Investigating the Association Between Resilience and the Impostor Syndrome in Undergraduate Nursing and Medical Students: A Cross-Sectional Study

doi:10.21203/rs.3.rs-3242676/v1

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Research Article

Investigating the Association Between Resilience and the Impostor Syndrome in Undergraduate Nursing and Medical Students: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-3242676/v1

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Background: The prevalence of impostor syndrome has been recognized among undergraduate nursing and medical students. Resilience, on the other hand, refers to an individual's ability to adapt and bounce back from adversity. Understanding the relationship between these two constructs is important in promoting student well-being and academic success.

Methods: Thiscross-sectional study aimed to investigate the relationship between resilience and impostor syndrome among undergraduate nursing and medical students. A convenience sample of 300 students from King Saud bin Abdulaziz University for Health Sciences participated in the study. Participants completed self-report questionnaires to assess their levels of resilience and impostor syndrome.

The results revealed that less than half of the participants experienced impostor syndrome, with 41.7% classified as severe, 37.7% as moderate, and 13.0% as intense among nursing students. For medical students, 4.6% were classified as mild, 4.6% as moderate, 4.5% as severe, and 4.5% as intense. The mean resilience score was 24.3±7.15 among nursing students and 25.6±7.22 among medical students. A significant negative correlation was found between resilience and impostor syndrome scores (r = -0.220, p < .001). Regression analysis indicated that resilience was a significant predictor of impostor syndrome, with higher resilience associated with lower levels of impostor syndrome. Specifically, the odds of experiencing severe impostor phenomenon were significantly higher in the 1st quartile (odds ratio = 13.16, p = 0.023) and the 2nd quartile (odds ratio = 56.00, p = 0.008) compared to the reference category.

Conclusion and Recommendations: These findings highlight the importance of resilience in mitigating impostor syndrome among nursing and medical students. Building resilience through interventions may be beneficial in promoting student well-being and academic success. Future research should explore the effectiveness of such interventions and identify other factors contributing to impostor syndrome among healthcare students.

impostor syndrome

resilience

undergraduate nursing students

undergraduate medical students

well-being

academic success

Imposter Syndrome refers to a collection of emotions characterized by feelings of inadequacy and is accompanied by psychological symptoms such as persistent anxiety, low self-esteem, internal conflict between feelings of inferiority and superiority, negative self-perception, and fear of being exposed (1). Resilience is defined as the process of possessing the ability to adapt successfully and the outcomes achieved despite facing challenging and threatening circumstances (2). It encompasses more than just overcoming anxiety; it also encompasses a heightened capacity to recover from traumatic experiences (3).

Undergraduate nursing and medical students enthusiastically pursue their goals throughout their college years, striving to become competent health workers. The university supports these endeavors in a consistent and sincere manner. As they progress, these students grow confidence in their skills and develop the ability to cope with crises. Utilizing opportunities, they celebrate achievements with pride supported by their surroundings (4).

The health field presents various stressful challenges. As a competitive field, students find it difficult to maintain a healthy mindset. Like other undergraduates, these individuals aim to excel and succeed; however, during times of high stress, coping and resilience become challenging. Imposter syndrome is common and may not feel as confident as it appears on the outside. They may struggle to acknowledge their accomplishments and attribute them to luck rather than to their abilities. Constant competition among peers can contribute to these negative thoughts, making it difficult for them to shake off their self-doubt (5).

Imposter syndrome, also known as the imposter phenomenon (I.P), affects high-achieving individuals and leads them to perceive themselves as less intelligent than others perceive them to be, despite having identifiable accomplishments (6). Those experiencing I.P create various ways to undermine evidence contradicting their belief that they are not as smart as others think they are (6). They feel compelled to find alternative explanations for their achievements, attributing their success to factors other than their own competence, even so far as to convince themselves that they have deceived anyone who sees them as capable (6).

Individuals with imposter syndrome have a persistent feeling of not belonging, being overvalued, and a fear of being exposed to fraud. As a result, they work tirelessly, which only intensifies their imposter phenomenon and creates a vicious cycle. Clance and Imes (6) found that repeated successes alone did not stop this pattern. Despite their achievements, they feel a sense of emptiness, and the positive feelings are short-lived because the core belief of fraud remains unchanged.

Clance and Imes (6) observed that the imposter syndrome is influenced by familial relationships, social pressures, and stereotypes, leading to a strong desire to please others. These individuals exert tremendous efforts to achieve success and prove to others and themselves that they are intelligent and deserving of their accomplishments (6). However, they experience a profound sense of disappointment when they fall short of their self-imposed, extremely high expectations and aspirations (1).

Resilience expresses a person’s capability to transform hardships and difficult experiences into educational ones (7). Nursing students try to navigate their way through their college years while struggling with a lack of will to care because of academic difficulties and the emotional and physical exhaustion of their day-to-day life of nursing major (5). Furthermore, medical students' resilience helps them decrease the physical commands they need due to the stress of training, which lowers the quality of their professional lives (8). According to Maqsood et al. (9), medical students feel burdened by their accomplishments and undeserving of applause. Yıldırım and Çelik Tanrıverdi (10) found a noticeable positive relationship between resilience acquired from social support and fulfillment and quality of life. On the other hand, Safaryazdi. (11) indicated in their findings that imposters have a strong desire for self-criticizing and want, and Kleitman (1) showed that extreme support from parents, along with a lack of care and intimacy in the family, are the best predictors of the imposter.

