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Background: Clinical reasoning (CR) involves intertwined cognitive and affective processes, yet the specific contribution of emotional competence (EC) sub-dimensions to CR remains underexplored in undergraduate nursing education. Identifying which EC components matter can inform targeted, low-cost educational routines to support decision quality and patient safety. Aim: To examine the association between EC and CR and to determine, among PEC dimensions (intrapersonal, interpersonal) and the ten PEC sub-dimensions, which independently predict CR in undergraduate nursing students. Methods: A cross-sectional study was conducted in Morocco (Tanger-Tétouan-Al Hoceïma region, March-May 2025). Students completed the Profile of Emotional Competence (PEC, 50 items) and the Nurses’ Clinical Reasoning Competence Scale (NCRCS). Analyses included descriptive statistics, Pearson/Spearman correlations and multiple linear regressions. Results: Clinical reasoning (CR) was positively associated with both intrapersonal emotional competence (EC) (r = 0.23, p<0.01) and interpersonal EC (r = 0.19, p<0.01). In the two-dimensional model, the regression was significant (F(2, 308) = 11.27, p<0.001, R² = 0.07), with independent contributions from intrapersonal EC (β = 0.19, p = 0.002) and interpersonal EC (β = 0.13, p = 0.027). In the ten-subdimension model, overall fit remained significant (F(10, 300) = 3.56, p<0.001, R² = 0.106, adjusted R² = 0.076). Two intrapersonal subdimensions, emotional expression (β = 0.15, p = 0.013) and task-oriented use of emotions (β = 0.17, p = 0.005), emerged as independent predictors of CR when modeled simultaneously. Conclusion: Two intrapersonal emotional micro-skills, expressing emotions and using them in a task-oriented way are priority targets to strengthen clinical reasoning. Embedding brief metacognitive prompts and structured debriefings (including simulation) may offer scalable, cost-effective ways to improve decision quality in undergraduate nursing.
Clinical reasoning (CR) is a major determinant of care quality and patient safety. It integrates cue collection, hypothesis generation and appraisal, evidence evaluation and in-situ decision-making, engaging cognitive, metacognitive and affective processes whose integration conditions the reliability of judgment [1,2]. Emotions do not operate in the background; they guide attention, evidence appraisal and choices, with potential effects on bias and diagnostic error [3,4]. In nursing education, the development of CR increasingly relies on active and authentic approaches: simulation, virtual patients and problem-based learning, with documented effects on judgment and decision-making [5, 6].
Across health systems, strengthening non-technical skills: communication, emotion regulation, teamwork is central to patient-safety policies [7]. In Morocco, this objective is embedded in the recent health-system reform and aligned with the regional orientations of the World Health Organization’s Eastern Mediterranean Regional Office [8]. Studies from hospital and primary care settings in Morocco suggest that a structured safety culture and professional capacity building contribute to better care [9].
Nursing education is therefore encouraged to align CR with non-technical skills, including emotional competence (EC), to support safer and context-sensitive decisions.
EC comprises five cross-cutting components, identification, understanding, expression, regulation and use of emotions, assessed at the intrapersonal (self) and interpersonal (others) levels [10]. The Profile of Emotional Competence (PEC; 50 items) provides a multi-level operationalization global score, two dimensions, ten sub-dimensions with established psychometric properties [10]. This granularity is pertinent to explore differential effects of emotional components on complex performances such as CR.
Among nursing students, several studies link EC with clinical performance, decision making and academic success [11,12]. However, most rely on global scores and do not test the unique effect of each sub-dimension when modeled simultaneously, which limits the identification of precise pedagogical targets and their curricular translation [12]. Alignment with contemporary learning environments enables brief, low-cost instructional routines, structured debriefings and short metacognitive prompts, that make the impact of affective states on reasoning steps visible and explicitly connect affect, cues and action choices [13,14]. These didactic principles are consistent with recommendations for teaching CR and making expert strategies explicit [15].
Objectives
The aim of this study was to assess the association between EC and CR among undergraduate nursing students and to identify among the two PEC dimensions (intrapersonal, interpersonal) and the ten sub-dimensions those that independently predict CR when modeled simultaneously.
Study Design and Setting
A cross-sectional study was conducted and reported in accordance with STROBE [16]. Data were collected in Morocco at the Higher Institutes of Nursing and Health Techniques in the Tanger-Tétouan-Al Hoceïma region from March 3 to May 2, 2025.
Participants
The target population comprised second- and third-year undergraduate students in nursing and midwifery (N = 1,501; year 2 = 802; year 3 = 699). Stratified random sampling proportional to year was applied. Sample size was calculated with Cochran’s formula with finite-population correction (required n = 306); a target of n = 360 was set to offset nonresponse. Complete cases included in analyses were n = 311. Inclusion criteria were enrollment in semester 3/5, presence on data-collection day and written informed consent; exclusion criterion was incomplete questionnaires.
