Confidence-weighted testing: A descriptive study of Japanese nursing students



Nurses' lack of self-confidence in their own nursing skills is one of the main reasons that novice nurses leave the profession in Japan. Nursing education must help students gain self-confidence in their nursing skills in order to allow more novice nurses to stay in their profession. In this study, we evaluated whether confidence-weighted testing feedback actually improves students' self-confidence in their basic nursing skills. Confidence-weighted testing, which provides quantifiable results, might allow students to objectively assess their skill-related self-confidence. Sixty-seven first-year nursing students took two confidence-rating examinations on the knowledge and practical skills related to pulse and blood pressure measurement of immobile patients. Feedback was given to each participant after the first examination. After the first examination with confidence-weighted testing feedback, students showed higher levels of self-confidence in their practical skills, but not in knowledge. The improvement of self-confidence in practical skills suggests that there is still room for improvement in confidence-weighted testing feedback in knowledge. Further research is required to identify more effective feedback methods to improve students' self-confidence levels in knowledge using the results of confidence-weighted testing.


Since 2002, high attrition rates of newly-qualified nurses in healthcare institutions in Japan have been a major problem, and further contribute to the chronic shortage of nurses. The Japanese Nursing Association Central Nurse Center (JNA) (2006) state that one of the reasons for such high attrition rates is novice nurses' awareness of their insufficient professional nursing knowledge and skills. Most novice nurses (76.9%) reported that their insufficiency in professional nursing knowledge and skills ranked first among the causes of their distress. A JNA report stated that the true issue is that novice nurses do not recognize their skills as being sufficient for professional nurses. In general, self-confidence plays a major role in determining nurses' well-being in their profession, but many novice nurses report negative clinical experiences with fear and stress, become distressed, lose self-confidence, and leave their profession (JNA, 2006). If novice nurses have appropriate self-confidence and cope with their stress early in their career, they might acquire the nursing knowledge and skills required in clinical settings without unnecessary fear and loss of self-confidence, ultimately allowing them to stay in their profession. In nursing education, self-confidence is important for students; however, it is unknown whether students can accurately recognize and measure their own self-confidence.

Aoyama et al. (2009) conducted research on students' self-confidence using a questionnaire regarding nursing knowledge and skills. Some students showed low levels of self-confidence, even though their answers were correct, while others showed higher levels of self-confidence, despite giving wrong answers. Students failed to sufficiently estimate or measure self-confidence. Students' failure to recognize self-confidence might be partly attributable to the educational program in nursing schools, which does not focus on fostering students' acquisition of appropriate self-confidence reflecting their actual nursing skills. One possible solution to the current shortage of nurses is to improve the quality of nursing education (Turale, 2008; Fagin et al., 2009). Along with this approach, this study attempts to focus on improving students' levels of self-confidence by providing them with the opportunity to engage in simulated clinical environments to address the global issue of the shortage of nurses.

This study aimed to verify whether giving feedback based on the results of confidence-weighted testing (CWT) actually improves students' levels of self-confidence in basic nursing skills. CWT is an evaluation tool that properly and quantitatively determines levels of self-confidence, of which the individual is usually unaware (Morita et al., 1999; Morita & Hatao, 2004). This study examines students' levels of self-confidence before and after providing feedback, and evaluates the effects of providing feedback in building sound self-confidence.

Literature review


Merriam-Webster's Collegiate Dictionary defines “confidence” as “a feeling or consciousness of one's power or of reliance on one's circumstance” (Mish et al., 2003, p. 261) and defines “self-confidence” as “confidence in oneself and in one's powers and abilities” (Mish et al., 2003, p. 1127). If people have self-confidence, they can overcome difficulties, even when facing formidable challenges. Therefore, self-confidence is related to self-efficacy in Bandura's social cognitive theory (Perry, 2011). Bandura (1997, p. 2) states that: “Perceived self-efficacy refers to beliefs in one's capabilities” to control their actions and their lives. Indeed, improved levels of self-confidence in nursing skills enhance students' motivation regarding the acquisition of nursing skills.

