Explaining Novice Nurses’ Experience of Weak Professional Confidence: A Qualitative Study

Abstract

Introduction

The majority of newly graduated nurses are not prepared to work at the bedside; therefore, they may not have the appropriate self-confidence.

Objective(s)

The present qualitative study aimed to explain the novice nurses’ experience of weak professional confidence.

Design

This qualitative study was performed using a content analysis method.

Methods

Content analysis was utilized to identify themes from interview transcripts. They were included in the study by purposeful sampling. Participants were interviewed through face-to-face and unstructured interviews. All data were recorded, transcribed, and analyzed based on the Graneheim and Lundman method.

Results

Thirteen nurses participated in interviews. After data collection, all interviews were implemented and reviewed and the categories and subcategories were extracted. Three main categories containing turbulence in working life, unpleasant interactions, and lack of knowledge were extracted.

Conclusion

According to the study findings, most novice nurses experienced turbulence in their working life, unpleasant interactions, and a lack of knowledge that affected their self-confidence. Therefore, educational and support programs are suggested to improve novice nurses’ professional confidence.

Relevance to Clinical Practice

According to the results of the study, the lack of self-confidence in novice nurses reduces the quality of care. Therefore, taking into account the experiences of the participants, nursing education managers should plan in such a way as to improve the self-confidence of the graduates. In addition, novice nurses need to be supported by their managers and colleagues to develop their professional confidence to provide more effective care.

Introduction

Nursing is a profession that is effective in maintaining health and rehabilitation of patients to achieve optimal health (Patidar et al., 2011). Nurses are the first professional staff in any healthcare organization and provide quality care to patients (Chiang & Chang, 2012). The quality of healthcare depends a lot on how nurses work. Nowadays, with the advancement of the nursing profession, nurses are expected to provide more complex care based on patients’ needs (Roghani et al., 2006). Novice nurses comprise approximately 80% of the nurses’ population (Kovner et al., 2014) and studies show that the majority of novice nurses at the beginning of their work express the feeling of being insufficiently prepared to play a new role (Gardiner & Sheen, 2016; Kim et al., 2015).

The conducted studies show that undergraduate nursing courses are insufficient and novice nurses have not obtained the necessary preparation for care in a real work environment (Maria et al., 2020; Lee et al., 2013). Studies show that novice nurses are frequently left out of by professional standards and commit errors, negligence, and ultimately malpractice in clinical environments (O'Shea & Kelly, 2007; Zamanzadeh et al., 2014). Stress and anxiety are directly related to the increase in nursing errors (Clipper & Cherry, 2015). The other factor that causes novice nurses’ errors is their stress during their first workdays. A review of studies showed that stress and anxiety are directly related to the increase in nursing errors (Kneafsey & Haigh, 2007; Theisen & Sandau, 2013). Washington (2012) stated that lack of clinical experience and complex nursing care methods cause functional anxiety. Stress and lack of confidence in new graduate nurses affect their ability to provide quality care (Kim et al., 2015). Clark and Springer (2012) reported that a lack of knowledge and fear of harming patients reduce nurses’ self-confidence. Nurses’ self-confidence is aligned with their ability to communicate, having positive attitudes toward their profession, and their feelings about themselves as professionals, which significantly affects their thinking and practice (Cowin et al., 2006). Since high self-confidence improves the attitude toward the profession and career development, low self-confidence, in addition to the mentioned negative effects can push novice nurses to quit their job (Rudman et al., 2014). Considering the importance of the quality of care and concern about preparing novice nurses to perform their duties in clinical environments, many managers state that majority of new nursing graduates are not prepared at the beginning of their work. In this regard, novice nurses’ lack of self-confidence has long been the main causes of concern of nursing managers (Rudman & Gustavsson, 2011). To understand and explore phenomena such as nurses’ self-confidence, it is necessary to focus on understanding their life experiences and the views of those who are closely involved with this phenomenon (Squires & Dorsen, 2021). In this regard, qualitative studies that emphasize the life experiences of people who have experienced a certain phenomenon and try to examine the dimensions of that experience in a specific cultural and social context are appropriate (Graneheim et al., 2017). However, the best sources of information that can explain novice nurses’ experiences of low professional self-confidence are themselves. The majority of the participants of the present study suggested that the effective actions of managers, including supervisors, increases their self-confidence, by placing experienced nurses next to novice nurses and increasing their skill and decision-making power. Considering the importance of self-confidence in novice nurses to perform clinical work, identifying the challenges that novice nurses with weak self-confidence have in clinical work can help to find the roots and adopt measures to solve the problem.

