The transition to practice for newly licensed nurses remains challenging. Many new nurses stated that they feel unprepared for the responsibilities and realities of nursing practice in the acute care setting (Chandler, 2012; Cubit & Lopez, 2011; Draper et al., 2014; Feng & Tsai, 2012). Self-efficacy in nursing practice is the individual's belief that they possess the necessary knowledge, skills, and abilities to provide safe, quality patient care (Wolff, Regan, Pesut, & Black, 2010). This lack of self-efficacy in nursing practice is related to the increased complexity of health care, requiring nurses to have strong interpersonal and technical skills to effectively and efficiently coordinate patient care within an interprofessional team (Feng & Tsai, 2012). A lack of self-efficacy contributes to high levels of stress and anxiety as new nurses enter the workforce (Chandler, 2012; Cubit & Lopez, 2011; Draper et al., 2014; Feng & Tsai, 2012). Nurse leaders continue to report high turnover in the first year of practice and attribute it to lack of self-efficacy in nursing practice (Chandler, 2012; Feng & Tsai, 2012). Reducing turnover and retaining skilled licensed nurses are essential considering the projected 16% increased need for nurses over the coming decade (Friday, Zoller, Hollerbach, Jones, & Knofczynski, 2015; U.S. Department of Labor, 2015). The U.S. Department of Labor (2015) has projected that this increased need is due to additional emphasis on preventative care, increase in chronic conditions, retirements, and use of health care by older adults (Friday et al., 2015). Projected need and poor retention indicate the need to implement interventions that improve the transition to practice.
Many studies have explored ways to ease the transition into practice and reduce the stress experienced by new nurses as they enter the workforce. Completed studies explored postgraduation interventions and demonstrated the importance of role socialization to ease the transition to practice and recommended creation of support programs, such as residency programs (Chandler, 2012; Cubit & Lopez, 2011; Feng & Tsai, 2012; Sedgwick & Rougeau, 2010). Few researchers have explored pregraduation interventions; those completed demonstrated the positive effects of clinical partnerships, paid work experience in health care, and paid nonhealthcare work experience on socialization to teamwork, communication, financial independence, and increased postgraduation work opportunities (Kenny, Nankervis, Kidd, & Connell, 2012; Newton, Cross, White, Ockerby, & Billett, 2011; Phillips, Esterman, Smith, & Kenny, 2013; Phillips, Kenny, Smith, & Esterman, 2012). Many nursing students work during college for a variety of reasons, which include financial security, work experience, and future employment alignment, yet little is published regarding how this experience affects the students' subsequent self-efficacy in nursing practice.
The purpose of this study was to determine the relationship between the type and amount of prelicensure employment to student nurse self-efficacy in nursing practice of nursing students in their last semester of their nursing program. The aims of the study were to identify the relationship between the type of prelicensure employment and self-efficacy in nursing practice, the relationship between the amount of prelicensure employment and self-efficacy in nursing practice, the relationship between the type and amount of prelicensure employment and self-efficacy in nursing practice, and what combination of the type and amount of prelicensure employment best predicts positive self-efficacy in nursing practice.
LITERATURE REVIEW
The literature review was completed using CINAHL, MEDLINE, CINAHL Plus With Full Text, MEDLINE With Full Text, and ProQuest Nursing and Allied Health Source. The database search was limited to peer-reviewed articles written between 2010 and 2016 using the following search terms: self-efficacy, readiness for practice, self-efficacy in nursing practice, transition to practice, prelicensure employment, and paid employment.
Self-Efficacy in Nursing Practice
Self-efficacy in nursing practice is the individual's belief that they possess the necessary knowledge, skills, and abilities to provide safe, quality patient care (Wolff et al., 2010). Studies have found that individuals with higher self-efficacy experience less stress during clinical practice (Zhao, Lei, He, Gu, & Li, 2015). A study exploring the coping strategy and the effects of self-efficacy found that nursing students with higher levels of self-efficacy used positive coping strategies when faced with stress from assignments and workload during their clinical experience (Zhao et al., 2015). Individuals with higher self-efficacy in nursing practice are more likely to not perceive stress as a stressor and instead use problem-solving skills (Zhao et al., 2015).