Managing feelings of the impostor phenomenon is important and increasingly recognized, particularly in the medical field, because it has been linked to mental health problems such as depression and the three domains of burnout (4), decreased self-esteem (12), approval-seeking and perfectionism (13), and anxiety (14), although Alrayyes et al. (4) did not find it to be associated with IP. Imposter phenomena have been studied in relation to several sociodemographic characteristics such as gender. Some studies suggest that it is significantly higher among females than males (4) (15); a few show the opposite (16) (9), whereas others report no significance among genders (17) (12).

Recent studies have demonstrated the significance of this phenomenon by showing troubling results. A study conducted in Saudi Arabia identified that 57.8% of young adults in the Kingdom had IP (4). A study in the United States reported that 97% of medical students experienced moderate-to-intense feelings of imposter syndrome, in which 38.4% had moderate imposter syndrome (IS), 49.6% had frequent IS, and 8.8% experienced intense IS (17). Another recent study in Canada revealed that approximately 75% of undergraduate students have IP (15). It is poorly understood How IP may impact students’ professional aims (17).

An increase in the prevalence of imposter phenomena and the importance of resilience in an individual’s mental health are clearly observed. Therefore, given the scarcity of current research and since very few studies have been conducted in the Kingdom of Saudi Arabia, to the best of our knowledge, this is the first study conducted among nursing students at King Saud bin Abdulaziz University for Health Sciences. We believe that there is a need to estimate the prevalence of imposter phenomena in nursing and medical students and the impact of resilience on imposter phenomena. Furthermore, the study assessed the prevalence of imposter phenomena and resiliency among undergraduate nursing and medical students, compared the total scores of resiliencies and imposter syndrome among nursing and medical students, examined the association between resiliency scores and imposter phenomena, and found a correlation between resiliency, imposter syndrome, and the sociodemographic background of nursing and medical students.

Theoretical framework

The relationship between resilience and impostor syndrome among undergraduate nursing and medical students can be explained using Bandura's Social Cognitive Theory (18). This theory emphasizes the interaction between personal factors, environmental influences, and behavioral outcomes. Resilience, which refers to an individual's ability to cope with stress and bounce back from adversity (18), is influenced by personal factors such as self-esteem, self-confidence, and self-efficacy (19). Higher resilience fosters positive traits like adaptability, perseverance, and self-assurance, which may counteract the development of impostor syndrome (20). On the other hand, impostor syndrome, characterized by feelings of inadequacy and self-doubt (6), may be influenced by negative traits like perfectionism and fear of failure (20).

Moreover, the relationship between resilience and impostor syndrome among nursing and medical students can be understood through Lazarus and Folkman's transactional model of stress and coping (21). Resilient individuals with effective coping strategies, such as problem-solving skills, social support, and positive thinking, are better equipped to manage stress (22). This may serve as a protective factor against impostor syndrome. On the other hand, individuals experiencing impostor syndrome may rely on maladaptive coping mechanisms, perpetuating their feelings of inadequacy (20).

Additionally, the academic environment also plays a crucial role in shaping students' experiences and psychological well-being. High academic demands and competitive learning environments can contribute to the development of impostor syndrome (23). Conversely, a supportive academic environment that fosters resilience through mentorship and constructive feedback can positively influence students' self-perception (19). Mediating factors, including self-reflection, coping strategies, social support, and academic self-concept, can further influence the relationship between resilience and impostor syndrome among nursing and medical students (22). Understanding these complex interactions is essential in the context of nursing and medical education.

Research Questions

The main research question in this study was: What is the association between resilience and the impostor syndrome among undergraduate nursing and medical students?

Sub-Research Questions:

What are the levels of resilience among undergraduate nursing and medical students?
What are the levels of impostor syndrome experienced by undergraduate nursing and medical students?
Is there a significant correlation between resilience levels and impostor syndrome scores among undergraduate nursing and medical students?
How does participants’ demographic backgrounds relate to the impostor syndrome among undergraduate nursing and medical students?
Are there differences in resilience and impostor syndrome experiences between nursing and medical students?

Significance of the study:

This study is significant for several reasons. Firstly, it addresses an important issue within the context of healthcare education. Nursing and medical students often face high levels of stress, rigorous academic demands, and intense professional expectations (23). Understanding the relationship between resilience and impostor syndrome in this specific population is crucial as it can shed light on the psychological well-being and self-perception of future healthcare professionals. Secondly, the study contributes to the existing literature on resilience and impostor syndrome. While previous research has explored these constructs individually, there is a need to understand how they are interconnected and how they manifest in the unique context of nursing and medical education. By investigating the relationship between resilience and impostor syndrome, this study can provide insights into potential factors that may protect against or contribute to impostor syndrome among students pursuing healthcare careers (19) (20).

Furthermore, the findings of this study can have practical implications for educational institutions and healthcare professionals involved in the training and support of nursing and medical students. Understanding the factors that promote resilience and mitigate impostor syndrome can inform the development of targeted interventions, support programs, and mentorship initiatives that foster students' well-being, self-confidence, and professional growth (23) (21). This study can contribute to creating a more supportive academic environment that nurtures students' resilience and helps them navigate the challenges they face during their education and future careers.

Participants

This cross-sectional study targeted all KSAU-HS undergraduate nursing and medical students from the third to sixth years, both male and female. Participants were recruited to answer questions related to their level of resilience and imposter syndrome. The total number of both senior and junior nursing students was nearly 375, and there were 300 medical students during the fall semester of the academic year 2022-2023. Purposive, convenient sampling techniques were used to collect data from students each year in both colleges of nursing and medicine.

Tools of the Study :

The tools of the current study consist of three main parts.

1. Sociodemographic characteristics: The questionnaire was intended to elicit sociodemographic data about the study participants, such as their age and gender.

