professional confidence in baccalaureate nursing students

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Article

Barbara BrownMScN, AssociateProfessor, Schoolof Nursing,Member, NursingEducationResearch Unit,McMasterUniversity, 1200Main Street West,Hamilton, Ont.L8N 3Z5, CanadaTel.: 1-905-525-9140x22310;fax: 1-905-570-0667; E-mail:[email protected] O’MaraAssistantMabelHunsbergerPhDBarbara LoveMHSc,AssistantMargaret BlackPhD, AssociateProfessorBarbara CarpioMScN, AssociateProfessorDauna CrooksDNS, AssociateProfessorCharlotteNoesgaardAssistant

Research fundingwas provided by aNiemeier Grant,McMasterUniversity.

(Requests foroffprints to BB)

Manuscriptaccepted:31 October 2002

Professional confidence inbaccalaureate nursingstudents
Barbara Brown, Linda O’Mara, Mabel Hunsberger, Barbara Love,Margaret Black, Barbara Carpio, Dauna Crooks andCharlotte Noesgaard
‘‘You need to develop more confidence’’ is a common refrain noted by students and facultyalike. As nurse educators, we believe that encouraging students to develop their professionalconfidence is an important role. Moreover, the nursing profession demands that nursing care

be delivered with confidence. Although the importance of professional confidence isacknowledged in the literature, there is surprisingly little written about its development or

strategies that promote professional confidence in nursing education. A qualitative studywas conducted to explore the meaning and influences on professional confidence as

perceived by nursing students enrolled in a four year generic baccalaureate nursing program.Focus groups were audiotaped, transcribed verbatim and analyzed using Burnard’s (1991)

thematic content analysis method. The meaning of professional confidence involved: feeling,knowing, believing, accepting, doing, looking, becoming, and evolving. Positive andnegative influences in developing professional confidence centered around two time

periods, prior to entering nursing, and within the nursing program. Students identifiedstrategies to assist themselves in developing professional confidence. Faculty development is

one recommendation for faculty.

�c 2003 Elsevier Science Ltd. All rights reserved.

Professional confidence inbaccalaureate nursing students

The need for nursing students ‘‘to developmore confidence’’ is a common refrain thatstudents and faculty alike use on studentevaluations. As nurse educators, we agree thatnursing students should be encouraged toachieve a level of confidence in theirprofessional role. Copeland (1990) considersconfidence an important aspect of renderingnursing care and that the process of nursingeducation must foster the development ofconfidence. Ferguson (1996) states thatenhancement of student confidence is a desiredoutcome ‘‘because confident students are morelikely to be more effective nurses and moreinnovative ones.’’ (p. 60). Although the

t matter�c 2003 Elsevier Science Ltd. All rights reserved.3(02)00111-7

importance of professional confidence isacknowledged, there is a paucity of nursingliterature describing professional confidence,its acquisition and measurement as well as therole the educational process has in itsdevelopment. Thus, as one step in advancingan understanding of professional confidence,we explored the conceptualization anddevelopment of professional confidence fromthe nursing student’s perspective.

Review of the literature

Professional confidence has been described aspart of, related or integral to, professionalidentity (Kelly 1992), self-confidence and self-esteem (Copeland 1990, Davidhizar 1993,Grainger 1990), self-concept (Ellis 1980,

Nurse Education in Practice (2003) 3, 163–170 163

Professional confidence in baccalaureate nursing students

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Hughes et al. 1991), professional self concept(Arthur 1992, 1995), competency (Mozingo et al.1995), clinical confidence (Bell et al. 1998,Grundy 1993), critical thinking (Facione et al.1994), and self-efficacy (Bandura 1977, Bell et al.1998, Ferguson 1996, Grundy 1993). Whilethere seems to be a lack of clarity incharacterizing professional confidence, itsimportance has been well documented withFerguson (1996) and Grundy (1993) purportingthat positive changes in nursing students’confidence will have a significant impact ontheir performance as nurses.