The assumptions and relationships of Bandura's social cognitive theory have assisted nursing faculty to explore the impact of nursing curriculum to the self-efficacy of nursing students. Studies have demonstrated that clinical experience has the most influence over student nurse self-efficacy when compared to theoretical preparation (Chesser-Smyth & Long, 2013; Franklin, Gubrud-Howe, Sideras, & Lee, 2015). In addition, observation of role models during the clinical experience increased nursing student self-confidence (Chesser-Smyth & Long, 2013).
Prelicensure Employment
Many nursing students are employed during college for a variety of reasons (Casey et al., 2011; Woods et al., 2015). According to Phillips et al. (2012), over 90% of newly licensed nurses worked at least 15 hours a week while completing their academic nursing preparation. Many students are reportedly working in a variety of roles in health care (Phillips et al., 2012). Reasons for working during academic preparation vary and have been reported as financial independence and autonomy, confidence and experience, future opportunity, and ease of transition (Phillips et al., 2012). The transition scores for those who completed prelicensure employment are significantly higher than those who did not complete prelicensure employment (Phillips et al., 2013). Similarly, Hasson et al. (2013) found that newly licensed nurses who had worked in the healthcare setting during their academic preparation felt more confident regarding their nursing skills, and prepared for the realities of nursing practice due to their time spent in the acute care setting.
Considering that many nursing students seek paid prelicensure employment, many healthcare organizations, colleges, and universities have developed programs in the acute care setting to provide healthcare experience in the hopes of improving the transition to practice. Nurse externships are an example of these experiential experience programs. However, Friday et al. (2015) determined there was no impact of offering a prelicensure extern program in conjunction with a postlicensure transition-to-practice program in comparison to providing the transition-to-practice program alone (Friday et al., 2015). Conversely, Draper et al. (2014) found that employers of newly licensed nurses who completed an externship were adequately prepared to achieve the competencies and expectations of the nursing profession. The employers consider the preregistration program as a method to increase the employability of newly licensed nurses and subsequently aids in developing the workforce. In addition, many of the newly licensed nurses who participated in the preregistration program advanced in their career quicker than those without the experience (Draper et al., 2014).
THEORETICAL FRAMEWORK
The theoretical framework for this study was Albert Bandura's social cognitive theory. Bandura describes how individuals' self-judgment of their capabilities determines how they behave, their thoughts, and their emotional reactions (Bandura, 1989). This belief is called self-efficacy (Bandura, 1977, 1989, 1999). Perceived self-efficacy is determined by four sources: performance accomplishments or mastery of experiences, vicarious experiences, verbal persuasion, and physiological states or emotional arousal (Bandura, 1977, 1989). Bandura demonstrated that, although mastery experiences, vicarious experiences, verbal persuasion, and emotional arousal each impact self-efficacy, performance accomplishments or personal mastery experiences are the strongest predictors of self-efficacy (Bandura, 1977).
The social cognitive theory provides a framework in which to evaluate the relationship between nursing students' self-efficacy in nursing practice during their final semester, and the type and amount of prelicensure work experience completed during the final year of nursing school. According to social cognitive theory (Bandura, 1977, 1989, 1999), the type and amount of prelicensure employment would be considered personal mastery experience; it can lead to performance accomplishments that are linearly related to the nursing students' self-efficacy in nursing practice.
METHOD
Design
This study used a quantitative approach to determine the relationship between the type of prelicensure employment and the amount of prelicensure employment and self-efficacy in nursing practice of students in the final semester of their nursing program. Data were collected using a cross-sectional survey distributed to southwest Michigan nursing students during one of their classroom sessions. The survey collected demographic data and information about the student's prelicensure employment. In addition, the survey included questions to evaluate the student's level of self-efficacy in nursing practice and self-efficacy in managing the patient care assignment. This study was approved by the institutional review board to ensure the protection of human subjects and review of any ethical issues that may have been present.
Sample
This study was completed using a convenience sample of nursing students in their final semester of college in southwest Michigan, including five colleges and universities. There were 277 potential participants. Of the 277 potential participants, 138 returned the survey providing a 49.8% response rate.