The concept of self-confidence/confidence is often discussed in the context of clinical practice, particularly in regard to skill acquisition, clinical decision-making, professional socialization, collaboration, and autonomy (White, 2009). Furthermore, self-confidence/confidence is a crucial practice element in nursing education and practice (Perry, 2011). As nursing students enter their final year of study, they are expected to prepare for their professional responsibilities with self-confidence (Drexler, 2009). However, learning how self-confidence is gained is at best ad hoc (Roberts & Johnson, 2009). Novice nurses commonly experience feelings of inadequacy when entering employment as registered nurses, and the majority of novice nurses do not have either the self-confidence or competence to assume responsibility for patient safety (Casey et al., 2004). According to a recent study, nurses with low levels of self-confidence in their nursing care can cause patients or care recipients to feel uncomfortable and uneasy (White, 2009; Perry, 2011). Nurses' lack of self-confidence might impact on the overall quality of nursing care, including economic aspects. Mayeroff (1971) insists that those engaged in any kinds of care should have determination, self-confidence in their own skills and as well as understand their own limitations as care givers. Zimmerman (1997) also states that students need to monitor their own learning continuously and accurately. Taking Mayeroff's and Zimmerman's statements into account, nursing students might benefit from objective and accurate observation of self-confidence in their nursing knowledge and skills while in the process of acquiring necessary nursing skills. Turning to the authors' teaching context, the following research questions are posed: How can students be objectively aware of their self-confidence? How can teachers effectively intervene in students' learning process to help them to become self-regulatory learners?


Nursing students' levels of self-confidence are believed to be improved through mechanisms, such as sharing stories about common experiences, coaching from mentors, and working alongside other students (Roberts & Johnson, 2009). Hattie and Timperley (2007) define feedback as information provided by a teacher or a peer with respect to an individual's performance or level of understanding. Morita (2000) further explores feedback for the educational process. According to Morita, educational feedback is a system whereby teaching staff and students use their own experiences and analyze the results of students' actions as data to successfully enter the next stage in the learning process. The benefits of such feedback include increased student self-confidence, stronger motivation, elevated self-esteem, and improved clinical practice (Clynes & Raftery, 2008). According to Oermann (1990), providing feedback enables nurses to modify their performance skills until they become competent in providing nursing care in an appropriate manner. In our previous study, providing effective feedback appeared to raise students' levels of self-confidence in basic nursing skills (Aoyama et al., 2009). Further exploration of effective feedback is necessary.

Feedback from teaching staff offers students the opportunity for self-evaluation (Kage, 2000), and allows them to reflect on their actions and reactions by evaluating the results (Morita, 2000). Such reflection is considered to be one of the basic abilities of professional nurses, particularly in regard to improving the overall quality of their nursing care. Furthermore, reflection offers a foundation for nurses to gain sound self-confidence in nursing care, and the self-efficacy to employ knowledge gained from their experience (Ikenishi & Tamura, 2009).

Definition of terms

As defined by Tajima (2004), “nursing skills” comprise content related to the following three areas: the cognitive domain, the psychomotor domain, and the affective domain. Abilities required in the practice of nursing involve the integration of these three domains. Tajima (2004) discussed appropriate evaluation methods for each of these, according to Tajima, the cognitive domain has been associated with knowledge, while the psychomotor and affective domains have been associated with practical skills. “Self-confidence” is defined as students' belief in their own knowledge and practical skills, as applied to nursing care (Aoyama et al., 2007; 2009).



A prospective and descriptive design was used. To analyze and compare the results of a pretest/post-test, a single sample group was used.


The participants in this study comprised 67 first-year nursing students (66 females, 1 male), who were taking a basic nursing skills course at a suburban nursing university in Japan in 2006–2007. The majority of the participants ranged from 18 to 20 years of age.

