Self-Efficacy and Resilience among Nursing Students in Central Appalachia
Tauna Gulley, Tansy Hall, Meg Wright Sidle, and Mary R. Simpson, Nursing Faculty, University of Pikeville
ABSTRACT
- Intended Audience: nursing faculty and other health professional faculty
- Introduction: Self-efficacy beliefs and resilience among nursing students in associate degree nursing programs is an area that requires further understanding.
- Purpose: Nursing students in rural areas overcome unique challenges to do well in nursing school, and pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Challenges include lack of reliable internet service and economic resources. Nursing students must believe their efforts will result in desired effects (efficacy) and they must be able to gain strength from hardships (resilience). Year 1 and Year 2 nursing students were asked to rate themselves regarding self-efficacy beliefs and resilience.
- Methods: A descriptive design was used. The New General Self-Efficacy Scale and the Brief Resilience Scale were administered during scheduled class periods for Year 1 and Year 2 associate degree nursing students. Independent t-tests were performed to determine differences among the two groups.
- Results: Overall, students reported higher levels of self-efficacy in comparison to resilience. Year 1, semester 2 nursing students reported higher levels of resilience in comparison to Year 2, semester 4 students.
- Implications: Nurse educators must consider resilience as a valuable characteristic among graduating nurses. Nurses are expected to function effectively in high stress situations and promoting resilience among student nurses will better prepare them for success in nursing school and the reality of nursing practice.
Self-Efficacy and Resilience among Nursing Students in Central Appalachia
According to the American Nurses Association (ANA) (2021), the average age of employed registered nurses have increased from 42.7 years in 2000 to 44.6 years in 2010. In addition, 500,000 experienced nurses will retire by 2022 and the U.S. Bureau of Labor Statistics anticipates a need for 1.1 million nurses by 2022 (ANA, 2021). Therefore, there is a critical need for nursing students to graduate and pass NCLEX-RN to increase the number of licensed registered nurses in the workforce. In addition to exploring factors that increase the number of newly licensed registered nurses in the workforce, gaining a better understanding of factors that promote longevity in the nursing profession is an important consideration for nurse educators.
Nursing students in rural Appalachia must overcome unique barriers to achieve success; lack of reliable internet access and decreased economic resources has been challenging especially during COVID-19 when instruction transitioned from face to face to online teaching. Being able to overcome hardship and gain strength from adverse experiences is defined as resilience(Thomas & Asselin, 2018). Nurse educators must gain an understanding of resilience among their students because nurses are expected to perform effectively while on the job even in stressful and demanding circumstances, (Ozsaban, Turan & Hatice, 2019; Thomas & Asselin, 2018).
The third Mental Health and Wellness survey by the American Nurses Foundation (ANF) (2021) studied the impact of the COVID-19 pandemic on the well-being of nurses, with survey items on emotional health, resiliency, post-traumatic stress, and stigma in seeking mental health services. Resiliency was rated on a 0-10 scale with 10 reflecting strong resiliency, nurses under age 25 had the lowest average resiliency score (5.61) and nurses age 25-34 had the next lowest score (5.69), while nurses age 55 or older had the highest average resiliency score (7.34) (American Nurses Foundation, September 2021). Thus, if an increase in the age of nurses is parallel with increased resiliency, and if a majority of nursing students tend to be under 35 years of age, then nursing faculty must focus on non-academic factors such as resilience and well-being for nursing student success.
In a systematic review exploring relationships among well-being, resilience, and stress among undergraduate nursing students in different countries, Li and Hasson (2020) reported a positive correlation between resilience and well-being, with academic efficacy being a predictor of resilience. Academic efficacy is the belief that one can achieve academic success through goal-setting (Nasir & Iqbal, 2019) and perceived self-efficacy is defined as the belief about one’s ability to achieve goals that one has set for themselves (Bandura, 1997). Self-efficacy expectations have been found to be a significant predictor of passing NCLEX-RN (Silvestri, Clark & Moonie, 2013) and passing the licensure exam is necessary to increase the number of employed licensed registered nurses.
Since nurses experience physically and psychologically demanding events every day, resilience is an essential characteristic for nurses to develop. The American Association of Colleges of Nursing (AACN) (2020) endorsed a nationwide call to action for leaders in academic nursing to prioritize practices among nursing students to enhance well-being, resilience, and suicide prevention. Achieving optimal first-time pass rates for NCLEX-RN is the foundation to having a nursing workforce. Fostering non-academic factors such as self-efficacy and resilience among nursing students can help to prepare students for the demands of nursing practice and promote longevity of years employed in the profession of nursing.
