Table of Contents
Abstract
The Nursing Students' clinical practice stress Scale (NSCPSS) is a specialized psychometric instrument designed to quantify the unique psychological burdens experienced by nursing undergraduates during their clinical training. Developed through a rigorous exploratory sequential mixed-methods approach, this tool bridges the gap between theoretical classroom learning and the high-stakes reality of patient care environments. By capturing the nuanced stressors specific to developing healthcare contexts, the NSCPSS provides educators and researchers with a targeted metric to assess student well-being.
Clinical placements are universally recognized as the cornerstone of nursing education, yet they frequently serve as a primary catalyst for student anxiety and burnout. The NSCPSS was conceptualized to isolate and measure these specific environmental and academic pressures, moving beyond generalized stress metrics. It evaluates four distinct domains of clinical stress, offering a granular view of where Students struggle most, whether it be in practical skill application or navigating complex hospital hierarchies.
In the broader landscape of psychometrics, the introduction of the NSCPSS represents a critical step toward culturally and contextually responsive measurement. By validating this tool within a South Asian educational framework, the authors have provided a robust mechanism for identifying at-risk Students, tailoring institutional support systems, and ultimately safeguarding the mental health of the future nursing workforce.
📊 Psychometric Scorecard
17
Multidimensional
0.69
0.954
Authors
Purpose
While general stress inventories like the Perceived Stress Scale (PSS) are ubiquitous in psychological research, they often fail to capture the idiosyncratic pressures of specialized training environments. Similarly, existing nursing-specific tools frequently reflect Western educational paradigms, limiting their ecological validity in resource-constrained or culturally distinct settings like Sri Lanka. The NSCPSS was developed to address this critical measurement gap by providing a contextually grounded instrument that accurately reflects the lived experiences of Nursing Students in developing healthcare systems.
For researchers and clinical educators, the NSCPSS serves as a vital diagnostic tool to evaluate the efficacy of clinical placement structures. High levels of unmanaged stress not only compromise academic performance but also pose direct risks to patient safety and student retention. By deploying this scale, academic institutions can pinpoint specific systemic failures—such as inadequate faculty support or excessive workload demands—and implement targeted interventions to foster a more resilient and competent nursing workforce.
Construct
The psychological construct of 'clinical practice stress' as operationalized by the NSCPSS is inherently multidimensional, reflecting the complex intersection of cognitive, interpersonal, and environmental demands placed on Nursing Students. The scale conceptualizes this stress through four distinct but interacting theoretical dimensions. The primary dimension centers on the internal deficit of knowledge, skills, and experience, capturing the anxiety Students feel when their perceived competence does not align with clinical expectations. This is closely tied to the fear of causing patient harm, a profound stressor unique to healthcare education.
Secondary dimensions focus on external and systemic pressures. These include the lack of academic communication and support systems, which highlights the stress induced by poor mentorship and ineffective evaluation protocols. Additionally, the construct encompasses the logistical friction of balancing dual roles—managing simultaneous academic coursework and clinical shifts—as well as navigating the physical and hierarchical challenges inherent to the clinical learning environment itself. Together, these facets form a comprehensive model of the occupational and educational stress unique to pre-registration nursing.
Validity
The validation framework for the NSCPSS employed a comprehensive, multi-stage approach to ensure robust psychometric properties. Initial content validity was established through rigorous expert review, yielding an excellent Scale-Level Content Validity Index (S-CVI/Ave) of 0.89, indicating strong consensus that the items accurately represent the clinical stress construct. Construct validity was subsequently evaluated using Confirmatory Factor Analysis (CFA), which refined the item pool by eliminating indicators with suboptimal factor loadings or conceptual overlap, ensuring a parsimonious and highly targeted instrument.
Beyond basic structural validation, the researchers meticulously assessed both convergent and discriminant validity. Convergent validity was supported by Composite Reliability (CR) scores exceeding the standard 0.60 threshold across all subscales, demonstrating that items within each construct share significant variance. To rigorously confirm that the four subscales measure distinct facets of stress without excessive overlap, the Heterotrait-Monotrait (HTMT) ratio of correlations was utilized. All HTMT values fell comfortably below the conservative 0.85 ceiling, providing compelling evidence of discriminant validity and confirming the multidimensional nature of the scale.
Reliability
Internal consistency for the NSCPSS was evaluated using Cronbach's alpha, yielding a range of coefficients that demonstrate acceptable to strong reliability across its subscales. The primary domain assessing knowledge and skill deficits showed robust internal consistency with an alpha of 0.83, while the academic support subscale followed closely at 0.79. These values indicate that the items within these dimensions are highly intercorrelated and reliably capture their respective constructs.