The acquisition of self-confidence has beenexamined through the impact of clinicalteaching behaviours. Nursing students haveidentified teacher behaviours that helped themdevelop self-confidence, i.e., encourager,resource person (Flagler et al. 1988). Ferguson(1996) noted that preceptors used supportivelearning experiences and teaching strategies toenhance student self-confidence: includingmodelling, dialogue, feedback, commitment,mutual respect and acceptance. While on onehand students reported that evaluation did notcontribute to the development of confidence(Flagler et al. 1988), on the other hand,Mozingo et al. (1995) found that studentsdesired more positive feedback to increase self-confidence.

Developing clinical skills has also beenidentified in supporting confidence (Kelly1992, Mozingo 1995). Senior nursing studentsperceived themselves as caring and competent,but lacked confidence in their nursing skills(Kelly 1992). Mozingo et al. (1995) found thatsenior students strongly felt that their self-confidence would have been enhanced if theyfelt more competent in their clinical andtechnical skills. Haffer and Raingruber (1998)noted that threats to confidence and ways ofbuilding confidence emerged as a significantaspect in students’ experiences of clinicalreasoning and critical thinking development.They speculated that classes, clinical practice,and other life experiences may shapedeveloping a sense of confidence.

Using a self-efficacy framework, twomeasures have been developed to assessclinical confidence. First, the C-Scale measuresconfidence levels for specific physicalassessment skills (Grundy 1993). Second, Bell

tion in Practice (2003) 3, 163–170

et al. (1998) developed The Mental HealthNursing Clinical Confidence Scale whichdetermines the degree of confidence inundergraduate learning following a mentalhealth placement. A caution with both thesemeasures is that of equating perceivedconfidence with actual student learning.

The conceptualization and development ofprofessional confidence remains unclear.Therefore, the purpose of this study was toderive a beginning understanding of hownursing students perceive the meaning ofprofessional confidence and to explore thoseinfluences that affect the development ofprofessional confidence.

Methods

A qualitative research approach was used toexplore the meaning and influences onprofessional confidence as perceived bynursing students. The setting was McMasterUniversity School of Nursing, a four yearbaccalaureate program. Small-group tutorials,problem-based learning (PBL) and self-directed learning (SDL) are used as theprincipal teaching-learning modalities (Callin1996, O’Mara et al. 1996). Ethics approval wasreceived from both the Committee forScholarly Activities and the UndergraduateNursing Education Committee of McMasterUniversity School of Nursing.

An invitation was extended to 12 randomlyselected nursing students from each year toparticipate in focus groups. Each of the focusgroups (6–10 students per group) wasfacilitated by paired faculty members whowere not currently tutoring in that year of theprogram. The focus groups were relativelyunstructured although a set of questionsrelated to the purpose of the study was used asa guide; lasted one and a half to two hours,were audio taped, transcribed verbatim andchecked for accuracy.

Qualitative data analysis was done usingBurnard’s (1991) method of thematic contentanalysis. According to Burnard (1991), the aimof the analysis was to produce a detailed andsystematic recording of themes addressed inthe focus groups and to link these themestogether under a reasonably exhaustivecategory system. All transcripts were read and



�c 2003 Elsevier Scienc

notes were made about general themes.Categories were then created and subheadingswere subsumed under the categories. Facultydyads, different from the faculty whoconducted the focus groups, each reviewedand revised categories and subheadings fortwo focus group interviews. When it becameapparent a process was occurring across thefour years, researchers also reviewed thecategories and subheadings across the years.Subsequently, all researchers held rigorousdiscussions reviewing the revised lists andculminating in a further and final refinement ofcategories and subheadings.

Methodological rigour was supported inseveral ways. First, to enhance validity ofcategorizing the data and to screen forresearcher bias, both independent and pairedreviews were conducted and researcherschallenged ideas and looked for alternatepoints of view. Second, sufficientdocumentation, by way of quotations from thefocus groups, is provided to allow the reader toparticipate in the validation of the findings.Lastly an audit was kept, including: (a)interview transcripts; (b) theoretical notes andtentative categories; (c) progress notes frommeetings where methodological and dataanalysis decisions were made; and (d) drafts ofreports (Lincoln & Guba 1985, Polit & Hungler1997).

