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Effects of perceived stress and professional values on clinical performance in practice nursing students: A structural equation modeling approach
Accepted Manuscript Effects of perceived stress and professional values on clinical performance in practice nursing students: A structural equation modeling approach
Yansheng Ye, Rujun Hu, Zhihong Ni, Ning Jiang, Xiaolian Jiang PII: DOI: Reference:
S0260-6917(18)30703-2 doi:10.1016/j.nedt.2018.09.036 YNEDT 3990
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
3 October 2017 9 June 2018 25 September 2018
Please cite this article as: Yansheng Ye, Rujun Hu, Zhihong Ni, Ning Jiang, Xiaolian Jiang , Effects of perceived stress and professional values on clinical performance in practice nursing students: A structural equation modeling approach. Ynedt (2018), doi:10.1016/ j.nedt.2018.09.036
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ACCEPTED MANUSCRIPT Effects of Perceived Stress and Professional Values on Clinical Performance in Practice Nursing Students: a structural equation modeling approach
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Yansheng Ye, Rujun Hu, Zhihong Ni, Ning Jiang, Xiaolian Jiang*
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West China Hospital / West China School of Nursing, Sichuan University, Chengdu
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* Correspondence author: Xiaolian Jiang
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610041, Sichuan, China
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Tel.: 00862885422070; fax: 00862885422070
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E-mail address: [email protected]; [email protected]
Rujun Hu
PhD candidate
PhD candidate
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Zhihong Ni
PhD candidate
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Yansheng Ye
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Word count: 4494
Ning Jiang
PhD candidate
Xiaolian Jiang
PhD RN Professor
Authors’ Contributions Y. Ye was involved in the design of this study, data collection, analysis and interpretation of data, drafting and revising the manuscript. R. Hu, Z. Ni, and N. Jiang 1
ACCEPTED MANUSCRIPT provided help with the data collection, analysis and interpretation. X. Jiang made substantive intellectual contributions to the interpretation of data and draft of the manuscript. The authors had read and approved the final manuscript.
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Conflicts of interest: none
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Funding statements
This research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
Acknowledgments
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The authors are thankful for the supervisors and 435 nursing students who took
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part in the study for assisting with data collection.
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ACCEPTED MANUSCRIPT Abstract Background: Clinical performance is regarded as a basic and core content of nursing quality. Professional values of nursing students may play an important role in improving clinical performance. Few studies reveal the relationship between professional values,
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perceived stress and clinical performance. This research has found that professional
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values plays a moderating role in the relationship between perceived stress and clinical
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performance.
Objective: To examine the negative association between perceived stress and clinical
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performance among practice nursing students, and to determine whether professional
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values plays a moderating role in the relationship between perceived stress and clinical performance among Chinese practice nursing students.
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Design: A cross-sectional descriptive design has been used.
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Methods: From May to June 2017, a total of 435 Chinese practice nursing students from 4 hospitals filled out the questionnaires. The response rate was 94.57%. Three
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questionnaires including the Perceived Stress Scale ( PSS ), Nursing Professional Value
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Scale-Revised ( NPVS-R ), and Clinical Performance Scale ( CPS ). Structural equation modeling was used to deal with the relationships among perceived stress, professional values, and clinical performance. Results: Perceived stress was negatively associated with clinical performance ( P＜ 0.01 ). Professional values significantly affected clinical performance ( P＜0.01 ) and moderated the relationship between perceived stress and clinical performance ( P＜ 0.01 ). 3
ACCEPTED MANUSCRIPT Conclusions: Perceived stress is negatively related to clinical performance among Chinese practice nursing students, and professional values moderates the relationship between perceived stress and clinical performance, which can form scientific evidence
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to develop intervention strategies to improve clinical performance.
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Keywords:
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Clinical performance Perceived stress
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Professional values
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Moderator effect
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Practice nursing students
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ACCEPTED MANUSCRIPT 1. Introduction Clinical performance is the ability of practice nursing student to indicate the performance of professional skills or behaviors including communication, knowledge, technical skills, clinical reasoning, emotions and values ( Tilley, 2008; Epstein et al.,
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2002 ). It is regarded as a basic and core content of nursing quality ( Teng, 2015 ).
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Clinical nurses with higher levels of clinical performance are better able to practice
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effectively and offer high quality of care in hospital ( Hsiu et al., 2008 ), which contributes to improvement on metrics like provided quality assurance and clinical
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support, higher patients satisfaction, and decreased hospital stay lengths, readmission
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rates and health costs ( Horrocks et al., 2002; Percy et al., 2007 ).So, it is important to improve clinical performance served as a useful screening indicator for practice nursing
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students’ professional competence.
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Several negative characteristics decrease clinical performance. It is commonly associated with stress ( Elcigil et al., 2007 ). Perceived stress among practice nursing
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students is a hot topic which got increasing interest of nursing educators and nursing
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managers to identify stressors and its consequences ( Chan et al., 2009; Shaban et al., 2012 ).Most of stressors appear during the internship, including lack of clinical skills, heavy workloads, relationship problems with companions, instructors and nursing staff, being bullied by companions or hospital staff, time pressure to deal with nursing tasks, and employment pressure ( Gorostidi et al., 2007; Burnard et al., 2008; Hakojarvi et al., 2014 ). Studies show most people successes were got under pressure, but lasting or high stress would bring negative consequences. Students with higher levels of stress made 5
ACCEPTED MANUSCRIPT more mistakes which would damage to develop clinical performance ( Cheung et al., 2011 ). Professional values，a positive characteristic, has many advantages including promotion of care quality, increasing patient’s understanding, increasing job
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satisfaction and nurse retention, and helping the professional socialization process
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( Horton et al., 2007; Ravari et al., 2013 ). Professional values is defined as the
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individual’s cognition and attitude for his ／ her career and his ／ her pursuit and yearning for his／her career goals (Rassin, 2008). The nursing professional value scale-
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revised developed by Weis et al. ( 2000 ) was used to measure nurses’ professional
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values. According to the AACN ( 2008 ), American Association of Colleges of Nursing, professional values and its related behaviors are the standard guideline and directions
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of professional nursing practice and are footstones to guiding nurses’ clinical
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performance. The studies show that nurses with positive professional values understood as a method in problem-solving strategies incline to achieve better results of solving
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current clinical nursing problems than other nurses ( Hall et al., 2008; Parandeh et al.,
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2015 ). Professional values is a significant predictor of care quality and development of nursing profession ( Donmez et al., 2016 ). Additionally, according to the studies, professional values may be a moderator of professional psychological responses and adjustment ( Choi et al., 2016; Ros et al., 1999 ). Therefore, the researchers inferred that professional values may enhance the relationship between perceived stress and clinical performance. However, a study has not yet explored the relationship. Based on the conceptual bases, the purpose of this study is ⑴ to examine the 6
ACCEPTED MANUSCRIPT negative association between perceived stress and clinical performance among practice nursing students, and ⑵ to explore the moderating effect of professional values on the relationship between perceived stress and clinical performance.
