 369; t(144) = 182, P = 0025]. At
Time 2, the Academic performance score remained statistically significant (mean = 1863 SD 402) compared with no
study [mean = 1731 SD 388; t(144) = 198, P = 0050].
No statistical differences were detected in comparing those
who had studied a prenursing course with studying other
courses.
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Understanding the influences on self-confidence

Table 4 Results of paired samples t-tests to compare the self-confidence sub-scale scores over the first year at the three centres.
Centre 1

Centre 2

Centre 3

Subscales

Time 1

Time 2

P value

Time 1

Time 2

P value

Time 1

Time 2

P value

Academic performance
Physical appearance
Athletics
Romantic relationships
Speaking before people
Social interactions
Mood
General

1781
1872
1296
2028
1722
2167
2048
1770

1812
1954
1277
2087
1855
2255
2066
1887

0410
0035*
0371
0411
0008**
0014*
0686
0001**

1803
1870
1257
1943
1740
2083
2113
1773

1633
174
1260
1830
1643
1990
1823
1613

0015*
0032*
0915
0082
0130
0097
0000**
0010*

1721
1767
1227
1906
1842
2176
2052
1758

1852
1830
1282
1955
1842
2161
2021
1852

0109
0361
0275
0476
1000
0806
0690
0180

*Statistically significant at P < 005.


**Statistically significant at P < 001.

Results: students perceptions


SSEQ
Making new friends, academic success, and peer feedback
were the predominant sources reported to boost self-confidence in the classroom environment and are illustrated in
Table 5. Chi-square analyses were used to determine any
statistically significant associations between the variables and
each of the centres. A statistically significant association was
found between the support of the studies advisors role and
Centre 3 [v2(2) = 1619, P < 0001]. Similarly, there was a
statistically significant association between the use of tutorial
groups and Centre 2 [v2(2) = 1464, P = 0001].
The main boosters in clinical practice were being given
responsibility, clinical familiarity, feeling part of the team,
recognition for performance, feedback from staff, and feeling
capable (Table 6). In clinical practice, the clinical placement
coordinator supports students and facilitates their learning. A
chi-square analysis revealed a statistically significant association between the support of the clinical placement coordi-

nator [v2(2) = 829, P = 0016] and peer-feedback from


fellow students [v2(2) = 678, P = 0034] at Centre 2. Overall, fear of making a mistake was the most common factor in
reducing self-confidence (Table 7).
Focus groups
The main issues identified by participants were the vital role of
the preceptor, being part of the team, peer support, intrapersonal factors, and negative socialization. Preceptorship was

Table 6 Factors influencing self-confidence in the clinical environment.


Confidence boosters in the clinical environment

n (%)

Being given responsibility


Clinical familiarity
Part of the team
Recognition for performance
Feedback
Feeling capable
Teaching from staff
Having your voice heard
Clinical placement coordinator support

132
130
127
121
121
115
84
81
77

(90)
(89)
(87)
(83)
(83)
(79)
(58)
(56)
(53)

Table 5 Factors influencing self-confidence in the classroom environment.


Confidence boosters in the classroom environment

n (%)

Making new friends


Academic success
Peer feedback
New knowledge
Peer learning
Studying with peers
Communication with lecturers
Feedback from study advisors
Online learning
Tutorial groups
Self-directed study
Evidenced-based learning

124
103
98
94
88
78
77
62
47
45
43
30

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(85)
(70)
(67)
(64)
(60)
(53)
(53)
(43)
(32)
(31)
(30)
(21)

Table 7 Factors that hinders self-confidence in the clinical environment.


Factors that hindered self-confidence

n (%)

Fear of making a mistake


Stress
Isolation
High expectations from staff
Little or no communication with staff
Humiliation
Inability to cope
Alienation from staff
Not being part of the team
No feedback

80
45
29
26
22
21
18
17
15
15

(55)
(31)
(20)
(18)
(15)
(14)
(12)
(12)
(10)
(10)

151

P.A. Chesser-Smyth and T. Long

identified as being central to students learning in clinical


practice, although variation in quality of preceptorship was
reported. Positive preceptor experience was held to be a
powerful vehicle for harnessing self-confidence:

student nurses found that what they sometimes perceived to


be indoctrination could be exhibited as bullying behaviour.
On my second placement, there were days when I went home and
doubted if I even wanted to be a nurse anymore because of the

Just to let you know that you are doing OK...when we get to practice

treatment and attitudes and made you feel like a nuisance. (C3-P4-

on placement and when the nurses have time with us, it increases our

13)

confidence. (Centre1-Participant 2-line 50) (C1-P2-50)

Its demoralising, as we were only used to empty a catheter bag or to

Being valued as a team member and feeling trusted was


crucial for students. Positive experiences in clinical practice
led to increased self-confidence.

give a wash.......we wanted to do the right skills, not to be

Being part of the multidisciplinary team....sharing things that

Results: curriculum analysis

happened would boost ones confidence. (C1-P6-54)

