Adaptation and Validation of the Readiness for Practice Instrument for Senior Undergraduate Nursing Students in China

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Background
Newly graduated nurses (NGNs) play a critical role in the nursing workforce as a human resource supply. Te State of the World Nursing Report 2020 proposed by the World Health Organization (WHO) highlights that the nursing profession receives an infux of 1.7 million NGNs each year [1]. However, the turnover rates of NGNs were especially high, ranging from 8% to 69% in the frst year and 26.2% to 57% in the second year worldwide [2,3]. In the United States, NGNs' turnover rate was 27.6% in the frst year, accounting for 32.1% of all nursing turnover in 2019 [4]. A longitudinal study in China also demonstrated that the turnover rate of NGNs was approximately 33.2% [5].
Te high turnover rate further exacerbated globally the nursing shortage problem.
Previous studies have shown that a variety of factors contribute to the high turnover rate among NGNs, including their low clinical competence, coping self-efcacy, and working environment. Among these reasons, low competency is identifed as one of the main reasons for their intention to leave and actual turnover [6]. Low competency usually leads to negative experiences and feelings for new nursing graduates, such as low professional confdence, high confusion and challenges, and even transition shock [7]. NGNs often express feelings of being unprepared to apply clinical knowledge and technical skills in practical settings to perform the expected professional roles and responsibilities when transitioning from an academic to a professional clinical setting. Tus, practice readiness is believed to be the key element in understanding reality/transition shock among new graduate nurses [8].
Readiness is usually described as a feeling or state of being fully prepared for the required action [9]. Practice readiness typically refers to the extent to which individuals are perceived to possess the knowledge and skills to practice autonomously [10]. Mirza et al. identifed three attributes of practice readiness for newly graduated nurses, including clinical capability, cognitive capability, and professional capability [11]. Baumann et al. also identifed the personal, clinical, and relational characteristics and organizational acuity as the four characteristics of practice readiness for new nurses [12]. Although diferent scholars may report diferent components of practice readiness, the maturity of nursing students, the knowledge and skills they learned in school, and their clinical practice experience during clinical practicums are believed to be the antecedents of new nurses' practice readiness [8].
Nursing students are an important resource for new nurses. Tousands of nursing students enter the nursing workforce and profession every year. In Australia, 10,000 nursing graduates enter the profession each year, and the majority of them work in acute care settings [13]. In China, 203,000 nursing graduates with advanced nursing degrees begin nursing practice each year [14]. Although nursing students do not carry the same level of roles and responsibilities as qualifed clinical nurses, they still need to care for patients during clinical practicum with the professional knowledge and skills they learned in educational institutions [15]. Tey also face transition issues and encounter high levels of stress due to their limited clinical experience and insufcient readiness [16,17].
Senior nursing students' readiness for practice refers to their perceptions of readiness and preparation for professional nursing roles, which are usually regarded as their ability to fulfll professional roles incorporating knowledge, behaviors, skills, and attitudes [2,18]. Teir readiness for practice largely hinges on their exposure to opportunities to practice the key dimensions of nursing during their education [19]. It has been proved that senior nursing students who possess a high level of practice readiness often experience less anxiety when transitioning to qualifed nurses and are more likely to adapt to the work environment [20].
Due to the importance of practice readiness, many strategies and supports have been suggested to achieve and enhance the level of practice readiness of nursing students. Te most widely employed strategies are the fnal clinical practicum and internship [21]. Undergraduate nursing education in China consists of a four-year program, with a clinical internship lasting over eight months in the fourth year [5]. However, nursing students are still intended to report their stressful and helpless experiences upon entering the clinical workplace [5]. Since nursing education does not always prepare nursing students for practice during the clinical practicum, they were not confdent in their practice readiness [22]. Casey et al. [18] reported that only 3% of senior nursing students felt capable of independently carrying out specifc skills and procedures, such as urinary catheter insertion, in an actual clinical context.
Te assessment of senior nursing students' readiness for practice with a culturally appropriate assessment tool is crucial in addressing low readiness upon entering the clinical workplace. However, specifc instruments to evaluate the readiness for practice of senior nursing students in China are lacking. Since many instruments have been developed in this regard, adapting and validating an appropriate instrument are more efcient solutions. Tere exist several assessment tools that may be used to assess the readiness for practice among senior nursing students in the Chinese cultural context. Te Work Readiness Scale [23] is one of the widely used assessment tools, but its evaluation is time-consuming due to its 64 items in four dimensions. Walker improved the original Work Readiness Scale to the Work Readiness Scale for Graduate Nurses (WRS-GN), adding 9 nursing items based on the original items [24]. While Li translated and validated the WRS-GN into Chinese [25], the scale is more suitable for assessing the work readiness of new nurses rather than senior nursing students. Shahsavari developed the Perceived Professional Preparedness of Senior Nursing Students questionnaire (PPPNS, [19]), but it is more efective to evaluate nursing students' perceived preparedness to enter the clinical setting. Te Casey-Fink Readiness for Practice Survey (CFRPS) [18] was developed to assess the practice readiness of senior nursing students in the United States. It was further revised and validated in the New Zealand context [26].
Terefore, this study aims to translate and validate the CFRPS and evaluate its psychometric properties in Chinese senior nursing students to provide a culturally appropriate tool for assessing their practice readiness in senior nursing students in the Chinese cultural context.