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2. Methods
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2.1. Respondents and Procedures
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A cross-sectional design was used in this study. A convenience sample of 435 practice nursing students ( 393 female and 42 male ) was recruited from four teaching
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hospitals in Hubei province and Sichuan province. Practice nursing students matching
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the following criteria were recruited in the study: ⑴ undergraduate nursing students, and ⑵ students who were interns in the Three-level A-rate hospital.
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2.2. Instruments
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The questionnaires comprised sections assessing practice nursing students demographic characteristics (age, gender, character, student leader, whether you were
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an only child, and family income status), perceived stress, professional value, and
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clinical performance.
The Perceived Stress Scale ( PSS ) measuring perceived stress was first developed by Cohen et al. ( 1983 ). Using this original version, Yang et al. ( 2003 ) created a new perceived stress scale that was suitable for the Chinese. The questionnaire consisted of 14 items categorized into 2 subscales: tension ( 7 items ) and uncontrol ( 7 items ). The PSS scores were computed as the sum of the two subscales and varied between 14 and 70, with higher scores indicating a higher level of the stress. On a 5-point scale, 7
ACCEPTED MANUSCRIPT responses range from 1 ( Never ) to 5 ( Always ). 0～28 of scores denote normal of the stress, 29～42 of scores denote a little bit of the stress reminding yourself to pay attention to the stress decompression, and 43～56 of scores denote higher the stress needing for external resources for the stress decompression. The questionnaire is a
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reliable tool to measure nursing students’ perceived stress ( Ye et al., 2016 ). In this
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study, Cronbach’s alpha coefficient was 0.87.
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The nursing professional value scale-revised ( NPVS-R ) measuring professional value was developed by Weis et al. ( 2000 ). Gong et al. ( 2011 ) created a new nursing
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professional value scale that was suitable for the Chinese nursing students. The
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questionnaire consisted of 26 items categorized into 4 subscales: professionalism ( 7 items ), caring ( 10 items ), trust ( 6 items ), and activism ( 3 items ). The NPVS-R
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scores were computed as the sum of the 4 subscales and varied between 26 and 130,
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with higher scores indicating a higher professional values. On a 5-point scale, responses range from 1 ( Not important ) to 5 ( Most important ). The questionnaire is a reliable
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tool to measure nursing professional value ( Yang et al., 2015 ). In this study,
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Cronbach’s alpha coefficient was 0.86. The clinical performance scale ( CPS ) measuring clinical performance was developed for the practice nursing students by Deng et al. ( 2006 ). The questionnaire consisted of 28 items categorized into 7 subscales: applying theoretical knowledge ( 3 items ), professional role and role development ( 5 items ), self-directed studying behavior ( 4 items ), clinical skills ( 3 items ), identifying the patients’ rights and obligations ( 3 items ), communication ( 4 items ), and applying nursing procedure ( 6 8
ACCEPTED MANUSCRIPT items ). The CPS scores were computed as the sum of the 7 subscales and varied between 28 and 140, with higher scores indicating a better clinical performance. On a 5-point scale, responses range from 1 ( Never ) to 5 ( Always ). The questionnaire is a reliable tool to measure clinical performance ( Ye et al., 2016 ). In this study, Cronbach’s
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alpha coefficient was 0.91.
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2.3 Ethical Considerations
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Prior to the investigation, ethical approval for this study was obtained from West China Hospital of Sichuan University Biomedical Research Ethics Committee (Ethics
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number: 2017-273). The ethical approval includes consent procedure and written
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informed consent form. All the practice nursing students were briefed about the purpose and significance of the study and their right to not participate or to withdraw at any time
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without any consequences. They were then asked to sign the written informed consents
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if they had interests in taking part in the study. The anonymity and confidentiality of all data were considered in this study. Student’s information like name and other identifiers
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were not included in the study. Furthermore, student’s personal data would not be used
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for any goal other than that of in this study. 2.4 Data Collection The data was collected from May to June 2017. Before the investigation began, the researchers briefed potential respondents about the procedures for filling out the questionnaires by oral forms. The practice nursing students filled out the questionnaires for 15-25 min. Among the 460 returned questionnaires, the 25 questionnaires’ answer was incomplete with missing values or regular such as the repeated options were 1, 2, 9
ACCEPTED MANUSCRIPT 3. Only the filled out questionnaires which researchers have checked and identified were considered qualified. There are 435 practice nursing students ( 94.57% ) who had filled out the whole questionnaires which were suited for statistically analysis without missing values in the total 460 returned questionnaires.
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2.5. Data Analyses
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Statistical Product and Service Solutions(SPSS, version 22.0) was used to deal
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with descriptive statistics, independent-samples t-test, a one-way Analysis of Variance(ANOVA), and Pearson correlation. Analysis of Moment Structure(AMOS,
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version 22.0 ) was used to estimate structural equation modeling ( SEM ).
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Independent-samples t-test and one-way ANOVA were used to test the differences in clinical performance in terms of the categorical demographic characteristics. Pearson
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correlation analyses were dealt with determining the direction and size of the
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relationships among perceived stress, professional values, and clinical performance. SEM with maximum likelihood was used to confirm relationships and predictions
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among perceived stress, professional values and clinical performance. Measurement
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errors of SEM were taken into account during the analyses. The goodness fit of SEM was evaluated by the likelihood ratio ( x2/df ), the goodness of fit index ( GFI ), the comparative fit index ( CFI ), Tucker-Lewis fit index ( TLI ), and root mean square error of approximation ( RMSEA ). The acceptable threshold of RMSEA was ≤ 0.08, that of x2/df was ＜ 3, and that of the rest of the indices such as GFI was ≥ 0.90 ( Bae, 2011 ).
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ACCEPTED MANUSCRIPT 3. Results 3.1. Demographic Characteristics and Clinical Performance The participants had a mean age of 22.16 years ( SD = 0.86; range 19-24 ). A total of 90.3% of participants were female and 9.7% were male. Of the participants, 37.9%
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were only children and 34.9% were student leader. In regard to character and family
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income status, 62.5% of participants were extrovert and 78.6% were from a middle-
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income family. The mean total clinical performance score was 98.00 out of 140. Female interns ( 90.3% ) were reported better clinical performance than male interns ( 9.7%, t
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= 4.655, p ＜ 0.001 ). Those participants who were extrovert ( 62.5% ) were reported
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better clinical performance than those who were introvert ( 37.5%, t = -5.580, p ＜ 0.001 ). There were no other demographic differences in the scores of clinical
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performance ( see Table 1 ).
