RELATED LITERATURE

Ensuring that nursing students receive sufficient practical experience to develop

the full range of skills they need for effective practice has become a focus in nurse
education (DOH, 1999).

The clinical placement experience is a significant

learning component within the nursing curriculum. It provides
nursing students with an opportunity to use the theory and
skills they have learned in the classroom and laboratory
settings (Barney).

The rapid changed in the health care environment have many implications for

nursing education and nursing practice. The rapidity of knowledge changes have resulted

in knowledge become obsolete. Thus, nurses need to keep learning in response to the

rapidly changing healthcare environmenr so they can keep abreast of expectations of

patient and the health care system (Studdy, Nicol & ox-Hiley, 1994).

Various studies have suggested that not all practice settings are able to provide

nursing students with a positive learning environment. In order to maximize nursing

students' clinical learning outcomes, there is a need to examine the clinical learning

environment. (Chan,)

SOURCE:

Benner, P. (2004). Using the Dreyfus model of skill acquisition

to describe and interpret skill acquisition and clinical
judgment in nursing practice and education. Bulletin of

Chan, D. (). Nursing Student’s Perceptions of Hospital Learning

Environments: An Australian Perspective.
http://www.bepress.com/ijnes/vol1/iss1/art4. April 2,
2009.5:10 PM

Barney, Amanda. (). Nurses from Across the State Learn the
Importance of Providing A Welcoming Environment.
http://www.hari.org/press/06profdevelop.pdf) April 2,
2009.5:15PM.

Barriers to effective clinical decision

making in nursing
Phillipa O'Reilly

Abstract

Phillipa O'Reilly is the Clinical Nurse Consultant: Nutrition and

Intravenous Therapy at St Vincent's Hospital, Sydney.

Clinical decision making is an essential component of professional nursing practice. One

of the goals of the nursing profession therefore should be to enhance the clinical decision
making abilities of nurses. This paper examines the factors; experience, knowledge,
creative thinking ability, education, self concept, work environment and situational
stressors, and, discusses how these factors can either enhance or impede decision making
for nurses. Strategies to reduce the barriers to clinical decision making are suggested.

Introduction

Clinical decision making, the ability to sift and synthesize information, make decisions
and appropriately implement these decisions in the clinical environment is an essential
component of professional nursing practice. The nursing discipline's pursuit of
professional recognition relies heavily upon the ability of practicing nurses to correctly
define and solve problems which are uniquely nursing in origin (Jones, 1988: 185).

Nurses are expected to be competent decision makers (Pardue, 1987: 355), therefore the
nursing profession has a responsibility to enhance the clinical decision making abilities of
its members. One means of doing this is to identify factors which act as barriers to
effective problem solving. By recognising the nature and existence of barriers, strategies
may be developed to overcome them.
Clinical decision making is a complex process whereby practitioners determine the type
of information they collect, recognise problems according to the cues identified during
information collection, and decide upon appropriate interventions to address those
problems (Tanner, Padrick, Westfall & Putzier, 1987: 358; Thomas, Wearing & Bennett,
1991: 1). The complexity of the process is due to the variation in cues, the magnitude of
information to be processed, and the difficulty in predicting outcomes (Hammond, 1960,
cited by Pardue, 1987: 355).

Numerous factors influence the clinical decision making process (Pardue, 1987: 55).
These factors include individual variables, such as experience and knowledge (Benner,
1984; Benner & Tanner, 1987), creative thinking ability, education (Pardue, 1987: 355),
and self concept (Joseph, 1985: 22), as well as environmental and situational stressors
(Cleland, 1967; Evans, 1990). These factors may serve to enhance or impede clinical
decision making.

Experience and knowledge

Experience and knowledge are two of the major factors affecting decision making.
Decision making within practice disciplines, such as nursing, involves more than the
application of theoretical knowledge. A deep understanding of the situation is required if
treatment approaches are to address the experience of illness as it relates to a particular
patient. This understanding evolves from knowledge and experience (Mattingly, 1991:
979; Correnti, 1992: 91). Experience increases the cognitive resources available for
interpretation of data (Liek & Cifford, cited by Evans, 1990: 180), resulting in more
accurate decision making.

Tanner et al. (1987), studied the diagnostic reasoning strategies of nurses and nursing
students and found that increased knowledge and experience yielded more. systematic
data acquisition and greater diagnostic accuracy (Tanner et al., 1987: 362). This
difference in diagnostic accuracy has been attributed to the ability of the expert nurse to
intuitively determine the correct region for assessment, select relevant data and recognise
the changing relevance of cues as the situation evolves (Benner & Tanner, 1987: 31).

