Introduction

Communication is an indispensable component of the nursing profession, facilitating the comprehension, investigation, and attention of the unique requirements of each patient [1]. This key component is essential for establishing therapeutic relationships with patients and their families, as well as fostering collaborative relationships with other healthcare providers (HCPs) [2]. However, nurses frequently encounter difficulties in communicating with patients, their families, and other HCPs. These challenges reduce the standard of nursing care and increase the likelihood of medication errors, which could result in undesirable consequences or even mortality [3]. Improved communication skills among nurses have also been associated in several studies with lower medical errors, outstanding nursing care, greater clinical performance, increased self-efficacy, stronger organizational commitment, and enhanced job satisfaction [4–6].

Therefore, nurses should communicate in a goal-oriented manner in their clinical practice, focusing on promoting the physical and mental health of patients. This approach is called patient-centered communication [7], also known as person-centered communication or client-centered communication [8]. Joo et al. (2024) defined patient-centered communication as a series of actions designed to empower patients and their families. This encompasses providing sufficient information, emotional support, empathetic expression, actively reflecting their values and preferences in decision-making, and engaging in treatment-related decisions [9]. In other words, patient-centered communication denotes a process that promotes the active involvement of patients and their families in decision-making on their care requirements [8].

Patient-centered communication cultivates trust and mutual respect in the care process, enhancing practices that correspond with the needs, concerns, and preferences of patients and caregivers [2]. This concept is crucial in achieving desirable health outcomes, as it reflects longstanding nursing values that prioritize individualized care [2]. The goal of patient-centered communication is to prevent illness and promote patient well-being through their active participation in treatment and decision-making, all based on respect for patients and their families [10]. In contrast, ineffective nurse-patient communication undermines patients’ trust in HCPs, which can lead to them withholding important information that requires immediate intervention [11]. This ineffective communication can also lead to increased length of stay, patient dissatisfaction, and waste of resources [12], as well as reduced quality of nursing care and increased patient stress. It can also make patients feel insecure and uninformed, leading them to view HCPs as inexperienced or incompetent [13]. Consequently, it is important to have a comprehensive, valid, and reliable instrument to assess patient-centered communication from the viewpoint of nurses as primary HCPs and to identify its associated factors in clinical settings.

The Global Interpersonal Communication Competence Scale (GICCS) is commonly used to assess the communication skills of clinical nurses [14], despite not being specifically designed for nurses in clinical settings [9]. Alshammari et al. (2021) also conducted a study to determine the psychometric properties of the Arabic version of the Patient-Centered Communication Instrument (PCCI). This 36-item instrument, with satisfactory validity and reliability, measures six subscales: (a) exchanging information, (b) fostering healthy relationships, (c) making decisions, (d) responding to emotions, (e) enabling patient self-management, and (f) managing uncertainty from the perspectives of adults with cancer [15]. Similarly, Demiris et al. (2023) evaluated the validity and reliability of the English version of the Caregiver-Centered Communication Questionnaire (CCCQ). This 30-item questionnaire not only has desirable psychometric properties but also measures five subscales: (a) exchange of information, (b) fostering health relationships, (c) recognizing and responding to emotions, (d) managing care, and (e) decision-making from the perspective of family caregivers of patients hospitalized in hospice care [16].

The aforementioned instruments, while possessing suitable psychometric indicators and evaluating multiple dimensions of patient-centered communication, were specifically designed and psychometrically validated to measure this concept from the viewpoint of patients and their families [15,16]. However, patient-centered communication is an interactive concept, and assessing it solely from the perspective of patients and their families may not provide a comprehensive understanding of how this approach is realized in clinical practice. Nurses, who are the primary HCPs and have the most frequent and continuous interactions with patients and their families throughout this process, play a fundamental role in transforming the principles of patient-centered communication into everyday practical behaviors. Therefore, their perspective can provide unique information about communication behaviors, clinical decision-making processes, contextual factors, and organizational conditions that facilitate or inhibit this specific type of communication. On the other hand, evaluating this concept from the perspective of nurses may lead to identifying training needs, designing quality improvement programs, and developing effective interventions to improve patient-centered communication practices. For example, nurses can provide valuable information about how to apply communication strategies in clinical settings, how to address the needs, preferences, and concerns of patients and their families, how to facilitate their participation in the care process, and how to collaborate with other members of the treatment team. Such information can help identify factors that influence the achievement of patient-centered communication and better understand the mechanisms that facilitate or inhibit it, aspects that cannot be assessed solely from the perspective of patients and their families. Therefore, assessing patient-centered communication from the perspective of nurses does not replace assessing it from the perspective of patients and their families, but rather complements it. This approach contributes to a more multidimensional understanding of this concept in clinical settings [9].