3.2. Perceived stress, Professional values, and Clinical performance
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Means, standard deviations, and correlations among the related variables are
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presented in Table 2. Clinical performance had a significant positive correlation with professional values ( r = 0.507, P ＜0.01 ) which means when professional values score increases, clinical performance score would also enhance. Additionally, clinical performance had a significant negative correlation with perceived stress ( r = -0.562, P ＜0.01 ) which means when perceived stress score increases, clinical performance score would decrease. Further, perceived stress had a significant negative correlation with professional values ( r = -0.369, P＜0.01 ) which means when perceived stress score 11
ACCEPTED MANUSCRIPT increases, professional values score would decrease.
3.3. Moderating Effects of Professional Values on Perceived Stress and Clinical Performance.
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The SEM analysis of the effect of professional values on perceived stress and
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clinical performance throughout the entire sample had a good fit of the data to the model
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( see figure 1 ). As seen in Fig. 1, perceived stress was negatively related to clinical performance ( B = -0.59, P ＜ 0.01 ); perceived stress was negatively related to
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professional values ( B = -0.68, P＜0.01 ); professional values was positively related to
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clinical performance ( B = 0.33, P＜0.01 ). The results suggest that professional values moderate the effects of perceived stress and clinical performance among practice
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nursing students.
4. Discussion
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The direct effect of perceived stress on clinical performance was further verified, and initial evidence for the moderating role of professional values in the effect of
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perceived stress on clinical performance was found. Furthermore, this finding opened the window to a new means of improving clinical performance among practice nursing students that emphasizes the important role of professional values. Perceived stress was negatively related to clinical performance among practice nursing students, which support the previous studies. For instance, Harvey et al. ( 2010 ) and Liaw et al. ( 2012 ) found that excessive or lasting stress may impair clinical performance deserved. Nursing students with higher or lasting stress levels got 12
ACCEPTED MANUSCRIPT experience of greater psychological distress which could provoke various emotional reactions like nervous, anxious, etc. ( Klainin et al., 2014; Pryjmachuk et al., 2008; Mikolajczyk et al., 2008 ). Furthermore, nursing students with higher or lasting stress may be have an affect on memory, concentration, and problem solving ability, which
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may lead to decreased learning, poorer academic performance, depression, headache,
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and serious health problem ( Goff et al., 2011; Braga et al., 2012 ). Many research have
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associated higher or lasting stress and energy draining aspects ( Jan et al., 2014; Jimenez et al., 2010 ). Consequently, nursing students with poor confidence and competence
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( Ulrich et al., 2010 ) may have poor motive to deal with various nursing problems,
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which in turn decreases the level of clinical performance. Therefore, nursing educators and administrators should assess and monitor the stress levels of nursing students
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clearly. If the excessive or lasting stress was exist, nursing educators and administrators
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could help nursing students adopt appropriate measures such as biofeedback and mindfulness meditation to reduce the stress (Ratanasiripong et al., 2015).
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Professional values was positively associated with clinical performance, which
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echo the results of previous research. For example, McNeese-Smith et al. ( 2003 ) found that professional values can improve nurses’ practice, aid for team performance and assist in performance of counselling. Furthermore, Altun ( 2002 ) showed that nurses with high professional values usually possessed better decision-making, critical thinking and communication, and enhanced the ability to deal with conflicts and prioritize actions. In accordance with the findings, the study added evidence that professional values can be a significant stimulus for enhancing clinical performance 13
ACCEPTED MANUSCRIPT among practice nursing students. Related studies indicate that a person with high level of professional values usually owns others resources like high levels of self-esteem, confidence, spirituality, and self-efficacy, which might use as predictors enhancing clinical performance ( Trisha et al., 2012; Masoudi et al., 2014 ). For instance, one
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research showed that increased self-efficacy enables individuals to improve the
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necessary confidence to take on the challenge, which brings about success in their
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profession ( Abdal et al., 2015 ). Professional values could be cultivated by prelicensure education or progressing education and could also be enhanced by job satisfaction and
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career development ( Moon et al., 2014; Gallegos et al., 2015; Yarbrough et al., 2017 ).
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This study not only confirmed the direct relationship between professional values and clinical performance further but also is the first to verify the moderating
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effect of professional values on the relationship between perceived stress and
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clinical performance. Professional values strengthened the positive effect of perceived stress on clinical performance. In other words, the relationship between
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perceived stress and clinical performance was enhanced because of professional
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values. It might be that individuals with higher professional values showed a better capacity to cope with difficult nursing situations ( Abdal et al., 2015 ) and had capacity to improve self-awareness in professional activities and change their own ways of dealing with things ( Jun et al., 2016 ), which leads to practice nursing students with more resources coping with stress and improving clinical performance. Incidentally, according to demographic variables, the significant differences of this study in clinical performance among practice nursing students was found. Female 14
ACCEPTED MANUSCRIPT practice nursing students had better clinical performance, which may be that they have more responsibility among college students ( Zhang et al., 2009 ), leading to them have more careful and responsible attitude to deal with clinical nursing problem. Second, participants with extroversion reported better clinical performance, which may suggest
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that they might acquire more useful resource like seeking to support to reduce perceived
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stress and got better clinical performance.
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These findings- perceived stress and professional values may influence clinical performance among practice nursing students undergoing clinical practice- have
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important implications for clinical practice of nursing students. It may help clinical
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nursing educators and administrators develop the related intervention strategies such as developing decreasing stress training or developing fostering professional values to
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improve practice nursing students’ clinical performance.
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This study has distinct strengths, such as using of SEM approach to explore the moderating effect of professional values in the association of perceived stress and
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clinical performance among practice nursing students firstly. This study also had some
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limitations. First, the use of convenience sampling ( from four teaching hospitals ) might limit generalization of these findings. Second, given a cross-sectional design and self-report nature of the study, these findings from the study must be interpreted with caution because it might not show the relationships at different time frames and the questionnaire might not really reflect the thoughts among practice nursing students. It is crucial for following longitudinal research which should be designed to
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ACCEPTED MANUSCRIPT replicate the current study from different regional hospitals to further verify these results.
