الفهرس 
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Abstract
Stress is a common phenomenon among nursing students. Stress can have both positive and negative effects on clinical competence. In some cases, stress can enhance performance by increasing focus, motivation, and alertness. However, high stress can have detrimental impacts on clinical competence. So, nursing educators must be aware of the stressors that nursing students face during clinical practice. By knowing these stressors, educators can develop strategies and interventions to help students effectively manage and overcome the stressors as well as enhance clinical competence.
Aim of This Study
Assess the levels of clinical practice stress and clinical competence and explore the relationship between clinical practice stress and clinical competence among pediatric nursing students.
Research Questions:
• What are the levels of clinical practice stress among pediatric nursing students?
• What are the levels of clinical competence among pediatric nursing students?
• Is there a relationship between clinical practice stress and clinical competence among pediatric nursing students?
• What is the relationship between clinical practice stress and clinical competence among pediatric nursing students?
Research design
A descriptive correlational research design was followed in the present study.
Setting
This study was conducted at five Neonatal Intensive Care Units (NICU) in the following settings: Maternity University Hospital at El-shatby, Alexandria University
Children’s Hospital at Smouha, El-Raml Children Hospital at Wingate, Alexandria Maternity Hospital, and El-Gomhoria Public Hospital.
Subjects
The subjects of this study comprised 200 nursing students who were selected conveniently to represent all nursing students (N=240) who enrolled in the Pediatric Nursing Department, during the second semester of the academic year 2021-2022.Tools
Three tools were used in this study for data collection:
Tool I: Perceived Stress Scale (PSS)
This tool was developed by Sheu et al, (1997) and it was modified by the researcher to be applicable for measuring pediatric nursing student clinical practice stress. It consists of 37 statements. Students’ responses were measured on the 5-point Likert scale ranging from very often (4) to never (0). The scoring system of this tool ranged from 0- 148 distributed as follows: < 49 indicates a low level of clinical practice stress, 49- 98 indicates a moderate level of clinical practice stress, and 99- 148 indicates a high level of clinical practice stress. The higher the score, the higher the perceived level of stress.
Tool II: Clinical Competence Self-Assessment (CCSA)
This tool was developed by the researcher after an extensive review of related literature
(Limão, 2016; Abo Zeed et al., 2019) to assess pediatric nursing students’ clinical competence regarding gavage feeding. It is composed of two parts; the first part is related to knowledge about gavage feeding and the second part is related to the attitude of pediatric nursing students toward their competence in gavage feeding. The first part consists of 15 MCQs. The scoring was categorized based on Benner’s theory as follows: > 90% Proficient (Excellent), 80% to 89% Competent (Very good), 70% to 79% Advanced Beginner (Good), 60% to 69% Novice (Fair), < 60% Fail. The second one consists of 11 statements. Students’ responses were measured on the 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1). The scoring system of this tool ranged from 11-55 distributed as follows: 11 - 47 indicates a negative attitude toward their competence in gavage feeding and > 47 indicates a positive attitude toward their competence in gavage feeding.
Tool III: Gavage feeding observational checklist.
This tool was adopted from the procedural and conceptual manual of the Pediatric Nursing Department, Alexandria University (February 2020) to evaluate the pediatric nursing students’ performance in gavage feeding in clinical areas. It consists of 17 steps for performing the gavage feeding procedure. Students’ performance was measured on a threepoint Likert scale ranging from achieved (2) to not done (0). The scoring system was categorized based on Benner’s theory as follows: > 90% Proficient (Excellent), 80% to 89%
Competent (Very good), 70% to 79% Advanced Beginner (Good), 60% to 69% Novice (Fair), < 60% Fail.
Methods
1. An approval to conduct the study was obtained from the Research Ethics Committee (REC) at the Faculty of Nursing, Alexandria University.
2. Official Permission to conduct the study was obtained from the Dean and the head of the Pediatric Nursing Department, at the Faculty of Nursing, Alexandria University after explaining the study’s aims.
3. An official permission to conduct the study was obtained from the head of Neonatal Intensive Care Units (NICU) in the five setting areas mentioned before.