The remaining two subscales—measuring academic/clinical demands and environmental challenges—both produced alpha coefficients of 0.69. While slightly below the traditional 0.70 heuristic often cited in psychometric literature, an alpha of 0.69 is generally considered acceptable in the context of newly developed scales, particularly for subscales with fewer items capturing broad psychological experiences. Furthermore, the Composite Reliability indices for all factors exceeded 0.60, providing additional mathematical confidence in the scale's overall reliability profile.
Factor Analysis
The structural architecture of the NSCPSS was uncovered and verified through a classic exploratory-to-confirmatory factor analysis pipeline. The initial Exploratory Factor Analysis (EFA), conducted on a subsample of 95 Students, utilized visual scree plots and parallel analysis to extract a four-factor solution that accounted for a substantial 57.0% of the total variance. During this phase, items demonstrating cross-loadings or weak primary loadings (below 0.40) were systematically pruned, refining the scale from 30 to 19 highly representative items.
The subsequent Confirmatory Factor Analysis (CFA) tested this four-factor model on an independent subsample. After examining modification indices and removing two conceptually peripheral items with standardized loadings below the 0.50 threshold, the final 17-item model demonstrated exceptional fit. The data yielded a non-significant chi-square (p = 0.066) and a chi-square to degrees of freedom ratio of 1.21, indicating superior model-to-data alignment. Furthermore, absolute and incremental fit indices were highly favorable, with an RMSEA of 0.049, a CFI of 0.954, and a TLI of 0.942, all comfortably exceeding the stringent psychometric benchmarks required for structural validation.
Subscales
| Subscale | Items | Description |
|---|---|---|
| Lack of knowledge, skills and experience | Measures stress arising from feelings of inadequacy regarding clinical competence and fear of harming patients. | |
| Lack of academic communication and support systems | Measures stress related to poor mentorship, ineffective educators, and inadequate evaluation by academic/clinical staff. | |
| Challenges in managing academic and clinical demands | Measures stress caused by the dual burden of academic coursework/examinations and clinical placement responsibilities. | |
| Challenges in the clinical learning environment | Measures stress stemming from systemic, infrastructural, and hierarchical difficulties within the hospital setting. |
Instrument
| Test Type | Self-report questionnaire |
| Format | 17 items, 5-point Likert scale |
| Scoring | Sum of all items, total score ranges from 17 to 85. Higher scores indicate a higher level of clinical practice stress. |
| Population | Students, Nurses |
| Age Group | Mean age 24.68 years |
| Administration | Self-administered |
Nursing Students' Clinical Practice Stress Scale Items
Items are currently not available
The individual items of this scale are not publicly available. Researchers interested in using this instrument should contact the original authors directly to request the scale materials.
Sample
183 undergraduate Nursing Students (mean age = 24.68, SD = 1.47; 73.8% female) from the University of Peradeniya, Sri Lanka. The sample was split into an EFA subsample (n = 95) and a CFA subsample (n = 88).
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References
48 references
- Abell, N., Springer, D., Kamata, A. (2009). Developing and Validating Rapid Assessment Instruments. 🔗 https://doi.org/10.1093/acprof:oso/9780195333367.001.0001
- Al-Worafi, Y. (2024). Nursing Education, Practice, and Research in Sri Lanka. Handbook of Medical and Health Sciences in Developing Countries,, 1-39. 🔗 https://doi.org/10.1007/978-3-030-74786-2_509-1
- Braun, V., Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. 🔗 https://doi.org/10.1191/1478088706qp063oa
- Braun, V., Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597. 🔗 https://doi.org/10.1080/2159676x.2019.1628806
- Braun, V., Clarke, V. (2021). To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Research in Sport, Exercise and Health, 13(2), 201-216. 🔗 https://doi.org/10.1080/2159676X.2019.1704846
- 🔗 https://doi.org/10.1186/s12906‐019‐2733‐z
- Cohen, S., Kamarck, T., Mermelstein, R. (1983). A Global Measure of Perceived Stress. Journal of Health and Social Behavior, 24(4), 385. 🔗 https://doi.org/10.2307/2136404
- Creswell J. W. (2023). Research Design: Qualitative, Quantitative, and mixed methods Approaches.
- Creswell J. W. (2018). Qualitative Inquiry and Research Design: Choosing Among Five Approaches.
