Translation and psychometric evaluation of the persian version of the “Nursing Profession Self-Efficacy Scale”

Nurses, as a large part of healthcare staff, cover a major part of health-related services and with their behavior and performance, play an essential role in providing quality care [1]. Among the key missions of nurses is to understand the needs and interests of community and to promote a safe and effective environment in the administration and promotion of health policies. Recorded information indicates that if nurses do not play an active role as members or coordinators of the treatment team, provision of medical care will face some difficulties [2]. Nurses are required to provide quality and satisfactory services for patients. To perform each task, they must have certain behavioral tendencies [1]. One of these behavioral tendencies is self-efficacy, which affects the performance of employees [3].

Self-efficacy theory acquires its roots from Bandura's socio-cognitive theory [4], which emphasizes the beliefs that people have about their abilities to solve problems and challenges in certain situations [5]. In this theory, self-efficacy is one of the personal beliefs that people need for success and it can be an indicator of a person's manner of thinking and acting [6]. Bandura defines self-efficacy as people's belief in their ability to perform desired functions, and considers it the determining factor of how people think, behave, and feel [7]. Bandura has acknowledged that four important factors play a role in the emergence and promotion of self-efficacy. These factors include: mastery experiences or performance outcomes, vicarious experiences or social patterns, social encouragement or verbal persuasion, and emotional or physiological states [7].

Self-efficacy is a known concept that affects nurses' beliefs, actions, and behaviors while caring for patients [8]. It plays an important role in nurses' motivation for care, decision-making, prioritizing interventions, and encouraging them to continue caring for patients despite problems and failures [9]. Increased self-efficacy can lead to high-quality nursing care and improve individual and organizational performance [10]. Bandura's self-efficacy theory has been repeatedly researched in nursing clinical settings and the results of existing studies confirm the appropriate application of this theory in clinical settings [11]. Nursing research has revealed that nurses who believe in high self-efficacy consider obstacles as an opportunity instead of a threat [12]. Nurses’ self-efficacy affects the quality of their work. Nurses with low self-efficacy often do not have enough self-confidence and this affects the quality of care [13]. In their study, Zulkosky et al. stated that nurses who believe in their clinical ability and effectiveness and consider it efficacious and useful will have better mood and mental ability [14]. Moreover, Manojlovich's study showed that self-efficacy plays a mediating role between the structural strength and professional performance of nurses and recommends nursing managers to improve nurses' professional performance behaviors by creating opportunities to strengthen nurses' self-efficacy [15]. Kurnia et al.'s study showed that nurses should have high self-efficacy to provide quality palliative care for patients and their families [16].

To improve nurses' self-efficacy, their self-efficacy level should be evaluated first [17]. Yet, it should be noted that the self-efficacy of an individual to perform work in a professional field may be very different depending on the desired profession [18, 19]. The use of general questionnaires to evaluate the self-efficacy of the nursing profession can affect the accuracy and correctness of the results and weaken it [20]. This is consistent with Bandura's theory, which suggests that self-efficacy beliefs are behavior- and situation-specific. Bandura states the basic principle that "the content of self-efficacy scale items should express beliefs about individual abilities to determine specific levels of performance” [7]. Since the range of skills required for nursing is different [21], therefore, to evaluate professional self-efficacy, special evaluation tools should be developed for the profession [20].

The existing self-efficacy scales in Iran are insufficient due to lack of focus on the specific issues of the nursing profession. Many studies that evaluate the self-efficacy of health care professionals, including nurses in Iran, have been conducted using Sherer's general self-efficacy scale [22]. Besides, the Clinical Performance Self-efficacy Questionnaire was developed in Iran by Cheraghi et al., which measures the self-efficacy of nursing students [11]. One of the existing tools to evaluate self-efficacy of nursing profession is the Nursing Profession Self-Efficacy Scale (NPSES), which was developed by Caruso et al. in Italy [18]. This scale is based on Bandura's theory. It assesses nurses’ general confidence in coping with daily challenges. This scale has two dimensions of characteristics of nursing situations and professional situations [18]. This scale was investigated in South Korea by Oh et al. for validity and reliability; the results showed that it is a suitable psychometric instrument for use in the clinical environment of Korea [20].

Iran is a developing country and the nursing workforce in Iran is estimated to be 150,000 at different levels. The healthcare system in Iran, like other countries, faces challenges such as lack of human resources and job dissatisfaction [23, 24]. Considering the similar environmental conditions of nursing in Italy and Iran, such as difficult working conditions [18], shortage of nurses, and high ratio of nurses to patients [24‐27], NPSES can be a potentially valid tool to be used for Iranian nurses. Since this tool is used to check nurses' confidence in dealing with job challenges, its validation in the Iranian context can have a major impact on nursing management. Also, using a valid specialized index to evaluate the level of self-efficacy of Iranian nurses can lead to more accurate and efficient results. Thus, this study was conducted with the aim of psychometrically validating the Persian version of the special self-efficacy tool of nurses developed by Caruso.