Parallel Translation.
With the permission of the scale developer, the original English CFRPS was translated into Chinese using a parallel blind technique to facilitate an open discussion and collaboration. Two associate professors with Ph.D. degrees and experiences as visiting scholars in Britain and the United States, respectively, completed the independent translation. Ten, two English teachers working in nursing colleges with master's degrees completed the independent back-translation. Subsequently, diferent versions of CFRPS are cross-checked and modifed. Te fnal Chinese version of the instrument was confrmed after any discrepancies were resolved through consensus among the translators.

Study Design and Participants.
In this study, a descriptive cross-sectional design was utilized and STROBE was employed as the reporting method. Participants were recruited from three nursing schools in North China. Senior undergraduate nursing students were invited to fll out a questionnaire including demographics and the Chinese version of the CFRPS, by convenience sampling from May 2021 to May 2022. Te inclusion criteria were senior nursing students who (1) were in the last year of undergraduate study; (2) complete the practicum internship; (3) were preparing for clinical practice; and (4) were willing to participate in the survey. Te exclusion criteria were as follows: senior nursing students who plan to work in nonnursing felds after graduation. Te minimum sample size of this study was calculated on the principle of "above ten participants per scale item" [27]. Finally, 591 senior nursing students that met the criteria above accomplished the questionnaire, and 590 samples were included in the analysis after deleting one sample questionnaire with incomplete answers and missing values.

Measures.
In this study, two parts of the survey questionnaire were used to measure participants' practice readiness. Section A collected demographic information, including age, gender, educational level, and questions related to clinical practicum. Section B used the Casey-Fink Readiness for Practice Survey-Chinese Version (CFRPS-C) to collect data about the practice readiness of participants. Te original CFRPS is a 4-point Likert scale consisting of 18 items (1 � strongly disagree to 4 � strongly agree). It has four subdomains: clinical problem-solving (7 items), learning techniques (2 items), professional identity (5 items), and trials and tribulations (4 items). Higher scores in clinical problem-solving, learning techniques, professional identity, and lower scores in trials and tribulations indicate a higher level of readiness for practice. Cronbach's α of the original CFRPS was 0.69 for all items and 0.80 for clinical problemsolving, 0.50 for learning techniques, 0.65 for professional identity, and 0.63 for trials and tribulations, respectively, which indicates good internal consistency reliability. Exploratory factor analysis suggested that the four-factor set of correlated subscales accounted for 48.2% of the variance across all survey items [18].

