Translation and validation of the Chinese version of the Attitudes Related to Trauma-Informed Care (ARTIC-C) scale in nursing inters: a psychometric analysis
verfasst von:
Qin Qin, Luqing Zheng, Le Chen, Yang Yang, Huifang Li, Jingjing Wang, Linan Cheng, Noorsuzana Mohd Shariff
Nursing interns, the future nurses, often find it challenging to interact with trauma survivors due to their lack of experience and training. Assessing their attitudes and knowledge in trauma-informed care can improve their clinical performance.
Objective
To culturally adapt and assess the reliability and validity of the Attitudes Related to Trauma-Informed Care Scale in Chinese nursing interns.
Design
Quantitative cross-sectional design.
Methods
The translation of Attitudes Related to the Trauma-Informed Care (ARTIC) Scale followed guidelines for the cross-cultural adaptation process. A survey was conducted with 490 nursing interns from two colleges in China in February and May 2024, and seven experts evaluated the content equivalence of each item. Reliability and validity were assessed using item analysis, exploratory factor analysis, confirmatory factor analysis, internal consistency reliability, and test–retest reliability.
Results
The Chinese version of the ARTIC-C retained 35 items and demonstrated high content validity. Exploratory factor analysis revealed a 6-factor structure, explaining 61.887% of the total variance. Confirmatory factor analysis indicated that the 6-factor model adequately represented the scale structure: chi-square/degree of freedom (CMIN/DF) = 1.544, root mean square error of approximation (RMSEA) = 0.045, comparative fit index (CFI) = 0.969, incremental fit index (IFI) = 0.969, Tucker Lewis index (TLI) = 0.966, and standardized root mean square residual (SRMR) = 0.046. The scale had a Cronbach's alpha of 0.916 and test–retest reliability of 0.876.
Conclusions
The Chinese version of the ARTIC-C scale has demonstrated strong reliability and validity, making it an effective tool for measuring Chinese nursing interns' attitudes and knowledge regarding trauma-informed care.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abkürzungen
ARTIC
Attitudes Related to Trauma-Informed Care
CFA
Confirmatory factor analysis
CFI
Comparative fit index
CR
Critical ratio
CMIN/DF
Chi-square/degree of freedom
EFA
Exploratory factor analysis
I-CVI
Content Validity Index
IFI
Incremental fit index
TIC
Trauma-Informed Care
TLI
Tucker Lewis index
PTSD
Post-traumatic stress disorder
S-CVI
Scale-level Content Validity Index
S-CVI/Ave
Scale Content Validity Index/Average
S-CVI/AU
Scale Content Validity Index/Universal Agreement
SRMR
Standardized root mean square residual
RMSEA
Root mean square error of approximation
Background
Trauma is defined as a distressing experience that significantly impacts an individual’s psychological, emotional, and physiological well-being [1]. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), trauma encompasses events or circumstances perceived as physically or emotionally harmful, such as violence, abuse, neglect, or disasters, often resulting in long-term adverse effects on an individual's mental, physical, social, and spiritual health [2]. There is a significant correlation between trauma and psychological health. Those who endure prolonged, recurrent trauma often display mental health problems, including post-traumatic stress disorder, depression, and suicidal tendencies [3, 4]. Trauma is highly prevalent globally due to crises like natural disasters, violence, and the COVID-19 pandemic, with studies indicating that over half of the population experiences at least one traumatic event in their lifetime [5, 6]. Traumatic experiences can have detrimental effects on an individual's quality of life [7]. Healthcare professionals play a key role in caring for traumatized patients [8]. However, they also face verbal abuse or violence by patients, negative emotions triggered by patients’ traumatic experiences, and interpersonal relationship issues among colleagues [9‐12]. These factors can lead to work stress and burnout, which may result in the traumatization or secondary traumatic stress, affecting their work efficiency and potentially causing them to leave their jobs [7, 13]. Therefore, an important service model or framework is necessary to help healthcare providers enhance their skills in caring for traumatized patients, besides also protecting themselves from the effects of trauma.
