VOL. 5 NO. 2 DECEMBER 2021 104 IJNP (Indonesian Journal of Nursing Practices) Vol 5 No 2 DECEMBER 2021: 104-111 Shinta Antin Kumalasari¹, Sri Suparti¹*, Kala Raani² ¹ Faculty of Health Sciences, Universitas Muhammadiyah Purwokerto, Indonesia ² Faculty of Health and Life Sciences, Management and Science University, Malaysia Corresponding Author: Suparti Email: srisuparti@ump.ac.id Self-Efficacy and Readiness Towards Early Clinical Exposure Among Nursing Students Article Info Online ISSN DOI Article History Received Revised Accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (Print) : 2548 592X (Online) : 10.18196/ijnp.v5i1.13460 : 21 Aug 2021 : 10 Oct 2021 : 18 December 2021 Abstract Background: Early Clinical Exposure is a learning approach that integrates classroom learning with the clinical practice at the students' academic stage. Based on an interview with 3rd- semester Nursing Students, the results showed that they had low self-efficacy and readiness towards early clinical exposure. Objective: This study aims to evaluate self-efficacy and readiness towards early clinical exposure among nursing students of Universitas Muhammadiyah Purwokerto (UMP). The study design was a cross-sectional study involving 218 undergraduate students at a private Islamic university in their third semester. Methods: Data were collected using an online questionnaire of Google Form developed by the researcher, and the questions were valid and reliable based on a reliability test. The sampling method in this study was the total sampling technique. There were 50 questions of the item in the questionnaire and 6 items for demographic data. Result: The majority of pupils showed strong self-efficacy (98.2%) according to the findings of this study and moderate self-efficacy (1.8%). The majority of students presented high readiness (97.7%) and moderate readiness (2.3%). According to the correlation test results, a correlation (r = 0.545, p0.05) was found between self-efficacy and readiness for early clinical exposure. Conclusion: The higher the student's self-efficacy is, the more the readiness will be to face the practice of early clinical exposure. Keywords: Early Clinical Exposure; nursing students; Self- efficacy; Readiness INTRODUCTION Early clinical exposure (ECE) is a learning approach that integrates classroom learning and clinical learning at the students' academic stage. Early Clinical Exposure is a program that prepares first- year nursing students to meet and learn about patients in a real-world context. It is the early initiation of professional socialization and the basics in learning in their relevance to medical practice. The purpose was to show students the real experience of taking care of patients in a real environment. Early clinical exposure will be a medium for students to apply their knowledge from University into real clinical settings. Effective implementation of early clinical exposure can increase learning motivation and depth of learning, impacting better understanding and retention of knowledge. Early clinical exposure also facilitates http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 INDONESIAN JOURNAL OF NURSING PRACTICES 105 students' ineffective learning of clinical skills (Govindarajan et al., 2018). Effective clinical education can build self-confidence and help students achieve competency. It is an important part of the nursing education process as it provides much experience for students in cognitive, psychomotor, and affective aspects (Löfmark et al., 2012). Nursing students need clinical education to apply classroom information to real-world patient care, practice therapeutic communication, apply technical skills, have caring behaviors, and know or experience nursing duties (Benner et al., 2010). ECE makes students understand the illness and the concept of health and sickness (Yuliana et al., 2012). According to Meshram, Shaikh, & Khobragade (2016), the total state of a person that makes them ready to respond in a specific way to a situation is known as readiness. Factors that influence self- efficacy include experience in taking charge of something, social modeling, social persuasion, physical and emotional conditions. The first-year nursing undergraduate students often encounter difficulty in contextualizing their learning and integrating knowledge and skills into clinical settings (Siah et al., 2019). Factors that influence readiness are internal factors such as health, physical condition, mental condition, emotional condition, free-time availability, hobbies, self-maturity, intelligence, skills, and personality. Meanwhile, the external factors are family, friends' support, faculty facilities, problems encountered, relationships with friends, parents, and environmental influence. Emotional conditions also affect readiness to face early clinical exposure, such as tension, anxiety, insecurity (Nyambe et al., 2016). Students can adapt their role as nurses in a clinical environment to carry out nursing care properly, using the nursing process approach, professional attitudes, behavior, and applying skills professionally. The construct of Self-efficacy supports professional education and practice as it is an assessment of someone's ability to manage and carry out their actions and accomplishments. More importantly, increased self-efficacy has been linked to improving professional practice behaviors. It has potentially significant implications for nursing education and early clinical exposure or any other clinical practices (Cox & Simpson, 2016). Based on the study of Nyambe et al. (2016), the average score of first-year students' readiness to face