4. The tools were tested for their content validity by five experts in Nursing Education and the Pediatric Nursing departments then the necessary modifications were made accordingly. (Appendix IV)
5. A pilot study was carried out on 24 nursing students (10% of the total sample) who were selected conveniently to assess the feasibility, clarity, and applicability of the tools, and to identify the difficulties that may be faced during data collection. Those students were excluded from the total study sample.
6. The reliability of the tools was tested for internal consistency using Cronbach’s alpha test. The tools were reliable and the coefficient values for tool I, tool II (part I and part II), and tool III were 0.917, 0.719, 0.923, and 0.932 respectively.
7. Data collection was carried out in five settings of NICU that were mentioned before from the third academic level of pediatric nursing students during the second semester of the academic year 2021-2022.
8. Data was collected through an observational checklist and questionnaire over three months starting from the beginning of March 2022 and continuing till the beginning of June 2022.
9. The researcher introduced herself to the students, the aim of the study was explained to them.
10. Tools I and II were distributed to each nursing student at the end of the clinical day to prevent learning interruption; they were asked to fill it in and return it to the researcher.
11. The researcher evaluated the students in the clinical hospital while demonstrating the gavage feeding procedure using tool III.
Results
The present study revealed the following results:
• The majority of pediatric nursing students (83%) were aged 21 years or younger and almost half of them were males (50.5%). The last GPA of one-third of pediatric nursing students (33%) had a b grade. Furthermore, nearly half of them (51%) had previous experience in caring for sick neonates.
• The majority of pediatric nursing students (71%) experienced moderate levels of clinical practice stress which is proved by their responses in all perceived stress scale (PSS) dimensions, with mean scores between (3.06±1.93 to 25.78±8.78), concerning all scale dimensions: stress from (taking care of neonates; teacher and nursing staff; assignments and academic workload; peers; lack of professional knowledge and skills; and clinical environment. The total mean score of PSS was (77.05±24.04).
• Concerning clinical competence among pediatric nursing students, it was found that more than one-third of the study subjects (36%) experienced competent knowledge in the gavage feeding procedure. Besides, the majority of them (95.5%) had a positive attitude toward their competence in the gavage feeding procedure, and 69.5%, had competence in practicing the gavage feeding procedure.
• The correlation between clinical practice stress and clinical competence was a significant positive weak correlation (p = 0.002, r = 0.173).
It can be concluded from the present study that clinical practice stress is a prevalent issue facing pediatric nursing students. There are many stressors experienced by them which include stress from taking care of neonates, stress from teachers and nursing staff, stress from assignments and academic workload, stress from peers, stress from professional knowledge and skills, and stress from the clinical environment. These stressors have impacted their clinical competence. Pediatric nursing students had a competent level of knowledge and skills in the gavage feeding procedure, as well as positive attitudes toward their competence in this procedure. As a result, there was a significant positive, weak relationship between clinical practice stress and clinical competence. This finding confirms that a moderate level of stress plays a role in enhancing students’ focus and learning in clinical settings.
Recommendations
Based on the findings of the current study, the following recommendations are suggested:
• Provide pediatric nursing students with online resources and multimedia materials. These resources can include instructional videos, virtual anatomy models, and online textbooks to help them reduce stress and promote competence.
• Encourage students to engage in self-reflection that can guide students to explore their emotions and thoughts.
• Incorporate stress-coping strategies in the curriculum such as using guided imagery and mindfulness meditation to help students to manage their stressors.
• Integrate simulated and virtual lab educational technology into the pediatric nursing curriculum. It can help students build confidence, improve their clinical competence, and mitigate the negative impact of stress on their learning.
• Foster a supportive learning environment such as clear learning objectives, opportunities for active learning, and debriefing that help students acquire clinical competence.
Recommendations for Further Studies
• Exploring interventions and strategies to reduce stress and enhance clinical competence among nursing students.
• The impact of clinical practice stress on patient safety outcomes among nursing students.
• Identifying factors hindering nursing students’ clinical competence.
• The relationship between clinical competence and educational environment among nursing students.