International Journal of
Environmental Research
and Public Health
Article
Translation, Adaptation, and Validation of the Self-Efficacy
Scale for Clinical Nurse Leaders for the Portuguese Culture
Marlene Carvalho 1,2, *, Filomena Gaspar 1 , Teresa Potra 1 and Pedro Lucas 1
1
2
*
Citation: Carvalho, M.; Gaspar, F.;
Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon,
1600-190 Lisbon, Portugal; mfgaspar@esel.pt (F.G.); tsantos@esel.pt (T.P.); prlucas@esel.pt (P.L.)
Central Lisbon Hospital and University Centre, 1150-199 Lisbon, Portugal
Correspondence: ortiga_m@hotmail.com
Abstract: Studies related to the competencies of clinical nurse leaders as an advanced practice demonstrate that they are an asset to health organizations. However, it is pertinent to use an instrument to
measure the self-efficacy of clinical nurse leaders in Portugal to facilitate managers’ decision-making.
In this study, we aimed to translate, adapt, and validate the Clinical Nurse Leader Self-Efficacy
Scale for the Portuguese cultural context. This is a quantitative, observational, and descriptive
cross-sectional study. The sample of this study was non-probabilistic and intentional, consisting of
329 nurses responsible for shift and specialist nurses. The translation and validation process followed
the internationally recognized guidelines on the psychometric properties of measurement instruments. The factor analysis explained 62.1% of the variance and had a seven-dimensional structure.
The seven factors were: Patient-Centred Care; Unit Management; Clinical Leadership; Strategic
Leadership; Team Management; Cost Reduction; and Care Planning. The confirmatory analysis
showed that the seven-factor model achieved a suitable adjustment in the Portuguese context. The
self-efficacy scale for clinical nurse leaders can be considered a valid and reliable instrument for
application in Portugal in any care context. This scale allows the assessment of the nurse’s perception
of their ability to intervene effectively as a clinical leader in their care team.
Potra, T.; Lucas, P. Translation,
Adaptation, and Validation of the
Self-Efficacy Scale for Clinical Nurse
Keywords: health services administration; leadership; management; nurses; psychometric properties;
validation studies
Leaders for the Portuguese Culture.
Int. J. Environ. Res. Public Health 2022,
19, 8590. https://doi.org/10.3390/
ijerph19148590
1. Introduction
Academic Editor: Hideya Kodama
Policymakers increasingly recognize the need to align the size, composition, skills,
and performance of health sector workforces with the increase and diversification of
population needs [1]. At the International Workforce Forum in 2019, the reality of the
current state of the global nursing workforce was confirmed, warning that actions are
needed to promote positive and supportive work environments, including fair funding,
safe teams, and professional development [2].
For professional nursing development, it is essential to develop an advanced practice
that promotes the quality of nursing care. An advanced nursing practice involves the
acquisition of advanced clinical knowledge and skills of greater depth, the complexity of
critical thinking, and more autonomous roles to respond to the care needs of individuals,
families, groups, and communities. Nurses with advanced practice skills are well positioned
to promote evidence-based care practices and exercise effective clinical leadership in both
the micro- and the mesosystem [3].
These nurses should develop skills of evaluation, diagnosis, planning, implementation, and evaluation of the necessary care [1,4], in which care should be focused on
the nurse–client relationship to achieve positive results, as well as problem-solving and
decision-making.
Thus, the leadership of the teams is decisive. The concept of leadership speaks to a
multidisciplinary approach to quality patient care, which is conducted by experienced,
Received: 31 May 2022
Accepted: 8 July 2022
Published: 14 July 2022
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Int. J. Environ. Res. Public Health 2022, 19, 8590. https://doi.org/10.3390/ijerph19148590
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Int. J. Environ. Res. Public Health 2022, 19, 8590
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autonomous, competent, and responsible professionals [4]. Therefore, without the appropriate skills and knowledge, it becomes difficult for nursing leaders to maintain a favourable
work environment that promotes quality of care [5]. Here, the intervention of nurse managers is fundamental. A managing nurse is a driver of change towards excellence, through
organizing existing resources and creating a safe environment for quality care [5].
Leading nurses influence nursing practice environments and the quality of nursing
care [5,6] with their practice and intervention. Nursing practice environments are changeable; that is, the action of the nurse manager is decisive in making them favourable [7]. The
nurse, as a leader, is essential to improving communication between teams to achieve goals
and increase the quality of nursing care, promote care safety, and develop innovation in
practice [5].
