Development and Psychometric Evaluation of the Critical Reflection Competency in Delirium Care Scale (CRCDCS) Among...

This study aimed to develop and psychometrically evaluate the Critical Reflection Competency in Delirium Care Scale (CRCDCS) among ICU nurses in Iran.

This exploratory mixed-methods study was conducted in Iran between June 2025 and March 2026 based on the eight-step scale development framework proposed by DeVellis and Thorpe.

Item generation was performed using a systematic literature review and semi-structured interviews with 15 ICU nurses. Following qualitative and quantitative assessment of content and face validity, the preliminary 19-item CRCDCS was administered to 700 ICU nurses. Participants were randomly allocated into two equal subsamples for exploratory factor analysis (EFA; n = 350) and confirmatory factor analysis (CFA; n = 350). Psychometric evaluation included parallel analysis (PA), exploratory graph analysis (EGA), convergent and discriminant validity, random forest modeling (RFM), and reliability assessment using Cronbach's alpha (α), McDonald's omega (ω), intraclass correlation coefficient (ICC), and standard error of measurement (SEM).

EFA identified a three-factor structure comprising Analytical-Evaluative Clinical Reflection (AECR), Person-Centered Ethical Reflection (PCER), and Risk-Oriented Preventive Reflection (ROPR), explaining 57.34% of the total variance. PA, EGA, and CFA supported the three-factor model with excellent fit indices (χ²/df = 1.14, CFI = 0.986, TLI = 0.984, RMSEA = 0.029, SRMR = 0.041). All factor loadings exceeded 0.40. Convergent and discriminant validity were confirmed. The scale demonstrated strong internal consistency (α = 0.876; ω = 0.861) and good test-retest reliability (ICC = 0.85, 95% CI: 0.82-0.91). RFM indicated that AECR items contributed most to the internal item-set structure of the total score.

The CRCDCS demonstrated sound internal structure, internal consistency, and test-retest reliability among ICU nurses in this Iranian sample. Further research is needed to establish external criterion validity, predictive validity, and measurement invariance before broader application of the scale.

The CRCDCS is a multidimensional instrument for assessing ICU nurses' critical reflective competence in delirium care, capturing analytical, ethical, and preventive dimensions of reflective practice. Pending further validation, the scale may inform the design of educational programs and clinical training aimed at strengthening reflective decision-making in delirium care within critical care settings.

This study was reported in accordance with the GRAMMS guidelines for mixed-methods research and the COREQ checklist for the qualitative component.

No patient or public contribution.