Instrument
The study used the Casey-Fink Readiness to Practice Survey developed by Kathy Casey, MSN, RN, and Regina Fink, PhD, RN, FAAN, AOCN, in 2008. Permission for use of this survey was obtained from the tool developers. The Casey-Fink Readiness for Practice Survey includes three sections. The first section asks for demographic data and was adapted with permission from its authors to determine if the nursing student worked during the past year; the type of employment completed in the last year; the number of hours worked per week; the school attended; the type of program; and nursing students' age, gender, ethnicity, and marital status. Types of employment listed in the demographic section were identified from the U.S. Department of Labor Bureau of Labor Statistics website, which lists occupation groups and healthcare occupations along with coinciding labor statistics (U.S. Department of Labor, 2015).
The second section includes three subsections. The first subsection evaluates the nursing student comfort with skill performance using a list of 18 skills. Students are asked to pick the top three skills they are uncomfortable with (Casey et al., 2011). The second subsection asks the nursing student to rate their level of confidence in managing multiple patient assignments using a Likert scale (1 = not confident, 2 = somewhat not confident, 3 = neutral, 4 = somewhat confident, 5 = very confident). The third subsection includes 20 questions and uses a Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree) to address nursing student confidence and comfort (self-efficacy) in their readiness to practice (Casey et al., 2011).
The Casey-Fink Readiness for Practice Survey has demonstrated reliability and validity. Through factor analysis, the survey demonstrated an overall Cronbach's alpha of .69 for the 20 confidence and comfort questions asked in the second section of the survey (Casey et al., 2011). Using the collected data, reliability for the 20 survey items was confirmed (Cronbach's [alpha] = .72). In addition, the section assessing students' comfort in caring for two, three, and four patients found items measuring comfort in caring for two patients (s2 = 0.42), three patients (s2 = 0.72), and four patients (s2 = 1.13). The descriptive statistics identified that most students were comfortable with two and three patients, as M = 4.7 for two patients and M = 4.1 for three patients. The items caring for four patients was selected less often as M = 3.2 (Casey et al., 2011). Using the collected data, the variances were s2 = .60 for comfort in caring for two patients, s2 = 1.10 for comfort in caring for three patients, and s2 = 1.42 for comfort in caring for four patients.
RESULTS
Demographics
Participants were primarily single or married Caucasian women in associate degree programs with an average age of 28.7 years (SD = 7.38, range 19-62 years). Participant demographic information is summarized in Table 1. Most participants (92.8%) reported working an average of 24.7 hours a week (SD = 12.94, range 2-90 hours a week) during the past year. Fifty-eight percent of those working reported having multiple jobs in the previous year. Of those working, the majority reported having healthcare experience (see Table 2). The participants' top five healthcare and nonhealthcare work areas are summarized in Table 3. The number of participants in Table 3 does not equal 138, as many participants identified working in multiple roles. The top five skills and procedures participants were uncomfortable with are summarized in Table 4. Participants selected the top three skills they were uncomfortable with from a list of 18 skills. Participants were also able to write in any skill not listed or select they were comfortable with all skills.
Self-Efficacy in Nursing Practice
An independent t test was completed to determine the relationships between the type of prelicensure employment and self-efficacy in nursing practice. Analysis revealed that there was no significant difference in the self-efficacy scores of those who completed prelicensure work experience and those who chose not to work, t(10.77) = 1.05, p = .33. In addition, there was no significant difference in the self-efficacy scores for those with healthcare prelicensure work experience and those without healthcare experience, t(136) = -1.28, p = .20. Similarly, there was no significant difference in the self-efficacy scores for those with nonhealthcare prelicensure work experience and those without nonhealthcare experience, t(136) = .77, p = .44.
Review of the Pearson correlation results found a weak positive relationship between the amount of prelicensure work experience and self-efficacy in nursing practice. However, this relationship was not significant (r = .01, p = .44). Similarly, the analysis found a small positive relationship between the type and amount of prelicensure work experience and self-efficacy in nursing practice. However, the analysis was not significantly related to self-efficacy in nursing practice, F(2, 123) = .49, p = .61, R = .09, adj. R2 = .01. In addition, the model did not predict self-efficacy in nursing practice, F(2, 123) = .49, p = .61.