clinical practice is lower than second and third- year students. It occurs since the first-year students have no experience in clinical practice. The first year of nursing education (especially the first two years) or 2nd semester are crucial to nursing students' success. The success not only depends on knowledge gained but also practices in the real environment, attitude, therapeutic communication, relationship with patients, and family. Besides, the senior nurses' perceptions of nursing students on professional nurses and patients' status based on nursing knowledge also affected their success. However, students' self-efficacy and readiness are important for completing their clinical practice, not only their skills, knowledge, and attitude. Students who have confidence in their abilities are ready to carry out early clinical exposure, face challenges, and not be afraid of obstacles. In other words, if the students' self-efficacy is low, they might not be ready to carry the clinical posting and not get high results. If the students have low self-efficacy and readiness, they cannot adjust the condition of the problems. Furthermore, the students feel helpless when encountering the real situation undergoing clinical exposure. In August 2019, the researcher interviewed ten 3rd semester Nursing Students and revealed that they had low self-esteem to face the early clinical exposure and learn the real clinical settings for the first time. The students mentioned they were afraid and not ready to carry out nursing services to real patients. Their low self-efficacy leads to a lack of readiness to conduct early clinical exposure. Students have to feel confident about their ability to do clinical practice and that they will be ready, prepare themselves to deal with clinical practice, challenges and tasks well. Clinical practice can be challenging for students, and some of them require additional supervision. As clinical experience is a major source of clinical self-efficacy, nurse educators must enhance learning in the clinical context (Plemmons et al., 2017). According to Bandura and Watts (1996), self-efficacy is individual beliefs about their ability to carry the tasks or actions to achieve an outcome. VOL. 5 NO. 2 DECEMBER 2021 106 More importantly, increasing self-efficacy will also increase professional practice, readiness to face any situation, and problem-solving skill (Fitri et al., 2016). The graduates meet the specified quality standard and prepare students to become professional health workers. Nursing students of Universitas Muhammadiyah Purwokerto have begun to deploy for clinical practice in the 3rd semester with Early Clinical Exposure. The Early Clinical Exposure is only allowed for the 3rd- semester nursing students to make observations and not make independent interventions without senior nurses' assistance. Students are expected to apply what has been taught in preclinical learning during class, with the assistance of senior professional nurses, and expected to pay attention, gain new knowledge that has not been taught in preclinical learning during class and laboratory skills. Based on the explanation above, this study aims to assess UMP nursing students' self-efficacy and preparation for early clinical exposure. METHODS This study is an observational analytic descriptive study with a cross-sectional approach (Sugiyono, 2017). Primary data were obtained using a questionnaire of Google Form with 50 questions developed by the researcher. The instrument's content was demographic data such as age, gender, previous course, and motivation to take nursing; there were 50 Likert questions items in the questionnaire. Cronbach's Alpha reliability was used to evaluate the measurement scale's precision. The results for readiness (0.831) indicated a high level of reliability. Self-efficacy of 0.669 indicated a good level of reliability. The questionnaire was administered and distributed in Bahasa Indonesia to the respondent as it is their first language. Furthermore, it was administered in English in this thesis to ease the reader from other countries. The target for this study was 3rd-semester bachelor nursing students at Universitas Muhammadiyah Purwokerto. The 3rd semester BNS students were selected as they did not experience any early clinical exposure yet; thus, they still had no idea how it felt to carry out early clinical exposure. The population of the 3rd-semester BNS students was 292 active students. However, only 218 students responded to the questionnaire because 74 students were doing the OSCE exam and could not fill the questionnaire. As a total sampling method, the number of samples was equal to the total number of students. The ethical clearance of the research was obtained from the ethics department of Universitas Muhammadiyah Purwokerto Number KEPK/UMP/19/XI/2019. This study discovered the association between self-efficacy and readiness for early clinical exposure using correlation analysis and Pearson product-moment. RESULT Descriptive analysis has been used in this study to define respondents' demographic profile, including age, gender, the course in high school before taking nursing, and motivation to take nursing. The results are based on the population's demographic data in Table 1. (see table 1) Based on the demographic data of the population, the finding in Table 1 clearly shows that the majority of the respondent was 19 years old. 83.5% were females, 121 of the respondents previously took science courses, and 55.5% were their self- motivation to take the nursing department. Table 3 shows that third semester BNS students at UMP had high self-efficacy (98.2%) and moderate self-efficacy (1.8%), with no students falling into the low self- efficacy category. Meanwhile, the majority of the students obtained a high level of readiness (97.7%) and moderate readiness (2.3%). This study also discovered a link between self-efficacy and readiness for early clinical exposure (r= 0.545, p0.05). It suggested that self-efficacy can influence readiness for early clinical exposure among students; if self-efficacy is strong, so is readiness (table 2). DISCUSSION Readiness for the students is crucial as unreadiness will affect their belief of inability to carry out the early clinical exposure. As the students will be in professional healthcare, they must have self- efficacy, self-confidence, self-belief, readiness besides knowledge, skills, and others. It is in line with a study by Akhmad et al. (2019), which showed that the majority of the students obtained high self- efficacy (56.8%), and the majority of students showed high readiness (89.6%). Therefore, it can be assumed that high self-efficacy will raise self- confidence. In other words, self-efficacy is self- confidence in individuals to achieve some goals or results in their activities. Readiness is affected by INDONESIAN JOURNAL OF NURSING PRACTICES 107 confidence, self-ability or self-efficacy. Self-efficacy is correlated with social cognitive knowledge or self- knowledge (Arifin et al., 2014). Self-efficacy is well correlated with readiness. They are both important. If one’s self-efficacy is high, so is their readiness, and vice versa. It also implies that students' self-efficacy has an impact on their preparation for early clinical exposure. Self-confidence in their abilities affects the students’ early clinical exposure journey. Low self-efficacy will close their attention to early clinical exposure even though they are interested in it. Nevertheless, if their readiness is low, they are afraid and worried that they could not do the early clinical exposure well and get satisfying results. The Impact of Self- Directed Learning Readiness on Critical Thinking and Self-Efficacy among Pupils in the Class of Physical Education and Sports discovered a significant link between self-directed learning readiness and general self-efficacy (r=.623 p=.000). The findings implied that self-directed learning preparedness impacts critical thinking, general self-efficacy, and other areas of education (Turan et al., 2018). It is in line with the researcher's results that self-efficacy and readiness have a considerable positive link towards early clinical exposure. Self-efficacy affects readiness and might influence other aspects of education such as knowledge, attitude, and others. A result by Meshram, Shaikh, & Khobragade (2016) showed that ECE piqued their interest in the subject, according to most students. They believed that ECE helped them visualize concepts and remember details from their medical classes better than individuals who had not been exposed to clinical settings. It indicated that ECE has a big impact on students and helps them understand the clinical practice, making them more familiar with various fields. Most students regarded the ECE experience as an inspiring, motivating, engaging, wonderful, useful, good form of learning that elicited self- interest. They revealed that it helped them appreciate the importance of basic science in clinical practice. Practically, interested students contacted doctors in their chosen specialty and pursued their interest in the issue (Govindarajan et al., 2018). First-year medical students were introduced to the ECE program to supplement standard clinical teaching sessions. The efficacy of this study was demonstrated by the students' ability to use their ECE abilities in their usual clinical placements (Rawekar et al., 2016). ECE is helpful for the students in their routine clinical postings, and that they need to gain their self-efficacy to get them ready for clinical postings to achieve high results. According to research, there is a link between preparation for substance abuse treatment and self- efficacy based on life skills (Moeini et al., 2020). The results of this study found that there was a significant relationship between self-efficacy and the substance users' readiness for treatment improvement. The present study was showed that the self-efficacy model predicts 20% to 25% of the readiness for treatment variance. Significantly predictors of readiness for the treatment variables are communication and assertiveness, but ambivalence is highly correlated with problem- solving abilities. This result is in line with the researcher's findings that there was a significant relationship between self-efficacy and readiness, indicating that self-efficacy is affecting the students' readiness to carry out the early clinical exposure in order for them to get satisfied and high results. Clinical practice experiences allow nursing students to apply what they have learned in lab practice skills and interact with patients, families, and nurses in a real environment. The higher the self-efficacy is, the higher the readiness will be. The higher the self- efficacy is, the more motivated and ready the person can be to achieve high results (Rowbotham & Owen, 2015). According to Baiti, Abdullah, & Rochwidowati, (2017), higher self-efficacy is followed by higher readiness, while lower self-efficacy is followed by lower readiness. This study also showed a significant positive correlation between self-efficacy and readiness towards early clinical exposure. It is presented in Table 4 that the results for Pearson Correlation are r=0.545, p<0.05 for both self- efficacy and