5. Conclusions
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This study results strongly indicate that perceived stress has a direct effect on
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clinical performance among practice nursing students. Also, the researchers verified
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that professional values moderated the relationship between perceived stress and clinical performance. Thus, nursing educators and administrators should pay more
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attention to enhancing clinical performance among practice nursing students by
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strengthening their stress management and professional values. Consequently, this findings can form the basis for evidence-based development of intervention strategies
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for improving clinical performance among practice nursing students. For example,
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nursing educators and administrators should not only improve the job satisfaction and self-worth of practice nursing students, but also teach the practice nursing students to
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manage their own excessive or lasting stress using biofeedback and mindfulness
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meditation, which leads to practice nursing students with better clinical performance.
Table 1. Demographic characteristics and differences in clinical performance.
Table 2. Correlations between perceived stress, professional values, and clinical performance.
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ACCEPTED MANUSCRIPT Fig. 1. Results of SEM analysis of the effect of professional values on perceived stress and clinical performance among the whole sample. All the coefficients in the figure 1 are standardized and significant at level 0.01. x2/df = 1.891, GFI = 0.927, CFI
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= 0.935, TLI = 0.959, and RMSEA = 0.073.
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Nurs. Scholarship. 32, 201-204. Yang, L.L., Xian, X.M., Lu, S.M., et al., 2015.Present situation and influencing factors on occupational values of undergraduate nursing students. Chin J. Nurs. Rehabi. 14, 824-827. Yang, T.Z., Huang, H.T., 2003. An epidemiological study on stress among urban residents in social transition period. Chin J. Epidemiol. 24, 760-764. Yarbrough, S., Martin, P., Alfred D., et al., 2017. Professional values, job satisfaction, 22
ACCEPTED MANUSCRIPT career development, and intent to stay. Nurs. Ethics. 24, 675-685. Ye, Y.S., Zhang, Z.X., Ye, L., et al., 2016. Influence of emotional resilience training on perceived stress of undergraduate nursing students. Chin Nurs. Res. 30, 27752777.
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Ye, Y.S., Zhao, J., Bao, C.Y., et al., 2016. Influence of student-based flipped teaching
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on clinical practical performance of nursing undergraduates. Chin J. Nurs. 23, 16-
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19.
Zhang, H., Sun, T.T., Du, T.J., et al., 2009. Investigation on 449 college students’ sense
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of responsibility. Chin J. School Doctor. 23, 187-188.
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ACCEPTED MANUSCRIPT Table 1 Demographic characteristics and differences in clinical performance (N = 435)
character Student leader Income status
t(F)
P
42 (9.7) 393 (90.3) 165 (37.9) 270 (62.1) 272 (62.5) 163 (37.5) 152 (34.9) 283 (65.1) 59 (13.6) 342 (78.6) 34 (7.8)
95.83±8.23 98.68±9.80 99.15±9.62 97.75±10.71 100.20±8.23 95.00±10.31 98.53±9.23 97.84±10.42 96.99±9.76 98.13±8.72 97.46±8.71
4.655
p＜0.001
-1.372
0.171
-5.580
p＜0.001
-0.698
0.485
0.398
0.672
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Family with only child
Male Female Yes No Extrovert Introvert Yes No High Medium Low
Mean ± SD
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Gender
N(%)
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Variable
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High: ≥ 10000 Yuan; Low: < 5000 Yuan; 5000 Yuan ≤ Medium < 10000 Yuan
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Table 2 Correlations between perceived stress, professional values, and clinical performance (N = 435) Vari
Mean
able
± SD
1T
15.58±
1
2
3
4
5
6
7
8
9
10
11
12
13
1
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19.27±
0.43
2.09
9**
34.86±
0.71
0.66
2.78
4**
9**
4
91.03±
-
-
-
NPV
7.79
0.20
0.43
0.36
6**
5**
9**
24.52±
-
-
-
0.63
2.51
0.11
0.37
0.28
4**
0
9**
5**
34.95±
-
-
-
0.72
0.43
3.06
0.14
0.36
0.29
9**
4**
4
9**
9**
21.11±
-
-
-
0.66
0.40
0.57
2.22
0.12
0.32
0.25
2**
3**
0**
0
0**
9**
10.44±
-
-
-
0.58
0.41
0.49
0.37
1.72
0.32
0.30
0.36
8**
8**
1**
4**
3**
6**
9**
98.00±
-
-
-
0.50
0.55
0.36
0.29
0.48
9.78
0.41
0.57
0.56
7**
4**
1**
3**
1**
0**
7**
2**
-
-
0.33
0.50
0.18
0.14
0.19
0.60
0.39
0.30
1**
2**
2*
1
1*
1**
1**
3**
8 AC
9 CP
10
9.47±1
-
ATK
.21
0.13 1
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1
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1
1
D
7 TR
1
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6 CA
1
CE
5 PR
1
AC
3 PS
1
1
1
11
16.33±
-
-
-
0.44
0.56
0.29
0.27
0.28
0.67
0.55
PRR
1.95
0.26
0.54
0.26
6**
2**
4**
5**
5**
6**
9**
0**
9**
0**
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15
1 6
1.73 2N
14
1
12
15.53±
-
-
-
0.45
0.31
0.39
0.31
0.52
0.62
0.28
0.40
SSB
1.63
0.52
0.49
0.58
9**
5**
8**
3**
6**
6**
7**
3**
6**
5**
5**
1
13
11.77±
-
-
-
0.33
0.24
0.25
0.16
0.52
0.57
0.23
0.29
0.57
CS
1.45
0.37
0.34
0.41
6**
7**
2**
4*
4**
5**
4**
0**
0**
3**
2**
7**
25
1
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10.19±
-
-
-
0.34
0.50
0.19
0.16
0.16
0.58
0.55
0.56
0.31
0.18
IPR
1.29
0.18
0.43
0.36
3**
8**
8*
9*
4*
5**
3**
4**
4**
2*
7*
7**
0**
15.51±
-
-
-
0.37
0.28
0.27
0.20
0.58
0.60
0.25
0.34
0.63
0.69
0.19
1.94
0.41
0.39
0.46
8**
6**
4**
4**
3**
7**
7**
3**
3**
6**
1*
3**
1**
6**
O 15 C
1
1
19.21±
-
-
-
0.32
0.45
0.19
0.14
0.18
0.58
0.45
0.61
0.28
0.18
0.45
0.23
ANP
2.31
0.16
0.40
0.33
0**
5**
2*
1
7*
5**
1**
4**
3**
8*
5**
1**
8*
7**
3**
PT
16
1
T: tension, N: uncontrol, PS: perceived stress, NPV: nursing professional value, PR: professionalism, CA: caring, TR: trust, AC: activism, CP: clinical performance, ATK: applying theoretical knowledge, PRRD: professional role
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and obligations, C: communication, ANP: applying nursing procedure
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and role development, SSB: self-directed studying behavior, CS: clinical skills, IPRO identifying the patients’ rights
AC
CE
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D
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** P＜0.01，* P＜0.05
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ACCEPTED MANUSCRIPT Highlights
Perceived stress is negatively related to clinical performance among Chinese practice nursing students. Professional values significantly affected clinical performance.
