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Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 515-522

Cultural adaptation and validation of the nursing students' perceptions of instructor caring into spanish

1 Department of Nursing, Red Cross Nursing School, University of Seville, Spain
2 Department of Sociology, Social Work and Public Health, University of Huelva, Spain; Safety and Health Posgrade Program, University Espíritu Santo, Guayaquil, Ecuador
3 Department of Cardiology, Virgen Macarena Hospital, Seville, Spain
4 Department of Social, Developmental and Education Psychology, University of Huelva, Burgos, Spain
5 Faculty of Health Sciences, University Isabel I, Burgos, Spain

Date of Submission25-Jul-2019
Date of Acceptance30-Nov-2019
Date of Web Publication4-Apr-2020

Correspondence Address:
Dr. J Gomez-Salgado
Department of Sociology, University of Huelva, Social Work and Public Health, Faculty of Labour Sciences, Avenida 3 de Marzo, S/n. 21071 Huelva

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_386_19

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Objective: This paper aims to provide a Spanish version of the nursing students’' perceptions of instructor caring with content validity and reliability. Methods: A forward and backward translation procedure was conducted, and a panel of 15 experts assessed face validity. Content validity was established by calculating content validity indexes for each item and for the scale. The internal consistency was assessed in a sample of 120 students. Results: Content validity indexes resulted in higher than 0.78 for all items except Does not reveal any of his or her personal sides and serves as a trusted resource for personal problem solving; content validity index for the scale was 0.9 and Cronbach α was 0.942. Discussion: Results regarding reliability were similar to that of other studies in which the nursing students' perceptions of instructor caring has been used as a measuring tool. Item 12 deletion implies a considerable improvement in internal consistency. Conclusion: The Spanish nursing students' perceptions of instructor caring is a valid and reliable tool to be used in the Spanish context. Its use will enhance the understanding of clinical mentors' impact on nursing students.

Keywords: Education, nursing, nursing care, students

How to cite this article:
Romero-Martin M, Gomez-Salgado J, Safont-Montes J C, Navarro-Abal Y, Climent-Rodríguez J A, Jimenez-Picon N. Cultural adaptation and validation of the nursing students' perceptions of instructor caring into spanish. Niger J Clin Pract 2020;23:515-22

How to cite this URL:
Romero-Martin M, Gomez-Salgado J, Safont-Montes J C, Navarro-Abal Y, Climent-Rodríguez J A, Jimenez-Picon N. Cultural adaptation and validation of the nursing students' perceptions of instructor caring into spanish. Niger J Clin Pract [serial online] 2020 [cited 2022 Nov 28];23:515-22. Available from:

   Introduction Top

Caring is the essence of nursing; it is the focus of the discipline that guides the profession and its moral, philosophical, and technical foundation.[1] It is the central and unifying concept for nursing practice, the center of the body of nursing knowledge, and the distinguishing element of the rest of the disciplines, its identity trait.[2]

According to Watson, caring is developed in the transpersonal relationship that the nurse establishes with the patient. It means an encounter at a subjective level of both during a shared moment of caring that goes beyond them. This caring moment is described as a conscious, intentional, and meaningful union between two people, in which experiences are shared that allows each one to expand their worldview and leads them to spiritual growth and new discovery of oneself and new life possibilities.[1] The caring moment is not exclusive to the nurse-patient relationship, it can be transferred to the academic environment, where lecturers and mentors build and share intersubjective experiences with the students, which help them to acquire skills of transpersonal caring.[3]

If caring is considered a transpersonal and intersubjective process of the exchange of experiences and meanings modulation, then, caring relationships are an excellent opportunity to learn the art of caring. Caring relationships students experience during their training provide future nursing professionals with a reference for the understanding and internalization of caring, as well as a model for future caring relationships that they establish in their professional performance.[4] The reciprocal relationship between students and mentors help students grow as people who care, so nursing training is an opportunity to develop, improve, and promote caring behaviors in students.[5]

