Scarlett, Yvonne. The Experience of Becoming Clinically Self-Confident

The Experience of Becoming Clinically Self-Confident

Scarlett, Yvonne

Pre-clinical Jitters

I was assigned to Ward 4 one of the busiest male medical unit in the hospital. It was rumored that the staff nurses ate first year student nurses for breakfast. I was going to be there for sixteen agonizing weeks! I decided that I was not prepared for any hassles so I called my former employer and asked for my job back just in case I did not make it through the rotation. The feeling of having something to fall back on was reassuring. I had some wonderful friends and peers who encouraged me to try the clinical experience for at least one week.

I had spent days trying to build up my self-confidence to even walk onto the ward. I would go by the ward several times and try to create a mental picture of the experiential outcome. Each time the prospects appear inadequate. I began to count the weeks, then days and finally hours when I would have to face clinical. The feeling of waiting, anticipation, and fear of the unknown were at times overwhelming. I sometimes could not eat, sleep or study.

On the night prior to clinical I could not fall sleep. When I finally did, I dreamt that I dropped a patient on his head in front of the Director of the School of Nursing who said, “I knew you wouldn’t make it.” I woke up shaking and afraid. I could not get back to sleep no matter how hard I tried.

Finally the day arrived, bright and sunny. I felt it would have been better if the day was dull and rainy, it would have matched my mood. I was up and dressed for clinical by 0530hrs for the 0700hrs shift. I did not want to be late although it would take less than five minutes to walk to the ward.

Moving closer and closer to the ward made the upcoming experience more real and also more scary. Why did I not leave before this time? I reasoned. Not everyone can be a nurse, so why should I feel guilty if I quit now? Failure at one thing can be success turned inside out. Before I knew it, I was on the ward and realizing that this was the point of no return. My classmate, Jeanette seemed to be experiencing the same feelings as her neck and face were covered with red flush marks. This was one day I was happy to be black.

I did not eat breakfast that morning as my stomach could not tolerate food or drink. It was twisted in knots and peristalsis had speeded up considerably overnight. Our senior nursing sisters told us that our first jobs on the wards were the cleaning and sterilizing of bedpans and sputum mugs first thing in the morning! I felt this was the supreme test for “stayers” and “leavers” during the first year of nursing. I did not want any food in my stomach to augment the contents of those containers. They would have to find another way to break down my resolve to get me to leave nursing. I was not going to help.

Ward Four

I stood at the nursing station and looked around tentatively. My hands were sweating, heart pounding, and my throat was dry and parched. I felt weak but it was debatable whether it was from lack of sleep, food or fear of the unknown. My “good morning” went unanswered, so I just stood where I thought I could not do any harm.

The staff gathered together at the nursing station for the night’s report and Jeanette and I joined them without being told. They sat down but did not make any effort to create space for us to sit so we stood throughout the report. After the report was completed, we continued to stand until all the staff dispersed without inquiring who we were or even acknowledging our presence. The lack of stripes on our sleeves, starched uniforms reaching two inches below the knees, immaculate aprons, and perfect caps set at the right angle on our heads clearly identify us as the new “probies.”

Jeanette and I looked at each other then looked around us hesitantly with mounting anxiety. This was it I thought. I will have to actually talk with a real patient and do something nursy. Prior to today, all my skills were done in the laboratory setting on dummies or with our peers acting as models. But these were real patients who had tubes, pain, and some looked as if they could even die. What would I do if that (death) happen to my patient? Would I remember what to say or do? The more I thought of all the things I could do wrong, the stronger the urge was to run away. Not having an instructor to guide and direct me was very, very scary. I had resented having an instructor with me all the time trying to prepare me for this day. Somehow I felt more than prepared. Now I was ambivalent about the independence I sought. It sure did not feel right. It was not what I envisioned it would feel like.

The Initiation

My first task was to collect all the bedpans and sputum mugs, empty, clean and sterilize them. I was happy I did not have breakfast that morning. I will never forget the disgust I felt when the smell of the sputum mugs and bedpans came into contact with my delicate sense of smell. I did not realize that there were smells like what I experienced that day. Like a drowning man, I struggled to hold my breath for as long as possible, but when I did take a breath it was so deep I felt I had inhaled all the impurities in the whole world, and it was going to remain in my lungs forever. I could feel my stomach churning and my throat contracting. My eyes watered as the urge to vomit became very strong. Right then, my primary job was to use all the reserve I possessed to prevent myself from vomiting, fainting or making a fool of myself. How I survived that experience is still beyond my comprehension today.

Throughout this horrible experience I kept thinking, “is this really nursing?” If it is, then someone has betrayed me and I am trapped into this unreal situation. I am going to wake up and find out it was only an awful dream! I wondered if it was like being caught up into a cult when one realizes that it was too late to get out. I was ready to leave nursing as it did not seem to fit in with my perception of what nursing should be. How come the Harlequinn romances and television protray nurses as being so efficient and clean? I don’t remember seeing a nurse on TV with a bedpan. I needed a way out. Breaking an arm or leg would do but then I hated pain, needles and having my mother fussing over me. The trick was, how to escape without appearing to be a coward.