Self-Efficacy in Managing the Patient Care Assignment
A subset of the Self-Efficacy in Nursing Practice Comprehensive Scale includes questions related to the nursing students' self-efficacy in managing a patient care assignment with two, three, and four patients. Independent samples t test, Pearson's correlation, and multiple linear regression were completed to determine if there were relationships between the types and amount of prelicensure work experience and self-efficacy in managing a patient care assignment.
Two-patient assignment
The independent t-test analysis identified that there was no significant difference in the self-efficacy in managing a patient care assignment of two patients for those with healthcare prelicensure work experience (M = 4.49, SD = 0.71) and those without healthcare experience (M = 4.24, SD = 1.01), t(29.57) = -1.16, p = .26. Similarly, the independent t-test analysis identified that there was no significant difference in the self-efficacy in managing a patient care assignment of two patients for those with nonhealthcare prelicensure work experience (M = 4.20, SD = 0.94) and those without nonhealthcare experience (M = 4.47, SD = 0.75), t(134) = 1.28, p = .20. The Pearson correlation analysis found a positive relationship between the amount of prelicensure work experience and self-efficacy in managing a patient care assignment of two patients. However, this relationship was not significant (r = .12, p = .09). In addition, the model did not significantly predict self-efficacy in managing a patient care assignment of two patients, as the F ratio was 2.26 (p = .11). Thus, the null hypothesis was accepted for the type and amount of prelicensure work experience.
Three-patient assignments
The independent t-test analysis identified that there was no significant difference in the self-efficacy in managing a patient care assignment of three patients for those with healthcare prelicensure work experience (M = 3.69, SD = 1.00) and those without healthcare experience (M = 3.36, SD = 1.22), t(135) = -1.42, p = .16. Similarly, the independent t-test analysis identified that there was no significant difference in the self-efficacy in managing a patient care assignment of three patients for those with nonhealthcare prelicensure work experience (M = 3.2, SD = 1.15) and those without nonhealthcare experience (M = 3.68, SD = 1.03), t(135) = 1.68, p = .10. The Pearson correlation analysis found a positive significant relationship between the amount of prelicensure work experience and self-efficacy in managing a patient care assignment of three patients (r = .19, p = .02). Thus, the alternative hypothesis was accepted for the amount of prelicensure work experience, whereas the null hypothesis was accepted for the type of prelicensure work experience. In addition, the model significantly predicted self-efficacy in managing a patient care assignment of three patients, as the F ratio was 4.60 (p = .01). The multiple linear regression for nonhealthcare prelicensure work experience revealed b = -0.60 [-1.16, -0.04], p = .04. The multiple linear regression for average hours worked a week revealed b = 0.01 [0.00, 0.03], p = .04. Thus, healthcare experience is a better positive predictor of positive self-efficacy.
Four-patient assignments
The independent t-test analysis identified that there was no significant difference in the self-efficacy in managing a patient care assignment of four patients for those with healthcare prelicensure work experience (M = 2.85, SD = 1.18) and those without healthcare experience (M = 2.56, SD = 1.23), t(133) = -1.12, p = .27. Similarly, the independent t-test analysis identified that there was no significant difference in the self-efficacy in managing a patient care assignment of four patients for those with nonhealthcare prelicensure work experience (M = 2.27, SD = 1.03) and those without nonhealthcare experience (M = 2.87, SD = 1.19), t(133) = 1.86, p = .07. The Pearson correlation analysis found a positive relationship between the amount of prelicensure work experience and self-efficacy in managing a patient care assignment of four patients. However, the relationship was not significant (r = .13, p = .07). Thus, the null hypothesis was accepted for the type and amount of prelicensure work experience. In addition, the model significantly predicted self-efficacy in managing a patient care assignment of four patients, as the F ratio was 3.42 (p = .04). The multiple linear regression for nonhealthcare prelicensure work experience demonstrated b = -0.70 [-1.25, -0.17], p = .01. The multiple linear regression for the amount of prelicensure experience demonstrated b = 0.01 [-0.01, 0.04], p = .22. Thus, the amount of healthcare experience is a better positive predictor of positive self-efficacy.