Professional values moderates the relationship between perceived stress and
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clinical performance, which can form scientific evidence to develop intervention
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strategies to improve clinical performance.
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Figure 1
Yansheng Ye, Rujun Hu, Zhihong Ni, Ning Jiang, Xiaolian Jiang PII: DOI: Reference:
S0260-6917(18)30703-2 doi:10.1016/j.nedt.2018.09.036 YNEDT 3990
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
3 October 2017 9 June 2018 25 September 2018
Please cite this article as: Yansheng Ye, Rujun Hu, Zhihong Ni, Ning Jiang, Xiaolian Jiang , Effects of perceived stress and professional values on clinical performance in practice nursing students: A structural equation modeling approach. Ynedt (2018), doi:10.1016/ j.nedt.2018.09.036
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ACCEPTED MANUSCRIPT Effects of Perceived Stress and Professional Values on Clinical Performance in Practice Nursing Students: a structural equation modeling approach
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Yansheng Ye, Rujun Hu, Zhihong Ni, Ning Jiang, Xiaolian Jiang*
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West China Hospital / West China School of Nursing, Sichuan University, Chengdu
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* Correspondence author: Xiaolian Jiang
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610041, Sichuan, China
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Tel.: 00862885422070; fax: 00862885422070
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E-mail address: [email protected]; [email protected]
Rujun Hu
PhD candidate
PhD candidate
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Zhihong Ni
PhD candidate
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Yansheng Ye
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Word count: 4494
Ning Jiang
PhD candidate
Xiaolian Jiang
PhD RN Professor
Authors’ Contributions Y. Ye was involved in the design of this study, data collection, analysis and interpretation of data, drafting and revising the manuscript. R. Hu, Z. Ni, and N. Jiang 1
ACCEPTED MANUSCRIPT provided help with the data collection, analysis and interpretation. X. Jiang made substantive intellectual contributions to the interpretation of data and draft of the manuscript. The authors had read and approved the final manuscript.
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Conflicts of interest: none
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Funding statements
This research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
Acknowledgments
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The authors are thankful for the supervisors and 435 nursing students who took
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part in the study for assisting with data collection.
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ACCEPTED MANUSCRIPT Abstract Background: Clinical performance is regarded as a basic and core content of nursing quality. Professional values of nursing students may play an important role in improving clinical performance. Few studies reveal the relationship between professional values,
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perceived stress and clinical performance. This research has found that professional
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values plays a moderating role in the relationship between perceived stress and clinical
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performance.
Objective: To examine the negative association between perceived stress and clinical
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performance among practice nursing students, and to determine whether professional
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values plays a moderating role in the relationship between perceived stress and clinical performance among Chinese practice nursing students.
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Design: A cross-sectional descriptive design has been used.
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Methods: From May to June 2017, a total of 435 Chinese practice nursing students from 4 hospitals filled out the questionnaires. The response rate was 94.57%. Three
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questionnaires including the Perceived Stress Scale ( PSS ), Nursing Professional Value
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Scale-Revised ( NPVS-R ), and Clinical Performance Scale ( CPS ). Structural equation modeling was used to deal with the relationships among perceived stress, professional values, and clinical performance. Results: Perceived stress was negatively associated with clinical performance ( P＜ 0.01 ). Professional values significantly affected clinical performance ( P＜0.01 ) and moderated the relationship between perceived stress and clinical performance ( P＜ 0.01 ). 3
ACCEPTED MANUSCRIPT Conclusions: Perceived stress is negatively related to clinical performance among Chinese practice nursing students, and professional values moderates the relationship between perceived stress and clinical performance, which can form scientific evidence
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to develop intervention strategies to improve clinical performance.
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Keywords:
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Clinical performance Perceived stress
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Professional values
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Moderator effect
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Practice nursing students
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ACCEPTED MANUSCRIPT 1. Introduction Clinical performance is the ability of practice nursing student to indicate the performance of professional skills or behaviors including communication, knowledge, technical skills, clinical reasoning, emotions and values ( Tilley, 2008; Epstein et al.,
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2002 ). It is regarded as a basic and core content of nursing quality ( Teng, 2015 ).
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Clinical nurses with higher levels of clinical performance are better able to practice
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effectively and offer high quality of care in hospital ( Hsiu et al., 2008 ), which contributes to improvement on metrics like provided quality assurance and clinical
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support, higher patients satisfaction, and decreased hospital stay lengths, readmission
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rates and health costs ( Horrocks et al., 2002; Percy et al., 2007 ).So, it is important to improve clinical performance served as a useful screening indicator for practice nursing
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students’ professional competence.
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Several negative characteristics decrease clinical performance. It is commonly associated with stress ( Elcigil et al., 2007 ). Perceived stress among practice nursing
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students is a hot topic which got increasing interest of nursing educators and nursing
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managers to identify stressors and its consequences ( Chan et al., 2009; Shaban et al., 2012 ).Most of stressors appear during the internship, including lack of clinical skills, heavy workloads, relationship problems with companions, instructors and nursing staff, being bullied by companions or hospital staff, time pressure to deal with nursing tasks, and employment pressure ( Gorostidi et al., 2007; Burnard et al., 2008; Hakojarvi et al., 2014 ). Studies show most people successes were got under pressure, but lasting or high stress would bring negative consequences. Students with higher levels of stress made 5
ACCEPTED MANUSCRIPT more mistakes which would damage to develop clinical performance ( Cheung et al., 2011 ). Professional values，a positive characteristic, has many advantages including promotion of care quality, increasing patient’s understanding, increasing job
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satisfaction and nurse retention, and helping the professional socialization process
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( Horton et al., 2007; Ravari et al., 2013 ). Professional values is defined as the
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individual’s cognition and attitude for his ／ her career and his ／ her pursuit and yearning for his／her career goals (Rassin, 2008). The nursing professional value scale-
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revised developed by Weis et al. ( 2000 ) was used to measure nurses’ professional
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values. According to the AACN ( 2008 ), American Association of Colleges of Nursing, professional values and its related behaviors are the standard guideline and directions
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of professional nursing practice and are footstones to guiding nurses’ clinical
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performance. The studies show that nurses with positive professional values understood as a method in problem-solving strategies incline to achieve better results of solving
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current clinical nursing problems than other nurses ( Hall et al., 2008; Parandeh et al.,
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2015 ). Professional values is a significant predictor of care quality and development of nursing profession ( Donmez et al., 2016 ). Additionally, according to the studies, professional values may be a moderator of professional psychological responses and adjustment ( Choi et al., 2016; Ros et al., 1999 ). Therefore, the researchers inferred that professional values may enhance the relationship between perceived stress and clinical performance. However, a study has not yet explored the relationship. Based on the conceptual bases, the purpose of this study is ⑴ to examine the 6
ACCEPTED MANUSCRIPT negative association between perceived stress and clinical performance among practice nursing students, and ⑵ to explore the moderating effect of professional values on the relationship between perceived stress and clinical performance.