Real Nursing and I

Bedmaking was my second task. I was going to make beds with real patients in them for the first time! The fear of turning a patient and not having him fall out of the bed, or hurting himself while making the bed with him in it was palpable. Could I do it? Would it be the same as when I practised in the lab? After collecting the bed linen and pillowcases from the linen closet, I walked to the patient’s bedside on wooden legs. I was conscious of some patients talking about how cute the new student nurses recruits were. I felt ready to turn and run but something kept me going. I felt exposed and self-conscious. I felt everyone could read my mind and knew I did not feel confident and maybe they were right.

I approached the first bed with a little old man it. He was groaning. “God I can’t touch him. I am going to hurt him. I am not supposed to hurt these people, nursing is caring and doing good,” I reasoned silently. I began to concentrate on the task on hand focussing on the step-by-step process.

In my head Sister Mell was saying, “tell the patient what you plan to do even if he is unconscious. Raise the side rail on the side to which the patient is being turned. You do not want him to fall. Make one side totally. Raise the side rail on the side made and pull the patient toward your side, then lower the siderails on the side to be made. Warn the patient that he will have to move over a kind of hump from the folded sheets. Be gentle and reposition when you are finished. Maintain good body mechanics.

My knees locked as I tried to bend and pull the patient over toward me. My hands were shaking and I could feel my body tensed as I touched him. His skin was hot and dry. He was drooling from the corner of his mouth and did not seem to care. I took the sheet and wiped the sputum away. He whispered his thanks and continued to groan loud and long. I felt sorry and scared for him as I thought he must have been having excruciating pain.

Mechanically and slowly the first bed was made and the patient repositioned and still safely in bed! It was then that I looked into his face and realized that I had actually touched someone and made his bed without hurting him. That someone was my first real patient, a person who was ill and who I could help if only I could overcome the fear of failure and not doing things perfectly. I looked into his face, he reminded me of my adopted grandfather who was very frail but also very friendly. I wondered about this old man’s family and friends. Where did he come from and what kind of life did he have? Why was he here? Was he going to live? It was too soon to speak with him, I was too nervous. All the communication strategies and skills I learned in class vanished. My head was empty of anything intelligible, hence it was appropriate to speak as little as possible.

Once I had made the first bed it became easier and easier. It took me hours to make the beds during the first few days, and to form the corners just right. I would make them, check and recheck them again and again. I was so consumed in making the beds correctly that I did not even consider the patients in the beds. I did not really see them. I did not initiate conversation unless it was absolutely necessary. When I did initiate conversation with a patient, it was to give direction such as “turn toward me, raise your feet. Roll over the hump. The finished beds were always checked by the nurse in charge, whose lack of criticism indicated to me that my work was satisfactory.

Dejavu

On our second day on the ward, I was asked to assist a patient to sit out of bed for breakfast. He had weakness on his right side due to a left cerebrovascular accident (stroke). My mind flashed back to the dream about the man I had dropped on his head. I was really scared. I requested Jeanette’s help. Mentally I ran through what I needed to do according to Mell’s gospel. It was ironic how we all complained when she tried to reinforce clinical expectations and ensure we really understood what she was saying. She must have been effective despite our sometimes negative attitude of “where have we heard that before.” In my mind, Sister Mell was like an invisible guide and I could hear her saying:

Good body mechanics, bend knees, brace his weak knee, let stand on good leg, then wait a minute or so just in case his blood pressure falls suddenly, pivot and put in chair. Use the belt for heavy patients. If you are alone and your patient is inconsistent with his transfers, use the belt. It is better to be safe than to be sorry.

Jeanette and I completed our first transfer without any problems. We simultaneously breathed a sigh of relief. For the first week the routine remained the same, bedpans, sputum mugs, bedmaking, patient transfers, assisting with feeding and bedbaths.

Emerging from the Cocoon

I soon realized that feeding patients was the job most hated by nurses on the ward, so it was assigned to the the students. It was through feeding patients that I gradually got the courage to speak with them. You had no choice. The conversation would start like this:

This is porridge what would you like in it today? It is fairly hot and it looks better than yesterday. Would you like your eggs crushed with butter or do you like it with salt only? Toast? With butter or honey? What would you like in your tea today?

One learns very quickly that ill patients have a variety of ways to use salt, sugar, black pepper, butter, and honey. You don’t forget the first lesson given by the patient on how to customize his meal unless you will be in big trouble. Mr Jones likes two sugars in his porridge with no milk. The milk is to soak his toast. Try and remove the shell from his egg without breaking it open. He likes to eat it whole with salt only. Mr. Kiw, on the other hand, likes all his milk in the porridge, honey on the toast cut up in four pieces, and scrambled eggs with butter. If the patient could not communicate, trial and error helped the nurse determine if she was feeding him correctly. For example, the patient may always push away the meat and potatoes together but will eat them separately. He may refuse tea but would drink milk when offered.