Statistical Analysis.
A descriptive analysis was employed to examine participants' demographic characteristics. Pearson correlation analysis was employed to examine the correlation between the four subscales of CFRPS-C. A fourfactor confrmatory factor analysis (CFA) with oblique rotation was performed to evaluate the reliability and validity of CFRPS-C. Due to the ordinal nature of items in CFRPS-C, mean-variance-adjusted weighted least squares (WLSMV) estimation was employed to estimate the parameters of the factor model. Te structural validity of CFRPS-C was evaluated by Kaiser-Meyer-Olkin (KMO) and Bartlett's test of sphericity, and the model ft indices included χ 2 , df, root mean square error of approximation (RMSEA), comparative ft index (CFI), Tucker-Lewis Index (TLI), and standardized root mean square residual (SRMR). Te criteria of a good model ft were: χ 2 /df < 5, RMSEA < 0.08, CFI > 0.90, TLI > 0.90, and SRMR < 0.08 [28]. Te reliability and convergent validity of the model were evaluated by standardized factor loadings, Cronbach's α, composite reliability (CR), and average variance extracted (AVE), where CR > 0.80 and AVE > 0.50 indicate good reliability and convergent validity [29]. Te discriminant validity of the model was evaluated by the bootstrap confdence interval test, where the bootstrap confdence interval not including one suggests discriminant validity [30,31]. Statistical analysis was completed with SAS 9.4 and Mplus 8.3.

Ethical Considerations.
Ethical approval for the survey was obtained from the Ethics Committee of the University of the Corresponding Author. All participants were informed of the purpose of this study and were free to participate in this survey. All participants gave written informed consent for their anonymized data to be used for research purposes, including publication. We also received permission from Dr. Casey (e-mail communication with Kathy Casey, 26 April 2020), the author of the CFRPS, to adapt and validate the scale in the Chinese context.

Participant Characteristics.
In this study, a total of 590 nursing students were enrolled, comprising predominantly female participants (83.1%, n � 490). Te mean age of the participants was (21.73 ± 0.33). Notably, all of the senior nursing students had undergone an 8month practicum in various clinical settings, including medical, surgical, gynecological, pediatric, emergency, and intensive care units.

Structural Validity.
Te KMO measure of CFRPS-C was 0.909, indicating enough items are predicted by each factor in the current study. Te result of Bartlett's test of sphericity was statistically signifcant (χ 2 � 4874.185, P < 0.001), suggesting the study data is suitable for factor analysis. Te model ft indices of the confrmatory factor analysis (CFA) are illustrated in Table 1. Te initial CFA model ( Table 1, Model 1) with full items showed χ 2 / df � 17.181, RMSEA � 0.166, CFI � 0.771, TLI � 0.735, and SRMR � 0.104, suggesting an unacceptable model ft. After deleting two items ("I am comfortable delegating tasks to the nursing assistant" and "I have had opportunities to practice skills and procedures more than once" in Trials and Tribulations) with low standardized factor loadings (<0.5), the CFA model (  Figure 1 displays the standardized loadings for the fnal 18-item CFA model of CFRPS-C.

Reliability and Convergent Validity.
All four dimensions of the 18-item CFRPS-C showed statistically signifcant and satisfactory reliability and convergent validity, as evidenced Journal of Nursing Management by the standardized factor loadings above 0.5 and signifcant (see Figure 1 and Table 2), Cronbach's α and composite reliability values (CR) above 0.7 (see Table 2). Te average variance extracted values (AVE) of the four dimensions were all equal to or above the recommended value of 0.5 (see Table 2).

Discriminate Validity.
Te absolute values of the correlation coefcients between the four dimensions of the 18item CPRS-C ranged from 0.213 to 0.898 (see Table 3). Te confdence interval of correlations derived from 5000 bootstrap samplings all did not include 1, suggesting acceptable discriminate validity of the 18-item CFRPS-C [30,31].