Review of Literature

Self-confidence is a dynamic process that occurs during clinical work. It helps novice nurses to adapt to the work environment to perform high-quality healthcare and increase their self-confidence (Ortiz, 2016; Ostini & Bonner, 2012). Many novice nurses do not have professional confidence in their first year of work (Ostini & Bonner, 2012). Urban and Barnes (2020) mentioned that novice nurses feel unprepared for clinical work at the beginning of their work, and the majority of them mentioned lack of self-confidence as one of the reasons for their lack of preparation in clinical work (Urban & Barnes, 2020). Maria et al. (2020) pointed out that the majority of novice nurses report poor performance in caring for patients (Maria et al., 2020). Wu et al. (2012) novice nurses experience stress and anxiety when patients’ condition worsens due to insufficient mastery (Wu et al., 2012). Since self-confidence is considered a basic factor in caring in the nursing profession, therefore, dealing with the experiences of novice nurses in the field of self-confidence can be valuable and useful for identifying the factors that cause weak self-confidence in novice nurses caring for patients. Removing underlying causes will help to perform effective care. The purpose of this study was to explain novice nurses’ experiences of weak professional confidence.

Methods

Study Design, Inclusion Criteria, and Sample

A qualitative descriptive study with a conventional content analysis approach was used to analyze data and extract concepts. In this study, which lasted from August 2021 to June 2022, participants were selected among three hospitals. In this conventional content analysis, 13 novice nurses were selected using purposeful sampling.

According to the inclusion criteria, participants were clinical nurses with 6 months to 1 year of work experience who were willing to explain their experiences. Both male and female participants of a variety of ages were included in the study.

Interview Structure

After explaining the purpose of the study to all the participants, individual and unstructured in-depth interviews were conducted.

All participants received a written information sheet about the research and its background and an oral explanation of the study plan was given to them. Then, they signed the consent form. Before the interview, the participants were asked about the preferred place and time of the interview. According to the participants’ preference, the place of the interview (home or workplace) was selected, and confidentiality was respected. Participants were asked to start the discussion based on the qualitative studies interview method; interviews were started with a general question such as “Please explain the first days of your work?” or “How was your emotional status at the beginning?” Then other questions were asked according to the participants’ conversations. For example, participants were asked to explain more or were asked what they meant. In other words, in the first interviews, general questions were asked and subsequent interviews were directed based on concepts extracted from the initial interviews. Also, when necessary, follow-up questions such as “please explain more,” etc. were asked to clarify and resolve the ambiguities. The interviews of participants lasted for about 20 to 45 min. Then the interviews were transcribed and analyzed. After the interview 11, no new concepts were obtained; however, two more interviews were conducted to ensure data saturation. Interviews and their analysis were conducted continuously by researchers proficient in qualitative data analysis. This process continued until data saturation, after which the transcription of each interview was written verbatim and then encoded and after analyzing each interview, the next interview was conducted. All interviews were recorded by digital voice recorder and carefully and immediately transcribed verbatim. Data was analyzed by the conventional content analysis method and categories and subcategories were extracted directly from raw data (Tesch, 2013).

Analysis

Graneheim and Lundman's conventional qualitative content analysis was used for data analysis. Based on their guidelines, interviews were transcribed first. Then, researchers listened to the recordings and reviewed the transcripts several times to find the meaning units. In the third stage, initial codes were extracted and formed from the meaning units. The researchers categorized the codes according to conceptual similarities during the fourth stage. Finally, categories and subcategories emerged considering the continuous analysis of units (Graneheim et al., 2017).

