Impostor phenomenon, characterised by persistent self-doubt and feelings of inadequacy, despite noteworthy achievements, has been extensively studied across various professions. However, its prevalence among nurses, particularly those in specialist roles, remains a relatively unexplored area. This research had a dual purpose: first, to determine whether impostor phenomenon is a concern within this group; and, second, to identify contributing factors, such as tenure in the role, prior experience, self-confidence levels, access to training and support, and instances of absence due to confidence issues.
Given the NHS's current focus on nurse recruitment and retention, comprehending the impact of impostor phenomenon on this crucial segment of health professionals carries significant implications for workforce wellbeing and patient care (Stacey, 2022). This study concentrated on this under-researched area, seeking to highlight the experiences of impostor phenomenon among nurses in specialist roles and proposing specific interventions to alleviate its effects.
Narrative literature review
Impostor phenomenon is a term originally coined by Clance and Imes (1978) to describe individuals who, despite substantial professional accomplishments, are unable to internalise their success and suffer from chronic self-doubt. They think their achievements are not due to their competence, but are down to luck, effort or the ability to deceive others into thinking they are more competent than they believe themselves to be.
Research has shown that many with impostor phenomenon live in fear of being ‘exposed’ and struggle with anxiety and depression. They are unable to accept praise and attribute any success to external factors, thus perpetuating a cycle of self-doubt (Pinker, 2009). The phenomenon has been observed across various fields such as industry, academia and medicine, affecting staff at all levels (Rosenthal et al, 2021). Although a significant body of research has explored the prevalence of impostor phenomenon in various demographics and professions, there is a dearth of research concerning its impact in nursing, particularly among nurses in specialist roles.
Initial studies focused mainly on women, reporting that they were more prone to experience impostor phenomenon than men (Clance and Imes, 1978). Subsequent research has both supported and challenged this view, suggesting that impostor phenomenon does not discriminate on the basis of gender (September et al, 2001; Clark et al, 2014).
Nurses are regularly exposed to high-stress situations, emotional trauma and relentless work pressures. Such conditions make the nursing profession vulnerable to both impostor phenomenon and its associated effects, including anxiety, depression and burnout (Peng et al, 2022). In fact, the transition to specialist roles in nursing has been shown to be a particularly vulnerable time, often characterised by increased responsibility and less-defined role guidance (Mannix and Jones, 2020). The absence of structured support systems during such transitions can exacerbate feelings of inadequacy and heighten the experience of impostor phenomenon (Barnes, 2015).
Design
The study focused on nurses occupying specialist roles, specifically nurse specialists and nurse practitioners (NPs), within a large NHS foundation trust in the North East of England. These roles are classified under the Agenda for Change bands 6-7.
A cross-sectional study design was adopted for this research. Participants were required to fill out a web-based, anonymous questionnaire. This method was chosen over interviews to accommodate the busy schedules of health professionals and to maintain anonymity, thereby encouraging candid responses. The questionnaire included both closed and open-ended questions, providing a mix of quantitative and qualitative data for analysis. Before the main survey distribution, the questionnaire was piloted among a small group of nurse specialists to refine its structure and content.
Between January and March 2019, approval for the study was secured from the trust research and development department. Subsequently, email invitations were sent to 304 nurses working in specialist roles within the trust. Of these, 15 were male and 289 were female. To boost awareness about the study, an announcement was also made on the trust's intranet, featuring a Participant Information Sheet (PIS) about the research. No additional reminders were sent to potential participants.
In this study, informed consent was considered to be implied upon completion of the anonymous questionnaire, as clearly stated in the PIS. Ethical approval was obtained from the Health Research Approval committee, with the following trial and protocol registration details: IRAS Project ID: 243970, protocol number: One, REC/Reference: 19/HRA/0558. This study also received the necessary permissions from both the trust and Newcastle University Research and Development departments.
Participants were provided with information on how to contact the researcher or the trust's occupational health department in case they experienced emotional distress during their participation, ensuring that their wellbeing was a priority. The research team also maintained transparency by informing participants about the planned dissemination of the study's findings.
Data collection
Data collection was completed within the stipulated time frame, and additional insights were gathered post data collection to shape the narrative, presentation of the data and the final paper. The demographic data gathered covered variables such as gender and age, with the latter categorised into the following brackets:
- 21-30 years
- 31-40 years
- 41-50 years
- 51-60 years
- 61-70 years
- 70+ years.
Additional data points included the year the participant had qualified as a staff nurse and the length of time they had been in their current specialist role. These were each categorised into the following time spans:
- Less than 6 months
- 6 months–1 year
- 1-2 years, 2-5 years
- More than 5 years.
The questionnaire also explored whether the current role was the participant's first specialist position, awareness of the term ‘impostor phenomenon’, and their ability to relate to the concept now that they were aware of it.
