Self-efficacy, uncertainty and anxiety among nursing graduates in response to licensing test postponement due to the COVID-19 pandemic: A mixed-methods study.

AIM: To examine the relationships between self-efficacy, uncertainty and anxiety among nursing graduates waiting for a mandatory nursing licensing test that was postponed due to the COVID-19 pandemic.
METHODS: A total of 352 graduates of nursing education programs participated in this mixed-methods study. The data were collected using an online questionnaire in June 2020.
RESULTS: The participants demonstrated high uncertainty and anxiety and low self-efficacy towards the ability to succeed in the licensing exam. Graduates, who started working, reported lower uncertainty. Self-efficacy, uncertainty, gender and family status contributed significantly to the explanation of 24% of the variance of the anxiety. The qualitative analysis revealed three themes: (a) emotional distress, cognitive challenge and social implications, (b) consequences for significant others and (c) strengthening of professional values and norms.
CONCLUSIONS: A significant crisis like a pandemic is accompanied by acute cognitive burden and stressful emotional experiences and creates an unconventional situation that requires unusual solutions. Granting a temporary permit for employment as a nurse following the postponement of a licensing test contributed to the ability of nursing graduates to cope with the situation. Policies to deal with similar situations in the future emergencies should be developed and implemented.

INTRODUCTION

The current study focuses on global aspects of nursing education during a health crisis. In this context, we examined the significance and intensity of anxiety, uncertainty and self‐efficacy among nursing graduates waiting for the certification examination, which was postponed indefinitely. The importance of the research in the field of anxiety and uncertainty among health workers is intensified by the current extreme crises in the fields of health, economy, society and climate, which now more than ever demand the existence of a health system based on professional and resilient human resources.

Following the first cases of COVID‐19, on March 2020, significant changes and restrictions were enforced in Israel, and these led to the closure of nursing educational institutions and the initiation of distance learning (MOH, 2020a). The pandemic emerged before nursing students who graduated in February 2020 could take the Israel Mandatory Registered Nurses Certification test (IMRNCT) scheduled for April. Guidelines prohibiting gatherings were issued, and the certification test was postponed indefinitely. About 2000 affected nursing graduates found themselves without a work permit and outside the nursing education system. Besides the economic challenges resulting from the inability to work as a nurse, many graduates reported feelings of uncertainty and fear of the future. In an unusual move by the Nursing Division, the graduates were granted temporary permits to work with the status of registered nurse (Nursing Division, 2020; MOH, 2020b). Most rapidly integrated into the healthcare system, which urgently needed working nurses. These new nursing graduates were faced with unexpected changes in the professional, academic and personal levels involving family, employment and restrictions related to the pandemic. Such a significant crisis created a heavy emotional burden, provoking feelings of anxiety and uncertainty and with a possible impact on the ability to deal with the new unexpected state.

The months before this exam are routinely used by nursing graduates to study and begin to plan their first steps in the profession. For them, this period is typically characterized by tension and worries about the choosing a place of work and is full of substantial changes and important decisions. The general reasons for anxiety among nursing students at this time include failure in exams, failure to perform clinical skills, making mistakes and personal anxiety about possible infection with diseases contracted from patients and other clinical field experiences (Tung et al., 2018). Additionally, the spread of the pandemic created a particular health threat related to exposure to COVID‐19‐infected patients during clinical practice, and fear of contagion, which manifested in higher levels of anxiety (Cao et al., 2020; Savitsky et al., 2020).

Anxiety is defined as a negative level of arousal that can cause efficient propulsion and action at critical points in time, but that, over time, reduces the quality of performance and decision‐making ability (Croy et al., 2020). Normal anxiety is a state that acts as a positive motivating force towards adaptive coping, but may also reach a state of acute fear ‘discomfort’ that appears incongruent with conscious reality and reduces effective cognitive and professional functioning (Tuma & Maser, 2019, p. 23).

Global crises are well known as catalysts that raise the levels of public anxiety, and this effect is intensified by uncertainty. The restrictions imposed following the pandemic dramatically affected the social and economic resilience of the citizens in Israel. The health threat, the increase in unemployment rates and the decrease in economic activity caused significant potential and actual harm to the financial situation of many. The nursing profession is usually characterized by high demand in emergency and therefore enjoys relative economic security. We assume that nursing graduates would also enjoy this sense of security, but that this would be lessened and the levels of uncertainty raised by postponement of their graduation. This period was an unusual and unprecedented situation, and our graduates expressed feelings of ambiguity and worry.

