Background
During the first year of employment, novice nurses are expected to bridge the gap between theoretical knowledge and clinical practice, often under limited time frames dictated by demanding patient care schedules and administrative responsibilities [1]. However, senior nurses who support novice nurses find it difficult to find time for guidance in the busy daily work schedule [2]. Therefore, a sustainable, long-term supportive learning environment that is integrated into daily operations is needed [3, 4], and active learning is necessary for novice nurses to effectively deepen their learning.
Modeling, which involves active learning, has been the subject of much research, however few studies have focused on learners. Learning from role models takes place through observation and reflection, a complex interplay of conscious and unconscious activity [5]. “Modeling” refers to the process of learning through observation and reflection, while “conscious modeling” specifically emphasizes deliberate and intentional learning from role models. These concepts are closely related but distinct, as conscious modeling involves a more focused and purposeful approach to emulating behaviors. Despite its significance, modeling often presents challenges for novice nurses, such as confusion about what to observe or how to apply observed behaviors. By utilizing a modeling self-assessment scale, learners can objectively identify specific areas they need to observe and pinpoint where they are struggling. This approach facilitates the smoother implementation of modeling, ultimately supporting novice nurses in integrating theoretical knowledge with practical application.
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A gap exists between the clinical practice skills required in workplace and the nursing practice skills acquired in basic nursing education [6]. Novice nurses often experience anxiety about their nursing skills, frustration with their inability to perform nursing and work tasks smoothly, and uncertainty about specific methods for assisting with medical care and daily living. These challenges arise from the gap between the fundamental nursing skills learned during basic education and the advanced, situation-specific practices required in clinical settings [6]. Therefore, novice nurses have trouble with anxiety about nursing skills, impatience with the inability to smoothly perform nursing and work tasks, and not knowing specific ways to assist with medical care and daily living [7], and the discrepancy amplifies these difficulties. Under these circumstances, novice nurses learn nursing behavior by observing senior nurses.
Bandura states that from the perspective of social learning theory, modeling is the process by which observers acquire new patterns of behavior through observation. For novice nurses, this involves learning professional behaviors and skills from observing senior colleagues. Modeling allows them to adopt effective practices and avoid unnecessary mistakes by reducing the amount of trial and error required to master new tasks [8, 9]. Novice nurses observe others nurses in the early stages of their learning process [10] and developing expertise through observation, the beginning of the learning process, with self-regulation and feedback [11]. This allows them to effectively learn their role as nurses in the midst of a busy work through modeling. Also, modeling can be effectively used to teach challenging clinical skills such as verbal and nonverbal communication, humanism, professionalism, and teamwork [12]. These suggest that modeling is a necessary learning strategy for novice nurses.
Modeling has also been shown to affect self-efficacy [13]. Additionally, Zimmerman [14] suggests that modeling is necessary for self-regulation learning, stating that it is necessary to observe others’ self-regulation activities and internalize them through imitation. Self-regulated learning refers to learner’s active involvement in metacognition, motivation, and actions. Self-regulation is believed to be formed through modeling, which involves observing others to learn new behavioral patterns.
In the nursing field, it is easy to model nursing skills, communication, care, and compassion [5] as novice nurses in clinical settings routinely and unconsciously imitate or identify with the nursing gestures and practices of senior nurses by observing the effects of their practices on patients [15]. Additionally, novice nurses learn compassion and use of evidence from observation [16]. As learners, new nurses are expected to advance their professional development by observing and imitating the actions and practices of senior nurses in the clinical setting. Through the process of modeling, they integrate various approaches and behaviors observed in senior nurses to develop their own unique nursing practices. Bandura [8] describes “creative modeling” as the observer not patterning behavior according to only one model but combining various aspects of models to create new patterns of behavior. Therefore, novice nurses engage in creative modeling in nursing practice.
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Previous research identified a distinct process in the modeling behaviors of novice nurses [17]. The study highlighted that, in practice, certain aspects of modeling are not seamless. Novice nurses often experience confusion due to the diverse methods employed by their senior colleagues and may struggle to replicate their proficiency. Additionally, if a senior’s behavior is overly fast or complex, learning becomes limited and fragmented, requiring repeated observations [18]. Therefore, it became clear that novice nurses were not modeling smoothly, but through trial and error. Indeed, the increased complexity of the disease, the faster pace of the clinical environment, and the increased skills and competencies required to provide care have lengthened the transition time from novice to competent nurse [19]. Therefore, to facilitate smooth modeling by novice nurses, it is necessary to establish objective evaluation indicators.