Findings

The three main categories that emerged were(1) the meaning of professional confidence; (2)

Table 1 Meaning and influences of professional con-fidence

Meaning Influences

Feeling Prior to Entering NursingKnowing Growing UpBelieving Venturing OutAccepting Within the Nursing ProgramDoing Promoting DevelopmentLooking Curriculum CultureBecoming Interaction with TutorsEvolving Clinical Experiences

Student Directed StrategiesImpeding DevelopmentImage of NursingProgram PerceptionsTutor Behaviours

e Ltd. All rights reserved.

influences prior to entering nursing; and (3)influences within the nursing programme. Anumber of subheadings were also identifiedwithin these three categories (see Table 1). Inpresenting the categories and subheadings, themeaning of professional confidence will bedescribed first, followed by influences on thedevelopment of professional confidence, bothprior to entering nursing and within thenursing program. Findings are presented usingquotations as exemplars.

Meaning of professional confidence

The meaning of professional confidence wascaptured by eight subheadings: Feeling,Knowing, Believing, Accepting, Doing,Looking, Becoming, and Evolving.

Feeling was described as a generalizedsensation, such as, ‘‘feeling good about myself’’and ‘‘feeling comfortable in a situation.’’ ‘‘Itwas nice that he [patient] felt comfortablehaving me there. . . I felt good about myself.’’(Year 1). Knowing was perceived in two ways:as not having knowledge and accepting this, oralternatively, as having knowledge andrecognizing it.

I think it [confidence] also has to do withknowing that it’s okay not to knoweverything. . . you’re not always feelingpressured to always have an answer toeverything,. . . you just feel good about whatyou do know and know how to use that.(Year 1).

Believing was expressed as having faith, self-liking, and an internal sense of trust.‘‘Confidence is a stronger sense of myself sothat I am not so scared of what other people arethinking about me or how they are going tolook at me.’’ (Year 4). In turn, Accepting wasseen as the students’ acknowledgment of whatthey knew and did not know, and having anopenness to feedback regarding their strengthsand limitations.

As you go through the years, you kind of getused to the program, what it entails, whatnursing entails. You get used to the wholecontext. Therefore, confidence increases.Getting used to the fact that you have a right tobe in these places and it’s your job. (Year 3).

Doing involved taking initiative for activitiesand carrying them to fruition. ‘‘. . .all of a



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sudden, they [patients] have confidence in youand you have established that you can give abed bath.’’ (Year 2). Looking entailed a two-way mirror process, where students lookedboth, in at themselves, and then looked out athow others perceived them. ‘‘I think you haveyour own perception of your confidence andthen other people have a perception of howconfident you are.’’ (Year 3). A sense ofBecoming confident emerged through self-discovery and growth, educational integrationand professional awakening. ‘‘I think I felt Icould apply for a job and be able to do it. . . Iactually feel like a nurse now.’’ (Year 4).

The development of professionalconfidence was an Evolving process. Thisevolution began with ‘‘Feeling good aboutyourself’’ and being able to completespecific nursing skills in Year One. ‘‘It’s hardto describe but I think just feeling goodabout yourself, not necessarily being able tostand up all the time and talk, but just feelinggood about what you can do.’’ (Year 1). Asstudents progressed through Year 2, theKnowing aspect of professional confidencebecame more pronounced. Student’s actionswere now based on having knowledge:‘‘You might have it all in your head. . . likeyou knew what to do and what to say.’’(Year 2).

Students in Year 3 focussed more onBelieving in and Accepting their abilities. Therewas comfort in integrating Knowing andDoing, specifically initiating and taking actionsin the clinical setting.

I guess for me professional confidence wouldmean really being confident that you areskilled, that you are accountable to what youteach and the skills that you perform withinnursing. (Year 3).

Students were also aware about Lookingover-confident or faking confidence, yetrecognized that a quiet confidence can alsoexist. ‘‘. . . I have seen it on more than oneoccasion with people that are too confident,carrying out their skills first. . . they think theyknow it but they don’t.’’ (Year 3).

