Australasian Emergency Nursing Journal (2014) 17, 91—97

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RESEARCH PAPER

Confidence and impact on clinicaldecision-making and behaviour in theemergency department

Margaret Fry, NP, BASci, MEd, PhD a,∗Casimir MacGregor, BA (Hons), MA, DPH, PhD b

a Nursing and Midwifery Directorate, Northern Sydney Local Health District, Royal North Shore Hospital,St Leonards, NSW 2065, Australiab Faculty of Health, University of Technology, Sydney, Jones Street, Broadway, NSW 2007, Australia

Received 11 December 2013; received in revised form 25 March 2014; accepted 28 March 2014

KEYWORDSConfidence;Self-efficacy;Extended practice;Emergency care;Clinical initiativenurse

SummaryBackground: Clinical competency is underpinned by the self-confidence of nurses to act. Confi-dence may be critical to the understanding of how practice choices are made and not made bynurses in extended practice roles. The aim of this study was to explore how emergency nursesperceived (i) self-confidence in undertaking an extended practice role; and (ii) the factorsassociated with confidence within clinical practice.Methods: A multicentred qualitative exploratory study. Fifty two participants were includedin the study. Across three sites 36 (28 females, 8 males) face to face interviews and 16 non-participant observations (13 females, 3 males) were conducted.Results: The study generated new knowledge about self-confidence, self-efficacy and the rolethat contextual factors have in regulating behaviour. It shows that self-confidence is an impor-tant resource that sustains a nurse’s ability to problem solve and to critically think in order todetermine how best to act.Conclusions: The development of self-confidence is important if we are to promote effective

clinical decision-making. Education programmes need to identify strategies that can promoteand support the development of self-confidence and resilience.© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

∗ Corresponding author. Tel.: +61 0299264693/0417985214; fax: +61 02E-mail addresses: margaret.fry@health.nsw.gov.au, margaretfry1@gm

casimir.macgregor@uts.edu.au (C. MacGregor).

http://dx.doi.org/10.1016/j.aenj.2014.03.0031574-6267/© 2014 College of Emergency Nursing Australasia Ltd. Publish

95144835.ail.com, margaret.fry@uts.edu.au (M. Fry),

ed by Elsevier Ltd. All rights reserved.

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What is known

• Confidence is critical to clinical decision making andunderstanding how practice choices are made or notmade by clinicians.

• Understanding confidence may assist with bettercomprehension of how nurses experience and under-take new clinical roles.

• There is little research to date exploring the utility ofself-confidence within the emergency department,especially in relation to extended practice roles.

What this paper adds?

• Individual behaviour and social context are impor-tant factors in regulating clinical decision makingand practice.

• Confidence is an important resource that sustains aclinician’s ability to problem solve and to determinehow best to act.

• The development of confidence is important if we areto promote and support the development of selfcon-fidence and resilience in clinical practice.

ntroduction

he New South Wales Clinical Initiative Nurse (CIN) role wasntroduced as an extended practice role that enabled expertmergency nurses to initiate diagnostic tests, treat and man-ge a range of patient conditions.1—3 The extended nurseole aimed to meet the needs of waiting patients, achieveimely and appropriate patient care with other emergencyepartment team members and provide coordinated care.1

xtended practice policy guidelines enabled nurses to workithin a broader scope of practice.4

The CIN scope of practice is between that of a RN andhe regulated Australian Nurse Practitioner (NP) role.5

spects of the CIN role have similarities with roles, suchs the Clinical Nurse Specialist (CNS) in the USA, Emer-ency Nurse Practitioner (ENP) in Britain or the Australianlinical Nurse Consultant (CNC).6 The CIN role also sharesimilarities to other international roles such as the rapidssessment nurse, fast track nurse, stat nurse and advancedractice nurse roles seen in other Australian states, Newealand and Canada.6,7

Clinical decision-making by expert nurses is a complexrocess set within dynamic contexts and comprises a diversenowledge base and experience.8,9 Within practice a dis-inction is typically made between novice and expert. Thexpert is generally understood to have superior decision-aking skills that draw on a deep reservoir of knowledge

nd experience.8 However, within clinical settings cliniciansave varying degrees of transition between more and lessxperience and expertise.8

