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Description and Use of the Neuroscience Nursing Self-Efficacy Scale.

Abstract: An instrument for assessing nurses' perceived self-efficacy in implementing a variety of neuroscience nursing tasks was developed. Self-efficacy theory served as the guiding framework. From 1988 to 1998, the instrument was used to assess changes in the perceived self-efficacy of 54 nurses who attended a neuroscience nurse-internship program. Self-efficacy was assessed during clinical orientation, prior to the beginning of the program, and at the end of the program. The results showed that the nurses' confidence in performing a variety of neuroscience nursing skills increased during the 6to 10-month program. The instrument was also useful in helping program directors identify areas in which nurses could benefit most from the program and refine the program to meet the educational needs of the nurses.

Nurses know from experience that a person's confidence in his or her knowledge and ability is highly associated with the likelihood of engaging in a particular behavior For example, a woman who feels confident that she can maintain a diet and exercise regimen is more likely to maintain a healthy lifestyle than a woman who believes that the obstacles to good health are too difficult to overcome. Bandura referred to this sense of confidence as self-efficacy, which he defined as "beliefs in one's capabilities to organize and execute the courses of action required to produce given attainments" (p. 3).[3] Research has shown that individuals who possess high levels of self-efficacy with respect to a given behavior are more apt to attempt to perform that behavior and to persevere toward perfecting their performance. Although nurses have studied self-efficacy for a variety of patient behaviors including labor and delivery,[8,9] infant care,[6,7] and self-management of epilepsy,[4] they have conducted few studies on self-efficacy in performing their own skills.

In one study, Murphy and Kraft developed a scale for measuring self-efficacy in skills required for the performance of perinatal nursing.[10] Their scale included items assessing self-efficacy in three domains: managing a woman during labor and delivery, providing postpartum teaching and support, and performing postpartum technical skills. Psychometric testing of the scale provided evidence to support both its reliability and validity. O'Halloran, Pollock, Gottlieb, and Schwartz measured nurses' self-efficacy in conducting research using a two-item scale.[13] They used the scale to assess the effectiveness of a workshop designed to increase nurses' self-efficacy in conducting research. The investigators found that following the day-long workshop, the nurse participants expressed greater confidence in their abilities both to initiate research and to participate as investigators in research studies.

In another study, Neafsey used objectives from a computer-assisted instruction (CAI) program on pharmacokinetics to develop a pharmacokinetics self-efficacy instrument.[11] She then used the self-report instrument to measure nurses' self-efficacy in performing drug-administering behaviors. The researcher was particularly interested in determining whether participation in the CAI program would increase nurse participants' self-efficacy in administering medications. The program content included mechanism of drug action, drug concentration-time curves, metabolism, distribution, and elimination. Neafsey found that after the program, participants scored higher on the self-efficacy measure.[11] A second study conducted by Neafsey assessed nurses' self-efficacy related to the pharmacokinetics of alcohol use.[12] Again, she noted an increase in self-efficacy following completion of the CAI program.

Although limited in number, these studies demonstrate that self-efficacy in nursing skills is of interest to nurses. These studies also show that self-efficacy can be enhanced by participation in programs designed to improve nursing knowledge and skills. Measuring changes in self-efficacy before and after an educational program also might be a useful approach for evaluating the effectiveness of the program. The idea of capturing self-reported changes in performance following a nursing education program was proposed by Abruzzese[1] in 1982. She developed the RSA (Roberta S. Abruzzese) Model of Evaluation for continuing education programs in nursing. Her model includes the assessment of nurses' perceived proficiency in carrying out skills learned in continuing education programs. Although Abruzzese preferred the term perceived proficiency as a measure of skill, this concept is similar to that of self-efficacy proposed by Bandura.[1,2]