Towards the end of the second week, I was allowed to take vital signs. Taking the temperature and pulse was alright but getting the blood pressure was a struggle. I would start by:

wrapping the blood pressure cuff around the arm. Invariably it was either too loose or too tight. I would redo it three or four times. Now to get the reading. Pump! Pump! all the way up to 200mmHg and then straining to hear the first bip, bip sound. The process is repeated three, four times before I would be satisfied that I actually heard the bip, bip sounds. “Listen Jeanette and tell me what you hear.” By the time we were finished the patient would be asking to have the air released. We were so focused on whether we could hear the bip, bip sounds that we forgot we were occluding the patient’s blood flow.

As with bedmaking, vital signs took me hours to complete initially. Sometimes I would ask the nurse to double check the readings as I was still unsure of what I was hearing. When the results were confirmed as accurate, I always felt as if I was achieving something. If, however, the nurse said the readings differ even by 5mmHg, I would worry about it. Now I know that such changes were expected, especially when the patient had to contend with a student trying to get one blood pressure reading over ten minutes!

The Bedbath

Nothing in the laboratory setting or in the textbooks prepared me for the reaction to my first bedbath. I had practised it flawlessly in the lab on dummies, so what could go wrong? I felt prepared and confident. When the day came for me to actually do the skill I was seized by a feeling of embarrassment and awkwardness. I remember trying to appear busy with other activities. The longer I delayed the process, the more nervous I became.

I suddenly realized that although I had seen naked people in books and on TV, it was all distant. The distance was now being reduced between theory and practice, fantasy and reality, the abstract and concrete. I would be undressing and touching this person. This person who was unfamiliar to me. This person who I did not really know except for what I read on his chart. The unfamiliarity scared me.

One is familiar with one’s own body and feels comfortable touching it. The touching of one’s body may bring about familiar feelings, thoughts and responses. However, with an unfamiliar body like that of a patient’s, the experience may be quite different. The recipient of the touch would have to describe to the nurse how he is affected by her touching. If he does not do so, (it is unlikely he would do so) then the nurse would have to guess as to the response and decide unilaterally what would be considered “right” or “wrong”. It is not appropriate to ask the patient.

When I was a student nurse I kept wondering if my touch was cold, warm, tickly, gentle or rough? How did the patient feel and what did he experience when he was touched? Did he feel as embarrassed as I sometimes were when I had to clean his perineum and give him peri-care? How did he feel about his “private body” which has been his to touch and wash as he chooses, now being seen and touched by a stranger? Was making his private body public to another bothersome to him? Did he feel helpless and afraid of what sounds he may make during the procedure? Many times when I was bathing a patient he may pass flatus and I could see the embarrassment on his face. I wondered how my face reflected acceptance or non-acceptance of such normal physiological processes to the patient? Were my verbal and non-verbal behaviors congruent in embarrassing situations? Did the patient feel comfortable? Did he feel it was just her job and she must say those reassuring “words” without really meaning them? When I touched patients, I generally felt a sense of trespassing or violating their “space”.

My first bedbath was on a young slightly disoriented male patient.

Generally, a nurse would use one basin of water, and probably a maximum of two facecloths, and finish the bath before the water gets too cold. As a student, it was a bit different. Three or more facecloths and the same number of towels may be used, along with a minimum of two basins of water.

The way the facecloth is held and its movement on the body follows precise steps for the student nurse. Some strokes are downward and others circular. In addition to concentrating on the strokes, the water must also be attended to. It cannot be allowed to lose any of its warmth unless it must be changed, patient comfort is most important.

This day after I had completed the bath except for the peri-care. I got fresh warm water and concentrated on finishing. I was so slow and precise that the patient became stimulated and ended up having a sudden erection. The suddenness shocked me and I unconsciously made a screeching sound which embarrassed the patient and myself. I felt I would never live down the experience and avoided the patient for days after that. Now, when I teach nursing fundamentals, I always remember to relate this story to the students, while reminding them not to linger too long on male peri-care.

Bonding

Most patients chose to speak about themselves and families during feeding or bathing times, as well as try to find out something about the nurse. It was a time when I was truly alone with the patient. I generally felt comfortable talking on a one-to-one basis with them and asking questions. I could even admit to them that I was a bit unsure and nervous. They never failed to try and make me feel more comfortable. Being authentic in these situations I found was very important in conveying caring and in developing a genuine helping relationship. Heidegger (1971, p. 138), says that by giving a voice to how we think and feel, and making noticeable our authentic self by unmasking it into the open, can improve communication and our ability to touch others.

I found that as the individual in the bed and I shared some common experiences and understandings through language or from doing something with him, he became “my patient”. I began to expend a lot of energy to ensure he gets the best. I began to take a keener interest in him as a person. I felt more comfortable in performing skills on, or with the patient without feeling unsure or afraid. The patient also began to contribute more to the relationship through positive feedback to myself, to the staff and ward manager. At this stage the patients felt comfortable enough to confide in the student nurses about how they felt about the “real” nurses and the doctors. They seemed to have a bond with the students, probable because they perceived that both groups were somewhat powerless. The student patient relationship was on the road to becoming a dynamic one.