The motivation for this study was to gain a deeper understanding of resilience and self-efficacy among associate degree nursing (AD) students in the central Appalachian region of the United States. In one pilot study, students reported elevated levels of self-efficacy regarding passing NCLEX-RN. The current study will further explore the concept of self-efficacy and resilience, given that resilience is considered a component of self-efficacy. This study will serve as a guide for curriculum revision to investigate non-academic factors that may contribute to improved pass rates for NCLEX-RN first time test takers for an ADN program that experienced a decrease in pass rates for NCLEX-RN from 2017 (96%) to 2018 (77%) and then in 2019 (69%); though, pass rates increased in 2020 (82%) (kbn.ky.gov).
Conceptual Framework
This study was guided by Albert Bandura’s Social Cognitive Theory (Bandura, 1999) that posits self-efficacy is the belief that individuals can produce desired effects by their actions. Self-efficacy influences motivation through personal goal setting and evaluation of achievement. For example, goal setting is completing intentions to achieve valued objectives. Motivational effects result from self-evaluation of efforts to achieve goals. Individuals with high levels of efficacy will increase efforts to achieve goals and develop ways to overcome challenges which supports resilience in the individual (Bandura, 1999).
Research Questions
1.) What are the self-efficacy beliefs of Year 1, semester 2 students and Year 2, semester 4 students in an associate degree nursing program regarding their perceptions of their ability to pass NCLEX-RN?
2.) How do Year 1, semester 2 and Year 2, semester 4 associate degree nursing students rate themselves regarding resilience?
We hypothesize that Year 2 nursing students will rate themselves higher on self-efficacy regarding their ability to pass NCLEX-RN since they will soon graduate and Year 2 participants will rate themselves higher in resilience as they have overcome numerous obstacles to achieve an associate degree in nursing. It is worthy to note that one major obstacle faced by Year 2 participants was the need to transition from a face-to-face method of instruction to remote online learning for classroom, lab, and clinical requirements during their second and third semesters of the ADN program due to the COVID-19 epidemic.
Method
Design and Sample
This descriptive study examined resilience, and self-efficacy beliefs of associate degree nursing students regarding their perceived ability to pass NCLEX-RN. All students enrolled in the spring term of a two-year, four semester, associate degree nursing (ADN) program at one private, liberal arts and sciences university in central Appalachia (N=86) were eligible to participate in the study. The resulting convenience sample consisted of 85 of 86 (99%) eligible participants. These 85 participants included 46 of the 47 students (98%) in Year 1, semester 2,and all 39 students (100%) in Year 2, semester 4 of the ADN program.
Procedures
The University Institutional Review Board reviewed and approved this study prior to data collection. The IRB-approved consent form and the two surveys, the New General Self-Efficacy Scale (NGSES) and the Brief Resilience Scale (BRS), were given to students during scheduled class or clinical skills lab periods. Surveys and consent forms for Year 1 students were administered at one time in the afternoon at the start of a face-to-face clinical skills lab. Surveys and consent forms for Year 2 students were administered in the classroom in the morning prior to a non-graded Kaplan exam. All consent forms were distributed by the respective instructor to the students in class. The instructor verbally summarized each section of the consent form. Time was provided for students to read the form and ask questions before signing, if they chose to do so. After signing the consent form, students placed them in an envelope at the front of the room. Year 1 had 46 of 47 students (98%) in attendance; all 46 signed the consent form. Year 2 had all 39 students (100%) in attendance; all 39 signed the consent form. Thus, there were a total of 85 of 86 potential participants in attendance at their respective class. These 85 students signed the consent form for a 99% participation rate from the pool of Year 1 and Year 2 ADN students.
Next, the two surveys were given to the students. First, The General Self-Efficacy Scale was administered and the directions were read by the instructor as follows: Use the following scale to indicate how much you disagree or agree with each of the statements regarding your ability to pass the National Council Licensure Exam (NCLEX-RN). Then, the Brief Resilience Scale was administered with instructions for them to indicate how much the student disagreed or agreed with each statement. Students completed each survey and left them face down on a desk at the front of the room. Surveys were collected and placed in an envelope, sealed, and hand-delivered to the primary investigator.
Instruments
Self-efficacy was measured using the New General Self-Efficacy Scale (Chen, Gulley, & Eden, 2001), an 8-item Likert-type scale. This scale has been reliable among university students (ɑ = 0.84) (Azizli, Atkinson, Baughman, & Giammarco, 2015).
