The relationship between nursing students’ perceived self-efficacy in physical examination and their attitudes toward clinical practice: a cross-sectional study

Self-efficacy, defined as an individual’s belief in their ability to successfully perform a specific task, is a central construct of social cognitive theory and a key predictor of motivation, learning, and performance [1]. In nursing education, self-efficacy plays a vital role in shaping students’ confidence, clinical decision-making, and engagement in practice environments [2, 3]. Students with higher self-efficacy are more likely to persevere when faced with clinical challenges, actively participate in patient care, and approach clinical tasks with confidence, whereas low self-efficacy is associated with avoidance, anxiety, and reduced skill performance [4].

Among the variety of clinical competencies required in nursing, self-efficacy in performing physical examination skills holds unique importance. Physical examination is one of the foundational components of clinical assessment, forming the basis of patient evaluation, early problem identification, and safe clinical decision-making [5]. Unlike many procedural skills that are performed under supervision or with guidance, physical examination requires the integration of cognitive, psychomotor, and communication skills simultaneously. Therefore, low self-efficacy in this area can directly limit students’ ability to conduct accurate assessments and may negatively affect their overall clinical performance [6]. Despite its critical nature, existing studies indicate that nursing students often feel inadequately prepared and lack confidence in performing physical examination skills [7, 8]. A growing body of research has explored general clinical self-efficacy among nursing students; however, studies specifically examining self-efficacy related to physical examination—and how it shapes students’ attitudes toward clinical practice—remain limited and inconsistent. Some studies report that students demonstrate low confidence in physical examination despite receiving theoretical instruction [9], while others highlight that physical examination training is not sufficiently reinforced throughout the curriculum [10]. Moreover, although several studies suggest a potential association between self-efficacy and students’ attitudes toward clinical learning, the extent and direction of this relationship particularly in relation to physical examination skills are not clearly established in the current literature. As a result, it is uncertain whether students who feel more competent in physical examination also hold more positive attitudes toward clinical practice [11].

Research in this field has consistently demonstrated that nursing students’ perceived self-efficacy in performing physical examinations significantly predicts their attitudes, motivation, and performance in clinical practice settings. According to social cognitive theory, self-efficacy refers to individuals’ beliefs in their ability to successfully perform specific tasks or behaviors, which can profoundly influence their motivation, effort, and performance [13‐15]. Nursing students with strong self-efficacy in physical examination tend to approach clinical practice with confidence, demonstrate greater engagement, and show a willingness to handle challenging situations, thereby facilitating the development of essential skills and competencies required to become competent, safe, and clinically proficient nursing professionals [7, 12, 16, 17]. Conversely, students with lower self-efficacy may struggle to fully engage in clinical practice, experience higher levels of anxiety, and adopt a less proactive approach, which can hinder their professional growth and performance. Understanding and addressing this relationship is therefore crucial for nursing education programs to better support and empower students, ultimately fostering the development of clinically competent and confident nurses.

In this context, the aim of this study is to examine the relationship between nursing students’ perceived self-efficacy in physical examination and their attitudes toward clinical practice. By addressing the specific gap regarding physical examination self-efficacy, this study seeks to provide evidence to guide educational strategies that strengthen students’ clinical confidence and readiness.

The descriptive characteristics of the students who participated in the study are presented in Table 1. Accordingly, the students’ ages ranged from 19 to 30 years, with a mean age of 21.59 ± 1.76 years. Among the participants, 28.2% were 22 years old, 75.6% were female, and 35.5% were second-year students. Additionally, 71.1% of the students reported that their maternal education level was primary school or below, while 44.9% stated the same for their father. Regarding parental occupations, 76.3% of the students’ mothers were housewife, and 58.9% of their fathers were self-employed or tradespersons. Furthermore, 66.2% of the students perceived their family income level as moderate or lower (Table 1).

