Adaptation and assessment of the psychometric properties of the Turkish version of the nursing student competence scale

Abstract

Background

It is critical to evaluate competence and learning outcomes in nursing education. The purpose of the study was to adapt the Nursing Student Competency Scale (NSCS) into Turkish and to determine its validity and reliability.

Methods

This methodological study was conducted between March 2023 and May 2023 with 2nd, 3rd, and 4th-year students enrolled in the nursing program at a university. The data were collected using the “Student Identification Form” and the “Turkish version of NSCS (NSCS-T)”. Content, face and construct validity were evaluated. Reliability was examined with internal consistency and test-retest.

Results

A total of 316 nursing students voluntarily participated in the study. The item-level content validity index of the scale ranged between 0.80 and 1.00. According to confirmatory factor analysis, the six-factor model consisting of 30 items (medical-related knowledge, basic nursing skills, communication and cooperation, life-long learning, global vision, and critical thinking) had a good fit index (χ2/df = 2.54; GFI = 0.852; CFI = 0.943; RMSEA = 0.063; TLI = 0.936; SRMR = 0.038). The factor loadings of the scale are greater than 0.30, explained 75.8% of the total variance. The Cronbach’s alpha of the scale was 0.97 across the scale and 0.86–0.93 among the subscales; item-total correlations were between 0.55 and 0.83. Intraclass correlation coefficient ranged between 0.95 and 0.98.

Conclusions

The results indicated that the NSCS-T is a sufficiently valid and reliable instrument to measure the competency level of Turkish nursing students.

Trial registration

Not applicable.

Background

The concept of basic competence is critical in establishing a common language and optimal work expectations for health professions - as in all professions, making changes in healthcare-related education programs, managing these changes, and ultimately improving the quality of care [1, 2]. In this context, competency-based education in nursing constitutes a valuable framework for nursing education programs in delivering high-quality training for nursing students [3, 4].

Nursing practice requires a complex combination of various characteristics such as the development of new technologies, the management style and needs of healthcare institutions, and the changing patient care processes [5, 6]. Therefore, nursing students need specialized competencies that require knowledge as well as clinical skills, such as being able to accurately determine patients’ conditions and anticipate and cope with problems that may arise during nursing care [7, 8]. In addition, most employers expect new nursing graduates to be prepared to perform a wide range of functions and to have the skills to provide safe care [8]. To ensure that nursing education aligns with these expectations, competency-based education focuses on defining and assessing both competencies and learning outcomes [9]. While competencies refer to the essential knowledge, skills, and professional behaviors required for nursing practice, learning outcomes define the measurable achievements students must attain by the end of their education [10, 11]. Nursing schools play a crucial role in structuring curricula to develop these competencies and systematically evaluating whether students meet the expected learning outcomes. By establishing a clear competency framework, nursing education ensures that graduates are equipped to transition into professional practice with the necessary qualifications and readiness to meet the challenges of modern healthcare [10,11,12].

Competency-based education in nursing is implemented differently across countries, with some placing a stronger emphasis on extensive clinical training and evidence-based practice, while others prioritize theoretical instruction [13,14,15]. In Türkiye, nursing education is structured as a four-year undergraduate program comprising approximately 240 ECTS credits, integrating both theoretical coursework and clinical practice to ensure that students develop essential competencies for professional nursing. The curriculum covers core nursing subjects, including fundamental nursing sciences, medical-surgical nursing, pediatric and maternal health nursing, community health nursing, and leadership in nursing, totaling an average of 2.000–2.400 h of theoretical instruction. In addition, students are required to complete at least 1.200–1.500 h of supervised clinical training in various healthcare settings, such as hospitals, primary care centers, and community health organizations [16, 17]. This structured education framework aligns with national competency guidelines; the “Guideline on Core Competencies in Nursing,” developed in collaboration with the Ministry of Health and nursing education academics, defines seven core competencies: professionalism, effective communication, evidence-based practice, care management, quality improvement, teamwork/collaboration, and professional leadership [18]. Additionally, the Turkish Association for Evaluation and Accreditation of Nursing Education Programs (HEPDAK) has identified key competencies that nursing students must achieve, such as applying up-to-date knowledge, engaging in lifelong learning, and collaborating effectively within healthcare teams [19]. These competency requirements reflect global standards and are analogous to the core competencies established by the American Association of Colleges of Nursing (AACN) [20].