Intuition, defined by Benner and Tanner (1987: 23), as "understanding without rationale"
represents the hallmark of expert judgement. The ability to rapidly identify the important
facts, limits the number of alternatives to be evaluated, and thereby reduces decisional
conflict and stress (Evans, 1990: 180). In this context the ability to use intuition in
decision making is a factor enhancing decision making.

However, despite research findings which advocate intuition as central to expert

judgement (Benner, 1984: xviii; Rew, 1990: 37), intuition has been dismissed as
irrational guessing (Correnti, 1992: 92). Many nurses, because of this view, are reluctant
to follow their 'gut feelings', and reject the use of intuition in decision making. Often
expert nurses know that something is wrong before clinical signs manifest, but they deny
this knowledge due to the debasement and suspicion of intuition as a valid nursing
assessment technique. This attitude of dismissing intuitive judgement as irrational
guessing, generates decisional conflict and substitutes a barrier to expert nursing
judgement.

Promotion of nursing expertise requires the acceptance of intuitive understanding as a

valid method of decision making, and challenges experts to share their experiences of
making decisions (Corcoran, Perry & Bungert, 1992: 69). Nurse educators are
encouraged to teach the application of intuitive skills, cultivate intuitive knowledge and
promote the development of creative thinking abilities for problem solving (Correnti,
1992: 99).

Creative thinking

Problem solving involves organisation of new and previously learned information to form
new responses to novel situations (Brooks & Shepherd, 1990: 392). This incorporates two
major components, reasoning and imagination. Reasoning is the basis of critical thinking
which produces comprehensible, methodical outcomes. Creative thinking however, is the
product of reasoning and imagination. Past impressions are integrated to form unique
conclusions (Berger, 1984: 306) which are essential for problem solving.

Education and the learning environment play a crucial role in the promotion of creative
thinking ability. Depending on the learning environment and attitudes of educators, the
development of creative thinking ability may be either enhanced or delayed (Berger,
1984: 307).

The promotion of creative thinking through education calls for teachers to endorse the
creative thinkers' self-worth, listen to them, challenge learners to develop new ideas and
to question their taken-for-granted ideas, demonstrate critical thinking ability, encourage
breadth of reading, invite learners to talk about what they think and feel, and to adopt a
conversational approach (Burnard, 1989: 273-274). Encouraging "success" rather than
"failure" enhances problem solving capabilities (Hartnett and Barber, 1981, cited by
Berger, 1984: 307) through the promotion of positive notions of self-concept and self-
efficacy. In order to effectively make clinical decisions the individual must perceive that
they actually can make the decision.

Self Concept

Perceptions of being less intelligent, less educated and less competent result in
relinquished authority to those perceived as being better (Joseph, 1985: 22). An important
component of self-efficacy and self-concept is the individual's locus of control (Joseph,
1985: 22). Locus of control refers to the extent to which a person believes they can
control events and outcomes. Those with an internal locus of control believe in their
ability to influence results, whereas, those possessing an external locus of control believe
that events are contingent upon the actions of others (Lazarus & Folkman, 1984: 67).
Locus of control has significant ramifications when investigating the effects of stress on
decision making, since locus of control is fundamental to the individual's perception of
stress.
Stress

Stress arises when an individual perceives the environment as demanding because it

exceeds his/her resources and threatens personal well being (Lazarus & Folkman, 1984:
19). As a result of this perceptual component, situations that are anxiety provoking and
stressful for one individual may be stimulating for another depending on their appraisal
of the situation (Bailey, Steffen & Grout, 1980: 24; Wakefield, 1992: 24). Those with an
internal locus of control, usually view life as challenging and perceive themselves to have
an influence on the outcomes of stressful life events (Lazarus & Folkman, 1984: 69; Rich
& Rich, 1987: 64). By perceiving crises as challenging rather than threatening, stress is
minimised. Those with an internal locus of control are therefore inclined to deal with
stress more effectively than those with an external locus of control (Rich & Rich, 1987:
65). However, because stress interferes with a persons concept of self-efficacy (Jenkins,
1985: 43), situations of extreme stress can have a negative impact affecting locus of
control, thinking (Cleland, 1967: 110), and decision making ability (Neaves, 1989: 15).