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2. Methods
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2.1. Respondents and Procedures
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A cross-sectional design was used in this study. A convenience sample of 435 practice nursing students ( 393 female and 42 male ) was recruited from four teaching
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hospitals in Hubei province and Sichuan province. Practice nursing students matching
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the following criteria were recruited in the study: ⑴ undergraduate nursing students, and ⑵ students who were interns in the Three-level A-rate hospital.
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2.2. Instruments
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The questionnaires comprised sections assessing practice nursing students demographic characteristics (age, gender, character, student leader, whether you were
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an only child, and family income status), perceived stress, professional value, and
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clinical performance.
The Perceived Stress Scale ( PSS ) measuring perceived stress was first developed by Cohen et al. ( 1983 ). Using this original version, Yang et al. ( 2003 ) created a new perceived stress scale that was suitable for the Chinese. The questionnaire consisted of 14 items categorized into 2 subscales: tension ( 7 items ) and uncontrol ( 7 items ). The PSS scores were computed as the sum of the two subscales and varied between 14 and 70, with higher scores indicating a higher level of the stress. On a 5-point scale, 7
ACCEPTED MANUSCRIPT responses range from 1 ( Never ) to 5 ( Always ). 0～28 of scores denote normal of the stress, 29～42 of scores denote a little bit of the stress reminding yourself to pay attention to the stress decompression, and 43～56 of scores denote higher the stress needing for external resources for the stress decompression. The questionnaire is a
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reliable tool to measure nursing students’ perceived stress ( Ye et al., 2016 ). In this
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study, Cronbach’s alpha coefficient was 0.87.
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The nursing professional value scale-revised ( NPVS-R ) measuring professional value was developed by Weis et al. ( 2000 ). Gong et al. ( 2011 ) created a new nursing
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professional value scale that was suitable for the Chinese nursing students. The
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questionnaire consisted of 26 items categorized into 4 subscales: professionalism ( 7 items ), caring ( 10 items ), trust ( 6 items ), and activism ( 3 items ). The NPVS-R
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scores were computed as the sum of the 4 subscales and varied between 26 and 130,
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with higher scores indicating a higher professional values. On a 5-point scale, responses range from 1 ( Not important ) to 5 ( Most important ). The questionnaire is a reliable
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tool to measure nursing professional value ( Yang et al., 2015 ). In this study,
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Cronbach’s alpha coefficient was 0.86. The clinical performance scale ( CPS ) measuring clinical performance was developed for the practice nursing students by Deng et al. ( 2006 ). The questionnaire consisted of 28 items categorized into 7 subscales: applying theoretical knowledge ( 3 items ), professional role and role development ( 5 items ), self-directed studying behavior ( 4 items ), clinical skills ( 3 items ), identifying the patients’ rights and obligations ( 3 items ), communication ( 4 items ), and applying nursing procedure ( 6 8
ACCEPTED MANUSCRIPT items ). The CPS scores were computed as the sum of the 7 subscales and varied between 28 and 140, with higher scores indicating a better clinical performance. On a 5-point scale, responses range from 1 ( Never ) to 5 ( Always ). The questionnaire is a reliable tool to measure clinical performance ( Ye et al., 2016 ). In this study, Cronbach’s
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alpha coefficient was 0.91.
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2.3 Ethical Considerations
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Prior to the investigation, ethical approval for this study was obtained from West China Hospital of Sichuan University Biomedical Research Ethics Committee (Ethics
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number: 2017-273). The ethical approval includes consent procedure and written
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informed consent form. All the practice nursing students were briefed about the purpose and significance of the study and their right to not participate or to withdraw at any time
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without any consequences. They were then asked to sign the written informed consents
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if they had interests in taking part in the study. The anonymity and confidentiality of all data were considered in this study. Student’s information like name and other identifiers
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were not included in the study. Furthermore, student’s personal data would not be used
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for any goal other than that of in this study. 2.4 Data Collection The data was collected from May to June 2017. Before the investigation began, the researchers briefed potential respondents about the procedures for filling out the questionnaires by oral forms. The practice nursing students filled out the questionnaires for 15-25 min. Among the 460 returned questionnaires, the 25 questionnaires’ answer was incomplete with missing values or regular such as the repeated options were 1, 2, 9
ACCEPTED MANUSCRIPT 3. Only the filled out questionnaires which researchers have checked and identified were considered qualified. There are 435 practice nursing students ( 94.57% ) who had filled out the whole questionnaires which were suited for statistically analysis without missing values in the total 460 returned questionnaires.
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2.5. Data Analyses
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Statistical Product and Service Solutions(SPSS, version 22.0) was used to deal
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with descriptive statistics, independent-samples t-test, a one-way Analysis of Variance(ANOVA), and Pearson correlation. Analysis of Moment Structure(AMOS,
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version 22.0 ) was used to estimate structural equation modeling ( SEM ).
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Independent-samples t-test and one-way ANOVA were used to test the differences in clinical performance in terms of the categorical demographic characteristics. Pearson
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correlation analyses were dealt with determining the direction and size of the
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relationships among perceived stress, professional values, and clinical performance. SEM with maximum likelihood was used to confirm relationships and predictions
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among perceived stress, professional values and clinical performance. Measurement
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errors of SEM were taken into account during the analyses. The goodness fit of SEM was evaluated by the likelihood ratio ( x2/df ), the goodness of fit index ( GFI ), the comparative fit index ( CFI ), Tucker-Lewis fit index ( TLI ), and root mean square error of approximation ( RMSEA ). The acceptable threshold of RMSEA was ≤ 0.08, that of x2/df was ＜ 3, and that of the rest of the indices such as GFI was ≥ 0.90 ( Bae, 2011 ).