A number of personal capabilities are present in decision-aking that enable nurses to make effective clinicalecisions. Personal capabilities are defined by the notionf self-efficacy or a person’s ability to organise and execute

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M. Fry, C. MacGregor

he action required for designated types of performances.10

elf-efficacy is an individual’s confidence in their abil-ty to successfully accomplish a given task or activity.11

andura10,11 has stated that self-efficacy is more than aelief in ability level; it orchestrates the motivation nec-ssary to conduct behaviour. Thus self-efficacy assists toetermine what activities nurses engage in and the degreef effort they have for pursuing the task and their resiliencen the face of adversity. An individual’s confidence leveleflects personal self-efficacy and sustains the individual’serception of the ability to successfully accomplish a par-icular task or activity.12 Self-confidence also influences aurse’s ability to undertake tasks appropriately, effectivelynd brings critical thinking into clinical practice.

To date there is little research that has explored a nurse’self-confidence when undertaking extended practice roles.onfidence may be critical to the understanding of howractice choices are made or not-made in everyday practice.nderstanding confidence may also assist with better com-rehension of how nurses experience and undertake newlinical roles. To date there has been minimal researchxploring the utility of self-confidence within complex andhanging environments, such as emergency departmentsED).

im

he aim of this study was to explore the emergency nurseserceived (i) confidence in undertaking extended practiceoles; and (ii) the factors associated with confidence, self-fficacy and role behaviour within clinical practice.

ethods

his was a multicentred qualitative exploratory study.

tudy sites and sample

he study was undertaken across three EDs and included aetropolitan university tertiary referral hospital, a regional

eferral hospital and a regional hospital. A purposeful sam-le of nurses that undertake the CIN role was sought. Thenclusion criteria included CIN+ who had two years emer-ency experience and had worked in the role for more thanne year.

nterviews

n 18-item semi-structured interview tool was developednd comprised open-ended questions that assisted to directhe nurse’s thoughts towards role activities and behaviour.ive items measured confidence (self-efficacy). Confidenceas rated on a scale that ranged from 1 (uncertain) to0 (extremely confident). The self-efficacy measure iden-ified if nurses felt capable of performing in the role (the

um of affirmative responses is the magnitude of the self-onfidence). The sum of confidence ratings was the strengthf the self-efficacy. The interviews were audio taped to min-mise distraction and encouraged the free flow of thought.

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Confidence and clinical practice

Non-participant observationNon-participant observations were also conducted todevelop an understanding of how nurse’s experience andmake sense of practice and this was triangulated withinterview data. During the collection of observationaldata participant confidentiality and privacy was maintainedand de-identified for transcription. Each individual non-participant observation session was negotiated with theparticipant.

Data analysis

Confidence measures were analysed using descriptive statis-tics, frequencies and correlation statistics using SPSSv.19. Interview data were analysed and organised the-matically, and stored and managed using NVivoTM v9.2.Gibbs’ framework guided thematic analysis and included:(1) transcription and familiarisation; (2) code building; (3)dis/confirmatory theme development; and (4) data con-solidation and interpretation.13 The authors discussed andreviewed the emerging codes and themes.

Research ethics statementThis paper reports the findings of a research study thatadhered to the National Statement on the Conduct of HumanResearch by the Australian National Health and MedicalResearch Council, and has been approved by a local HumanResearch Ethics Committee (reference number HE 10/421).

Results

Across the three sites 36 face to face interviews were con-ducted. Of those interviewed 28 (78%) were females and themean age of participants was 39 years (SD 11.3 years). ED(mean 12.2 years; SD 7.8 years) and CIN (5.8 years; (SD 2.8years) experience was extensive.

Across three sites 16 participant observation sessionswere conducted. Each hospital had 5 non-participant obser-vation sessions conducted which lasted between 4 and 5 hfor a total of 65 h. From the interviews and observationsa number of themes emerged relating to self-confidence,self-efficacy and decision-making. The themes included:confidence to act; the influence of contextual factors onself-confidence; and self-confidence in role tasks.

Confidence to act

Self-confidence and self-efficacy supported the nurses’ability to act. Nurses identified how self-confidence and self-efficacy were intimately aligned with practice. The strongquantitative ranking of self-confidence, using a Likert scale,was widely supported in the everyday talk of nurses. Therole was perceived by all participants as an autonomousindependent role.