readiness. It can be assumed that self- efficacy affects readiness, as the readiness is also high. The self-efficacy variable contributes readiness of the students (Baiti et al., 2017). Results from another study about The Relationship Between Self- Efficacy and Readiness for Change: The Mediator Roles of Employee Empowerment demonstrated a significant effect on self-efficacy towards readiness VOL. 5 NO. 2 DECEMBER 2021 108 (Emsza et al., 2016). As a result of the findings of the study on Self-efficacy with Vocational High School Students Work Readiness, there is a positive and significant correlation between self-efficacy and work readiness, with coefficients of r=.676 and p=.000; p0.05 indicating that the higher the self- efficacy is, the higher the readiness will be, and vice versa, (Utami & Hudaniyah, 2013). The research results by Reed et al. (2019) revealed a connection between self-efficacy and change preparedness. It indicated that self-efficacy and readiness to control heavy drinking could be important factors. It aligns with this research revealing that self-efficacy and readiness are important factors for students to obtain high results on early clinical exposure as they are the internal factors. In other words, they have to believe in themselves and be ready to carry out the early clinical exposure. Furthermore, they also could encounter all of the obstacles without any doubt as they believe in themselves. In another study (Alfaiz et al., 2017), self-efficacy as a students' readiness prediction factor greatly influences self-capability and affects every activity. Self-confidence produces self-readiness, and that the results showed that the students' self-efficacy affects self-capability and individual student activity. When the students have high self-efficacy, their readiness will also be high. Moreover, a study by Mitchell & Mcmillan (2018) revealed that self-efficacy improved where assignments of increasing complexity were used to stimulate critical thinking, analysis, and reflexivity. It is also affected when course subject instructors, not writing instructors, were the primary assignment- specific writing supports. Furthermore, another study by Fitriati & Dewi (2018) denoted that the higher the students' self- efficacy is, the higher the evaluation results will be. Thus, all of the results supported the researcher's results that the higher students' self-efficacy is, the higher their readiness towards early clinical exposure will be. Students who have high self- efficacy and readiness are expected to improve quality. The self-efficacy in students is related to readiness. It can help them ensure their abilities to do the tasks or actions needed to achieve certain satisfying and high results. To have high self- efficacy, the students need to develop through exercises carried out continuously according to students' capabilities. In this case, the exercises include preclinical (class theory) and laboratory exercises. These aspects can be a reference for the students to be more confident of their ability to solve the problems, more confident and motivated to achieve their goals, and students can well undergo early clinical exposure tasks and obstacles (Omer, 2016). Nursing students' confidence levels in the clinical setting may vary due to changes in the nursing curriculum that encourage more student- centered learning activities (Panduragan et al., 2011). The self-efficacy and readiness concept is important to undergo the clinical practice. Thus, in preparing early clinical exposure, efforts are needed to improve self-efficacy and develop self-confidence optimally to get satisfying results. Readiness shows a condition where someone can respond to early clinical exposure using mind, body strength, skills, and knowledge. Moreover, students need a positive self-concept from self-confidence and self- acceptance to support their readiness. Other aspects of supporting the readiness include self- efficacy through decision making, confidence in their abilities, and belief in themselves on how far they can identify their abilities to carry out early clinical exposure with satisfying results (Yuwanto et al., 2016). CONCLUSION Based on the result of this study, it can be drawn that self-efficacy and readiness had a considerable positive correlation towards early clinical exposure among 3rd Semester Nursing Students in UMP. The higher the student's self-efficacy is, the higher their readiness will be to undergo the practice of early clinic exposure. The suggestion for the further research project is to add more variables and investigate pre-post early clinical exposure. ACKNOWLEDGEMENT I would like to thank Universitas Muhammadiyah Purwokerto for all of the support, Management & Science from the University as a collaborated university and the support and Directorate of Higher Education for Credit Program. REFERENCES Akhmad, V. S., Yusuf, S., Safitri, A., Juwita, H., Risnah, R., & Arbianingsih, A. (2019). 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Demographic Data of the Study Population (n=218) Demographic Characteristic f % Age 18 years old 19 years old 20 years old 21 years old >21 years old Gender Male Female Previous Course Science Social Non-health science Health science The motivation of taking Nursing Self-motivation Parents Other people Other reasons 22 152 36 5 2 36 182 121 36 20 42 121 89 3 5 10.1 69.7 16.5 2.3 1 16.5 83.5 55.5 16.5 9.17 19.3 55.5 40.8 1.4 2.3 Table 2. Level of Self-efficacy, Readiness and Pearson Correlation Test Variable Low Moderate High r p-value Self-efficacy 0 4 (1.8%) 214 (98.2%) 0.545** <0.001 Readiness 0 5 (2.3%) 213 (97.7%)