Cleland (1967) studied the effects of stress upon nurses thinking. She concluded that a
moderate amount of stress was required for optimal thinking. Situations of low stress
provided insufficient stimulation and impaired functioning, while moderately high to
very high environmental stressors resulted in a deterioration in the quality of thinking.
This deterioration was found to be more rapid when complex thinking processes were
required (Cleland, 1967: 110). Situations of high or low stress, must therefore adversely
affect decision making, since complex thinking is often utilised in the decision making
process.

The long term effects of functioning within highly stressful environments include
stereotypical, unimaginative thinking, over generalisation and loss of interest (Cleland,
1967: 110). Excessive, unrelieved stress may result in burnout, a syndrome resulting in
the development of negative work attitudes, poor professional self-concept and loss of
empathy (Rich & Rich, 1987: 63). Many authors (Wakefield, 1992: 24; Rich & Rich,
1987: 65), believe that nurses are particularly prone to developing burnout because of the
stresses inherent in nursing. Rich and Rich (1987: 65), identified that young, unmarried
nurses are at greatest risk.

Nurses themselves identify individual factors which produce the greatest stress. These
include interpersonal conflict, inadequate staffing, lack of support when dealing with
death, unresponsive leadership, and physical environment inefficiencies (Bailey et al.,
1980: 25). The sources of stress, identified by nurses, fall into five major categories;
interpersonal relationships, knowledge and skills, patient care, management problems,
and the work environment (Huckabay & Jagla, 1979: 21; Bailey et al., 1980: 16-17).

One of these sources of stress is the shiftwork component of nursing work. Much has
been written on the effects of shiftwork on workers. It is believed to be a major factor
contributing to tiredness, and it constitutes a source of physical and psychological stress,
and predisposes workers to tranquilliser and alcohol use (Siebenaler & McCovern, 1991:
563). All of these factors impair judgement and decision making ability (Thomas et al.,
1991: 64; Wakefield, 1992: 24).

Deficient performance as a result of shiftwork is principally due to disruption of normal

circadian rhythms (Siebenaler & McCovern, 1991: 558). Circadian rhythms are regular
endogenously controlled biological and behavioural patterns, synchronised to a twenty
four hour period by external influences such as night and day, clock time and social
activities. Performance and cognitive functioning are influenced by circadian rhythms.
Shiftworkers therefore, are prone to work performance problems, because their circadian
rhythms are disrupted, resulting in impaired attention, judgement, accuracy and safety
(Siebenaler & McCovern, 1991: 563). All of these factors impact upon the clinical
decision making abilities of nurses. Shiftwork therefore can be seen as a barrier to
effective decision making. Another major source identified is that of inadequate staffing.

Inadequate Staffing

That it is stressful to work when staffing levels are inadequate for the tasks required
would be disputed by few. However, Huckabay and Jagla (1979: 25) suggest that
inadequate staffing may be related, not only to the total staff numbers, but to the skill
index as well. It is suggested that most nurses have frequently encountered circumstances
when experienced staff are replaced with novices. This situation places stress on staff of
all levels. Experienced nurses encounter the additional effort of teaching and supporting
inexperienced nurses, particularly in view of Rich and Rich's (1987: 65) suggestion that
young nurses require more supervisory and coping support than their older counterparts.
For novices, the presence of highly skilled people, the performance of tasks for the first
time, and situational factors undermine confidence and increase anxiety (Jenkins 1985:
243). These factors all have an effect on decision making.

Jenkins' (1985) proposition that the presence of skilled expert nurses may undermine the
confidence of novice nurses, has implications for management and more experienced
practitioners in terms of allocation of patient loads, rostering of nursing staff and the
nature of clinical support available. If nurses are to develop perceptions of self-efficacy
related to decision making, management should attempt to allocate patient loads that are
challenging, without being overwhelming. Clinical support should be provided by
rostering inexperienced nurses on shifts with nurses of greater competency so that
situational demands encourage perceptions of self-efficacy.

Competent, proficient and expert nurses have the responsibility to guide beginners
through decision making processes, demonstrate patience when doing so, and encourage
reflective practice. They must endeavour to create an environment in which the learner
can fully experience the decision making process.

Interpersonal Conflict

The stressors involved with interpersonal conflict constitute another barrier to decision
making. Clinical decision making is a social activity involving health care team members
and the patient. The social context in which the clinician functions impacts upon decision
making (Thomas et al., 1992: 67). A significant influence for nurses involves their
relationship with physicians (Haddad, 1991: 151). Stein (1967), identified a fundamental
communication pattern used by physicians and nurses, which he called the 'nurse-doctor
game'. Interestingly, when Stein (1990, cited by Haddad, 1991: 152) reviewed the 'nurse-
doctor game' in 1990 he found only minor changes in the way the game was played
today, compared to when it was first discussed.