I think it is quite autonomous, you know so you do getsatisfaction that you feel you are doing something forpeople out there that is making a difference. Interview23.

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The majority of nurses spoke with confidence in caring foratients and undertaking extended practices. All the sitesequired the role to be undertaken by experienced nursesnd it was the experience of working in the ED that assistedo develop self-confidence.

I think once you get to the CIN role. . .the way the depart-ment works seems to fall into place, and that’s when youfeel you have gotten to a more senior level. Interview 27.

The majority of nurses reported feeling extremely con-dent with the many aspects of the CIN role. Interview 15choes the voices of many ‘Fine, you know, I’d be a tenhere. I can do it and I’m confident to do it’. In relation tohe activities of the role many nurses perceived that theyere extremely confident in the activities required for the

ole ‘I think I would have to say I would be a 9, because inerms of the practical skills of dealing with people, taking

history I feel quite confident’ Interview 29. Confidenceurfaced in the course of everyday work for example, whenhe nurse stepped in to help the medical practitioner havingifficulty with a procedure.

Doctor — tried twice to cannulate. . .. CIN stepped in —took over and cannulated (a teenager — brought in bytriage). CIN starts IV infusion pump — judges rate. Goesand talks to Doctor — re adjusts rate. Observation 1.

Part of the role required nurses to initiate a range of diag-ostic and interventional activities for waiting patients. Allurses perceived high self-confidence which sustained theirbility to self-direct nurse initiated activities. As Intervie-ee 23 illustrates ‘I would probably be quite confident to

nitiate the skills’.For the majority of nurses self-confidence was perceived

y many as the reason they were more frequently rosterednto the role. Interviewee 34 explained that self-confidencend the ability to act in the role resulted in more frequentllocation to it ‘that’s why they put you in that CIN role.hey know that you can do it so, you do it’.

Many nurses explained that their self-confidence hadrown in the extended practice role with the repetitivenessnd frequency of role tasks. As Interviewee 19 describes:

Five years ago when I first started it was. . . I was mod-erately comfortable, and as the years have progressed Ihave become more confident [as a CIN].

Nurses reported high levels of self-confidence andere perceived to be sustained by experience, knowledgend skills. Self-confidence enabled adaptation within thextended practice role and supported the ability to initi-te and adapt to the care needs of waiting patients. Morepecifically, nurses perceived that independence and auton-my were embedded within the role unlike other emergencyursing roles.

he influence of contextual factors onelf-confidence

any nurses described contextual factors that could supportr mitigate self-confidence within the extended practiceole. Contextual factors described by nurses included:

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olicies and guidelines; overcrowding and patient acuity;nd infrequency exposure to tasks.

The majority of nurses described feeling more confidents a result of the availability of extended practice policies.olicy guidelines were perceived to provide nurses with theapacity to act and to bolster and sustain self-confidence.

Confident yeah cause you’ve got the policy to back youup, this morning, I haven’t done a catheter out in Con-sults for a while, for urinary retention, and the triagenurse said that you can’t do it and I thought no I’m sureyou can. I found the policy, so I did it. You know, becauseeverything is black and white it’s pretty hard not to feelconfident. Interview 22.

The nurses regularly spoke of the policies and how theyffered a safer practice boundary. Policies were perceiveds offering a layer of protection, medico-legally thattrengthened self-confidence and motivated nurses to ini-iate interventions and treatment for the range of patientsn the waiting room.

Well we are quite bound by the CIN role, of the stand-ing orders they are clearly set out, as long as you meetcriteria you can go right ahead, and if not I just discuss itwith a senior ED doctor to have permission for those whodon’t meet criteria for the standing orders, everyone isvery approachable. Interview 30.

Self-confidence sustained the nurses ability to problemolve and critically think in order to make determine howest to act. In this way self-confidence can motivate a nurseo utilise all available resources to meet a patient’s need.or the majority of participants having ready access to poli-ies assisted to sustain self-confidence and the ability toct.

At times policies were identified as limiting. But the poli-ies were supported and valued by all.

For the past 4 years there had been difficulty, we wereworking all over the ED trying to do clinical initiatives,where it was quite ambiguous, well now it’s waiting roombased. We have had the course which has confirmed andconsolidated all of our knowledge. Great yeah, for allthe protocols that we use. Interview 19.