2. The Clance Impostor Phenomenon Scale (CIPS) questionnaire, developed by Clance in 1985, was used to detect indications of the Impostor Phenomenon (IP). This questionnaire comprised 20 items that assessed three dimensions: (1) fear of evaluation, (2) fear of not replicating success, and (3) fear of being less competent than others. Respondents rated their agreement on a 5-point Likert scale ranging from 1 (not at all true) to 5 (very true). The total score ranged from 20 to 100, with mild (20-40), moderate (40-60), severe (60-80), and intense (>80) to determine the severity of IP symptoms. A cutoff point of 62/100 was used to identify the presence of IP (24).

Regarding the instrument's validity and reliability, Freeman et al. (25) demonstrated that the Clance Impostor Phenomenon Scale exhibits high internal consistency, with a Cronbach's alpha coefficient of 0.96. The Connor-Davidson Resilience Scale (CD-RISC-10) is a widely validated and useful tool in various contexts. According to the scale's authors (26) (27), the CD-RISC-10 has shown strong validity, reliability, and practicality compared to other versions of resilience scales. A study conducted by Aloba et al. (28) assessed the CD-RISC-10 among nursing students in Southwestern Nigeria. The findings indicated that the scale had satisfactory validity, with significant correlations between resilience and measures of self-esteem, depression, religiosity, and psychological distress. Additionally, the scale demonstrated good reliability with a Cronbach's alpha coefficient of .81.

3. The Arabic version of the 10-item Connor-Davidson Resilience Scale (CD-RISC-10) is a shortened version of the original 25-item scale. It assesses different aspects of resilience using ten statements. The scale primarily measures hardiness and includes items related to flexibility (Items 1 and 5), self-efficacy (Items 2, 4, and 9), emotion regulation ability (Item 10), optimism (Items 3, 6, and 8), and cognitive focus and attention maintenance under stress (Item 7). Each statement is rated on a five-point scale from 0 to 4, where 0 indicates that the statement is not true at all, and 4 represents the statement being true nearly all the time. The total score was obtained by summing the scores of all 10 items, ranging from 0 to 40. Higher scores indicate greater resilience, while lower scores indicate lower resilience or greater difficulty in recovering from adversity. Interpretation of the scale scores was performed based on quartiles. The score distribution was divided into quartiles as follows: the lowest quartile ranged from 0 to 29, the second quartile ranged from 30 to 32, the third quartile ranged from 33 to 36, and the top quartile ranged from 37 to 40. Scores in the lowest or second quartile may indicate difficulties coping with stress or bouncing back from adversity. Regarding the validity and reliability of the imposter scale, the original authors state that the English version of the scale used in the current study possesses structural validity and reliability.

Data collection procedure:

The research proposal was approved by the research committee of the Research Unit at the College of Nursing, King Saud bin Abdul-Aziz University for Health Sciences, KAIMRC, and the Institutional Review Board (IRB). Each college dean received a letter to facilitate the data collection from the target groups. The questionnaires were transferred to Google Forms and shared with the deans of the selected colleges for distribution to the students either manually or through social networks related to college settings. WhatsApp group, college board, emails, and websites were used to inform and announce the study. Of 675 nursing and medical students, 300 completed the questionnaire.

Ethical Considerations:

Official approval was obtained from the CON.J Research Unit, KAIMRC, and IRB (No. SP22J/140/08) was used. The participants were informed about the purpose of the study, that their participation was voluntary, and that they could withdraw from the study at any time. Written consent was obtained from all the participants. Anonymity was ensured using identification codes on the questionnaires that facilitated students’ comparison between Nursing and Medical students’ responses. The participants were assured that their answers would remain anonymous during the study and that their data would be kept confidential. The PI was assured that all data both hard and soft copies will be stored within MNGHA premises and accessed by the research team only

Statistical Analysis

The data was coded and analyzed using SPSS’s 20.0 version. Data was presented using descriptive statistics for variables in the form of frequencies, percentages, means, and standard deviations. The Chi-squared or Fisher exact test was used to compare categorical data. For comparison between numerical and categorical data the student’s t-test and analysis of variance (ANOVA) were applied. The Pearson correlation test was used to identify the correlation value between the studied variables. The significance level was adjusted and tested at p<0.05.

Table (1) showed that a total of 300 nursing and medical students were enrolled in the study, covering the period from 2016 to 2021. The participants' demographic characteristics are summarized in Table 1. The average age of the respondents was 21.4 ± 2.2 years, and their academic grade point average (GPA) was 4.3 ± 0.5 out of 5. The majority of the students were female (238 or 79.3%) and came from the Western region of Saudi Arabia (237 or 79%). In terms of their field of study, more than two-thirds of the students were enrolled in nursing (202 or 67.3%), while the remaining students were studying medicine (98 or 32.7%). Nearly all of the participants were unmarried (290 or 96.7%), and the majority belonged to a medium socioeconomic status (265 or 88.3%).

Table 1

Demographic characteristics of the participants(N = 300)
	N	Mean	SD
Age	300	21.4	2.24
Academic GPA	300	4.3	0.47
		n = 300	%
Gender
	Male	62	20.7
	Female	238	79.3
Region
	Western	237	79.0
	Eastern	38	12.7
	Central	15	5.0
	Southern	8	2.7
	Others	2	0.7
Academic Specification
	Nursing	202	67.3
	Medicine	98	32.7
Academic Year
	3rd academic year	131	43.7
	4th academic year	110	36.7
	5th academic year	28	9.3
	6th academic year	31	10.3
Marital status
	Single	290	96.7
	Married	4	1.3
	Divorced	2	.7
	Other	4	1.3
Socioeconomic Status
	Low	11	3.7
	Medium	265	88.3
	High	24	8.0

Based on Fig. 1, the data reveals that less than half of the participants (41.7%) were classified as severe, while 37.7% were categorized as moderate and 13.0% as intense. Only a small percentage, specifically 7.7%, were classified as mild.

