Relationship between Professional Confidence and Professional Socialization among Nursing Students: A cross-sectional study View PDF

Today, nurses as the largest part of professional personnel, nurses play multiple and extensive roles in the frontline of service provision in a healthcare system [1,2]. Given these diversities and complexities, nursing is considered as the role of a professional activity. Moreover, growing needs and demands within society for professional and committed nurses as well as improved quality of services have converted professionalization and professional practice into a key issue in healthcare systems [3-5].

Professional confidence

Studies have shown a mutual relationship between professional development and professional confidence [6-8]. This means that benefiting from professional confidence in individuals involved in a profession can significantly assist them to become professionalized in that society because professionalization i.e. working professionally requires endowment with high levels of knowledge and skills so that services are provided with the highest levels of quality and working in this way in a profession is in need of professional confidence [9]. Besides, evidence suggests that professional confidence in medical sciences among those having professions with higher levels of professionalization is more than other professions [10]. Professional confidence also refers to an inner sense of confidence in oneself and a feeling of calmness and it similarly means a sense of being retested and reassured by colleagues and patients [11]. As well, professional confidence can affect all the aspects of healthcare including relationship with clients, colleagues, and other healthcare members who can ultimately influence patient care [12,13]. According to Holland, one of the consequences of professional confidence is its positive impact on the skills of critical thinking and clinical reasoning and thus greater contribution to individuals’ advanced clinical practices, increased job satisfaction, as well as reduced anxiety and stress [14]. Professional confidence needs to be fostered by the curriculum and during professional life through clinical supervision, training, as well as peer support and also nurtured in the workplace after graduation. In order to further professional confidence, instructors also need to have enough confidence and competence in action and in the classroom [15,16].

The process of socialization is also taken into account as one of the important processes that occurs during education in the process of professionalization [17]. The purpose of professional socialization is the development of professional behavior i.e. a series of learning experiences and socialization are required to transform an individual from the role of a university student to the role of a professional nurse [13]. Professional socialization is also defined as the process of internalization and evolution of professional identity through acquisition of knowledge, skills, attitudes, beliefs, values, norms, and moral standards in order to play a professional role [18].

The results of the Tahmasebi study showed that taking measures such as having comprehensive training programs, benefitting from good role models, supporting educational clinical structures, as well as providing employment field opportunities in order to gain experience and to provide constructive feedback could be considered as determinants [19]. In this regard, Ravanipour in his study concluded that attention to education and ongoing evaluation of nursing knowledge and skills, its status in the healthcare system, as well as socialized nursing could have basic roles in professional empowerment and nursing professionalism [20]. Appropriate implementation of this process can also lead to attaining professional identity, being compatible with professional role, giving professional and organizational commitment, and consequently improving quality of care to clients. In contrast, inappropriate and inadequate implementation of the socialization process can bring about negative consequences such as job loss and job burnout, decreased production, as well as lowered or lost motivation and satisfaction among nurses in terms of their future occupation and profession [21]. Given the importance of the concepts of professional confidence and professional socialization from academic years to periods of independent professional activities, the purpose of this study was examine the relationship between professional confidence and professional socialization among undergraduate nursing students in southeastern Iran.

Design and Participants

This cross-sectional study was conducted on 179 nursing students from 1 July, 2018 to 1 April 2019 at nursing School of Kerman University of Medical Sciences, south of Iran. Participants were selected using convenience sampling method. The inclusion criterion for this study was being a BSc nursing student at Kerman University of Medical Sciences and the exclusion criteria were guest or transferred students or those who had not started practical clinical internship. The total number of first-year university students (freshmen) to fourth-year university students (seniors) was 201 people who all participated in this study.

Instruments

Data collection instruments in this study were three questionnaires on “demographic information”, “professional confidence” and “professional socialization”.

The demographic information form included (age, gender, marital status, academic year, grade point average, student work experience, knowledge of nursing before enrollment, tendency to change field of study in future, and level of interest in nursing).

The “Inventory of Professional Confidence in Nursing Students” was comprised of 35 items associated with professional confidence with three dimensions (faith in professional values, sense of efficiency in profession, acceptance of profession). Scoring the given items was based on a 6-point Likert-type scale with options from “always” to “never” and values from 1 to 6. The minimum and the maximum scores obtained from this questionnaire were 35 and 210, respectively. Arbitrarily, the minimum score was deducted from the maximum score and the result was divided by three: then the distances between scores showed high, moderate, and low levels of professional confidence. The validity of the questionnaire was also determined through content validity index and it was confirmed by 10 faculty members at Kerman University of Medical Sciences. The reliability of the given questionnaire was also calculated through Cronbach’s alpha method whose coefficient was equal to 0.81 [22].