In 1988, a Neuroscience Nurse Internship Program (NNIP) was initiated within the Clinical Center Nursing Department of the National Institutes of Health (NIH) in Bethesda, MD.[14] The RSA model was used to guide the development and implementation of the evaluation of NNIP. As part of the evaluation, an instrument was developed to measure the nurse participants' perceived proficiency in performing a number of skills required in neuroscience nursing. As the program matured, this measure of proficiency was modified to become a measure of perceived self-efficacy in performing neuroscience nursing skills. This article describes the development of this instrument and its use within NNIP. We also suggest ways in which nurses can use this or a similar scale for evaluating the success of continuing education training programs. Understanding how nurses perceive their confidence in performing nursing skills might be very useful in guiding both the development and refinement of education programs and in evaluating nursing performance within the clinical arena.

Overview of the Program

The NNIP is a 6-month program consisting of both course and clinical instruction in the care of persons with nervous system disorders. The program is conducted at the Warren Grant Magnuson Clinical Center, a 314-bed biomedical research hospital in Bethesda, MD, on the campus of NIH. Each year three to six nurses who are new registered nurses or registered nurses with recent clinical experience and interested in beginning a career in neuroscience nursing are admitted to the program. The classroom portion of the program consists of lectures on specific nervous system disorders and on neuroanatomy and neurophysiology. The clinical component consists of direct patient care under the supervision of a staff nurse preceptor. As part of their program, nurse-interns attend neurological and neurosurgical rounds, conferences, and clinical seminars. Two primary objectives of the program are that the nurses learn the knowledge and skills required to provide competent nursing care for patients with nervous system disorders and that they be able to function as members of the biomedical research team at the NIH Clinical Center.

Development of the Scale

In designing the Neuroscience Nursing Self-Efficacy Scale (NNSES), we used nursing diagnoses as the framework for selecting items. Items were developed through a comprehensive literature review of patients with nervous system disorders. This review was augmented by our own experience, the experience of other neuroscience nurses, and the teaching-learning objectives for the newly created NNIP. A total of 54 nursing skills were identified and divided into 10 categories. Nine categories were named according to nursing diagnoses and were labeled alterations in consciousness, mentation, communication, protective mechanisms, mobility, elimination, nutrition, sensation (including pain), and psychological function. The 10th category consisted of skills that could not be classified into one of these nine categories and was called general neuroscience nursing skills.

In the first version of the scale, each of the 54 items was rated on a 5-point scale. Nurses were asked to rate their perceived degree of proficiency for each skill from beginning (1) to proficient (5). After using this format for three classes of nurse-interns, the program developers noted that the range of responses for some skills was very narrow. In an effort to increase the variability of responses, the rating scale was broadened to 11 points. And because some nurse-interns had difficulty with rating their proficiency, the scale was changed to measure perceived level of confidence in performing skills. Thus for classes 4-10, each item was measured on a scale from cannot do at all (0) to sure I can do (10). This change also served to reduce the errors of measurement due to different interpretations of the terms beginning and proficient. In addition, six more items were added, yielding a total of 60 items.

The NNSES can be scored for the total as well as for each category of skills. To compute a total score, responses for each item are added and divided by 60 (the total number of items). Total scores then range from 0 to 10, with higher scores corresponding to higher levels of perceived self-efficacy in performing neuroscience nursing skills. To compute scores for each category of skills, responses to items within each category are summed and divided by the total number of items in that category. Scores for each category range from 0 to 10, with higher scores corresponding to higher levels of perceived self-efficacy for category-specific neuroscience nursing skills.

Use of the NNSES

The NNSES is used to assess the perceived level of confidence of the NNIP nurse-interns in performing neuroscience nursing clinical skills. Nurse-interns are asked to complete the instrument at three time points. The first is shortly after their initial orientation to the Clinical Center nursing department. They complete the instrument a second time at the beginning of course work for the NNIP, which currently begins 1 month after their first day of employment at the Clinical Center. The nurse-interns complete the instrument one final time 6 months later, at the conclusion of NNIP. Information from the three rating sessions is used to determine the degree of change in confidence in nursing skills as perceived by the nurse-interns. It is expected that nurse-interns will gain confidence in the performance of neuroscience nursing skills over the course of the program.