The primary assessment tool used in the online questionnaire was the Clance Impostor Phenomenon Scale (CIPS). This is a 20-question validated instrument that uses a Likert scale, with the score ranging from 1 (‘not at all true’) to 5 (‘very true’). The maximum CIPS score is 100, as each of the 20 questions can score a maximum of 5 points. Scoring follows Clance's guidelines, where a total score below 40 suggests few impostor characteristics; between 41 and 60 indicates moderate experiences of impostor phenomenon; between 61 and 80 signifies frequent experiences; and above 80 implies intense experiences of feeling like an impostor. The scale was used with permission from its creator, Dr Pauline Clance. Although alternative scales are available, the Clance scale was selected for its sensitivity and frequent citation in academic literature. It has Cronbach's alpha score of between 0.87 and 0.92, which is a measure of its reliability.
Last, the online survey incorporated free-text questions, offering participants the opportunity to elaborate on issues concerning support and training, as well as reflections on their transition into their current role. These qualitative data were analysed using inductive theming as outlined by Joffe and Yardley (2004), allowing for the identification of key themes from the responses.
Data analysis
Data analysis was conducted in two main phases. The first involved a comprehensive examination of descriptive statistics to portray a nuanced understanding of impostor phenomenon among specialist nurses. This phase entailed an analysis of the CIPS scores, segmented by variables such as gender and length of time in the role. Additionally, the analysis considered whether respondents had previously been aware of the term ‘impostor phenomenon’.
In the second phase, a regression analysis was carried out to determine whether the Clance scores could be predicted by various factors. These included gender, age, years since qualification, length of time in the current role, and whether the role was the respondent's first specialist position. Due to the categorical nature of some variables, dummy variables were used in the regression model. Correlation tests were not employed, as they were deemed uninformative, given the extensive use of dummy variables in the analysis.
Finally, a thematic analysis was undertaken of the free-text comments submitted by participants. Through this qualitative methodology four key themes were identified, adding depth and context to the quantitative findings.
Results
Of the 79 nurses in specialist roles who participated, 78 completed the CIPS. Most participants were female (n=69), with a small number of male nurses (n=9). The scores varied significantly, yet 85% of the women and 80% of the men recorded moderate to frequent impostor characteristics (scores 41-80).
When examining the length of time in their current nurse specialist role, it was noted that prior to the study only 18 respondents (22.7%) had been aware of the term ‘impostor phenomenon’, and 61 (77.2%) had not heard of it. After becoming aware of the term, 68 (86%) could identify with it, but 11 (13.2%) could not.
Multiple regression analysis using the statistical software package SPSSv26 found that none of the measured variables significantly predicted impostor phenomenon scores.
Key themes that emerged from the qualitative findings
Four main themes emerged from the free-text analysis:
- Self-doubt and lack of confidence
- Expectations and role transitions
- Perceived perceptions of others
- Risk of burnout.
Theme 1. Self-doubt and lack of confidence
Participants frequently mentioned feelings of self-doubt, regardless of their years of experience, as the following comments illustrate:
‘I feel like I am shrinking. I don't feel as though I can articulate my thoughts the way I used to, and I feel less and less confident.’
Male, more than 2-5 years' experience (CIPS 75)
‘I sometimes feel [that], even though I have been an NP for over 16 years, I may not know very much and sometimes doubt myself. When I am talking to an audience, I have to remind myself that I know more than the audience.’
Female, more than 5 years' experience (CIPS 37)
‘I have feelings of self-doubt and compare myself to others.’
Female, 2-5 years' experience (CIPS 64)
Theme 2. Role transition
Role transition was often described as challenging. While some reported receiving practical support and training, this did not necessarily correlate with lower CIPS scores.
‘Always a period of uncertainty when transitioning and developing confidence and competence.’
Female, 2-5 years in current specialist role (CIPS 53)
‘Hard to think of yourself as a specialist when you first take on a new role.’
Female, 1-2 years in current specialist role (CIPS 55)
‘I can relate to this term (impostor phenomenon) when I reflect on when I started in my role many years ago.’
Female, >5 years in current specialist role (CIPS 32)
‘Clinical training and experience help to improve confidence in the clinical situation, which helps emotionally as well.’
Female, 1-2 years in current specialist role (CIPS 84)
‘Not directly. I was very much left to learn the role myself, taking over immediately from the person who had retired. Have attended a number of study days/forums relating to different aspects of the role, but this was once I had been in post for some time.’
Female, 2-5 years in current specialist role (CIPS 79)
‘The ward I worked on previously links very closely with the role I have now, so I had some of the practical skills already.’
Female, more than 6 months in current specialist role (CIPS 44)
‘Competency-based training, support from medical colleagues.’
Female, 5-7 years in current specialist role (CIPS 78)
‘I receive support both practically and emotionally from colleagues within my team.’
Female, 6-12 months in current specialist role (CIPS 72)
Key theme 3. Perceptions of others
Many nurses reported a fear of being exposed as unqualified, attributing their achievements to luck rather than ability, as illustrated in the comments below.
‘Have always felt that I am about to be ‘found out’.’
Female, 2-5 years in post (CIPS 79)
‘I constantly feel [that] someone is going to find out I don't know what I am doing.’