Trauma-informed care (TIC) is an approach that recognizes the widespread occurrence of trauma and emphasizes the importance of creating a safe environment to prevent re-traumatization [14]. SAMHSA has proposed that the core principles of TIC include safety, trust, peer support, empathy, collaboration, choice, and empowerment [2, 15]. It requires a shift in focus from "What is wrong with you?" to "What has happened to you?", promoting a more compassionate, patient-centered approach to care [2, 16]. TIC practices are widely used in the healthcare and social services sectors. According to Cara A. Davidson's review, healthcare professionals' adoption of the TIC framework in emergency settings has proven effective in promoting both physical and psychological safety for patients [17]. Moreover, Anna Goddard's research emphasizes the importance of trauma-informed health promotion for children and their families, revealing that such practices enhance family resilience and improve child health outcomes [18]. Additionally, by integrating TIC into healthcare settings, patients experience reduced anxiety and a more positive, healing environment, ultimately resulting in improved health outcomes [19]. As nurses often work with trauma patients for extended periods, TIC offers them a method to comprehend and address the adverse effects of trauma on patients' symptoms and behaviors within healthcare settings [20]. Therefore, before implementing TIC, nurses need to acquire knowledge about trauma and related nursing skills to effectively support these patients.
Anzeige
Trauma-informed Care is increasingly recognized in nursing practice as an essential approach for addressing the diverse needs of patients who have experienced trauma [21]. Research shows that nurses' attitudes toward TIC significantly affect their ability to execute TIC principles effectively [22‐24]. Nurses with a positive attitude toward TIC are more likely to consciously apply TIC principles in their daily practice. This can lead to a more empathetic and patient-centered approach to care, particularly when dealing with patients who have experienced complex trauma, such as those in pediatric, emergency, and psychiatric settings [25‐27]. Nursing interns, who represent the future of the nurse, have successfully completed at least two years of comprehensive nursing education, encompassing fundamental nursing, adult nursing, pediatric nursing, and emergency nursing, among other crucial areas [28]. Currently, they are engaged in clinical nursing practices across diverse healthcare settings, under the meticulous guidance of seasoned clinical instructors [29]. They are in the transitional phase from theoretical learning to practical clinical nursing. Their attitudes toward Trauma-informed care (TIC) influence their interactions with trauma patients and clinical practice [30]. Additionally, interns are susceptible to secondary traumatic stress and burnout while caring for trauma-affected patients [31]. A positive attitude toward TIC can serve as a protective factor, helping them cope with the emotional and psychological challenges of nursing work. Thus, the timely and effective assessment the attitudes of TIC by nursing interns are of great importance.
There is limited research on attitudes in clinical practice related to TIC, with most studies relying on qualitative interviews, thus lacking objective evidence [22‐24]. In current quantitative research, one of the most commonly used tools for assessing attitudes towards TIC is the Attitudes Related to Trauma-Informed Care Scale (ARTIC), which was developed and validated by Professor Baker and her team [32, 33]. The ARTIC scale helps evaluators understand and assess staff perceptions, beliefs, and attitudes toward trauma-informed care (TIC), thereby guiding related training and interventions. The scale typically assesses multiple dimensions, such as understanding trauma, empathy for trauma survivors, and support for trauma interventions. By implementing the ARTIC scale, organizations can better evaluate and enhance their ability to provide TIC, ensuring improved quality of service and recovery for trauma survivors. Currently, the ARTIC scale primarily assesses the attitudes of staff members in the mental health, education, and community service sectors, with less frequent use in healthcare settings. Although Canada, Malta, and Japan [25, 34, 35] have employed the ARTIC scale to assess nurses' attitudes and knowledge concerning TIC, no evaluations have been conducted on nursing interns in this context. Since nursing interns are essential future contributors to clinical practice, evaluating their attitudes toward Trauma-Informed Care (TIC) becomes particularly crucial.
Therefore, this study aimed to translate the ARTIC scale into Chinese, validate its applicability to nursing interns, and help nursing educators quickly and effectively assess nursing students’ knowledge and attitudes toward TIC during clinical internships. By understanding nursing students’ TIC perspectives, timely adjustments can be made to training programs to enhance their skills and mental health, foster positive professional attitudes, and prevent attrition in the nursing field.
Methods
This study was conducted in two phases. The first phase focused on translating the ARTIC scale from English to Chinese, and the second phase utilized a cross-sectional design to perform its psychometric evaluation.