“Toit’s Standardized Scale of Professional Socialization in Nursing Students” was included 48 items. Scoring the given items was based on a 7-point Likert-type scale with options from “very low” to “very high” and values from 1 to 7. The minimum and the maximum scores obtained from this questionnaire were 48 and 336, respectively. Considering the instructions of the given questionnaire; scores between 48 and 107 were considered as very low, scores from 108 to 162 were assigned as low, and scores between 163 and 222 were considered as moderate. Scores from 222 to 278 and 279 to 336 were also assigned as high and very high, respectively. The reliability of the given questionnaire was similarly calculated through Cronbach’s alpha method whose coefficient was equal to 0.89. The validity of the questionnaire was also determined through content validity index [23].

Data collection

The objectives of the study were first explained to the students to data collection. Questionnaires were then distributed among the nursing students. Students are given 20 min to complete the questionnaires. Questionnaires were collected after completing.

Ethical Considerations

This study approved by institutional review board (IRB) and ethics committee of Kerman medical university (IR.KMU.REC.1394.145). Oral and written consent form was obtained from participants. Participation was voluntary, and all data were confidential and anonymous.

Data analysis

Descriptive (frequency, percentage, mean and standard deviation) and analytical tests (Pearson correlation coefficient) were used to analyze the data. Pearson correlation coefficient test was used to determining the relationship between professional confidence and professional socialization. SPSS Version 18.0 for Windows (SPSS Inc., Chicago, IL, USA) was used to analyze the data. Confidence interval of 95% and a significance level of P-value less than 0.05 was considered significant.

Demographic characteristics

Of the total number of 179 individuals participating in this study, 39 of them were first-year students (freshmen) (21.8%), 42 individuals were second-year University students (sophomores) (23.5%), 58 of them were third-year university students (juniors) (32.4%), and 40 individuals were fourth-year university students (seniors) (22.3%). The demographic characteristics of the study samples were also presented in the below table based on the academic years (Table 1). In this respect, the results showed that professional socialization and professional confidence were at high levels in more than fifty percent (55.3%) and more than seventy percent (70.9%) of nursing students.

Table 1: Comparison of mean and standard deviation / frequency distribution of background variables in nursing students.

Main results

The findings of the Pearson correlation coefficient also revealed a significant and direct relationship between professional confidence and professional socialization (r=0.799 and p=0.000). Moreover, the results showed that the mean scores of professional confidence and professional socialization in second-year university students (sophomores) and fourth-year university students (seniors) were of minimum values (Table 2). Besides, the results of the Pearson correlation test suggested a significant relationship between age, average grade point, and the scores of professional confidence and professional socialization.

Table 2: Mean and standard deviation scores of professional confidence and professional socialization in terms of academic years.

Also, the findings of the independent t-test indicated a significant difference between the variables of gender, student work, knowledge of field of study, and tendency to change field of study in future, and professional confidence. The results of the analysis of variance also revealed a significant relationship between academic years and the scores of professional confidence and professional socialization; however, no significant relationship was found between marital status, professional confidence, and professional socialization (Table 3).

Table 3: Relationship between study variables and the scores of professional confidence and professional socialization.

Overall, the results of this study showed that professional confidence and professional socialization among undergraduate nursing students enrolled in Razi School of Nursing and Midwifery were at high levels. As well, the findings of this study revealed a significant difference between mean scores of professional confidence and professional socialization in different academic years. The mean scores of professional confidence and professional socialization were also higher among second-year university students (sophomores) than those of other students. Thus, the results were interpreted in the way that presentation of trainings during the basic lessons and those of principles and techniques could help university students reach acceptable levels of professional confidence and professional socialization because the mean scores of professional confidence and professional socialization among second-year university students (sophomores) were higher. Also the mean scores of professional confidence and social professionalization among the fourth-year students (seniors) were high. To interpret these results, the issue of “theory-practice gap” was included generally referring to the distance between what students learn in the classroom and what they experience in real work environments which can bring about numerous outcomes for nursing [24]. Its first negative impact can be on the process of professional socialization among nursing students [25]. The given shock can also have crippling effects on newly-employed nurses including reduced interest and professional confidence, job dissatisfaction, and leaving the profession and consequently weaknesses in nursing profession. This means that if professional behaviors in university students are not established in the form of theory-based performance, they can lead to their non-professionalization and thus distance from professional standards can inhibit growth in nursing performance [24]. There are also some other points to interpret these results such as how to practice field internship, a deeper understanding of professional facts, unofficial professional education, hidden curriculum, as well as clinical education environment. Thus, university students can assume more responsibilities in terms of patient care through entering into clinical environments and following their increased academic years. Accordingly, the supports received from clinical instructors can reduce in clinical internship courses and university students can encounter with real work environments [25,26].