Resilience was measured using the Brief Resilience Scale (Smith, Dalen, Wiggins, Tooley, Christopher, & Bernard, 2008), a 6-item Likert type scale. Participants indicated if they agreed or disagreed with how well each statement described them from “1” = strongly disagree to “5” = strongly agree. Items 2 (I have a hard time making it through stressful events), 4 (It is hard for me to snap back when something bad happens), and 6 (I tend to take a long time to get over set-backs in my life) were reverse-coded, and the data were re-coded before data analysis.
The Brief Resilience Scale was reliable among a sample of 277 undergraduate students attending a small university in the Southern United States (ɑ = 0.84) (Thomas & Zolkoski, 2020). Higher scores indicate greater resilience.
Statistical Methods
Statistical analysis was based on participant response data using IBM SPSS® Statistics version 25 to perform measures of central tendency (mean) and an independent t-test.
Results
Self-Efficacy
Participant response data were classified into two groups, Year 1 and Year 2 as presented in Table 1. Year 2 students scored higher than Year 1 students on every question except for the last question, “Even when things are tough, I can perform quite well,” in which both groups scored equally at 4.13. Year 1 students scored lowest at 3.93 on question 2, “When facing difficult tasks, I am certain that I can accomplish them.” Year 2 students scored highest on question 3, “In general, I think that I can obtain outcomes that are important to me,” at 4.38, which was very similar to Year 1 students, whose mean score was 4.36. The highest score on the survey was among Year 2 students on question 4, “I believe I can succeed at almost any endeavor to which I set my mind,” at 4.41.
Resilience
Year 1 and Year 2 nursing students scored below 4.0 on every question as presented in Table 2. Year 1 students scored higher on all questions in comparison to Year 2 students. Year 1 students scored highest when asked about their ability to “bounce back quickly after hard times,” scoring 3.89. The lowest score was among Year 2 students when asked, “I have a hard time making it through stressful events,” at 2.92. There were no significant differences among Year 1 and Year 2 responses to either survey; however, there is nearing significance between the groups for the question, “I usually come through difficult times with little trouble” (p = .051).
Discussion
The purpose of this study was to describe self-efficacy and resilience of Year 1 and Year 2 students in an ADN program. The two groups scored low on both surveys, that is, less than 4.5 on self-efficacy and less than 3.9 on resilience, based on a 1-5 Likert rating. The majority of study participants were under age 35. The American Nurses Foundation Mental Health and Wellness Survey 3 (September 2021) also found that nurses under age 25 and age 25-34 had the lowest resiliency scores compared to ages 35 or older. Results of this study warrant further investigation to determine strategies to increase self-efficacy and resilience among nursing students that, in turn, may increase the number of licensed registered nurses, and promote longevity in the field of nursing. Year 2 students scored higher than Year 1 students regarding self-efficacy, which can be attributed to Year 2 students being in the program longer and gaining confidence in their ability to pass NCLEX-RN. Year 1 students scored lower in self-efficacy regarding their perceptions of ability to pass NCLEX-RN. These results are not surprising since students have only completed one year of the program, and they will learn more skills and increase test-taking ability as they progress in the ADN program. A pilot study found that students reported high levels of self-efficacy whether or not they passed NCLEX-RN on the first attempt (Gulley, Hall, Newsome, Sidle, & Simpson, 2021).
There was no statistical significance regarding resilience among the groups. However, as noted on question five, “I usually come through difficult times with little trouble,” a p-value of 0.051 is nearing meaningful significance. On this question, Year 1 students scored higher at 3.50 compared to Year 2 students at 3.13. The lower score in Year 2 students could be attributed to the fact that they were unaware if they were going to graduate, as final grades had not been posted at the time of the surveys and students still had standardized testing to complete.
Year 1 nursing students reported higher levels of resilience than Year 2 students who would soon be graduating; therefore, it is important to include activities that promote resilience across the curriculum, including both Year 1 and Year 2 nursing students. Overall, participants in this study rated self-efficacy higher than resilience. Since self-efficacy is a characteristic of resilient behavior (Walsh, Owen, Mustafa, & Beech, 2020), addressing self-efficacy is important during curriculum planning.
Central Appalachia is more economically depressed, and the residents suffer poorer health outcomes and more overdose deaths in comparison to the non-Appalachian regions of the United States (Appalachian Regional Commission, 2022). Nursing students in central Appalachia overcome financial burdens and lack many of the resources their urban counterparts may experience to achieve academic success and gain licensure to practice nursing. Data in this study did not support the hypothesis that Year 2 students would rate themselves higher on self-efficacy and resilience which is unexpected and warrants further investigation
This study has a small sample size and cannot be generalized to other associate degree nursing programs students. The timing of the surveys may have influenced results of this study. Year 1 and Year 2 students completed the surveys at the end of the spring semester when almost all course requirements were completed. At this time, students were not aware of whether or not they were successful in completing the first year of the nursing program or graduating from the ADN program; this personal knowledge may have affected survey responses. Another limitation of the study was that each survey was submitted anonymously, and there was no way to determine relationships between self-efficacy and resilience.