The Lincoln and Guba criteria were used to guarantee the trustworthiness of the data (Lincoln et al., 2011). The researcher tried to increase the study credibility by collecting valid information. A researcher involved in data analysis, coding and comparing the data separately. In addition, external experts checked to audit the interview process, coding, and analysis warranted the research dependability. Prolonged engagement, sufficient interaction with the participants, and approval of the codes by them were used to achieve confirmability. The study transferability was provided by a rich and complete description of the results. In addition, the demographic characteristics of the participants and the study area were explained in detail, so that the reader could decide how to use the study results (Lincoln et al., 2011).

Results

Sample Characteristics

Thirteen novice nurses working in hospitals were interviewed. The participants were aged between 22 and 30 years. Three of them were male, and 80% were married. They had work experience between 6 months and 1 year (Table 1).

Table 1.

Demographic Characteristics of the Participants (n=13).

Participant code	Age (year)	Gender	Duration of work experience	Hospital ward
P1	22	Man	6 months	Emergency
P2	24	Female	7 months	Emergency
P3	25	Female	7 months	Emergency
P4	30	Man	9 months	Children
P5	28	Female	1 year	Neonatal
P6	27	Female	7 months	Neonatal
P7	26	Female	9 months	Children
P8	25	Female	8 months	ICU
P9	25	Man	7 months	ICU
P10	23	Man	11 months	Surgery
P11	24	Female	10 months	Surgery
P12	25	Female	8 months	CCU
P13	23	Female	9 months	CCU

Note. CCU= cardiac care unit; ICU=intensive care unit.

Research Question Results

After the interviews were coded, repeated codes were removed, similar codes were merged, 2,315 open codes were obtained, and finally, three major categories with 12 subcategories were extracted. The majority of participants stated that at the beginning of their work, they lacked professional confidence, and stated the conditions that led to the creation of confidence in them. The existence and lack of confidence depended on the situations in which individuals were placed. The obtained categories and subcategories are stated in Table 2.

Table 2.

Categories and Subcategories of Weak Professional Confidence.

Categories	Subcategories
Turbulence in working life	Clogging due to insufficient mastery of the work
	Mental conflict due to doubts in decision making
	Apprehension of failure in independent care taking
	Insufficient performance independence
Unpleasant interactions	Degrading behavior of some doctors
	Degrading behavior of some colleagues
	Unpleasant actions of some companions
	Ignoring by some managers
Lack of knowledge	The gap between theory and practice during education
	Poor quality of internship
	Insufficient experience
	Doing frequent errors

Three major categories and 12 subcategories were extracted by data analysis, including:

1. Turbulence in working life with subcategories of clogging due to insufficient mastery of the work, mental conflict due to doubts in decision making, apprehension of failure in independent caretaking, and insufficient performance independence.

2. Unpleasant interactions with subcategories including degrading behavior of some doctors, degrading behavior of some colleagues, unpleasant actions of some companions, and ignoring by some managers.

3. Lack of knowledge involved the gap between theory and practice during education, poor quality of internships, insufficient experience, and doing frequent errors.

Category 1: Turbulence in Working Life

By entering the workplace, novice nurses experience adversity during their working life. These adversities are a set of internal and external factors affecting the creation or exacerbation of a lack of confidence in work.

Clogging due to Insufficient Mastery of the Work

Clogging is due to insufficient mastery of the field and the events that occur to the participants upon entering the ward which challenges them. One of the participants said:

“I didn't have enough scientific knowledge at the beginning of my career, and I admitted to the inadequacy of my professional knowledge, and I felt stressed and disappointed that I couldn't accurately answer the questions of patients and their companions." (Participant #8)

Mental Conflict due to Doubts in Decision Making

Many careful nursing interventions are the result of nursing decisions based on reasoning and inference and providing solutions and finally choosing the best option as the final decision to be implemented in clinical settings. Novice nurses were hesitant to make their decisions due to the lack of experience and because of doubts in decision making. They experienced mental problems and clinical situations.