One of the personal motivational factors that can affect the appearance and severity of anxiety and uncertainty in stressful situations is self‐efficacy, which is the belief in one's ability to perform activities and to achieve goals. This also affects ‘their ability to influence events that affect their lives’ (Bandura, 2010, p. 1). Higher self‐efficacy is associated with lower anxiety and uncertainty and better performance (Bandura, 2010, pp. 3, 6). Here, we supposed that self‐efficacy towards the ability to succeed in the licensing exam might be related to the anxiety and uncertainty levels among the graduates and might affect the readiness for the exam.

To the best of our knowledge, the unique situation that the nursing graduates encountered in the current emergency is unprecedented in recent decades. We did not find any reports of the effects on students of cancellation or postponement of such a significant examination as the licensing examination. The information provided by this study may serve as a basis for preparing for similar cases in other countries that are pursuing policies of a governmental mandatory examination prior licensure to practice nursing. The findings of the study also may shed light on the emotional affect and challenges that graduates experience in this special situation. Therefore, the current study aimed to examine (a) self‐efficacy, uncertainty and anxiety, (b) the relationships between these variables and (c) personal experiences among nursing graduates waiting for a mandatory RN licensing test that was postponed due to the COVID‐19 pandemic.

METHODS

Study design

The study was conducted as a mixed‐methods design.

Population and sample

The study population included nursing graduates, who completed their studies in Israel in 2020 and were forced to wait for a postponed IMRNCT. All graduates who registered for the mandatory licensing test in April 2020 were invited to participate. The sample size was calculated using G*Power 3.1 software, which indicated that 146 subjects could provide a power of 0.95, with effect size of 0.15 and 6 predictors at a significance level of 0.05.

Data collection: Tools

The data were collected using a self‐administered online questionnaire examining: (a) socio‐demographic characteristics, (b) uncertainty, state anxiety and self‐efficacy towards the ability to succeed in the IMRNCT and (c) open‐ended questions collecting qualitative data on personal experiences.

Demographic data

Demographic data included gender, age, family status, number of children, nursing education program, country of birth and residential area.

State anxiety

State anxiety was measured using six items from a Hebrew version of Spielberger's State‐Trait Anxiety Inventory questionnaire (Spielberger, 1970). In order to improve compliance, we asked four experts in psychosocial research and nursing education to review the original 20 statements and to choose 10 statements that represent anxiety before an exam. Six statements (three negative and three positive) consistently selected by all the judges were included in the questionnaire. Participants were asked to rank the statements on a scale of 1 (not at all) to 5 (very much). A higher mean score represents higher anxiety. Cronbach's alpha coefficient for this section was .86.

Students' uncertainty

Students' uncertainty was measured using a seven‐item tool (Kagan et al., 2004; Melnikov et al., 2012) that assesses uncertainty related to significant organizational change. For this study, the questionnaire was adapted to the unique state of the waiting period following postponement of the IMRNCT. Participants were asked to respond to statements on a scale of 1 (Not at all) to 5 (Very much). A higher mean score represents higher uncertainty. The Cronbach's alpha score for this section was .90.

Self‐efficacy towards the ability to succeed in the licensing examination

Self‐efficacy towards the ability to succeed in the licensing examination was measured using two items constructed for this study according to the guidelines for self‐efficacy questionnaires described by Bandura (2006). Participants were asked to rank the following statements ‘I believe I can prepare for the government exam postponed to the new date’ and ‘I believe I can succeed in the licensing exam on the new date’ on a scale from 1 (cannot at all) to 9 (definitely can). A higher score represents higher self‐efficacy.

Validation of the questionnaire

The sections measuring uncertainty and self‐efficacy were reviewed and validated by an external panel of experts (three senior nursing educators and one psychologist who researches self‐efficacy and uncertainty). The experts were asked to verify that the items express self‐efficacy regarding the ability to succeed in passing a final exam and uncertainty due to the postponement of the exam. Items in full consensus were incorporated into the survey.