There is no consensus among educators about which basic competencies should be assessed or which tools should be used in nursing education programs. Moreover, despite the existence of various programs for nursing education, there is little data on the assessment processes and tools used for nursing students experiencing classroom learning and clinical practice. Considering these issues, Huang et al. (2022) developed the Nursing Student Competence Scale (NSCS), a specialized instrument that comprehensively measures competence in nursing students. In order to capture the multidimensional nature of nursing competencies, this instrument consists of six competency domains: medical-related knowledge, basic nursing skills, communication and cooperation, life-long learning, global vision, and critical thinking, based on the initial concepts of nursing competencies [21]. These themes are similar to the seven core competencies in Türkiye (see Supplementary File 1, Table S1) [18]. Although there are some scales adapted to Turkish to assess the competence of nurses and nursing students, they are limited in fully meeting the need for basic competencies because they were developed before the current core competency guideline or they address competency in a single dimension (e.g., cultural, spiritual care) [22,23,24] or within the framework of a specific nursing field (e.g., intensive care nursing) [25]. Therefore, this study aimed to adapt the NSCS to the Turkish language and examine its psychometric properties.

Methods

Design, setting and sample

This methodological study was conducted between March 2023 and May 2023 with students who were 2nd, 3rd, and 4th-year students in a nursing education program at a university in Türkiye. Students with reading and comprehension problems in Turkish, those with visual or hearing impairment, those who had dropped out of the nursing education program, and those who resumed their studies after dropping out were excluded from the study. Within the scope of these criteria, there were 486 nursing students enrolled in the classes specified in the program.

The criteria established for validity and reliability studies in the literature were utilized to determine the sample size of the study [26, 27]. Accordingly, for a good sample size, the recommendations are that the research sample should be 10 times the number of items in the measurement tool and should consist of at least 300 participants for factor analysis. Since the number of items in the measurement tool was 30 and factor analysis was to be performed, it was aimed to reach at least 300 participitants.

A total of 376 nursing students who met the criteria voluntarily participated in the study (response rate: 77.4%). A total of 60 students were excluded from the main study sample, with 30 students (10 from each class) allocated to the test-retest phase and a further 30 students (10 from each class) designated for the pre-testing phase to assess the clarity and comprehensibility of the scale. Consequently, the final study sample comprised 316 nursing students.

Instruments and data collection procedures

The data were collected using the “Student Identification Form (SIF)” and the “Turkish version of the NSCS (NSCS-T)” through a face-to-face questionnaire method after obtaining informed consent from the students. The students who participated in the test-retest phase were requested to provide pseudonyms on the questionnaires so that the responses could be matched in an anonymous manner. We completed the questionnaire in approximately 8–12 min.

The SIF was created by the researchers and consisted of a total of seven questions about the socio-demographic characteristics of the students (age, gender, previous high school, etc.). The NSCS was developed by Huang et al. (2022) to assess the degree of core competencies in nursing students [20]. The scale consists of 30 items addressing core competency behaviors in six sub-dimensions (medical-related knowledge, basic nursing skills, communication and cooperation, life-long learning, global vision, and critical thinking). Scale items are graded as “Not Agree (1 point)”, “Somewhat Agree (2 points)”, “Agree (3 points)”, “Quite Agree (4 points)”, and “Highly Agree (5 points)”. The score obtained from the scale ranges between 30 and 150, where higher scores represent higher levels of nursing competence. In the original study where the scale was developed and tested, the factor loadings of the items were found to be 0.72–0.95, and the internal consistency was found to be 0.98, which were highly acceptable [20].

Scale translation and validation processes

We followed the guidelines proposed by Beaton et al. (2000) for the translation and cultural adaptation of the scale into Turkish [28]. We adhered to the guide’s recommendations by implementing the following six-step process:

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Step 1-Translation from English to Turkish: A translation panel consisting of eight nursing faculty members, each with at least 10 years of experience in nursing education (education/training, department, association, accreditation, etc.) and expertise in scale development/adaptation, along with two faculty members from the department of foreign languages, translated the scale from English into Turkish.

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Step 2-Synthesis of translations: The researchers and two independent translators reviewed the translations provided by the translation panel and selected the most accurate and contextually appropriate expressions, ensuring conceptual equivalence. A single Turkish version of the scale was created based on consensus among the researchers and translators.

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Step 3-Back translation: To ensure semantic equivalence, the finalized Turkish version was back-translated into English by two independent linguists, who were not familiar with the original scale. A high level of similarity between the original scale and the back-translated version confirmed the linguistic validity of the translation.