Sometimes novice nurses lack adequate clinical experience in the selection situation, the presence of doubt in the selection causes a feeling of tension in novice nurses. Most of the participants in the current research have doubts at the beginning of their work when deciding on the right type of care for patients. In this regard, one of the participants said:

“When a problem happened to my patient in the ward, I didn't know what to do (I have a mental conflict due to hesitation in making a decision).” (Participant #2)

Apprehension of Failure in Independent Caretaking

In the work of novice nurses based on the participants’ experiences, many underlying factors reduced self-confidence in novice nurses, because, during university education, they did not receive enough training about familiarity with critical thinking skills, and most of the training provided to them relied on basic knowledge and their previous experiences, so they felt apprehension when independently took care of patients. One of the participants said:

“I was in the surgery ward and we had a patient who had cancer and was metastasized. He suddenly suffered a cardiac respiratory arrest. I could not do anything for the patient alone, and I felt a lot of anxiety. At that time, I lost my confidence a lot.” (Participant #11)

Insufficient Performance Independence

Based on the experiences of the participants in this study, a lack of independence in performance reduces professional self-confidence. One of the participants said”

“I was in the internal ward of the shift once and the patient suddenly became very ill, and because I could not do anything without the doctor's permission, I lost my self-confidence a lot because the nurses only have to follow the doctors’ orders.” (Participant #11)

Category 2: Unpleasant Interactions

Since interpersonal relationships with colleagues are effective factors in facilitating adaptation to the workplace, interpersonal interactions confirm a special and unique type of communication. The lack of appropriate interpersonal communication was the cause of increased anxiety and stress in novice nurses.

Degrading Behavior of Some Doctors

Most of the participants in the present study stated that doctors do not behave well with novice nurses. One of the participants stated:

“Once I made a mistake in calculating the medicine and injected half a gram of antibiotics instead of one gram, the doctor scolded me and I completely lost my confidence.” (Participant #7)

Degrading Behavior of Some Colleagues

Based on data from information analysis, many participants expressed that they were humiliated and ignored by their colleagues, one of the participants said:

“It was the first days of my work, I was in the surgery ward and I had to change the dressing of one of the patients and I didn't know how to do it and I asked my colleague to help me change the dressing, my colleague made fun of me because I didn't know how to change the dressing. His behavior embarrassed me.” (Participant #1)

Unpleasant Actions of Some Companions

Based on the data obtained from data analysis, correct communication with patients and companionship plays an effective role in building the self-confidence of nurses. They should be accepted by patients and accompanied by them to create an effective interaction with them, so that the interaction is effective, therefore, interpersonal skills are effective in building self-confidence. A participant in this field said:

“Once, I wanted to take blood from the patient, I failed once or twice, and then the patient's companion treated me so insultingly, and because I did not have enough skills to take blood from the patient, I lost my confidence.” (Participant #11)

Ignoring by Some Managers

The results of this study indicated that managers such as head nurses and supervisors have an effective role in creating self-confidence in novice nurses so that if they are receptive, patient, and appropriate, they will create and promote self-confidence in novice nurses. The majority of participants in this study expressed dissatisfaction with ignoring by some managers. In this regard one participant stated:

“On the first day, I started working; I went to the hospital manager and said that I am not interested in the adult ward. If possible, I would work in the children's ward, and she (hospital manager) did not pay attention to my interest at all and said that I will determine where you should work and assigned me to the adult section. In the adult ward, because I could not communicate with the patients, my self-confidence was very weak.” (Participant #2)

Category 3: Lack of Knowledge

The majority of participants of this study stated that inadequate university education is an effective factor in performance weakness and subsequently low confidence.

The Gap Between Theory and Practice During Education

The gap between university and clinical courses was the reason for not mastering clinical skills. One of the participants said:

“The material that was taught at the university was more theoretical than practical, at the beginning of the work, because we did not have enough preparation for clinical work, we lacked self-confidence.” (Participant #7)

Poor Quality of Internship

The participants in this research stated that the low quality of the practical lessons during the studentship was an effective factor in their lack of self-confidence. Many participants pointed to educational problems, including short practical courses during the studentship, and stated the shortcomings of the learning environment as an effective factor in low self-confidence:

“The training courses had low quality, and most of the training courses had a short duration, and due to the low quality of these courses, we did not have enough preparation for clinical work.” (Participant #8)

Insufficient Experience

Based on the experiences of the participants of the present study, insufficient experience reduces their professional self-confidence. One of the nurses said:

“I was on shift in the emergency ward and I wanted to request medicine for the patient via the computer, and because I had never done this before, and despite trying very hard, I failed to, so I lost my confidence a lot.” (Participant #12)

Doing Frequent Errors

According to some of the participants, committing errors due to the weakness of knowledge would reduce their professional self-confidence, one of the participants stated in this field:

“Once, due to the similarity of the patients’ names, I mistakenly gave the medicine of patient 1 to patient 2. When I realized that I had made a mistake, I lost my confidence.” (Participant #4)

Discussion

Based on the findings of this study, several factors play role in the weakening of confidence in novice nurses. Also, the majority of participants stated that positive interpersonal relationships with physicians, colleagues, patients, and even companions promote professional self-confidence and, on the contrary, inappropriate interpersonal relationships with physicians and colleagues reduce self-confidence. This study showed that a lack of self-confidence is widely experienced in the majority of graduates at the beginning of work and causes a lot of stress upon just graduating. Also, the findings indicated that the lack of preparation is not limited to clinical skills, but there are deficiencies in other skills, especially communication with others. One of the results was the lack of awareness of novice nurses, which caused a decrease in self-confidence and the biggest challenge for novice nurses was the application of learned knowledge during studying periods in real conditions of patient care. Therefore, paying attention to the challenges of newly graduated nurses at the beginning of their work reduces stress and improves their performance, as well as prevents them from quitting their jobs and thus, preventing from the shortage of nurses (Wolff et al., 2010).

In the present study, three main categories were revealed. In relation to the subcategory of clogging due to insufficient mastery of work, consistent with this finding Christensen et al. (2016) also expressed feelings of unpreparedness, and lack of mastery of skills and adequate patient care by participants.

In relation to the subcategory of mental conflict due to doubts in decision making, and consistent with the present study, Washington (2012) also stated that newly graduated nurses are usually skeptical about performing their duties and are uncertain which leads to their mental conflict (Washington, 2012). Based on the results obtained from the present study, hesitancy in decision making and doubt in decision making are the causes of low self-confidence.

Another subcategory of this study was apprehension of failure in independent caretaking. Edinburgh (2011) also showed in the report regarding practical skills that novice nurses feel unprepared in terms of mastering clinical skills at the end of the study period (Danbjørg & Birkelund, 2011). In line with this finding, Tastan et al. (2013) also stated that novice nurses experience a lot of stress and anxiety when caring at work. The experience of perceived incompetence by participants leads to anxiety and stress, lack of confidence, feelings of insecurity, and performance anxiety (Ortiz, 2016). Participants in this study expressed feelings of apprehension during independent care. It can be said that one of the causes of participants’ anxiety is the lack of dominance of clinical practice because mastery of clinical practice is an effective factor in reducing stress and anxiety.

In relation to the subcategory of insufficient performance independence, the performance of doctors in the country's health system is an effective factor in reducing trust. In Iran's medical system, nurses are used as an auxiliary tool to carry out doctors’ orders. Their thinking power and knowledge is not very valuable and this component affects the reduction of self-confidence (Rafii et al., 2015).

The second category obtained based on data analysis was unpleasant interactions, including four subcategories. In relation to the subcategory of degrading behavior of some doctors, the majority of study participants stated that physicians behaved in a derogatory manner toward novice nurses, which is consistent with the findings of Anderson and Edinburg, a 2010 study stating that physicians do not treat novice nurses appropriately (Andersson & Edberg, 2010). One of the reasons for the poor relationship between doctors and novice nurses is their lack of mastery of clinical practice. Doctors accept and respect most nurses who are proficient in clinical practice, and do not accept novice nurses due to their lack of mastery which in turn, weakens the novice nurses’ self-confidence. In relation to the finding of degrading behaviors of some colleagues, in the study conducted by Casey et al. (2011), novice nurses experienced resentment and inappropriate respect from experienced colleagues. The other subcategory obtained from the study was the unpleasant actions of some companions. Consistent with the findings of Washington (2012) also stated that novice nurses are unable to establish appropriate interactions with patients, companions, and experience challenges with them at the beginning (Washington, 2012). Walker's findings, also stated that new nursing graduates encounter interpersonal conflicts at work and are not able to cope with communication challenges in the workplace (Walker & Campbell, 2013). In addition, Andersson & Edberg (2010) expressed the problems and communication challenges of novice nurses in their study. Based on the results obtained in this study, one of the reasons for the existence of challenges in the interpersonal communication of novice nurses is lack of experience, therefore, with the passage of time and increasing experience, communication challenges are reduced and, as a result, self-confidence in people increases.

