Introduction

In recent years, nursing education in Portugal has undergone significant changes, reflecting the need to align academic training with the demands of clinical practice. Training students in a clinical setting plays a crucial role in consolidating their skills, making it essential to ensure that, throughout their undergraduate studies, they acquire the necessary capabilities to provide safe and quality care (^{Albloushi et al., 2023}; ^{Immonen et al., 2019}). The assessment of clinical competencies in clinical education has been one of the challenges in nursing training, as it involves multiple domains, from theoretical knowledge to decision-making ability and clinical judgment (^{Cantante et al., 2020}).

Despite acknowledging the importance of developing clinical competencies, gaps remain in the literature regarding the systematic assessment of these competencies in undergraduate nursing students, particularly in the Portuguese context and based on its sociodemographic characteristics. Identifying these competencies and the factors that influence them proves essential to support the definition of pedagogical strategies and clinical supervision models better suited to the current needs of students. In this context, the present study aims to assess the clinical competencies of undergraduate nursing students and analyze the influence of sociodemographic variables on these competencies, contributing to a deeper understanding of the process of developing clinical skills throughout academic training. The assessment of clinical competencies thus constitutes a central element in facilitating the transition to professional practice, promoting a safer, more autonomous, and confident integration of future nurses into the labor market.

1. Theoretical framework

The concept of competence has been widely debated in the literature, with different approaches to its definition and assessment. According to ^{Cantante et al. (2020}, p. 267), the competence of the general care nurse refers to "a level of professional performance that demonstrates the effective application of knowledge and skills, enabling clinical judgment and decision-making." Complementarily, the Order of Nurses (^{OE, 2017}) states that the competency profile of the general care nurse is structured into three main domains: professional, ethical, and legal responsibility; care delivery and management; and professional development. These domains reflect the complexity of nursing practice and the need to prepare students to face the challenges of practice with autonomy and safety.

The transition from theoretical learning to clinical practice is a dynamic process that requires clinical teaching spaces to be structured to provide meaningful, reflective, and integrative experiences. ^{Mahboob (2019}) emphasizes that the quality of clinical teaching depends on creating opportunities for sharing experiences, developing projects that address emerging questions, and the continuous integration of theoretical knowledge with care practice. ^{Berndtsson, Dahlborg, and Pennbrant (2019}) state that learning in a clinical context allows students to integrate theoretical frameworks into care, enabling them to develop practical skills and knowledge. The integration of theoretical frameworks with clinical practice is essential for the development of nursing students' competencies, allowing them to gradually progress toward autonomy and decision-making ability. To understand this process of transition and the development of clinical competencies, one of the most widely used models is that of Patricia ^{Benner (2001}). This model describes five levels of development: initiated, advanced beginner, competent, proficient, and expert; showing that students start by needing clear rules and structures, progressively developing greater autonomy and clinical judgment as they accumulate competence. Given the complexity of developing clinical skills, it becomes essential to use valid and reliable instruments that allow the assessment of students' progress throughout their academic training. The Clinical Competence Questionnaire, developed by ^{Liou & Cheng (2014}), is a self-assessment tool that measures students' perceptions of their clinical competencies in different areas of professional practice. In the present study, the Portuguese version of the instrument, called the Clinical Competence Questionnaire (QCC), which had previously been adapted and validated for the Portuguese population, was used, allowing the assessment of essential dimensions of the professional performance of nursing students, namely professional behaviors, overall performance, core competencies, and advanced nursing skills. These dimensions are aligned with the competency domains of the General Care Nurse defined by the Portuguese Nursing Association (OE, 2017), ensuring conceptual consistency between the theoretical framework, the instrument used, and the objectives of the study.