With the progression of the student/patient relationship, the patients became paternal and more forgiving of my mistakes. They sought to protect me if they felt I would get into trouble. For example, one day when I was very busy, I forgot to change my patient’s dressing and he told the staff I had done it. I had called back to tell the staff to change it and he refused. “She forgot she had done it,” he insisted. The dressing was being changed twice per day so it was changed late at night. Next day he said, “one day would not kill me, you worked hard yesterday, I did not want you to get into trouble.” Even with his health at stake he was protective of me.

Once I began to feel less afraid and unsure about implementing skills in the clinical setting, some nurses gradually began to acknowledge me by calling my name, asking for my help with other activities and inviting me to coffee break with them. Going to coffee break with the staff was the ultimate sign that you were being accepted, you have made it into the inner circle. All nursing students aspire to be accepted by the grads. Such acceptance removes one obstacle ( that of working for their acceptance and approval) to becoming self-confident. These social get togethers helped the staff and student to develop a bond and better understanding of each other’s role and reponsibilities. They foster respect which was necessary to mentor novice learners like myself.

It is well known that human beings has a strong need for love and belonging , the need to be recognized and be included as a higher level need necessary for self- growth and self-actualization. Lakoff and Johnston (1980, p.232), felt that once individuals have figured out what they have in common, what is safe to talk about, and how to communicate unshared experiences or create a shared vision, mutual understanding will emerge.

In my case, I had allowed the staff the necessary time to observe and feel satisfied that I was committed and willing to be involved in the “bad” and “good” aspects of nursing. In nursing, the unspoken rule was that there was a certain rite of passage which must be negotiated in coming to be accepted in the clinical setting. I realized that it was important not to show my true self or appear over-confident until I had bonded with the staff. If one moves too fast it was possible to find oneself in embarrassing situations in front of the patients or other staff members. Some staff members “set up” students to fail in the presence of patients if the felt they were acting over-confident.

Sometimes I resented that I had to wait to show what I could do. I felt as if my capability and level of self-confidence had to be forgotten for a time until someone external to the me decides I could make it visible. I am usually motivated internally and it was difficult to wait on others. I did wait. Waiting is part of the nursing culture.

Sister Han

After three weeks in clinical, I became bored and was just about to give up on nursing. Although the nurses had become more friendly, I was still not convinced that nursing was for me. That was before Sister Han entered the picture. At the end of the third week on Ward 4, Sister Han arrived. She was in charge of the unit but was on vacation when we started. She was very businesslike. She addressed Jeanette and myself by name and gave us specific assignments. She took me in the first cubicle with her from then on. This was the cubicle with four patients who were on the dangerously ill list. It functioned like a medical intensive care would, except we did not have ventilators.

For weeks Sister Han worked alongside with me doing everything for the patients. It was very hard work, but I learned so much working with her that I can truly say that the experience shaped my whole nursing future.

“We have to put a nasogastric tube down Mr. J.”, Sister would casually inform me. I would look at her with fear in my eyes and she would tell me to collect the equipment and bring them to her. She would explain step by step what she was doing and then allow me to help her. Next time she would allow me to do it and praise me profusely.

Sister Han had a very good sense of humor which she used lavishly with me. For example, one day I became excited when a male patient bled a bedpan full of blood. I shouted for help and stated that he was bleeding per vagina. It was not until the patient was transferred to the Operating Room and everything had settled down that Sister Han calmly told me about the instant sex change I made to that gentleman. It was a big joke for her and it became a standing joke with my peers as well. I learned to laugh at and with myself when I committed the ultimate faux pas.

Working with Sister Han, I learned to organize my day. She would spend a few minutes prioritizing patient care, then set about accomplishing the task. I observed her every move and imitated them. She talked with and taught the patients and family members during procedures and at specific times. She referred to me as her “right hand person” to the patients and family, hence I was accepted as legitimate even when I felt otherwise.

Sister Han believed that all work and no theory was not good for her students. So each day at 1400 hrs, she would take Jeanette and myself into the middle of the ward and cover at least one patient condition thoroughly with us for an hour. She promised that no patient regardless of how sick they were would die during that time, and no one did. She encouraged us to ask questions and guided us through any difficulties we encountered.

Most of the difficulties student nurses experienced were with doctors who felt they were insignificant beings who could be treated as the doctors see fit. Sister Han made it quite clear that good communication was important and that she did not approve of student nurses being treated as doormats. This was obvious in the way she expected the gods (doctors) to treat us. She would have me accompany her on ward rounds and would ask my opinion about a particular patient, or refer the doctor’s questions to me. She kept saying to the doctors “she is the primary caregiver, she knows just as much as I do about the patient.” One incident stood out in my mind: I was on my way to lunch when a doctor asked me for an IV pole. Sister told him I was off for lunch and the look she gave me meant I better leave. She told him where the IV pole was as I was leaving the unit.

