Self‐efficacy in the context of nursing education and transition to practice as a registered practitioner: A systematic review

Abstract Aim The aim of this systematic review is to identify, describe and synthesize evidence from experimental studies conducted to measure and conceptualize self‐efficacy within the context of nursing education and the transition of nursing students to practice as a registered practitioners. Design Systematic review. Methods Papers were screened by four independent reviewers, and data were extracted using a standardized data extraction tool. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidance and checklists were used to guide this review. Results The review included 47 studies, using a quasi‐experimental pre‐test–post‐test design (n = 39) and randomized control trials (n = 8). Various teaching and learning interventions were used to enhance self‐efficacy; however, there is no definitive conclusion to be drawn regarding the most effective educational interventions. Various instruments were used in the studies to measure self‐efficacy. 10 of these were related to general self‐efficacy, while 37 instruments measured self‐efficacy in the context of specific skills.

tors and researchers globally have considered self-efficacy as one of the target process level and terminal programme outcomes which can influence nursing practice.
Self-efficacy is a vital component for independent performance in nursing. Bandura has described self-efficacy as one's belief in the ability to perform the desired functions in their role (Bandura, 1995). Self-efficacy is an important motivator for medical and nursing students' development (Klassen & Klassen, 2018) and is key to nursing students' and clinical nurses' performance in their roles (Mohmmdirezi et al., 2015). Therefore, developing and implementing education programmes which facilitate the development of self-efficacy is essential for healthcare professionals. Over the past 20 years, self-efficacy has been linked to academic achievement and workplace performance (Artino, 2012;Goldshmidt, 2018).
Although the effectiveness of educational programmes is well documented, specific analysis of self-efficacy as an outcome is less evident. For example, based on a systematic review of 19 included articles, McCutcheon et al. (2015) found limited evidence in support of using blended learning approaches to teach clinical skills in nursing education programmes. Only two papers reported on selfefficacy, and they all used different outcome measures. McMullan et al. (2011) found no significant differences in students' selfefficacy before and after drug calculation training. McConville and Lane (2006), using an online video increased students' self-efficacy scores when faced with difficult situations. Furthermore, a number of authors conducted systematic literature reviews of self-efficacy with varying foci: concluding that high levels of academic selfefficacy significantly increased university students' academic performance (Honicke & Broadbent, 2016); self-efficacy is important for healthcare professionals' communication skills, where training in these skills can enhance their performance and self-efficacy (Mata et al., 2021); considering a breastfeeding education programme during pregnancy and continued to the first week of postpartum.
Self-efficacy provides an important opportunity for health professionals to improve breastfeeding confidence among mothers when they encounter breastfeeding problems (Maleki et al., 2021). Systematic reviews, by synthesizing the available evidence, enable the consistency of results to be analysed and provide a more solid basis for decision-making. Several systematic reviews exploring the role of self-efficacy in nursing studies have been published. However, little attention has been given to understanding self-efficacy baseline levels and the choice of pedagogy or the most effective teaching methodologies to support the development of self-efficacy of Registered Nurses and nursing students that would allow us to pool the different results. Therefore, considering selfefficacy's importance, an in-depth systematic review of the literature will be presented in this paper, which will explore the impact of educational interventions on nurses' self-efficacy.

| Aim
The aim of this systematic review is to identify, describe and synthesize evidence from experimental studies conducted to measure and conceptualize self-efficacy within the context of nursing education and the transition of nursing students to practice as a registered practitioner. A systematic review of empirical literature will be used to broaden the conceptualization and understanding of the evidence, due to the inclusive nature and the predefined rigorous methodological processes used. Specifically, in this review, we sought to answer the following questions: a. How do education programmes impact the self-efficacy of nursing students and Registered Nurses?
b. What educational programme characteristics have been linked with changes in self-efficacy? c. What role does self-efficacy have in facilitating the transition of nursing students from an educational programme to practice as a registered practitioner?

| Design
A systematic literature review design was selected to synthesize empirical study findings and to address the research questions.
The Preferred Reporting System for Systematic Reviews and Meta-Analyses (PRISMA) guidance and checklist was followed in this study (Page et al., 2021).

