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Imposter syndrome: when you feel like you’re faking it

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Colleen Jackson recently was promoted to a manager position on her unit. At first, she was thrilled with the opportunity to advance her leadership skills, but now she’s having second thoughts. She doesn’t feel confident in her new role and worries how her team views her. She confesses to her manager, “I keep thinking someone will figure out how much I really don’t know and question whether I should’ve been given the position. Sometimes I feel like an imposter. When I mention this to my friends, they tell me to ‘fake it until you make it.’ But I’m not so sure about that!”

Colleen isn’t alone in feeling like an imposter. In imposter syndrome, a person doesn’t feel good enough, is unsure of what she’s doing, and feels she can’t live up to others’ expectations. She may be afraid she’ll be found out as an imposter at any moment. The syndrome is most common among women leaders who feel they don’t deserve the success they’ve achieved despite external evidence of their competence. It’s more likely in perfectionists who constantly compare themselves to others.

Certain situations, such as taking on a new role, can lead to imposter syndrome. For instance, Colleen may think that because she was seen as qualified for her new role, others expect her to immediately have expert knowledge. If, like Colleen, you feel you don’t deserve the career success you’ve had, you may experience deep feelings of inauthenticity and fear you’ll be found out as a fake. (See Inside the imposter syndrome.)

In small doses, feelings of inadequacy may not be a bad thing, because they remind us to work on building our competency. But people with imposter syndrome feel a level of self-doubt that can lead to overwork and a paralyzing fear of failure. The fear of being unmasked causes incredible stress. Colleen and others like her may have unrealistic expectations of themselves in a new role—expectations that can compromise their success.

Overcoming imposter syndrome

For people with imposter syndrome, the response to their success may rest too heavily on others’ approval, recognition, and opinions. A wise mentor once told me we can easily overestimate how much time others spend thinking about us and our behaviors. Most people, she observed, are self-absorbed. This is important to consider, because the idea that Colleen is an imposter probably has never crossed her team members’ minds.

Imposter syndrome can create performance anxiety and lead to perfectionism, burnout, and depression. So learning how to manage these feelings is important. Cathy Robinson-Walker, MBA, MCC, who coaches nurse leaders, provides advice to help cope with imposter syndrome. Her recommendations include the six actions steps below.

Discuss your feelings with a trusted mentor.
Sharing your insecurities with someone you trust and respect can help you separate what’s real from your perceptions of insecurity. A trusted mentor might inform Colleen she’s making good progress as a beginning leader and that no one expects her to be an expert at this point. The mentor can provide guidance about specific areas where Colleen might need additional growth and how to best go about this.

Pay attention to your own self-talk and consider whether your thoughts are empowering or disabling.
Do you often say to yourself, “I achieved this only because I work harder than anyone else, not because I’m more competent”? Valerie Young, author of The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It, makes a strong case that your internal script is a well-rehearsed pattern that serves as a key to feelings of being an imposter. She cautions that individuals with imposter syndrome may sabotage themselves as a way of holding back, due to feelings of being a fraud.

Instead, choose a different script and talk yourself down during times of self-doubt. Instead of thinking, “I’m the wrong person for this job,” retrain yourself to say, “I have a lot to offer in this position.”

Make of list your strengths.
Take the time to make a written list your strengths and what you contribute. Ask others for input, and refer to the list in times of self-doubt. If you’re in a new role, remember that you were chosen for a reason. In Colleen’s case, her supervisor saw her leadership potential. Also realize that most people overestimate their abilities; people with imposter syndrome underestimate theirs.

Accept that perfection is unrealistic and costly.
Trying to be perfect and feeling you need to “know it all” is unrealistic and can be costly on a personal level. Perfectionists typically believe anything short of a flawless performance all the time is unacceptable. But none of us can live a mistake-free life; we all make errors. Those with imposter syndrome hold themselves to impossibly high standards and feel shame, insecurity, and low self-esteem when they don’t meet their own expectations. But progress, not perfection, is what really matters.

Know you’ll need to develop your competencies at certain times in your career.
Throughout your career, you’ll go through periods when you’re on a steep learning curve and will need to further develop your competencies. You may feel like a novice and have to work hard to build new competencies.

Be honest about what you know and don’t know, and seek advice from experts on your unit or in your organization. The simple act of saying, “This is new for me, and I’m working hard to learn this role” can be empowering. Colleen, for instance, might be surprised at others’ reactions to hearing this from her. They might perceive her as a more authentic leader.

Be willing to be uncomfortable and move through your fear.
In Fear of Flying, author Erica Jong urges readers engaging in new experiences to feel the fear and do it anyway. Fear is a useful emotion, as long as it doesn’t escalate to the level of paralyzing behaviors. Practice and preparation can help ease new leaders’ fears. The fear of new challenges will never truly go away, but it can be managed.

Building competence leads to competency
People with imposter syndrome generally are intelligent, thoughtful, and capable but lack self-confidence. Over time, clinicians like Colleen will grow out of feeling like an imposter as they build their competency and become more comfortable in their roles. Eleanor Roosevelt said, “I believe that anyone can conquer fear by doing the things he fears to do, provided he keeps doing them until he gets a record of successful experience behind him.” If you feel like an imposter, this is good advice to ponder.

Selected references
Clance PR, Imes S. The imposter phenomenon in high achieving women: dynamics and therapeutic intervention. Psycho Theor, Res and Prac.1978;15(3):241-7.

Jong E. Fear of Flying. Austin, TX: Holt, Reinhart & Winston; 1973.

Robinson-Walker C. The imposter syndrome. Nurs Leader. 2011;9(4):12-13.