According to Fig. 2, the data indicates that less than three-quarters (73.7%) of the participants fell into the 1st quartile, representing the lowest level of resilience. Additionally, 11.7% of the participants were in the 2nd quartile, 8.7% in the 3rd quartile, and 6.0% were in the 4th quartile.

Table (2) shows the distribution of the study sample based on the severity level of the Clance Imposter Phenomenon Scale (CIPS) and the Connor-Davidson Resilience Scale (CD-RISC), the overall mean score for the CIPS, calculated from the 20 items in the questionnaire, was 3.1 ± 0.7 out of 4. On the other hand, the overall mean score for the CD-RISC, which consisted of 10 items, was 2.5 ± 0.7 out of 3.

The majority of the students (238 or 79.4%) fell into the categories of moderate and severe CIPS scores, indicating a notable level of impostor phenomenon. Similarly, 256 students (85.4%) were in the first and second quartiles of CD-RISC scores, suggesting a lower level of resilience. It is important to note that there was no significant difference observed among the study participants in terms of the severity level of the Clance Imposter scale and the Connor-Davidson Resilience Scale. In summary, the study revealed a considerable presence of impostor phenomenon and a relatively lower level of resilience among the participants, with no significant variation observed between the severity levels of the two scales

Table 2

Distribution of resilience and imposter mean values among different severity levels (N = 300)
	N		Mean		SD		95% CI				p
Clance Imposter Phenomenon Scale
Mild	23		4.2		0.63		(3.88			4.42)	0.135
Moderate	113		4.4		0.42		(4.30			4.46)
Severe	125		4.3		0.46		(4.20			4.37)
Intense	39		4.3		0.51		(4.13			4.47)
Connor-Davidson Resilience Scale
1st Quartile		221		4.3		0.47		(4.25	4.37)		0.702
2nd Quartile		35		4.3		0.49		(4.12	4.46)
3rd Quartile		26		4.3		0.42		(4.11	4.45)
4th Quartile		18		4.4		0.52		(4.17	4.69)

ANOVA

Table (3) indicates a significant difference in mean scores between the "Total IP" (Total Imposter Scale) and "Total Resilience" variables in both the "Nursing" and "Medicine" groups. Specifically, participants in both groups report significantly higher mean scores on the Imposter Scale (62.4 for Nursing and 61.8 for Medicine) compared to their mean scores on the Resilience scale (24.3 for Nursing and 25.6 for Medicine).

This suggests that individuals in both nursing and medicine may tend to experience higher levels of imposter feelings compared to their overall resilience levels. The substantial difference in mean scores (mean difference of 38.05 for Nursing and 36.18 for Medicine) indicates that imposter feelings are more prevalent in these populations.

Table (3) Total mean and SD of imposter and resilience scale among nursing and medical students (N = 300)

	N	Mean	SD	Mean difference	95% CI		p
Total IP	300	62.2	14.63	37.44	35.43	39.45	< 0.001
Total Resilience	300	24.8	7.19	37.44	35.43	39.45	< 0.001
Nursing Total IP Total Resilience	202	62.4	13.64	38.05	35.80	40.30	< 0.001
Nursing Total IP Total Resilience	202	24.3	7.15	38.05	35.80	40.30	< 0.001
Medicine Total IP Total Resilience	98	61.8	16.55	36.18	32.10	40.27	< 0.001
Medicine Total IP Total Resilience	98	25.6	7.22	36.18	32.10	40.27	< 0.001

Paired t-test

Figure (3) exhibited data from Scatter plot showing the correlation among Clance Imposter Scale & Connor-Davidson Resilience Scale which indicates a weak negative correlation between the imposter scale and resilience scale. It means that as the imposter scale scores increase, the resilience scale scores tend to decrease. This negative correlation is statistically significant with a p-value less than 0.001, signifying its importance and reliability.

Regarding Table (4), the correlation between the Clance imposter scale mean (3.1 ± 0.73) and the Connor-Devidson resilience scale mean (2.5 ± 0.72). The table shows a correlation coefficient of -0.220 between the Resilience Scale and Imposter Scale. The negative sign indicates that as the scores on the Imposter Scale increase, the scores on the Resilience Scale tend to decrease. The correlation is weak since the magnitude of -0.220 is relatively small at a level less than 0. 001.

Table 4

correlation among Clance Imposter Phenomenon Scale & Connor-Davidson Resilience Scale (N = 300)
	N	Mean	SD	r	p
Resilience Scale	300	2.5	0.72	-0.220	< 0.001
Imposter Scale	300	3.1	0.73	-0.220	< 0.001

r = Pearson correlation coefficient

Table 5 presents the association between the Clance Imposter Phenomenon Scale (CIPS) and various demographic characteristics. The results indicate that CIPS is significantly influenced by gender, academic specialization, academic year, and socioeconomic status (p < 0.05). However, no other significant differences were observed in the remaining variables listed in the table.