LIMITATIONS
The results of this study are limited in generalizability as the participants were recruited using a convenience sample of senior nursing students in southwest Michigan. In addition, although bachelor of nursing students were included for recruitment, the number of those who participated from the bachelor of nursing program was small (8%). Thus, regions where a higher number of bachelor programs are provided may achieve different findings. Therefore, replication of this study would be needed to achieve generalization.
DISCUSSION
Results of this study did not find significant relationships between the type and amount of prelicensure employment and self-efficacy in nursing practice. However, this study did identify that health care, as the source of prelicensure work experience, predicts positive self-efficacy in managing a patient care assignment of three and four patients. Results are consistent with the literature regarding self-efficacy in nursing practice as they have found that self-reported self-efficacy in nursing skills, such as delegation of task, communication with patients, and use of evidence-based practice, is generally high in all nursing students (Karabacak, Serbest, Kan Onturk, Eti Aslan, & Olgun, 2013). In addition, it has been identified that nursing students believe they have the essential nursing knowledge to begin their practice (Casey et al., 2011; Chappy, Jambunathan, & Marnocha, 2010; Guner, 2014; Woods et al., 2015). When considering self-efficacy in managing the patient care assignment, literature supports that observation of expert role models in the clinical setting increases self-confidence of nursing students (Chesser-Smyth & Long, 2013; Franklin et al., 2015). Although nursing students have equal amounts of clinical experience as part of their academic preparation, those working in health care have additional exposure to expert role models. Studies have confirmed that nursing students struggle with managing a multiple-patient assignment of more than three patients (Casey et al., 2011; Woods et al., 2015).
Nursing professional development (NPD) practitioners preparing orientation and transition-to-practice programs should take into consideration the prediction of positive self-efficacy in managing the patient care assignment of more than three patients for those with healthcare prelicensure experience. Modeling allows the individual to observe events and develop behavior patterns through personal performance feedback (Bandura, 1977). Therefore, increased positive modeling by preceptors of the management of the patient care assignment results in increased positive self-efficacy in managing the patient care assignment for new nurses. Knowledge regarding nurses' previous work experience could be used by NPD practitioners and nurse managers to individualize orientation by providing a gradual increase in the number of patients to promote self-efficacy in managing the patient care assignment through modeling with an experienced nurse preceptor. In addition, NPD practitioners coordinating transition-to-practice programs can use the results of this study to provide content and application opportunities related to managing care for an increased number of patients over time with modeling from an experienced nurse preceptor.
FUTURE RESEARCH
Students can select either an associate degree in nursing or a bachelor degree in nursing path for education. This study was open to participants from both degree paths. Yet, most of the participants were from associate programs. Therefore, replication of this study comparing associate and bachelor of nursing students may provide additional insight into self-efficacy in nursing practice. Differences in self-efficacy may be related to program structure and length, which may provide differences in role modeling of skills, procedures, and management of multiple patient assignments.
CONCLUSION
In conclusion, the transition to an acute care setting from academia is difficult and causes a significant amount of stress for newly licensed nurses (Chandler, 2012; Cubit & Lopez, 2011; Draper et al., 2014; Feng & Tsai, 2012). Subsequently, stress during the transition leads to decreased retention of new nurses (Chandler, 2012; Feng & Tsai, 2012). Healthcare leaders attribute the difficulty experienced by new nurses to poor self-efficacy in nursing practice. Healthcare leaders will continue to face this issue with increased hiring needs over the next decade (Friday et al., 2015; U.S. Department of Labor, 2015). NPD practitioners need to identify ways to improve the transition to practice by improving newly licensed nurses' self-efficacy.
Although many nursing students are actively employed during college, before this study, little was published regarding how this employment affects their self-efficacy in nursing practice. This study identified healthcare prelicensure work experience as the best predictor of positive self-efficacy in managing a patient care assignment of three and four patients. Findings of this study could be used by NPD practitioners to individualize the orientation of new nurses based on their prior work experience to assist with improving their self-efficacy in managing the full patient assignment. NPD practitioners coordinating transition-to-practice programs could use the results of this study to provide content and application opportunities related to managing care for an increased number of patients over time with modeling from an experienced nurse preceptor.
References