Anzeige
Study design and participant's setting
A convenience sampling method was employed to select nursing interns from two colleges located in Zhejiang and Hunan provinces in China between February and May 2024. In this study, the sample size was calculated using the Kendall estimation method, with the sample size being at least five to ten times the number of items on the scale [36]. The ARTIC scale used in this study has a total of 35 items. Calculating a sample size requirement of 10 times the number of items, a sample size of 350 cases is needed, and considering 20% invalid questionnaires, the final sample size should not be less than 420 cases. Additionally, within the frameworks of Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), the recommended sample size should not be less than 200 [37]. The inclusion criteria for the participants encompassed the following: (1) individuals aged 18 years or older, (2) nursing students who had completed a minimum of two years of academic nursing coursework, (3) nursing interns with more than two months of clinical experience, and (4) those who willingly volunteered to participate in the study. Conversely, the exclusion criteria comprised: (1) students who had already obtained a nursing certificate, and (2) clinical practice positions that solely involved clerical and administrative tasks, without any direct clinical patient interaction. Ultimately, a total of 540 nursing interns participated in the cross-sectional study.
The measurement instrument
General information questionnaire
The general information questionnaire was self-designed based on the purpose of the study and included demographic information (gender, age, specialty, internship hospital, and length of internship), whether or not participants were familiar with the TIC scale, and whether or not they had received training in TIC.
Attitudes Related to the Trauma-informed Care Scale (ARTIC)
The ARTIC survey used in this study was original developed by Professor Baker et al. [32], and is intended for use by service professionals who may not be familiar with the concept of TIC. The scale contains 35 pairs of entries divided into 5 dimensions: underlying causes (item 1, 6, 11, 16, 21, 26, 31), responses (item 2, 7, 12, 17, 22, 27, 32), job behavior (item 3, 8,13, 18, 23, 28, 33), self-efficacy (item 4, 9, 14, 19, 24, 29, 34) and reactions (item 5, 10, 15, 20, 25, 30, 35). Participants were asked to rate the degree to which each of the two opposing statements best reflected their attitude on a seven-point bipolar Likert scale. Using a Likert scale ranging from 1 to 7 for each item, the total score falls between 35 and 245, with a higher score signifying a more positive attitude. The Cronbach’s alpha for the reliability of internal consistency was very good (> 0.90) [32, 33].
Translation process and pre-survey
Phase I: translation and back translation
We obtained the authors’ permission via email to translate the ARTIC scale into Chinese. The translation process followed the guidelines for cross-cultural adaptation [38]. Four nursing experts with English language proficiency and no prior exposure to the original scale, along with two translation experts unfamiliar with the original scale, were invited to participate. Two nursing experts independently translated the original scale into Chinese, resulting in versions T1 and T2. A third nursing specialist reviewed these versions, facilitated discussions, and synthesized them into a unified version, T12. Subsequently, two independent English translators back-translated T12 into B1 and B2. A comparative analysis of B1, B2, and the original scale was conducted by a fourth nursing specialist, leading to the development of version B12. All versions were then reviewed by the translators, who engaged in discussions to finalize the preliminary Chinese version of the ARTIC scale, referred to as ARTIC-C1.
PhaseII: cultural adaptation
Seven experts participated in the cultural adaptation process, including six females and one male. Among them, three held doctoral degrees, and four held master's degrees. Five participants had senior professional titles, while two held intermediate titles. The group included three clinical nurses from tertiary hospitals with backgrounds in psychological nursing, two nursing psychology course instructors, and two psychologists engaged in research. The participants' professional experience ranged from 11 to 40 years. The background and expertise of these experts contributed to making the revised scale more applicable to the nursing context and cultural background in China.
Two rounds of expert consultation were conducted [39]. The first for content adaptation, replacing proper nouns to fit China's nursing context while preserving meaning, and modifying statements for language logic. The second for cultural adaptation and content validity, where experts judged the relevance of entries for TIC in nursing practice. This led to the initial ARTIC C2.