However, our observations identified a tension betweenospital policies, role expectations and the nurse’s abilityo meet care demands:

Nurse gives update of other patient — describing place-ment of patients. CIN explains ‘patient shuffling’’ —discussing how in-charge nurse may ask where thepatients are, why she hasn’t done some patient obser-vations. Why are patients waiting so long in the WaitingRoom — CIN stressed/annoyed by this. . . CIN sees triage —advises, she is angry with her boss — ‘‘I always say sorry’’but I should say something back like ‘‘are you kidding-I’ve got 12 patients out there’’. Observation 14.

This disjuncture between contextual factors and theurse’s personal feelings was also expressed in other areas.

s participants spoke, of situations, when role policies wereot broad enough to support the actions needed for patients.owever, in these situations, nurses felt confident to oper-te outside the guidelines and use strategies to better

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anage role goals. In these situations knowledge, skill andndependence sustained the nurse’s self-confidence to act.

I have to say that we do overshoot the criteria — I meanit’s acknowledged in the department that we do it. Weare told in a tokenistic fashion. . . that we are not to do itbut really. . .say for instance — a dehydrating, vomitingyoung person. You know they need a stat litre of fluidand that’s not within our guidelines, but we’ll do it. . .

Interview 17.

Some nurses described other contextual factors thatould diminish self-confidence. Two contextual factors thatroded self-confidence were high patient numbers and acu-ty in the waiting room.

I guess it’s just our patient numbers and I guess there areno beds available. So, as the CIN, I work 12 hour shiftsby the time I finish I could have up to 17 waiting roompatients waiting for a bed. Interview 23.

Loss of control or a sense of not coping could erode self-onfidence and undermine the ability to achieve role goals.t times a nurse’s sense of doubt about their ability to man-ge their workload and role expectations would surface.

CIN trying to remember different staffrequests/discussions of a variety of patients. Toomuch work for one nurse. CIN worried about whatwas happening to other patients she couldn’t get tosee/do observations on. . .expresses concern regardingher ability to manage high workload. Observation 12.

At times of high workload environmental factors surfacednd the nurse could experience a lack of self-confidence. Aommon environmental factor was when patient need fellutside of role policies eroding self-confidence to initiatehe desired patient diagnostics, intervention or manage-ent required. In response nurses would seek out medical

taff to support decision-making.

If I’m not confident I usually have a scout round the doc-tors and see who I can go and talk to, and say ‘lookI’m worried about this person, would you be able to seethem’, I have a fairly good rapport with most of the doc-tors, there’s some doctors I wouldn’t go to. Interview2.

A lack of self-confidence created a sense of ‘not coping’r ‘losing control’ for some and could result in nurses seekingo leave the ED environment.

One of my friends today said to me that they are going todo midwifery — a very experienced nurse. Just to escape.Just to get away. They’ve just had enough. Somebodyelse is going to be a bed manager of a private nursinghome. Both are leaving and both said ‘‘I’m burnt out’. Ihave to protect me and my family.’’ Interview 36.

Self-confidence appeared to be a complex construct and

nfluenced by contextual factors and intrinsic structureshat could mitigate these factors. A lack of self-confidencean precipitate burnout, dissatisfaction and compromise theustainability of a workforce.

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Self-confidence in role tasks

Self-confidence enabled nurses to independently practice,initiate patient diagnostic, interventions and make patientmanagement care decisions. When nurses spoke of role tasksthe majority spoke of extreme confidence to undertake therange of extended role tasks. One task echoed by all andspoken about with extreme confidence involved pain man-agement initiatives. In providing analgesia to patients nursesspoke as one. Interviewee 29 describes:

I would probably score myself a 10 there to be honest,in my previous life I was initiating intravenous morphineand monitoring people for its effect, and sometime giv-ing quite substantial doses of it backed up with fluidboluses, so you know I feel quite confident that peopleare well analgesed and safe.