Clinical nurse leaders are responsible for their own identity and professional practice,
and have essential and crucial characteristics and skills for their role. Within the scope of
their autonomy and initiative, they design and implement care, and are responsible for
improving nursing outcomes, quality, and the cost-benefit ratio [3]. Clinical nurse leaders’
competencies include compassion, intelligence, and confidence [8–11]. Intelligence and the
ability to work with others under stress are necessary characteristics, as their workload can
be adjusted at any given moment, as they are a change agent and care coordinator [12]. The
measures implemented by the clinical nurse leader must be agreed on by the other team
members [12]. The clinical nurse leader should be an element of advanced practice and be
motivated to perform their functions [12].
In the literature review we conducted, Carvalho and Lucas (2020) [3] demonstrated
that clinical nurse leaders work at the level of services and units and are responsible for
coordination between disciplines and the management of clinical results, with a special
focus on health promotion and disease prevention in patients and the implementation
of programs for quality improvement and clinical risk management [3,13]. They have a
vision for the role and measurement of the impact of care, as well as critical thinking and
skills for reviewing client outcomes and teaching/managing change and evidence-based
practices [3,12]. Thus, they boost quality and are active [3,8–11,14].
Therefore, the leading clinical nurse:
•
•
•
•
•
•
Integrates the management of the units, promoting a calm and structured care environment through the coordination of the team and strategies for change [8–11,15];
Is an information manager who uses the research results and promotes the fluidity of
communication in clinical practice [3];
Is a team leader, information manager, and systems analyst and anticipates clinical
risks, alongside being a provider of excellence in all care delivery contexts [3,8–11,16];
Advocates for the integration of different disciplines in the provision of care, improves
safety, and demonstrates critical thinking, communication, and strong assessment
skills [17];
Knows information systems and standardized languages to improve clinical outcomes,
participates in monitoring of the performance of their team, and supports evidencebased decision-making and practice [10,11];
Actively intervenes in improving the quality of care provided to patients, based on
evidence-based practice and critical thinking [10,11].
The clinical nurse leader practices transformational leadership, an exemplary professional practice, and implementation of new knowledge [18,19]. Thus, the evidence also
reports capacity for clinical leadership, team leadership, information management, and
resource management, and adds the defense not only of patients but of communities and
health programs, presenting a potential for practice in new environments [14,18,19].
In short, it is an advanced practice nurse who develops the critical thinking and
evaluation skills essential to promoting evidence-based practice. Subsequently, they use
evidence to support decision-making in relation to practice, as well as to influence team
and organizational practices [11,13]. Thus, the core practice competencies of clinical nurse
leaders can be organized into three domains: (a) nursing leadership in care management
Int. J. Environ. Res. Public Health 2022, 19, 8590
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and coordination; (b) clinical outcome management to promote evidence-based practice
and decision-making; and (c) efficient management to promote quality of nursing care and
client safety [20,21].
Gilmartin states that self-confidence is a significant predictor of successful career
transitions [21]. The confidence of co-workers and managers in clinical nurse leaders
becomes crucial to their ability to perform their roles effectively, notably in promoting
overall team performance, job satisfaction, and retention of nurses [18]. Clinical nurse
leaders with more developed self-efficacy have improved performances [3,21].
Therefore, self-efficacy is important to successful role transition, job satisfaction, and
performance [3]. The Self-Efficacy Assessment Scale of Clinical Nurse Leaders by Gilmartin
and Nokes assesses nurses’ perception of their ability to intervene effectively in the performance of their clinical leadership functions [3,20]. Assessing the self-efficacy of leading
clinical nurses throughout their practice is fundamental for the provision of care and the
management of health units and organizations, as they improve the performance of these
professionals, increasing the quality and safety of nursing care and health gains [3].
Function transitions imply two interdependent adjustment processes: personal development and role development [21]. This transition process is increasingly complex due
to the increased demands on the practices of clinical nurse leaders. Hiring clinical nurse
leaders is an effective approach towards ensuring excellent nursing care, maximizing research, and influencing the ways other health professions provide care in the microsystem.
This transition is an ongoing process in which age, academic degree, and professional
experience can be catalysts for change and wisdom [18–21].
Currently, greater emphasis is placed on evidence-based practice to support clinical decision-making. This decision is supported by the best evidence, based on nurses’
experience, client values, and quality care needs, as well as care costs [22].