Sherman R.O. Imposter syndrome in nursing leadership. Emerging RN Leader: A Leadership Development Blog. May 7, 2012. www.emergingrnleader.com/
imposter-syndrome-in-nursing-leadership/. Accessed February 26, 2013.

Young V. How to feel as bright and capable as everyone seems to think you are: a handbook for women (and men) who doubt their competence…but shouldn’t. ImposterSyndrome.com. 2004. http://
impostorsyndrome.com/_content/How%20to%20Feel%20As%20Bright%20and%20Capable%20As%20Every
one%20Seems%20to%20Think%20You%20Are%20
Workbook.pdf Accessed February 26, 2013.

Young V. The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It. New York: Crown Business; 2011.

Rose O. Sherman is an associate professor of nursing and director of the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton. You can read her blog at www.emergingrnleader.com.

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Clinician Resources

 

Here are resources that can help you in your busy clinical practice by giving you information quickly. Don’t miss out!

Free educational and clinical resources on pressure ulcers

Access valuable educational and clinical resources from the National Pressure Ulcer Advisory Panel. Among the free resources are:
• poster of best practices for prevention of medical device–related pressure ulcers (available as a PDF)
• pressure-ulcer prevention points (available as a PDF)
• registered nurse competency-based curriculum: pressure ulcer prevention.

Tutorials on diabetes foot care

Take an interactive tutorial on foot care for patients with diabetes. The module was published by the Patient Education Institute. You can also choose to watch in a self-playing mode and download a PDF text summary.

Quality assurance resources for long-term care

The resources in “Quality Assurance Performance Improvement (QAPI) Resources” are targeted toward those working in long-term care. The list includes links such as:
• Advancing Excellence in America’s Nursing Homes National Campaign, which has resources and tools for nursing homes to improve in several different areas
• Implementing Change in Long-Term Care, a detailed guide on how to engage nursing home staff in the change process
• The Long-Term Care Improvement Guide, developed by Planetree in partnership with Picker Institute.

Prescription assistance programs

Do you have patients who need help paying for their prescriptions? “Understanding Prescription Assistance Programs,” from the National Council on Patient Information and Education, explains how these programs work and provides resources.

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Apply QAPI to reduce pressure ulcer rates

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

The Affordable Care Act of 2010 requires nursing homes to have an acceptable Quality Assurance and Performance Improvement (QAPI) plan within a year after the start of the QAPI regulation. While the implementation of this regulation may be a year out, now is the time to start applying its principles. Reducing pressure ulcer rates is a great program to target for a QAPI plan.

A team approach

If you decide to use pressure ulcers as your QAPI project, don’t take on your entire program at once. Break the program down into system subsets (for example, admission process, prevention program, and weekly rounds). Determining the status of your program in each subset—completed, needs improvement, or not completed—can help you prioritize which areas to target. It’s important you have support from leadership for your efforts.

I’ll use the example of the admission phase (ensuring that within the first 24 hours, skin and risk concerns are identified and a temporary plan of care is implemented) to illustrate a QAPI project. To address this area, a team was created, including representation from staff members involved with the admission process. The team then used the problem-solving model Plan-Do-Study-Act (PDSA) to examine the process.

The first step in the PDSA cycle is to Plan. During this step, you:

• evaluate and analyze the current process to determine baseline data, which are used to measure progress
• identify system performance gaps
• determine the root cause of the performance gaps
• develop an action plan that identifies the goals, steps, responsible staff, and target dates.

In our example, the team determined that within the first 24 hours, skin inspections were being completed only 10% of the time. The root-cause analysis revealed that the admission nurses didn’t feel competent to document identified pressure ulcers or skin concerns, so they deferred it until the wound nurse was available. The team’s action plan included the following:

• Develop and educate all the facility nurses on how to complete and accurately document a skin inspection.
• Develop and implement a competency evaluation to assess the nurse’s ability to apply the knowledge at the bedside.
• Develop an ongoing plan to ensure all nurses receive this education during orientation and yearly thereafter.

The team also set the following goal:
By the end of the next quarter, 100% of admitted patients will have an accurate skin inspection completed within 24 hours of admission.

The second step of the PDSA cycle is Do. During this step, you implement and execute the plan, while documenting your observations and recording data.

In our example, the “Do” was to:
• develop and provide the skin inspection education and bedside competency evaluations
• develop an evaluation and tracking
system
• add the education to the orientation program
• add the education to the staff development calendar to be offered yearly.

The third step of the PDSA cycle is to Study: In this phase, you:
• reevaluate and analyze the system
• compare the results with the baseline data and predictions
• summarize what was learned and accomplished and what needs to be improved
• determine if another PDSA cycle is
necessary to continue to improve the system.

Once all staff had been properly educated and competency testing completed, an analysis of the rate and accuracy of the admission skin inspections done within 24 hours of admission was completed. It was found that 100% of the patients admitted had a complete skin inspection done within 24 hours. However, not all the nurses could accurately stage pressure ulcers, so it was determined that the system needed improvement to ensure accurate assessments.

The last step of the PDSA cycle is to Act. In this step, you:
• determine what changes need to be made
• modify the plan to continue to improve the system
• repeat the PDSA cycle as necessary.

In our example, the team determined the nurses needed more guidance and education on staging of pressure ulcers. Therefore, a new PDSA cycle was set to ensure the nurses are competent in this area.

Benefits for staff and patients

It may be difficult to start the QAPI project and at times the process may be stressful, but keep in mind that a successful pressure ulcer QAPI project can improve not only the quality of life and care of your patients but also morale and team building for your staff. n

Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has beenspecializing in wound prevention and management since 1990.

 

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