The principal rule of the 'nurse-doctor game' is that overt disagreement must be avoided.
In order to obey this rule, nurses must communicate their recommendations without
appearing to make recommendations. (Haddad, 1991: 151; Porter, 1991: 729). Nurses
have been socialised into playing the nurse-doctor game, to avoid open debate. The
result, as Joseph (1985: 31) found, is that experienced nurses are less likely to feel that
nurses should assume responsibility. This reluctance to assume responsibility creates a
barrier to effective clinical decision making.

A second factor influencing the nurse-physician relationship stems from the an inequity
in power relations between the two groups. Doctors exert direct power in the health care
system, determining who will be admitted as well as the type of treatments to be
performed (Haddad, 1991: 152). Their professional and financial status also allow them a
degree of political power, their statements influencing the actions of politicians when
determining health care. policies. Nurses, although an essential component to the
functioning of any health care organisation and by far the most powerful group in terms
of numbers employed, exert little authority in regard to decisions affecting their work or
wellbeing. Their contribution to the organisation often receives little recognition, and
their wages often do not reflect the responsibility afforded them (Haddad, 1991: 152).

Porter (1991) examined the nurse-doctor relationship and its impact on nursing
participation in decision making in an intensive care unit and a medical ward. He found
that while doctors, in particular, the consultant medical officers, still possess power over
nurses, the nurse-physician relationship has become more equitable. Some nurses are
beginning to be more open in their participation with informal decision making, however
many still continue to demonstrate subservience by observing the rules of the doctor-
nurse game, and are reluctant to assume responsibility for decision making.

Haddad (1991: 152) offers a third factor influencing the nurse-physician relationship,
namely the different approaches doctors and nurses use in decision making. Nurses,
because of their holistic approach to health care and the degree of female representation,
tend to acknowledge that patients exist within social networks and that the relationships
embedded in these networks are central to decision making. As a result, nurses have a
tendency to become concerned with the specifics of a situation and therefore, are slow to
make decisions. Doctors, due to a reductionist approach to health care and dominant male
representation, are inclined to analyse problems, dispensing with details that nurses may
believe are important, and take it upon themselves to make decisions with little or no
collaboration (Haddad, 1991: 152-53). Shared authority for decision making produces
better decisions and promotes greater commitment to the decision (Haddad, 1991: 156).
Without this collaboration, decision making can be problematic.

Since each group has a different approach to decision making, and in health care
collaborative decision making is encouraged, the only way forward is for doctors and
nurses to learn from each other. Consequently, nurses must encourage doctors to develop
an understanding of decision making in nursing. Nurses must also learn to be credible
and articulate, to expect arguments, be assertive and avoid over-qualifying (Haddad,
1991: 154). This can be achieved by direct communication, the abandonment of the
doctor-nurse game, and demonstrated cohesive support by nurses, educators and
administrators, for the role of nurses as decision makers (Joseph, 1985: 32, Haddad,
1991: 155).

References

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stressors of ICU nursing'. Journal of Nursing Education, 19 (6): 15-25.
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Nursing Education, 23(7): 306-308.
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decision-making skills in nursing and general critical thinking abilities of senior
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25.

Strategies to Improve Final Year Nursing Students’ Confidence

Linh Drexler
University of Windsor

Abstract

Final year nursing students have reported a lack of confidence in fulfilling the
expectations and responsibilities of professional nursing. This article looks at final year
nursing students’ experiences and feelings of confidence and explores interventions,
strategies, and programs that help maximize their confidence in relation to social learning
theory. Confidence building approaches include use of clinical demonstrators, mentors,
peer instructors and models, human patient simulators, feedback, praise, humor, and
mindfulness training. Sharing stories and experiences, as well as allowing students to
practice on their own are also discussed.

Strategies to Improve Final Year Nursing Students’ Confidence

As nursing students enter their final year of study, it should be expected that they are
preparing to take on the responsibilities of their profession with confidence. However,
final year nursing students experience apprehension and lack of confidence in fulfilling
the expectations and responsibilities of professional nursing (Carson, Kotzé & van
Rooyen, 2005; Heslop, McIntyre & Ives, 2001). This article describes graduating nursing
students’ experiences and feelings of confidence and provides an overview of
interventions and strategies that help to maximize their confidence.

