Cross-cultural adaptation and validation of the advanced practice nursing assessment instrument for the Portuguese context: A methodological study
-
Ivo Filipe Dias da Costa
,
Marlene Patrícia Ribeiro
,
Luísa Castro
,
Andreia Teixeira
,
Matilde Delmina Martins
Abstract
Background & Aim: Advanced Practice Nursing plays a crucial role in improving healthcare access, quality, and efficiency, being increasingly recognized in Portugal as a growing professional field. However, no validated instrument exists in Portugal to rigorously assess advanced practice nursing competencies. The Advanced Practice Nursing Competency Assessment Instrument, originally developed and validated in Spain, represents a robust tool for this purpose. This study aimed to cross-culturally adapt and validate the Advanced Practice Nursing Competency Assessment Instrument for the Portuguese context.
Methods & Materials: This methodological study was conducted in two phases. Cross-cultural adaptation followed established stages: two independent forward translations, synthesis, two back-translations, expert committee review, pre-test, and feedback to the original author. Psychometric evaluation used a cross-sectional sample of nurses from a local health unit in Northern Portugal. Analyses included descriptive statistics, exploratory factor analysis through principal component analysis, and internal consistency calculated by Cronbach’s alpha, item–total, and inter-item correlations.
Results: Expert consensus was achieved during the review process. The pre-test with a sample size of thirty-five nurses confirmed instrument clarity and usability. The validation sample included two hundred and sixty-four nurses and specialist nurses. Seven factors explained sixty-six percent of the total variance, representing a reduction from the original eight-factor structure. Two dimensions, Quality Management and Care Management, converged into a single factor in the Portuguese version. The scale demonstrated excellent reliability, with a total Cronbach’s alpha of 0.960, factor alphas ranging from 0.821 to 0.916, and adequate corrected item–total correlations.
Conclusion: The Portuguese version demonstrates adequate content validity, a coherent factor structure, and excellent reliability, supporting its use to assess advanced practice nursing competencies in the Portuguese health system.
1. International Council of Nurses. Guidelines on Advanced Practice Nursing 2020. Geneva: ICN; 2020.
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8. Woo BFY, Lee JXY, Tam WWS. The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review. Human Resources for Health. 2017;15:63. doi:10.1186/s12960-017-0237-9.
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11. Maier CB, Aiken LH. Task shifting from physicians to nurses in primary care in 39 countries: A cross-country comparative study. European Journal of Public Health. 2016;26(6):927-34. doi:10.1093/eurpub/ckw098
12. Tanabe S, Tanaka M, Arai Y, Matsuo K, Nakrem S, Gardulf A. Development and psychometric evaluation of the Japanese version of the Nurse Professional Competence Scale Short Form. Belitung Nursing Journal. 2025;11(2):252-60. doi:10.33546/bnj.3726
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17. Souza AC, Alexandre NMC, Guirardello EB. Psychometric properties in the evaluation of reliability and validity. Epidemiologia e Serviços de Saúde. 2017;26(3):649–659. doi:10.5123/S1679-49742017000300022.
18. Lynn MR. Determination and quantification of content validity. Nursing Research. 1986;35(6):382-85. doi:10.1097/00006199-198611000-00017.
19. Grant JS, Davis LL. Selection and use of content experts. Nursing Research. 1997;46(6):373–375. doi:10.1097/00006199-199711000-00015.
20. Ribeiro JL. Metodologia de investigação em psicologia e saúde. Porto: Legis Editora; 2010. ISBN: 9789898148469.
21. Marôco J. Análise estatística com o SPSS Statistics. Pêro Pinheiro: Report Number; 2014.
22. Streiner D, Norman R, Cairney J. Health measurement scales: A practical guide to their development and use. 5th ed. Oxford: Oxford University Press; 2014.
23. Clark LA, Watson D. Constructing validity: Basic issues in objective scale development. Psychological Assessment. 1995;7(3):309-19. doi:10.1037/1040-3590.7.3.309.
24. Cruchinho P, López-Franco MD, Capelas ML, Almeida S, Bennett PM, Miranda da Silva M, et al. Translation, cross-cultural adaptation, and validation of measurement instruments: a practical guideline for novice researchers. Journal of Multidisciplinary Healthcare. 2024;17:2701–2728. doi:10.2147/JMDH.S419714.
