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Experiences of Newly Graduated Nurses on Strategies of Gaining Self-Confidence During Their Initial Work: A Qualitative Study

Zamanzadeh, Vahid1; Roshangar, Fariborz2*; Fathi-Azar, Eskandar3; Valizadeh, Leila4; Kirkwood, Jodyanne5

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doi: 10.1097/jnr.0000000000000050
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Abstract

Introduction

One of the most important challenges experienced by newly graduated nurses (NGNs) during early clinical work is low self-confidence. This is associated with limited practical knowledge and experience and may cause problems in patient management. Self-confidence is defined as the belief of a person in her or his own abilities to achieve goals and perform tasks and practices in an effective and efficient manner (Chesser-Smyth & Long, 2013). The professional self-confidence of nurses develops in two phases. In the first phase, nurses gain the theoretical knowledge and critical thinking in academic and practicum environments necessary to support appropriate decision making. In the second phase, nurses consolidate their evidence-based learning in clinical and academic environments, which creates a feeling of ownership and a sense of attachment to the workplace (Crooks et al., 2005). Self-confidence works as a strong tool for nurses in solving problems and challenges after they have been on the job for several months. However, NGNs have little self-confidence during their initial months on the job. Although 10% of hospital staff are NGNs, just 10% of hospital executives believe NGNs have adequate preparation and self-confidence (Berkow, Virkstis, Stewart, & Conway, 2009). One study showed that 41% of NGNs still feel a lack of self-confidence and discomfort on the job a year after starting their careers (Casey, Fink, Krugman, & Propst, 2004). In fact, having a low level of self-confidence increases the likelihood of errors in performing various tasks and skills (Boswell, Lowry, & Wilhoit, 2004). This results in turnover rates for NGNs of 30%–60% during the first year of their career and results in financial costs that total US$80,000 for each nurse in medical institutions (Halter, Stoffers, Kelly, Redding, & Carr, 2011). In Iran, one study on the perspective of NGNs concerning the support they received during their transitions from the academic environment to the professional environment showed that 37.5% did not have adequate confidence in their ability to perform critical care tasks (Nemadi Vosughi & Tazakkori, 2008). In addition, the work experience of NGNs in Iran revealed low self-confidence, little readiness for performing specified duties, general incapability, and incompetence during their early careers (Labaf Ghasemi, Marbaghi, Joz Kabiri, & Hosseini, 2005). Furthermore, in the process of gaining self-confidence during the first 3 months of work, NGNs tend not to trust their knowledge and experience. Consequently, this self-doubt results in not fully understanding or assessing the problems of their patients. As a result, they do not act independently but rather rely heavily on senior staff. However, within 9–12 months of starting their careers, their ability to make accurate decisions about patient care builds their self-confidence (Chandler, 2012). Although NGNs have little initial confidence because of problems with task performance and patient care, which leads to increased nursing errors and staff turnover (Casey et al., 2004), NGNs attempt to apply appropriate coping strategies to overcome stress and increase self-confidence. However, few studies have been conducted on the issue of novice nurses gaining self-confidence (Berkow et al., 2009). A review of the extant literature indicates that no comprehensive study about the ability of NGNs to gain confidence via specific strategies has yet been conducted. In Iran, it remains unclear regarding what strategies NGNs typically use to gain self-confidence. Therefore, this study is the first research in Asia to investigate this topic and thus contributes to the body of knowledge related to confidence-building strategies used by nurses.

Methods

This study used qualitative content analysis to describe the strategies used by NGNs to gain self-confidence. It was conducted in multiple teaching hospitals located in Iran’s northwest provinces. These hospitals all provide clinical education and training to future and current doctors, nurses, and other health professionals while delivering medical care to patients. The hospitals targeted by this study are all affiliated with medical science universities.