| Search methods
Inclusion and exclusion criteria were drafted based on review questions and reported in accordance with the PICOS framework (Population, Interventions, Comparators, Outcomes and Setting/ Study design) (Santos et al., 2007; Table 1). The review considered experimental studies published from 01 January 2010 to 31 March 2021. Papers were included if: (a) they focused primarily on nursing students or Registered Nurses undertaking any educational programme (undergraduate or graduate entry or postgraduate or continuing professional development (CPD) programmes); (b) measured or explored self-efficacy as an outcome (c) reported on studies conducted in healthcare settings or educational institutions.
The search strategy was developed iteratively and reviewed by five authors. In a preliminary scoping search of databases, we tested and refined the search strategy as a group, which ensured the sensitivity of the search in sourcing key papers within the search results.
A comprehensive search was conducted using the EBSCO host platform and key databases, that is Educational Resources Information Center (ERIC), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline. A title or abstract keyword search was conducted using Boolean terms (see Table 2).
The papers identified by the electronic database search were imported into a Mendeley library at https://www.mende ley.com, and duplicates were removed. The remaining citations were transferred to Rayyan, an online screening tool (Ouzzani et al., 2016). Papers were blindly screened on the basis of title and abstract, and irrelevant records were excluded. Following that, papers that might be eligible were assessed in full text. Title, abstract and full-text screening were conducted independently by two reviewers based on predefined inclusion and exclusion criteria. Any disagreements at the full-text screening were resolved through discussion and consensus. TA B L E 1 Overview of inclusion and exclusion criteria using the PICOS model.

Inclusion criteria Exclusion criteria
Population Nursing students and registered nurses undertaking any educational programme (undergraduate or graduate entry or postgraduate or CPD programmes) Interprofessional learning, including nursing students or registered nurses where the data pertaining to nursing students and nurses can be clearly extracted Other healthcare professionals, dental nurses, veterinary nurses, health care assistants and doctors

Interventions, Variable of Interest
Experimental studies which sought to understand the impact of a specific educational programme/ intervention where self-efficacy was explored as an outcome variable Patient educational programmes Measurement of self-efficacy in the context of correlational or interventional studies relating to general concepts such as nursing/midwifery's personal self-image, eating habits, tobacco cessation and engagement in exercise Non-interventional studies

Comparison
As reported in the study

Outcome of interest
Research reporting on self-efficacy as an outcome variable Self-efficacy is mentioned in the title or abstract Related concepts, for example confidence where selfefficacy is not the focus Studies that present the psychometric evaluation of an instrument Studies with no self-efficacy outcome data Writing self-efficacy

Studies
All experimental designs Publications in peer-reviewed journals

83,244
These terms were chosen to target the population S2 TI ((educat* OR program*OR train* OR graduat* OR clinical OR competen* OR student OR undergraduate OR preregistration OR "pre-registration" OR baccalaureate OR prelicensure OR "prelicensure")) OR AB ((educat* OR program* OR train* OR graduat* OR clinical OR competen* OR student OR undergraduate OR preregistration OR "pre-registration" OR baccalaureate OR prelicensure OR "pre-licensure")) 979,778 These terms were chosen to target the education programmes' context S3 TI ((self-efficacy OR "self efficacy")) OR AB ((self-efficacy OR "self efficacy")) 16,553 These terms were chosen to target the main concept S4 (S1 AND S2 AND S3) 723 These terms were chosen to target the empirical literature in a nursing education context involving selfefficacy as a major concept or variable

| Quality assessment
Five authors in pairs independently assessed quality and scored included papers using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018; see Appendix S1). The tool facilitated the assessment of included studies based on their design category. Studies that met the following criteria were rated as follows: 0% for one criterion met, 25% for two, 50% for three, 75% for four or 100% for five criteria met.