Conversely, negative experiences were also reported and an


instant reduction in self-confidence resulted from a lack of
inclusion as a valued member of the team:
You could have someone who doesnt have much interest in you...we
dont feel of much use. (C1-P6-68)
They can knock you back down a few pegs or they can bring you on
in your confidence. (C3-P2-12)

Peer support was a powerful influence in reaffirming students


abilities in a supportive environment:
Everyone has a good and a bad day, so we keep each other going.
[We] make each other confident that way. (C1-P2-21)

Intrapersonal factors were reported, too. Younger participants acknowledged that studying at school recently to be
advantageous to academic confidence. Although mature
students lacked confidence with academic study skills, they
acknowledged the benefits of self-confidence that they
brought from previous work experience and interaction with
people:
Yeah, we were just after the leaving [terminal high school
examinations] so we were in the study mode. (C1-P8-38)
I worked in shops for years so I was well-prepared for people and
communication but the academic part was a nightmare. (C3-P1-22)

Socialization in nursing was another vital element. The


inability to challenge the status quo and the fear of a negative
clinical assessment report thwarted the enhancement of selfconfidence:
They are the ones signing off on all your performances so you cant
say no.... Its like a threat really... You dont want to give the wrong
impression so you say nothing. (C1-P7-74)

Participants felt submissive such as experiencing exclusion,


isolation, and humiliation. Within the cultural hierarchy,
152

photocopying a thousand pages for someone. (C1-P3-70)

Centres 1 and 3 each maintained three separate documents


for general, psychiatry, and intellectual disability disciplines.
General and psychiatry curriculum documents were available
at Centre 2. These documents were all congruent with the
requirements of the National Qualifications Authority of
Ireland (NQAI 2002) and with ABA (2005) Requirements
and Standards. Table 8 details the contact teaching hours at
each centre in relation to personal and professional development topics. Core teaching sessions meant that all three
disciplines were subjected to the same content. In Centre 2,
discipline-specific lectures were provided separately for the
general and psychiatric students.
Centre 1 delivered the least amount of relevant teaching
time (31 hours) for all students. Centre 2 delivered the
highest amount: 44 hours for general nursing and 52 hours
for psychiatric nursing. Centre 3 provided 38 hours for all
students. Assertiveness as a topic was specified by only one
centre and for only one nursing discipline (psychiatric
nursing). The same centre was the only one to include
empowerment (for both general nursing and psychiatric
nursing). Communication theory, self-awareness, reflection,
and professional issues were covered by all centres, although
with considerable variation in the hours allocated for each
topic. Overall, however, 96 (66%) participants felt that the
teaching content in relation to personal and professional
development had helped to develop their self-confidence.

Discussion
These findings support Banduras (1977, 1986) Social
Learning Theory where students desire and motivation were
evident in their ability to perform in practice. Successful
performance in clinical practice was the most influential
source of self-efficacy. Whilst Bandura (1986) stressed the
importance of the four sources of self-efficacy, this finding is
in agreement with Goldenberg et al. (2005), Sinclair and
Ferguson (2009) and Pike and ODonnell (2010) who found
 2012 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Understanding the influences on self-confidence

Table 8 Hours taught per subject at each centre.


Hours per subject

Communication theory
Self and self-awareness
Reflective process
Assertiveness
Empowerment
Professional issues
Total taught hours

Centre 1

Centre 2

General, psychiatry,
intellectual disability

General

Psychiatry

General, psychiatry,
intellectual disability

5
1
5
0
0
20
31

14
4
4
0
2
20
44

30
4
4
2
2
10
52

10
4
4
0
0
20
38

that successful performance in simulated situations was the


most influential source. Vicarious experiences (role-modelling) generated through students observations of role-models
in practice raised their self-confidence, which was demonstrated through teamwork and learning opportunities. Verbal
persuasion (feedback) from qualified practitioners encouraged students beliefs that they had the ability to demonstrate
their performance. In addition, peer feedback was pivotal to
enhancing self-confidence. Physiological factors such as stress
and anxiety were decreased among students when teamwork,
personhood, and inclusion were evident leading to a sense of
feeling capable. In this study, the experience of feeling selfconfident appeared to be the catalyst that was required to
develop competence and ultimately capability for effective
practice that is alluded to by Stephenson and Yorke (1998)
and Watson (2006).
Students at Centre 1 had the greatest increase in selfconfidence despite the least amount of classroom preparation.
In contrast, students at Centre 2 received the most classroom
preparation yet self-confidence decreased. In addition, the
support mechanisms of tutorials, peer feedback, and the role
of the clinical placement coordinator were underused at
Centre 2. Similarly, at Centre 3, the benefits of the role of the
studies advisor were not realized. While it might seem that
self-confidence developed despite theoretical preparation, the
students accounts showed that factors in clinical practice had
exerted the most influence. Self-confidence was promoted
particularly through positive preceptorship experiences, peer
support, and successful mastery experiences of clinical
practice. It was instilled through a sense of trust, recognition
of performance, constructive feedback, and being made to
feel part of the team. Evidence suggests that feeling accepted
and valued within the team is important for learning to take
place (Anderson & Kiger 2008). Bradbury-Jones et al. (2007)
alluded to supportive mentors who instill empowerment that
led to increased self-esteem and self-confidence.
 2012 Blackwell Publishing Ltd

Centre 3

The generation of self-confidence in the first clinical


placement is supported by other studies where students
sense of self was strengthened through trust and recognition
of performance (Eps et al. 2006, Miles 2008). Focussing on
raising self-confidence in practice has ramifications not only
for self-confidence but for the generation of a more conducive
psychological environment to motivate and support students.
The linking of theory to practice was realized only on return
to the classroom.