2. Methods

A quantitative study was conducted, with a descriptive and exploratory design, aiming to assess clinical competence in undergraduate nursing students in a clinical teaching context. The evaluation was carried out through the application of the Clinical Competence Questionnaire (CCQ), a validated instrument adapted to the Portuguese population, which allows measuring levels of clinical competence across multiple dimensions fundamental to professional practice. The Portuguese version of the Clinical Competence Questionnaire (CCQ) was used, culturally adapted, and validated for nursing students in Portugal by ^{Oliveira, Barroso, and Carvalho (2025}), which demonstrated good psychometric properties, namely content validity, construct validity, and high internal consistency (overall Cronbach's α > 0.90). The sample consisted of 251 undergraduate nursing students enrolled in the 2024-2025 academic year, from three Schools of Nursing of Lisbon and the Tagus Valley region, integrated into institutions in the public and private sectors. Data collection took place between May 1 and November 15, 2024, a period coinciding with the completion of clinical teaching in various practice settings. The study was approved by the Ethics Committees of the participating institutions (opinions nº: 1097/2024 and nº 97/2024) and conducted in accordance with the ethical principles of research on human beings, namely the principles of autonomy, beneficence, non-maleficence, and justice, in accordance with the Declaration of Helsinki. Participation was voluntary, through the signing of the Informed Consent Form, after reading and understanding the study's explanatory note. Data were collected on paper, using a standardized procedure that ensured the anonymity and confidentiality of participants. Each student received a set of documents consisting of an explanatory note, two copies of the form of informed consent (one for signed return and another for the participant) and the CCQ questionnaire. After completion, the questionnaires were returned in sealed envelopes and deposited in a pre-defined location at each institution, ensuring the security and integrity of the collected information. The sample size calculation was carried out based on the formula for finite populations, considering a 95% confidence level (Z = 1.96), a 5% margin of error, and an expected proportion of 50% to maximize the sample size. A 10% margin was added to this value to account for potential losses or non-responses, estimating a minimum number of 246 participants. The final sample, composed of 251 students, proved adequate to ensure the robustness of the statistical analysis. The statistical analysis was performed using Jamovi® software, applying both descriptive and inferential analyses. Descriptive statistics included the calculation of frequencies, measures of central tendency (mean and median) and dispersion (standard deviation and interquartile range). The normality of the data distribution was assessed through the Kolmogorov-Smirnov and Shapiro-Wilk tests, as well as by analyzing the skewness and kurtosis coefficients. Given the absence of a normal distribution, non-parametric tests were used. To compare the levels of clinical competence according to gender and academic year, the Kruskal-Wallis test was applied. The association between age and levels of clinical competence was analyzed using Spearman's correlation. A significance level of 0.05 was considered, with the results interpreted in light of this criterion.

3. RESULTS

This study presents the results obtained from the application of the Clinical Competence Questionnaire (CCQ) to a sample of 251 undergraduate nursing students. The data analysis is organized into three sections: (i) sociodemographic characterization of the sample; (ii) assessment of students' clinical competencies, according to the four dimensions of the CCQ; and (iii) analysis of the influence of sociodemographic variables (gender, academic year, and age) on perceived clinical competencies.

4. Discussion

The assessment of nursing students' clinical competencies, carried out through the QCC, revealed differing levels of proficiency across the various dimensions analyzed. The results of this study suggest that nursing students show greater competence in professional behaviors and overall performance, while core and advanced competencies register lower levels, especially in more specific technical procedures. This pattern reflects a progressive consolidation of relational, ethical, and organizational skills, contrasting with greater difficulties in more complex technical competencies, which aligns with findings from previous studies emphasizing the importance of continuous practical exposure in the development of clinical competencies (^{Benner, 2001}).

The sociodemographic analysis revealed that the majority of students belong to Generation Z (82.47% are between 18 and 25 years old). Studies indicate that this generation, strongly influenced by technology, values emotional, financial, and physical security but may face difficulties in developing interpersonal skills and managing professional autonomy (^{Lee et al., 2023}; ^{Luukkonen et al., 2023}). These characteristics may influence the way students engage in clinical settings, highlighting the need for innovative pedagogical methodologies that promote motivation, interaction, and adaptation to the new dynamics of clinical education (^{Lennon et al., 2020}).

Professional behaviors were the dimension with the best results, particularly standing out were the adherence to the ethical principles of secrecy and confidentiality, and the maintenance of an appropriate appearance. This result suggests an early internalization of the ethical and deontological values of the profession, possibly due to the emphasis given to these topics in the course curriculum structure, combined with the influence of clinical supervision during the initial clinical teachings (^{Albendin-Garcia et al., 2023}).

However, lower levels of competence were observed in items that require critical thinking, problem-solving, and effective interprofessional communication. These weaknesses are consistent with the literature, which identifies these skills as particularly demanding from a cognitive and relational standpoint, and often less developed in the early stages of clinical education (^{Foronda et al., 2020}; ^{Lee et al., 2023}; ^{Scheckel et al., 2023}).

In overall performance, students demonstrated greater competence in everyday direct care tasks, particularly those related to basic care and continuity of care. These skills tend to be more frequently trained and reinforced in early clinical settings, which explains the higher levels of proficiency observed (^{Reeve et al., 2021}; Zyond et al., 2022). Conversely, weaknesses were evident in activities requiring structured therapeutic communication and clinical documentation, suggesting limited clinical autonomy, reflecting challenges in transitioning from theoretical knowledge to its application in real care settings (^{Papathanasiou et al., 2019}; ^{Valizadeh et al., 2019}).

Core competencies showed significant variability. Stronger performance was observed in more frequent and routine technical procedures, whereas competencies associated with invasive or less common procedures in a clinical context demonstrated lower levels of perceived competence. The lower exposure to these practices in real clinical settings may explain these results, highlighting the need to reinforce supervised training and the use of complementary methodologies (^{Said & El-Shafei, 2020}). In this regard, clinical simulation emerges as a particularly relevant educational strategy, especially in low-frequency procedures in current clinical practice (^{Cant & Cooper, 2017}). The dimension of advanced competencies showed the lowest results in clinical competence. This finding reinforces the idea that students have limited access to practical experiences in more complex clinical settings, which is consistent with studies that point to barriers in accessing these practices, as well as limitations in the available supervision resources (^{Uncu & Gunes, 2021}).