In the final year, students pulled all thecategories together, and described a sense ofprofessional self, a sense of Becoming a nurse.They reflected beyond situations or tasks, to thecomplexity of interactions and explored


professional issues. Being responsible andaccountable for clinical care along with theability to learn from mistakes were nowapparent. Integration of knowledge,experiences, and skills were seen asbenchmarks of developing professionalconfidence.

I think when you interview someone, forexample, they are having shoulder pain. Youhave the confidence because you know theanatomy and you know what could be theproblem. (Year 4)

Ultimately, professional confidence beganwith a sense of feeling good about one’s selfin first year and evolved to becoming aprofessional nurse by fourth year.

Influences prior to entering nursing

The development of professional confidenceprior to entering nursing was linked topersonality and life experiences involvingtwo subheadings: Growing Up and VenturingOut.

Growing Up

Several nursing students described attributesthat began in childhood, such as the tendencyto ‘‘be involved and to take initiative.’’ Thesepersonality characteristics, in conjunction withhow they were treated by family members,affected the development of their personalconfidence both positively or negatively. Theseinfluences carried over into adulthood andaffected their development of personal, andultimately, professional confidence. ‘‘From thetime I was in kindergarten, I have always beenthe one to put my hand up first. It’s seventeenyears later, and it’s still the same.’’ (Year 3). Inattempts to shape confidence, some studentsnoted that they had made deliberate decisionsas children to change their behaviour. ‘‘Therecame a point when I decided, am I going to gothrough the rest of my life being shy, or amI going to try and do something about it?’’(Year 3).

Venturing Out

As children, some students had deliberatelysought out specific confidence-building




activities through jobs, school and volunteerwork that counter-acted negative childhoodexperiences. ‘‘What I did was I took aleadership role as camp counsellor, whereyou really are forced into the role of aleader and you have to be assertive and youhave to be confident.’’ (Year 3). A majorcontribution to confidence development wasfeedback received from others. Positivecomments were reassuring while negativeones were seen as demoralizing. ‘‘She wasthe worst manager [non-nursing related]you could ever have. . . she never focussedon the good things. It was emotionallydifficult for me.’’ (Year 2). Influences priorto entering the program provided abackdrop for experiences within the nursingprogram.

Influences within the nursing program

Influences within the nursing program werecaptured by two subheadings: PromotingDevelopment and Impeding Development.

Promoting Development

Under this subheading, four components wereidentified: Curriculum Culture, Interactionswith Tutors, Clinical Experiences, and StudentDirected Strategies.

The Curriculum Culture of small-grouplearning was seen as helping students todevelop confidence in a safe environment. Thesmall number of students per group (8–10)allowed for positive interactions anddiscussions. ‘‘Because you know everybody,there is a point when you become comfortablewith everybody and you can ask them as muchas you want without them thinking-that is astupid question.’’ (Year 1). It was anenvironment that permitted risk-taking andlearning from mistakes. ‘‘I think [thatinterviewing] standardized patients is onething. These are actors. . . They are going togive us feedback on what we are doing. Youcan’t harm them.’’ (Year 1).

Interactions with Tutors had a major impacton how comfortable students felt in theirlearning environments. Several tutorbehaviours were identified as important:challenging the student; protecting the student


‘‘from doing something harmful’’; andencouraging and responding to studentquestions. One student described a particularfaculty member as follows:

She is very personable and veryapproachable and you do feel confident andeven if it is something that you wanted to askor that you are unsure of, she doesn’t make youfeel that you don’t know what you are doing.(Year 2).

Tutors who ‘‘walked’’ a student through aclinical skill, pointed out that mistakes were apart of learning and provided feedback werehelpful. ‘‘Confidence is a personal thing for me.I doubt myself and if someone says, youapproached that situation really well, thatboosts my confidence.’’ (Year 2).