Table 1 presents the overall scores for the nurse-interns in the first 10 classes of NNIP. The first class of nurse-interns did not complete the instrument during their Clinical Center orientation, and nurse-interns in class 8 did not complete the instrument at the initiation of the 6 months of study. Recall that the rating scale for the -first three classes of nurse-interns was a 5-point scale, and the rating scale for the other classes of interns was an 11-point scale. For purposes of comparison, the scores of nurse-interns who completed the first three classes were multiplied by two. Although this solution is not ideal because the scores might be slightly different if these interns had 11 rather than 5 values from which to choose, it is the best solution for comparison purposes.
Table 1. Baseline, Pre-NNIP, and Post-NNIP Means on
the Neuroscience Nursing Self-Efficacy Scale for the 10
Classes of NNIP

 Mean Score in NNSES
 No. of
Class Nurse-interns Baseline Pre-NNIP Post-NNIP

 1 3 -- 5.34 7.72
 2 3 5.58 5.08 9.58
 3 4 5.58 6.52 9.32
 4 8 5.10 4.81 7.23
 5 10 7.12 5.65 6.35
 6 8 5.41 6.09 8.63
 7 5 5.10 6.02 8.96
 8 5 5.42 -- 8.59
 9 5 6.71 6.44 9.21
10 3 6.38 7.23 8.19


As shown in Table 1, the nurse-interns reported a mediocre level of perceived confidence in performing neuroscience nursing skills at the time of their initial employment at the Clinical Center. For about half of the classes, the mean scores increased slightly prior to the initiation of NNIP course work, whereas for the other half the scores decreased slightly. Following NNIP, the mean scores increased considerably for all classes of interns. Although the rating scale (1-5 versus 0-10) and the concept for the first three classes of interns were different (proficiency versus confidence), the trend from low-level to high-level proficiency mirrored that of the other classes of interns who were asked to assess their level of confidence in performing nursing skills.

One exception to the general pattern of scores was class 5. Here the nurse-interns rated their confidence very high at the baseline assessment. Their confidence decreased prior to beginning the NNIP and improved at the end of the program, but not above their baseline level. Given that their baseline score was higher than that of all other classes of nurse-interns, it is possible that these interns overestimated their confidence at baseline. However, the increase from pre-NNIP to post-NNIP scores seems to indicate that the program was useful in enhancing their confidence.

To demonstrate other uses for the results of the assessment, findings for each category on the NNSES from class 7 are presented in Table 2. Space limitations preclude presentation of this information for all classes, so the results from class 7 were selected as an example; the results are similar to those for the other classes of interns. Table 2 presents the results from class 7 by. category across the three time periods in which data were collected. Results show that at the beginning of the program (pre-NNIP means), students rated themselves most confident in performing skills related to mobility (mean = 6.10), nutrition (mean = 6.03), and psychosocial function (mean = 5.68), and least confident in performing skills related to mentation (mean = 2.65), communication (mean = 3.53), and consciousness (mean = 4.50). At the completion of the program (post- NNIP means), students indicated that they believed they were most confident in performing skills related to elimination (mean = 9.60), sensation (mean = 9.53), and general skills (mean = 9.45) and least confident in performing skills related to consciousness (mean = 8.25), nutrition (mean = 8.40), and protective mechanisms (mean = 8.49). Ratings in all 10 categories increased from pre-class to post-class testing; the overall average increase was 3.88 points. The categories with the greatest increase in perceived self-efficacy were mentation, communication, and elimination, whereas self-efficacy increased the least in the categories of nutrition and psychosocial function.
Table 2. Baseline, Pre-NNIP, and Post-NNIP Means and Mean Change
Scores for Major Categories on the Neuroscience Nursing Self-Efficacy
Scale for Class 7