Qualitative data

Qualitative data were collected using one open‐ended question. The respondents were given the opportunity to share their experiences and were asked to response to the following question: ‘What would you like to add about the current period of waiting for the licensing test and what would you change or retain in light of your experiences?’

Data collection: Process

A pilot study (n = 7) was conducted to evaluate the clarity and usefulness of the questionnaire. Data were collected during June 2020. After receiving approvals from the Nursing Division, an e‐mail with a cover letter and a link to the survey was sent through the Ministry of Health corporate communications network to all graduates waiting for the examination. This included an informed consent form in which it was made clear that answering the survey was optional and not mandatory. The survey remained open for 2 weeks and was closed a few days before the IMRNCT.

Data analysis

Quantitative statistical analysis

Continuous variables were summarized as mean and standard deviation. Categorical variables were summarized as number and percentage. A two‐sample t test was used to compare continuous variables. Pearson or Spearman correlations were used to determine the associations between variables. Multiple regressions were performed to examine the contributions of independent variables to explaining the dependent variables. The explanatory variables were significant in univariate models (up to a threshold of p < 0.2). A p value < .05 was considered statistically significant. Data were analysed using SPSS 26.0 (IBM, US).

Qualitative analysis

Qualitative analysis was performed manually using the constant comparative analysis. This classic method allows respondents a wide range of expression of their experiences, feelings and thoughts (Glaser, 1965). The data, which consisted of hundreds of respondent's comments, underwent in‐depth content analysis, and the results were clustered into main themes and categories.

After completing the data analysis, the researchers met to discuss the relationships between the quantitative and qualitative findings. We examined the fit in the responses at the level of each participant, who responded to the open‐ended questions. The themes and categories from the qualitative analysis were then integrated with the quantitative findings. The integration of findings was accomplished by a joint discussion, comprising all the researchers.

Ethical considerations

The study was approved by the ethics committee of Tel Aviv University (IRB), Israel (Approval #0001958‐1).

RESULTS

Participants

The population of the study comprised nurses (n = 840) who graduated in 2020, of whom 352 (41.9%) completed the survey. Of the sample, 269 (76.4%) were female; 199 (56.7%) were married. The average age of the participants was 32.89 years (SD = 7.60; range 22–60). Most members of the sample (317; 90.1%) received a temporary permit to work as registered nurses, until the postponed exam. Additional data are presented in Table 1.

TABLE 1

Participants' demographic and background characteristics (n = 352)

Characteristics	Category	n	%
Place of birth	Israel	268	76.1
	Former Soviet Union	63	17.9
	Other	20	5.7
	Missing	1	0.3
Residential area in Israel	Centre	144	40.9
	North	143	40.6
	South	29	8.2
	Jerusalem and the surroundings	33	9.4
	Missing	349	99.1
Family status	Single	3	0.9
	Married	199	56.7
	Divorced	15	4.3
	Widowed	2	0.6
	Separated	1	0.3
	Missing	1	0.3
Education program	Basic RN (3‐year) program	49	13.9
	Generic RN BA program	51	14.5
	Second career (RN) program	183	52.0
	Second career (RN BA) program	69	19.6
	Missing	0	0
Temporary licence	Yes	317	90.1
	No	35	9.9

Quantitative findings

Descriptive statistics

The participants demonstrated high levels of uncertainty (M = 3.18, SD = 0.74; on a 1–5 score), a high state anxiety (M = 3.81, SD = 0.92; on a 1–5 score) and low self‐efficacy towards the ability to succeed in the licensing exam (M = 3.99, SD = 2.06; on a 1–9 scale). The majority (56.2%) of the sample ranked their uncertainty as 3 and above, while 78.1% ranked their anxiety as 3 and above, and 74.1% ranked their self‐efficacy as 5 or below.