25. Machado RS, Fernandes ADBF, Oliveira ALCB, Soares LS, Gouveia MTO, Silva GRF. Métodos de adaptação transcultural de instrumentos na área da enfermagem. Revista Gaúcha de Enfermagem. 2018;39:e2017–0164. doi:10.1590/1983-1447.2018.2017-0164.
26. Lino CRM, Brüggemann OM, Souza ML, Barbosa SFF, Santos EKA. The cross-cultural adaptation of research instruments, conducted by nurses in Brazil: an integrative review. Texto e Contexto Enfermagem. 2017;26:17. doi:10.1590/0104-07072017001730017.
27. Dias FCP, Baitelo TC, Toso BRG de O, Sastre-Fullana P, Oliveira-Kumakura AR de S, Gasparino RC. Adaptation and validation of the Advanced Practice Nursing Competency Assessment Instrument. Revista Brasileira de Enfermagem. 2022;75(5):e20210582. doi:10.1590/0034-7167-2021-0582.
28. Ikedo F, Castro L, Fraguas S, Rego F, Nunes R. Cross-cultural adaptation and validation of the European Portuguese version of the Heartland Forgiveness Scale. Health and Quality of Life Outcomes. 2020;18(1):289. doi:10.1186/s12955-020-01531-9.
29. Ribeiro MP, Gasparino RC, Ribeiro OMPL. Cross-cultural adaptation and content validation of the Nurses’ Professionalism Inventory to the Portuguese context: A methodological study. Frontiers in Public Health. 2025;13:1473677. doi:10.3389/fpubh.2025.1473677.
30. Polit DF, Beck CT. Essentials of Nursing Research: Methods, Appraisal, and Utilization. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006.
31. Campbell CM, Taylor-Clark T, Loan LA. Protecting nurse survey participants: Ethical considerations for conducting survey research among nurses. Clinical Ethics. 2022;17(4):391-408. doi:10.1177/14777509211036639.
32. Story DA, Tait AR. Survey research. Anesthesiology. 2019;130(2):192–202. doi:10.1097/ALN.0000000000002436.
33. Jolliffe IT, Cadima J. Principal component analysis: A review and recent developments. Philosophical transactions of the royal society A: Mathematical, Physical and Engineering Sciences. 2016 Apr 13;374(2065):20150202. doi:10.1098/rsta. 2015.0202.
34. Matos DAS, Rodrigues EC. Análise Fatorial. Brasília (DF): ENAP; 2019. (Coleção Metodologias de Pesquisa.) ISBN: 978-85-256-0118-6.
35. dos Enfermeiros O. Regulamento n. 429/2018: Regulamento de competências específicas do enfermeiro especialista em enfermagem médico-cirúrgica na área de enfermagem à pessoa em situação crítica. Diário da República. 2018;2:135-6.
36. Altafini J, Dias FCP, Ferreira TDM, Sastre-Fullana P, São-João TM, Gasparino RC. Validation of the Advanced Practice Nursing Competency Assessment Instrument in a hospital environment. Revista Brasileira de Enfermagem. 2023;76:e20220705. doi:10.1590/0034-7167-2022-0705.
37. Dias FCP, Ferreira TDM, Vergílio MSTG, Sastre-Fullana P, São-João TM, Gasparino RC. Avaliação de competências do enfermeiro de prática avançada: Validação de um instrumento para atenção primária. Revista Latino-Americana de Enfermagem. 2025;33:e4450. doi:10.1590/1518-8345.6958.4450.
38. Ghanei Gheshlagh R, Pour Mohammadi N, Dehvan F, Sharif-Nia H. Psychometric evaluation of the Persian version of the stressor scale for emergency nurses. Nursing Practice Today. 2025;12(3):275-84.
https://doi.org/10.18502/npt.v12i3.18976
2. Hamric AB, Tracy MF. A definition of Advanced Practice Nursing. In: Tracy MF, O’Grady ET, eds. Advanced Practice Nursing: An Integrative Approach. 6th ed. St. Louis: Elsevier; 2019.
3. Delamaire ML, Lafortune G. Nurses in advanced roles: A description and evaluation of experiences in 12 developed countries. OECD Health Working Papers. No. 54. 2010. doi:10.1787/5kmbrcfms5g7-en.