Ethical considerations

Careful attention was given to ethical considerations regarding participants and others who helped with our validity survey using the nursing skills evaluation tools. All of the methods used in this study were approved by the Nara Medical University Medical Ethics Committee and the Kobe University Graduate School of Nursing Research Ethics Committee. All 67 participants received a written explanation and a timetable of the study beforehand, gave informed consent and were informed of their right to withdraw from the study at any time. In the survey on the validity of evaluation criteria, each participant signed a questionnaire and submitted it to the staff.

Data collection


The research instruments included a multiple-choice test comprising 14 questions based on the measurement of pulse and blood pressure in immobile patients, as well as a 38-item checklist of students' performance of practical skills related to the knowledge covered by the test. The practical skills evaluation criteria were not only limited to the implementation of nursing skills, but also examined the entire process from preparation to clean-up to create a situation that was as realistic as possible. Therefore, communication with patients as a part of holistic nursing care was also evaluated. The questions and demonstration items were extracted from foundational nursing procedures in textbooks and reference books. The validity of the evaluation criteria was based on the result of our survey of 69 of 109 teachers (63.3%) at 36 of 128 nursing universities throughout Japan from June to August 2006.

The matrix for calculating/scoring the CWT level of self-confidence for each item by using the CWT (Morita et al., 1999; Morita & Hatao, 2004), considering students’ self-evaluation of their self-confidence in their answers to the questions, their performance of nursing skills, and the correctness of their responses based on the teacher's evaluation, (“Teacher evaluation” was done based on the students' conventional scores of the questions on knowledge and the teachers' observation on the students' skills performance.) is shown in Table 1. For students' self-evaluation of their levels of self-confidence in knowledge, a three-grade scale (full, half, and none) was used. The CWT confidence level was assessed using a six-grade scale (1, 0.6, 0.2, −1, −0.6, and −0.2). Students' correct answers determined via conventional examinations were positively weighted in accordance with their self-confidence levels for each item, while incorrect answers were negatively weighted. Therefore, CWT point 1 indicates that the student's answer was correct and the student had full self-confidence; CWT point −0.2 indicates that the student's answer was incorrect and the student showed no self-confidence. Positively-weighted CWT points indicate relatively sufficient levels of self-confidence, whereas negatively-weighted CWT points indicate insufficient levels of self-confidence.

Table 1. Confidence levels through confidence-weighted testing (CWT) of basic nursing skills
Confidence levels through CWTStudentsTeacher
Confidence levels through self-evaluationevaluation
Practical skills  
−0.2None (conducted/not conducted)

Additionally, in regard to levels of self-confidence in practical skills, a three-grade scoring method was used. Participants assessed their levels of self-confidence after performing nursing skills according to a checklist of their actions. Levels of self-confidence were then calculated with one of the six grade scores by comparing their self-evaluation with one of the two grade scores (sufficient or insufficient) given by the teacher, based on observation of the student's performance.


The study was conducted in October 2006, and included an orientation for 67 participants and two examinations that evaluated students' level of knowledge and practical skills. In November 2006, approximately one month after the first examination, the researcher provided students with feedback on their performance. In February 2007, a second examination was carried out to determine whether there were any differences in students' levels of self-confidence in both knowledge and practical skills.

To ensure consistency in feedback, the same researcher provided feedback to all participants. The levels of confidence and comparisons between conventional testing scores (CT scores: 0–100) and CWT points for both knowledge and practical skills were included on the feedback sheets. During the feedback, the researcher explained typical features of CWT points for knowledge and practical skills in basic nursing skills and learning skills to subjects in order to strengthen their motivation. The students were encouraged to interpret their own results and understand where they were and how well they performed, and based on their CWT points, whether they had sufficient self-confidence in their knowledge and practical skills.