The mean scores obtained from the scales by the students participating in the study are presented in Table 2. Accordingly, the mean scores of the subdimensions of the Perceived Self-Efficacy in Physical Examination Scale (PSE-PE) were as follows: face and neck: 2.54 ± 0.62, eye: 2.29 ± 0.69, cardiovascular: 2.44 ± 0.63, ear, nose, and throat: 2.24 ± 0.69, chest: 2.38 ± 0.65, and other skills: 2.39 ± 0.60. The total PSE-PE scores ranged from 1.16 to 4, with a mean score of 2.38 ± 0.56. When the self-efficacy categories were examined based on the mean scores of the PSE-PE subdimensions and total scores, the following distributions were observed: 38.7% of students reported being “Confident” in the face and neck subdimension. 39% reported being “Not very confident” in the eye subdimension. 42.5% reported being “Not very confident” in the cardiovascular subdimension. 39.7% reported being “Not very confident” in the ear, nose, and throat subdimension. 39.4% reported being “Confident” in the chest subdimension. 40.4% reported being “Not very confident” in the other skills subdimension. 45.3% reported being “Not very confident” in the total PSE-PE score. When examining the mean scores of the Attitude Toward Clinical Practice Scale (ATCPS) subdimensions, the results were as follows: Belief and expectation: 33.34 ± 5.02 Positive approach: 24.15 ± 6.11 Negative approach: 28.84 ± 3.68 Personal development: 16.10 ± 2.58 The total ATCPS scores ranged from 60 to 130, with a mean score of 102.43 ± 14.29 (Table 2).

According to the analysis results, when comparing academic year levels with the belief and expectation subdimension mean scores, it was observed that as the academic year increased, the mean score decreased. Post-hoc analysis revealed that the mean score of second-year students was significantly higher than that of fourth-year students (p = 0.005). In the positive approach subdimension, second-year students had a significantly higher mean score than students in other academic years (p < 0.001). When comparing the negative approach subdimension mean scores by academic year, it was found that as the academic year increased, the mean score also increased. Post-hoc analysis showed that the mean score of second-year students was significantly lower than that of fourth-year students (p = 0.008). For the personal development subdimension, a significant difference was observed (p = 0.003), with post-hoc analysis indicating that third-year students had a significantly lower mean score compared to other academic years. Regarding the total ATCPS scores, the analysis demonstrated that as the academic year increased, the total mean score decreased (p < 0.001). Post-hoc analysis further revealed that second-year students had a significantly higher total mean score than fourth-year students.

According to the analysis results, a significant difference was found between the PSE-PE categories and the belief and expectation subdimension mean scores (p = 0.001). Similarly, significant differences were observed in the positive approach, negative approach, and personal development subdimensions (p < 0.001). In addition, the total PSE-PE mean scores differed significantly across confidence categories (p < 0.001). Overall, these results indicate that perceived self-efficacy levels are significantly associated with all subdimensions of the scale.

Examining the relationship between PSE-PE scores and ATCPS subdimension and total scores, a low to moderate positive correlation (0.250–0.499) was identified (p < 0.001) (Table 3).

The relationship between students’ descriptive characteristics and PSE-PE scores with ATCPS according to multiple linear regression analysis is presented in Table 4. According to the analysis, when examining the models established using the Stepwise method, the explanatory power of PSE-PE scores for ATCPS total scores was found to be 9.7% (Model 1; Adjusted R²: 0.097, F = 31.844, p < 0.001). It was determined that a one-unit increase in perceived self-efficacy score increased the attitude toward clinical practice score by 8.19 units (B = 8.196, p < 0.001). In another model, which included PSE-PE scores and being a second-year student, the explanatory power for ATCPS scores increased to 18.5% (Model 2; Adjusted R²: 0.185, F = 33.398, p < 0.001). According to this model, a one-unit increase in perceived self-efficacy score increased the attitude toward clinical practice score by 10 units (B = 10.010, p < 0.001), while being a second-year student increased the attitude toward clinical practice score by 9.2 units (B = 9.228, p < 0.001) (Table 4).

In this study, the perceived self-efficacy score in physical examination among nursing students was found to be 2.38 ± 0.56. This result indicates that students’ perceived self-efficacy regarding physical examination skills is at a moderate level. The moderate level of self-efficacy observed in students may be related to insufficient course hours, limited number of instructors, and large class sizes, all of which reduce practice opportunities and individualized feedback. These factors can negatively influence students’ skill development and ultimately lower their perceived self-efficacy in physical examination. Analyses of the subdimensions of the Perceived Self-Efficacy in Physical Examination Scale (PSE-PE) reveal that students are not fully confident in their physical examination skills and that their self-confidence in this area needs to be further developed. Kıskaç and Rashidi (2024) reported a lower perceived self-efficacy score of 1.83 ± 0.50 among nursing students [22]. The discrepancy between the lower self-efficacy levels reported by Kıskaç and Rashidi and the findings of the present study may be attributed to the fact that their research was conducted exclusively with second-year students. In contrast, the inclusion of second-, third-, and fourth-year students in the current sample likely contributed to higher self-efficacy scores, as perceived self-efficacy in physical examination tends to increase with advancing academic level and accumulated clinical experience. Studies evaluating nursing students’ physical assessment skills have shown that while students possess theoretical knowledge of the assessment process, they encounter difficulties in its practical application [23‐25]. Nursing education is a critical process aimed at developing students’ clinical skills, with physical assessment being a fundamental component of this training. The teaching of physical assessment begins in the early years of nursing education and is continuously reinforced through clinical practice and laboratory courses [26].