It is also important to emphasize that the development of these skills requires the integration of clinical decision-making, risk anticipation, and time management, aspects that tend to become consolidated only with continued clinical experience (^{Mancin et al., 2024}; ^{Marques et al., 2021}; ^{Rogers et al., 2025}; ^{Yoong et al., 2023}).

The results show a progressive pattern of skills acquisition, beginning in ethical and relational areas and advancing, with less consistency, to technical and more complex skills. This progression is consistent with ^{Benner's (2001}) model, which describes the evolution of clinical performance from the novice level to the expert level, through practical experience and the learning context.

Inferential analysis revealed that students' academic progress and age positively influence the development of clinical skills. The year of study stood out as the variable with the greatest impact, reflecting the importance of progressive and cumulative exposure to clinical teaching contexts. These findings are consistent with studies suggesting that experience, maturity, and self-regulation capacity influence clinical performance (^{Silva et al., 2022}; ^{Vasconcelos et al., 2019}).

Regarding gender, the results indicated no statistically significant differences in overall clinical skills, suggesting that gender is not a relevant differentiating factor in clinical performance. The occasional differences observed in certain skills may reflect contextual variations related to clinical practice opportunities rather than factors intrinsic to gender, which is consistent with recent studies pointing to increasing gender equity in nursing education (^{Pérez-Cañaveras et al., 2021}).

In turn, age showed a moderate positive correlation with clinical skills, especially in technical and advanced competencies. This result suggests that older students tend to exhibit higher levels of performance, possibly associated with greater maturity, prior experiences, and critical thinking ability (^{Currie et al., 2022}; ^{Liou et al., 2020}). This finding reinforces the importance of differentiated pedagogical strategies that take into account the age heterogeneity of the student population.

The results of this study support the need for the adoption of integrated pedagogical strategies, highlighting the use of clinical simulation, the construction of reflective portfolios, and the implementation of structured supervisory processes as facilitators of clinical development (^{Cant & Cooper, 2017}; ^{Choi & Jeon, 2022}; ^{Peddle et al., 2019}). Considering sociodemographic variables in the organization of clinical teaching is a key element for a more balanced and effective training, reinforcing the connection between theoretical teaching and clinical practice and promoting a safe transition from knowledge to know-how.

5. Study limitations

This study has some limitations that should be considered when interpreting the results. First, it is a cross-sectional study, which prevents establishing causal relationships and limits the understanding of the development of clinical competencies over time. Second, the assessment of clinical competencies was based on a self-report instrument, which may be subject to biases associated with students' individual perceptions, such as social desirability or overestimation of their own abilities. Additionally, the sample consisted of undergraduate nursing students from three institutions in the Lisbon and Tagus Valley region, which may limit the generalization of the results to other geographic or institutional contexts. Despite these limitations, the sample size and the use of a validated instrument provide robustness to the results obtained.

Conclusion

This study allowed for an in-depth analysis of the clinical competencies self-perceived by nursing students, highlighting a pattern of progressive development throughout their academic training. The results showed higher levels of competence in the dimensions of professional behaviors and overall performance, contrasting with lower values in technical and advanced skills, particularly in more complex procedures. These gaps appear to reflect the clinical development stage of the students, as well as their limited practical exposure to certain specialized interventions during initial training. The analysis of the different dimensions revealed an early internalization of ethical and professional values, suggesting that these constitute a central framework of nursing education. In contrast, competencies related to critical thinking, problem-solving, and interprofessional communication were less consolidated, which underscores the need for educational strategies that promote clinical reasoning, decision-making, and the integration of theoretical knowledge into clinical practice.

Regarding sociodemographic variables, it was found that the year of study and age have a significant influence on the development of clinical competencies. Progression throughout the academic course was associated with higher levels of competence, particularly in the core and advanced dimensions, highlighting the positive impact of accumulated clinical experience. Similarly, the positive association between age and more complex competencies suggests that factors such as maturity, previous experiences, and greater self-regulation capacity can enhance clinical performance.

Together, these results highlight the need to strengthen differentiated and student-centered pedagogical strategies, emphasizing active methodologies that promote the integration of theoretical teaching and clinical practice. Adapting training processes to the sociodemographic characteristics of students is seen as a fundamental element to ensure education balanced, fair, and effective, capable of supporting a safe, autonomous, and competent transition to professional nursing practice.

Authors´ contribution

Conceptualization, P.O., C.B., and A.C.; data curation, P.O., C.B., and A.C.; formal analysis, P.O., C.B., and A.C.; investigation, P.O., C.B., and A.C.; methodology, P.O., C.B., and A.C.; project administration, P.O., C.B., and A.C.; resources, P.O., C.B., and A.C.; software, P.O., C.B., and A.C.; supervision, C.B., and A.C.; validation, P.O., C.B., and A.C.; visualization, P.O., C.B., and A.C.; writing-original draft preparation, P.O., C.B., and A.C.; writing-review and editing, P.O., C.B., and A.C.

Conflict of interests

The authors declare no conflict of interests.