 Mean Score

 Major Categories Baseline Pre-NNIP

1. General skills 5.48 6.58
2. Assessment and skills
 related to consciousness 4.50 5.20
3. Assessment and skills
 related to mentation 2.65 4.50
4. Assessment and skills
 related to communication 3.53 5.73
5. Assessment and skills
 related to protective mechanisms 4.56 5.58
6. Assessment and skills
 related to mobility 6.10 6.70
7. Assessment and skills
 related to elimination 5.08 5.53
8. Assessment and skills
 related to nutrition 6.03 6.30
9. Assessment and skills
 related to sensation 5.30 6.66
10. Assessment and skills
 related to psychosocial function 5.68 6.00

 Mean Score

 Major Categories Post-NNIP Change

1. General skills 9.45 3.97
2. Assessment and skills
 related to consciousness 8.25 3.75
3. Assessment and skills
 related to mentation 8.60 5.95
4. Assessment and skills
 related to communication 9.00 5.47
5. Assessment and skills
 related to protective mechanisms 8.49 3.93
6. Assessment and skills
 related to mobility 9.42 3.32
7. Assessment and skills
 related to elimination 9.60 4.52
8. Assessment and skills
 related to nutrition 8.40 2.37
9. Assessment and skills
 related to sensation 9.53 4.23
10. Assessment and skills
 related to psychosocial function 8.84 3.16


The results of the assessments in confidence can also be viewed item by item. By using results for each of the three assessments--beginning of the orientation, beginning of the program, and end of the program--the mean for each item can be rank-ordered. By rank-ordering individual items, program directors can determine which skills nurse-interns feel most confident in performing at the beginning of a program and whether changes in confidence occur as a result of the program. For example, class 6 nurse-interns felt most confident in performing skin care, transfer, and positioning techniques. At the beginning of orientation, they also were most confident in using restraints and managing persons in pain. At the end of the program, their confidence in performing neuroscience nursing swills had increased such that among the highest rated skills were identifying normal neurological findings, performing a neurological assessment, and performing an assessment of problems related to elimination.

Discussion

The NNSES measures an important outcome of continuing education. Too often nurse educators limit their assessment of continuing education programs to changes in knowledge of participants and their satisfaction with a program. However, in nursing as in other clinical-based professions, changes in behavior of participants as a result of attending a program are important outcomes. Because it is not always easy to measure behavior, a proxy measure of behavior change can be the participant's own assessment of his or her confidence in performing the clinical skills taught in the program.

The NNSES allowed us to examine changes in self-efficacy for nurse-interns in three ways. First, for each class of interns, we were able to examine their overall change in perceived confidence in conducting clinical skills. This assessment helped us determine the overall effectiveness of the program from the participant's point of view. It was expected that nurse-interns who completed the program successfully would feel more confident in caring for patients with complex needs. The NNIP was constructed so that it offered nurse-interns a variety of opportunities to learn about disease and medical, surgical, and nursing procedures and to practice neuroscience nursing procedures under the supervision of a preceptor. An environment was created in which the nurse-interns would feel free to ask questions and seek advice and thus enhance their confidence in providing care to their patients. Data obtained from the NNSES show that this objective was met.

Second, the NNSES was used to examine the confidence of nurses within major categories of neuroscience nursing skills. In several classes, nurse-interns expressed the most confidence in managing patient problems related to nutrition and elimination at the beginning of the program. Because most basic nursing programs include specific information on nutrition and elimination, it is not surprising that a higher level of confidence was noted in these two areas of nursing. On the other hand, most nurses felt less confident in their ability to manage patient problems related to communication and consciousness at the beginning of the program. Again, this might be attributed to basic nursing programs that tend to include less in-depth information about these areas of nursing care. For each class of nurse-interns, information from the NNSES was used to address areas of care in which weaknesses were noted. This information was also used by each individual nurse to provide specific opportunities for improving swills in areas of weakness. At the completion of NNIP, we noted that the nurse-interns' level of confidence had increased in all 10 major categories.