When I returned, the doctor waited and asked me for the IV pole again. I boldly told him I was busy and showed him where the IV pole was. Sister stood there laughing as he walked to the room and collected the pole grumbling that “nursing these days have gone to the dogs.” Sister Han gave me the thumbs up and winked. I felt very confident in myself, this was a turning point for me.

Ambivalence

As student nurses:

We are searching as inquisitors at the door of truth. We are trusting as consorts in the times of youth. We are growing as disciples in the mystery of life. We are serving as resources in a world of strife. We are dreaming as romantics, souls filled with belief. We are healing as friends, who bring sweet relief.

Giving makes living more loving.

(Eric F. Sumnicht)

Sumnicht (1990), said he wrote the above poem “as his expression of the ideals that grace the student nursing experience with sapience and life.”(p.31). In doing so, he captured the very essence of what it was like for me as a nursing student.

In my diary from which I have extracted the various anecdotes, I read of painful and frustrating days. I remembered thinking that I was just wasting my time. I believed I would never get the simplest procedure right. But then, peeking through the clouds of despair are descriptions of poignant moments such as the birth of a baby, or when my patient survived a cardiac/respiratory arrest, was given a new lease on life, and was so happy to be alive that his hopes, joy and aspirations enveloped my whole being and thoughts for weeks. It gave me hope. Then again I read of feeling frustrated when I felt helpless and unable to reach and help my patient. I received the biggest surprize at the end of the shift, the ultimate compliment a nurse could ever wish for – the patient thanks for understanding and just being there for him. I felt good again about my choice of nursing.

The journey to becoming a self-confident student nurse has not been a smooth one. The process was not easy as the road was long, winding and rocky. One reason being that “beginning nursing students enter nursing with an idealism most of us have forgotten, yet with a fear of being expected to know what to do before they have ever given themselves a chance to learn. Relearning certain skills previously learned (e.g. bedmaking), can result in lack of confidence and increased anxiety……causing the student to have mixed feelings about working in the clinical area” (Hayes-Christiansen, 1988, p. 14-15).

It is not unusual to be excited and scared at the same time. How could this be? Williams (1993), explained that the tension between excitement about the prospect of becoming a nurse on one hand is tempered with numerous concerns and conflicting emotions. Many beginning nursing students feel overwhelmed with the prospect of all there is to learn and intimidated by the awesome responsibility that goes with being a nurse. These feelings may lead to questions such as: “Will I make it?” “Do I have enough self-confidence?” (p. 178). Williams arguments are correct. That was exactly how I remember feeling.

What is Self-confidence?

But in reality, what is clinical self-confidence? Is it a feeling or knowing about one’s capabilities? Does one become self-confident once he/she has overcome his shyness, naivity, and self-consciousness? Can one learn to be self-confident through observation? Or must there be a certain amount of practice involved in its development? Is there truly a time when an individual does not possess any self-confidence at all? If yes, then how does that person develop self-confidence? Is self-confidence related to competence? If so, how?

The definition of self-confidence which is most familiar to me and which speaks to my experience is that of Davidhizar (1991). She defines self-confidence:

as a feeling that can be created and rationally controlled. Self-confidence is the feeling that you know how to do something, that you have the power to make things happen, and that your efforts will be successful. She states it comes from knowing that knowledge, skill, and experience will result in success – self-confidence being a key ingredient for success. Self-confidence is always related to performance, that is, self-confidence increases the likelihood of a task being accomplished well. It enables the individual to make the most of the ability he/she has (p.105).

Self-esteem and Self-confidence

“Self-confidence” and “self-esteem” have been used interchangebly by many writers. The implication being that if one has self-confidence, then he/she must also possess high self-esteem. Is this linking appropriate? Is self-confidence and self-esteem the same? If they are not, then how are they related? According to Grainger (1990), self-esteem is an intrinsic feeling of self-worth and self-respect (p.12). It evolves developmentally from the reflected appraisals of significant others. Self-confidence, on the other hand, depends not on others but on you (Davidhizar, 1991, pp.105-106).

It would appear that with self-esteem one experiences an I-You sort of reciprocity? For example: You, (my teacher) say I am good and I have done a great job with my dressing change. Actually, if you have been very consistent in recognizing my achievements and giving me ongoing positive feedback, I will feel a sense of satisfaction which comes from hours of preparation culminating in this particular achievement. At the end of each day I will feel more fulfilled and may feel more comfortable trying out other new skills. Your feedback has boosted my morale (self-esteem). At the end of the rotation I may be able to enhance your self-esteem by giving positive feedback about your performance as my teacher on the instructor appraisal form.

Competence and Self-confidence

Self-confidence is exhibited when the student completed the dressing change and “felt/knew” that he/she had done well. There was no doubt about the outcome of the performance. No external feedback was necessary to convince the student that the skill was executed perfectly. He/she just knew.