In this part, we modified the scale to reflect the Chinese healthcare system, replacing “sever” and “work” with “care” to emphasize nursing professionalism and “relationships” with “nurse-patient relationships” to suit the context. Item 1 was revised for nursing interns' comprehension, changing “Patients’ learning and behavior problems are rooted in their history of difficult life events” to “Patients’ learning and behavioral problems stem from traumatic or difficult experiences, such as childhood trauma, domestic violence, and poverty.” Item 35 was adapted to refer to “experiencing stress or burnout at work” instead of “taking my work home,” based on Chinese nursing experts' understanding of workplace stress [40, 41]. This modification was consulted with the original scale authors and deemed feasible.
PhaseIII:pre-survey
In March 2024, 35 nursing interns from a Chinese college were selected for a pre-survey using convenience sampling. Inclusion/exclusion criteria matched previous descriptions. The aim was to assess comprehension and gather suggestions. Following feedback and expert input, the ARTIC C2 was adjusted to create the ARTIC C for formal assessment. Two weeks later, the same 35 interns were retested for reliability. The translation and cultural adaptation processes are illustrated in Fig. 1.
Fig. 1
Translation and Cross-cultural adaptation process of ARTIC
×
Data collection procedures
Data were obtained from nursing students of two Chinese colleges. The questionnaire link and Quick response code were created by using an anonymous questionnaire through an online platform which is www.wjx.cn, and distributed through the WeChat and QQ platforms by the researchers. The researchers described the aims and procedures of the study before distributing the electronic questionnaires. Students who accessed the survey were required to review the informed consent form and confirm their voluntary participation before proceeding. They were also informed that they could withdraw at any time without any repercussions.
To ensure questionnaire quality, several control measures were implemented. Responses that were incomplete, contained missing values, or had a response time of less than 100 s were excluded. Additionally, surveys with inattentive answers, such as repetitive, patterned, or illogical responses, were removed. These steps ensured the data's reliability and validity [42]. After excluding 50 invalid entries, a total of 490 valid questionnaires were retained, resulting in an effective response rate of 90.7%.
Data analysis procedure
IBM SPSS 25.0, and AMOS 25.0, were used for data analysis. Statistical significance was set at P < 0.05. Continuous demographic data are presented as mean (standard deviation) or frequency (percentage) values. The item analysis, construct validity, and reliability were assessed as followed.
Item analysis
Before screening or revising scale items, it is essential to conduct an item analysis to evaluate their discrimination and homogeneity. Subjects with total scale scores in the top 27% are classified as the high group, while those in the bottom 27% are categorized as the low group. An independent sample t-test is used to calculate the critical ratio (CR) to assess differences in item scores between the two groups. A p-value of < 0.05 indicates good item discrimination [43]. The homogeneity of individual items and the overall assessment tool was examined through correlation analysis. Items with a correlation coefficient below 0.4 or without statistical significance were considered for removal from the study [44].
Content validity
Scale-level Content Validity Index (S-CVI) and item-level Content Validity Index (I-CVI) were used to evaluate the content validity [45]. Seven nursing experts involved in the cultural adjustment of the ARTIC were invited to participate in two rounds of expert consultations. The experts compared the relevance of each item to the respondents’ evaluations of attitudes related to TIC using a 4-point scale: 1 = Not Relevant, 2 = Slightly Relevant, 3 = Moderately Relevant, and 4 = Highly Relevant. An I-CVI of ≥ 0.78 and an S-CVI/Ave of ≥ 0.80 were deemed acceptable [46].
Construct validity
The construct validity of this scale is assessed in two phases: exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Initially, the 490 eligible nursing students were assigned unique identifiers. Subsequently, 245 students were randomly selected for exploratory factor analysis (EFA), and the remaining 245 students were selected for confirmatory factor analysis (CFA) [47].
The EFA process begins with evaluating the Kaiser–Meyer–Olkin (KMO) test's appropriateness, followed by determining factors and their loading values using principal component analysis and maximum variance rotation [48]. Factors with eigenvalues greater than 1 are extracted, and those with loading values of 0.4 or higher are deemed appropriate [49]. In the CFA, the indices used to evaluate the model fit included the following criteria: Chi-square/degree of freedom (CMIN/DF) < 5, root mean square error of approximation (RMSEA) < 0.08, comparative fit index (CFI), incremental fit index (IFI), Tucker Lewis index (TLI) ≥ 0.9, and standardized root mean square residual (SRMR) < 0.08 [50, 51].