4. Nunes P, Almeida A, Tavares M, Gomes L. Prática avançada de enfermagem em Portugal – em que ponto estamos? Revista de Investigação & Inovação em Saúde. 2024;10(2):338-55.
5. Organização Mundial da Saúde. Orientações da OMS para o desenvolvimento, atração, recrutamento e retenção da força de trabalho da saúde em zonas rurais e remotas. Genebra: OMS; 2021.
6. Ordem dos Enfermeiros. Regulamento das Competências Comuns do Enfermeiro Especialista. Diário da República. 2019;2. Série (26):4744–4750.
7. Lowe G, Plummer V, O’Brien AP, Boyd L. Time to clarify – the value of advanced practice nursing roles in health care. Journal of Advanced Nursing. 2018;74(2):357-64. doi:10.1111/jan.13465.
8. Woo BFY, Lee JXY, Tam WWS. The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review. Human Resources for Health. 2017;15:63. doi:10.1186/s12960-017-0237-9.
9. Kilpatrick K, Geese F, Zhou W, Bryant-Lukosius D. Advanced Practice Nurses and Engagement in Research, Quality Improvement, and Evidence-Informed Decision-Making. In: Rogers M, Lehwaldt D, Roussel J, Acorn M, eds. Advanced Practice Nurse Networking to Enhance Global Health. Cham: Springer; 2024. doi:10.1007/978-3-031-39740-0_8.
10. Sastre-Fullana P, Morales-Asencio JM, Sesé-Abad A, Bennasar-Veny M, Fernández-Domínguez JC, De Pedro-Gómez J. Advanced Practice Nursing Competency Assessment Instrument (APNCAI): clinimetric validation. BMJ Open. 2017;7(2):e013659. doi:10.1136/bmjopen-2016-013659.
11. Maier CB, Aiken LH. Task shifting from physicians to nurses in primary care in 39 countries: A cross-country comparative study. European Journal of Public Health. 2016;26(6):927-34. doi:10.1093/eurpub/ckw098
12. Tanabe S, Tanaka M, Arai Y, Matsuo K, Nakrem S, Gardulf A. Development and psychometric evaluation of the Japanese version of the Nurse Professional Competence Scale Short Form. Belitung Nursing Journal. 2025;11(2):252-60. doi:10.33546/bnj.3726
13. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An international Delphi study. Quality of Life Research. 2010;19(4):539–549. doi:10.1007/s11136-010-9606-8.
14. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186–3191. doi:10.1097/00007632-200012150-00014.
15. Oliveira F, Kuznier TP, Souza CC, Chianca TCM. Theoretical and methodological aspects for the cultural adaptation and validation of instruments in nursing. Texto Contexto Enferm. 2018;27:e4900016. doi:10.1590/0104-070720180004900016.
16. Alexandre NMC, Coluci MZO. Validade de conteúdo nos processos de construção e adaptação de instrumentos de medida. Ciênc. Saúde Coletiva. 2011;16(7):3061–3068. doi:10.1590/S1413-81232011000800006.
17. Souza AC, Alexandre NMC, Guirardello EB. Psychometric properties in the evaluation of reliability and validity. Epidemiologia e Serviços de Saúde. 2017;26(3):649–659. doi:10.5123/S1679-49742017000300022.
18. Lynn MR. Determination and quantification of content validity. Nursing Research. 1986;35(6):382-85. doi:10.1097/00006199-198611000-00017.
19. Grant JS, Davis LL. Selection and use of content experts. Nursing Research. 1997;46(6):373–375. doi:10.1097/00006199-199711000-00015.
20. Ribeiro JL. Metodologia de investigação em psicologia e saúde. Porto: Legis Editora; 2010. ISBN: 9789898148469.
21. Marôco J. Análise estatística com o SPSS Statistics. Pêro Pinheiro: Report Number; 2014.
22. Streiner D, Norman R, Cairney J. Health measurement scales: A practical guide to their development and use. 5th ed. Oxford: Oxford University Press; 2014.
23. Clark LA, Watson D. Constructing validity: Basic issues in objective scale development. Psychological Assessment. 1995;7(3):309-19. doi:10.1037/1040-3590.7.3.309.
24. Cruchinho P, López-Franco MD, Capelas ML, Almeida S, Bennett PM, Miranda da Silva M, et al. Translation, cross-cultural adaptation, and validation of measurement instruments: a practical guideline for novice researchers. Journal of Multidisciplinary Healthcare. 2024;17:2701–2728. doi:10.2147/JMDH.S419714.
