Psychometric properties of the nursing start-up attitude scale in Iranian nursing students

Nursing professionals have the ability to play a significant role in tackling worldwide healthcare obstacles such as chronic diseases, the emergence of new illnesses like COVID-19, the growing elderly population, advancements in technology, and inequalities in healthcare access [1]. Through the expansion of their skill set and the exploration of entrepreneurship opportunities, nurses have the potential to emerge as leaders in population health management, effectively facilitating access to healthcare services for diverse populations [2]. Consequently, nurses are uniquely positioned to make a substantial impact on the healthcare system by assuming the role of nurse entrepreneurs [3].

According to the International Council of Nurses, nurse entrepreneurs are individuals who are owners of businesses that encompass a wide range of nursing services, including the provision of direct patient care, educational initiatives, research endeavors, administrative functions, and consultation services [4]. These nurse entrepreneurs are independent practitioners and business owners who deliver care to their patients [5]. The American Nurses Association Enterprise Innovation (2023) reports that over 300 nurse entrepreneurs are currently driving innovation in the nursing field as change agents. They are involved in various aspects of nursing entrepreneurship such as medical equipment and devices, care delivery models, business creation, research, and educational interventions [6]. Additionally, Sanders and Kingma (2012) outline the characteristics of entrepreneurial nursing, which include nurse-led units, clinics, emergency services, telephone consultation services, and nurse-owned nursing homes [4]. These contributions signify the rise of new healthcare roles, innovative care models, advancements in healthcare legislation, and progress in health equity [7]. However, data from the National Nurses Association suggests that only a small percentage, ranging from 0.5% to 1%, of nurses worldwide currently pursue entrepreneurial roles [8]. In New Zealand, the percentage is less than 1% [9], while in the United States, it is 0.18% [10]. Notably, specific statistics for the Iranian context are currently unavailable.

Entrepreneurial attitude pertains to an individual's acquired inclination, either positive or negative, towards a specific object that is connected to personal views regarding entrepreneurship [11]. A positive attitude is linked to optimistic beliefs about the results of particular actions and favorable outcomes in terms of behavior [12]. Prior to embarking on entrepreneurial endeavors, attitudes towards entrepreneurship play a crucial role in various activities such as formulating a business plan, securing investments, establishing a company, and engaging in entrepreneurial pursuits [13]. Essentially, a positive entrepreneurial attitude can act as a motivating factor for commencing and prospering in entrepreneurship. Research on entrepreneurial attitudes in nursing remains limited. While qualitative research utilizing the Q-method has explored nursing students' attitudes towards entrepreneurship [14], there is a scarcity of quantitative studies that objectively measure these attitudes within the Iranian context [15, 16]. One possible reason for this gap could be the absence of valid instruments for assessing entrepreneurial attitudes.

The most of existing measurement tools for entrepreneurial attitudes have primarily been developed and studied in the field of business management. These tools often contain items that are specific to certain specialized areas, such as "development of business products and services" or "entrepreneurial expert networks" [17, 18]. Using such tools to measure entrepreneurial attitudes in the nursing field has limitations.

Several instruments, including the Nursing Start-up Attitude Scale (NSAS) [11], Personal Attitude in Liñán and Chen entrepreneurial intention instrument [19], and Son’s start-up attitude scale [15] have been used to measure nurse attitude. Among these instruments, the 12- item NSAS was originally developed to measure six key factors: opportunity for self-realization, network formation, enhance start-up capabilities, achievements of start-ups, start-up preparation, and risk taking. These factors are derived from a robust theoretical framework grounded in entrepreneurship theory [20], which underscores the importance of these dimensions in predicting entrepreneurial success [11]. The developer of this scale recommended that, due to the dynamic nature of entrepreneurship and its susceptibility to societal and temporal shifts, it is essential to consistently evaluate the validity and reliability of the scale. Additionally, it is important to make appropriate adjustments and enhancements to align with the changing landscape. Continuous assessment and refinement of the tool are strongly advised to maintain its relevance and effectiveness in measuring nursing students' entrepreneurial attitudes in the future [11].