In this regard, Joo et al. (2024) conducted a study with the aim of designing and validating the Patient-Centered Communication Scale (PCCS) in Korean clinical nurses. After conceptualizing patient-centered communication, the mentioned study designed the initial items of this scale through a literature review and online interviews with 10 qualified clinical nurses. 51 items were selected as the initial items of this scale. Following the removal, integration, and modification of some items in the content validity stage, a 31-item scale was obtained. Then, the remaining items were perceptually tested in terms of understandability, completion time, and layout appropriateness by 10 qualified clinical nurses. The construct validity of the mentioned scale was assessed using exploratory factor analysis (EFA) (on 175 qualified clinical nurses) and confirmatory factor analysis (CFA) (on 150 qualified clinical nurses). Finally, 12 items remained, covering three factors: (a) information sharing (5 items), (b) patient-as-person (4 items), and (c) therapeutic alliance (3 items). The positive and significant correlation between the PCCS and the GICCS also suggested its desirable convergent validity. Its reliability was also reported to be acceptable by the internal consistency method through Cronbach’s alpha coefficient for the aforementioned factors, as well as the entire scale [9].

Accordingly, Joo et al. (2024) introduced a valid and reliable instrument that assesses patient-centered communication as a three-dimensional construct by implementing a step-by-step and systematic approach [9]. On the other hand, no study has yet addressed the cultural adaptation and psychometric evaluation of the PCCS in clinical nurses from other societies. Only Amin et al. (2025) in a study that examined the mediating role of moral distress in the relationship between patient-centered communication and palliative care competence among Egyptian oncology nurses, despite not evaluating the psychometric properties of this scale in the aforementioned society, referred to the PCCS as a three-dimensional scale and used its total score in the analyses [17]. However, no other evidence was found regarding the factor structure and model fit of the original version of this scale in clinical nurses from other societies. Therefore, the present study, while translating and culturally adapting, first examines the three-dimensional model presented by the initial study of scale design, including information sharing, patient-as-person, and therapeutic alliance through CFA. If the presented three-dimensional model is rejected, then the factor structure and model fit of the Persian version of the PCCS are determined through exploratory and confirmatory approaches of factor analysis, respectively.

Materials and methods

Face validity

The face validity of the PCCS was evaluated using both qualitative and quantitative methods.

Qualitative face validity assessment.

In the qualitative method, face-to-face interviews were conducted with ten qualified clinical nurses who had a diverse range of demographic characteristics. These interviews aimed to evaluate each item in terms of difficulty, relevance, and ambiguity [24,25].

Quantitative face validity assessment.

In the quantitative method, a five-point Likert scale was utilized, with responses varying from “completely understandable” (5 points) to “not understandable at all” (1 point). Ten qualified clinical nurses rated each item using this Likert scale. The impact score (IS) for each item was subsequently calculated using the following formula:

(1)

Frequency (%) denotes the proportion of respondents assigning a score of 4 or 5 to an item, whereas Comprehensiveness reflects the average score of that item on the Likert scale. Items with an IS above 1.50 are retained for further analysis, whereas those with an IS below 1.50 are revised but not eliminated [25,26].

Content validity

Similar to face validity, both qualitative and quantitative methods were employed to evaluate the content validity of the PCCS.

Qualitative content validity assessment.

In the qualitative method, the mentioned scale was provided to 10 nursing faculty members and specialists in patient-centered communication and nurse-patient communication. This group consisted of two nursing professors, two associate professors of nursing, two assistant professors of nursing, two clinical psychologists, and two instrument development specialists. Their feedback on grammar, sentence structure, item placement, and scoring accuracy was then collected [27,28].

Quantitative content validity assessment.

In the quantitative method, the content validity ratio (CVR), the content validity index (CVI) at both item and scale levels, and the modified Kappa statistic (K^*) were calculated.