Procedure
A pilot (n = 40) tested clarity and timing; pilot data were excluded from analyses. Questionnaires were paper-based, self-administered under standardized instructions and supervised on site.
Measures
Statistical Analysis
Analyses were conducted in IBM SPSS v27. Descriptive statistics summarized all variables. Primary associations were estimated with Spearman’s rho; Pearson correlations were examined as sensitivity analyses. Two multiple linear regression models were fitted: (1) CR as a function of intrapersonal and interpersonal EC; and (2) CR as a function of the ten PEC sub-dimensions entered simultaneously. Statistical significance was set at two-sided α = 0.05. Model assumptions (normality, independence, homoscedasticity) were checked.
Ethics
The study complied with the Declaration of Helsinki and institutional standards. Authorization was obtained from the Regional Health Directorate of Tanger-Tétouan- Al Hoceïma (Ref. 3508). Participation was voluntary and anonymous; all students received study information and provided written informed consent.
Participants
We analyzed 311 complete cases. These came from a source population of 1,501 second- and third-year students (year 2 = 802; year 3 = 699). After the pilot (n = 40) and exclusions for incomplete questionnaires, the analytic sample was finalized.
Descriptives and Reliability
Overall levels were moderate and relatively homogeneous. The EC global mean was 3.04 (SD 0.27; range 2.28-4.20). The intrapersonal EC mean was 3.02 (SD 0.33), while the interpersonal EC mean was 3.06 (SD 0.34). In parallel, CR averaged 3.32 (SD 0.55; range 1.53-5.00). Internal consistency was acceptable for all scales: NCRCS α = 0.75, PEC global α = 0.78, intrapersonal α = 0.77 and interpersonal α = 0.73 (Table 1).
In our sample, emotional competence (EC) and clinical reasoning (CR) showed moderate, relatively homogeneous levels. Beyond the positive associations between CR and EC (intra- and interpersonal dimensions), the simultaneous analysis of the ten sub- dimensions highlighted two intrapersonal targets, emotional expression and task- oriented use of emotions, as independent predictors of CR. These findings suggest that explicitly training both the mobilization of emotion for task goals and its accurate verbalization may strengthen CR in undergraduate nursing students.
These results align with recent nursing literature linking EC to clinical performance, decision making and academic outcomes in students [11,12]. They also fit contemporary decision-making accounts in which emotions guide attention, evidence appraisal and hypothesis prioritization, with implications for bias and diagnostic error [3,4], as well as foundational descriptions of CR processes in health-professions education [1,2]. In addition, updated syntheses outline how CR is taught across programs [18].
Our findings are compatible with instructional designs that make reasoning visible, explicit strategy talk, authentic and progressively challenging tasks and timely feedback, consistent with recent guidance on CR teaching [18]. Consolidated evidence base supports technology-enhanced simulation to develop clinical and decision-making skills [19] and virtual simulation/virtual patients enable concise metacognitive prompts followed by debriefings that connect affect, cues and action choices [20]. Furthermore, structured debriefings can scaffold guide reflection and self-regulation [21]. Assessment approaches such as the objective structured clinical examination complement these strategies and help capture behavioral indicators of performance [22,23].
Alignment with our prior work in the same population further strengthens the overall picture: self-efficacy emerged as a major predictor of CR, perceived stress was not predictive and selected features of the clinical learning environment remained correlated with CR [24]. The present study complements that picture by identifying two intrapersonal emotional levers. Taken together, these results point to complementary pathways, motivational-cognitive (self-efficacy) and emotional (expression and use), that can be trained jointly within reasoning activities without disproportionate curricular burden. Consistently, recent Moroccan data indicate that development of emergency- care competencies among new graduates remains sensitive to training quality and learning environments [25], reinforcing the value of targeted emotional micro- competencies closely coupled to reasoning tasks. Finally, emerging technology enhanced strategies suggest additional, scalable avenues to support CR.
Our results identify two intrapersonal levers to improve clinical reasoning in nursing students: emotional expression and task-oriented use of emotions, which support cue gathering, hypothesis prioritization and decision making. Aligned with judgment models and current pedagogy, these targets lend themselves to brief, integrable and evaluable interventions.
Limitations
This study has several limitations. First, the use of self-reported measures may introduce social desirability bias. Second, it was conducted in a regional context, which constrains generalizability. Finally, the explained variance is moderate, as is typical for multifactorial competencies in health-professions education [18,19]. In practice, these points call for intervention studies in authentic settings with behavioral indicators (simulation, OSCE) and, ideally, longitudinal follow-up [22,23].
Acknowledgement
We would like to thank all the nursing students who participated in the study.
Ethical Statement
All student participants provided written informed consent for participation.
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