Nursing writers such as Bergman & Gaitskill (1990); Boyer, (1990); Knox & Mogan, (1987); Nehring, (1990); and del Bueno, et al, (1990) all link the skill, knowledge and ability necessary to actually perform a procedure such as a dressing change well to something other than self-confidence. This other component is referred to as competence. Like self-esteem, competence is in some way connected to self-confidence. Grainger, (1990), believes that most people reIate self-confidence to competence or ability to perform, based on actual skill and knowledge (p.12). “To be competent indicates the possession of organization, relevant abilities, insights, and knowledge in a certain field or domain by an individual or individuals” (Gentzler, 1987, p.40; Gaut 1986, p.78; Cox, 1988, p. 25). Hence, with increasing knowledge, skill, practice and experience one gradually begins to develop competence. Benner, (1984) describes this growth process as moving from a novice stage to that of the expert (pp. 20-31).

Incompetence and Self-confidence

The monitor registered a Type 1 deceleration in the fetal heart rate. I began to worry. I have a placenta previa (placenta cover the cervix) and I am not allowed to go into labor.

“Would you please call my doctor”, I calmly requested of the nurse sitting by the monitor. She was talking gingerly to a friend who stopped by “to see how she was doing.”

“I will give you oxygen at 10 liters by mask and you can lay on the other side”, she responded and continued to converse with her friend. From experience with this pregnancy, I knew that “laying on the left side” would lead to greater compression of the placenta, thus cutting off blood supply to the fetus. I half turned just to demonstrate my point. The monitor registered a Type 2 deceleration in the heart rate. I start to feel panicky but I do not want her to know I am a registered nurse and a midwife as well. She did not notice the change so I turned onto my back and again requested she call the doctor right away. She gave me a dirty look and ignored me. I removed the leads and called the doctor myself. Within ten minutes of that call my child was delivered in mild distress by cesarian section. Another fifteen minutes and he may have died.

Investigation into the above true incident found that the nurse in question possess a high self-confidence level but lacked competence in interpreting the fetal monitor strips. This knowledge and skill was compulsory for anyone assigned to a high risk obstetrical unit. She was a confident nurse who was incompetent in monitoring a woman with a high risk pregnancy. The question is: “How could a self-confident individual be identified as being incompetent?” The two concepts seemed incompatible.

We are reminded that even when the ability to perform is lacking (competence), it is still possible to feel self-confident. This is because self-confidence is unique and personal to the individual. It is possible, however, to have unrealistic self-confidence or over-confidence which may masquerade as self-confidence. This can become very detrimental and unsafe. Overconfident individuals may be less likely to evaluate their own actions, and therefore less likely to learn from their experience. It can lead to to a false sense of security, leading to premature closure and non-perception of alternatives. In nursing this could lead to errors which may cause patient harm (Baumann, Deber, & Thompson 1991, p.167; and Davidhizar, 1991, p.106). Acquisition of knowledge and skills necessary for the job combined with a healthy sense of self-confidence will correct the situation.

Competent and Non-confident

I knew I could make the patient understand the discharge teaching. He speaks a dialect with which I was familiar, I taught it in the public school for a couple of years. But I was a first year student on the ward for the third day of my first clinical rotation in nursing. The unsuccessful teacher was an experienced nurse. The prevailing culture and attitude dictated that I was not yet capable of functioning at the level where I could do discharge teaching well. I, on the other hand, did not have the self-confidence to intervene in the situation even though I was quite competent. Instead, offering to escort the patient to the discharge office alone gave me a chance to give the necessary explanations in the patient’s dialect without anyone present to object.

The “feeling” of knowing and not being allowed to do is very claustrophobic. Yet that feeling must be controlled for the novice until the time is right. It is usually “foolish to rush in where angels fear to tread”. It is important to be perceived as being somewhat competent before attempting to reveal your potential capability. Professional cultural boundaries should never be ignored by novices. The presence of competence and lack of self-confidence in a nurse could be as detrimental to the patient as being over-confident and incompetent. Without each being present in the individual in the correct proportion, mistakes could be made.

Competent and Self-confident

Documentation in my diary has moved to another time dimension in my nursing experience. It is twelve weeks into the journey and I seem to be happier and less burdened with uncertainties. I wondered why?

It was time for daily patient rounds with the doctors. The Chief of Medicine comes up three times weekly. He is usually condescending to the nurses except to Sister Han. Both Sister Han and I were assigned to “rounds” today and she was off the unit. I could not keep the “Chief” waiting. He looked at me as I picked up the kardex and asked him with which patient he would like to start “It is Junior Han doing ward rounds today,” he said contemptuously leaning against the nursing station. The medical residents and interns snickered. I ignored him and asked instead where he would like to begin his rounds. I reminded him that we were very busy. “A clone, ” he said. “Even when she (referring to Sister Han) is not here she is here.” I smiled inwardly. He led the way to cubicle one with the dangerously patients. “Tell me about him,” he commanded throwing his head back as if to dare me to know enough to relate adequate information about the most complex patient and medical condition on the ward. Mr. K. had his bone scan done late yesterday but the results are not back. His vital signs have stabilized but his potassium levels keep going up. They are 4.8 mmol today, up from 3.9 yesterday, etc., etc. With each patient I noticed the “Chief” became quieter and less inclined to “quiz.” His attempt to make me appear less knowledgeable and confident than I was did not work. I was truly ‘Junior Han’. She had been an excellent role-model. I felt proud of myself.