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Step 4-Expert panel: A second panel of ten independent experts, who were not part of the translation expert panel but met the required experience criteria, was convened to evaluate the content validity of the scale. Experts assessed each item’s clarity, relevance, and importance using a 4-point Likert scale (1 = not clear/relevant/important, 2 = somewhat clear/relevant/important, 3 = quite clear/relevant/important, and 4 = highly clear/relevant/important) [29]. Experts also provided additional comments and feedback where necessary. The item-level content validity index (I-CVI) and scale-level content validity index (S-CVI/Ave) were calculated based on Polit & Beck (2006), who recommend a minimum acceptability threshold of ≥ 0.80 for content validity indices. The I-CVI for each item was computed as the proportion of experts rating the item as 3 or 4, while the S-CVI/Ave was determined as the average of all I-CVIs across items. According to the expert panel’s evaluations, all 30 items demonstrated highly acceptable levels of content validity (I-CVI range: 0.80–1.00; S-CVI/Ave: 0.91–0.96) [29].

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Step 5-Pre-stesting: Following the expert panel evaluation, a pre-test was conducted with a sample from the target population to ensure that the adapted scale was clear, understandable, and culturally appropriate. For this purpose, 30 nursing students, who were not part of the main study sample, were asked to complete the scale and provide feedback on its clarity and comprehensibility. Each student independently assessed the scale items using a 4-point rating scale (1 = not clear/understandable, 2 = somewhat clear/understandable, 3 = quite clear/understandable, and 4 = highly clear/understandable). During this phase, the researcher was present while participants completed the scale, allowing them to express any difficulties or ambiguities they encountered. The results indicated that all items were rated as clear and understandable by at least 90% of the participants (i.e., rated 3 or 4). As no concerns were raised regarding wording or cultural relevance, no modifications were deemed necessary, and the adapted version was finalized for use in the main study.

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Step 6-Submission to developers and psychometric testing of the pre-final version of the translated instrument: Following the pre-testing phase, the pre-final version of the Turkish NSCS was submitted to the original developers for appraisal of the adaptation process. The developers reviewed the documentation, which included all reports and forms detailing the translation, synthesis, back-translation, expert panel evaluation, and pre-testing processes. No modifications or additional recommendations were provided by the developers, and the adaptation was approved.

Subsequently, the psychometric evaluation of the pre-final version was conducted with the target population. Construct validity was assessed through exploratory and confirmatory factor analyses. Reliability was examined by internal consistency (Cronbach’s alpha) and test-retest reliability (30 nursing students). The procedures for these psychometric assessments are detailed in the Data Analysis section.

Data analysis

The study data were analyzed on SPSS (Statistical Package for Social Sciences, version 28.0) and AMOS (Analysis of Moment Structures, version 28) software packages for Windows. The conformity of the data to normal distribution was checked by skewness/kurtosis values and the Kolmogorov Smirnov test. Descriptive characteristics of nursing students were presented as frequency (n), percentage (%), and mean ± standard deviation (X ± SD) values.

Exploratory factor analysis (EFA) is used to verify the validity of the data, and confirmatory factor analysis (CFA) is used to verify the accuracy of the data. EFA was performed using the principal axis factoring with direct oblimin rotation. Bartlett’s test of sphericity and Kaiser–Meyer–Olkin (KMO) statistic were used for testing the possibility of performing factor analysis. CFA with maximum likelihood was performed to test whether the factor structure of the adapted scale. The current structure of scale was examined according to the cut-off values for goodness-of-fit indices as follows: the chi-square/degree of freedom (χ2/df < 5), goodness-of-fit index (GFI > 0. 85), comparative fit index (CFI > 0.90), root mean square error of approximation (RMSEA < 0.08), Tucker-Lewis Index (TLI) ≥ 0.90 and Standardized Root Mean Residual (SRMR) ≤ 0.06 [30,31,32]. Item factor loadings were expected to be 0.30 and above [33]. Cronbach’s alpha coefficient and item-total correlation (ITC) were used to measure internal consistency reliability. Cronbach’s alpha results were considered excellent (α ≥ 0.9), good (0.9 > α ≥ 0.8), acceptable (0.8 > α ≥ 0.7), questionable (0.7 > α ≥ 0.6), poor (0.6 > α ≥ 0.5), and unacceptable (0.5 > α) [34]. Intraclass correlation coefficient (ICC) was used to determine test-retest reliability (stability). The acceptable value for ICC was determined as ≥ 0.70 [35]. The significance level was accepted as p < 0.05.

