One of the aims of the study was to identify how levels of confidence in students’ clinical and patient communications skills evolved over the duration of an internship in relation to selected demographic factors. The survey data revealed that prior experience was significantly related to initial and evolving levels of confidence in both patient communication and clinical skills. In contrast, gender, age and prior qualification were related to the development of either clinical or patient communication skills.
The relationship between initial confidence and prior experience was expected, and is consistent with Schunk’s  claims that exposure to models can instill self-beliefs that influence individuals’ subsequent course of action. Yet the finding that the sub-group of students with no prior experience displayed higher levels of confidence than those with moderate experience may indicate overconfidence, a concerning phenomenon which is discussed extensively in the literature .
The finding that male students rated their confidence in clinical skills higher than female students is consistent with evidence of females tending to underestimate their abilities  while their male counterparts overestimate their abilities . This is consistent with those found in other fields, such as confidence in physics and computing [23, 24]. According to Beyer & Bowden , confidence may differ between genders due to the type of skill or task involved. They found that females consider themselves equally competent (high level confidence) when tasks are perceived as gender-neutral or (traditionally) ‘feminine-type’ skills (e.g. verbal or interpersonal) and underestimate their abilities in (traditionally) ‘masculine-type’ skills or occupations. This was demonstrated in studies with medical students [25–27], where female students underestimated their surgical skills, possibly due, according to the researchers, to the perceived notion of surgeon as a (traditionally) ‘masculine’ occupation. A similar perception may have contributed in explaining the findings in the present study. Some of the clinical skills utilized in manual medicine, such as joint manipulation, possibly being perceived as more physical and therefore ‘masculine’.
The significant relationship between age or a prior degree and initial levels of confidence in patient communication skills, may indicate that interpersonal communication is a generic skill acquired through life experience and transferable to professional situations. In contrast, the lack of relationship between these two factors and confidence in clinical skills is consistent with those skills being highly specific to the profession. Interestingly, the sub-group of students in the highest age category tended to display lower levels of confidence in clinical skills than those in the mid age range. This might be due the myriad of issues that mature-age students face in their lives, which can lead to erosion in their confidence [28, 29]. For example, in the field of health education, Feil et al  reported older medical students’ sense of loss of previous personal and professional identity, and Donaldson and Graham  reported older students’ frequent admission that they possess ‘rusty study skills’, low self-confidence and apprehension upon re-entering college.
The present study also aimed to examine the factors perceived by students as contributing to increase or decrease their confidence over time. The interview data with sub-groups of students, who demonstrated either a limited or a substantial increase in confidence, provided insight into the evolution of their confidence during the internship.
Interaction with clinicians and clinician feedback emerged as a prominent factor in the evolution of clinical and patient communication skills. The criticality of constructive feedback is well documented in the mentoring literature [32, 33]. In the study, negative feedback was primarily reported as being in the form of verbal comments in which the students perceived the clinicians as putting them down and not treating them as peers, or taking over for the student and treating the patient. In contrast, positive feedback was verbal and non-verbal with clinicians providing supporting comments but also demonstrating how to perform a skill. This is consistent with Pitney and Ehlers  who stressed how mentor accessibility, approachability, and student initiative need to be enforced as these create an environment encouraging student participation and assist in the building of confidence .
Over time, students with high increases in confidence relied less on the clinicians while the other group continued to have mixed relationships with them. Some admitted relying too much on them while others still perceived them as being harsh in their approach. Interestingly, students displaying higher increases in confidence appeared more proactive and mature as student-clinicians, resulting in them relying less on clinician support. In contrast, those with low increases had not yet matured as student-clinicians. They continuously relied on clinicians, struggled with challenging patient conditions and patient conflicts and perceived limited skills. This is consistent with Bandura’s  claim that self-efficacy, or confidence, is the foundation of human agency, since unless people believe they can produce desired effects by their actions, they have little incentive to act. This may explain why in this study, one sub-group had little incentive to seek ways to improve. More research is needed to fully understand this phenomenon.
A factor which was brought up by both sub-groups was the importance of the audible noise released from a manipulative procedure, as evidence of successful adjustment and with a direct effect on confidence, has received limited attention in the literature. Yet, according to Flynn et al , and Cleland et al , a joint audible can have a powerful placebo effect on both the patient and practitioner. This was demonstrated in this study, with some students attributing even more importance to the audible noise than patient outcomes as a measure of success. However, even if students focused on patient outcomes such as pain, range of motion and daily living activities, and minimized their confidence in the audible, they would still need to contend with the effect it has on patients. When their confidence is limited, they may struggle to communicate to their patients that the audible is not a representation of success.
Finally, some students’ reflections on the chiropractic profession raises the broader issue of how students perceive their chosen profession and in this instance, chiropractic. However, the fact that only students with limited increases in confidence addressed this issue is noteworthy. A myriad of reasons may explain such perceptions but recent research involving non-practicing chiropractors  has pointed to chiropractic dogma and philosophy as reasons to abandon active practice.
There were a number of limitations that warrant attention. First, focusing on and measuring students in the chiropractic field may not be generalized to the full range of manual medicine programs, also including osteopathy, physiotherapy and athletic training fields. Second, the contextual scope of the qualitative (interview) data was limited to two separate student cohorts from a single university chiropractic program. These factors make it difficult to generalize the findings to other contexts and student experiences. Due to the small sample size, this study could not reliably relate interview findings and demographic factors, and therefore identify tendencies. Yet, such connections may exist and could be examined in future research. Also the research did not compare the impact of different clinical opportunities, such as the on-campus internship and the external placement.
This study revealed that such perceptions could evolve as early as during professional education.