To determine the CVR, which assesses the necessity of items in the scale, a group of 10 specialists in the field of patient-centered communication and nurse-patient communication evaluated each item using a three-point Likert scale (unnecessary = 1 point, useful but unnecessary = 2 points, necessary = 3 points). The CVR was then calculated using the following formula:

(2)

nE denotes the count of specialists who regard the item in question as essential, whereas N represents the total number of specialists. The Lawshe table facilitates result interpretation, with CVR values exceeding 0.62 signifying the importance of items within the scale [29].

To ascertain the item-level content validity index (I-CVI), which measures the relationship of items to the scale, another group of 10 specialists in the aforementioned fields evaluated each item on a four-point scale: not pertinent = 1 point, somewhat pertinent = 2 points, pertinent but requires amendment = 3 points, and completely pertinent = 4 points. The I-CVI for each item was determined by dividing the number of specialists who rated the item as 3 or 4 by the total number of specialists [30,31]. The scale-level content validity index/average (S-CVI/Ave) is calculated by averaging the I-CVI scores. This is done by dividing the sum of the I-CVI scores by the total number of items [32].

I-CVI values less than 0.70 are considered unacceptable, values between 0.70 and 0.78 are deemed questionable, and values greater than 0.79 are considered acceptable. Therefore, unacceptable items are removed, questionable items are modified, and acceptable items are retained [30]. Additionally, S-CVI/Ave values greater than 0.90 are considered desirable [32].

The K^* was calculated for each item to reduce the likelihood of random agreement. To do this, the probability of chance agreement (P_c) must first be determined using the following formula:

(3)

N denotes the total count of specialists, whereas A signifies the number of specialists who evaluated the item with a rating of 3 or 4. Subsequent to calculating the P_c, the K^* was ascertained utilizing the following formula:

(4)

Therefore, K^* values less than 60.00% are considered poor, 60.00% to 74.00% are considered good, and greater than 75.00% are considered excellent [33].

Results

Demographic characteristics of participants

Nurses with official employment status (69.33% for the first sample and 77.33% for the second sample) and a BSN (88.00% for the first sample and 82.00% for the second sample) constituted the majority of the participants in the first and second independent samples. The mean of the participants’ work experience in the first and second independent samples was also 12.51 ± 7.78 and 12.09 ± 7.56, respectively. The two samples were also homogeneous in terms of all demographic characteristics (P > 0.05). Other demographic characteristics of the participating nurses are presented in Table 1, separated by the first and second independent samples.

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Table 1. Demographic characteristics of participants by the first and second independent samples.

https://doi.org/10.1371/journal.pone.0358575.t001

Construct validity

Before conducting EFA, the three‑factor model proposed by Joo et al. (2024) was tested using CFA on the first independent sample (n = 150). This initial model yielded the following fit indices: χ²(41)=210.091, P < 0.001, χ²/df = 5.12, RMSEA = 0.11, CFI = 0.86, TLI = 0.88, PNFI = 0.74, and PCFI = 0.75. Additionally, the correlations among the three factors exceeded 0.85, indicating poor discriminant validity. Based on these inadequacies—particularly the unsatisfactory RMSEA and the high interfactor correlations—the original three‑factor structure was rejected. Consequently, we proceeded with EFA on the first sample to explore a better‑fitting structure.

The KMO value of 0.97 and Bartlett’s sphericity test (χ² = 4292.43, df = 55.00, P < 0.001) indicated the adequacy of the sampling. Conversely, skewness values (±3.00) and kurtosis values (±7.00), along with the Mardia coefficient values (<8.00), respectively, demonstrated no substantial deviation from the univariate and multivariate normal distribution of the items. Following this, EFA using the ML approach extracted only one factor with an eigenvalue of 8.56, covering 77.78% of the entire variance of the Persian version of the PCCS. The lowest and highest commonality values and factor loadings were attributed to items 6 (h² = 0.59 and factor loading = 0.77) and 9 (h² = 0.92 and factor loading = 0.96), respectively (Table 2).