Participants

The participants in this study were 30 NGNs working in one of the following medical units: coronary care, intensive care, medical, surgical, obstetrics, pediatric, emergency, orthopedic, general, and psychiatric. Recruitment was handled based on the data saturation principle and targeted to achieve the maximum possible variation in terms of demographic variables such as age, sex, education, and clinical experience. The inclusion criterion for the participants was 2–3 years of clinical experience in teaching hospitals after finishing a Bachelor of Science in Nursing. Those with clinical experience before earning their Bachelor of Science were excluded. Participants were aged between 24 and 30 years with a mean age of 25 years. Women accounted for 83.3% of the participants (see Table 1).

TABLE 1
TABLE 1:
Demographic Characteristics of Participants (N = 30)

Data Collection

After obtaining the required ethical permissions for conducting research and after introducing the researcher and the subject to the hospital matron and head nurses, one head nurse from each unit was selected as the initial contact. The initial contact was responsible for introducing the researcher to potential participants. Qualified participants were interviewed after receiving a detailed description of the research subject and research objective. Participants were further informed that they might be reinterviewed at a later time. After completion of each initial interview, and based on the objective of the research, the researcher purposefully selected the subsequent participant to be interviewed. Interviews were conducted either at the participant’s workplace or in a consulting room at the researcher’s office. Only one of the participants withdrew from the study during this phase because of personal reasons. Data were collected using in-depth, semistructured interviews from 22nd of January 2012 to 18th of February 2013. The sample size was based on data saturation principles, which is based on obtaining new information from participants of purposive sampling. At the beginning of each interview, the interviewer started with one or two general questions to create an appropriate atmosphere and to reduce the tension of the nurse being interviewed. Next, the main questions regarding the experiences of participants in developing self-confidence were asked (see Table 2). All interviews were recorded and transcribed verbatim. The mean time for interviews was 59 minutes with a range of 46–70 minutes.

TABLE 2
TABLE 2:
Examples of Questions From the Interview Guide

Ethical Considerations

The ethics committee of Tabriz University of Medical Sciences approved this research (Institutional Review Board number 5/4/2738). Oral and written information about the research was provided to all participants. A signed consent form was obtained from all participants. In addition, participants were allowed to withdraw at any time without prejudice.

Data Analysis

Data were analyzed using qualitative content analysis based on the Graneheim and Lundman (2004) method. Analysis was done by reading each interview several times to achieve a sense of the whole meaning. Further detailed analysis was conducted by closely examining the transcribed interviews and assigning specific units. For instance, units could be words, sentences, or paragraphs that are related to each other in terms of content. Each meaning unit was then abstracted and assigned a unique code. Continuous comparison and reflection were then used to group interpretation codes into appropriate categories and subcategories.

Rigor

Credibility was strengthened through prolonged engagement with participants and through the researcher checking the results. Dependability was achieved by engaging three researchers separately in data analysis and then comparing the degree of agreement of the researcher’s analysis. Furthermore, conformability was attained via a clear description of the research steps through examining raw data, data reduction, and the combination and reproducing of data using the audit trial method. Finally, transferability was attained by describing the demographic characteristics of participants, selecting participants of various demographic characteristics, and externally checking results by means of querying nurses who had had similar experiences.

Results

The eight strategies that participants used to enhance self-confidence during their first 2 years of work were familiarity, knowledge enhancement, clinical skills learning, self-exploration, validation, responsibility, mutual interaction, and personal creativity.

Familiarity

Participants gained familiarity through having a sense of curiosity and exploring the human and physical aspects of their work environment. This increased their level of comfort within the workplace. Familiarity usually happens in three forms: personal familiarity, familiarity facilitated by initial training, and familiarity facilitated by implicit training.

Personal familiarity

Personal familiarity is an approach typified by becoming close, taking advantage of opportunities, and recognizing/becoming familiar with workplace-related phenomena. In this way, NGNs try to reduce new-position-related fear and stress by becoming more familiar with situational details and recognizing their different aspects.