Results

Characteristics of the students

In total, 316 nursing students with a mean age of 22.02 ± 1.20 years participated in the study (Table 1). Most of the students (86.4%, n = 273) were female and reported completing their high school education in a public high school (91.1%). The majority of students reported staying with their families or in public dormitories (43.4% and 38.6%, respectively). More than half of the students reported that they chose the nursing profession willingly (70.6%, n = 223) and planned to pursue postgraduate education (68%, n = 215).

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Validity

Construct validity

In the EFA, six factors were determined in accordance with the original structure of the scale. The EFA showed that the data were appropriate for factoring (KMO  =  0.966; Bartlett’s test χ2  =  8601.48, p < 0 0.001). The six-factor structure of the scale explains 75.8% of the total variance. Subsequently, CFA was conducted to verify and validate the factor structure. CFA model was created with a path diagram in which six factors were latent and the statements constituting these factors were included as indicator variables (Fig. 1). The maximum likelihood method was used to estimate the parameters including the regression coefficients for the errors of the indicator variables, the variances of the latent variables, and the paths drawn from the latent variables to the indicator variables. Then, the fit indices were improved by establishing a two-way correlation between the error terms of the items with the highest modification indices (MK1 and MK4, MK1 and MK5, NS2 and NS5, C2 and C3, GV1 and GV2, and GV4 and GV5). As a result, the fit indices of the NSCS-T were as follows: χ2/df = 2.252; GFI = 0.852; CFI = 0.943; RMSEA = 0.063; TLI = 0.936; SRMR = 0.038 (Table 2). As a result of CFA, the factor loadings of the scale items ranged between 0.68 and 0.90, the critical ratio (CR), and p-values of the items were significant (p < 0.05) (Table 3).

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Reliability

Internal reliability

Cronbach’s alpha values were found to be 0.86–0.93 in the sub-dimensions of the scale and 0.97 in the total scale; the distribution of items in the sub-dimensions is given in Table 4. The ITC values of the scale were found between 0.55 and 0.83.

Test-retest reliability

The test-retest measurement according to ICC was determined between 0.95 and 0.99 (Table 4).

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Discussion

Nursing education programs have been evolving towards competency-based education. It is imperative that nursing programs align the education offered with the current and future needs in healthcare to best prepare students [4]. One of the areas affected by competency-based education has been accreditation. HEPDAK, which carries out the accreditation process of nursing education in Türkiye, stated that the program outcomes, which define the knowledge, skills, and behaviors that students should acquire until they graduate from a nursing program, should cover the components necessary to achieve the educational objectives of the program and include the 11 HEPDAK outcomes (see Supplementary File 1, Table S2) [19]. In addition, it emphasized the implementation of valid, reliable, and useful measurement and evaluation systems for the learning/teaching process in order to determine and prove that the objectives of the educational programs have been achieved. In this process, several nursing education programs in Türkiye started to update their program outcomes in line with the HEPDAK recommendations. In this context, the NSCS emerged as an up-to-date scale during the process of searching for options to evaluate the outcomes of our education program. Before testing the validity and reliability of the NSCS, we meticulously examined its compliance with the standards in Türkiye in terms of accreditation requirements and our competencies. We decided that the scale met our expectations, also in line with the feedback we received from experts in content analysis. Therefore, in this study, we aimed to examine the psychometric properties of the NSCS-T with a sample of Turkish nursing students. To our knowledge, this is the first study to test the acceptability and psychometric properties of the NCST in another language. The results of this study confirm that the NSCS-T possesses highly appropriate and acceptable psychometric properties, comparable to those of similar scales such as the Nurse Competency Scale (NCS) and the Competency Inventory of Nursing Students (CINS) [36, 37].

Within the framework of the language, content, and face validity of the scale, translation, back-translation, and cultural adaptation procedures were meticulously carried out and discussed within the scope of expert panels consisting of nursing faculty members with many years of experience in many branches of nursing education/training and linguists. The results obtained from the experts showed that the scale had an acceptable CVI value (≥ 0.80) for individual items and overall. At this stage, the Turkish version of NSCS was created without the need for serious revision and elimination of the items. In the original study, the content validity of the scale was evaluated with the Davis technique and it was reported to have an acceptable CVI (0.97 for relevance and 0.98 for importance) similar to our study [21].