Learning new information and skills and dealing with challenging situations can all be
negatively impacted by lack of confidence, and students with low confidence often
visualize defeat before it occurs (Lundberg, 2008). Disempowering experiences can lead
to fragile levels of self-confidence which can result in students disengaging from
placements or leaving the program (Bradbury-Jones, Samsbrook & Irvine, 2007). These
experiences can make the difference between newly graduated nurses staying in or
leaving the profession (Cowin, Craven, Johnson & Marsh, 2006).

Increased self-confidence and empowerment is related to improved motivation for

learning and better outlook on a situation (Bradbury-Jones et al., 2007). When students
have a higher sense of self-confidence about their skills, they are more likely to think of
these skills as important in nursing care and have an increased commitment to using them
(Clark, Owen & Tholcken, 2004).

Lofmark, Smide and Wikblad (2006) report that final year nursing students rate their
strongest areas as being holistically focused, being aware of ethical issues,
communicating with patients, cooperation, and self-knowledge. Heslop et al. (2001)
found that students report high levels of organizational commitment and professionalism.
The areas students report lowest confidence in are the amount of practical experience
(Lofmark et al.) and the development of management skills in planning work and
distributing tasks (Heslop et al.).

It is essential that students are provided with constructive learning environments; ones
that recognize under-confidence as well as foster the early development of confidence.

Theoretical Framework

Albert Bandura (1982) postulates that self-efficacy, also commonly referred to as self-
confidence is connected to “judgments of how well one can execute courses of action
required to deal with prospective situations” (p. 122). People will take on and perform
activities which they perceive themselves as capable of accomplishing. They will also
have a tendency to avoid activities which they judge to be beyond their coping
capabilities.
In Bandura’s social learning theory (1982), people learn from one another. Four sources
of information that judgments about self-efficacy are derived from are: enactive
attainment, vicarious experiences, verbal persuasion, and physiological state. Enactive
attainment has the most impact on confidence judgments. It is based on mastery
experiences. Students should be given opportunities to practice and perform skills and
procedures to experience success first hand. Repeated failures adversely affect self-
confidence, especially those that occur early on and that are not based on lack of effort.
Vicarious experiences or modeling allows one to witness others successfully perform
activities. Adept models can also show students how to effectively handle difficult
situations. Verbal persuasion or praise can be employed to convince students that they
have the capabilities to achieve what they seek. Social persuasion is especially effective
in enhancing successful performance when it is within realistic bounds of what the
student can do. Physiological states such as anxiety or stress can lead people to judge
their capabilities as less effective and therefore adversely affect performance.

Confidence-building strategies and teaching approaches that take into account these four
sources of self-efficacy information will be most effective in helping nursing students.

Strategies to Build Confidence

Enactive Attainment

The role of clinical demonstrator was outlined by Hilton and Pollard (2005). Clinical
demonstrators are experienced clinicians who work at hospitals or agencies and are hired
by nursing schools. They work with lecturers in introducing nursing care skills to
students in classrooms and skills labs. Clinical demonstrators also support nursing
students in transferring these skills to real life practice in their clinical placements. They
are able to provide extra hands-on teaching sessions to struggling students and those who
feel they have had limited clinical experience. It was found that senior nursing students
brought up concerns regarding areas of practice they had low confidence in, such as more
advanced clinical skills. The clinical demonstrators were able to organize specific
teaching sessions to address their needs, while also working with students in the hospital
setting performing skills and delivering care to patients. Students described feeling less
nervous and having greater confidence after working with clinical demonstrators. The
clinical demonstrators helped close the theory gap (defined as the discrepancy between
what is practiced in a clinical setting versus what students are taught in the classroom)
that students expressed as frustrating (Moscaritolo, 2009).

Nursing mentor programs can also help support the transition to practice for final year
nursing students. Theobald and Mitchell (2002) described a mentor program whereby
students applied for and were matched with volunteer registered nurses (RN) who were
practicing in areas of nursing that the students were interested in, for the duration of one
academic year. Each student worked with an RN for an average of two hours per week,
with the mentor acting as “guide, professional colleague, tutor, supporter, or informal
counselor” (2002, p. 28). The program did not include any element of student assessment,
unlike the preceptorship component of the nursing program. Students reported gaining
greater insight into the working of a hospital ward and enhanced confidence and skill
acquisition. Some activities the students were able to experience through the program
included having assistance with preparing for future workplace interviews, attending in-
services and educational seminars, providing supervised patient care, and exchanging
ideas regarding legal and ethical issues.