Reliability
The internal consistency of the scale was evaluated using Cronbach's alpha. Additionally, two weeks later, retest reliability was measured with a sample of 35 nursing interns during the pretest phase [52]. An acceptable threshold for reliability used was an effective value of 0.70 [53].
Results
Characteristics of the participants
Table 1 presents the demographic characteristics and the ARTIC scores among 490 students. A total of 432 (88.16%) interns were female, and 400 (81.63%) were aged between 20 and 24 years. Nursing students constituted 385 (78.57%) of the sample, and 377 (76.94%) were interning at tertiary hospitals. Additionally, 256 students (52.24%) had an internship duration of less than six months. Only 81 (16.73%) students reported being relatively familiar with TIC knowledge, while 149 (30.41%) had participated in TIC-related training. Students who considered themselves more familiar with TIC scored significantly higher on the ARTIC scale compared to those with limited or no familiarity (P < 0.05). Similarly, students who had received TIC-related training had significantly higher attitude scores than those who had not (P < 0.05). No statistically significant differences were found in attitude scores based on gender, age, major, internship hospital, or internship duration (P > 0.05).
Table 1
Characteristics of the participants (N = 490)
Characteristic
Total (N = 490) N%
M ± SD
t/F
P-value
Gender
Male
58(11.84%)
153.17 ± 28.57
Female
432(88.16%)
149.23 ± 31.85
0.893
0.372
Age
18–20 years
90(18.37%)
150.63 ± 33.32
20–24 years
400(81.63%)
149.72 ± 30.92
0.249
0.804
Major
Nursing
385(78.57%)
149.98 ± 31.83
Midwifery
105(21.43%)
148.65 ± 30.26
What is your internship hospital?
Tertiary Hospital
377(76.94%)
149.90 ± 31.82
1.67
0.189
Secondary Hospital
64(13.06%)
153.69 ± 28.48
Other Hospitals
49(10.00%)
142.92 ± 32.12
Time
0–6 months
256(52.24%)
148.63 ± 32.96
6–12 months
234(47.76%)
149.98 ± 31.12
Are you familiar with trauma-informed care?
Familiar
82(16.73%)
158.26 ± 28.33
4.026
0.01
Knowledgeable
271(55.31%)
148.98 ± 31.85
Unfamiliar
137(27.96%)
146.07 ± 31.77
Have you received training in trauma-informed care (such as courses, lectures, etc.)?
Yes
149(30.41%)
156.42 ± 29.76
3.14
0.02
No
428(69.41%)
146.76 ± 31.80
Item analysis
The results of the outlier analysis showed that in a comparison between the high group (top 27%, total score ≥ 165) and the low group (bottom 27%, total score ≤ 135), all items had significant P-values (P < 0.001). Therefore, none of the items were eliminated as these showed good discriminant validity. In the homogeneity test, the correlation coefficient between all items and the total score was 0.435–0.606 (P < 0.01), and no items were deleted. (See Appendix 1: Tables A1 and A2).
Content validity
After cultural adaptation of the scale, 80% to 100% of the seven consulting experts rated each item as “Moderately Relevant (3 points)” or “Highly Relevant (4 points)”, with the I-CVI for each item ranging from 0.85 to 1.00, with the responses all exceeding 0.78. Calculations showed that S-CVI/AU = 28/35 = 0.8, and S-CVI/Ave = (1.0028 + 0.857)/35 = 0.97 (see Appendix1: Table A3).
Construct validity
The evaluation of the construct validity of the scale was conducted in two phases: exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).
Anzeige
Exploratory factor analysis
In the part of EFA, KMO = 0.796 and Bartlett's test of sphericity was statistically significant (χ2 = 0.796, p < 0.001), indicating that the translated scale was suitable for factor analysis. A total of six factors with eigenvalues greater than 1 were extracted, accounting for 61.887% of the variance. Additionally, the results indicated that all items had factor loadings greater than 0.4, with no evidence of cross-loadings (see Table 2). The factor analysis results demonstrated a high degree of consistency with the original scale's structure.