Overall, the fit indices of the NCSC-T (χ2/df = 2.252; GFI = 0.852; CFI = 0.943; RMSEA = 0.063; TLI = 0.936; SRMR = 0.038) are satisfactory and comparable to those reported for other scales in the literature. In the original study, Huang et al. (2022) reported fit indices of χ2/df = 2.240; CFI = 0.944; RMSEA = 0.072; TLI = 0.937; SRMR = 0.042, while Toprak & Aslan (2020) found χ2/df = 3.62; RMSEA = 0.084; CFI = 0.94; SRMR = 0.098 for the Turkish NCS [21, 36]. Similarly, the Turkish version of the CINS showed fit indices of χ2/df = 2.02; RMSEA = 0.055; CFI = 0.943) [37]. These results indicate that the Turkish adaptation of the NCSC demonstrates evidence of validity in the studied sample. However, since the study was conducted in a single institution, further research is needed to confirm its validity in different contexts and across the country.

The internal consistency of the NSCS-T, with Cronbach’s alpha coefficients ranging from 0.86 to 0.93 for the sub-dimensions and 0.97 overall, demonstrates a high level of reliability. These values align well with the original study, which reported alpha coefficients between 0.91 and 0.98 for the sub-dimensions and 0.98 overall [21]. In the Turkish adaptation of the NCS, the reliability coefficients ranged from 0.74 to 0.92 for the sub-dimensions and 0.96 overall, while the Turkish version of the CINS showed alpha coefficients between 0.79 and 0.97 for the sub-dimensions and 0.97 overall [36, 37]. This comparison highlights that the NSCS-T not only meets but also closely mirrors the reliability standards of its original version and other well-established scales, reinforcing its robustness and suitability for assessing nursing students’ competencies.

A total of 30 students were administered a test-retest at two-week intervals and the results were evaluated by ICC in order to assess the stability of the scale. The results showed highly acceptable ICC values (> 0.70) in subscales and overall. In the original study, 30 students in the only 4th grade participated in the test-retest process, and the ICC value across the scale was reported as 0.515, which is different from our results [21]. This low ICC value in the original study may be because the test-retest interval was longer (4 weeks) than that in our study. The time interval between two test administrations is critical for test-retest reliability. If the time interval is too short, individuals may remember their previous responses, leading to artificially high results. On the other hand, if the time interval is too long, the stability of the construct being measured may change, making test-retest reliability less meaningful [38, 39]. While research shows that the optimal time interval between tests will vary depending on the construct being measured, the stability of the construct over time, and the target population, a target interval of two weeks is most often recommended [40, 41].

Limitations

Despite the contributions of this study to the existing literature, it has some limitations. The main data of the study were obtained through self-report questionnaires and may involve response bias. The results may not be generalized as this study was conducted with nursing students in only one institution. Since this study was the first adaptation study of the NSCS to a different culture, the comparison of the results was limited to the original study and similar scales. Although the sample size of 30 participants for test-retest reliability is categorized as moderate according to the COSMIN Study Design Checklist, a larger sample could have provided more robust reliability estimates. Future studies with larger samples are recommended to further validate the findings.

Conclusion

Valid and reliable scales can be preferred to measure the degree of development of nursing competence. Identification of core competencies related to nursing student may help in the review of the content of curricula and nursing education/training programs and in making necessary improvements within the framework of the characteristics that form the basis of each competency. Our results suggest that the NSCS-T can be integrated into undergraduate nursing education in Türkiye to effectively assess the development of core competencies among nursing students and can be used to assess program outcomes in accreditation processes.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

NSCS:

Nursing student competency scale

NSCS-T:

Turkish version of nursing student competency scale

HEPDAK:

Turkish association for evaluation and accreditation of nursing education programs

EFA:

Exploratory factor analysis

CFA:

Confirmatory factor analysis

I-CVI:

Item-level content validity index

S-CVI/Ave:

scale-level content validity index

SPSS:

Statistical package for social sciences

AMOS:

Analysis of moment structures

X:

Mean

SD:

Standard deviation

χ2/df:

The chi-square/degree of freedom

GFI:

Goodness-of-fit index

CFI:

Comparative fit index

RMSEA:

Root mean square error of approximation

TLI:

Tucker-Lewis index

SRMR:

Standardized root mean residual

ITC:

Item-total correlation

ICC:

Intraclass correlation coefficient

CR:

Critical ratio

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