Across the years, Clinical Experiences wereidentified as important in confidencedevelopment. Year 1 students pointed to thebenefits of being able to practice clinical skillsbeforehand with standardized patients. In thestudents first hospital clinical experience, onesecond year student focussed on the difficultyof ‘‘walking into the room.’’ Students neededsomeone to say that they ‘‘did well’’ and ‘‘it’sokay if you’ve done something wrong’’ whenbeing supervised in clinical practice. Patientsalso enhanced professional confidence bygiving feedback, asking questions and seekingopinions. ‘‘When this mother asked mequestions about her kid and herself and I wasable to answer them. . . it makes me feel like Ican do it.’’ (Year 2).

Clinical skills were viewed especially bythird year students to be instrumental indeveloping confidence. They expressedconcerns about a lack of confidence inperforming clinical skills, yet acknowledgedthese could be learned with practice. ‘‘Withinclinical, I have become more confident if I feellike I have been taught the skills properly.’’(Year 3). Students commented that theincreased amount of time spent in the clinicalsetting in third year was a transition periodthat helped them.

Student Directed Strategies were alsoidentified across the program. Students sawthemselves engaged in a dynamic process inwhich they could use a variety of studentdirected strategies to enhance theirprofessional confidence. Preparation for



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clinical experiences was seen as key to beingable to answer patient questions, completeskills, and manage care issues. ‘‘This week I feltlike, okay, I’m prepared. I can do this and I hadto give myself almost like a pep talk before Iwent into the room.’’ (Year 2). This preparationalong with continual practice enhancedprofessional confidence sustaining the studentsto take on new clinical opportunities. Inaddition, preparation for problem-basedtutorials allowed students to contribute todiscussions which in turn they linked todeveloping confidence.

Learning more about oneself was viewed asan important strategy. All students addressedthe need to recognize their strengths and areasfor improvement. ‘‘I think the ability toevaluate your own weaknesses and limitationsas well as your strengths is vital in order toprogress in your confidence level.’’ (Year 1).Students also valued a combination of learningmethods and used them to try out new skills.‘‘. . .it just works better if you read and prepare,also, if you just watch and experience it on areal person.’’ (Year 3). Reflection was used bystudents to evaluate how they did in a situationand presented the opportunity for professionalgrowth and revision of care; ‘‘I might say, howdid I do today?’’ (Year 2). Overall, havingprofessional confidence meant not having totell people about it or having the need to showstrengths; it was simply there.

Impeding Development

The development of professional confidencewas impeded from three directions: the Imageof Nursing, Program Perceptions, and TutorBehaviours.

The devalued Image of Nursing amongstpracticing nurses was a factor that plaguedstudents and led them to question theirdecisions to enter nursing. ‘‘Nursing as a wholeseems to have trouble getting together andshowing that professional confidence to societyis important.’’ (Year 3).

Students identified several negative ProgramPerceptions such as unclear, rigid orincongruent course/clinical expectations. Insome cases, students felt there was not enoughclinical variety or continuity of experience.‘‘With moving every semester we have a


different placement all the time. There is notenough opportunity to become good.’’ (Year 3).Time pressures felt overwhelming, andgrading practices in several courses gave rise tocompetitiveness. ‘‘For a program that issupposed to stress so much on all of usworking together, trying to get along, helpingeach other, there is so much competitiveness,obsession with marks.’’ (Year 3).

Tutor Behaviours were also seen asimpeding the development of professionalconfidence when they restricted the students’involvement in experiences, or providedinsufficient guidance and supervision. Thesebehaviours led to feelings of uncertainty andinsecurity by students. Perceived judgmentalattitudes of tutors, not valuing or listening tostudents and setting unrealistic, unclear orincongruent expectations were consideredharmful. ‘‘I was terrified of my tutor. . . Ofcourse you don’t have confidence when youthink that she is judging you on everything thatyou say or do.’’ (Year 2).

Discussion

The impetus of this study came from therecognition of a wide-spread practice amongfaculty and students with respect to evaluativecomments about lack of confidence on clinicalevaluations. Of importance was also therecognition that there was a gap in ourunderstanding of how to assist students todevelop more confidence. In this study weexplored the meaning of and influences onprofessional confidence from the perspective ofnursing students.