Several questionnaires have been developed in the nursing field to assess various aspects of learning and professional development. For instance, the Clinical Learning Environment Inventory (CLEI) is commonly used to evaluate the learning environment and its impact on nursing students [20]. Additionally, the Nursing Self-Efficacy Scale (NSES) has been utilized to measure self-efficacy in clinical practice [21]. These scales primarily focus on environmental factors and individual confidence levels, rather than the specific modeling behaviors of novice nurses. While these existing tools provide valuable insights, they do not specifically address the process of modeling, which involves observing and emulating the practices of senior nurses. The Modeling Scale for Novice Nurses (MSNN) fills this gap by objectively evaluating the modeling process and supports novice nurses’ ability to practice.
This study aims to develop the MSNN. If novice nurses can self-evaluate their own modeling status using the scale, it will facilitate smooth modeling. In addition, novice nurses can learn nursing practice more smoothly and objectively by reflecting on their own modeling. The supervisor of the novice nurse can also grasp the novice nurse’s modeling status by checking the self-assessment given by the novice nurse. This will be a useful resource for senior nurses to identify what specific support needs to be provided to novice nurses.
Creating draft scale items
In the first phase of scale development, 61 items were extracted from interviews with novice nurses about modeling and conceptual analysis of modeling. In a conceptual analysis of modeling in nursing practice [22], eight attributes were extracted: model selection, model observation, information collection, interpretation of model behavior, learning of model behavior, performance of behavior, acquisition of performed behavior, and formation of ideal behavior. Also, the interviews consisted of semi-structured interviews with 20 novice nurses, asking them how they modeled in their nursing practice [17].
In the second phase, 61 items extracted from interviews with novice nurses and conceptual analysis of modeling were discussed at an expert meeting in March 2019. The meeting of experts was conducted with five researchers who had a master’s degree or higher and had experience in teaching clinical practice to novice nurses. The meeting reviewed the consistency, sequencing, clarity of expression, and ease of answering the questions in accordance with the interview guide. Based on the considerations, items that could be explained under other categories were removed, item descriptions were revised, items with similar meanings were consolidated, and items with dual meanings were divided, resulting in a total of 66 items: four subscales (Observation, Preparation, Imitation, and Developing behaviors).
In the third phase, in August 2019, item validity was examined using the Item-level Content Validity Index (I-CVI) for ten participants (five researchers and five nurses) with a master’s degree or higher, more than five years of clinical experience, and experience teaching clinical practice to novice nurses. After reviewing the content validity, seven items were rejected and 59 items were adopted [23].
Methods
Design
This study employed a cross-sectional design. The analysis was performed with reference to the consensus-based standards for the selection of health measurement instruments (COSMIN) [24].
Participants and data collection
The participants were novice nurses who began working in April of the study year. The selection criterion was that they had no work experience before starting work as nurses. For the selection of participants, medical facilities were selected by random sampling method from the data of the list of 1,458 hospitals. A written request for research cooperation was sent to the 103 selected medical facilities, and questionnaires were distributed to novice nurses at the facilities who responded that they would cooperate in the study. Institutions willing to participate in this study were asked to specify the number of potential participants, with a maximum of 15, and return. Questionnaires and retest request form were then sent to each institution based on the reported number of participants, for distribution to the respective individuals. Responses to the questionnaire were collected anonymously using a self-administered format, and completed questionnaires were mailed directly to the researchers by the participants. Additionally, for participants who indicated willingness to cooperate in a retest, a second questionnaire was mailed three weeks after the initial questionnaire submission. Participants completed the retest anonymously and returned it to the researchers. To ensure confidentiality, matching of responses between the initial and retest questionnaires was conducted using a password created by each participant. Data were collected from November 2019 to January 2020.
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After excluding responses with missing values, 337 valid questionnaires were completed (valid response rate: 23.1%). The sample size met this criterion, as Confirmatory Factor Analysis requires a sample size of at least 200 [25].
Measurement
The draft MSNN
The modeling questions used a 59-item 6-point Likert scale, ranging from 1 (not at all applicable) to 6 (very much applies).