Anderson and Kiger (2008) describe an initiative whereby final year students nearing the
final stages of their community health placements make patient visits without the direct
supervision of a preceptor. This afforded the students some degree of independence in
patient care. The care provided by nursing students still required the supervision of a
qualified practitioner for accountability purposes, but they were not directly supervised,
with the preceptor available for support and reassurance by telephone if needed. Students
reported feelings of increased competence and confidence in being able to, and being
trusted to, work without direct supervision.

Vicarious Experiences

Use of peer instructors and models can involve matching more clinically confident
students with less confident ones so a desired behavior or skill may be observed. This is a
form of learning vicariously (Lundberg, 2008). Because the model and the observer are
both students, the encounter may be perceived as less intimidating. There is the
implication that if a peer can successfully perform a skill, the student can as well.

Another form of vicarious learning involves sharing stories, experiences and feelings.
This allows students to realize that their capabilities are comparable to their classmates
and that others share similar insecurities (Haffer & Raingruber, 1998). Giving students
opportunities to talk about their experiences with peers and nurses allows them to
cultivate reasonable expectations of their clinical skills as well as learn from the
experiences of others (Lundberg, 2008).

The use of human patient simulators (HPS) in training nursing students has helped in
developing and increasing confidence in assessment, critical thinking, and clinical skills
that can then be applied to real life situations (Bremner, Aduddell, Bennett & VanGeest,
2007). HPS are life-sized mannequins containing electronic and mechanical technologies
that allow them to mimic human physiology and react to different treatments in real time.
Teaching sessions generally include a small number of students, one facilitator, and one
HPS. Students can learn and gain confidence by observing each other, working as a team,
and observing outcomes of different actions without fear of harming an actual patient
(2007).

Verbal Persuasion

Nursing students need feedback and praise about their developing skills. If recognition is
not given, their sense of emerging confidence and skills may be impaired (Haffer &
Raingruber, 1998). Giving students regular, timely, and specific feedback along with
constructive comments and warranted praise are all activities which nursing instructors
can employ to build confidence (Lundberg, 2008). Students need to communicate with
instructors, nurses, and preceptors about their performance in order to receive
encouragement and feedback. Educators can enhance this process by providing clinical
learning environments which fosters students’ decision making without concern of
punishment or embarrassment (Baxter & Boblin, 2008; Haffer & Raingruber, 1998).

Physiological State

Using humor in teaching or having a lighthearted attitude can benefit learners by

enhancing self-esteem, and decreasing stress and anxiety (Moscaritolo, 2009). Use of
humor in the classroom has been found to increase students’ retention of content. Its use
in the clinical setting has helped reduce anxiety which in turn enriched performance and
confidence.

Cultivating mind-body awareness and being attuned to the present moment through
mindfulness training activities such as meditation, yoga, and relaxation techniques has
helped reduce stress in nursing students (Wolfgang, Turner, Young & Bruce, 2001). In
clinical placement settings, nursing students used strategies of mindfulness to quiet their
bodies, thoughts, and feelings. This resulted in greater stress management, reduced
anxiety, and increased feelings of being able to handle stressful situations in both
classroom and clinical settings (Moscaritolo, 2009).

Implications for Nursing Education

Nursing students have reported that they are highly skilled self-doubters (Haffer &
Raingruber, 1998). It would follow that any educational approach should avoid activities
that reinforce these thoughts. Rather, nursing education programs should counter the
development of self-doubt through opportunities to gain skilled practice in an
encouraging and supportive environment.

Students can implement confidence building strategies by seeking out vicarious

experiences and being mindful of their physiological states. Although it is important that
students have some sense of accountability and self-motivation for their skills and
education, educators retain a high degree of influence over strategies and programs that
reflect all domains of self-efficacy. Because of the inherent power difference between
students and teachers, it is essential that educators be leaders in providing the most
constructive confidence building environment they can; one in which students feel safe in
asking questions and instructors are willing to guide students in the process of
discovering answers (Haffer & Raingruber, 1998).

There are many innovative strategies being used by different nursing schools. It is
important to gauge student needs, consult leading research about strategies that are
succeeding, and collaborate with local and regional agencies. In this way, nursing
students will benefit from greater confidence and skills. In turn, the nursing profession
will benefit from the greater morale and retention of new graduates.
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