The findings suggest that nursing studentsperceive the meaning of professionalconfidence as an internal process comprised ofa set of components that evolves across the fouryears. Ellis (1980) noted that self-confidenceand self esteem declined as the students movedthrough the nursing program, which was incontrast to our findings. As teachers we need tobe cognisant of this evolving nature ofprofessional confidence and use teachingstrategies that are in synchrony with thisprocess. Students also recognized thatconfidence was nurtured during theirchildhood and accept its presence as anintegral part of themselves. This finding is




congruent with Haffer and Raingruber’s(1998) speculation that life experiences mayshape development of confidence.

Within the nursing program studentsaddressed numerous influences that positivelyaffected the development of professionalconfidence. Students acknowledged thespecific culture of the nursing programincluding small-group learning, permission totake risks, use of standardized patients,interactions with tutors, opportunities forclinical experiences, receiving feedback andemphasis on self evaluation. These features ofthe nursing program are consistent with factorsthat contributed to confidence building in areasoning course reported by Haffer andRaingruber (1998). This raises the question asto how influential our educational approachmight actually be in the development ofprofessional confidence.

As in other studies, the tutor’s influence infostering professional confidence wassubstantial. Challenging, guiding, protecting,being approachable, encouraging, providingfeedback are essential interactions. They aresimilar to those effective teaching behavioursidentified by Flagler et al. (1988) and Ferguson(1996 & 1999). Students placed considerableemphasis on the importance of feedback andself evaluation. Several authors concur with theneed to provide feedback, particularly positivereinforcement to support student confidence(Ferguson 1996, Glover 2000, Gray & Smith2000, Kelly 1992, Mozingo et al. 1995).

Influences within our program included therole of peers and experiences with patients.Students referred to engaging in risk-takingand feeling comfortable in their interactionswith peers in small-group tutorials. It isanticipated that peers would be valued as apositive influence in the development ofconfidence, but the recognition of the role ofpatients is an interesting one. Suikkala andLeino-Kipi (2001) have highlighted that‘‘relationships with patients are connected withstudent’s personal and professional growth,confidence, and self-esteem.’’ (p. 48). It wasapparent that comments from patients werevalued and recognized by students as abuilding block in their development ofconfidence. Students also identified strategiesthat they themselves found helpful such as


preparation, self-awareness, understanding oflearning styles, self-evaluation and recognitionof their confidence.

Students also described impediments todeveloping professional confidence. Theidentification of the devalued image of nursingamong practising nurses as one impediment isa disconcerting finding that requires furtherstudy. Program issues were also identifiedincluding incongruent course expectations,insufficient clinical continuity, time pressures,grading and competition. When addressinginsufficient clinical continuity, students may besaying they do not have enough opportunity tolearn and practice clinical skills. Kelly (1992)and Mozingo et al. (1995) would both supportthis interpretation. They suggest students’ self-confidence would be enhanced if they felt morecompetent about their clinical and technicalskills. Students also clearly described tutorbehaviours that evoked uncertainty andinsecurity. Ellis (1980) identified nursingfaculty as prime suspects in ‘‘destroying’’student self-confidence.

Conclusion

This study contributes to our understanding ofthe meaning and development of professionalconfidence as perceived by nursing students.Professional confidence is developmental,dynamic, complex and essential. Theinfluences that contribute to its developmentare multiple including childhood and familyexperiences as well as their interactions withinthe nursing program they attend. Inacknowledging limitations of this study it is ofimportance to note that these findings are notexhaustive. The descriptive nature of this studylimits the depth of understanding achievedabout the development of professionalconfidence. Further research is required tocapture whether these results are unique to ourprogram philosophy and educationalapproach. An additional study of interestwould be the influence of patients and theimpact of the devaluing of nursing. Workshopsthat emphasize teaching behaviours whichpromote development of professionalconfidence is a need for all faculty. Tocounteract impediments to the development ofprofessional confidence, attention should be



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given to monitoring consistency andcongruency among small-group tutorials andclinical experiences. These strategies have thepotential to contribute to the development ofprofessional confidence, a quality that theprofession of nursing demands.

Acknowledgements

The authors acknowledge the support of LeeWilson and Rose Gregor in the preparation ofthe manuscript.

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