Regarding the theme of ignoring by some managers, based on the findings of this study, the lack of support from some managers causes a decrease in self-confidence and increases anxiety. The study conducted by Olson (2009) showed that the expression of work experience was an effective factor in empowering novice nurses in caring. Based on the findings of the present study, it can be concluded that establishing proper communication between managers and also presenting the work experiences of managers, including supervisors and head nurses, is an effective factor in strengthening the novice nurses’ morale and empowering their care performance at the beginning of work.

In another category of this study, regarding the gap between theory and practice during education, Heitz stated that university education has not been able to prepare nurses to work in today's complex environments (Heitz et al., 2004). According to the subcategory of low-quality internships, according to the findings of Al Awaisi et al. (2015), with low-quality practical courses during education, new graduates have limited practical practice during their university studies and are not ready for clinical work (Al Awaisi et al., 2015). Benner et al. (2009) also reported that because newly graduated nurses are not adequately prepared for clinical work, more practical work with students on skill acquisition and development is needed. Considering that the strength and richness of university course training leads to the success of newly graduated nurses in clinical practice, it seems that educational programs of university courses should be considered more by educational managers to increase self-confidence and improve the quality of care.

Another subcategory obtained was insufficient experience, in this regard, insufficient experience in novice nurses is reported to cause uncertainty in decision making (Casey et al., 2004). Ferguson (2011) also reported that the participants of their study, who were novice nurses, mentioned feeling of unpreparedness, lack of self-confidence and insufficient experience and lack of mastery of adequate patient care skills. Regarding the subcategory of insufficient experience, Ortiz (2016) stated that the experience of perceived lack of competence by participants has led to anxiety and stress, lack of confidence, feelings of insecurity, and performance anxiety. Since experience is an effective factor in increasing the quality of care and promoting professional self-confidence, providing suitable conditions for novice nurses to gain experience seems to be a suitable action. In relation to frequent errors, the little experience and knowledge of novice nurses at the time of starting work, are the factors that increase the error in decision making and expose them to many errors in the field of clinical environments (Gillespie & Peterson, 2009). Nurses face conflicting challenges in choosing decisions, especially in critical situations, due to fear of errors and the possibility of making wrong decisions in clinical settings (Saintsing et al., 2011).

Strengths and Limitations

This study provided information on novice nurses’ experiences with low self-confidence. The results of the research showed that unpleasant interactions, the gap between theory and practice in the academic courses, the low quality of the practical courses during studentship, insufficient experience, and weak knowledge are the factors that increase errors. These factors decrease self-confidence in novice nurses and by identifying these factors, as well as by planning and revising the theoretical and practical courses of the undergraduate course and improving the clinical work experiences during studentship, self-confidence can be strengthened in these people.

This study provided information on novice nurses’ experiences of low self-confidence. According to the results of the research, the lack of self-confidence in novice nurses reduces the quality of care, so that managers and curriculum planners can strengthen and build self-confidence in novice nurses by revising undergraduate courses. The results of the present study can be used to design and support novice nurses in the workplace.

Implications for Practice

According to the results of the present study, we suggest that both clinical administrators and academic managers provide educational and psychological support to novice nurses to improve the quality of patient care. In this regard, it is hoped that educational managers can take effective measures to increase graduate nurses’ self-confidence. In addition, clinical managers also must provide a platform for improving human resources, so that the self-confidence of novice nurses can be improved.

Conclusion

According to the findings of the current study, factors such as the gap between theory and practice, the low quality of practical courses during education, insufficient experience, and the lack of knowledge in university courses lead to a decrease in self-confidence in novice nurses.