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Table 2. Exploratory factor analysis to evaluate the factor structure of the Persian version of the Patient-Centered Communication Scale (n = 150).

https://doi.org/10.1371/journal.pone.0358575.t002

After the EFA extracted a single factor, this unidimensional model was tested using CFA on the second independent sample (n = 150) and demonstrated excellent fit. To formally compare the retained unidimensional structure with the original three-factor solution, the three-factor model was also re-estimated on the same CFA sample (χ²(39)=104.52, P < 0.001, χ²/df = 2.68, RMSEA = 0.08, CFI = 0.98, TLI = 0.97, PNFI = 0.72, and PCFI = 0.73). Although this three-factor model met some conventional fit thresholds, the Δχ² between the unidimensional and three-factor models was not significant (Δχ²(3)=4.21, P = 0.24), and ΔCFI was 0.01, which is below the conventional threshold for a meaningful improvement. Because the three-factor model already demonstrated satisfactory fit on the second independent sample, we did not examine its modification indices for residual correlations, as further adjustments were not warranted. Residual covariances were added only to the initially poorly fitting unidimensional model, and the final model comparison was conducted between the well-fitting three-factor model and the revised unidimensional model, using Δχ², ΔCFI, AIC, and BIC as recommended. Moreover, the AIC and BIC values favored the more parsimonious unidimensional model (AIC = 189.63 vs. 195.84; BIC = 253.21 vs. 262.45). Therefore, the unidimensional structure was retained as the final model.

Before reaching this final model, the initial unidimensional solution without correlated residuals was tested and showed a slightly suboptimal fit (χ²(44)=185.24, P < 0.001, χ²/df = 4.21, RMSEA = 0.12, CFI = 0.89, TLI = 0.87, PNFI = 0.47, and PCFI = 0.48). Inspection of modification indices revealed that adding covariances between the residuals of items 11 and 12 and items 6 and 7 would substantially improve the model. These correlations were theoretically defensible: items 11 (“Introduce departments or other organizations that can help the patient or family”) and 12 (“Collaborate across disciplines to establish therapeutic interventions”) both concern interdisciplinary coordination and external resource linkage; items 6 (“Use open‑ended questions to allow the patient and family to express their feelings”) and 7 (“Encourage the patient or family to express any feelings related to the illness”) both focus on eliciting and responding to patients’ emotional expressions. After adding these two residual covariances, the final model achieved the excellent fit (χ²(42)=103.63, P < 0.001, χ²/df = 2.47, RMSEA = 0.07, CFI = 0.99, TLI = 0.98, PNFI = 0.75, and PCFI = 0.75). Table 3 compares the fit of different CFA models, including the three-factor model provided by the initial study of scale design on the first and second independent samples, as well as the single-factor model obtained from the EFA with and without correlated residuals. Fig 1 also displays the conclusive model of the Persian version of the mentioned scale.

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Table 3. Comparison of the fits of different confirmatory factor analysis models.

https://doi.org/10.1371/journal.pone.0358575.t003

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Fig 1. The conclusive model of the Persian version of the Patient-Centered Communication Scale (n = 150).

https://doi.org/10.1371/journal.pone.0358575.g001

Convergent validity

As indicated in Table 4, the CR value surpasses 0.70, the CR value exceeds the AVE, and the AVE value surpasses 0.50, confirming the convergent validity of the single-factor model of the Persian version of the PCCS. It is worth noting that meeting only one of the aforementioned conditions was sufficient to confirm convergent validity.

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Table 4. The method established by Fornell and Larcker (1981) for assessing convergent validity, along with reliability indices.

https://doi.org/10.1371/journal.pone.0358575.t004

Discussion

This study sought to determine the psychometric features of the PCCS among Iranian clinical nurses. Reviewing the literature about the assessment of the psychometric features of the mentioned scale revealed that the present study is the inaugural evaluation of its validity and reliability across other societies, including Iran. An exploratory approach was used to evaluate the factor structure of the Persian version of the PCCS, which identified only one factor that explained 77.78% of the entire variance of the mentioned scale. A confirmatory approach was also used to evaluate the model fit of the Persian version of the PCCS, showing the goodness of fit of the single-factor model of this scale. Joo et al. (2024) also used factor analysis, both exploratory and confirmatory, to assess the construct validity of the original version of the PCCS. Accordingly, EFA extracted three factors, namely (a) information sharing, (b) patient-as-person, and (c) therapeutic alliance, which explained 59.00% of the entire variance of the original version of this scale. CFA also supported the goodness of fit of the three-factor structure of the original version of the mentioned scale [9].