Discussion
Clinical internships are a crucial period for nursing students to experience clinical nursing and develop a professional identity, enabling them to transit smoothly into professional clinical nurses [32]. Yet we have no specifc instruments to evaluate the practice readiness of senior nursing students during this critical period in China. Terefore, the primary objective of this study was to translate and adapt the Casey-Fink Readiness for Practice Survey (CFRPS) into the Chinese version through a parallel translation process.
Te Chinese version of the CFRPS, which is an 18-item scale, has been validated through a parallel translation process. Te results of the confrmatory factor analysis (CFA) showed that all the standardized factor loadings of the fnal 18-item CFRPS-C was statistically signifcant and above the recommended value of 0.5, indicating good commonalities of items [33]. Furthermore, the values of Cronbach's α and CR for the four dimensions were above 0.7, and the average variance extracted (AVE) of the dimensions was above 0.5. Tis suggests that the Chinese version of CFRPS has acceptable reliability and convergent validity [28]. In addition, the discriminate validity of the CFA model was acceptable according to the correlation coefcients between the four dimensions [30,31]. Terefore, the fndings indicated that the Chinese version of CFRPS is reliable and valid for the evaluation of readiness for practice in Chinese senior nursing students.
In the original CFRPS, Casey identifed four factors closely related to the readiness for practice, including clinical problem-solving, learning techniques, professional identity, and trials and tribulations. Previous studies also focused on these domains singly or combined to refect the practice readiness of nursing students or new nurses [8]. In our study, we found the fnal Chinese version of CFRPS has 18 items in the same dimensions as the original CFRPS. What's more, all the items in the dimensions of clinical problemsolving skills, learning techniques, and professional identity    have completely remained, indicating that these factors can also assess the practice readiness of Chinese senior nursing students. But in this study, two items in the "Trials and Tribulations" dimension were deleted from the original CFRPS, namely, "I am comfortable delegating tasks to the nursing assistant" and "I have had opportunities to practice skills and procedures more than once" due to their poor interpret-ability to the whole Chinese version of the CFRPS. In addition, these items are not consistent with the Chinese nursing education background. During the 8-month clinical internships, the roles and responsibilities of Chinese senior nursing students are almost the same as those of clinical nurses. Tey all have many opportunities to practice nursing skills and procedures [5]. But they have to practice under the supervision of experienced clinical preceptors without nursing licenses [34]. Tus, the deletion of these two items also implied the importance of the scale cultural adjustment.

Strengths and Limitations
From a methodological perspective, this study has notable strengths. First, to ensure the accuracy of the translation and adaptation process, four experts who are knowledgeable about undergraduate nursing education issues in China and possess good English language skills were involved. Second, the use of CFA in the validation process enabled the assessment of construct validity. Finally, with a sample size of 590 Chinese senior nursing students who fully completed the questionnaires, this study had a sufciently large sample for psychometric testing. Tis study has several limitations. First, the convenience sampling method used in this study may limit the generalization of the fndings. In addition, the study only included senior nursing students from one region in China, which may not be representative of senior nursing students in other regions. Further studies that include participants from various regions are necessary to confrm the validity of the Chinese version of CFRPS. Another limitation of the study is that the CFRPS is a self-report instrument, which may be infuenced by social desirability bias. Participants may give a subjective or socially appropriate answer that does not accurately refect their actual level of practice readiness. Future studies that use a combination of qualitative and quantitative methods may provide more comprehensive and accurate data. Besides, the survey was conducted from May 2021 to May 2022. Te clinical experience of senior nursing students may be limited due to the online clinical practicum during the COVID-19 pandemic. Tus, the result obtained in this study is difcult to work as the norm for practice readiness of Chinese senior nursing students to compare with other studies.

Conclusion
Te 18-item CFRPS-C demonstrated good construct validity and provides stronger psychometric support for the original CFRPS. Tus, the CFRPS-C is a useful tool to assess practice readiness among Chinese senior nursing students. Its brevity also enhances its convenience and practicality in clinical settings.

Implications for Nursing Management
New Nurses are the main supplier to the nursing workforce, and the transition issue contributes a lot to their retention rate. Nursing management should recognize the importance of practice readiness in the clinical practicum for senior nursing students, as it is a critical factor in their transition to professional clinical nurses and can afect their high turnover rate. Yet there is a lack of specifc instruments to evaluate the readiness for practice in China. Tis study's adaptation and validation of the Readiness for Practice Instrument for Chinese senior undergraduate nursing students provide a valuable tool for evaluating practice readiness in China. Data from surveys with this scale in China may enrich and deepen the understanding of readiness for practice. Culturally specifc strategies should be developed based on diferent cultures to optimize the readiness for practice and promote retention of the nursing profession.

Data Availability
Te datasets generated and analyzed during the current study are not publicly available to ensure data confdentiality.

Additional Points
What Does Tis Paper Contribute To the Wider Global Clinical Community? (1) It adapts and validates a reliable and valid instrument to measure the readiness for practice among Chinese senior nursing students. (2) It provides increased psychometric support for the original Casey-Fink Readiness for Practice Survey. (3) It makes it possible to enrich the understanding of readiness for the practice among diferent cultures with the same instrument, to optimize the readiness, and help retention of the nursing profession.

Conflicts of Interest
Te authors declare that they have no conficts of interest.