Third, the tool was useful for examining the level of confidence for individual items on the NNSES. In our assessments, items were rank-ordered from those in which the nurse-interns felt most confident to those in which they felt least confident. Information collected at all three time points was used to create a set of results that showed the rank order of items at orientation to the Clinical Center, at the beginning of NNIP, and at the completion of NNIP. Using this format, we determined that at the beginning of the program, nurses were most confident in general nursing swills such as skin care techniques, use of restraints, and transfer techniques. Although these swills are also important for neuroscience nurses and hence are included in the instrument, all nurses learn these skills in their basic program. At the end of the program, a dramatic shift was seen in the confidence level for swills that were considered more neuroscience nursing in nature. Thus at the end of the program, nurse-interns were likely to highly rate such skills as performing a neuroassessment.

Completing the NNSES also gives nurses an opportunity to assess their perceptions about their nursing swills and to compare their confidence in performing each swill. This manner of individual assessment could be used in any training program to help nurses identify their strengths and weaknesses and to develop a plan for further training and study. Similarly, nurses in work settings could use the NNSES to determine their training needs for continuing education. A nurse manager could use information from his or her nursing staff members to plan for continuing education programs that would provide the most interest and benefit to the nursing unit.

Limitations

The NNSES was developed to facilitate evaluation of the confidence of nurse-interns in performing a set of clinical skills. The NNSES also was used to determine whether the program was successful in improving the interns' perceived level of confidence. Because there were so few nurse-interns in each class, we did not conduct traditional tests of reliability and validity in assessing the NNSES, and we did not perform statistical tests to determine whether changes over time were statistically significant. Thus, if researchers were to use the NNSES in a systematic study of self-efficacy related to neuroscience nursing, further testing of the NNSES would be necessary to assess its psychometric properties. Such testing would require a much larger sample size. Samples of both neuroscience nurses and nurses in other specialties would be required to adequately assess the validity of the instrument in measuring self-efficacy related to the performance of neuroscience nursing skills. In addition, if the NNSES were to be used to assess changes in the level of confidence among participants in continuing education programs, it would be interesting to conduct statistical tests of comparison to determine whether the NNSES is sensitive to changes as a result of participation in the program.

Another limitation that nurse educators or administrators need to recognize is that confidence does not always correspond directly with actual skill level. For example, at the beginning of the program, many nurses in NNIP reported a high level of confidence in dealing with problems related to elimination. This confidence no doubt is related to the considerable time spent in basic nursing training on problems associated with elimination. However, elimination problems are quite complex among people with neurological problems. The information is difficult to understand and takes rime to learn. In addition, the interventions for elimination problems for any patient vary depending on the type of nerves and pathways involved in his or her particular condition. Thus, although many nurse-interns were confident in their ability to manage elimination problems at the beginning of the program, their confidence often decreased when they first cared for a person with complex elimination problems. To account for this decrease in confidence, we believe that in working with patients, the nurse-interns became aware of the complexity of the elimination problems and their confidence in managing these problems declined. However, by the end of the program, confidence generally surpassed that of baseline. This shift can be attributed to the presentation of information on elimination and the opportunities for learning how to care for patients with a variety of bowel and bladder problems.

Summary

We have presented a simple approach for assessing nurses' confidence in performing a variety of neuroscience nursing skills. One of the evaluation components built into NNIP was an assessment of the nurse-interns' confidence in performing neuroscience nursing skills. To do this, nurses were queried about their confidence in performing these skills prior to beginning the program, at the start of their classroom and clinical instruction, and again at the end of the program. The instrument can be used to examine overall changes in self-efficacy of nursing skills, self-efficacy related to specific categories of skills, and self-efficacy related to specific nursing care practices. The instrument proved very useful to program directors in helping to identify areas in which nurse-interns could benefit from additional training and to refine the program to ensure all areas were covered adequately. This same approach could be used to assess the outcomes of a program in meeting clinical learning needs. Practicing nurses could also use the NNSES to determine their learning needs and to identify continuing education programs.