Comparative analysis

Comparative analysis revealed gender differences in the distribution of the state anxiety variable. Female graduates demonstrated higher levels of anxiety than their male counterparts (M = 3.91, SD = 0.90 vs. M = 3.53, SD = 0.95, respectively; t = 3.21, p = .001). Graduates who started working while waiting reported lower levels of uncertainty than those who stayed at home (M = 3.09, SD = 0.75 vs. M = 3.32, SD = 0.72, respectively; t = 2.66, p = .008). Married graduates demonstrated higher self‐efficacy than those living alone (M = 4.20, SD = 2.08 vs. M = 3.75, SD = 2.02, respectively; t = 2.18, p = .03) but felt more anxious (M = 3.97, SD = 0.88 vs. M = 3.63, SD = 0.94, respectively; t = 3.39, p = .001). One‐way ANOVA revealed significant differences in all three study variables between the students from the different nursing education programs (see Table 2). Post hoc Scheffe test revealed that students from a second career program scored the lowest in self‐efficacy, but were more resilient to uncertainty and anxiety. The highest scores of anxiety and uncertainty were found among graduates of a generic RN BA program. ANOVA revealed significant differences in the state of anxiety values according to the residential area in Israel. Graduates living in the south (more peripheral area) reported higher anxiety than residents of the centre, north and east of the country.

TABLE 2

One‐way ANOVA results for the differences between educational programs

Variables		df	F	p
Self‐efficacy	Between groups	3	5.017	.002
	Within groups	348
	Total	351
Uncertainty	Between groups	3	4.628	.003
	Within groups	348
	Total	351
Anxiety	Between groups	3	5.905	.001
	Within groups	348
	Total	351

Correlational analysis

There were significant positive correlations between uncertainty and anxiety variables (higher uncertainty related to higher anxiety), while both were significantly associated with self‐efficacy (see Table 3). Surprisingly, participants with higher self‐efficacy were more anxious and uncertain. There were no correlations between age and any study variables.

TABLE 3

Correlations between the study variables and age, Pearson correlations (n = 352)

Variables	Self‐efficacy	Uncertainty	Anxiety	Age
Self‐efficacy	—
Uncertainty	.37**	—
Anxiety	.39**	.38**	—
Age	.08	−.07	.04	—
Number of children	.12*	−.03	.14*	.53**

p < .05.

p < .01.

p < .001.

Regression analysis

Multiple linear regression analysis was performed in order to identify predictors of a state anxiety among graduates waiting for the postponed RN certification test (see Table 4). Self‐efficacy, uncertainty, gender and family status contributed significantly contributed to the explanation of 24% of the variance of the dependent variable.

TABLE 4

Multiple regression analysis: State anxiety

Variables	B	Std. error	Beta	t	Sig.
Constant	2.197	.427		5.148	<.001
Family status	−0.229	.096	−.124	−2.381	.018
Uncertainty	0.319	.065	.257	4.887	<.001
Self‐efficacy	0.119	.023	.269	5.091	<.001
Age	−0.002	.006	−.013	−0.240	.810
Gender	0.270	.108	.124	2.502	.013
Educational program	0.018	.051	.018	0.357	.722

Note: R 2 = .24, adjusted R 2 = .22.

Qualitative findings

The graduates were asked to describe their experiences while waiting for the examination, by free‐text answers to an open‐ended question, with the opportunity to contribute any recommendations in light of their experiences. Their answers were analysed by identifying key themes emerging from the text and classifying the content around them. Content analysis revealed three main themes: (a) emotional distress, cognitive challenge and social implications, (b) consequences for significant others and (c) strengthening of professional values and norms. Most of the participants responded extensively, describing emotional distress, as well as physical, social and family challenges. These qualitative findings support the quantitative findings, while broadening and deepening the overall perspective. The common themes that emerged from the graduates' free‐text responses highlight the complexity of the situation and the reasons underlying the feelings of anxiety, uncertainty and the poor self‐efficacy.

Here are some representative comments of fear, surprise and devastation.

Emotional stress, cognitive challenge and social implications

‘All bets were off, for five years I was on my way to a nurse's license and all at once, the rug was pulled from beneath my feet’. Change, lack of frame and fear: ‘Everything is shattered with no way out’. Suffering: ‘Real abuse, nightmare’ and extreme socio‐economic distress: ‘I went into a problematic economic situation’. Responses emphasized the students' uncertainty: ‘The uncertainty is infuriating and creates an unpleasant atmosphere’, demonstrating sadness and frustration: ‘Sucks and so frustrating that the exam is suddenly postponed even though no one knows what is happening’. A consistent theme was the difficulty of making decisions due to uncertainty about the near future: ‘We moved around for days not knowing what was going on and what was going to happen. Somebody could have said something’.