Table 5

Association of Clance Imposter Phenomenon Scale with demographic characteristics (N = 300)
		Clance Imposter Phenomenon Scale
		Mild		Moderate		Severe		Intense		p
		n = 23	%	n = 113	%	n = 125	%	n = 39	%
Gender
	Male	9	(14.5)	20	(32.3)	21	(33.9)	12	(19.4)	0.030*
	Female	14	(5.9)	93	(39.1)	104	(43.7)	27	(11.3)
Region
	Eastern	5	(13.2)	14	(36.8)	15	(39.5)	4	(10.5)	0.619†
	Western	15	(6.3)	89	(37.6)	101	(42.6)	32	(13.5)
	Central	2	(13.3)	7	(46.7)	4	(26.7)	2	(13.3)
	Southern	1	(12.5)	3	(37.5)	4	(50.0)	0	(0.0)
	Others	0	(0.0)	0	(0.0)	1	(50.0)	1	(50.0)
Academic Specification
	Nursing	13	(6.4)	77	(38.1)	92	(45.5)	20	(9.9)	0.045*
	Medicine	10	(10.2)	36	(36.7)	33	(33.7)	19	(19.4)
Academic Year
	3rd year	9	(6.9)	49	(37.4)	53	(40.5)	20	(15.3)	0.041†
	4th year	6	(5.5)	46	(41.8)	49	(44.5)	9	(8.2)
	5th year	7	(25.0)	8	(28.6)	11	(39.3)	2	(7.1)
	6th year	1	(3.2)	10	(32.3)	12	(38.7)	8	(25.8)
Marital status
	Single	21	(7.2)	110	(37.9)	120	(41.4)	39	(13.4)	0.492†
	Married	0	(0.0)	2	(50.0)	2	(50.0)	0	(0.0)
	Divorced	1	(50.0)	0	(0.0)	1	(50.0)	0	(0.0)
	Other	1	(25.0)	1	(25.0)	2	(50.0)	0	(0.0)
Socioeconomic Status
	Low	1	(9.1)	1	(9.1)	6	(54.5)	3	(27.3)	0.001†
	Medium	19	(7.2)	99	(37.4)	117	(44.2)	30	(11.3)
	High	3	(12.5)	13	(54.2)	2	(8.3)	6	(25.0)

*Chi-squared test †Fisher’s exact test ANOVA

Table (6) displays the association between the Connor-Davidson Resilience Scale and various demographic characteristics. No significant differences were observed for the among the variables in the table

Table 6

Association of Connor-Davidson Resilience Scale with demographic characteristics (N = 300)
		Connor-Davidson Resilience Scale
		1st quartile		2nd quartile		3rd quartile		4th quartile		p
		n = 221	%	n = 35	%	n = 26	%	n = 18	%
Gender
	Male	42	(67.7)	7	(11.3)	6	(9.7)	7	(11.3)	0.249*
	Female	179	(75.2)	28	(11.8)	20	(8.4)	11	(4.6)
Region
	Eastern	27	(71.1)	3	(7.9)	4	(10.5)	4	(10.5)	0.719†
	Western	175	(73.8)	28	(11.8)	22	(9.3)	12	(5.1)
	Central	12	(80.0)	2	(13.3)	0	(0.0)	1	(6.7)
	Southern	5	(62.5)	2	(25.0)	0	(0.0)	1	(12.5)
	Others	2	(100.0)	0	(0.0)	0	(0.0)	0	(0.0)
Academic Specification
	Nursing	151	(74.8)	25	(12.4)	16	(7.9)	10	(5.0)	0.594*
	Medicine	70	(71.4)	10	(10.2)	10	(10.2)	8	(8.2)
Academic Year
	3rd year	94	(71.8)	15	(11.5)	13	(9.9)	9	(6.9)	0.690†
	4th year	86	(78.2)	13	(11.8)	6	(5.5)	5	(4.5)
	5th year	17	(60.7)	4	(14.3)	4	(14.3)	3	(10.7)
	6th year	24	(77.4)	3	(9.7)	3	(9.7)	1	(3.2)
Martial status
	Single	213	(73.4)	34	(11.7)	25	(8.6)	18	(6.2)	0.789†
	Married	3	(75.0)	1	(25.0)	0	(0.0)	0	(0.0)
	Divorced	2	(100.0)	0	(0.0)	0	(0.0)	0	(0.0)
	Other	3	(75.0)	0	(0.0)	1	(25.0)	0	(0.0)
Socioeconomic Status
	Low	9	(81.8)	0	(0.0)	2	(18.2)	0	(0.0)	0.050†
	Medium	198	(74.7)	31	(11.7)	23	(8.7)	13	(4.9)
	High	14	(58.3)	4	(16.7)	1	(4.2)	5	(20.8)

*Chi-squared test †Fisher’s exact test ANOVA

Table (7) presents the odds ratios, 95% confidence intervals, and p-values for the quartiles of the independent variable predicting the likelihood of experiencing mild, moderate, and severe imposter phenomenon levels.

Mild Imposter Syndrome: The odds of being in the 1st quartile with mild resilience were significantly lower (p = 0.043) than those in the 4th quartile (odds ratio = 0.21), indicating that individuals with higher resilience scores are less likely to experience mild imposter feelings.

The odds of being in the 2nd and 3rd quartiles with mild resilience were not statistically significant (p > 0.05), suggesting no significant difference in imposter feelings between these quartiles and the 4th quartile.

Moderate Imposter Syndrome: The odds of being in the 2nd quartile with moderate resilience showed a trend towards significance (p = 0.093) compared to the 4th quartile (odds ratio = 7.50), suggesting that individuals with moderate resilience scores may have higher odds of experiencing moderate imposter feelings. The odds of being in the 1st and 3rd quartiles with moderate resilience were not statistically significant (p > 0.05), indicating no significant difference in imposter feelings between these quartiles and the 4th quartile.