The more frequently a task was undertaken the morelikely nurses would articulate greater self-confidence. How-ever, other tasks could elicit low self-confidence related tothe frequency of task exposure. All nurses explained thatit was a lack of exposure or frequency for undertaking thetask that reduced self-confidence. Some skills mentionedincluded: ‘accessing porta-caths . . . I still hate doing that,but do it under necessity’ Interview 8 and ‘I’m fine witheverything really, I don’t suture that often so that sortof a practice thing. . . But in most things I am confident’Interview 7.

Another contextual factor that could erode self-confidence was medico-legal concerns. Medico-legal con-cerns could diminish the desire to undertake a task. As onenurse described how medico-legal concerns were often inthe back of their minds:

CIN talks about a patient yesterday in Waiting Roomlost consciousness — ‘‘you worry about your registra-tion because he had been there three hours and I hadn’tdone his observations. But what can you do? It’s hard’’.Observation 14.

When nurses operated within policy self-confidence wasenhanced, although a lack of exposure to certain taskscould undermine or erode self-confidence levels. Whenself-confidence was eroded participants avoided the activ-ities and tasks. Behaviour was perceived by participants tochange as nurses decided to avoid the waiting room and pur-sue other activities in which self-confidence was sustained.

They haven’t got the confidence even though they’resenior staff members — to go and actually speak to some-one and pull someone out of a large group. So I thinkthose people are hindering the CIN process because theygo and find something else to do. They go and help some-one in the back . . . which is a good help, but it’s notthe role. . .they won’t step into the waiting room. Inter-view 15.

When self-confidence was undermined task avoidancewas noted to occur. Generally self-confidence was reported

as high, although specific extended practice tasks couldcause self-confidence to fluctuate. Conversely, task repe-tition could build self-confidence and enhance knowledgeand learning.

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iscussion

he study provided a rich description of the confidenceerceived by emergency nurses when undertaking anxtended practice role. The findings suggest that confi-ence, which is a related to self-efficacy, enabled nurses touccessfully complete role tasks. The findings supported thextended practice role, but affirmed how contextual fac-ors can impede nurse self-confidence and the contributionurses make to emergency services.

Our data suggested that self-confidence and ultimatelyelf-efficacy is tied to individual behaviour and the socialontext. Theories of self-efficacy place emphasis on an indi-idual’s belief and perception of agency and control. Gecas14

ses the notions ‘‘internal’’ and ‘‘external’’ locus of con-rol as generalised expectations that individuals develop inelation to their environment. The distinction between the‘internal’’ and ‘‘external’’ is also helpful for our studyn order to illuminate how self-confidence influences self-fficacy and should not be reduced to individual psychology,ut concern the wider social environment.

The internal locus of control has been further refinedo include a distinction between ‘‘personal control’’ (one’serceived sense of control) and ‘‘control ideology’’ (one’sudgement of how much control people in general have overheir situations).14 The nurses in our study demonstrated

strong sense of personal control and control ideology. Ase identified their high self-confidence measures expressed

confidence in their knowledge, but also in their abilityo apply that knowledge in clinical interventions such asain management. This strong sense of self-confidence wasmportant as the nurses felt that their confidence was inti-ately tied to their nursing praxis — as their confidence gave

hem the ability to act securely in the extended practiceole.

Bandura11 suggested that in the development of self-fficacy there needs to be a process of self-evaluation.his process of self-evaluation entails the distinctionetween efficacy expectations and outcomes expectations.n efficacy expectation is a belief that an individual canuccessfully perform a particular action and an outcomexpectation is an estimate that a given action will leado a certain outcome.11 What was interesting about theurses’ strong demonstration of an internal locus of controlas that it was defined by experience. The findings suggest

hat extended practice roles need experienced nurses withtrong self-confidence to avoid role dissatisfaction. Further-ore, nurses perceived that they undertook role activitiesith confidence and possessed ability to problem solve andritically reflect on practice while recognising their situa-ional limitations.

The self-confidence expressed by nurses was positivend enabled them to perceive greater role independence.ohn and Schooler have demonstrated that the greaterhe freedom experienced in a position, and the moreomplex and challenging the work, the more likely theorker values their individual freedom and self-directionnd to be intellectually more flexible and to have greater

elf-efficacy.15 The CIN role required nurses to act inde-endently, apply a high level of judgement to practicend was perceived to have a level of autonomy. The studyas also highlighted the importance of self-confidence to

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References

1. Fry M, Borg A, Jackson S, McAlpine A. The advanced clinical

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nurse’s perception to undertake extended practices in challenging environment. While role experience assistedo build self-confidence more regular exposure to infre-uently undertaken skills would assist to improve thebility to act. In this way new nursing roles can beetter supported, and evolution of practice roles can con-inue.