Female, 1-2 years in post (CIPS 78)
‘IP [imposter phenomenon] explains the feelings I had when beginning my role: feelings of self-doubt and anxiety.’
Female, more than 5 years in post (CIPS 58)
Theme 4. Risk of burnout
Several participants commented on the mental toll of their work, mentioning that, although they had not taken time off due to self-doubt, they felt the strain could lead to burnout.
‘No, although sometimes I have felt I needed to.’
Female, 2-5 years in post (CIPS 64)
‘No, but I could have on a number of occasions.’
Female, more than 5 years in post (CIPS 63)
‘No, I was determined not to go down that slippery slope and turned up to work every day, even though it was difficult, and I felt I didn't deserve to be in that role.’
Female, 1-2 years in post (CIPS 84)
With prior research on impostor phenomenon mostly focusing on fields such as medicine, industry and academia, the current study aimed to fill a gap by exploring the presence and impact of the phenomenon among registered nurses in specialist roles. This study primarily aimed to:
- Confirm the existence of impostor phenomenon among nurses in specialist roles
- Explore various factors, such as time in post, self-confidence, and training, that could influence impostor phenomenon.
Discussion
The study found that impostor phenomenon is widespread among specialist nurses, irrespective of variables such as age, gender and time in post. Contrary to Bravata et al's (2020) literature review suggesting that age reduces impostor phenomenon, this study, much like Want and Kleitman (2006), found that age does not significantly affect the experience of impostor phenomenon.
Gender differences were also explored, but with a small sample size of male nurses it was difficult to draw conclusive insights. Nevertheless, moderate levels of impostor phenomenon were found in most male participants, aligning with previous research, suggesting that gender does not strongly influence impostor phenomenon (September et al, 2001).
Through qualitative data, it emerged that transitioning to a new specialist role often triggered impostor phenomenon, undermining the nurse's existing experience and expertise. Despite being senior nurses, many participants reported ongoing feelings of impostor phenomenon, which aligns with findings from previous research (Cope-Watson and Smith Betts, 2010).
In terms of training and emotional support, there was a marked inconsistency. While some of the nurses had had adequate preparation, others lacked the emotional resources required for their specialist roles. This echoes Hochman et al (2023), who identified the importance of supervision and peer support in reducing stress and building resilience, thereby potentially reducing impostor phenomenon.
The lack of consistent training and emotional support could increase the risk of burnout, as corroborated by other research findings (Joshi and Mangette, 2018). Anxiety and stress were commonly reported, highlighting the need for better support systems to cope with the demands of specialist roles.
One notable finding was that the majority of participants, once educated about impostor phenomenon, could identify with it. This identification with impostor phenomenon is a new insight not often discussed in existing literature.
Limitations and future research
This study had limitations in its scope, as it surveyed only one sample population from a single trust, limiting generalisability. Future research should focus on multiple trusts for a more comprehensive understanding. Additionally, further qualitative studies using interviews or focus groups could add depth to these findings.
Conclusion
This research underscores the significant and widespread presence of impostor phenomenon among nurses working in specialist roles. The implications of impostor phenomenon are far-reaching, affecting not only self-esteem but also professional efficacy and general wellbeing. The study uniquely reveals that impostor phenomenon is commonly experienced during times of career transition and is not largely influenced by demographic factors such as gender. This calls for a tailored approach to tackle the phenomenon within this specific nursing community. Given these findings, it becomes imperative to devise focused interventions that provide both emotional and practical support, along with targeted training, to mitigate the effects of impostor phenomenon.
Recommendations for practice
Based on this research study, several recommendations for practice emerge. First, the introduction of a structured orientation programme for nurses entering specialist roles is essential for preparing them both practically and emotionally. Second, ongoing support mechanisms, such as mentorship schemes and emotional wellbeing assessments, should be established to identify and manage cases of impostor phenomenon. Third, targeted training sessions should focus specifically on overcoming impostor phenomenon, with the option of incorporating these into existing professional development programmes. Last, awareness-raising initiatives could educate staff about the signs and symptoms of impostor phenomenon and direct them towards available resources for support. These recommendations offer a comprehensive approach to mitigating the impact of this phenomenon among specialist nurses.
KEY POINTS
- Moderate to frequent experiences of impostor phenomenon were experienced in 83% of the study group, across genders and in periods of transition
- The number of roles and length of time in clinical practice do not exclude participants from feelings of imposter phenomenon
- The insecurities of nurses in specialist roles, how they are perceived and the support they receive appear to drive experiences of impostor phenomenon
- Devising focused interventions that provide both practical and emotional support, with training to mitigate the effects of impostor phenomenon is necessary within this group of health professionals
CPD reflective questions
- Have you experienced impostor phenomenon during your career, or have you noticed this within any of your colleagues?
- How does this impact on your/their practice, such as working longer hours to prove that you/they can carry out your role, or prevent you/them from speaking up in meetings, for example?
- Find out if there are any support groups/strategies for nurses working within specialist roles in your area of practice, which could help to develop interventions to mitigate imposter phenomenon