Table 2
Rotated component matrix in EFA
Item
F1
F2
F3
F4
F5
F6
6
0.756
11
0.748
7
0.748
33
0.726
21
0.711
31
0.706
16
0.695
1
0.673
26
0.663
32
0.795
17
0.795
22
0.794
23
0.789
27
0.784
2
0.755
12
0.733
8
0.843
28
0.824
13
0.808
3
0.802
18
0.790
10
0.829
20
0.783
34
0.775
5
0.769
35
0.736
19
0.797
15
0.795
14
0.779
29
0.747
25
0.734
9
0.834
4
0.806
24
0.795
30
0.755
Factor naming and interpretation
In the exploratory factor analysis (EFA), new six factors were differed slightly from the five-factor structure of the original ARTIC scale. These differences may be attributed to variations in nursing cultural contexts and the characteristics of the study population. To better understand these differences, we reviewed relevant literatures on TIC and consulted nursing experts to rename and interpret certain factors.
F1 retained most of the original factor structure of “Underlying Causes,” reflecting nursing interns' understanding of the root causes behind patient behaviors in clinical practice. As this aligns with the original dimension's meaning, the original naming was preserved. F2 was renamed "TIC nursing approach," refining the original "Job Behavior" factor and emphasizing specific methods of applying TIC principles in nursing practice. F3 was named "Empathic Behavior," derived from a further refinement of the original "Responses" factor, emphasizing the importance of empathy in clinical practice. F4 was named "Social Support," primarily describing the social support sought by interns during their clinical training. F5 represents a newly added factor, "Occupational Trauma," highlighting the unique psychological and emotional challenges in the Chinese nursing context, such as high work pressure, patient violence, and burnout, emphasizing the impact of occupational trauma on nursing practice. F6 retained the majority of items from the original dimension "Self-Efficacy," which reflect an individual's confidence in meeting the demands of working with trauma patients. Therefore, the original dimension name was retained. In summary, these changes in factor structure reflect the profound influence of cultural and professional contexts on the applicability of the TIC scale. Detailed factor names and their corresponding items are provided in Table 3.
Table 3
ARTIC compared to the final subscale of the EFA factor
A total of 245 students participated in the factor analysis validation stage. Initially, we validated the original scale's 5-model structure, and the results were as follows: CMIN/DF = 5.881, RMSEA = 0.145, CFI = 0.720, IFI = 0.695, TLI = 0.697, and SRMR = 0.154. It showed that the 5-model fit was not satisfactory. Although we made several modifications to the model, the results were unsatisfactory. After expert discussions, we validated the 6-model structure (F1 to F6), the fit parameters were as follows: CMIN/DF = 1.544, RMSEA = 0.047, CFI = 0.96, IFI = 0.969, TLI = 0.966, and SRMR = 0.046, indicating that the modified fitting indices of the model are acceptable (see Table 4). Therefore, the Chinese version of the scale has six factors that can reasonably and accurately measure nursing students' attitudes toward TIC. Figure 2 shows the path diagram and CFA factor loading.
Table 4
Fit indices of the Chinese version of the ARTIC-C for nursing interns
Fit Indices
CMIN/DF
RMSEA
CFI
IFI
TLI
SRMR
Reference value
< 3.000
< 0.080
> 0.900
□ > 0.900
□ > 0.900
< 0.050
Model 5
5.881
0.145
0.720
0.695
0.697
0.154
Model 6
1.544
0.047
0.960
0.969
0.966
0.046
Fig. 2
CFA factor pathway and loading. US: Underlying Causes; TIC: TIC nursing approach; EB: Empathy behavior; SE: Self-efficacy; SS: Social support; OT: Occupational trauma
×
Reliability analysis
The overall Cronbach’s alpha coefficient for ARTIC-C was 0.916, whereas those for the six factors (ranging from F1 to F6) were 0.933, 0.933, 0.920, 0.906, 0.899, and 0.903. The test–retest reliability of ARTIC-C was 0.876, indicating high reliability. This indicates that ARTIC-C exhibits strong internal consistency.
Discussion
In this study, we culturally adapted the ARTIC scale into Chinese (ARTIC-C) following cross-cultural guidelines and expert input. Psychometric analysis showed strong item discrimination, reliability, test–retest stability, and validity. Six factors were identified and validated through confirmatory factor analysis, confirming a well-fitting model.
ARTIC has a good degree of discrimination
In item analysis, the critical ratio of 35 items more than 3.0 and all items had significant P-values(P < 0.001). The correlation coefficient between all items and the total score was 0.435–0.606 (P < 0.01), and no items were deleted [43, 44].This paves the way for further exploration of its validity and reliability.