SMSGSE
The Scale Measuring a Sense of Generalized Self-Efficacy (SMSGSE) [26], was used to confirm the criterion-related validity of the scale. Because modeling has been shown to increase self-efficacy [13]. Higher SNSGSE scores indicated higher self-efficacy. This is a one-subscale, six-item scale that measures self-efficacy as a long-term influence on behavioral persistence and is rated on a five-point Likert scale (“1 = not at all true” to “5 = very true”). The Cronbach’s α coefficient for the SMSGSE was 0.81.
SRLSN
The Scale of Self-Regulated Learning Strategy for Nurses (SRLSN) [27] was used to confirm the criterion-related validity of the scale. Theories of self-regulated learning state that modeling is necessary for self-regulated learning [14]. Higher SRLSN scores indicated better self-regulated learning. This scale is a 19-item scale consisting of four subscales: “Practical learning strategy,” “Upward learning strategy,” “Self-discipline learning strategy” and “Collaborative learning strategy.” It measures the degree to which novice nurses use autonomous learning strategies and is rated on a 5-point Likert scale. The Cronbach’s α coefficient for the SRLSN was 0.90.
Data analysis
Statistical analyses were performed using IBM SPSS Statistics Version 26 and IBM SPSS Amos Version 26. Sealing effects, floor effects, skewness, kurtosis, adjusted item total correlations, and item-to-item correlations were examined, and the presence of bias in the response trends was analyzed using item analysis [28].
An Exploratory Factor Analysis (EFA) was performed using the maximum likelihood and Promax methods of oblique rotation. The Kaiser Meyer Olkin (KMO) measure and Bartlett’s sphericity tests were performed to confirm that the data were suitable for factor analysis.
Confirmatory Factor Analysis (CFA), and the Goodness of Fit Index (GFI), Adjusted Goodness of Fit Index (AGFI), Root Mean Square Error of Approximation (RMSEA), and Comparative Fit Index (CFI) were used as goodness of fit indices. Goodness of fit thresholds for GFI and CFI are 0.9 or better, AGFI is closer to 1, a range of 0.85 to 0.90 is an acceptable fit, RMSEA less than 0.5 is good, and a range of 0.5 to 0.8 is an acceptable fit [28, 29].
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The correlation coefficients between the SMSGSE and SRLSN, respectively, and draft MSNN were calculated to examine criterion-related validity.
Cronbach’s α coefficient was calculated to examine the reliability of the draft scale. Intraclass correlation coefficient was calculated using test-retest analysis to examine the consistency of the draft scale over time.
Ethical considerations
This study was approved by the research ethics committee of the researcher’s institution (approval no. 2019-45). The scales used in the criterion-related validation were used with permission from the scale developers. A document explaining the outline of the study, that cooperation in the study was voluntary, and that personal information would be protected was distributed. Consent for the study was obtained by completing a consent form for the questionnaire.
Results
Participants’ characteristics
Table 1 presents the characteristics of the participants.
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Table 1
Characteristics of the participants (N = 337)
Mean ± SD | N(%) | ||
|---|---|---|---|
Age | 22.7 ± 1.8 | ||
Gender | Female | 316(93.8) | |
Male | 21(6.2) | ||
Educational Background | Non-Holders | 194(57.5) | |
Bachelor’s Degree Holders | 138(40.9) | ||
Master’s degree | 5(1.5) | ||
Ward Type | Internal Medicine Ward | 85(25.2) | |
Surgical Ward | 79(23.4) | ||
Mixed Medical-Surgical Ward | 58(17.2) | ||
Intensive Care Unit | 22(6.5) | ||
Pediatric Ward | 21(6.2) | ||
Maternity Ward | 21(6.2) | ||
Operating Room | 13(3.9) | ||
Psychiatric Ward | 13(3.9) | ||
Rehabilitation Ward | 5(1.5) | ||
Community based care ward | 4(1.2) | ||
NICU | 3(0.9) | ||
ER | 3(0.9) | ||
Severe Motor and Intellectual Disabilities Ward | 3(0.9) | ||
Outpatient | 2(0.6) | ||
Other (no specific ward name given) | 5(1.5) | ||
Item analysis
The range for confirming sealing effectiveness was 4.865–6.160, and eight items that showed > 6 were eligible for deletion. The floor effects ranged from 2.363 to 4.717, with no items below one eligible for deletion. Skewness ranged from − 1.409 to 0.073, kurtosis ranged from − 0.491 to 2.532, and six items with skewness and kurtosis greater than ± 1.0 were deleted. The Corrected Item Total Correlations (CITC) ranged from 0.343 to 0.778. There were no items below 0.3 [30] that were targeted for deletion. Inter-item correlations (IIC) ranged from 0.101 to 0.883. IIC > 0.7 indicates that the items are similar [31]. Therefore, 14 items that indicated IIC > 0.7 were removed. A total of 25 items were deleted through item analysis, resulting in 59 to 34 questions.