One of the other results of this study was the significant and negative relationship between professional confidence, professional socialization, and students’ age; so that older people had lower levels of professional confidence and they were less socialized in their profession. The results of the study by Parvan also suggested a significant and negative correlation between age and “confidence” as a dimension of professional values that were consistent with the findings of the present study [27]. The results of the investigation by Dalir similarly indicated that older age and more academic semesters had reduced intrinsic motivation among nursing students [29]. In this regard, Kosgeroglu shed light on awareness among students enrolled in higher semesters towards issues in their profession as the reason behind this issue [30]. In the study by Rognstad at the end of the course of nursing, internal motives such as a desire to help and make contacts with patients had dropped among nursing students and more emphasis had been put on higher salaries and job security that was probably due to change of attitudes and beliefs as well as a growing trend among the youth to respect themselves and to create a social identity [31]. The level of interest in nursing had also significantly declined from the first academic year to the fourth one. The results of the study by Heshmati Nabavi similarly suggested that the level of interest in fourth-year nursing students (seniors) was significantly lower than that of first-year university students (freshmen), and consequently the desire to leave the profession had increased. Nursing students can also face challenges in their academic years that are kind of associated with the nature of the nursing profession. Therefore, the descending interest in nursing during four academic years can be an indication of students’ inability in the management of their upcoming professional challenges. The related studies have also suggested that providing some care services that are sometimes unfavorable for students is one of the factors affecting dissatisfaction and tendency to leave the nursing profession [32]. One of the reasons for leaving the profession is also associated with education and work environments. The results of studies have demonstrated that lots of reasons behind student dropout are related to the lack of intimacy and coordination with the staff in work environments and also a feeling of stress in this respect. Moreover, no harmony between the ideals adopted by students and the real environments could lead to their dropout. It has been even reported among university students who have taken this field of study with interest [33]. The results of the study by Ildarabadi showed that the enthusiasm of the students and an appropriate educational environment facilitated professional performance whiles Stress and the absence of prerequisites were barriers to experiential learning [34]. In this respect, the results of the study by Rafati F, et al. showed that nursing students could feel several sources of stress in their first experiences in clinical environments; thus, nursing education planners were suggested to improve quality of education by giving appropriate feedback, increasing self-confidence, and creating a friendly atmosphere and a supportive environment to contribute to the clinical education of nursing students and to reduce their stress [35].

The tendency to leave the profession was significantly higher in students of higher academic years in the present study. The results of the study by Pilevarzadeh M, et al. (2004) also showed a direct and significant relationship between age and professional self-knowledge i.e. older age and more academic years had led to the establishment of more knowledge of nursing profession [36]. It could be stated that increased academic years and more familiarity with the existing facts in real work environments as well as a better understanding of the image of the nursing profession could result in lowered interest and confidence in students towards their profession and increase their tendency to leave their profession. Interpersonal interactions between students and other healthcare team members including instructors and students of other disciplines could also affect their professionalization. In the study by Brown, the manner of interactions between students and professors had a particular impact on the levels of confidence and learning. Some behaviors by professors including challenging students and at the same time supporting them from non-professional behaviors and responding students’ questions were of utmost importance in terms of the development of professional confidence from the students’ perspective. Thus, professors who had monitored students, considered their mistakes as part of their learning process, and provided feedback were more effective in shaping their professional confidence [10,37, and 38]. In this regard, the results of the study by Fathi M, et al. (2012) suggested that the first domain of stressful learning was associated with students’ humiliating experiences and “professors’ notifications in the presence of department personnel and doctors” which had the greatest impacts in this respect [39].

The major limitation of this study is that it used a cross-sectional design. Thus, a longitudinal study design is recommended to provide further evidence of linear relationships between Professional Confidence and Professional Socialization. Specially, cultural differences between other countries and Iran may have influenced the results. Thus, further studies that take into account cultural differences are needed.

The study indicated the strong and close relationship between professional confidence and professional socialization in nursing students. Thus, students’ attendance at bedside and also their transformation from student role to professional role as sensitive periods require more supports from professors, instructors, university officials, and administrators of hospitals and healthcare centers. It also seems that the grounds for fostering professional confidence and professional socialization can be provided among students of higher academic years through creating a relaxing educational environment and increased supports as well as establishment of professional relationships based on respect and mutual recognition. The results of this study could provide the basic information for educational planners to plan and adopt strategies for professional development during academic years. Thus, it is recommended that nursing education should emphasize a curriculum related to Professional Confidence and Professional Socialization to improve professionalism of nursing students.

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