| Data extraction
A standardized data extraction template was used to extract the data (see Appendix S2). The data from the identified studies were extracted by one reviewer, and the accuracy of the extraction process was verified by another reviewer. Disagreements between reviewers were resolved by consensus or by involving a third reviewer.
The data extracted included specific details about the author(s) and year, country and settings; aim(s); study design; study population; exposure/intervention description; outcome variables; selfefficacy theory and definition, self-efficacy data collection method and instrument; and the self-efficacy results. The findings are orga-

| Data synthesis
Researchers intended to pool quantitative study results and conduct a statistical meta-analysis. According to Field and Gillett (2010), this approach was not considered valid or feasible due to the considerable heterogeneity of interventions and outcome measures in included the studies. Therefore, the findings are summarized as a narrative without meta-analysis with supporting tables (Popay et al., 2006;Ryan, 2013). Where effect sizes were not reported by study authors, the standard effect sizes for the primary outcome (changes in self-efficacy) were calculated using an online calculator (https://www.uccs.edu/lbeck er/). Cohen's d statistic was used to report the effect size r (a Pearson correlation coefficient). As d is the standardized mean difference between two groups; r is the proportion of variance that can be explained (between zero and one). In the case where means and standard deviations were not fully reported, they were computed using other data, such as t-value and df methods.
The r statistic is generally interpreted as having a small effect of 0.10, a medium effect of 0.30 and above and a large effect of 0.50 and above (Anon, 2021). In this study, r was considered negligible when it was <0.2, so that no change was seen in mean self-efficacy scores; this indicates that the means of two groups differ by <0.2 standard deviations and that the difference is extremely small or negligible, even when statistically significant (Polit & Tatano-Beck, 2012).

| Selection of the studies
The search of the databases revealed 723 citations that were exported to Mendeley. A total of 259 duplicates were removed from Mendeley; 464 were imported to Rayyan, where two duplicates were removed. Finally, a total of 462 citations were screened at the initial title and abstract screening stage, and 346 irrelevant records were excluded from the results (Figure 1).
The full text of the remaining 116 papers was screened, and 69 papers that did not meet the review eligibility criteria were excluded, resulting in 47 studies that met the inclusion criteria. In addition to the included articles, the references of the included articles were searched manually, and no additional papers were found. The study identification, screening and selection process are presented in Figure 1.  Table 3).
Various educational modalities and programmes were highlighted in the reviewed literature (Appendix S3). Intervention types included single learning modalities like online training modules (n = 4), simulation learning (n = 4), multimodality learning programmes (multimodality-based simulation) (n = 10) and blended learning (n = 10). Other traditional educational programmes included didactic learning approaches (n = 21).

| Quality assessment
There were 47 studies that met all five Mixed Methods Appraisal Tool assessment criteria, indicating the studies' quality and methodology being generally acceptable to answer research questions.
(Appendix S1). The quality was highest in quasi-experimental pretest-post-test design studies, while the randomized control trial studies scores were lower. Many studies suffered from weaknesses with respect to sampling strategies, representativeness of samples, attrition rates and consideration of possible confounders in their design or analysis. For example, baseline data was not comparable between groups. However, there were strengths in the method of measuring the outcome data and reporting complete outcome data.
There were no studies that scored 0 and 4 (quasi-experimental pre-

| Theoretical perspectives around self-efficacy
Of the reviewed studies, 11 were underpinned by theoretical perspectives relating to self-efficacy theories. In addition, studies utilized a selection of educational theories, frameworks and models to understand and explain human behaviour and guide the intervention's identification, development and implementation (Table 3). The most used definition or explanation of self-efficacy within the review referenced Bandura's work (Bandura, 1977(Bandura, , 1986(Bandura, , 1995(Bandura, , 2006, defining that self-efficacy is 'the individual's judgment of their capabilities to organize and execute the necessary action

| Measurement of self-efficacy
There was significant heterogeneity in the tools (n = 47 individual tools) used to measure self-efficacy within the included studies with 138 items based on Bandura's (1977) writings and a revised version used for the PRONTO pilot study (Walker et al., 2014). All other measures were moderate in length, with 10-45 items.
Within the 47 studies reviewed, self-efficacy was operationalized as both a global measure and a caring domain/task-specific measure of self-efficacy (see Appendix S4). The general self-efficacy scale (GSES; n = 10) was the most popular global measure. In this self-efficacy scale, 10 items were used with a 4-point Likert scale, with one as no confidence, four as fully confident, and higher scores indicated higher self-efficacy (Schwarzer & Jerusalem, 1979, 1993, 1995, as cited in Saied, 2017Imus et al., 2017;Rambod et al., 2018;Topbaş et al., 2019;Hwang & Kim, 2020).
Measures specific to caring domains/tasks were used in seven studies. These included the interprofessional teamwork scale (IPT; n = 3), self-efficacy of clinical performance scale (SECP; n = 2) and self-efficacy in evidence-based practice scale (SE-EBP; n = 2). In the remaining studies, scales adapted from various sources were used (n = 1 each). A more recent self-efficacy tool assessed nurses' selfefficacy regarding the management of eclampsia with 16 statements and a 5-point Likert scale to measure nurses' self-efficacy. Higher scores indicate a higher level of self-efficacy (Said et al., 2021).
However, evidence within the publications of test-retest reliability