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ACCEPTED MANUSCRIPT 3. Results 3.1. Demographic Characteristics and Clinical Performance The participants had a mean age of 22.16 years ( SD = 0.86; range 19-24 ). A total of 90.3% of participants were female and 9.7% were male. Of the participants, 37.9%
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were only children and 34.9% were student leader. In regard to character and family
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income status, 62.5% of participants were extrovert and 78.6% were from a middle-
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income family. The mean total clinical performance score was 98.00 out of 140. Female interns ( 90.3% ) were reported better clinical performance than male interns ( 9.7%, t
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= 4.655, p ＜ 0.001 ). Those participants who were extrovert ( 62.5% ) were reported
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better clinical performance than those who were introvert ( 37.5%, t = -5.580, p ＜ 0.001 ). There were no other demographic differences in the scores of clinical
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performance ( see Table 1 ).
3.2. Perceived stress, Professional values, and Clinical performance
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Means, standard deviations, and correlations among the related variables are
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presented in Table 2. Clinical performance had a significant positive correlation with professional values ( r = 0.507, P ＜0.01 ) which means when professional values score increases, clinical performance score would also enhance. Additionally, clinical performance had a significant negative correlation with perceived stress ( r = -0.562, P ＜0.01 ) which means when perceived stress score increases, clinical performance score would decrease. Further, perceived stress had a significant negative correlation with professional values ( r = -0.369, P＜0.01 ) which means when perceived stress score 11
ACCEPTED MANUSCRIPT increases, professional values score would decrease.
3.3. Moderating Effects of Professional Values on Perceived Stress and Clinical Performance.
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The SEM analysis of the effect of professional values on perceived stress and
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clinical performance throughout the entire sample had a good fit of the data to the model
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( see figure 1 ). As seen in Fig. 1, perceived stress was negatively related to clinical performance ( B = -0.59, P ＜ 0.01 ); perceived stress was negatively related to
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professional values ( B = -0.68, P＜0.01 ); professional values was positively related to
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clinical performance ( B = 0.33, P＜0.01 ). The results suggest that professional values moderate the effects of perceived stress and clinical performance among practice
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4. Discussion
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The direct effect of perceived stress on clinical performance was further verified, and initial evidence for the moderating role of professional values in the effect of
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perceived stress on clinical performance was found. Furthermore, this finding opened the window to a new means of improving clinical performance among practice nursing students that emphasizes the important role of professional values. Perceived stress was negatively related to clinical performance among practice nursing students, which support the previous studies. For instance, Harvey et al. ( 2010 ) and Liaw et al. ( 2012 ) found that excessive or lasting stress may impair clinical performance deserved. Nursing students with higher or lasting stress levels got 12
ACCEPTED MANUSCRIPT experience of greater psychological distress which could provoke various emotional reactions like nervous, anxious, etc. ( Klainin et al., 2014; Pryjmachuk et al., 2008; Mikolajczyk et al., 2008 ). Furthermore, nursing students with higher or lasting stress may be have an affect on memory, concentration, and problem solving ability, which
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may lead to decreased learning, poorer academic performance, depression, headache,
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and serious health problem ( Goff et al., 2011; Braga et al., 2012 ). Many research have
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associated higher or lasting stress and energy draining aspects ( Jan et al., 2014; Jimenez et al., 2010 ). Consequently, nursing students with poor confidence and competence
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( Ulrich et al., 2010 ) may have poor motive to deal with various nursing problems,
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which in turn decreases the level of clinical performance. Therefore, nursing educators and administrators should assess and monitor the stress levels of nursing students
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clearly. If the excessive or lasting stress was exist, nursing educators and administrators
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could help nursing students adopt appropriate measures such as biofeedback and mindfulness meditation to reduce the stress (Ratanasiripong et al., 2015).
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Professional values was positively associated with clinical performance, which
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echo the results of previous research. For example, McNeese-Smith et al. ( 2003 ) found that professional values can improve nurses’ practice, aid for team performance and assist in performance of counselling. Furthermore, Altun ( 2002 ) showed that nurses with high professional values usually possessed better decision-making, critical thinking and communication, and enhanced the ability to deal with conflicts and prioritize actions. In accordance with the findings, the study added evidence that professional values can be a significant stimulus for enhancing clinical performance 13
ACCEPTED MANUSCRIPT among practice nursing students. Related studies indicate that a person with high level of professional values usually owns others resources like high levels of self-esteem, confidence, spirituality, and self-efficacy, which might use as predictors enhancing clinical performance ( Trisha et al., 2012; Masoudi et al., 2014 ). For instance, one
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research showed that increased self-efficacy enables individuals to improve the
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necessary confidence to take on the challenge, which brings about success in their
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profession ( Abdal et al., 2015 ). Professional values could be cultivated by prelicensure education or progressing education and could also be enhanced by job satisfaction and
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career development ( Moon et al., 2014; Gallegos et al., 2015; Yarbrough et al., 2017 ).
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This study not only confirmed the direct relationship between professional values and clinical performance further but also is the first to verify the moderating
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effect of professional values on the relationship between perceived stress and
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clinical performance. Professional values strengthened the positive effect of perceived stress on clinical performance. In other words, the relationship between
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perceived stress and clinical performance was enhanced because of professional
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values. It might be that individuals with higher professional values showed a better capacity to cope with difficult nursing situations ( Abdal et al., 2015 ) and had capacity to improve self-awareness in professional activities and change their own ways of dealing with things ( Jun et al., 2016 ), which leads to practice nursing students with more resources coping with stress and improving clinical performance. Incidentally, according to demographic variables, the significant differences of this study in clinical performance among practice nursing students was found. Female 14
ACCEPTED MANUSCRIPT practice nursing students had better clinical performance, which may be that they have more responsibility among college students ( Zhang et al., 2009 ), leading to them have more careful and responsible attitude to deal with clinical nursing problem. Second, participants with extroversion reported better clinical performance, which may suggest
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that they might acquire more useful resource like seeking to support to reduce perceived
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stress and got better clinical performance.
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These findings- perceived stress and professional values may influence clinical performance among practice nursing students undergoing clinical practice- have
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important implications for clinical practice of nursing students. It may help clinical
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nursing educators and administrators develop the related intervention strategies such as developing decreasing stress training or developing fostering professional values to
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improve practice nursing students’ clinical performance.