Students whose CT scores were below 60 points in the first examination were re-evaluated before the second evaluation in order to fill the gap in the students' performance levels. In our previous study, students whose CT scores were below 60 points in knowledge and practical skills demonstrated a tendency to show over-confidence (Aoyama et al., 2007). Students whose scores were lower than 60 were likely to be unaware of their poor levels of knowledge and practice skills, and more likely to be satisfied with themselves. Therefore, to obtain more accurate self-confidence levels of the students, the students were re-evaluated. After the re-evaluation, all participants scored 60 or more for their CT scores. To exclude psychological and emotional factors that could have confounded the results, the teaching staff did not mention any aspect related to the present study. In addition, the contents of the feedback were excluded in the orientation for the second examination.

Data analysis

The Wilcoxon signed-rank test was utilized to test for significant differences in CWT points between the two examinations conducted before and after feedback was provided. The same procedure was conducted for CT scores for each item. Spearman's rank correlation coefficient was used to determine significant correlations between knowledge and practical skills in the two tests at α levels of 0.05 and 0.01. The software program used in this study was SPSS (version 15.0J; SPSS Japan).


As shown in Table 2, the median values for CWT points and the CT scores between the first and second examinations were compared using the Wilcoxon signed-rank test. CWT points for practical skills increased by 5.00 in the second examination (from 71.00 to 76.00, adjusted P = 0.004). This result indicated that providing feedback based on CWT points for practical skills significantly improved students' self-confidence in their practical skills. In contrast, CWT points for knowledge were not significantly different between the first and second examinations (from 68.60 to 72.90, adjusted P = 0.06), indicating that providing feedback based on CWT points for knowledge did not significantly improve students' self-confidence in their knowledge on the second examination.

Table 2. Confidence-weighted testing (CWT) points and conventional testing (CT) scores in the first and second examinations (n = 67)
 1st exam2nd examP-value
  1. Wilcoxon signed-rank test. *P < 0.05, **P < 0.01.

CWT points



CT scores


Practical kills

CWT points



CT scores



Students' CT scores for knowledge (P = 0.04) and CT scores for practical skills (P = 0.02), as measured by conventional testing, improved significantly after providing feedback, as shown in Table 2. This improvement in both areas might have consequently influenced students' self-confidence. Significant correlations between the first and second examinations were determined using the Spearman's rank correlation coefficient. Only one correlation between self-confidence in knowledge in the second examination and actual knowledge in the first examination (P = 0.53, P = 0.000004) is shown in Table 3. Two statistically-significant correlations were found between self-confidence in practical skills in the second examination and self-confidence in knowledge in the first examination (P = 0.27, P = 0.03), and between self-confidence in skills in the second examination and actual skills in the first examination (P = 0.26, P = 0.03). One correlation was found between actual knowledge in the second examination and self-confidence in knowledge in the first examination (P = 0.48, P = 0.00004). No correlations were found between practical skills in the first examination and all the other results of the second examination. Students with high scores for knowledge in the first examination gained self-confidence in their knowledge after receiving feedback. Moreover, students with high scores for practical skills in the first examination gained self-confidence in their practical skills after receiving feedback. Students who showed appropriate self-confidence in their knowledge in the first examination had improved scores for knowledge in the second examination after receiving feedback. Those students also showed a slight tendency to gain self-confidence in their practical skills in the second examination after receiving feedback.

Table 3. Spearman's rank correlation coefficient (P) between the first and second examinations (n = 67)
 2nd Exam
  1. *P < 0.05, **P < 0.01. CT, conventional testing; CWT, confidence-weighted tested; NA, not applicable.
1st exam CWT points    
1st Exam CT scores    
Practical skills−0.010.26*−0.05NA


The main objective of this study was to discover whether providing feedback after the first examination increased students' levels of self-confidence in their basic nursing skills. Therefore, changes in CWT were analyzed on the basis of CWT points before and after providing feedback. CWT points for practical skills significantly increased after providing feedback. However, no significant increase in CWT points for knowledge was found, suggesting that feedback based on CWT points did not significantly improve self-confidence in knowledge. Students' levels of self-confidence for knowledge seemed more difficult to increase than those for practical skills, particularly after the feedback was provided.