Accordingly, the original version includes 12 items that measure patient-centered communication as a three-dimensional construct [9], while the Persian version includes 11 items that assess this concept as a unidimensional construct. Therefore, the deletion of item 4 (“Describe the medical treatment/procedure or nursing intervention”) in the content validity stage is one of the most important differences between this study and the initial study of scale design. Although the original version considered item 4 (what is the medical treatment/procedure or nursing intervention) as a distinct component from item 5 (why is the medical treatment/procedure or nursing intervention), the expert panel in the present study reported significant conceptual overlap between the two items. It should be noted that the conceptual overlap observed between these two items is not due to their simplification or homogenization in the process of translation and cultural adaptation, because in all stages of the model proposed by Wild et al. (2005), an attempt was made to maintain the conceptual distinction between what and why. This is while, from their perspective, in everyday nurse-patient interactions, explaining the type and nature of care or treatment is usually accompanied by explaining its cause and necessity. In fact, these two communication behaviors rarely occur independently of each other in such a way that their practical separation seems difficult in many clinical situations. As a result, both items were considered to reflect a common aspect of patient-centered communication, namely, providing information and explaining care or treatment to the patient or their families.

This perception is also consistent with the literature on patient-centered communication, in which information transfer, patient education, and the creation of a shared understanding of the care or treatment situation are considered interconnected components of an integrated communication process [43,44]. On the other hand, in cultural adaptation and psychometric evaluation studies, respondents’ and professionals’ perceptions of the content of the items may be influenced by professional, cultural, and organizational contexts. Therefore, the observation of overlap between items that were considered distinct in the original version does not necessarily mean a change or weakening of the theoretical concepts of the construct; rather, it may reflect how those concepts are expressed and perceived in a different cultural context. In such circumstances, their modification or deletion is considered an acceptable course of action [45]. However, the two items are not entirely identical from a theoretical perspective, as one emphasizes explaining “what is done” and the other emphasizes explaining “why it is done”. Therefore, since maintaining the two mentioned items and evaluating their performance in later stages of psychometric testing could provide more evidence about the degree of differentiation of these two concepts, it is suggested that future research examine this issue in independent samples and in different contexts.

Despite using the same approaches and achieving favorable construct validity results, what distinguishes these two versions from each other is the three-factor nature of the original version of the scale in Korean clinical nurses and the single-factor nature of the Persian version of the scale among Iranian clinical nurses. Conversely, to further validate the factor structure, the resulting unidimensional model was formally compared with the original three-dimensional model. Although both models showed adequate fit, the chi-square difference test (Δχ²) was not significant, and the parsimonious indices (AIC and BIC) clearly supported the unidimensional model. This strengthened the decision to use the unidimensional model for the Persian version. It also indicated that the items were integrated into an overall structure of this concept rather than separate subdomains of patient-centered communication. The difference in the dimensionality of the original and Persian versions of the PCCS can be assessed in many ways, and making a definitive decision about it is not so simple. However, a review of the observed and unobserved factors to which this difference can be attributed is not without merit.

Despite the almost identical inclusion and exclusion criteria in this study and the original study of scale design, the work experience of the participants in the present study (12.30 ± 7.66) was reported as almost twice the work experience of the participants in the original study of scale design (6.25 ± 3.55). However, the two populations did not differ significantly in terms of gender (majority female), level of education (majority BSN), department of practice (majority internal medicine), or age (mean age between 30 and 40 years). Therefore, some apparent differences between the work experience of the participants in the two studies may explain the difference in the dimensionality of the two versions. Other possible reasons for this discrepancy include personal or behavioral differences between Korean and Iranian clinical nurses, as well as the different conditions prevailing in the healthcare systems of the two countries. These factors play a key role in conceptualizing a specific type of communication, namely patient-centered communication, from the viewpoint of nurses as primary HCPs. Moreover, nurses’ favorable attitudes and perceptions are shaped by a combination of organizational factors such as adequate staffing, managerial support, and interprofessional relationships, which may vary considerably across different healthcare systems and cultural contexts [46]. A literature-based analysis of patient-centered communication in interactions between nurses and patients categorized the obstacles to effective communication into four distinct groups: (a) institutional barriers, also known as healthcare system-related barriers, such as deficiency of nursing personnel and excessive workload; (b) communication barriers, such as language differences between patients and HCPs and poor communication skills; (c) environmental barriers, such as noisy environments and untidy and crowded departments; and (d) personal or behavioral barriers, such as demographic characteristics and different cultural backgrounds, beliefs, and worldviews about health and illness [2]. On the other hand, the decision to delete an item at the content validity stage or the use of the English version provided by the original designer as the basis for translation may have contributed to the aforementioned difference to some extent. Although the translation and cultural adaptation process was carried out according to standard guidelines, the possible influence of these factors cannot be completely ruled out. However, examining the possible reasons raised in different societies with various characteristics not only covers institutional, communication, environmental, and personal or behavioral differences as much as possible, but also helps to better understand the origin of the differences in the factor structure of the original and Persian versions of the PCCS.