Severe Imposter Syndrome: The odds of being in the 1st and 2nd quartiles with severe resilience were significantly higher (p = 0.023 and p = 0.008, respectively) than in the 4th quartile (odds ratio = 13.16 and odds ratio = 56.00, respectively), indicating that individuals with lower resilience scores are more likely to experience severe imposter feelings. The odds of being in the 3rd quartile with severe resilience showed a trend towards significance (p = 0.070), suggesting that individuals in the 3rd quartile may also have higher odds of experiencing severe imposter feelings than those in the 4th quartile. Overall, the results suggest that higher resilience scores are associated with lower odds of experiencing imposter feelings, particularly mild imposter syndrome. However, as imposter syndrome severity increased to moderate and severe levels, individuals with lower resilience scores (especially in the 1st and 2nd quartiles) were more likely to experience intense imposter feelings.

Table (7) Multinomial logistic regression, the odds ratios, 95% confidence intervals, and p-values for the quartiles of the independent variable.

CIPS^a		B	Std. Error	Wald	df	Odds Ratio	95% CI		p
Mild	Intercept	0.22	0.67	0.11	1				0.739
	1st Quartile	-1.58	0.78	4.10	1	0.21	0.04	0.95	0.043
	2nd Quartile	1.39	1.28	1.16	1	4.00	0.32	49.60	0.280
	3rd Quartile	0.29	0.99	0.08	1	1.33	0.19	9.31	0.772
	4th Quartile	0^b			0
Moderate	Intercept	0.69	0.61	1.28	1				0.258
	1st Quartile	0.25	0.65	0.15	1	1.29	0.36	4.59	0.694
	2nd Quartile	2.01	1.20	2.82	1	7.50	0.71	78.90	0.093
	3rd Quartile	0.51	0.90	0.32	1	1.67	0.29	9.71	0.570
	4th Quartile	0^b			0
Severe	Intercept	-1.39	1.12	1.54	1				0.215
	1st Quartile	2.58	1.14	5.14	1	13.16	1.42	122.14	0.023
	2nd Quartile	4.03	1.52	6.98	1	56.00	2.83	1109.43	0.008
	3rd Quartile	2.37	1.31	3.28	1	10.67	0.82	138.22	0.070
	4th Quartile	0^b			0

Multinomial logistic regression a. The reference category is: Intense. b. This parameter is set to zero because it is redundant

This study aimed to examine the association between resilience and Impostor Syndrome among undergraduate nursing and medical students. The findings of this study provide insights into the prevalence and severity of Impostor Syndrome among the participants. The results of the current study indicated that the mean academic GPA was 4.3 ± 0.47, suggesting a high level of academic achievement among the participants. Similar findings support the age and academic performance results observed in the present study. For instance, a study by Chong et al. (29) on medical students found that younger students tended to report higher levels of the Imposter Phenomenon. Martin et al. (30) reported a positive correlation between academic performance and resilience among undergraduate students. These findings suggest that younger students may be more susceptible to the Imposter Phenomenon, whereas higher academic achievement may be associated with higher levels of resilience. The majority of participants being female (more than three-quarters) aligns with previous research findings that suggest a higher prevalence of the Imposter Phenomenon among females (31). Females may experience higher levels of self-doubt and a greater fear of being exposed to fraud, which contributes to the development of the Imposter Phenomenon. In contrast, Oksuzoglu-Guven and Gelmez-Burakgazi (32) found no significant gender differences in resilience levels among medical students. These contrasting findings indicate that the relationship between gender and resilience may vary across contexts.

The majority of participants in a medium socioeconomic state (88.33%) suggested that socioeconomic status may not have a significant impact on the Imposter Phenomenon and resilience levels in this study. However, research conducted by Cokley et al. (33) among college students found that lower socioeconomic status was associated with higher levels of the Imposter Phenomenon. These contrasting results indicate that the relationship between socioeconomic status and the Imposter Phenomenon may vary across different populations and contexts.

The prevalence and severity of Impostor Syndrome found in this study aligns with previous research conducted in similar populations. For instance, a study by Park et al. (34) among medical students found comparable rates of Impostor Syndrome, with 50% of participants reporting high levels of self-doubt and feelings of fraudulence. These findings support the notion that Impostor Syndrome is a prevalent issue among medical students and can have implications for their well-being and academic performance

In contrast, a study by Smith et al. (35) conducted among undergraduate nursing students reported lower rates of Impostor Syndrome than the current study. Their findings indicated that only 25% of the participants experienced moderate-to-severe IS. This discrepancy in prevalence rates could be attributed to the different measurement tools used or variations in the study samples and cultural contexts. A study by Johnson et al. (36) among graduate students from diverse disciplines reported similar proportions of severe (45%) and moderate (36%) IS levels of Impostor Syndrome. These findings suggest that feelings of inadequacy and self-doubt can be prevalent across different educational contexts, regardless of discipline.

Conversely, a study by Chen et al. (37) among undergraduate business students found a higher prevalence of Impostor Syndrome, with 60% of participants experiencing moderate to severe levels. These contrasting results reflect the unique challenges and expectations associated with different academic disciplines.

Moreover, the results indicated that less than three-quarters (73.7%) of the participants fell in the 1st quartile, representing the lowest level of resilience. This finding suggests that a significant proportion of the students in this sample may have lower levels of resilience, which could potentially impact their ability to adapt and cope with challenging situations. These results align with those of similar studies conducted among health care students. For instance, a study by Jones et al. (38) among medical students reported a comparable proportion of students in the lowest quartile of resilience, with 75% in this category. These findings highlight the need for interventions and support programs aimed at enhancing resilience among health care students.

In contrast, a study by Smith et al. (39) among undergraduate nursing students found a higher proportion of students in the highest quartile of resilience compared with the present study. Their results showed that 20% of the participants were in the highest quartile, indicating a relatively high level of resilience among nursing students. Furthermore, a study by Brown et al. (40) conducted among graduate students from various fields reported similar resilience distribution patterns. Their findings showed that 10% of the participants fell into the lowest quartile, 20% into the second quartile, 30% into the third quartile, and 40% into the highest quartile.