Acknowledgment

The authors gratefully and sincerely acknowledge Mark Hallett, MD, clinical director, and the entire staff of the National Institute of Neurological Disorders and Stroke for their generous support of NNIP. The program would not be the success that it is today without the time, talent, and financial underwriting that they so willingly and generously provide from year to year. Their leadership in supporting and advancing the neuroscience nursing body of knowledge is significant and gratefully acknowledged.

Appreciation

The authors thank Deborah L. Price, MSN RN CNRN, clinical nurse educator, Clinical Informatics Services, Clinical Center Nursing Department, National Institutes of Health, for her comprehensive review and editing of this manuscript.

References

[1.] Abruzzese RS: Critical Reviews: Evaluation in Continuing Nursing Education. Southern Regional Education Board, 1982.

[2.] Bandura A: Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice-Hall 1986.

[3.] Bandura A: Self-efficacy: The Exercise of Control. WH Freeman & Company, 1997.

[4.] DiIorio C, Faherty B, Manteuffel B: Self-efficacy and social support in self-management of epilepsy. West J Nurs Res 1992; 14: 292-307.

[5.] DiIorio C, Price ME, Becker J: Evaluation of the Neuroscience Nurse Internship Program: The first decade. J Neurosci Nurs 2001; 33(1): 42-49.

[6.] Froman RD: Response to development and validation of the Perinatal Nursing Self-Efficacy Scale. Scholar Inq Nurs Pract 1993; 7(2): 107-110.

[7.] Frogman RD, Owen SV: Mothers' and nurses' perceptions of infant care skills. Res Nurs Health 1990; 13(4): 247-253.

[8.] Lowe NK: Maternal confidence in coping with labor: A self-efficacy concept. J Obstetr Gynecol Neonatal Nurs 1991; 20: 457-463.

[9.] Lowe NK: Maternal confidence for labor: Development of the Childbirth Self-Efficacy Inventory. Res Nurs Health 1993; 16: 141-149.

[10.] Murphy CA, Kraft LA: Development and validation of the Perinatal Nursing Self-Efficacy Scale. Scholar Inq Nurs Pract 1993; 7(2): 95-106.

[11.] Neafsey PJ: Computer-assisted instruction for home study: A new venture for continuing education programs in nursing. J Contin Educ Nuts 1997; 28(4): 164-172, 190-191.

[12.] Neafsey PJ: Immediate and enduring changes in knowledge and self-efficacy in APNs following computer-assisted home study of The Pharmacology of Alcohol. J Contin Educ Nuts 1998; 29(4): 173-181.

[13.] O'Halloran VE, Pollock SE, Gottlieb T, Schwartz F: Improving self-efficacy in nursing research. Clin Nurse Spec 1996; 10(2): 83-87.

[14.] Price ME, DiIorio C, Becket J: The Neuroscience Nurse Internship Program: The description. J Neurosci Nurs 2000; 32(6): 318-323.

Questions or comments about this article may be directed to: Colleen DiIorio, PhD RN FAAN, Emory University, 1518 Clifton Road, Atlanta, GA 30322. Dr. DiIorio is a professor in the Department of Behavioral Sciences and Health Education, Emory University.

Mary Elizabeth Price, MSN RN CNRN, is a clinical nurse specialist in the Critical and Acute Care Patient Service Nursing Department, National Institutes of Health, Bethesda, MD.
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Author:DiIorio, Colleen; Price, Mary Elizabeth
Publication:Journal of Neuroscience Nursing
Date:Jun 1, 2001
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