I finished the rounds. ‘Thank you nurse.” The ‘Chief’ stared at me momentarily as if to say “you are good”. He did not have to say it. I already knew. Sister Han returned to the ward and accompanied him to the door. She came back beaming. “Whatever you did today must have been superb. He couldn’t stop talking about how professional you were.” I thanked her. In my heart I knew I was where I wanted to be. I had worked hard for this day and deserved to be recognized. I was not only becoming competent but self-confident as well. Doing rounds with the Chief was one of the most anxiety producing event for me, but I survived.

Twelve weeks into the clinical experience I kept writing that “I knew I could do it. I knew I did well”. Was it not only yesterday when I felt both non-confident and incompetent. I did not know whether I could or would ever be able to be a nurse. I did not have the knowledge, skills or experience to be competent. I was afraid to speak, walk or eat. I was so obsessed with myself and nursing procedures that I could not see beyond the bedmaking or the injection I had to give. I can remember the times when I did “not quite get things right.” Yet, everything I do now all seem to be related – is a whole. I can no longer separate the parts into entities. It would be difficult for me to do so. It seems as if I have developed a “knowing how” to act. Somehow the theories have become integrated in my personal knowing and being, has become a more “embodied” form of nursing intelligence (Benner, & Wrubel, 1989, p. 43).

There has to be some explanation for this metamorphosis. It is still a bit fuzzy in my mind but my diary entries for the first four weeks document the foreigness of nursing skills and procedures. I kept saying that the nurses were ignoring procedural rules but I stuck to them. Benner (1984) says this behavior and way of thinking is typical at the novice stage in nursing (p.21). She suggests that as the novice becomes more knowledgeable, competent and self-confident, factors such naviety, shyness and self-consciousness which may affect learning disappear as the nurse began to view patient care more holistically (pp. 21-38). At week nine according to my diary, I debrided a new burn wound and inserted a foley catheter on the patient without listing the steps and my concerns of failure. Big gap? Actually, after week six procedural concerns and anxiety related to same disappeared from my diary except when the skill was new. Could practice contribute to this?

Practice and Self-confidence

Practice? Does it have an impact on the way of thinking and relating in nursing? Polanyi (1969) said, “we must discover the right feel of a skillful feat for ourselves” (p. 126). It is through practice that we give and receive knowledge. Noddings, (1984), viewed clinical practice it this way:

students must be immersed in situations that continualy call forth the desire for competence; that is, educational situations must be so designed that students acquire knowledge and skills self-organized into systems of increasing power. What has been learned must be repeatedly called forth in situations of greater and more intricate complexity (p.24).

Benner (1985) confirms that practice is important in the development of self-confidence and competence, “as the development of clinical knowledge cannot occur without practical experience” (p. 43).

Role-modelling

Acquiring clinical knowledge and competence is made easier by the familiar. One observes and understands. A feeling of comfort develops. A feeling of “wanting to do” began to take root. Participation and performance of skills follow with gradual increase in proficiency. The growth process is enhanced by the presence of a mentor or supporter who may be an instructor or a buddy nurse. The presence of a supportive individual capable of role-modelling appropriate nursing behaviors, helps the student to think without the crowding in of anxiety from the unknown. Students see themselves in the person being the role-model and by observing gets to know his/herself a little more each day. For the “self we learn about and discover is every self: It is universal – the human self” (Watson, 1988, p.59). The relationship maybe “….intensely experienced…The relation is a life experience that has significance in and of itself (van Manen, 1992, p. 9).

Our relation to a real teacher-someone in whose presence we experience a heightened sense of self and a real growth and personal development-is possibly more profound and more consequential than the experience of relations of friendship, love, and so forth” (van Manen, 1992, p.9).

I am inherently better at medical nursing than any other nursing specializations, although I have spent many more years working in those areas. I attribute this to a type of “embodied knowledge” acquired from my clinical practice on Ward Four. I just seem to intuitively know what to do and say. Sometimes I smile to myself when I repeat some phrase Sister Han used several years ago. Where did that come from? What made me remember that phrase? How come I can remember that phrase/comment and not something I learned or read yesterday? This is because relational ties are personal and transcends time and place. I learned many theories that explained what Sister Han was doing with me as a student nurse, but it is not the theorists that I feel I am emulating or quoting when I speak to my students, it is Sister Han.

Completely Non-confident?

Is it possible to be completely non-confident? I doubt that. There must always be a certain degree of “knowing” which is not articulated due to fear or low self-esteem. In such cases, low self-confidence according to Davidhizar (1991), can be boosted by evaluating possible deficits in knowledge, skill and experience. Such deficits should be corrected. It is important to know the student role and accept that part of that role is to fill in gaps in knowledge and skill and realizing that self-confidence can also be based on potential to learn. Self-confidence can develop when one learns to cope with stress and use their support system” (pp.107-108).