I realized that if I hold back and just look I would not learn anything…. Each patient who came I went close to her/him…. I examined to see what was wrong with her/him…what can they do for her/him…in this way, my fear faded away and I was sure that I could do something for her/him. (P8)

I loved to jump inside the situation…. I started my job in the emergency department. The more I became involved, the more I learned…. I was becoming more proactive. (P15)

I started to learn the nature of the phenomena I had seen or I had felt such as what is wrong with the patient? In addition, how long does it take? How it could be healed? When I realized these things, I carried out cases more correctly with more confidence. (P21)

Familiarity facilitated by initial training

Upon entering their work units, NGNs engage in training periods with experienced nurses. These training periods, lasting for 14–20 days, give NGNs critical familiarity with the routines and rules of the unit, procedures, care programs, and types of disease cases through undertaking clinical work with one or more experienced nurse. Such orientation shifts help reduce the preliminary fear of NGNs and increase the self-confidence of NGNs in performing tasks and duties.

The first time that I started my work shift, it was just like I did not know anything…. I could not think…when I had shifts with my experienced colleague, he/she took me over to patients…. He/she explained them one by one…. I did my tasks under her/his supervision…. It was as if I was just learning…. It was reassuring. (P13)

Familiarity facilitated by implied training

NGNs receive group training through preliminary orientation programs and continuous education. Group training is further reinforced through participation in skill laboratories, workshops, conferences, and scientific seminars. These programs are based on the learning needs of NGNs and are scheduled by the educational supervisor of each medical institution. Classes and skill laboratory workshops are held that offer different educational packages and clinical guidelines. In addition, the continuous assessment provided by this training increases the scientific capabilities and self-confidence of NGNs.

Every time they held a workshop I learned something new…. It was very useful…. For example, I did not know how to intubate a patient, but I completely learned it in the skill lab and I did it. These kinds of workshops helped me a lot to trust myself…. Now I participate at any new workshop they hold. (P19)

Knowledge Enhancement

New clinical environments are unknown and mysterious to NGNs, especially at the earliest stage of their careers. As such, there is a need for NGNs to gain more knowledge and awareness in the care and treatment of patients. The various types of patients; the specialized procedures that need to be undertaken; the dispensing of medication; the procedures for using equipment; and the rules, regulations, and guidelines as well as dealing with experienced and knowledgeable colleagues and doctors will lead NGNs to apply strategies to enhance their professional knowledge and self-confidence. In this regard, NGNs apply knowledge enhancement using questioning, querying of sources, and personal study to increase self-confidence.

Questioning

Questioning is the most common method used by NGNs to gain information. In facing phenomena that challenge their minds, they must seek answers from reliable and available sources. Substantiating responses to questions with adequate objective evidence leads to sustained learning, increased knowledge, and increased self-confidence in confronting the unknown.

When I was working, everything was a question to me…. What is it? Why did it happen? What should I do?… I worked to find the answer to each question. If there was no answer, I asked my experienced colleagues or the doctors. When I got the answer, I felt relaxed and I continued my work with more confidence. (P18)

Querying of sources

Querying of sources is a strategy used when a nurse’s personal information is not sufficient or is vague. Therefore, NGNs try to enhance and develop their knowledge by querying human sources (such as fellow nurses and doctors) as well as books and digital media.

I felt that I knew very little. It (my knowledge) was not sufficient…. For example, a new drug just came out and my colleagues did not know about it. I immediately turned to Internet at home or in the hospital to find the answer. It always worked. Most of the resources are reliable. I had trust in them and I got the answer more quickly…. In this way, I was able to work easier…with a calm and confident mind…. (P10)

Sometimes, NGNs turned to trusted and credible human resources to gain more confidence.

My experienced colleagues had very good information. I went to them first…. If I could not get my answer, I went to doctors, specially attends and residents. Well, they were experts. I completely had trust in them. Their words were enough proof for me. (P7)

Personal study

Participants reported that their personal study of scientific and technical resources helped them gain more knowledge.

I wanted to improve and did not want to be seen as an illiterate…. I always had and still keep a Brunner medical surgical handbook in my pocket…. Whenever I have a problem, I immediately reference what it has to say. I read about what I don’t know…. Having it brings great comfort. (P22)

Thus, individual study helps NGNs to enhance their theoretical knowledge and confirm their practical experiences.