The clinical mentor is a health professional, who during his working shift is responsible for the practical training of the student that has been assigned. Their functions are to foster the development of practices and prepare a customized report of skills evaluation at the end of the training period.[6] It is essential that mentors work in coordination with academic lecturers and provide them with their support, guide, and collaboration.[7]

Clinical instructors have been described as strong role models for students, and as such, they can positively influence their attitudes.[8] If mentors are appreciated as an example of caring, after observing them, the students can select among their behaviors and imitate nursing caring actions.[9] Caring for nursing students is a prerequisite for learning to care for future patients.[10] Caring is also a demand on the part of students, who expect to be cared for, respected, and considered as unique individuals.[11] Nursing students prefer a care-based pedagogical relationship with their clinical mentors, as an extent to which they feel cared for guides them as future caregivers.[12] Then, knowing the care that mentors transmit to their students gives us some idea of the caring model they are acquiring.

The mentors' demonstration of caring attitudes can shape the way students perceive their training experience.[13] The caring environment influences the students' well-being, increases their confidence and motivation and helps them learn to care in a professional manner.[14] The figure of the clinical mentors helps students integrate theoretical knowledge into practice and build their professional identity.[15] Thus, the quality of the learning experience depends on the clinical mentor; a low-effective mentor leads to incomplete training and, consequently, to the performance of low-quality caring attitudes.[12] An example of careless practice makes students feel vulnerable and move away from humanizing care.[16] Staff nurses with whom students shared their clinical placement experiences are also responsible for promoting and enhancing their sense of belonging, which is a crucial precursor to students' learning and success. Belongingness is related to nursing students' self-concept, self-efficacy, and their capacity and motivation to engage in clinical learning opportunities.[17] Caring in academic environments reduce the dropout rate and encourage the completion of nursing studies.[14] In addition, care has been considered a key indicator of the quality of nursing education.[18] For all this, it is essential to know the students' perceptions of the care their mentors transmit to help them improve their teaching and develop caring behaviors that serve as a model.

The subjective nature of the concept of care makes it elusive and difficult to study and measure it in an authentic way.[19] But despite being an experiential phenomenon, measurements can be made of its external manifestations that allow approximation to its abstract dimension.[20] Care becomes visible when it is transmitted through demonstrable and recognizable behaviors and actions.[21] The nursing students' perceptions of instructor caring (NSPIC) is a tool designed to measure nursing students' awareness of their mentors' caring behaviors. This perception is defined as “nursing students' awareness of a mutual and reciprocal connection between the self and the instructor that enables them to search for meaning and wholeness and grow as caring professional nurses.”[22] It is a self-completed questionnaire of 31 items grouped into 5 domains: confidence through caring, supportive learning climate, appreciation of life's meanings, control versus flexibility, and respectful sharing.[23] Each item is valued with a Likert-type scale from 1 to 6. The scale has shown high reliability with a Cronbach α of 0.97 in the initial study conducted in the United States,[22] and transculturally adapted to China (α = 0.93)[23] and Italy (α = 0.94).[24]

Given that caring is the distinctive activity of the nursing profession, the nursing curricula should be focused on caring and should offer students a general appreciation of caring, so that they will be capable of performing their professional roles as caregivers.[25] Nursing students should be trained to acquire core human values of nursing such as empathy, respect, sensitivity, presence, or compassion, which have been already recognized.[26] As suggested, educational nursing programs should be designed with a caring orientation, with the principal aim of enhancing caring behaviors among the students.[27]

The aim of this work is to determine the content validity and reliability of the NSPIC scale and to assess its cultural adaptation.

   Materials and Methods Top

Study design

A descriptive cross-sectional study was conducted. For the translation and cultural adaptation, the steps proposed by Ramada-Rodilla et al. were followed: forward translation, synthesis, backward translation, consolidation, and piloting.[28]

Setting and sample

Regarding content validity, it is recommended that experts panel know in-depth the concept of research at the academic and/or professional level, represent the population who uses the scale, and have at least 5 years of experience in the field.[29] The following inclusion criteria were established for the expert panel:

  • Being an academic lecturer (knowledge of the concept).
  • Being a clinical instructor (knowledge of the concept).
  • Being a nursing student (user population).
  • Having 5 years of experience.