The graduates' addressed the changes, expressing disappointment and loss of direction: ‘We have been abandoned by everyone. The licensing system, the educational framework and the employers. We were left alone, isolated, with no prospects for the future’. On the other hand, graduates described factors that they considered would improve their ability to succeed: ‘I'm afraid of leaving the department I work in with the temporary permit. I hope we succeed and there will be help and relief in this exam’.

Consequences for significant others

Nursing graduates described additional difficulties caused by the postponement of the exam: negative consequences to the family, parents and children, spouses waiting to assist the family financially psychological impact of the stress on significant others. The intensity of the responses illustrated the emotional, mental, economic, and family challenges experienced by graduates in this period: ‘I have a hard time deciding what to take care of first ‐ my parents, children without educational frameworks or looking for a temporary job’.

Strengthening professional values and norms

Many of the graduates described re‐thinking and reorganizing priorities in relation to their professional values. This reflects the exceptional situation surrounding the COVID‐19 pandemic, which created an opportunity to re‐examine the motivations and perceptions regarding the profession. In this new reality, some graduates adopted heroic cultural and social narratives designed to give meaning to this dramatic period at the beginning of their new career. Many quotes addressed this point, such as ‘I am grateful for the opportunity to be a part of the health system, and participate in the fight against the coronavirus to save human lives’ or ‘I feel that I'm going to be part of a significant profession for the public health’.

A number of responses addressed the need for providing an alternative RN licensing test in times of emergency. Several participants queried the necessity of licensing test in light of the urgent demand for working nurses during the pandemic. The following quote was submitted by a graduate: ‘If we can work now for several months under a temporary permit with the status of qualified nurses, why don't they cancel our test? What difference does it make?’ The discussion about the importance of the licensing test fuels the need to strengthen its status and create a system that can maintain its relevance even during a pandemic.

DISCUSSION

This study examined the uncertainty, anxiety and self‐efficacy among nursing graduates faced with an indefinite postponement of their mandatory licensing test at the beginning of the COVID‐19 pandemic. In addition, their personal experiences of dealing with the ambiguity of their situation and other challenges were examined qualitatively. Individual quantitative and qualitative findings were integrated and cross‐referenced per participant. The results indicate high levels of uncertainty and anxiety, with low self‐efficacy. The challenging period of waiting for the postponed IMRNCT was characterized by negative emotional and cognitive experiences and low self‐efficacy towards the ability to pass the licensing exam. Qualitative data analysis supported these findings through examples and quotes that paint the whole picture in vivid colours.

The results indicate a positive association between uncertainty and anxiety. Although to our knowledge this study is the first of its kind, it could be argued that the results reflect an expected cognitive, motivational and emotional response to such a dramatic and unexpected change. Similar findings of high uncertainty and state of anxiety have been found previously in other groups during the COVID‐19 pandemic (Aksoy & Koçak, 2020; Shah et al., 2021). The graduates' expressions of ambiguity and concern add substantial support and embodiment to the quantitative findings. The positive relationships between uncertainty and anxiety are consistent with some previous reports (Aylward et al., 2019; Bakioğlu et al., 2021). Therefore, interventions designed to reduce uncertainty in periods of fast changing realities, may also reduce anxiety and thereby improve well‐being and the ability to cope in stressful situations.

We appreciate that the participants' psychological condition and negative personal responses to the postponement of the final exam and waiting for the unknown, may also have been influenced by the COVID‐19 pandemic itself. Although the questionnaires directly addressed the postponement of the exam, the overall situation of emergency and global epidemic probably also impacted participants' experiences. It can be assumed, for example, that self‐efficacy was also influenced by the social environment, since it is known to be directly affected by information obtained from the surroundings. Wang et al. (2020) described relationships between knowledge about the pandemic and self‐efficacy. It is possible that so early in the outbreak (a few weeks after the first COVID‐19 case in Israel), the level of knowledge was still low and that this may have contributed to the decline in graduates' self‐efficacy.