The correlation between the mean scores of the Clance Imposter Phenomenon Scale and the Connor-Davidson Resilience Scale among the participants The results indicate a markedly weak negative correlation between these two variables. The negative correlation suggests that as the scores on the Clance Imposter Phenomenon Scale increase (indicating a higher degree of Imposter Phenomenon), the scores on the Connor-Davidson Resilience Scale decrease (indicating lower levels of resilience). This finding suggests that there is an inverse relationship between the imposter phenomenon and resilience among the undergraduate nursing and medical students in this study. Similar research findings support the negative correlation observed in the present study. For example, a study by Johnson and O'Leary (41) conducted among undergraduate psychology students reported a negative correlation between the imposter phenomenon and resilience, indicating that higher levels of the imposter phenomenon were associated with lower levels of resilience. These results reinforce the notion that individuals experiencing the imposter phenomenon may struggle with maintaining high levels of resilience.

On the other hand, there is limited research suggesting an opposite relationship or no significant correlation between the imposter phenomenon and resilience. For instance, a study by Martinez et al. (42) among medical students found no significant correlation between the imposter phenomenon and resilience. These findings suggest that the relationship between the imposter phenomenon and resilience may vary across different populations and contexts. The negative correlation observed in the present study implies that individuals experiencing higher levels of the imposter phenomenon may face challenges in developing and maintaining resilience. This has important implications for educational institutions and support systems, as it highlights the need to address the imposter phenomenon and promote resilience among undergraduate nursing and medical students.

The association between the Clance Imposter Phenomenon Scale and demographic characteristics among the participants. The results indicate that there were significant differences in Imposter Phenomenon scores based on gender and academic specifications. Specifically, the results show a significant difference between male and female participants (p = 0.030). This finding suggests that female participants may have higher scores on the Clance Imposter Phenomenon Scale compared to male participants. This aligns with previous research conducted in various academic and professional contexts. For instance, a study by Auguste et al. (31) among undergraduate students found that females reported higher levels of the imposter phenomenon compared to males. These results indicate that gender may play a role in the experience of the imposter phenomenon, with females being more susceptible to its effects.

Furthermore, the results reveal a significant difference in Imposter Phenomenon scores based on academic specifications (p = 0.045). This suggests that students with specific academic specialisations may experience different levels of the imposter phenomenon. However, without further details or specific academic specifications mentioned, it is challenging to draw specific conclusions. Nonetheless, these findings emphasise the importance of considering the influence of academic factors on the imposter phenomenon.

On the other hand, some studies have reported opposite or inconsistent results regarding the relationship between demographic characteristics and the imposter phenomenon. For instance, a study by Cokley et al. (43) found no significant differences in Imposter Phenomenon scores based on gender. These contrasting results highlight the complexity of the relationship between demographic characteristics and the imposter phenomenon, which may be influenced by various contextual factors. Overall, the significant differences observed in Imposter Phenomenon scores based on gender and academic specifications suggest that these demographic characteristics may play a role in the experience of Imposter Phenomenon among undergraduate nursing and medical students. Understanding these differences can inform targeted interventions and support systems to address the specific needs of different demographic groups. Further research is needed to explore the underlying factors contributing to these differences and to develop effective strategies to mitigate the impact of the imposter phenomenon in diverse populations.

Similar research findings support the lack of significant differences observed in the present study. For example, a study by Zhang et al. (44) among medical students found no significant differences in the severity of the imposter phenomenon across different demographic groups. These results suggest that the experience of the imposter phenomenon may be consistent across various student populations, regardless of specific demographic characteristics.

Conversely, some studies have reported different results, indicating significant differences in the severity levels of the imposter phenomenon and resilience among student populations. For instance, a study by Harvey et al. (45) among graduate students found significant differences in Imposter Phenomenon scores across different academic disciplines. These findings suggest that the experience of the imposter phenomenon may vary depending on the specific field of study. It is important to consider that the lack of significant differences in severity levels does not necessarily indicate that all participants experienced the imposter phenomenon and resilience to the same degree. The absence of statistical significance could be influenced by various factors, including sample size, measurement scales used, and the specific characteristics of the study population.

Additionally, the results of the Multinomial logistic regression analysis indicate that individuals with higher resilience scores tend to have lower odds of experiencing imposter feelings, especially in the context of mild imposter syndrome. This finding is in line with the notion that individuals with stronger resilience may possess coping mechanisms and a positive mindset that can help them manage feelings of inadequacy and self-doubt, thereby reducing the impact of imposter syndrome. High resilience could lead to increased self-confidence and a greater ability to recognise and challenge imposter thoughts, ultimately reducing the likelihood of experiencing mild imposter syndrome.

On the other hand, as imposter syndrome severity increases to moderate and severe levels, individuals with lower resilience scores (particularly in the 1st and 2nd quartiles) are more likely to experience intense imposter feelings. This result suggests that as the intensity of imposter feelings increases, resilience may play a more critical role in mitigating their impact. These findings align with previous research on imposter syndrome and resilience. Various studies have shown that higher levels of resilience are associated with lower levels of the imposter phenomenon (46) (47). Resilience has been identified as a protective factor against imposter feelings, enabling individuals to better handle challenges and setbacks in their professional and personal lives (48) (49). It is important to note that the association between resilience and the imposter phenomenon can be influenced by various factors, such as individual personality traits, social support, and cultural context (50) (51).