Likewise, the role developed by the clinical nurse leader focuses on the management
of patient-centred care and clinical excellence [21]. Thus, it is pertinent to evaluate the
effectiveness of the clinical nurse leader in their care team. Given the lack of a validated
scale for the Portuguese population, this study performed the cultural and linguistic
adaptation of the Self-Efficacy Scale for Clinical Nurse Leaders after authorization from
the original author. This is the first psychometric validation study of this scale outside the
United States of America.
In this study, we aimed to translate, adapt, and psychometrically validate the SelfEfficacy Scale for Clinical Nurse Leaders for the Portuguese cultural context (SESCNL-PT),
starting from the guiding research question: to what extent does the SESCNL-PT have
psychometric qualities suitable for the Portuguese cultural context?
2. Materials and Methods
2.1. Study Design
This is a quantitative, observational, and descriptive cross-sectional study of the
translation and adaptation of the SESCNL scale to the Portuguese cultural context, and its
psychometric validation.
Gilmartin and Nokes’ (2015) original scale [20] assessed nurses’ perceptions of their
abilities to function effectively as a clinical nurse leader, and it demonstrated promising
measurement properties. The discriminant validity was assessed by examining intercorrelations among the indices. The inter-correlations among the indices range between
0.72 and 0.46. The reliability of the scale was examined, assessing the internal consistency
of CNLSES by Cronbach’s alpha scores between 0.83 and 0.98.
2.2. Methods
The development of the linguistic and conceptual equivalence of the SESCNL-PT
followed the methodological guidelines of several authors [22–27], namely Beaton et al.
(2000) and Sousa and Rojjanasrirat (2011) [25,26]. The translation of the original English
version into Portuguese was prepared independently by two Portuguese and bilingual
Int. J. Environ. Res. Public Health 2022, 19, 8590
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translators. One bilingual, fluent in Portuguese and English, with knowledge in the nursing
area and another translator with no knowledge in the health area. The analysis of the
discrepancies between the two versions resulted in a consensual translation version in the
target language, which was subjected to retroversion by two translators of English origin.
After analysis of the two versions, the instrument was adjusted to obtain the semantic,
idiomatic, and conceptual equivalence of the items. The conceptual equivalence focuses on
determining whether people from two different cultures of the original and translated scale
identify the concept/variable from the same perspective, so that the concept is assessed
as the same [22]. Semantic equivalence focuses on the meaning of each item; whether the
meaning of the words/phrases in the translation remains the same and is intelligible to
the respondents [22]. In the next stage, the analysis was submitted to a group of experts
(nurses responsible for the shift and with clinical specialty) with characteristics similar to
those of the population under study and, finally, in the third phase, the study proceeded to
psychometric validation of the instrument.
A group of 22 clinical nurse leaders from a hospital in the Lisbon region received the
reliability evaluation, or test–retest, at two separate times, about two weeks apart, in March
2018. The analysis evaluated the clarity and degree of understanding of the questions, as
well as the cultural relevance. The questionnaire was delivered along with an envelope to
be returned closed and anonymized.
The translated questionnaire was evaluated by eight clinical nurse leaders working in
hospitals with extensive clinical experience, fluent in English and Portuguese, with work
experience in the Portuguese health system for at least the last five years, and familiarity
with research processes. They were asked to assess whether the version was easy to
understand, whether it was adapted to the Portuguese context, and whether it could be
used in Portugal.
The analysis of the scale items allowed us to verify the absence of missing data and
confirmed all questions were answered. Pearson’s correlation coefficient was 0.77 both
times. Studies have determined that values below 0.70 are considered satisfactory [27,28],
verifying a reasonable consistency [24].
2.2.1. Data Collection and Procedures
The data collection was conducted in a hospital centre in the Lisbon region between
September and December 2018, and the treatment took place in 2019, after authorization
from the Board of Directors and the Ethics Committee.
The data collection instrument was presented with information about its purpose
and instructions on the cover page. The questionnaire was composed of three parts:
Part A—general characterization, sociodemographic and professional characterization;
Part B—clinical leadership, with the translated version consisting of 56 items evaluating
the effectiveness of the clinical nurse leader, each item rated on a five-point Likert-type
confidence scale; and Part C—suggestions.
