LEVEL OF PROFESSIONAL COMPETENCE OF STUDENT NURSES AT MEDICAL UNIVERSITY-PLEVEN FOR WORKING IN CRИCHES

Aim: The aim of this study is to determine the level of professional competence of students in the specialty “Nurse” at the Medical University Pleven for working in a crèche. Material and Methods: The study was conducted between March 2015 and February 2018. A total of 143 persons have enrolled: 60 students from the specialty “Nurse” at the Medical University of Pleven and 83 nurses working in crèches and crèche groups at integrated nurseries located on the territory of Pleven municipality. Documentary and questionnaire methods were used. Two types of original questionnaires were developed to examine respondents’ views. The survey data were processed with STATGRAPHICS statistical software packages; SPSS 19 and EXCEL for Windows. Results: According to the students, the main professional qualities for working in a day crèche are: communicative skills for working with children 96.67% (58); observational skills78.33% (47); good knowledge of the educational process 50.0% (30). Nearly half of the surveyed graduates 46.67% (28) believe that it is mandatory for healthcare professionals to have psychological and pedagogical training to work with young children. What is of particular note is the high proportion of students 78.10% (n = 32) who claim that their pedagogical and psychological training is insufficient to perform their duties effectively. Conclusion: The students defined the level of their pedagogical and psychological training as not good enough to pursue their profession in this health sphere.


INTRODUCTION
Caring for children in the early childhood proper period in Bulgaria is very often entrusted to public nurseries -crèches. According to Art. 2. (1) of Ordinance No. 26 of November 18, 2008, on the organization and operation of crèches and toddlers' kitchens and the health requirements to them: "Crèches are organizational structures in which nurses and other professionals provide care, educa-tion and training for children from three months to three years of age." [1]. In view of the mission of these health care establishments -protection, promotion and strengthening of children's health, the following specialists are necessarily employed in them: nurse or midwife; teacher; a babysitter (Article 9) [1]. It should be remembered that the promotion of children's health requires specially trained health professionals to carry out, control and accordingly implement preventive measures for the likely occurrence of diseases, which, according to the morpho-physiological development of the child, are common at this age [2]. This necessitates the need for nurses to provide daily care for the upbringing and nurturing of children during early childhood. In addition to purely medical activities related to the promotion of child health, health care professionals also play a pedagogical role, which historically is their youngest function [3]. Under the guidance of the teacher, they carry out purposeful educational work with the aim of optimal physical and neuro-psychological development of the children. The formation of the human psyche and personality is a complex, uneven and lengthy process that begins from the very birth of a child. It is performed in the process of active interaction and adaptation of the organism to environmental conditions, with the decisive participation of education and training. Without the impact of the social environment, the overall development of the child cannot be achieved [4]. In infancy, when childcare (very often in our country) is entrusted to crèches, part of this social environment is represented by the nurse working in them. This, in turn, creates high demands on her personality and on her professional qualities.

AIM
The aim of this study is to determine the level of professional competence of students in the specialty "Nurse" at the Medical University -Pleven for working in crèches.

MATERIALS AND METHODS
The survey was conducted between March 2015 and February 2018. A total of 143 persons have gradually enrolled: 60 students from the specialty "Nurse" at the Medical University of Pleven and 83 nurses working in crèches https://doi.org/10.5272/jimab.2021274.4030 and crèche groups at integrated nurseries located on the territory of Pleven municipality. Two types of original questionnaires were developed to examine the respondents' views.
The following were used: • A documentary method for researching and analyzing the literature available on the subject and reviewing and analyzing the curriculum for the specialty "Nursing" at MU-Pleven; • Questionnaire method: • Anonymous direct individual questionnaire among students -graduates in the specialty "Nurse" at MU-Pleven.
• Anonymous direct individual questionnaire among nurses working in crèches and crèche groups at United Childcare Centers (UCCs) located in the territory of Pleven municipality.
• Statistical methods -the survey data were processed with STATGRAPHICS statistical software packages; SPSS 19 and EXCEL for Windows. The results are described by tables, graphs and numerical indicators for structure, frequency, averages, correlation coefficients and more.

RESULTS
143 individuals participated voluntarily in the study, of them 83 nurses and 60 undergraduate students in the specialty "Nurse" at the Medical University of Pleven. The relative share of nurses working in crèches and crèche groups at the nurseries in the municipality of Pleven is higher -58.04% (83). Graduate students constitute 41.96% (60). The socio-demographic characteristics of the surveyed group are presented in Figure. 1.