I always had to read to compensate for my insufficiency in knowledge…. I used the hospital library…. I sometimes read my college books at home during the night…. Almost everything I do at work, I double-check it with books…. If it confirms my experience, I trust myself more. (P12)

Clinical Skills Learning

Proficiency in managing and caring for patients is a core competency of NGNs, the enhancement of which increases confidence. Depending on an individual nurse’s capability, effort, and practice, this process typically takes between 4 and 6 months. Through learning from personal experience and learning from the experiences of others, NGNs obtain vital skills that facilitate future patient care.

Learning from personal experience

NGNs experience challenges and manage patients through personal intervention and involvement in various clinical situations to gain self-confidence.

In the beginning, I did not even know how to take an IV line…. I learned how to do it from books, but I had no experience. I made mistakes a few times, but finally I learned it. (P2)

I tried so many different methods until I learned how to reduce the side effects of drugs during chemotherapy in cancer patients…. This was a personal experience…. I completely trust myself. (P28)

Learning from the experiences of others

Observing colleagues to gain practical skills and confidence is another strategy of NGNs.

I always asked my experienced colleagues what you do in this case. Could you do this for me? I was just looking at the movements of their hands and learning their patterns…. I repeated it. If it worked, I used it as a trusted method. (P19)

I tried to stand by scrub nurses in the operating room and copy their actions…all these things were in our books but actual practice by our colleagues was something different…my colleagues said to me: look what we do and repeat it…do it like this…do not do that. (P4)

Observing the performance of experienced colleagues and then repeating and practicing it are keys for building confidence in beginners.

I repeated all the things that I had learned from my colleague…. Repeat, repeat…. Then, that task and that work became normal to me. I mastered how to do it…. (P18)

Self-Exploration

To provide patient-centered, effective care, NGNs are continuously assessed to make sure their clinical decisions are appropriate to the condition of their patients and their environment and address care-program feedback. Self-exploration in NGNs occurs when they analyze their actions and use self-reflection methods. This provides positive feedback that increases self-confidence.

Analyzing

Decision-making situations require NGNs to assess a situation, gather evidence, and analyze alternatives for dealing with that situation properly. This process, which includes the regular review/analysis of the results of NGN decisions, leads to enhanced self-confidence and a better understanding of mistakes. This cycle of analysis and positive feedback increases self-confidence in NGNs.

I thoroughly pay attention to the symptoms and behaviors of my patients…. I watch their reactions when I do something to them. I check vital signs with a monitor…. I asked about her/his general condition, I pay close attention to the color of her/his skin, her/his condition and consciousness, lab tests results and all the things. If there is a change, I ask myself what happened and change my plan immediately…. If it works out, I understand the consequence and I have done the right thing. (P10)

Self-reflection

NGNs boost their self-confidence by reflecting on their decision-making processes and judgments, by critiquing their own activities and practices during clinical events, and by providing self-encouragement and positive feedback.

After I did all my tasks step by step and I had checked all the things that I had done one by one, I scored myself. If the consequence was good, I said to myself well done. If there was a problem, I reviewed it all again and checked to see what I did wrong in order to correct it if I could…. In this way, I increased the trust I had in my own work. (P25)

Validation

Validation is often used by NGNs for giving final approval to decisions. This process increases their confidence in their clinical decisions. The main sources that nurses use to confirm their decisions or their performance include feedback from other experienced nurses, physicians, and managers and the referencing of nonhuman resources such as books, journals, and the Internet.

My colleagues were the best and most accessible sources for confirming decisions…. If I had doubt, I would first ask my shift colleagues and if they confirmed it I continued. Sometimes I would go to my personal books. If it was confirmed scientifically, I always used that method. (P15)

Whenever I had doubt, I asked the head nurse of the unit. If he/she did not know, I went to the doctors…. I asked them if what I did was right or not…. If they confirmed what I did was right, I had no problem and I felt more assured…. Well, they are doctors, and most of them are scientifically reliable. (P21)

Responsibility

Although entering a new clinical environment and taking responsibility is stressful for novice nurses, it is an integral part of patient care and is an appropriate way to gain self-confidence and to overcome personal fears. Responsibility sometimes happens individually or through teamwork, as the patient who is under the supervision of the nurse is given careful attention, with the nurse having a sense of commitment to his or her patient. In addition, it encourages NGNs to increase their capabilities and self-confidence.