As nurse educators, perhaps we should try and see the clinical experience from the students’ perspectives. We need to develop greater sensitivity and understanding of the students plight. Williams (1991) states that, “it is about time nursing education embrace a more caring curriculum with the emphasis on providing more humanistic approaches to instruction……..If nursing faculty could anticipate the concerns of their entering students, they could institute more meaningful interventions that would directly address those concerns. High levels of student stress, which interfere with learning and subsequent success and satisfaction, may be avoided through the initiation of preventive measures” (pp. 178 & 183).

van Manen (1991) agrees with Williams when he said that “tact should rule praxis (defined as “action full of thought, thought full of action). Tact rules practice, although tact cannot be reduced to rules. Tact demands a delicate discipline. Tact requires that one can “read’ or interpret social situations for what actions or words are appropriate. Tact requires that one know how a situation is experienced by the other person”(p. 147). Whether we call what is needed to help nursing students develop clinical self-confidence caring or tact – it is definitely necessary.

The Future

The most satisfying aspect of rereading my diary was to find out that previous successes exceeded my failures. Time really heals and gives a new and better view. It is now easier to practice positive self-talk. I no longer fear to risk and my anxiety has been reduced through good time management and learning to enjoy one day at a time. I am now a proud self-confident nurse.

It has been a long journey though and I am still learning. The possibilities are endless. Expanding and increased in complexity of knowledge in nursing will provide the necessary tensions for me to continue to learn and grow in my self-confidence. I treasure the time spent re(view) ing my diary. It was good to look back, for by so doing I can chart my past and present, but only the future – tomorrow that really matters.

References

Baumann, A.O., Deber, R.B., & Thompson, G.G. (1991). Overconfidence among physicians and nurses: The ‘micro-certainty, macro-certainty’ phenomenon. Journal of Social Science and Medicine, 32 (2), 167-174.

Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley.

Benner, P. (1985). Quality of life: A phenomenological perspective on explanation, prediction, and understanding in nursing science. Advanced Nursing Science, 8 (1), 1-14.

Benner, P. & Wrubel, J. (1989). The primacy of caring. Menlo Park, CA: Addison-Wesley.

Bergman, K., & Gaitskill, T. (1990). Faculty and student perceptions of effective clinical teachers: An extension study. Journal of Professional Nursing, 6 (1), 33-44.

Boyer, E.L. (1990). Scholarship reconsidered: Priorities for the professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching.

Cox, K. (1988). What is included in clinical competence? The Medical Journal of Australia, 148, 25-27.

Davidhizar, Ruth. (1991). Ten strategies for increasing your self-confidence. Journal of NSNA/Imprint, (September/October), 105-108.

del Bueno, D.J., Griffin, L.R., Burke, S.M., & Foley, M.A. (1990). The clinical teacher: A critical link in competence development. Journal of Nursing Staff Development, 6 (3), 135-138.

Gaut, N. (1986). Evaluating caring competencies in nursing practice. Topics in Clinical Nursing, 8 (2), 77-83.

Gentzler, Y. (1987). A conceptualiization of competence: Constructs or professional development. Journal of Home Economics, 79 (4),39-42.

Grainger, Ruth Dailey. (1990). Self-confidence: A feeling you can create. American Journal of Nursing, 90 (10), 12.

Hayes-Christiansen, C.V. (1988). The beginning student: A faculty challenge. Nurse Educator, 13 (1), 14-15.

Heidegger, M. (1971). On the way to language. ( P. Hertz, Trans.). New York: Harper and Row. (Original work published in 1959).

Knox, J.E., & Mogan, J. (1987). Characteristics of ‘best’ and ‘worst’ clinical teachers as perceived by university nursing faculty and students. Journal of Advanced Nursing, 12, 331-337.

Lakoff, G. & Johnston, M. (1980). Metaphors we live by. Chicago: The University of Chicago Press.

Nehring, V. (1990). Nursing clinical teacher effectiveness inventory: A replication study of the characteristics of ‘best’ and ‘worst’ clinical teachers as perceived by nursing faculty and students. Journal of Advanced Nursing, 15 (8), 934-940.

Noddings, N. (1984). Competence in teaching: A linguistic analysis. In E. Short (Ed.), Competence: Inquiries into its meaning and acquisition in educational settings, (pp. 17-28). Lanham, MD: University Press of America.

Polanyi, M. (1969). Knowing and being: Essays by Michael Polanyi. In M. Grene (Ed.). Chicago: The University of Chicago Press.

Sumnicht, Eric F. (1990). Said another way: We are. Nursing Forum, 25 (4), 31-32.

van Manen, M. (1992). Pedagogy, virtue, and narrative identity in teaching. Class Handout. Edmonton: University of Alberta.

van Manen, M. (1991). The tact of teaching. New York: State University of New York Press.

Watson, J. (1988). Human caring as moral context for nursing education. Nursing & Health Care, 9 (1), 423-425).

Williams, Rhea P. (1993). The concerns of beginning nursing students. Journal of Nursing and Health Care, 14 (4), 178-184.