Beyond comparing the factor structure, examining the position of the PCCS among existing instruments also helps better interpret the results obtained. Although several instruments have been developed to assess patient-centered communication, most of them assess the experience or perception of patients and family caregivers of the quality of communication with HCPs. For example, the PCCI, which has undergone psychometric assessment by Alshammari et al. (2021), measures the aforementioned concept from the perspective of adults with cancer [15]. Similarly, the CCCQ, whose validity and reliability have been evaluated by Demiris et al. (2023), measures this specific type of communication from the perspective of family caregivers of patients hospitalized in a hospice [16]. These instruments are valuable because they reflect the direct experience or perception of healthcare recipients, whether patients or family caregivers, but they are not designed to measure clinical nurses’ communication skills from their own perspective. In contrast, the PCCS assesses this construct from the perspective of nurses as the primary HCPs and can be particularly useful for identifying training needs or planning interventions to improve communication skills. In addition, the aforementioned translation and validation studies assessed the factor structure only with a confirmatory approach and did not conduct factor analysis with an exploratory approach. However, the present study assessed the construct validity by simultaneously conducting exploratory and confirmatory approaches, while randomly assigning participants to two independent samples. This approach not only fully complies with the rigorous requirements of psychometric assessment but also minimizes overfitting and improves generalizability [37,47,48]. However, the results of the aforementioned instruments may be affected by various biases such as group conformity or social desirability, like other self-report instruments. Therefore, the simultaneous use of instruments based on the perspectives of clinical nurses and those of patients or family caregivers in future research could provide a more comprehensive and realistic assessment of patient-centered communication in clinical settings.

Although Joo et al. (2024) suggested the desirable convergent validity of the original version of the PCCS by evaluating its correlation with the GICCS (r = 0.68, P < 0.001) [9], the present study exhibited satisfactory convergent validity of the Persian version of the PCCS using the method established by Fornell and Larcker (1981) (CR > 0.70 or CR > AVE or AVE > 0.50). Therefore, despite the different approaches used, both the original and Persian versions of this scale had acceptable convergent validity.

This study confirmed the internal consistency, construct reliability, and external stability of the Persian version of the PCCS. In contrast, Joo et al. (2024) only reported the internal consistency of the original version of the PCCS. The Cronbach’s alpha coefficient values for the entire scale and the factors of (a) information sharing, (b) patient-as-person, and (c) therapeutic alliance were 0.84, 0.77, 0.72, and 0.60, respectively [9]. Calculating McDonald’s omega coefficient alongside Cronbach’s alpha coefficient to assess internal consistency, as it is less sensitive to sample size and does not require the assumption of tau equivalence [49,50]; determining construct reliability with two CR and MaxR indices; and assessing external stability by calculating ICC, as it is an integral part of the reliability analysis process [51], distinguish the present study from the initial study of scale design. This study not only addressed the limitations of the initial study of scale design but also showed satisfactory reliability for the Persian version of the mentioned scale in various forms such as internal consistency, construct reliability, and external stability.

After deleting item 4 during the content validity stage, the Persian version of the PCCS now consists of 11 items that assess patient-centered communication as a unidimensional construct. These items are rated using a five-point Likert scale, spanning strongly disagree (1 point) to strongly agree (5 points). Scores can differ from 11 (representing the lowest patient-centered communication skills) to 55 (representing the highest patient-centered communication skills). Higher scores suggest greater patient-centered communication skills in nurses and vice versa.

Conclusions

The Persian version of the PCCS not only exhibited favorable validity through various forms, such as face, content, construct, and convergent validity, but also showed satisfactory reliability through multiple approaches, including internal consistency, construct reliability, and external stability. However, due to the single-center data collection, caution should be exercised in generalizing the results to clinical nurses working in medical centers linked to other Iranian universities of medical sciences and non-university facilities, such as private medical centers.

Supporting information

Acknowledgments

This study is the result of a research project approved under number 14030089 at Shahroud University of Medical Sciences. The authors would like to acknowledge the support of the Vice Chancellor for Research and Technology of this university, and thank the esteemed officials of Imam Hossein and Bahar hospitals, all participating nurses, and other individuals who collaborated in conducting this study.