Our study also illustrated how ‘‘external’’ factors, suchs the social context can have a large influence on clin-cal decision making. Participants spoke of contextualactors as having an impact on self-confidence. Reducedelf-confidence influences a nurse’s ability to successfullyomplete role tasks. The re-positioning of the CIN role intohe waiting room, away from acute clinical areas, did noteem to adversely impact on a nurse’ self-confidence, buthis was challenged during periods of patient overcrowding.hen tension surfaced in the waiting room, self-confidenceould diminish and the ability to undertake role tasks suc-essfully reduced.

The study also identified that patient acuity gener-ted negative emotions and led to feelings of not coping.hus uncertainty can lessen self-confidence and reduce aense of control. Strategies to strengthen self-confidencend improve the perception of coping will sustain anddd a safety net for nurses working in extended practiceoles.

Self-confidence is a core aspect of nursing and can influ-nce the choices people make and the behaviour theyursue. Therefore, understanding the relationship of self-fficacy and self-confidence within nursing role behaviourould potentially identify strategies for governments andervice providers to optimise models of care and out-omes, while attracting and retaining sufficient numbers ofppropriately experienced staff. Targeted educational pro-rammes should aim to influence self-confidence therebynhance self-confidence and reduce inconsistencies withinractice.12

However, ‘‘external’’ factors or the social context mayffect self-confidence levels. For example, the use ofnformally chatting with others was used to check decision-aking or to gauge their decisions to decisions others hadade. Larrick noted the social context can have positive or

egative effect for decision-making.16 Some positive influ-nces are that individuals can check for errors, using theenefit of colleagues’ knowledge. But in the ED wherencertainty is ever-present, people could be susceptible toimiting their decision-making, by anchoring their judgmentso others rather than forming their own.16

Our research demonstrated that nurses may have theirelf-confidence challenged, but this allows for the creationf resiliency. Resilience (as a form of self-confidence) alongith self-control, gives a nurse the ability to engage, sup-ort and to learn from challenges, and promote persistencen response to barriers.17 Resilience is an important con-truct for researchers to explore and which enables nurseso thrive in a complex and changing environment.17 Furtherxploration is needed to identify the variables that con-ribute to and sustain resilience and the ongoing ability ofurses to adapt and change within practice. In our chang-ng healthcare setting, resilience may be a useful construct

o better understand and to consider as a goal of clinicalducation.

M. Fry, C. MacGregor

imitations

here were several limitations with the study. The studyarticipants were experienced emergency nurses who mayold different views when compared to those with lessxperience. The sample group was not inclusive of all CINshroughout NSW. While the three study sites were simi-ar to most EDs across Australia, the study was conductedn mixed adult and children hospitals, so little inferencean be extrapolated to roles in dedicated children’s hos-itals. However, the multicenter study maximised findingscross metropolitan and regional sites to capture howurses perceived self-confidence in an extended practiceole.

onclusion

ur study highlights the importance of experience withinursing praxis and the development of self-confidence.he study has generated new knowledge about the impor-ance of self-confidence and self-efficacy in regulatingurse behaviour. Future managers and policy makers cantilise this evidence to develop nursing roles that canontribute towards more consistent, enjoyable and safeealthcare roles. The study assisted to bring to theurface constructs than have the potential to enhancelinical practice roles, the learning experience and opti-ise contextually relevant educational content. If we are

o promote effective clinical decision-making, educationrogrammes need to identify strategies that can pro-ote and support the development of self-confidence and

esilience.

rovenance and conflict of interest

rofessor Fry is an Acting Deputy Editor of the Australasianmergency Nursing Journal but had no role to play in theeer review or editorial decision-making of the paper what-oever. There is no conflict of interest. This paper was notommissioned.

unding

his research was funded by an Early Career Grant from theniversity of Technology, Sydney.

uthors’ contribution

he authorship contributions are as follows: MF: studyesign; MF and CM: data collection, analysis and manuscriptreparation.

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