25. Machado RS, Fernandes ADBF, Oliveira ALCB, Soares LS, Gouveia MTO, Silva GRF. Métodos de adaptação transcultural de instrumentos na área da enfermagem. Revista Gaúcha de Enfermagem. 2018;39:e2017–0164. doi:10.1590/1983-1447.2018.2017-0164.
26. Lino CRM, Brüggemann OM, Souza ML, Barbosa SFF, Santos EKA. The cross-cultural adaptation of research instruments, conducted by nurses in Brazil: an integrative review. Texto e Contexto Enfermagem. 2017;26:17. doi:10.1590/0104-07072017001730017.
27. Dias FCP, Baitelo TC, Toso BRG de O, Sastre-Fullana P, Oliveira-Kumakura AR de S, Gasparino RC. Adaptation and validation of the Advanced Practice Nursing Competency Assessment Instrument. Revista Brasileira de Enfermagem. 2022;75(5):e20210582. doi:10.1590/0034-7167-2021-0582.
28. Ikedo F, Castro L, Fraguas S, Rego F, Nunes R. Cross-cultural adaptation and validation of the European Portuguese version of the Heartland Forgiveness Scale. Health and Quality of Life Outcomes. 2020;18(1):289. doi:10.1186/s12955-020-01531-9.
29. Ribeiro MP, Gasparino RC, Ribeiro OMPL. Cross-cultural adaptation and content validation of the Nurses’ Professionalism Inventory to the Portuguese context: A methodological study. Frontiers in Public Health. 2025;13:1473677. doi:10.3389/fpubh.2025.1473677.
30. Polit DF, Beck CT. Essentials of Nursing Research: Methods, Appraisal, and Utilization. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006.
31. Campbell CM, Taylor-Clark T, Loan LA. Protecting nurse survey participants: Ethical considerations for conducting survey research among nurses. Clinical Ethics. 2022;17(4):391-408. doi:10.1177/14777509211036639.
32. Story DA, Tait AR. Survey research. Anesthesiology. 2019;130(2):192–202. doi:10.1097/ALN.0000000000002436.
33. Jolliffe IT, Cadima J. Principal component analysis: A review and recent developments. Philosophical transactions of the royal society A: Mathematical, Physical and Engineering Sciences. 2016 Apr 13;374(2065):20150202. doi:10.1098/rsta. 2015.0202.
34. Matos DAS, Rodrigues EC. Análise Fatorial. Brasília (DF): ENAP; 2019. (Coleção Metodologias de Pesquisa.) ISBN: 978-85-256-0118-6.
35. dos Enfermeiros O. Regulamento n. 429/2018: Regulamento de competências específicas do enfermeiro especialista em enfermagem médico-cirúrgica na área de enfermagem à pessoa em situação crítica. Diário da República. 2018;2:135-6.
36. Altafini J, Dias FCP, Ferreira TDM, Sastre-Fullana P, São-João TM, Gasparino RC. Validation of the Advanced Practice Nursing Competency Assessment Instrument in a hospital environment. Revista Brasileira de Enfermagem. 2023;76:e20220705. doi:10.1590/0034-7167-2022-0705.
37. Dias FCP, Ferreira TDM, Vergílio MSTG, Sastre-Fullana P, São-João TM, Gasparino RC. Avaliação de competências do enfermeiro de prática avançada: Validação de um instrumento para atenção primária. Revista Latino-Americana de Enfermagem. 2025;33:e4450. doi:10.1590/1518-8345.6958.4450.
38. Ghanei Gheshlagh R, Pour Mohammadi N, Dehvan F, Sharif-Nia H. Psychometric evaluation of the Persian version of the stressor scale for emergency nurses. Nursing Practice Today. 2025;12(3):275-84.
https://doi.org/10.18502/npt.v12i3.18976
| Issue | Articles in Press | |
| Section | Original Article(s) | |
| Keywords | ||
| nursing advanced practice nursing clinical competence competency assessment psychometrics | ||
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How to Cite
1.
da Costa I, Ribeiro M, Castro L, Teixeira A, Martins M. Cross-cultural adaptation and validation of the advanced practice nursing assessment instrument for the Portuguese context: A methodological study. Nurs. pract. today. 2026;:X-X.