ARTIC has a good validity
The scale validity includes both content and construct validity [47]. After expert consultations, minor linguistic enhancements were incorporated into the Chinese version, maintaining the relevance of all conceptual domains to nursing practice in China. The content validity results of the ARTIC-C revealed I-CVI scores between 0.85 and 1.00, with an S-CVI/Ave of 0.97, surpassing the usual reference benchmarks of 0.780 and 0.900 [46]. This indicates that the translated instrument not only maintained consistency with the original English ARTIC but also exhibited high content validity.
Anzeige
The cultural adaptations enhanced the construct validity
Construct validity included the EFA and CFA. In the EFA, six factors with eigenvalues exceeding one were extracted, showing strong structural validity, with factor loadings between 0.663 and 0.843 for each item was considered ideal [49]. However, these six factors differ from the original five-dimensional structure of the scale. By referring to relevant literatures and expert insights, we renamed certain factors to better fit the context of Chinese nursing interns and to ensure that the scale accurately reflected their attitudes and beliefs about TIC.
The content of factors F1 and F6 closely aligns with the original items; thus, their original dimension names were retained. Meanwhile, the items on the F2 factor address how nursing interns can create a safe, healing environment for patients and build a positive nurse-patient relationship, which aligns with the TIC principles set forth by SAMHSA[2]. Similar items were identified in a study by Stokes et al. on Canadian nurses [34], where they were categorized as "TIC nursing approach."
This emphasis on creating a nurturing environment is further supported by the influence of cultural and philosophical perspectives. For instance, Confucian philosophy in China emphasizes the importance of benevolence, which means caring for and respecting others. In nursing practice, this is reflected in the deep empathy and compassion that nurses show toward patients [54]. Similarly, American nursing theorist Jean Watson's theory of human caring emphasizes that nurses should attend to the physical and psychological needs of patients, providing holistic care [55].While the original dimension "Job Behavior" represents "endorsing empathy-focused staff behavior versus control-focused staff behavior," placing emphasis on empathic versus non-empathic behaviors. Considering the cultural and theoretical alignment, and based on expert discussions, we named the F3 factor "Empathic Behavior" to better reflect nursing interns' perceptions of empathy in clinical practice.
In addition, nursing interns often rely on teachers, peers, and school support during clinical practice. Instructor guidance, peer support, and school support are critical for interns to adapt to the clinical environment [21]. This reliance on support systems is captured in Factor F4 (items 5, 10, 20, 34, and 35), which focuses on the ways in which interns seek help in clinical practice. To reflect this dynamic, F4 was named “Social Support,” emphasizing the intern's dependence on these networks during role transitions, thereby enhancing the scale's relevance.
Furthermore, the transition from campus to the clinical setting often brings significant adjustment stress for nursing interns. This includes coping with a new role, managing clinical challenges, and addressing emotional stress [56]. Factor F5 (items 14, 15, 19, 25, and 29) highlights the stress and traumatization that interns experience in clinical practice. Consequently, it has been named “Occupational Trauma” to underscore the unique challenges interns face. This designation not only aligns with the experiences of this population but also improves the scale's applicability and validity in assessing the complexities of their clinical practice environment.
Despite the similarities between the six-factor structure and the original scale, these adjustments profoundly reflect the influence of China-specific culture, professional background, and internship status. With these adjustments to the scale, the validity of the ARTIC-C was significantly improved, ensuring that it accurately assessed Chinese nursing interns' attitudes toward TIC.
In CAF, to verify the reliability of the constructs, we referred to the analysis of Z Zhang’s [57] and separately examined the original five-dimensional structure of ARTIC and the new six-factor structure. The results for the five-dimensional model indicated a CMID/DF of 5.821, RMSEA of 0.141, and GFI of 0.72, which did not meet the qualifying criteria for a model fit, suggesting a poor fit. Conversely, the six-factor structure showed a CMID/DF of 1.544, an RMSEA of 0.045, and a GFI of 0.840, and these parameters met the criteria for a model fit, indicating a better fit. Discussions with experts indicated that a few structural changes had occurred because of differences in the Chinese version of the ARTIC-C study population and the standardization of Chinese nursing terminology during the process of cultural adaptation. The CFA results further demonstrated that the new six-factor structure was more suitable for assessing TIC attitudes among Chinese nursing students.