Despite the significant potential of nurses in the entrepreneurial field [21], the concept of entrepreneurial attitudes in nursing remains largely underexplored, particularly within the Iranian context. Entrepreneurial nurses have the capacity to drive innovation by establishing independent businesses, developing novel care delivery models, and contributing to transformative healthcare reforms [22].

The current study highlights a critical gap in nursing education and practice in Iran—the lack of validated tools to measure nursing students' entrepreneurial attitudes. Developing entrepreneurial skills among nursing students is vital to prepare them for leadership roles and enable them to navigate the evolving demands of healthcare [23]. The absence of such tools hinders the ability to assess educational outcomes, design targeted interventions, and foster entrepreneurial capabilities in nursing education. This research addresses this pressing need by evaluating the psychometric properties of the NSAS in an Iranian context. By validating this instrument, we aim to provide a robust tool that educators and policymakers can use to assess and enhance entrepreneurial attitudes among nursing students, thereby equipping them to contribute innovatively to the healthcare sector.

This methodological study was designed to translate the NSAS into Persian and evaluate its psychometric properties, including validity and reliability, within the context of Iranian nursing students from 2021 to 2023.

The present study focused on evaluating the psychometric characteristics of a 12-item Persian version of the NSAS in Iran. The orginal scale was developed through a review of relevant literature on nursing entrepreneurship and an analysis of in-depth interviews with actual nurse entrepreneurs and then validated through various methods such as EFA [11]. According to the nursing students' perspectives, the scale adequately covered the fundamental elements associated with each stage of the start-up process, ranging from self-awareness to accomplishments. Comparing to the orginal version with six factors, the final Iranian version of NSAS was found to have five factors, in which the factor 5 and 6 was merged during EFA. Since the risk-taking factor in the original scale consists of only one item, and given that start-up preparation inherently involves risk, we decided to transfer the risk-taking item to the start-up preparation factor. This decision was further supported by our EFA analysis, which indicated that the factor loadings of the items for risk-taking and start-up preparation loaded onto a single factor. Factor 1 was identified as "Opportunities for Self-realization" (3 items), Factor 2 as "Network Formation" (2 items), Factor 3 as "Enhancement of Entrepreneurial Competence" (2 items), Factor 4 as "Entrepreneurial Performance" (2 items), and Factor 5 as "Preparation of Entrepreneurial Foundation" (3 items).

Through gathering feedback from 10 nursing students, the face validity of the scale were assessed, revealing that the items were easily understandable and unambiguous. Further, during content validity, the experts confirmed that the scale has acceptable given to language forms, diction, and the placement of words and phrases. Further, the criterion validity demonstrated that the iranian-version of nursing start-ups attitude scale has strong correlation with the Son's entrepreneurial attitude scale [15].

According to the results of EFA, The first factor with three items accounted for 20.6% of the explained variance. The included items suggested that nursing entrepreneurship has a higher chance of success when there is a blend of specialized nursing knowledge and skills, as well as experiences in community service [11]. Entrepreneurs typically possess a greater inclination towards seeking new challenges and experiences. Additionally, Hurst and Pugsley's study [41] revealed that nursing students perceive entrepreneurship as a path towards self-fulfillment, with non-monetary motivations carrying more weight than financial ones. Nursing students generally exhibit a strong sense of belief and pride in their field, considering entrepreneurship as a valuable opportunity to apply their expertise [42].

The second factor accounted for 18.53% of the explained variance. Nursing students recognize that nursing entrepreneurship requires collaboration with external entities, and they believe that networking and partnerships with relevant organizations and institutions are crucial for achieving success [11]. Furthermore, networking should extend beyond mere connections and encompass active collaboration and interdisciplinary work with experts in fields such as medical engineering, IT, and others [43].