Damaging effects of clinical experience


Some students in this study experienced the clinical environment with anxiety, stress, and vulnerability, which prevent
effective learning and is evident in the literature (Timmins &
Kaliszer 2002, Suliman & Halabi 2006, Moscaritolo 2009).
For some, fragile self-confidence was quickly eroded by poor
preceptor attitudes, lack of communication, and feeling
undervalued, while failure of a positive preceptorstudent
relationship is detrimental to student learning (Lloyd-Jones
et al. 2001, Pearcey & Draper 2007). While the potential
benefits of preceptorship are clear (Hyrkas & Shoemaker
2007, Andrew et al. 2009), this study found variation in
approach and intensity of preceptorship, and Carlson et al.
(2010) have identified that more effort should focus on the
challenges of this variation.

Oppression and disempowerment


Students did not have the skills or confidence to challenge the
dominant nursing culture that left them feeling vulnerable
and forced to conform. This resonates with other findings
(Begley & White 2003, Timmins & Mc Cabe 2005, Curtis
et al. 2007, Levett-Jones & Lathlean 2008) and implies that
such disempowerment jeopardizes the development of critical-thinking, problem-solving, and decision-making. Such
153

P.A. Chesser-Smyth and T. Long

What is already known about this topic


Self-confidence directly underpins a nurses level of
competency to carry out care effectively that leads to
better patient outcomes.
The development of self-confidence is an important
aspect to the learning process yet nursing
environments may have detrimental effects on students
well-being.
When student nurses qualify, many lack self-confidence
particularly in decision-making.

What this paper adds


This paper addresses a topic that is so far neglected in
the literature. Specifically, the way self-confidence is
developed (or hindered) is reported.
Specific factors are identified, particularly in clinical
practice that effected positive or negative effects on selfconfidence.
A complex pattern of developing self-confidence was
discovered, with particular emphasis on the role of the
preceptor, negative socialization, recognition for
performance, and supportive feedback.

The analysis of change over time was made on 145


matched pairs comprising 49% of the original sample. This
may be a weakness, particularly if student absence was nonrandom. However, it was easy to decline to participate in
Time 1 data collection without being readily identifiable and
a response rate of 78% was achieved. Attendance on the day
of Time 2 data collection was not primarily for the study, so
non-attendance was more likely to be for other reasons than
decisions about participating in the study. Moreover, additional 26 students were willing to contribute then who had
not participated at Time 1.
As all the participants were required by ABA to attend for
both theoretical preparation and clinical practice, the use of a
control group was precluded. The pretest posttest design was
a necessary compromise, which could not control for some
factors that might have affected the results. Whilst an effort
was made to gain a representative sample of students that
were typical of rural and urban areas in Ireland, sampling
only three of the six Institutes could be seen as a limitation.
Future collaborative research could address this with a larger
sample.

Conclusion

outcomes require action to address the oppressive elements of


nursing, which reduce self-confidence.

The findings from this study are supported by Banduras


(1977, 1982, 1997) Social Learning Theory and this framework has much to offer undergraduate education. It is
important to educate nursing students and qualified practitioners about the use of the four sources of self-efficacy that
may replace the negative socialization processes. When the
needs of the students are met through the application of
Banduras framework, the potential to develop a more
questioning approach may surface. This study offers a new
understanding of facilitators and barriers to the development
of self-confidence, and given the similarity of problems
internationally, these findings may be relevant in similar
contexts. Future research is warranted to explore the threat
of the assessment process and how student nurses can
become empowered. Action is needed for students to reach
their potential which is vital for the challenges of the 21st
century.

Study limitations

Funding

The study relied on students self-reported perceptions of


their self-confidence. Measuring any construct of a subjective
nature that is dependent on a self-report can be difficult
(Bowman 2010). It is also acknowledged that a fully
psychometrically tested instrument would be required to
provide credible measurements in this regard.

There was no funding, and this paper is based on a PhD


thesis.

Implications for practice and/or practice


The development of self-confidence must be recognized
as a central tenet for the design and delivery of
undergraduate nursing programmes.
Self-confidence must be fostered and nurtured from the
first day of the undergraduate nursing programme. The
benefits of Banduras (1977) sources of self-efficacy need
to be integrated in a partnership approach between
education and clinical practice.
Students need to be better prepared for the subtleties of
the socialization processes in clinical practice.

154

Conflict of interest
No conflict of interest has been declared by the authors.
 2012 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Author contributions
All authors meet at least one of the following criteria
(recommended by the ICMJE: http://www.icmje.org/ethical_1author.html) and have agreed on the final version:
substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of data;
drafting the article or revising it critically for important
intellectual content.

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