Fig. 1. Socio-demographic characteristics of the surveyed group
According to the students, the leading one among the necessary professional skills for working in a crèche is: having communicative skills for working with children -96.67% (58); observational skills -78.33% (47); good knowledge of the educational process -50.0% (30). (Note: respondents indicated more than one answer.) Nearly half of the surveyed graduates -46.67% (28) believe that it is mandatory for healthcare professionals to have psychological and pedagogical training in nursery work. For 38.3% (23) -it is desirable, and for 10.0% (6) -it is not necessary because the law does not require it.
An overview and analysis of the syllabus under which the students of the specialty "Nurse" study at MU-Pleven are made. A number of subjects are envisaged in their training, which enables them to acquire theoretical knowledge and to acquire practical skills regarding the specifics of working with children in crèches (Table 1). Table 1. Subjects studied by students in the specialty "Nurse" at the Medical University-Pleven

Discipline
Semester Hours (classes)

L E Theoretical preparation
Children's pedagogy and psychology I 26 4 The obligation of a nurse in raising and educating children II 10 5 Pediatrics IV 41 4 Health promotion V 10 5 of the students reported feeling confident in their knowledge and skills to work in a similar setting. Among those surveyed, there were also those who were uncertain -21.67% (13) and worried that they would have to contact such young children -21.67% (13). 24.99% did not express their views on the matter (15).
Students were asked to determine their vocational training in a crèche ( Figure 2).
From the summarized information presented in Table. 1 it is noteworthy that for the first time, students enter a crèche as a base for practical training in the second semester, i.e. already in the first year. At the same time, it is evident that the provision of comprehensive theoretical knowledge, directly and indirectly, related to childcare, is at a later stage. This may be the reason for the follow-up to the survey. When they first entered a crèche, 31.67% (19)

Clinical preparation
Practice in a crèche II 24 Practice in a crèche IV 36 Before graduate practice VII/VIII 120 Of interest is the fact that individuals who, at the end of their undergraduate experience, determined their vocational training to be inadequate had previously stated that they felt confident and calm when they first entered a crèche. A significant correlation was observed (p <0.05; r = 0.5). The students, having confidence and being calm at the beginning of their studies, we attribute to the lack of sufficient knowledge and experience in the professional orientation.
The group surveyed determined what was lacking in their professional training for efficient and relaxed work in a crèche. Just over half -53.3% (32) answered the question. Of particular note is the high share of persons -78.10% (n = 32) who pointed out pedagogical and psychological training (Figure 3), which were previously defined by the majority of students as compulsory -46.67% ( n = 32) and desirable -38.3% (n = 32) for working in a crèche.
Bearing in mind that during their studies, students acquire theoretical knowledge (on: the organization and management of nurses working in early childhood care facilities; the main regimes in crèches and health promo-tion among the children) and practical skills (during training and pre-graduate training) we gave them the opportunity to make a comparison between the theoretical statement of the above activities in brackets and their actual putting into practice (Table. 2). There are a significant difference between the statistical results obtained in the comparison groups due to the influence of significant, regular factors and reasons (p <0.05; r = 0.6).
According to a small proportion of the students surveyed -56.7% (34) the responsibility for the health of young children attending crèches lies with their parents; with the healthcare staff involved in their care and their GPs, i.e. with a specific person. Only 21.67% (13) -consider it to be the whole of society. Again, significant differences in the opinion of nurses (p <0.05; r = 0.5) is again observed, according to 72.29% (n = 83), of which the whole society is responsible.
More than half of the respondents from the group of students -63.3% (n = 60) report that they noticed (during their internship) that children with signs of illness (cough, runny nose) are admitted to the crèche. This result is not surprising given that 55.42% (n = 83) of the nurses admit to that, although this situation is rarely tolerated.