ARTIC has good reliability
The test–retest reliability was 0.876 and the Cronbach's alpha coefficient was 0.916, which were all higher than 0.7 [53]. This finding suggests that the ARTIC-C has good internal consistency and high reliability. Therefore, the Chinese version of the scale can be used to assess the attitude of TIC among clinical nursing interns.
Demographic characteristics' influence on attitudes toward TIC
The above findings indicate that the revised ARTIC-C scale demonstrates good reliability and validity. As shown in Table 1, factors such as gender, age, major, internship hospital, and duration of internship have minimal impact on nursing students' attitudes toward TIC. However, participation in TIC training and the level of understanding of TIC significantly influence students' attitudes. This result is consistent with the findings of Wholeben’s study [58], suggesting that knowledge of TIC can encourage students to more actively implement TIC practices, thereby preventing patient re-traumatization. Since this study primarily focuses on the localization and revision of the ARTIC scale, future research will further explore these influencing factors.
Implications for the TIC education
The findings of this study provide significant insights for advancing TIC education in nursing. By validating the six-factor structure of the ARTIC-C scale, key components of nursing trainees’ attitudes towards TIC were identified, including “TIC nursing approach,” “Empathic behavior,” “Social support,” and “Occupational trauma.” These insights serve as a foundation for designing targeted educational programs.
Nursing educators can specifically design nursing curriculum modules on the core principles of TIC, such as fostering safe and supportive care environments, while emphasizing the importance of empathy and effective communication through role-playing exercises and reflective practice. They can also promote teamwork and peer support to help nursing interns build resilient support networks essential for managing clinical challenges. Furthermore, incorporating stress management and self-care strategies into the curriculum can enhance resilience and mitigate burnout. In addition, nursing educators can utilize the validated ARTIC-C scale to systematically assess and refine the effectiveness of these interventions, ensuring their continued relevance. Overall, this approach provides an empirical basis for integrating TIC into nursing education, with the goal of enhancing professional competence and ultimately improving patient care outcomes.
Anzeige
Limitations
This study had some limitations. First, although the sample size meets the required criteria, it was relatively homogeneous, as the participants were nursing interns from two colleges with a higher proportion of female students. In the future, we plan to conduct a multicenter extensive sample survey to further validate the effectiveness of the tool. Second, the self-report format of the questionnaire may have introduced response bias. Nonetheless, the scale is the first TIC assessment tool specifically designed for nursing interns and demonstrates good reliability and validity. It effectively assesses nursing students’ comprehension of the TIC and provides a foundation for adjusting nursing education programs to enhance nursing competencies.
Conclusion
The study demonstrated good reliability and validity for the Chinese version of the Nursing Interns' Attitudes Toward Trauma-Informed Care Scale (ARTIC-C). Despite minor structural variations across different nursing cultures, the overall content of the ARTIC-C remains consistent. The revised scale serves as a suitable tool for assessing nursing students' attitudes toward TIC and offers valuable insights for evaluating and developing TIC-focused nursing education programs.
Acknowledgements
The authors would like to express their sincere gratitude to the original authors of the scale and the ARTIC research team. Thanks are also extended to Dr. Cilia Vincenti from the University of Malta for her assistance during the translation phase. Additionally, heartfelt thanks go to all the nursing inters who contributed to this study, as well as to the experts who provided invaluable guidance and support throughout the research.
Declarations
Ethical approval and consent to participate
The study was approved by the Universiti Sains Malaysia Ethics Review Committee (USM/JEPeM/PP/23100761) and the Quzhou College of Technology Ethics Review Committee (ethics approval number: 2023051907). All students provided informed consent before data collection. They participated voluntarily and anonymously, with the freedom to decline or withdraw from the study at any time without facing any repercussions. All methods adhered to the principles of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Translation and validation of the Chinese version of the Attitudes Related to Trauma-Informed Care (ARTIC-C) scale in nursing inters: a psychometric analysis
verfasst von
Qin Qin Luqing Zheng Le Chen Yang Yang Huifang Li Jingjing Wang Linan Cheng Noorsuzana Mohd Shariff