2.2.2. Sample
The sample of this study was non-probabilistic and intentional [24]. The inclusion
criteria for the selection of the sample were: nurses who had been shift managers over
their professional careers, with three fundamental functions/responsibilities: planning,
coordination, and evaluation of nursing activities; nurses with a postgraduate degree in an
area of specialization, performing in specialist positions for more than six months; shift
managers and/or postgraduate degree nurses in an area of specialization able to perform
tasks in a hospital context, over more than six months; shift managers and/or postgraduate
degree nurses in an area of specialization who agreed to participate in the study; inpatient
units in which the managing nurses were allowed to participate in the study; in a hospital
in the Lisbon region with a highly scientific, technical, and technological differentiation,
and one considered a Portuguese reference institution.
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We gave out 612 questionnaires and received a response from 329 nurses for this
validation study. This sample size is in line with the authors’ suggestions for validation
studies [28].
2.3. Analysis
IBM® SPSS® Software and AMOS Software version 25 (IBM Corp, Armonk, NY, USA)
were used to analyze the data to evaluate the psychometric qualities of SESCNL. The
criterion validity established the comparison between the proposed measure and another
measure that served as a criterion, and it assessed the sensitivity for the same [27].
Factor analysis evaluated the construct validity through analysis of the main components.
The study extracted the main components using the Varimax rotation method when
performing the exploratory factor analysis. In the investigation of data adequacy of the
exploratory factor analysis, the study used the Kaiser-Meyer-Olkin test of sampling adequacy measurement (KMO) method and Bartlett’s sphericity test, whose value should be
greater than 0.5 [24,28]. The analysis always used the cut-off point of 0.4; that is, variables
that assumed correlation values equal to or greater than 0.4 were part of the dimension [24].
The research analyzed the total explained variance of each dimension.
The reliability and internal consistency of the dimensions and the instrument were
estimated from Cronbach’s alpha internal consistency measure in the seven dimensions,
considering an acceptable reliability if α ≥ 0.70 [27].
The study evaluated the overall adequacy of the model in the confirmatory factor
analysis (CFA), using as indices of the quality of the adjustment of the SESCNL model:
Chi-square adjustment test statistics (DHL 2 /df), CFI, GFI, RMSEA, and MECVI. Important
considerations before starting CFA were the guarantee of multivariate normality: no variable presented values of Sk and Ku indicators of severe violation of the normal distribution
(|Sk| < 3 and |Ku| < 10), and at least two factors had at least two indicators per factor
and the presence of outliers: the Mahalanobis square distance (D2) [28].
2.4. Ethical Considerations
The investigation process respected ethical and legal principles and was approved
by the Board of Directors and Ethics Committee with the number 588/2018. The free
and informed consent of the participants in the study was guaranteed, according to Gray,
Grove and Sutherland [22]. The study ensured the confidentiality and anonymity of the
participants. The data were stored and treated anonymously and confidentially.
The translation and adaptation of the scale for the Portuguese cultural context had the
authorization of the author of the original scale, which can be found in Supplementary Materials.
3. Results
A total of 612 questionnaires were submitted, and the sample consisted of 329 nurses,
corresponding to a response rate of 53.8%.
Of the sample, 80.9% of the participants were female. For academic qualifications,
predominant was a degree, at 75.4%.
Regarding age group, the majority were between 34 and 39 years (23%) or between
44 and 49 years (20%). The mean age was 41.5 years old; the sample was predominantly
young/adult. The minimum age was 24 years, and the maximum was 61 years.
This sample represented participants without the title of specialist nurse (51.7%). Of
those holding a specialist nurse title (48.3%), the most typical specialties were Rehabilitation
(15.5%), Child and Paediatric Health (13.7%), and Maternal Health and Obstetric (8.5%).
For professional activity experience, most had been in the profession for 11–16 years (85%),
closely followed by those in the profession for 21–26 years (79%). The maximum time was
30 years, and the average was 11 years. Within the scope of professional activity in the
institution, the research confirmed a uniform distribution, especially for the period of 7 to
12 years (26.1%) and 22 to 27 years (20.4%).
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3.1. Exploratory Factor Analysis
At the end of the analysis, the study eliminated the items 5, 11, 19, 23, 24, 29, 30, 33,
and 54 due to their presenting factor weights below 0.40 [24].
The final questionnaire consisted of 47 items in 7 final components: patient-centred
care (11 items), unit management (10 items), clinical leadership (8 items), strategic leadership (5 items), team management (7 items), cost reduction (4 items), and care planning
(2 items).