Construct validity
Exploratory factor analysis (EFA)
The EFA was conducted using 34 items refined through item analysis. The Kaiser-Meyer-Olkin (KMO) measure of 0.949 and Bartlett’s sphericity test was significantly differences (χ2 = 6978, df = 561, p < 0.01). A KMO higher than 0.9 indicates a very good fit, and a Bartlett’s sphericity test that is significant indicates that it is suitable for factor analysis [32]. An EFA was performed with maximum likelihood Promax rotation. A four-factor structure was determined to be appropriate because the cumulative contribution ratio was greater than 50%. Items with factor loadings of less than 0.5 and items with factor loadings of 0.4 or greater for multiple factors were deleted, the factor analysis was repeated, and 21 items with four factors were extracted (Table 2).
Table 2
Results of factor analysis of the MSNN (N = 337)
Item | Factor loading | |||
|---|---|---|---|---|
1 | 2 | 3 | 4 | |
Factor 1: Observation (α = 0.867) | ||||
12. Learning to be considerate to patients by observing senior nurses’ behavior | 0.853 | |||
10. Learning how to take care of patients individually by observing senior nurses’ behavior | 0.744 | |||
3. Learning manners as a member of society by observing senior nurses’ behavior | 0.707 | |||
14. Learning ethically sensitive care by observing senior nurses’ behavior | 0.671 | |||
2. Learning the rules of the workplace by observing senior nurses’ behavior | 0.648 | |||
Factor 2: Imitation (α = 0.885) | ||||
33. Participating in training by observing senior nurses participating in training | 0.748 | |||
32. Being aware of how to communicate like senior nurses | 0.699 | |||
34. Observing senior nurses self-learning and I also self-learn | 0.669 | |||
45. Imitating the senior nurses’ way of communicating with patients | 0.65 | |||
47. Imitating the senior nurses’ way of communicating with colleagues | 0.617 | |||
52. Being conscious of time management, after imitating senior nurses’ behavior | 0.588 | |||
35. Imitating senior nurses that devising a way to make work more efficient | 0.53 | |||
Factor 3: Motivation (α = 0.834) | ||||
59. Experiencing a sense of growth, since I have been able to care like senior nurses | 0.843 | |||
55. Finding my own way of taking care of myself by imitating senior nurses’ ways | 0.706 | |||
57. Imitate the care methods of senior nurses and notice individualized care | 0.682 | |||
53. Giving care without being confused, by imitating senior nurses’ behavior | 0.647 | |||
Factor 4: Inquiry (α = 0.793) | ||||
26. Asking senior nurses for tips on how to care for patients | 0.828 | |||
24. Trying to understand the rationale behind the care given by senior nurses | 0.629 | |||
22. Seeking advice from senior nurses on how to improve care | 0.618 | |||
27. Taking notes on how senior nurses care for patients | 0.537 | |||
19. Observing senior nurses’ care when not confident about how to provide care | 0.508 | |||
Total (21 items) (α = 0.930) | ||||
Factor 1 | - | 0.684 | 0.515 | 0.56 |
Factor 2 | - | 0.653 | 0.649 | |
Factor 3 | - | 0.573 | ||
Factor 4 | - | |||
After the exploratory factor analysis, revealed that modeling for novice nurses includes four factors and 21 items. The first factor, Observation, consisted of five items based on what the novice nurses learned by observing their seniors. The second factor, Imitation, consisted of seven items and reflected the tendency to replicate the observed behavior of seniors. The third factor, Motivation, consisted of four items and reflected the drive to persist in the behaviors that were imitated. The fourth factor, Inquiry, consisted of five items reflecting the innovative approaches novice nurses employed to learn from their observations.
Confirmatory factor analysis (CFA)
A CFA was conducted to examine construct validity. CFA was conducted with four factors and 21 items. The modification index was checked, and covariance was applied to e2-e3 and e33-e34. The results were as follows: GFI = 0.896, AGFI = 0.868, RMSEA = 0.060, and CFI = 0.941 (Fig. 1).