However, the students with accurate knowledge in the first examination showed sufficient levels of self-confidence in their knowledge in the second examination, suggesting that accurate knowledge improves levels of self-confidence sufficiently after feedback. Therefore, students need to attain appropriate knowledge before the first examination, and then be given feedback using another contents of feedback in order to acquire high levels of self-confidence for their knowledge. Moreover, students with high levels of self-confidence for knowledge in the first examination indicated sufficient levels of self-confidence in their practical skills in the second examination after receiving feedback, suggesting a modest correlation between their levels of self-confidence of knowledge and practical skills (Aoyama et al., 2007). In this case, providing feedback based on CWT points improved the levels of self-confidence in practical skills, suggesting that students' self-confidence per se can influence levels of self-confidence after feedback. That is, the more self-confidence students have, the more self-confidence can be influenced by obtaining feedback and the more competently performance can be achieved. Indeed, the degree of self-confidence in nursing technique can determine students' care behaviors. According to Oermann (1990), the goal of skills performance development is to acquire the ability to “judge”.

The participants in this study were university students, and the sample size (n = 67) was relatively small. This was because the CWT points for knowledge after providing feedback didn't increase as much as expected, which resulted in failure to attain statistical significance. However, in the Japanese educational system, students in the same department at the same university tend to represent a relatively narrow range of intellectual abilities and self-confidence. Differences in intellectual abilities and self-confidence might be greater among different universities (Liachopoulou et al., 2008).

Our findings suggest that nursing students need to acquire reasonable self-confidence when learning basic nursing skills by judging their own clinical performance, while at the same time understanding their limitations. Several additional challenges remain for future studies. First, the internal process of improved self-confidence through feedback should be elucidated from the student's perspective. Second, to achieve the best learning outcomes, the contents of feedback must be considered (Dreifuerst, 2009). Third, teachers need to identify the ideal time and best method to provide feedback to students. Feedback provided by teachers who actively consider students' self-confidence in knowledge and practical skills might be more effective in improving students' self-confidence. Teachers have made significant efforts to help students to combine their knowledge and practical nursing skills exerted in clinical environments (Okamura et al., 2009; Hisada et al., 2011).


Providing feedback on knowledge and practical skills through CWT increased students' levels of self-confidence in their practical skills, but not in their knowledge. Based on the results of the second examination after feedback, sufficient levels of self-confidence in knowledge were associated with sufficient knowledge in the first examination.” into “levels of self-confidence in practical skills, but not in knowledge. Based on the results of the second examination after feedback, sufficient levels of self-confidence in knowledge were associated with sufficient actual knowledge in the first examination. These findings suggest that students need to gain appropriate knowledge and receive effective feedback. Therefore, research is necessary to clarify ways in which to provide better feedback and more effectively utilize CWT as an evaluation tool.

As mentioned earlier, students' low self-confidence in nursing care can make patients and care recipients feel uncomfortable (White, 2009; Perry, 2011). Based on these findings, staff members who teach nursing techniques should recognize that they must attempt to better comprehend each student's level of self-confidence to guide them toward obtaining sound self-confidence as future nurses (White, 2009). Teachers' appropriate and timely intervention in the students' learning process is crucial to help them to gain self-confidence in their nursing skills.


The authors would like to thank the students who participated in this study, as well as Ms Mieko Miyake and Ms Seiko Sudo for their kind support in performing the study. The authors would also like to thank Dr Takao Morita and Planning Laboratory Ltd. for assistance with the analysis. This study is part of a doctoral dissertation submitted to Kobe University Graduate School of Health Sciences. This study was supported by a Grant-in-Aid for Scientific Research (C) 2007–2010, no. 19592462.


Study design: AM, TY, IY.

Data collection and analysis: AM, TY, IY, YM.

Manuscript writing: AM, TY, YM, MI.