| Self-efficacy outcomes for single-group experimental study designs
Among 28 single-group studies that reported self-efficacy comparisons, 25 studies showed significant changes in general or subscale self-efficacy after the intervention (Table 4). Mean self-efficacy scores improved post-intervention significantly in 21 of 28 studies. There were only four studies with single-group data reporting positive changes in self-efficacy with an effect size r ≥ 0.5 (Chang & Levin, 2014;Dunn et al., 2014;Patton, 2018;Walker et al., 2014) ( Table 4). Although single-group studies indicated that interventions increased self-efficacy, effect sizes for changes in self-efficacy subscales or overall self-efficacy ranged from r = −0.38 to 0.93. In four studies, the self-efficacy intervention effects were lower than 0.20, while other studies reported no significant change in self-efficacy or no data (n = 2).
However, only one of the included pre-test-post-test studies (Doucet & Rhéaume, 2020) reported an effect size value for selfefficacy (r = 0.15). As a result, the research team calculated the effect size for each educational intervention to allow for cross-study comparisons. The standard effect sizes for the primary outcome (changes in self-efficacy) were calculated using an online calculator (https://www.uccs.edu/lbeck er/) where means and standard deviations were fully reported, they were computed using other data, such as t-value and df methods. Moreover, if none of these data TA B L E 3 Key study characteristics (N = 47).

TA B L E 4 (Continued)
were available for computing the effect size, no calculations were completed (NCC) written under the effect size.

| Self-efficacy outcomes for random control and non-random control two group studies
There were 16 studies that compared two groups. A total of eight studies randomly assigned participants to intervention or control groups; the other eight were non-randomized two-group studies ( Table 5) (Table 5). All two-group studies included in this review did not report effect size values. Therefore, the standard effect sizes for the primary outcome (self-efficacy level change) were calculated by the research team.

| EFFEC TIV E S ELF-EFFI C AC Y EDUC ATI ON S TR ATEG IE S
Various learning interventions targeting nurses' self-efficacy were reported across the included studies (n = 47) (Appendix S3). The interventions were broadly categorized as online learning approaches, simulation learning approaches, traditional didactic approaches and blended learning approaches.

| Single modality
Four studies, 4/47 (8.5%) used a pre-and post-test design. They used online learning approaches using a range of multimedia systems, including videos, pictures, text, diagrams, and case scenarios lasting between 30 min and 3 months. All four studies reported a significant effect of training on self-efficacy outcomes, with effect sizes r ranged from 0.28 to 0.63 (Chang et al., 2020;Curtis et al., 2016;Doucet & Rhéaume, 2020;Thompson, 2016) (see Appendix S3).
Only one study, 1/4 (25%), assessed the impact of self-efficacy in improving the transition of nursing students from education to clinical practice (Thompson, 2016). This study found that the selfefficacy of undergraduate students improved as they transitioned from academic settings to professional practices when responding to bullying.

| Single-modality simulation learning approaches
Four studies 4/47 (8.5%) used only simulations, and all of these studies reported positive effects on self-efficacy 4/4 (100%). These studies assessed the impact of educational interventions on contextspecific self-efficacy, such as on patient communication and physical care (Dunn et al., 2014); respiratory problems and cardiac scenarios (Saied, 2017); feeding tube insertion (Bourgault et al., 2019); counsel about nutritional health promotion and disease prevention (Gotwals, 2018). The majority of these interventions involved specific skills required for assessing and caring for patients.