When I was a student, I just looked at patients from a distance…. It was not important what happened…. The instructor explained the tasks and we performed them with her/his guidance, because of this I did not learn too much…. I said to myself, the unit nurses will handle it themselves…. When I became a nurse, it was different…the patient was mine and I had responsibility for her/him…. I could not make a mistake or would have to live with the guilt forever. Therefore, I had to learn tasks…. I had to do them myself…with my mind and my own hands…. The more responsibility I took, the more attention I paid to the patient…. As a result, I learned so many things and with thorough confidence I became an expert in my job. (P30)

Mutual Interaction

Interaction with the patient and with the environment is part of a nurse’s duties. NGNs provide a professional setting for patient care through mutual interaction with the patient in light of her or his physical and psychosocial needs. In fact, apart from expediting the treatment process, positive patient feedback affects the decisions and care provided by the nurse. In addition, this feedback assists the nurse to achieve her or his patient care objectives. Ultimately, the self-confidence of NGNs increases as the condition of their patients improves.

Pretty soon I realized that care would not work if you do not have a good relationship with the patient…. I try to be friends with my patients…. They trust me…. As a result, everything I did for them, they were so relaxed with me and gave me feedback. Now I am sure how to respond their demands. I have a strong sense of confidence. (P10)

Furthermore, NGNs obtain a higher degree of confidence through interacting with doctors, nurses, and other healthcare providers.

Good relationships with colleagues and doctors at the hospital help me to learn things quickly from them. If I did not have a good relationship with them, they would not have accepted me in their group…. I would have been alone…. But when I have a strong relationship with them, they help me a lot…both in terms of the tasks I should be doing and of confirming that I am doing these tasks right…. It provides assurance. I knew I was not alone…. This made me more self-assured in my work. (P3)

Personal Creativity

NGNs also use their own distinctive methods and techniques to improve their ability to manage patients in complex, clinical environments. By repeating these methods, NGNs develop special skills that result in significantly higher self-confidence in facing similar situations afterward. Creativity occurs both when NGNs improve existing procedures and as a result of keen observation and management.

Personally, I understood that methods taught in books or by my colleagues do not work for all patients. Therefore, I thought about it several times till some new innovative ideas came to my mind, I tested them on my patients. Surprisingly, they worked. For example, insufflating the eyes of an unconscious patient who had been brought to emergency department helps medical staff identify whether that patient has a histrionic personality or is really unconscious. Another example is that a subcutaneous injection of disturbed water into the arm of patients with high blood pressure who do not respond to standard treatments often quickly decreases blood pressure. Maybe science cannot explain why this works. But in practice, it worked. Therefore, I trust myself that I can manage patients. (P14)

Discussion

This study was the first study in Iran to examine the strategies used by NGNs to gain self-confidence during their early professional career. The results indicate that new nurses use various strategies to gain self-confidence, including familiarity, knowledge enhancement, clinical skills learning, self-exploration, validation, responsibility, mutual interaction, and personal creativity.

Familiarity, typified by orientation programs, is a key strategy that NGNs use to familiarize themselves with their new working environment and to begin developing validation, competence, and personal skills. Whereas most orientation programs last between 6 and 8 weeks, some continue for up to 6–12 months based on need (Godden, 2011). In Iran, most programs last from 2 weeks to 45 days (Labaf Ghasemi et al., 2005). Orientation programs focus mainly on improving NGNs in terms of knowledge, their socialization into the workplace, their clinical skills, and their interpersonal professional attitudes (Olson, 2009). The experiences of NGNs during orientation showed that orientation programs may increase self-efficacy and self-confidence (Delaney, 2003), which is consistent with our results. Chen, Duh, Feng, and Huang (2011) showed that practical workshops and orientation programs are useful strategies for NGNs with regard to education, learning, and gaining self-confidence.