The relationship between working and uncertainty is an interesting and important finding. Graduates who started working before the exam, reported lower levels of uncertainty than those who stayed at home. In our opinion, working as a nurse reinforced the sense of belonging, provided information, and created a better understanding of the reality in the field, thereby reducing uncertainty and improving confidence. Therefore, the Nursing Division's decision to grant graduates a temporary licence had a positive impact since it not only bolstered the work force at the patients' bedside, but also allowed the new graduates to integrate, earn wages, and to feel more certain in a fragile and unstable situation. The results of the qualitative analysis broaden our understanding regarding the contributions of this decision and suggest that practical field experience was also important for improving skills and preserving theoretical knowledge during the waiting period. Similarly, there is literature support for the idea that clinical experience contributes to practical wisdom and professional growth (Ingvarsson et al., 2019) by complementing the theoretical body of knowledge, strengthening confidence in clinical decision‐making and managing uncertainty when entering the nursing profession (Ingvarsson et al., 2019).

Another aspect related to the experience of working in the clinical field is the development of a sense of belonging and empowerment of the positive professional image. Students, who worked, felt a strong desire to be part of the team, and felt protected, even if challenged, by the powerful shared working experience. This is supported by testaments from students about gaining a learning experience as well as professional growth during work (Casafont et al., 2021; Delgado et al., 2021).

Another interesting finding is related to the differences in the levels of self‐efficacy, anxiety and uncertainty among graduates from different nursing programs. Students from second career programs demonstrated the lowest scores in self‐efficacy but were more resilient to uncertainty and anxiety. This finding can be explained by the differences in life experience and family commitments. Since such graduates have already completed a bachelor's degree, they tend to be older than students in a generic program and to have families and children as well as greater economic challenges. The second career program students may also have gained work experience and faced professional challenges in their previous careers. Their lower self‐efficacy may be explained by the differences in the length of the programs. Because the second career program is significantly shorter than the generic program (2.5 years vs. 4 years), students in this program undergo less socialization to the nursing profession and have less experience of dealing with nursing exams. This may be reflected in lower self‐efficacy towards success in the IMRNCT. The highest scores of anxiety and uncertainty were found among graduates of generic RN BA program. This finding is consistent with the high to moderate levels of anxiety among 56% of 244 nursing students during the COVID‐19 lockdowns in Israel (Savitsky et al., 2020).

The participants' expressions analysed qualitatively, reflected anxiety and uncertainty and illustrate the need for future provision of proactive assistance for nursing students studying in such extreme conditions. It is also interesting to examine to what extent such a traumatic event at the beginning of their professional career will affect the course of their professional lives and future career decision‐making.

Limitations

It is probable that study findings were influenced not only by the indefinite postponement of the exam, but also by the general atmosphere of stress and pressure that was prevalent at the beginning of the COVID‐19 outbreak in early 2020.

The cross‐sectional method of study was chosen as an opportunity to survey all nursing graduates in Israel found eligible to take the certification test. The inability to contact all members of the sample as a group for resampling is a limitation and there is no doubt that a research array that enabled resampling would have enriched and expanded our findings and insights.

CONCLUSIONS

Our research findings emphasize the importance of rapid implementation of policies and resources designed to reduce uncertainty and anxiety, and strengthen self‐efficacy. While a crisis naturally evokes anxiety and uncertainty, reinforcing those variable that are in areas of certainty can reduce the intensity of negative and stressful zfeelings and maintain the resilience of health care professionals in general and nursing graduates in particular. This may be achieved through establishment of the following initiatives: (1) Direct and transparent communication—establish online communication channels, accessible to nursing graduates, with the Ministry of Health. (2) Employing nursing students pre‐graduation—establish protocols for employing nursing graduates in a crisis. This will achieve two goals: the clinical fields will benefit from high‐quality health workers and the graduates will earn a living and benefit from clinical experience. (3) Early detection and identification of groups and individuals likely to develop high state anxiety. This may direct the provision of early assistance and support interventions to relieve stress, possibly as short‐term individual debriefing sessions or remote group interventions.

The efficiency of the health care system relies predominantly on human resources. Therefore, protecting and maintaining the mental and professional resilience of nursing graduates in a crisis is of paramount importance.

AUTHORSHIP STATEMENT

RZ was responsible for the conceptualization, methodology, project administration, resources, validation, writing – original draft, and writing – review and editing; IK was responsible for the conceptualization, data curation, formal analysis, methodology, writing – original draft, writing – review and editing; RHH was responsible for the data curation, formal analysis, project administration, resources, writing – review and editing.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

REPORTING GUIDELINES

STROBE and COREQ reporting guidelines were used.