| Multimodality simulation learning approaches
Less than a quarter 10/47 (21.3%) of the studies used simulation in combination with other educational approaches. Results showed that post-test self-efficacy was higher than pre-test self-efficacy in the nine studies. Among the intervention groups, 60% used lectures (n = 6), and 10% used low-fidelity manikins (n = 1). Simulation sessions were based on communication with a patient experiencing mental health issues (Kameg et al., 2010), maternity scenarios (Said et al., 2021), managing multiple simulation patients (Franklin et al., 2015), team training (Leithead et al., 2019), examining the graduate nursing students self-efficacy of counselling abilities among individuals with mental illness (Schwindt et al., 2019), septic shock and chemotherapy reaction management (Sharour, 2019), faculty self-efficacy (Crocetti, 2014) and effects of a visiting nursing simulation on nursing students' self-efficacy (Hwang & Kim, 2020).

| Traditional didactic learning approaches
Of the 47 studies, 44.7% (n = 21) were didactic-based interventions; 20 of these studies (20/21, 95.2%) showed statistically significant higher means for the post-test vs. the pre-test groups with a range of different teaching strategies/resources for improving self-efficacy such as in a sexual education programme (SEP) context, posters and graphics promoting self-efficacy (Baek et al., 2019), and lectures and didactic presentations (Kim et al., 2018). In addition, palliative care training that includes lectures and workshops has been shown to improve nurses' perceived self-efficacy (Dehghani et al., 2020), and the training in pain management, which incorporates lectures, group discussions, and case studies was found to be effective in improving paediatric nurses' self-efficacy (Parvizy et al., 2020) (see Appendix S3).
TA B L E 5 Self-efficacy Outcomes for random control and non-random control two-group studies.
In one study, a blended approach was used to measure the long-term effects of a diabetes education intervention (3 weeks

| Self-efficacy in the context of the transition of nursing students from an educational programme into clinical practice
Although some of the included studies were longitudinal and repeated self-efficacy scores after a semester or a year, there was limited evidence on self-efficacy in the context of transitioning nursing students from an educational programme into clinical practice. Of 47 studies, one study used an online educational module to support the development of self-efficacy relating to dealing with bullying behaviour; the study sample included undergraduate nursing students transitioning from the academic setting to professional practice (EG M = 32.1, SD = 3.7, CG M = 29.6, SD = 3.6; p < 0.001) (Thompson, 2016).

| DISCUSS ION
In this systematic review, evidence from interventions that promote self-efficacy was identified, critically evaluated and synthesized, along with examining the role self-efficacy plays in the transition from clinical to academic practice. 47 papers were included, and However, combining online and other practice-based approaches may provide a more comprehensive blended approach. (Doucet & Rhéaume, 2020;Iannuzzi et al., 2019). Nevertheless, it was difficult to make a conclusive judgement due to the lack of evidence available. The limited evidence suggests a need to research how to improve nursing self-efficacy through online learning approaches.
Within the reviewed literature, face-to-face approaches positively impacted self-efficacy in a larger number of included studies. Face-to-face interventions tended to have a larger effect size than other methods. With reference to simulation-based learning, the results suggest that multimodality approaches, such as simulations combined with other instructional methods, are more useful in developing self-efficacy for those who are less skilled, while a single simulation-based approach may provide greater benefits for those with more clinical experience in terms of developing selfefficacy and are moving from novice to expert (Benner, 1984). As a result, they are developing specialist skills associated with greater complexity.
There were variations in results between studies, and this might be due to differing operationalizations of self-efficacy and tools used in measuring self-efficacy, reflecting different aspects of selfefficacy. In this review, 10 studies used the general self-efficacy scale GSES (n = 10) (see Appendix S4) to evaluate the effects of educational interventions, while the remaining studies used a large variety of tools. Measuring a nurse's self-efficacy can be difficult, and comparison across studies is problematic due to variation in tools (37 tools sourced); and the focus on task/domain-specific self-efficacy (such as interprofessional self-efficacy, mental health nursing self-efficacy, and transcultural self-efficacy (n = 37 studies) in contrast to general self-efficacy (n = 10 studies)). Five of the included studies provided validity and reliability data on the selfefficacy tool (Alfes, 2015;Ataee et al., 2019;Daglar, 2018;Rambod et al., 2018;Topbaş et al., 2019). Other authors have commented on the need for researchers to consider the psychometric properties of self-administered instruments to ensure consistency in measurement and the highest quality of measurement (Hwang & Kim, 2020;Saxton,&nbsp;2012). This review shows that nursing education interventions affect nurses' and nursing students' self-efficacy. The evidence is primarily non-randomized, based upon small sample sizes, with data collected over relatively short timeframes which limits our ability to definitively link changes in self-efficacy to certain programme components. While authors sought to synthesize details of statistically effective interventions (Appendix S3); without meta-analyses and more longitudinal data, author conclusions have to be tentative. This review is important because it is one of the only reviews to focus on this topic area with an interventional focus. Self-efficacy in the context of nursing education is important because if students believe in their capabilities, they would use their maximal efforts in different situations. Moreover, when the self-efficacy of student nurses is developed, their achievement motivation is also improved. This review provides us with several take-home messages for nurse educators: some teaching and learning strategies appear more regularly in successful interventions, that is flipped classroom approaches, simulation, debriefing, and role-play; multimodal approaches seem to be more effective than single-mode educational interventions; researchers should provide more details of intervention components in line with recommendations.