Fig. 1
Results of CFA of the MSNN (N = 337)
×
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Criterion-related validity
The Spearman’s rank correlation coefficient between the total MSNN and SMSGSE was 0.035, and the correlation between the subscales and SMSGSE ranged from r=-0.044 to 0.142.
The Spearman’s rank correlation coefficient for the MSNN and SRLSN was 0.596 (P < 0.01), and the correlations for the subscales ranged from r = 0.266 to 0.451 (P < 0.01).
Reliability
Internal consistency - cronbach’s α reliability coefficients
To examine internal consistency, Cronbach’s α coefficients were calculated for each factor. Factors 1, 2, 3, and 4 were 0.867, 0.885, 0.834, and 0.793, respectively. Cronbach’s α coefficient was 0.930 for the total scale (Table 1). Table 3 shows the descriptive statistics of MSNN.
Table 3
Descriptive statistics of the MSNN (n = 337)
Range | Min | Max | Mean | SD | Skewness | Kurtosis | |
|---|---|---|---|---|---|---|---|
Total (21 items) | 84 | 42 | 126 | 97.3 | 13.4 | -0.3 | 0.4 |
Observation | 20 | 10 | 30 | 25.2 | 3.5 | -0.7 | 0.5 |
Imitation | 35 | 7 | 42 | 31.1 | 5.8 | -0.4 | 0.7 |
Motivation | 20 | 4 | 24 | 17.3 | 3.2 | 0.0 | 0.4 |
Inquiry | 18 | 12 | 30 | 23.8 | 3.6 | -0.1 | -0.4 |
Stability
Among the participants, 57 who cooperated with the retest were retested three weeks later. The intraclass correlation coefficient was calculated using test-retest, and the stability of the draft scale was examined. The intraclass correlation coefficient showed a subscale score of 0.771–0.786 and a total MSNN score of 0.889 (95% CI: 0.811–0.934).
Discussion
The MSNN is a six-point Likert scale consisting of 21 items across four subscales: Observation, Imitation, Motivation, and Inquiry. Although this scale generally followed the four modeling processes of social learning theory, “Inquiry” was a characteristic subscale of modeling for novice nurses. The following is a discussion of the subscales in order.
The first subscale “Observation” consisted of five items. This subscale implies that novice nurses observed and learned from the behaviors of their seniors. The attentional process of the four processes of modeling is the process of focusing on the important features of the model’s behavior, similar to “Observation” on this scale. Exemplary models possess professional and technical knowledge, excellent psychomotor, technical, and interpersonal skills, and pay attention to a few things [9]. Modeling can be performed by observing expert nurses and learning skills and professional attitudes. This subscale also includes items on learning individualized care and ethically sensitive care. Among nursing-related skills, individualized and ethical care is considered a particular focus for novice nurses. Modeling also involves learnings manners, ways of thinking, job skills, organizational and work values, and behaviors through observation [33]. This subscale also included items on manners, care, and workplace rules, which were learned from observations of the mannerisms of working adults and nurses.
The second subscale “Imitation” consisted of seven items. This subscale was content to imply what they were imitating to the behavior of their seniors. Among the four processes of modeling, the reproduction process is the process of actually acting out the observed behavior and is similar to “Imitation” on the MSNN. In a study that conceptualized novice nurses’ behaviors, novice nurses discovered and identified a nursing role model and learned nursing behaviors by imitating them [15]. The process of learning by example of professional behaviors and skills is important for developing resilience and integrating theoretical knowledge with practical application [34]. Thus, to learn about specific care, it is necessary to imitate senior staff members’ care.
The third subscale “Motivation” consisted of four items. This subscale recognizes one’s own behavior and growth as a result of acting in the same manner as seniors. The items included those that gave novice nurses confidence, such as starting to provide evidence-based care modeled by their senior colleagues, recognizing their own growth, performing tasks without confusion, and developing their personalized methods grounded in best practices. Nurses become more confident in their own nursing by practicing with awareness of the nursing they aim for, which leads to positive patient reactions and improved situations [35]. Therefore, novice nurses feel a sense of confidence and accomplishment because they could provide the same type of nursing care as an expert, which is the type of nursing they are aiming for. In a study examining the motivation of healthcare professionals [36], recognition and appreciation were the motivators and the most important motivators for healthcare professionals. Learners with high self-efficacy tend to actively seek strategies to overcome difficult challenges and maintain persistence in their learning [37]. Therefore, recognizing the certainty of one’s practice motivates one to sustain that practice.