After analyzing the factorial loads by components, determining the KMO and Bartlett’s
sphericity test, the study verified that the KMO presented a value of 0.94, p-value < 0.001,
which indicated an excellent correlation [24] between the SESCNL-PT variables. Bartlett’s
sphericity test demonstrated a p-value < 0.001 with a significance of less than 0.05, demonstrating that the variables were significantly correlated, and this sample was suitable for
analysis. Table 1 shows that the study obtained results with a 7-factor matrix, which
explains 62.1% of the variance of the phenomenon under study, with an eigenvalue of 1.246.
Table 1. SESCNL-PT components.
COMPONENTS
ITEMS
Patient-Centred
Care
1
0.63
2
0.61
6
0.60
7
0.66
8
0.73
9
0.66
10
0.64
12
0.57
13
0.54
14
0.42
15
0.57
Unit
Management
32
0.42
34
0.55
35
0.45
44
0.48
45
0.64
46
0.74
47
0.68
48
0.76
49
0.80
50
0.78
Clinical
Leadership
36
0.70
37
0.66
38
0.69
Strategic
Leadership
Team
Management
Cost
Reduction
Care
Planning
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Table 1. Cont.
COMPONENTS
ITEMS
Patient-Centred
Care
Unit
Management
Clinical
Leadership
39
0.70
40
0.68
41
0.65
42
0.50
43
0.44
Strategic
Leadership
51
0.71
52
0.59
53
0.74
55
0.62
56
0.62
Team
Management
16
0.50
17
0.52
18
0.54
20
0.53
21
0.56
22
0.55
25
0.43
Cost
Reduction
26
0.82
27
0.84
28
0.59
31
0.43
3
0.77
4
Cronbach’s alpha
Care
Planning
0.74
0.90
0.89
0.91
0.86
0.88
0.84
0.82
The components of the scale were as follows:
Component 1: Patient-Centred Care—refers to patient-centred care practices based on
scientific evidence, using information systems. This dimension also explores the unit and
its performance, given the quality of care and patient safety. It includes items 1, 2, 6, 7, 8, 9,
10, 12, 13, 14, and 15.
Component 2: Unit Management—reports to clinical supervision, where it aims to
promote autonomous decision-making, valuing client protection, safety, and quality of care
in the integration of nurses, and the guidance of nurses in training in clinical education.
This dimension also includes information about the importance of continuous practice and
the availability of a team/service/organization for its completion. It includes items 32, 34,
35, 44, 45, 46, 47, 48, 49, and 50.
Component 3: Clinical Leadership—related to organizational leadership since it refers
to a set of actions, such as assertive choice of strategies, organization of activities, motivation of employees, maintenance of interpersonal relationships, development of skills and
competencies, and crisis management. It includes items 36, 37, 38, 39, 40, 41, 42, and 43.
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Component 4: Strategic Leadership—part of the alignment between the organization’s
strategic objectives, culture, perception of organization gaps, competencies, and leadership
systems. These factors must be fully aligned for maximum effectiveness in the outcome of
care. It includes items 51, 52, 53, 55, and 56.
Component 5: Team Management—the ability to perform good team management is
fundamental to success. A team manager nurse should be able to lead, motivate, inspire,
support, and believe in the potential of their team, and be seen as an inspiring element that
represents the values of the organization and is committed to achieving the best results for
patient care. It includes items 16, 17, 18, 20, 21, 22, and 25.
Component 6: Cost Reduction—related to the improvement of the organization of
nursing care methods. Thus, weaknesses and unnecessary waste are detected that can be
reduced or eliminated, creating opportunities for cost reduction. It includes items 26, 27,
28, and 31.
Component 7: Care Planning—involves the responsibility for the well-being of the
client, identifying the needs, and involving the client in the elaboration/endorsement of
the care plan, with the client as the central focus of care. It includes items 3 and 4.
3.2. Reliability Analysis
The reliability of the Self-Efficacy Scale for Clinical Nurse Leaders for the Portuguese
cultural context was α = 0.96, which is an excellent value [24]. The dimension of Clinic
Leadership had very good consistency (α = 0.91), and the other dimensions of PatientCentred Care (α = 0.90), Unit Management (α = 0.89), Strategic Leadership (α = 0.86), Team
Management (α = 0.88), Cost Reduction (α = 0.84), and Care Planning (α = 0.82) were
considered good [24].