| S TRENG TH S AND LIMITATI ON S
This review contributes to the limited evidence base regarding educational interventions that build self-efficacy in nursing education (McCutcheon et al., 2015). An overview of self-efficacy findings from the last decade is presented in the review. This summary intends to highlight areas in need of further research, which may assist in planning future studies.
However, this review is limited by a lack of rigorous and highlevel evidence about the types of education programmes/interventions that cultivate self-efficacy most effectively. Additionally, based on our findings, studies included in the review lacked theoretical underpinnings. Over 60% of included studies lacked theoretical underpinnings, which is essential to developing and planning interventional studies (Iannuzzi et al., 2019). Thirdly, MMAT scores of 50 or below were found in nearly 60% of the studies. Fourth, the results provide little insight into the long-term relationship between self-efficacy and educational programmes. Only one study included longitudinal follow-up on participants. Further research is needed to explore how self-efficacy facilitates the transition from education to clinical practice for nursing students. The fourth limitation concerns the limited number of RCTs sourced; we found only eight eligible trials. Therefore, the conclusions of the review should be interpreted with caution. Additionally, the research team determined the search strategy without librarian support, including identifying databases and running the searches. Also, for this review, the absence of reported effect sizes for most of the included studies may indicate a weakness in the body of literature. Finally, meta-analyses were not conducted due to the heterogeneity of designs, data collection instruments, education programmes, sample sizes, data collection settings and outcome measures.

| CON CLUS ION
The review included a large body of literature (n = 47 studies), with the majority of empirical research in this area occurring in the United States (n = 21) and very little in Europe (n = 2). Limited higher-level evidence (e.g. randomized trials) was sourced, with the majority of studies being single groups, with no control group. There was a limited application of theory underpinning interventional studies. A large variety of tools were described, and most studies used general self-efficacy and researcher-designed scales.
This review demonstrates that nursing education programmes can develop and nurture self-efficacy. Some authors have proposed that self-efficacy has a mediating role in terms of bridging the gap between theoretical and practical knowledge, behaviours and clinical practice.
The majority of interventional studies statistically impacted selfefficacy; however, we cannot definitively conclude which educational interventions optimize self-efficacy. We can tentatively hypothesize that multimodal interventions are better than single-intervention studies and that simulation appears to support the development of self-efficacy in targeted skills/areas. Self-efficacy is an important variable in supporting nurses in making key transitions. However, limited empirical understanding of its role in the transition from student to practitioner was sourced, and longitudinal studies were lacking.

AUTH O R CO NTR I B UTI O N S
MA, NW, RC, BR and JH contributed to study design, data collection, data analysis and manuscript writing and supervised the study. All authors agreed on the final version.

ACK N OWLED G EM ENTS
The authors would like to thank Margaret Cole, a statistician from University College Cork, for reviewing statistical Tables 4 and 5.
Open access funding provided by IReL.

FU N D I N G I N FO R M ATI O N
There were no public, commercial or nonprofit organizations that funded this study.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors report no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data openly available in a public repository that issues datasets with

E TH I C S S TATEM ENT
There was no ethical approval needed since this is a systematic review of primary studies.