The fourth subscale “Inquiry” consisted of five items. This subscale included practices and strategies that novice nurses do to become more like their seniors. Nursing has become increasingly complex, with multiple diseases and advanced treatments. Novice nurses seek guidance and advice from senior nurses to bridge the gap between their current abilities and the advanced practices demonstrated by their more experienced colleagues. To provide appropriate care, it is important to continue trying to improve one’s own skills and learning new ones. To provide appropriate care, it is important to continuously improve one’s skills and acquire new ones. This can be achieved through self-reflection, seeking guidance from colleagues, reviewing relevant educational materials, and consulting current literature [38]. Novice nurses ask their seniors for tips and rationales for care and seek advice to learn new skills. It is difficult to learn a behavior by simply observing it once. In the field of nursing, the actions taken by nurses are highly contextual, relying on the specific circumstances and the patient’s condition at any given time. Therefore, asking senior nurses’ for tips and rationales for their care and seeking advice when modeling their behaviors is crucial. By doing these things, they remember the tips and rationale and are more likely to act on them.
Existing literature highlights the significance of role modeling in shaping novice nurses’ clinical competencies. For instance, a previous study [39] demonstrated that novice nurses acquire essential nursing skills through reflective learning and direct observation of senior nurses in clinical settings. This finding aligns with the “Observation” and “Imitation” subscales of the MSNN, underscoring the foundational role of observing and mimicking senior nurses in skill acquisition. In a previous study [40] identified role modeling as an effective teaching strategy, emphasizing its impact on professional development and the integration of theoretical knowledge into practical applications. This resonates with the “Motivation” subscale of the MSNN, which captures how novice nurses gain confidence and develop personalized methods by emulating the evidence-based practices of their senior colleagues. By comparing the MSNN with findings from these studies, it becomes evident that this scale provides a more comprehensive evaluation of the multifaceted modeling processes in nursing. These insights have significant implications for clinical practice and nursing education, as they emphasize the need for structured mentorship programs that facilitate not only observation and imitation but also active inquiry.
There was no correlation between the MSNN and SMSGE. However, criterion-related validity was obtained because there was a correlation between the MSNN and the SRLSN.
As the goodness of fit generally met the criterion values [29, 30], CFA confirmed the construct validity of this scale.
A Cronbach’s α coefficient of 0.80 or higher is considered to have high internal consistency [30]. Therefore, scale reliability was ensured.
Strengths and limitations
This study developed and validated a reliable scale to measure specific properties, which can also serve as an educational support tool for novice nurses. For instance, senior nurses can utilize the MSNN to evaluate novice nurses’ scores and collaboratively identify areas for improvement, providing targeted guidance on items with lower scores.
On the other hand, there are several limitations associated with this research. First, there was no criterion-related validity between this scale and the SMSGSE. In the future, it will be necessary to examine criterion-relevant validity, taking into consideration the type of scale and the survey period. In addition, because this research targeted novice nurses working in hospitals, it excludes novice nurses working in non-hospital settings, such as elderly care facilities and home nursing stations. In the future, it is necessary to broaden the range of subjects and generalize this scale. Additionally, further studies should consider differences in settings, such as variations in institutional environments, patient populations, and regional characteristics, to ensure the scale’s applicability across diverse contexts.
Conclusions
The MSNN consists of 21 items with four subscales. The results showed that the scale has construct validity, making it a reliable and valid instrument. This scale can be effectively utilized by novice nurses at various stages of their early careers, as it was validated specifically for this group. It can also be used to understand their own modeling.
Acknowledgements
We would like to express our deepest gratitude to the nurses who participated in this study and Professors Dr. Aiko Kitamura and Dr. Tayo Nagahata for their advice on this research. This study is part of a 2021 doctoral thesis submitted to the Graduate School of Nursing at Osaka Prefecture University.
Declarations
Ethics approval and consent to participate
The study was approved by the Osaka Prefecture University Graduate School of Nursing Research Ethics Committee (approval no. 2019-45). Consent was obtained from the study participants to conduct the study.
Consent for publication
No applicable.
Competing interests
The authors declare no competing interests.
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