3.3. Confirmatory Factor Analysis
The septa-factorial model of SESCNL-PT for the Portuguese population revealed an
adjustment quality with the need to correct trajectories in the model between the residues
of the item pairs e42–e43, (“Cost Reduction”), e37–e39, e36–e37, e40–e41 (“Team Management”), e30–e31 (“Strategic Leadership”), e27–e28, e24–e25, e22–e23 (“Clinical Leadership”),
e19–e20, e17–e18, e13–e14 (“Unit Management”), and e10–e11, e6–e7, e3–e5 (“PatientCentred Care”). Thus, a good adjustment quality (1995.475/999 = 1.997) was obtained with
RMSEA = 0.055; P [rmsea ≤ 0.05] < 0.001; MECVI = 7.005) for Standardized RMR values:
0.0723. Although the model was better adjusted, new covariances were performed between
e3–e4 (“Patient-Centred Care”). Thus, the research obtained a good adjustment quality
(with equal value 1973.461/998 = 1.997 and improved quality adjustment (GFI = 0.800) and
Good for CFI = 0.899. The substantial value of RMSEA = 0.055; P [rmsea ≤ 0.05] < 0.001;
MECVI = 6.945) was maintained for Standardized RMR values: 0.0721.
In Figure 1, the septa-factorial model of SESCNL-PT, adjusted to a sample of 329 clinical
nurse leaders, presented a good adjustment quality (1919,451/994) = 1931, p < 0.05) as well
as MECVI parsimony indices (8980), P [rmsea ≤ 0.05] < 0.001 for standardized RMR values:
0.0709. An adjustment of GFI = 0.805 and CFI = 0.904 was obtained.
Int.
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Figure1.1.Septa-factorial
Septa-factorialmodel
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ofSESCNL-PT
SESCNL-PTfor
forthe
thePortuguese
Portuguesepopulation.
population.
Figure
4.4.Discussion
Discussion
In
we carried
carriedout
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translation
and
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for Porthe
In this
this study, we
and
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Int. J. Environ. Res. Public Health 2022, 19, 8590
10 of 12
There were similarities between this study and that of Gilmartin and Nokes (2015)
concerning the dimensions.
The septa-factorial model of SESCNL-PT in the Portuguese cultural context presented
a good adjustment quality, which was significantly higher than that of the original model
(1919.451/994) = 1931, p < 0.05 vs. 2675.916/1013 = 2.642), as well as considerably lower
parsimony indices MECVI (6.809 vs. 8.980), P [rmsea≤ 0.05] < 0.001 for Standardized RMR
values: 0.0709 vs. 0.0723. A significantly improved quality adjustment was obtained with
GFI = 0.805 and CFI = 0.904.
Thus, the seven-factor model was the most stable and significantly represented the
study sample in Portugal. All coefficients were meaningful, and the model adjustment
coefficients were good, supporting the septa-factorial structure for SESCNL-PT.
Limitations
A limitation of the study was that the questionnaire was applied to a hospital centre,
although it was referenced at a national level. It would be helpful to use this scale at the
national level in different contexts of nursing practice: in the hospital context, primary
healthcare, long-term care, and nursing homes.
Another limitation of the study was the delay in publishing these results, which
was due to the research project being associated with a master’s dissertation. We believe
that this delay had no influence on the results or the importance of the psychometric
validation study.
5. Conclusions
The results of the adaptation and validation indicated that SESCNL-PT can be used in
the Portuguese cultural context because it systematically followed all methodological steps
and achieved satisfactory results regarding its reliability and validity.
The Portuguese version presents adequate sensitivity, reliability, and factor validity,
and it can be considered an instrument for the management of patient-centred care and
clinical excellence.
The adjustment of the factorial model allows us to propose a version of the scale in
Portuguese—the Self-Efficacy Scale for Clinical Nurse Leaders (Escala de Autoeficácia
para Enfermeiros Líderes Clínicos–versão portuguesa)—and facilitate an adjustment of the
performance of these professionals. Although advanced practice nurses were confident
that they positively influence their peers’ practice, there is a lack of evidence that demonstrates their impact. This scale allows for the evaluation of the perception of nurses in the
performance of the skills associated with their role, thereby closing this gap.
As implications for the context of practice, this study offers nurse managers a tool that,
when applied to practice nurses, provides results that indicate the effectiveness of their
clinical leadership; in other words, the essential procedures that nurses in charge of shifts
perform and are not recognized as such, although they are crucial in terms of outcomes for
patients and consequently for gains in health. This will be a significant contribution to the
promotion of favourable nursing practice environments.