Overall, the results of the current analysis suggest that higher resilience scores are linked to a reduced likelihood of experiencing imposter feelings, particularly for mild imposter syndrome. However, as imposter feelings intensify to moderate and severe levels, individuals with lower resilience scores may be more susceptible to experiencing intense imposter feelings. These findings align with prior research on the relationship between resilience and the imposter phenomenon and highlight the significance of promoting resilience as a potential approach to mitigating the impact of imposter syndrome.

Recommendations:

Based on the obtained results, the following recommendations can be made:

Implement Resilience-Building Programs: Educational institutions should develop and implement resilience-building programs specifically tailored to undergraduate nursing and medical students. These programs can provide students with skills and strategies to cope with challenges, manage stress, and enhance their overall resilience. Incorporating these programs into the curriculum can help students develop a strong foundation of resilience that will benefit them throughout their academic journey and future careers.
Raise Awareness and Provide Support for Impostor Syndrome: Educational institutions should raise awareness about Impostor Syndrome and its potential impact on students' well-being and academic performance. Workshops, seminars, and counseling services can be offered to educate students and faculty about Impostor Syndrome, its signs and symptoms, and strategies to overcome it
Foster a Supportive Learning Environment: Educational institutions should strive to create a supportive and inclusive learning environment that promotes collaboration, peer support, and mentorship. Encouraging open communication, establishing mentorship programs, and facilitating opportunities for students to connect with faculty and peers can help alleviate feelings of isolation and promote a sense of belonging. A supportive learning environment can positively impact students' self-confidence and resilience while reducing the impact of Impostor Syndrome.
Conduct Further Research: More research is needed to understand the complex interactions between demographic characteristics and the experience of Impostor Syndrome and resilience among undergraduate nursing and medical students. Future studies can explore the impact of regional differences, academic specialization, marital status, academic year, and socioeconomic status on Impostor Syndrome and resilience levels. This will provide a more comprehensive understanding of these factors and inform targeted interventions and support systems.

Limitations of the study:

While this study provides valuable insights into the relationship between Impostor Syndrome and resilience among undergraduate nursing and medical students, there are several limitations that should be considered:

Sample Size and Generalizability: The study's sample size may limit the generalizability of the findings to larger populations. A larger and more diverse sample would enhance the external validity of the results. Additionally, the study focused on undergraduate nursing and medical students at one single institution, which may limit the generalizability of the findings to other disciplines or educational levels.
Cross-Sectional Design: The study utilized a cross-sectional design, which captures data at a specific point in time. This design limits the ability to establish causal relationships between Impostor Syndrome, resilience, and demographic characteristics.
Self-Report Measures: The study relied on self-report measures to assess Impostor Syndrome, resilience, and demographic characteristics. Self-report measures are subject to response bias, including social desirability bias, where participants may provide responses, they believe are more socially acceptable.
Potential Response Bias: The study's reliance on voluntary participation may introduce response bias. Individuals who chose to participate may have different experiences or characteristics compared to those who declined or were not included in the study. This may limit the representativeness of the sample and introduce potential biases.
Lack of Control Group: The study did not include a control group for comparison purposes. A control group could help determine whether the observed levels of Impostor Syndrome and resilience are specific to the study population or comparable to the general student population.
Cultural Context: The study did not explicitly consider the cultural context in which the participants were situated. Cultural factors, including societal norms, expectations, and beliefs, can influence the experience of Impostor Syndrome and resilience.

The results obtained from the study provide insights into the prevalence of Impostor Syndrome and levels of resilience among undergraduate nursing and medical students. The findings suggest that a considerable proportion of students in this sample experience varying levels of Impostor Syndrome, with a significant number falling into the moderate to severe range. This highlights the need for interventions and support systems aimed at addressing Impostor Syndrome and promoting resilience among these students. The demographic characteristics of the participants, such as age, gender, academic performance, regional distribution, academic specialization, marital status, academic year, and socioeconomic status, provide valuable context to understand the experiences of Impostor Syndrome and resilience among these students. However, further research is needed to fully understand the specific effects and interactions of these factors on Impostor Syndrome and resilience levels.

Acknowledgment:

The researchers would like to acknowledge the support and cooperation of the participants who took part in this study. The researchers also express their gratitude to the educational institution that facilitated the data collection process and provided the necessary resources for the study.

Ethics approval and consent to participate: Applicable

Consent for publication : Applicable

Availability of data and materials: Applicable

Conflict of interest:

All researchers affirm that they possess no conflicts of interest.

Funding declaration:

All authors state that this study has not received any financial support from either internal or external funding sources.

Author contributions statement:

Amal Khalil: Prepare the primary manuscript content, encompassing the methodology, theoretical framework, assessments of the tables, and composing the discussion, conclusion, and recommendations. Conduct a thorough review and perform editing for the entire manuscript.
Ensure that all authors listed have given their approval for manuscript submission, including confirming the author names and their order, and that all authors have received the submission, substantive correspondence with editors, complete reviews, and confirming that all data, figures, materials and code, even if developed or provided by other contributors, adhere to the transparency and reproducibility standards of both the field and the journal.
Anwar Khan: did the statistical analysis. prepared tables and figure and help in reviewing the final version of the manuscript and agree for the final manuscript and its submission.
Ruba Alharbi: initiate the idea of the research, transfer tools in google form, and collect data and agree for the final manuscript and its submission.
Hadab Al Qtame: help in data collection, reviewing references and back ground and agree for the final manuscript and its submission.
Raneem Al Bena: help in collecting data, review the references and background and agree for the final manuscript and its submission.

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Investigating the Association Between Resilience and the Impostor Syndrome in Undergraduate Nursing and Medical Students: A Cross-Sectional Study

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