A total of 15 experts were established for a reliable estimate, 5 for each profile (academic and clinical teachers, and students). These criteria inevitably imply a convenience sample.

Regarding the reliability of the tool, the NSPIC-S 2 was distributed to a sample of 120 students enrolled in the Faculty of Nursing, University of Seville, Spain.

Ethical considerations

Participants were previously informed about the purpose of the study and they provided informed voluntary consent. The data were registered anonymously, in a way that it was not possible to identify the responses of each participant. The study obtained the authorization of the scale authors for its adaptation and use in this study. Changes suggested according to the results of this study were reported to the author of the original scale and she agreed and gave her consent. Approval from the Ethics Committee of Research at the Red Cross Nursing School, University of Seville, Spain, was obtained (date of approval 16th of January 2018, reference PI 03/18), was obtained. This paper is part of a larger survey that includes the cultural adaptation and psychometric testing of the S-NSPIC.[30]


Members of the panel were asked to value the relevance and pertinence to the concept of each item with a Likert scale of four points in which 1 meant non-relevant, 2 somehow relevant, 3 quite relevant, and 4 very relevant.

Data collection/procedure

Forward translation: Two bilingual translators whose mother tongue was Spanish, a nurse and an English philologist, first translated the scale into Spanish. This translation was carried out independently by both translators seeking a conceptual equivalence and considering both health-related technicalities and colloquial language.

Synthesis: The research team unified the two translators' versions and drafted a consensus request containing them. The two translators were asked to approve the unified version and the possible recommendations. The proposals were incorporated into the unified version and resent to the translators for their consensus.

Backward translation: The consensual synthesis version was retro-translated into English by two bilingual translators whose mother tongue was English, with the same linguistic and health baggage as the previous ones. The back-translators worked independently, blindly with respect to the original version of the scale and seeking the semantic equivalence of the concepts. After the retro-translations were finished, the original version of the NSPIC was provided to check if the translation had resulted in semantic or conceptual discrepancies between the original questionnaire and the unified version of the forward translation.

Consolidation: A multidisciplinary committee formed by a bilingual expert in research methodology, a bilingual expert in a nursing conceptual framework, the four translators, and the research team were set up. The objective of this committee was to compare the four translations, the unified version obtained from the forward translation, and to clarify ambiguities and discrepancies by consensus.

Piloting: The first Spanish version, the NSPIC-S 1, was distributed among a panel of 15 experts of similar characteristics to the study population, thus, complying with the recommendations. Regarding face validity, they valued the clarity of the instructions and items of the NSPIC-S 1, using a dichotomous scale (clear or not clear). If a non-clear item was considered, they were asked to draft a clearer paraphrased proposal. In addition, they were asked for their opinion in open comments to improve the understanding of the items.

For reliability testing, the students completed the questionnaire during their clinical practices. Participants were recruited by convenience and voluntarily agreed to be part of the study.

Data analysis

Regarding face validity, clarity was assessed by calculating the relative frequency of “clear” responses of the panel of experts during the piloting period for each item. Each element's clarity is considered when a match of at least 80% of the participants is obtained.[29] For content validity, the content validity index (CVI-I) was calculated for each item and scale (CVI-S). CVI-I higher than 0.78 and CVI-S higher than or equal to 0.9 were acceptable.[29] The internal consistency of the instrument was established by calculating the Cronbach's coefficient, both overall and for each dimension of the scale. Acceptable values higher than 0.7 were considered to ensure the internal consistency of the scale.[28]

   Results Top

The sociodemographic characteristics of the expert panel and those of the student sample are shown in [Table 1].
Table 1: Sociodemographic characteristics of the expert panel (n=15) and participants (n=120)