In terms of implications for research, this study makes available to the scientific
community a data collection instrument validated for the Portuguese language and cultural
context. The results of this study allow the establishment of a benchmark with the results
of international studies, and place Portuguese nurses in discussion with global researchers
on current and critical issues for the valorization and qualification of health systems.
We suggest the development of this theme by applying the SESCNL-PT in hospital settings, in primary healthcare, in long-term care units, and in nursing homes. It is important
to develop longitudinal studies with the SESCNL-PT, associated with the measurement
of favourable nursing practice environments. Longitudinal studies would allow causal
links to be established between CNL and better outcomes for patients, for teams, for the
organization and quality of nursing care and for the efficiency of healthcare organizations.
Int. J. Environ. Res. Public Health 2022, 19, 8590
11 of 12
The topic of clinical nurse leaders’ self-efficacy should be addressed in the training of
advanced practice nurses and in postgraduate and master’s training on nursing management,
because better self-efficacy means better performance by these specialized professionals.
Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph19148590/s1, a questionnaire.
Author Contributions: Conceptualization, P.L., M.C., F.G. and T.P.; methodology, P.L., M.C., F.G. and
T.P.; software, P.L.; validation, P.L., M.C., F.G. and T.P.; formal analysis, P.L. and M.C.; investigation,
M.C., F.G. and P.L.; resources, M.C., P.L., F.G. and T.P.; data curation, P.L. and M.C.; writing—original
draft preparation, P.L. and M.C.; writing—review and editing, M.C., F.G., P.L. and T.P.; visualization,
M.C., F.G., P.L. and T.P.; supervision, P.L.; project administration, P.L. All authors have read and
agreed to the published version of the manuscript.
Funding: The authors thank the Nursing Research, Innovation and Development Centre of Lisbon
(CIDNUR), Nursing School of Lisbon, Lisbon, Portugal, for the financial support given.
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Research Ethics Committee number 588/201821.06.2018).
Informed Consent Statement: Informed consent was obtained from all subjects involved in this study.
Data Availability Statement: Restrictions apply to the availability of these data. Data were obtained
from a third party and are available with the permission of the third party.
Conflicts of Interest: All the authors declare no conflict of interest.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Maier, C.; Aiken, L.; Busse, R. Nurses in Advanced Roles in Primary Care: Policy Levers for Implementation; OECD Health Working
Papers. 98; OECD Publishing: Paris, France, 2017. [CrossRef]
ICN (International Council of Nurses). International Workforce Forum Calls for Urgent Action from Governments to Address Global
Nursing Shortage; International Council of Nurses: Geneva, Switzerland, 2019. Available online: https://www.icn.ch/news/icninternational-workforce-forum-calls-urgent-action-governments-address-global-nursing (accessed on 22 February 2022).
Carvalho, M.C.; Lucas, P.R. The effectiveness of the clinical nurse leader practice—Systematic review. Millenium 2020, 2, 57–64.
[CrossRef]
Delamaire, M.; Lafortune, G. Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries; OECD
Health Working Papers; OECD Publishing: Paris, France, 2010. [CrossRef]
Lucas, P.; Jesus, E.; Almeida, S.; Araújo, B. Validation of the Psychometric Properties of the Practice Environment Scale of Nursing
Work Index in Primary Health Care in Portugal. Int. J. Environ. Res. Public Health 2021, 18, 6422. [CrossRef] [PubMed]
Lucas, P.R.M.B.; Nunes, E.M.G.T. Nursing practice environment in Primary Health Care: A scoping review. Rev. Bras. Enferm.
2020, 73, e20190479. [CrossRef] [PubMed]
De Sul, S.I.R.; Lucas, P.R.M.B. Translation and validation of the anticipated turnover scale for the Portuguese cultural context.
Nurs. Open 2020, 7, 1475–1481. [CrossRef] [PubMed]
Baernholdt, M.; Cottingham, S. The Clinical Nurse Leader—New nursing role with global implications. Int. Nurs. Rev. 2011, 58,
74–78. [CrossRef] [PubMed]
Stavrianopoulos, T. The clinical nurse leader. Health Sci. J. 2012, 6, 392–401. Available online: https://www.hsj.gr/medicine/theclinical-nurse-leader.pdf (accessed on 15 February 2022).