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This study has distinct strengths, such as using of SEM approach to explore the moderating effect of professional values in the association of perceived stress and
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clinical performance among practice nursing students firstly. This study also had some
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limitations. First, the use of convenience sampling ( from four teaching hospitals ) might limit generalization of these findings. Second, given a cross-sectional design and self-report nature of the study, these findings from the study must be interpreted with caution because it might not show the relationships at different time frames and the questionnaire might not really reflect the thoughts among practice nursing students. It is crucial for following longitudinal research which should be designed to
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ACCEPTED MANUSCRIPT replicate the current study from different regional hospitals to further verify these results.
5. Conclusions
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This study results strongly indicate that perceived stress has a direct effect on
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clinical performance among practice nursing students. Also, the researchers verified
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that professional values moderated the relationship between perceived stress and clinical performance. Thus, nursing educators and administrators should pay more
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attention to enhancing clinical performance among practice nursing students by
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strengthening their stress management and professional values. Consequently, this findings can form the basis for evidence-based development of intervention strategies
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for improving clinical performance among practice nursing students. For example,
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nursing educators and administrators should not only improve the job satisfaction and self-worth of practice nursing students, but also teach the practice nursing students to
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manage their own excessive or lasting stress using biofeedback and mindfulness
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meditation, which leads to practice nursing students with better clinical performance.
Table 1. Demographic characteristics and differences in clinical performance.
Table 2. Correlations between perceived stress, professional values, and clinical performance.
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ACCEPTED MANUSCRIPT Fig. 1. Results of SEM analysis of the effect of professional values on perceived stress and clinical performance among the whole sample. All the coefficients in the figure 1 are standardized and significant at level 0.01. x2/df = 1.891, GFI = 0.927, CFI
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D
MA
NU
SC
RI
PT
= 0.935, TLI = 0.959, and RMSEA = 0.073.
17
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ACCEPTED MANUSCRIPT Table 1 Demographic characteristics and differences in clinical performance (N = 435)
character Student leader Income status
t(F)
P
42 (9.7) 393 (90.3) 165 (37.9) 270 (62.1) 272 (62.5) 163 (37.5) 152 (34.9) 283 (65.1) 59 (13.6) 342 (78.6) 34 (7.8)
95.83±8.23 98.68±9.80 99.15±9.62 97.75±10.71 100.20±8.23 95.00±10.31 98.53±9.23 97.84±10.42 96.99±9.76 98.13±8.72 97.46±8.71
4.655
p＜0.001
-1.372
0.171
-5.580
p＜0.001
-0.698
0.485
0.398
0.672
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Family with only child
Male Female Yes No Extrovert Introvert Yes No High Medium Low
Mean ± SD
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Gender
N(%)
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Variable
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High: ≥ 10000 Yuan; Low: < 5000 Yuan; 5000 Yuan ≤ Medium < 10000 Yuan
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Table 2 Correlations between perceived stress, professional values, and clinical performance (N = 435) Vari
Mean
able
± SD
1T
15.58±
1
2
3
4
5
6
7
8
9
10
11
12
13
1
PT
19.27±
0.43
2.09
9**
34.86±
0.71
0.66
2.78
4**
9**
4
91.03±
-
-
-
NPV
7.79
0.20
0.43
0.36
6**
5**
9**
24.52±
-
-
-
0.63
2.51
0.11
0.37
0.28
4**
0
9**
5**
34.95±
-
-
-
0.72
0.43
3.06
0.14
0.36
0.29
9**
4**
4
9**
9**
21.11±
-
-
-
0.66
0.40
0.57
2.22
0.12
0.32
0.25
2**
3**
0**
0
0**
9**
10.44±
-
-
-
0.58
0.41
0.49
0.37
1.72
0.32
0.30
0.36
8**
8**
1**
4**
3**
6**
9**
98.00±
-
-
-
0.50
0.55
0.36
0.29
0.48
9.78
0.41
0.57
0.56
7**
4**
1**
3**
1**
0**
7**
2**
-
-
0.33
0.50
0.18
0.14
0.19
0.60
0.39
0.30
1**
2**
2*
1
1*
1**
1**
3**
8 AC
9 CP
10
9.47±1
-
ATK
.21
0.13 1
RI SC MA
1
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1
1
D
7 TR
1
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6 CA
1
CE
5 PR
1
AC
3 PS
1
1
1
11
16.33±
-
-
-
0.44
0.56
0.29
0.27
0.28
0.67
0.55
PRR
1.95
0.26
0.54
0.26
6**
2**
4**
5**
5**
6**
9**
0**
9**
0**
D
15
1 6
1.73 2N
14
1
12
15.53±
-
-
-
0.45
0.31
0.39
0.31
0.52
0.62
0.28
0.40
SSB
1.63
0.52
0.49
0.58
9**
5**
8**
3**
6**
6**
7**
3**
6**
5**
5**
1
13
11.77±
-
-
-
0.33
0.24
0.25
0.16
0.52
0.57
0.23
0.29
0.57
CS
1.45
0.37
0.34
0.41
6**
7**
2**
4*
4**
5**
4**
0**
0**
3**
2**
7**
25
1
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10.19±
-
-
-
0.34
0.50
0.19
0.16
0.16
0.58
0.55
0.56
0.31
0.18
IPR
1.29
0.18
0.43
0.36
3**
8**
8*
9*
4*
5**
3**
4**
4**
2*
7*
7**
0**
15.51±
-
-
-
0.37
0.28
0.27
0.20
0.58
0.60
0.25
0.34
0.63
0.69
0.19
1.94
0.41
0.39
0.46
8**
6**
4**
4**
3**
7**
7**
3**
3**
6**
1*
3**
1**
6**
O 15 C
1
1
19.21±
-
-
-
0.32
0.45
0.19
0.14
0.18
0.58
0.45
0.61
0.28
0.18
0.45
0.23
ANP
2.31
0.16
0.40
0.33
0**
5**
2*
1
7*
5**
1**
4**
3**
8*
5**
1**
8*
7**
3**
PT
16
1
T: tension, N: uncontrol, PS: perceived stress, NPV: nursing professional value, PR: professionalism, CA: caring, TR: trust, AC: activism, CP: clinical performance, ATK: applying theoretical knowledge, PRRD: professional role
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and obligations, C: communication, ANP: applying nursing procedure
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and role development, SSB: self-directed studying behavior, CS: clinical skills, IPRO identifying the patients’ rights
AC
CE
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** P＜0.01，* P＜0.05
26
ACCEPTED MANUSCRIPT Highlights
Perceived stress is negatively related to clinical performance among Chinese practice nursing students. Professional values significantly affected clinical performance.
Professional values moderates the relationship between perceived stress and
PT
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clinical performance, which can form scientific evidence to develop intervention
AC
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strategies to improve clinical performance.
27
Figure 1