It is important to use valid and reliable tools in any research. Invalid and unreliable tools may lead to false or questionable findings [38]. This study was conducted with the aim of translating and psychometrically evaluating the Persian version of "Nursing Profession Self-Efficacy Scale".

The translation is a process through which a message in the source language can be transferred to the target language. The basic issue in the use of foreign questionnaires is the correct translation and implementation of the culture of the research community. Foreign questionnaires provide the possibility of comparing the results with other countries in accordance with the culture of the target population [39]. The findings of the translation stage in this research indicated the acceptability of the translation of the original scale into Persian. In the study by Oh et al., which examined the validity and reliability of the same scale in Korea, the translated items were consistent in terms of meaning and the translation of the instrument was acceptable [20]. Therefore, good and culturally adapted translation of the NPSES creates an opportunity to compare concepts in the two target and reference societies.

The translated instrument should be revalidated with the target population due to the potential distortion of items during the translation process [39]. In the psychometric evaluation phase in determining the face validity, the Persian version of the Nursing Profession Self-efficacy Scale was evaluated as clear, suitable and satisfactory in terms of concept. Face validity is the degree of appropriateness of the appearance of the scale to collect the considered data from the point of view of the respondents [40]. In line with the present study, in Oh et al.'s study, at the face validity investigation stage, to identify items with unclear meanings and ambivalent understanding, the questionnaire was given to 28 nurses; after changing some phrases and terms by experts, the questionnaire was given to them again to finalize the scale, which was evaluated as appropriate and clear [20]. Taking the views of target users on the acceptability and validity of items into account is important, this can be achieved only through qualitative work with users [41].

The results of content validity investigation indicated the confirmation of content validity of the scale, and based on the calculated value of the content validity index, none of the items were deleted. In the present study, content validity was evaluated by 15 experts, but in Oh et al.'s study, content validity was evaluated by six experts in two stages. In the Korean version of this scale, none of the items were removed [20]. In Caruso's study, the average content validity index was 0.87 [18]. This evidence indicated the ability of the selected items to reflect the characteristics of the construct to be measured [42].

The output of the exploratory factor analysis suggested that according to the Eigenvalues, in total, 3 factors could be extracted and these three factors explained 62.38% of the total variance, which shows the desirability of the measurement. The values of fit indices in the confirmatory factor analysis also indicated the acceptable fit of the proposed model with the data. However, the original scale had two dimensions. The dimension of attributes of caring situations included 12 items and professionalism situations dimension included 7 items [18]. Consistent with the results of the present study, in Oh et al.'s study, after conducting exploratory and confirmatory factor analysis, this scale was finalized with three factors of professional, care, and support situation. In Oh et al.'s study, similar to the current study, the factor loading of all items was above 0.4 and none of the items were omitted [20].

Based on these findings, despite different cultures, it seems that there are similar attitudes towards professional and care situations in nursing environments in these countries. In both the original [18] and Korean [20] scales, in line with the results of the present study, items related to respect for patient autonomy, protection of community safety and health, care in accordance with professional standards, and care based on the principle of equality have been loaded in the care situation factor. Also, in both the original [18] and Korean [20] scales, avoiding participation in treatment contrary to professional values, participation in research, cooperation with nursing organizations, and reporting the unethical behavior of colleagues are loaded in the professional situation factor. In this study, consistent the original scale, compliance with professional confidentiality is included in the care situation dimension. Similar to the Korean scale, the item related to compensating for weaknesses, recognizing ethical dilemmas, and using ethical counseling for ethical dilemmas are loaded in the dimension of caring, professional and supportive situations, respectively. The rest of the items have been moved. It should be noted that differences in social norms and acceptance across cultures and generations can be the reason for moving items [20]. In other words, the difference in the characteristics of the participants and different cultural backgrounds are attributed to different nursing environments and may explain the differences in the structure of the factors [43].

Cronbach's α coefficient was 0.86 for the Persian version of the scale and the intra-class correlation coefficient was 0.83, which indicates the reliability of the instrument used. In Oh et al.'s study, Cronbach's α for the entire scale was 0.9 and intra-class correlation coefficient was 0.93 [20]. Finally, in Caruso's study, the Cronbach's α coefficient for the entire scale was 0.83 [18]. Reliability is a necessary condition for validity. According to the results, it can be argued that the Persian version of the scale has good internal consistency and stability.

The results of this study showed that the Persian version of "Nursing Profession Self-Efficacy Scale" is fluent and understandable for nurses due to the absence of difficult words. The results of face validity and content validity of the Persian version of "Nursing Profession Self-Efficacy Scale" indicated that the instrument has a good appearance and is suitable for assessing nursing profession self-efficacy. Construct validity indicated the existence of three factors: professional situation, care situation, and support situation. Further, the reliability of the Persian version of the scale showed that this questionnaire has good internal consistency.

It is suggested to conduct more studies on the validity of this scale in other social contexts. Other studies should be conducted to reinforce the validity (the convergent and discriminant validity) of the Persian version of "Nursing Profession Self-Efficacy Scale", as well as to explore its association with health outcomes.