In nursing education, clinical practice is a process in which theoretical knowledge is translated into practice, allowing students to gain experience and facilitating their transition into the profession [27]. In this study, which assessed nursing students’ attitudes toward clinical practice, it was found that their attitudes were generally positive and high. Similarly, Gezer & Temel (2019) reported that nursing students had high clinical practice self-efficacy, while Türker & Bulut (2023) found that students exhibited positive and high attitudes toward clinical practice [21, 27]. Additionally, second-year nursing students were found to have more positive attitudes toward clinical practice compared to students in other academic years. A noteworthy finding is that second-year students had more positive attitudes toward clinical practice and higher self-efficacy levels compared to those in upper years. While this may be partially attributed to the novelty of clinical exposure, another possible explanation is that early-stage clinical experiences are less complex and more guided, which can boost confidence. However, as students advance, clinical challenges intensify, and inadequate support may erode earlier gains in self-efficacy [27]. This pattern suggests the need for sustained mentorship and simulation-based learning beyond the early phases of nursing education.

A low but positive correlation was found between students’ PSE-PE scores and ATCPS subdimension and total scores. This indicates that as perceived self-efficacy in physical examination increases, students’ positive attitudes toward clinical practice also improve. The development of physical examination skills extends beyond the mere acquisition of technical knowledge and skills; it also plays a crucial role in helping students develop their professional identity in clinical settings [26]. This finding reinforces the idea that self-efficacy is not merely an internal perception but a factor that significantly shapes how students engage with clinical learning environments. Notably, students with higher self-efficacy likely interpret clinical challenges as opportunities rather than threats, which may lead to more proactive behaviors and professional identity development. In this context, enhancing students’ perceived self-efficacy in physical examination contributes to fostering a more positive attitude toward clinical practice.

While the results are promising, the relatively low explanatory power of self-efficacy in predicting attitudes (Adjusted R² = 0.097 in Model 1) indicates that additional variables—such as clinical instructor support, prior healthcare experience, peer collaboration, or academic stress—may also play critical roles. Future studies incorporating such variables could offer a more holistic understanding of the factors influencing students’ clinical attitudes. Additionally, the context of this study—conducted at a single university in Türkiye—warrants cautious interpretation. Cultural expectations, curriculum structure, and recent events such as the 2023 earthquake may have influenced students’ perceptions and learning experiences. As such, while the findings offer valuable insights, their generalizability remains limited. However, similar patterns have been observed in other countries. For instance, studies conducted in South Korea, Canada, and Saudi Arabia have reported that self-efficacy and early clinical exposure significantly impact students’ attitudes and professional identity formation [6, 9, 26]. These parallels suggest that despite cultural and structural differences, enhancing self-efficacy is a universally beneficial strategy in nursing education. Therefore, these results can inform educators in similar contexts and encourage comparative cross-cultural studies.

Integrating physical assessment skills into all stages of nursing education, both theoretically and practically, will enhance students’ clinical competence and significantly contribute to their professional development. This study revealed a positive relationship between nursing students’ perceived self-efficacy in physical examination and their attitudes toward clinical practice. Notably, second-year students reported higher levels of self-efficacy and more positive attitudes, underscoring the importance of early clinical exposure.

To enhance nursing students’ clinical readiness, the following recommendations are proposed:

Future research should explore other influencing factors such as institutional climate, student-instructor relationships, and stress levels. Multicenter or longitudinal studies would also provide broader perspectives and enhance generalizability.

In summary, improving nursing students’ perceived self-efficacy can have a meaningful impact on their clinical attitudes and learning outcomes. Purposeful curricular design that incorporates hands-on training, sustained support, and reflective opportunities is essential for fostering competent and confident future nurses.