DISCUSSION
The results of the study show that the nursing profession is predominantly selected by women and in crèches only by women. At this stage, there are no data on male nurses practicing in crèches. We consider this result logical because, in addition to the professional qualities necessary for the profession in dealing with children, a number of personal -typical for women, born of their maternal instinct -are required. The possession of personal qualities alone is not a sufficient condition for the successful accomplishment of professional obligations. There is a need for health care professionals who have decided to work in crèches to have professional qualities -common to the nursing profession and closely specialized in their field of activity. According to E. Lebikyan and P. Vassileva (2009), in the exercise of their profession, nurses should also acquire competencies that allow them to: identify health needs, physical, mental, social and cultural health risks (in the specific case of children's health) ); be able to identify health problems (of children) and make a nursing diagnosis; be responsible for their professional development; have knowledge and skills in planning and organizing health care (carried out in crèches). In the area of †these competencies, they take responsibility for the care they provide [5].
The training of nurses in Bulgaria is carried out ac- (note: respondents indicated more than one answer) cording to uniform state requirements [6]. In keeping with this, the curriculum for students in the specialty "Nurse" at MU-Pleven is up-to-date, in accordance with European and national standards. However, many students (who participated in the study) stated that they lacked pedagogical and psychological training for working with children. In support of our result L. Peneva (2011) writes that in Bulgaria, the majority of working medical specialists in crèches lack relevant, adequate volume and content, psychological and pedagogical knowledge and skills [7]. According to M. Grudeva (2014): "the emphasis should be placed on basic pedagogical training of students in the specialty in order to expand their pedagogical knowledge, skills and habits for working in crèches" [8].
In higher medical education, during their studies, students have the opportunity, in addition to gaining theoretical knowledge, to acquire practical skills. This is no exception for the students in the specialty "Nurse" at the Medical University-Pleven. Unfortunately, after a comparative analysis of student opinion and that of nurses (regarding the actual implementation of basic activities and programmes among children in crèches), differences were identified. It is not clear which results are more objective -those in the opinion of students or in the opinion of healthcare professionals. On the one hand, the results obtained from the survey of already existing health care professionals could be described as subjective because they make them self-assess their work. On the other hand, we cannot guarantee the objectivity of student opinion because much of the requested information could be out of their grasp due to inexperience. However, if we take students' opinions objectively, then we can claim that there are differences in the theoretical information provided to the students and their actual implementation. The reasons for the discrepancy have not been investigated.
There are differences of opinion between the two groups of respondents and in their responsibility for the health of young children. The results show that the surveyed future healthcare professionals still do not have the necessary experience (note: they may lack sufficient knowledge of the problem). As a result, they may not realize that: health at such an early age is fragile and needs an integrated approach to protection and stimulation; early investments in it will affect the whole of society in the future. One of UNICEF's efforts in Bulgaria is to create the conditions for every early childhood to receive quality health care [9]. To do this, healthcare professionals (nurses) must have the necessary professional training that (as can be seen from the results) students do not yet have.
However, it is worrying that quite a few students during their practical training witnessed admission to crèches of children with signs of illness. In this case, of some concern is not only the fact that the filter is ineffective but also the perceptions that future nurses build, as well as the professional example that is given to them. Demonstrating a poor professional example is a prerequisite for forming misconceptions about health care among future healthcare professionals. These results also testify to the discrepancy in the theoretical formulation and practical realization of one of the main tasks of nurses in crèches, namely, the elimination of risk factors that jeopardize the health of children (in this case, removal of patients in order to limit disease spread). The reasons for such an occurrence are not intended to be investigated in this scientific work.

CONCLUSIONS
In the final stage of their studies, after having gained theoretical knowledge and practical experience, students become aware of the specifics of working with children. They define the level of their pedagogical and psychological training as not good enough to pursue their profession in this health unit. They underestimate the fact that health at such an early age is fragile and needs an integrated approach to preservation and stimulation and that early investment in it will have an impact on society as a whole in the future. There is a need to increase the theoretical and practical training of students in the care of children in crèches.
We allow ourselves to make recommendations to the Universities of Medicine and also to the faculties of Universities where nurses are trained to focus their attention on the problem. Universities where nursing students are trained, could introduce additional freely elective courses in the development of communicative skills to work with children, as well as to enhance the psychological and pedagogical training of students.

ACKNOWLEDGMENTS
We would like to thank all those who responded to the survey: health care professionals practicing the Nursing profession in crèches and crèche groups of integrated nurseries located in the territory of Pleven municipality and graduating students in the specialty "Nurse" at MU-Pleven.
There is no additional funding or conflict of interest in the implementation of this scientific work. The questionnaires used were originally developed for the aims of the study and approved by the Ethics and Research Committee (Rector's Order No. 344 / 20.02.2015).