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The forward translations were unified, and the approval of both translators was obtained for 23 of the items. For 8 of them, proposals were made and incorporated into the unified version, and they were sent back to the translators for their consensus. Finally, the approval was obtained for the 31 items of the scale in the first Spanish version of the NSPIC. After the retro-translation, the translators identified semantic equivalence in all the items except in number 31, considering that it generated confusion. In the consolidation stage, committee members had the four translations and the original version and agreed on the ambiguities and discrepancies. As a single modification, it was proposed to shorten item 12, being reduced to Does not reveal any of his or her personal sides as it was considered redundant. As for the ambiguity generated around item 31, in view of the variety of opinions, it was agreed to maintain the direct translation of the unified version to continue with the adaptation process and to identify stronger criteria for discarding or admitting it. The first Spanish version of the scale was obtained, the NSPIC-S 1. The translation process is shown in [Figure 1].
Figure 1: Flowchart of the translation and cultural adaptation process

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The face validity results are shown in [Table 2]. All the items obtained a frequency higher than or equal to 80%, except in the case of items 6 and 25.
Table 2: Face validity and content validity

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The expert panel expressed proposals to improve clarity in the drafting of the items which were valued by the research team, and the following changes were made:

  • Added words to specify the scope of the item's meaning: clarifying meaning (items 3, 4, 7, and 15)
  • Examples of some situations (items 15, 22, 23, and 25)
  • Paraphrasing (items 6, 22, and 25)
  • Positive formulation (items 20 and 22)

The rest of the contributions were dismissed as they were considered synonyms for the original wording that did not add value, or because the suggested wording added nuances that did not fully reflect the original meaning.

The content validity results are shown in [Table 2]. All items obtained a CVI-I higher than 0.78, except in the case of items 12 and 16. The CVI-S gave a result of 0.9.

Regarding internal consistency, a general Cronbach α was obtained for the 0.942 scale, as shown in [Table 3]. That no item was discarded meant a significant improvement.
Table 3: Reliability. Cronbach á values for the NSPIC scale and subscales

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   Discussion Top

A Spanish culturally adapted version of the NSPIC, with face and content validity and internal consistency, was obtained. Although the NSPIC had been previously validated when it was designed, the validation process should be repeated when it is to be used in a different language and cultural environment to the designed one. Invalidated instruments limit data interpretation, and as they are not rigorous, they do not contribute to the building of scientific knowledge. The simple translation of a questionnaire is not enough; it can induce errors caused by cultural and meaning differences.[28] The transcultural adaptation seeks to obtain a tool equivalent to that elaborated in the country of origin, following a methodology that assures the conceptual and semantic equivalence with the original one.[29]

Both in the forward and the backward translation, the parallelism between the original and the final version of the scale was pursued, regarding semantic equivalence (in relation to the meaning of the words, vocabulary, and grammar), idiomatic equivalence (as for idioms and colloquial language requiring equivalent expressions), experiential equivalence (the situation it evokes makes sense in the cultural context), and the conceptual equivalence (regarding the explored concept).[29] This approach ensures that translations correspond to the original document.

In relation to face validity, items 6 and 25 did not obtain enough agreement on the clarity of their first translated version. After consulting the expert panel report and related published evidence, the research team decided to rephrase item 6 and provide some examples for item 25, in order to obtain semantic equivalence.

Item 6, Makes me feel like a failure, did not get an appraisal of enough clarity. This lack of clarity could be attributed to the negative emotional intensity of the concept of failure. Cordiality and kindness have been described by students as elements that influence their clinical learning. Affectionate, heartfelt, and friendly relationships with instructors help them fully benefit from clinical practices.[31] The emotional connection between the student and the mentor in the clinical environment is key to maintaining the continuity of the relationship. This phenomenon is characterized by integral attention to students, sensitivity to their concerns, and the provision of effective help to resolve their problems.[32] Showing positive attitudes and true compassion makes students feel comfortable and encourages them to get a better understanding of caring.[8] In the clinical student-mentor relationship, mutual respect and tolerance are required for fellowship, considering both opinions at the same level and respecting the knowledge of the other, since both are learning at the same time.[33] Therefore, in the emotionally effective, friendly, and respectful atmosphere in which the learning relationship between the mentor and the student is developed, the term “failure” is not considered appropriate, with its connotations so negative in the Spanish culture. In the Spanish culture, the translation of the word failure, is a very negative word, with such strong emotional intensity, that it could discourage students. As semantic and conceptual equivalence was desired, the research team agreed to replace it with “not suitable for nursing” which translation is closer to the original meaning.