Other studies have shown the impact of continuous education on improving the knowledge, attitudes, and confidence of novice nurses to enhance the quality of care provided to patients in the intensive care unit (Yeh et al., 2004). Knowledge enhancement was the second strategy identified in our study. Related techniques include questioning, querying of sources, and individual study. In this regard, apart from gaining information from colleagues and doctors, NGNs used sources such as specialized books, the Internet, and educational software. The result of Dee and Stanley’s (2005) study is consistent with our findings as it indicates that their nurse participants obtained medical information from books and digital sources. Furthermore, a previous Iranian study showed that 56.2% of NGNs refer to books and other source materials to increase their knowledge and gain confidence (Labaf Ghasemi et al., 2005). Questioning was another knowledge enhancement strategy used by our participants. One study in Iran indicated that 74.5% of NGNs increased their knowledge and information using the questioning strategy (Labaf Ghasemi et al., 2005). Crooks et al. (2005) posited that questioning enhances the opportunity for research through self-challenging and exploration and increases motivation, interaction, self-confidence, and creative thinking through active learning (Nicholl & Tracey, 2007). In other words, by recalling information and promoting cognitive activities and reasoning in addition to challenging their ideas, questioning promotes active learning and improves self-confidence in NGNs (Dyess & Sherman, 2009). This method is consistent with the related strategy in our findings. In terms of the strategy of personal study, Labaf Ghasemi et al. showed that 74.5% of NGNs use personal study to increase their knowledge in clinical fields. Clinical skills learning was the next strategy identified in this study as used by NGNs. It indicates their efforts to gain personal skills and observe/discuss the experiences of expert nurses to increase their self-confidence in learning and performing various clinical tasks. Casey et al. believe that, in the first 6 months of work, NGNs do not have enough self-confidence to perform their tasks and to learn new skills. In addition, they complain about feeling like a child without the ability to develop skills. Consequently, 41% of new nurses are uncomfortable in performing necessary skills. In this regard, the results of another study showed that more than 60% of head nurses believed that NGNs were capable of performing only 153 of 213 nursing skills. However, with a significant difference of about 60%, NGNs believed that they were able to perform just 82 of the 213 skills. This infers that low self-confidence limits the ability of NGNs to perform clinical skills (Lee, Chen, & Wang, 2002). In addition, it can be argued that this lack of clinical skill confidence among NGNs results from insufficient training in such areas as clinical skills, organizational skills, and managerial skills as well as a distrust in their ability to perform clinical skills (Higgins, Spencer, & Kane, 2010). McElhinney (2010) mentioned role clarity, preparation, sufficient training, and support from other disciplines as factors of influence on NGNs performing necessary clinical tasks. One of the training methods mentioned by participants in this study was seeking and gaining experience from experienced nurses to develop professional skills. Smith et al. (2012) showed in their study that gaining confidence in NGNs relies more on personal experience and communication with colleagues than on formal sources of knowledge. Smith et al. found that 63% of NGNs used experiences of others in making decisions, and one study in Iran showed that 67.1% of NGNs learn new skills from their colleagues (Labaf Ghasemi et al., 2005). In addition, Halter et al. (2011) pointed to the effectiveness of having experienced nurses meet with novice nurses during the first 4–6 weeks of familiarization to determine the learning needs of novice nurses to facilitate their learning appropriate skills, increase their self-confidence, manage their workload better, and enhance their decision-making abilities. Communication with experienced nurses and gaining knowledge through discussing their experiences reduced turnover among NGNs, increased performance quality, and increased self-confidence and competence (Reid, 2010), which is consistent with our results. With regard to the strategies that NGNs use to gain confidence, self-exploration strategy through methods such as analysis and self-reflection were mainly utilized. By assessing the situation and gathering evidence, NGNs analyze the situation, make judgments, and learn to make accurate and timely decisions. Furthermore, besides reflection and thinking about their performance in terms of a patient’s condition, NGNs assess their weaknesses and achieve a high level of self-efficacy and self-confidence based on