- Crosswell, A., Lockwood, K. (2020). Best practices for stress measurement: How to measure psychological stress in health research. Health Psychology Open, 7(2) 🔗 https://doi.org/10.1177/2055102920933072
- 🔗 https://doi.org/10.1108/qrj‐09‐2020‐0110
- 🔗 https://doi.org/10.1186/s12912‐024‐01962‐5
- 🔗 https://doi.org/10.1186/s13717‐016‐0063‐3
- Fornell, C., Larcker, D. (1981). Structural Equation Models with Unobservable Variables and Measurement Error: Algebra and Statistics. Journal of Marketing Research, 18(3), 382-388. 🔗 https://doi.org/10.1177/002224378101800313
- Gassas, R. (2021). Sources of the knowledge-practice gap in nursing: Lessons from an integrative review. Nurse Education Today, 106, 105095. 🔗 https://doi.org/10.1016/j.nedt.2021.105095
- Hair J. F. (2018). Multivariate Data Analysis.
- Hair, J., Howard, M., Nitzl, C. (2020). Assessing measurement model quality in PLS-SEM using confirmatory composite analysis. Journal of Business Research, 109, 101-110. 🔗 https://doi.org/10.1016/j.jbusres.2019.11.069
- Harvey, G., Carter-Snell, C., Hussein, M., Berlinguette, K. (2024). Coping with clinical related stress experienced by undergraduate Nursing Students: A scoping review. Teaching and Learning in Nursing, 19(4), 372-384. 🔗 https://doi.org/10.1016/j.teln.2024.06.012
- 🔗 https://doi.org/10.1007/s11747‐014‐0403‐8
- 🔗 https://doi.org/10.1016/j.jbusres.2023.113969
- 🔗 https://doi.org/10.1111/aogs.13331
- 🔗 https://doi.org/10.4300/JGME‐D‐21‐00752.1
- 🔗 https://doi.org/10.1016/j.jbusres.2011.10.026
- 🔗 https://doi.org/10.1111/j.1744‐6570.1975.tb01393.x
- 🔗 https://doi.org/10.1016/j.nepr.2022.103457
- 🔗 https://doi.org/10.1016/j.nedt.2017.11.029
- Myers N. D. (2016). An Introduction to Intermediate and Advanced Statistical Analyses for Sport and Exercise Scientists. 267.
- 🔗 https://doi.org/10.1111/ijn.12276
- 🔗 https://doi.org/10.1136/bmjopen‐2018‐028052
- 🔗 https://doi.org/10.1258/jhsrp.2007.007074
- 🔗 https://doi.org/10.1007/978-981-13-6106-7_10-1
- 🔗 https://doi.org/10.1007/s10488‐013‐0528‐y
- 🔗 https://doi.org/10.1002/nur.20147
- Polit D. F. (2018). Essentials of Nursing Research: Appraising Evidence for Nursing Practice.
- Preacher K. J. (2006). Computing Power and Minimum Sample Size for RMSEA.
- 🔗 https://doi.org/10.5772/intechopen.72993
- 🔗 https://doi.org/10.7777/jiemar.v2i
- 🔗 https://doi.org/10.1186/s12888‐020‐02964‐8
- 🔗 https://doi.org/10.1002/nop2.397
- 🔗 https://doi.org/10.1016/j.nepr.2012.01.005
- 🔗 https://doi.org/10.1111/jocn.14723
- 🔗 https://doi.org/10.1007/978-981-13-6106-7_117-1
- 🔗 https://doi.org/10.1515/ijnes‐2019‐0111
- 🔗 https://doi.org/10.1177/23779608231207274
- 🔗 https://doi.org/10.4103/sja.SJA_203_17
- 🔗 https://doi.org/10.1177/0095798418771807
- 🔗 https://doi.org/10.3928/01484834‐20221109‐03
- 🔗 https://doi.org/10.1186/s12912‐021‐00602‐6
Cite this article
Mohammed looti (2026). Nursing Students’ Clinical Practice Stress Scale. PSYCHOLOGICAL SCALES. Retrieved from https://scales.arabpsychology.com/s/nursing-students-clinical-practice-stress-scale/
Mohammed looti. "Nursing Students’ Clinical Practice Stress Scale." PSYCHOLOGICAL SCALES, 14 Aug. 2026, https://scales.arabpsychology.com/s/nursing-students-clinical-practice-stress-scale/.
Mohammed looti. "Nursing Students’ Clinical Practice Stress Scale." PSYCHOLOGICAL SCALES, 2026. https://scales.arabpsychology.com/s/nursing-students-clinical-practice-stress-scale/.
Mohammed looti (2026) 'Nursing Students’ Clinical Practice Stress Scale', PSYCHOLOGICAL SCALES. Available at: https://scales.arabpsychology.com/s/nursing-students-clinical-practice-stress-scale/.
[1] Mohammed looti, "Nursing Students’ Clinical Practice Stress Scale," PSYCHOLOGICAL SCALES, vol. X, no. Y, ص Z-Z, August, 2026.
Mohammed looti. Nursing Students’ Clinical Practice Stress Scale. PSYCHOLOGICAL SCALES. 2026;vol(issue):pages.