ACN (Australian College of Nursing). Nurse Leadership; ACN: Canberra, Australia, 2015; Available online: https://www.acn.edu.
au (accessed on 8 February 2022).
AACN (American Association of Colleges of Nursing). Competencies and Curricular Expectations for Clinical Nurse Leader Education
and Practice; American Association of Colleges of Nursing: Washington DC, USA, 2013; pp. 1–43. Available online: http:
//faculty.sites.uci.edu/ncrc/files/2016/01/60.pdf (accessed on 8 February 2022).
Sotomayor, G.; Rankin, V. Clinical Nurse Leaders: Fulfilling the Promise of the Role. Medsurg Nurs. 2017, 26, 21–32.
Gerrish, K.; Guillaume, L.; Kirshbaum, M.; Mcdonnell, A.; Tod, A.; Nolan, M. Factors influencing the contribution of advanced
practice nurses to promoting evidence-based practice among front-line nurses: Findings from a cross-sectional survey. J. Adv.
Nurs. 2011, 67, 1079–1090. [CrossRef] [PubMed]
Clavo-Hall, J.; Bender, M.; Harvath, T. Roles enacted by Clinical Nurse Leaders across the healthcare spectrum: A systematic
literature review. J. Prof. Nurs. 2018, 34, 259–268. [CrossRef] [PubMed]
OCDE. Health at a Glance 2017: OCDE Indicators; OCDE Publishing: Paris, France, 2017. [CrossRef]
Int. J. Environ. Res. Public Health 2022, 19, 8590
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
12 of 12
Wesolowski, M.; Casey, G.; Berry, S.; Gannon, J. The clinical nurse leader in the perioperative setting: A preceptor experience.
AORN J. 2014, 100, 30–41. [CrossRef] [PubMed]
Perry, A. The clinical nurse leader: Improving outcomes and efficacy in the emergency department. J. Emerg. Nurs. 2013, 39,
334–339. [CrossRef] [PubMed]
Bombard, E.; Chapman, K.; Doyle, M.; Wright, D.; Shippee-Rice, R.; Kasik, D. Answering the Question, “What Is a Clinical Nurse
Leader?”. J. Prof. Nurs. 2010, 26, 332–340. [CrossRef] [PubMed]
Bender, M.; Williams, M.; Su, W. Diffusion of a Nurse-led healthcare innovation: Describing certified clinical Nurse Leader
integration into care delivery. J. Nurs. Adm. 2016, 46, 400–407. [CrossRef] [PubMed]
Gilmartin, M.J.; Nokes, K. A Self-Efficacy Scale for Clinical Nurse Leaders®: Results of a Pilot Study. Nurs. Econ. 2015, 33,
133–143. Available online: https://cpb-us-e2.wpmucdn.com/faculty.sites.uci.edu/dist/d/469/files/2016/01/77.pdf (accessed
on 5 January 2018). [PubMed]
Gilmartin, M.J. Variations in clinical nurse leaders’ confidence with performing the core role functions. J. Prof. Nurs. 2014, 30,
307–316. [CrossRef] [PubMed]
Gray, J.; Grove, S.; Sutherland, S. Burns and Grove’s the Practice of Nursing Research, 8th ed.; Elsevier/Saunders: St. Louis, MO,
USA, 2017.
Polit, D.F.; Beck, C.T. Fundamentos de Pesquisa em Enfermagem: Avaliação de Evidências para a Prática de Enfermagem, 9th ed.; Artmed:
Porto Alegre, Brazil, 2018.
Almeida, S. Estatística Aplicada à Investigação em Ciências da Saúde—Um Guia com o SPSS; Lusodidacta: Loures, Portugal, 2017.
Beaton, D.; Bombardier, C.; Guillemin, F.; Ferraz, M.B. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report
Measures. Spine 2000, 25, 3186–3191. [CrossRef] [PubMed]
Sousa, V.D.; Rojjanasrirat, W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care
research: A clear and user-friendly guidelines. J. Eval. Clin. Pract. 2011, 17, 268–274. [CrossRef] [PubMed]
Souza, A.; Alexandre, N.; Guirardello, E. Psychometric properties in instruments evaluation of reliability and validity. Epidemiol.
Serv. Saúde 2017, 26, 649–659. [CrossRef] [PubMed]
Marôco, J. Análise de Equações Estruturais: Fundamentos Teóricos, Software e Aplicações, 2nd ed.; ReportNumber: Pêro Pinheiro,
Portugal, 2014.