The third factor, accounting for 15.47% of the explained variance, included two items, which emphasized the importance of nursing students acquiring knowledge in entrepreneurial theory courses and completing practical training courses in entrepreneurship (like practical training in entrepreneurial facilities, field visits) for nursing entrepreneurship preparation [44]. Currently, nursing bachelor's degree programs like other programs lack entrepreneurship-related courses or educational programs in Iran [45]. However, in light of the evolving healthcare policy direction towards primary healthcare and health promotion in an aging society, nursing students need to develop competencies in various nursing entrepreneurship models suitable for integrated home care services within the local community. This calls for the expansion of entrepreneurship education and support programs. Additionally, different studies [46‐48] reported that the nursing requires the profession to be responsive to changes in the fields of population, new diseases, and others. Future programs should prioritize the development of nursing students' entrepreneurial capabilities, including fostering creativity, openness, and other essential practical skills, in addition to specific disciplines like management and administration.

The fourth factor, accounting for 13.40% of the explained variance, consisted of two items. Based on research findings, nearly half (44.2%) of young entrepreneurs in South Korea expressed the desire to work well into their later years as a driving force behind their decision to embark on entrepreneurial ventures. Similarly, nursing students perceive nursing entrepreneurship as a pathway to extend their professional careers beyond retirement and create a significant and lasting impact in their field.

The fifth factor, accounting for 12.73% of the explained variance, consisted of three items. Despite consisting of a relatively small number of 12 items, the iranian version of scale proves to have a high explanatory power of 80.74%. As a result, it can be deemed a reliable and valid instrument for assessing nursing students' attitudes towards entrepreneurship. The total predicted varince to the orginal version was 74.4%.

CFA of the Persian version of the NSAS indicated satisfactory goodness-of-fit indices, confirming the adequacy of the model. These results were consistent with the five factors identified during the EFA phase. These findings provide support for the validity and reliability of the Persian version of the scale.

The relative and absolute reliability of our modified scale demonstrated significant improvement, underscoring the methodological soundness of our approach.Furthermore, the analysis of floor and ceiling effects revealed minimal bias, indicating that the instrument has a good distribution of responses and is capable of distinguishing between different levels of entrepreneurial attitudes among nursing students. This is a crucial methodological advantage, as it enhances the scale's sensitivity and specificity.

The literature currently has limited standardized, valid, and reliable tools specifically designed for assessing start-up attitudes. This limitation hinders researchers from comparing the psychometric properties of the Persian version of the NSAS with other studies. However, the Persian version of the scale can still be utilized in future research endeavors. Parsha Jyoti Bharadwaj in his study, developed an attitude scale to find out the attitude of students toward business. Although the scale was developded using literature reviewe and then by interviewing with the respondents, the 42 –items attitude scale was lack of any reporting of vaidity and reliabilty [49]. Similarly, in som other studies, the attitude toward starts-up was measured using self developed scale without and validity and reliabilty measurments [16, 50‐52].

The findings confirm the Persian adaptation of the NSAS as a valid and reliable instrument for assessing entrepreneurial attitudes among nursing students. This scale can be utilized in various settings, including research on nursing entrepreneurship, evaluations of entrepreneurship education programs, and curriculum development. By identifying strengths and gaps in entrepreneurial education, this tool supports the advancement of nursing students' entrepreneurial competencies and fosters innovation in nursing practice.

This study has several limitations. The overrepresentation of one university may have introduced selection bias, potentially limiting the diversity of perspectives. Additionally, the sample was primarily drawn from Tehran, restricting the generalizability of the findings to nursing students in other regions, particularly rural areas with differing educational and healthcare contexts.

The use of convenience sampling further limits the representativeness of the sample, potentially skewing results toward more accessible participants. Lastly, the study did not account for contextual factors, such as cultural or economic influences, which may affect entrepreneurial attitudes. Future research should address these limitations by employing randomized sampling methods and including participants from diverse geographic and socioeconomic backgrounds to improve generalizability.