The wording of item 25, Makes demands on my time that interfere with my basic personal needs, was not considered acceptable in relation to clarity. The clinical student-mentor relationship is sometimes based on power differences between both, so the mentor is considered the expert and the student adopts a subordinate role.[34] Mentors have a strong power over students, to the extent that students have expressed their feeling at their mercy.[35] Additionally, the cuts in health resources leave the staff with less time to devote to students and force them to prioritize the execution of tasks against the attention to learning.[34] There are mentors who have recognized the frustration that leads them to think that the time they spend on student learning might be useful in patient or family care.[36]

   Conclusion Top

In summary, the powerful role that the mentor has, coupled with the lack of learning prioritization and the overburden they suffer, can lead to situations in which the students perform tasks that do not provide them with any learning. These situations make students feel like hospital employees instead of apprentices, and that working is more important than their training.[37] For all this, in the drafting of item 25, it was considered essential to clarify with some examples of what kinds of activities could be asked to the students that interfere with their personal learning needs.

Regarding content validity, items 12, Does not reveal any of his or her personal sides, and 16, Serves as a trusted resource for personal problem solving, obtained an insufficient CVI-I. Both refer to a personal level approach between the mentor and the student. The lack of agreement on the relevance of these items could be explained from the interpretation of the mentor-student relationship as a process of learning and growth that develops in the exclusively professional field of both. In the mentor-student power relationship, mentors are aware of their position of superiority,[35] and this means a barrier that prevents the relationship from advancing in the personal field. In addition, demonstrations of practical skills of a procedural nature are valued on both sides,[38] something that inferred a more professional than personal character to the relationship. The authors suggested prior training to students on how to establish professional relationships with mentors to improve the quality of their learning experience.[39] Despite obtaining an insufficient CVI-I, the research team decided to keep these items and submit them to psychometric testing to identify more solid criteria of rejection or maintenance.

Regarding reliability, the version showed good internal consistency with a Cronbach α of 0.942. This result is similar to that of other studies in which NSPIC has been used as a measuring tool.[23],[24],[40] The lower scores for the control versus flexibility and the respectful sharing dimensions coincide with Meyer's findings, as well as the improvement of Cronbach α by deleting item 12.[40]

As limitations of the present study, the convenience of the sample is recognized, something that can affect the generalization of the results, the subjective nature of the construct that hinders the experts' judgment, and the ambiguity subjected to the translation process that can lead to different interpretations. Therefore, we suggest the development of more studies of methodological rigor that provide data on the psychometric behavior of the Spanish version of the scale.

The present study provides a Spanish culturally adapted translated version of the NSPIC. This tool allows assessing the care received by students from their mentors during their clinical practices. Knowing the type of caring that mentors transmit to their students allows us to shape an idea of the caring model they are acquiring and the role identity they are internalizing.

This perspective will help improve the teaching of the clinical mentors by developing caring behaviors that serve as a learning model. In addition, it will allow designing strategies to improve clinical practices in line with the students' experience and will result in greater use of the practices and better learning outcomes. The future results derived from the use of this tool will invite mentors to perform an exercise of self-evaluation and reflection for the development of their model role. This will help them become aware of the impact and scope of the relationship they establish with students, promoting improvement attitudes. The resulting S-NSPIC version shows good content validity and internal consistency. It is recommended to continue with a more extensive checking of the psychometric properties of the Spanish version of the tool.


We acknowledge Dr. Wade for giving us permission to use and translate the NSPIC into Spanish.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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