Conclusions
It is important to promote resilience among nursing students to support success and endurance in the profession. Nursing school and the nursing profession is stressful, demanding, and full of challenges. Effective strategies for promoting resilience among nursing students include encouraging social support from faculty, friends, and family, providing education modules on topics such as self-care, stress management, reflective journaling (Thomas & Asselin, 2018), and providing support services, and engaging students in peer-supported networks (He, Turnbull, Kirsbaum, Phillips, & Kainin-Yobas, 2018). Self-efficacy can be developed through experience and positive feedback; therefore, nursing faculty can enhance self-efficacy beliefs about passing NCLEX-RN by creating opportunities for students to practice test-taking skills throughout the curriculum (Rayan, 2019).
Implications for Nursing Practice
Resilience and self-efficacy are important concepts for nursing practice. Considering the current nursing shortage, efforts from ADN programs must continue to supply the workforce with resilient, registered nurses in all health care settings. Nurses who have developed high levels of resilience and self-efficacy while in nursing school will have the knowledge to guide their co-workers in developing these skills as well. Nurses face a variety of daily stressors and most recently the COVID 19 pandemic. Nursing education programs can promote resilience and self-efficacy among their students by encouraging supportive relationships with family, teachers, and peers. Nurses who enter any field of healthcare delivery can then encourage their co-workers to develop relationships that provide a foundation for developing skills that promote self-efficacy, resilience, and a safe and healthy workplace.
In Summary:
· Self-efficacy and resilience are important characteristics to promote among nursing students.
· Effective strategies for promoting resilience among nursing students include developing stress management and self-care skills which will enhance workplace health.
· Graduate nurses with high levels of resilience and self-efficacy will model and promote the development of these characteristics among their workers which will foster a safe and healthy workplace.
Table 1. Responses to New General Self-Efficacy Scale, All Participants
Instructions: Use the following scale and circle one number for each statement to indicate how much you agree or disagree with each statement regarding your ability to pass the National Council Licensure Exam (NCLEX-RN)
|
|
Year 1 Mean |
Year 2 Mean |
p value |
|
Sample Size: |
46 |
39 |
0.94 |
|
I will be able to achieve most of the goals that I have set for myself. |
4.22 |
4.38 |
.367 |
|
When facing difficult tasks, I am certain that I will accomplish them. |
3.93 |
4.13 |
.313 |
|
In general, I think that I can obtain outcomes that are important to me. |
4.36 |
4.38 |
.865 |
|
I believe I can succeed at almost any endeavor to which I set my mind. |
4.22 |
4.41 |
.338 |
|
I will be able to successfully overcome many challenges. |
4.27 |
4.31 |
.831 |
|
I am confident that I can perform effectively on many different tasks. |
4.13 |
4.21 |
.710 |
|
Compared to other people, I can do most tasks very well. |
3.96 |
4.03 |
.715 |
|
Even when things are tough, I can perform quite well. |
4.13 |
4.13 |
.978 |
Scale: Strongly Agree=5, Agree=4, Neither Agree/Disagree=3, Disagree=2, Strongly Disagree=1
Table 2. Responses to The Brief Resilience Scale, All Participants
Instructions: Use the following scale and circle one number for each statement to indicate how much you disagree or agree with each of the statements.
|
|
Year 1 Mean |
Year 2 Mean |
p value |
|
Sample Size: |
46 |
39 |
0.81 |
|
I tend to bounce back quickly after hard times |
3.89 |
3.69 |
.325 |
|
I have a hard time making it through stressful events * |
3.37 |
2.92 |
.070 |
|
It does not take me long to recover from a stressful event |
3.26 |
3.10 |
.439 |
|
It is hard for me to snap back when something bad happens * |
3.57 |
3.28 |
.152 |
|
I usually come through difficult times with little trouble |
3.50 |
3.13 |
.051 |
|
I tend to take a long time to get over set-backs in my life * |
3.72 |
3.44 |
.183 |
Scale: Strongly Agree=5, Agree=4, Neither Agree/Disagree=3, Disagree=2, Strongly Disagree=1
* Scale: Strongly Agree=1, Agree=2, Neither Agree/Disagree=3, Disagree=4, Strongly Disagree=5
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