feedback. In fact, self-reflection makes an individual explore and gain new perception of her or his mental and emotional activities that are associated with appreciation. Therefore, this approach helps develop competencies, self-efficacy, and self-confidence in nurses (Lew & Schmidt, 2011). Through self-reflection, nurses internalize events, which lead them to diagnose patient problems and their personal challenges (Bagay, 2012). Chen et al. (2011) showed that, by use of reflection strategy in learning experiences in novice nurses, previous experiences increase their self-confidence. Our participants introduced this point as one of the strategies. Validation was also a strategy frequently used by NGNs. Validation helps NGNs determine the validity of decisions and their judgments. Validation and verification of information and decisions by nurses through professional goals, guidelines, and results of personal knowledge development are useful in clinical decision making and in achieving self-confidence (Hedberg & Sätterlund Larsson, 2003). Through self-responsibility, NGNs strengthen their self-confidence and commitment to patient care. Although this commitment is associated with stress, NGNs use a reverse strategy. By taking personal responsibility and risk, they achieve a successful performance, which supports a sense of self-confidence (Clancy & Svensson, 2007). Dempsey and Burr (2009) conducted a study in Australia on the level of confidence and responsibility in 203 radiotherapists. They found that, with increased responsibility, beginner radiotherapists gained more confidence in performing their assigned tasks at the beginning of their careers. Mutual interaction between new nurses and others is the next important strategy that is used by NGNs to gain self-confidence. Mutual interaction is the starting point of professional socialization, learning skills, belonging to the workplace, facilitating the transition process, increased job satisfaction, and increased self-confidence (Thrysoe, Hounsgaard, Dohn, & Wagner, 2012). In this regard, Casey et al. reported that NGNs in their interactions with physicians, interns, residents, and nurses had little confidence during their first 6 months of work. However, after 6–12 months, their improved performance had increased their self-confidence (Casey et al., 2004). Mutual interactions with patients based on a friendly atmosphere, empathy, responding to patient’s questions, and engaging the patient in decision making as well as considering the patient’s perspective lead to patient cooperation. In addition, positive feedback from patient is likely to increase self-confidence in NGNs (Major, Holmes, & Hons, 2008). Creativity is the next strategy in gaining confidence. Creativity as a cognitive process causes innovative actions; facilitates problem-solving processes; and provides solutions, patterns, and structures to follow. The creativity process includes three main principles: a new rearranging of old ideas, selecting useful ideas, and discovering their relationships (Chan, 2013). Nurses, especially NGNs, because of unexpected occupational situations and faced with patients for the first time, need creativity and creative thinking to make advantageous decisions (Chan, 2013). Therefore, the use of intelligence, hard work, and interest in new things may help NGNs gain more self-confidence (Kaufman, 2002). This attitude is consistent with our findings on creativity.

Conclusions

At the beginning of their nursing career, NGNs require courage and a high level of confidence to overcome challenges. Our study highlights eight important strategies that NGNs use to increase self-confidence and efficacy to successfully adapt to the demands and expectations of their new career. For NGNs in Iran, limitations such as shortness of orientation periods and the lack of preceptorships for NGNs during orientation periods result in low rates of clinical internship, high workloads, and little time for learning during the first months and even years of work. This results in a generally low level of self-confidence among NGNs that subsequently encourages them to apply strategies to increase self-confidence and overcome challenges. This study aimed to improve the body of knowledge in nursing by introducing the experiences of NGNs in terms of the strategies they use to gain confidence early in their professional careers. Furthermore, the authors hope that the findings may help nursing managers better appreciate NGN adaptation strategies and develop strategies to improve the self-confidence of their NGNs.

Acknowledgments

The authors would like to thank all participants in this research. This article was a part of the findings of a doctoral thesis granted by the Tabriz University of Medical Sciences No. 5/4/2738.

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Keywords:

newly graduated nurse; self-confidence; strategy; qualitative content analysis

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