Self-confidence for emergency intervention: adaptation and cultural validation of the Self-confidence Scale in nursing students

Objective: develop the cultural adaptation and validation of a Portuguese version of the Self-confidence Scale. Method: descriptive and exploratory methodological research for the adaptation and validation of a measuring instrument. The translation, synthesis, back-translation, revision, pretest and semantic evaluation phases were accomplished. The evaluation involving 178 students from a Teaching Diploma Program in Nursing. The ethical principles were complied with. Results: the internal consistency analysis of the scale reveals good Alpha coefficients (0.92 for the global scale and superior to 0.83 for the different dimensions). The factor analysis presents a three-factor solution with rational meaning. Conclusion: The scale is easy to answer and understand. Based on the obtained results, it can be affirmed that the scale reveals good psychometric properties, with great potential to be used in future research.


Introduction
In an emergency situation, one of the factors that can influence the rapid and appropriate initiation of the nursing intervention is the self-confidence of the professional present when this intervention takes place.
The organization of care turns the nurse into the core element of this process.
When nurses graduate, they are expected to have gained the knowledge and competences, among others, to identify signs and symptoms, to assess the patient in a fast and systematic manner, to implement interventions according to their degree of priority and to evaluate the outcome of the interventions. That is the only way to achieve high quality in the intervention response to complex situations like a stroke, which can double or triple the patient's survival (1) . Therefore, students' education depends not only on the cases they are confronted with during the different clinical teaching periods. Schools are expected to reinvent themselves, using innovative pedagogical strategies that develop competences in the students, which allow them to act in high-complexity contexts, in which decision making is based on scientific evidence and derives from an easy, structured and fluid clinical judgment, with high levels of self-confidence. The pedagogical strategies need to facilitate the integrative construction of knowledge, as well as reflexive observation and experiencing through immersion in the reality (2) , so as to transmit security to the different actors (3) .
When included into the study plans of nursing colleges, simulation teaching is one way to achieve this competency building. A good study plan, which includes simulation, can contribute to the preparation of better nurses, who are capable of intervening in complex situations, of making correct decisions centered on each person and based on scientific evidence, of working in teams and of actively working to update their knowledge and competences, among others. In other words, it prepares people who know (considering knowledge in its different dimensions), who know what they know and who know everything they can still learn.
It should be observed that the replacement of clinical experience by simulated clinical experience is not defended here. Contact with real persons permits singular learning. The main advantage simulated practice has to offer is a safe environment for the student, the teacher and the patient in the teaching and learning process, in addition to its power to anticipate rare and/ or complex situations (3) .
In this context, the assessment of self-confidence to intervene in an urgency situation can be very useful.
In view of the above, the objective in this study was to develop the cultural adaptation and validation of a Portuguese version of the Self-confidence Scale.
Self-confidence, also described as self-efficacy, is always related to a behavior or task (4) . Confidence is an attitude, frequently related to repeated experiences and to the realistic perception of individual weaknesses and potentials.
Confidence is an important variable in nursing education (5) . Students with higher levels of selfconfidence have a greater probability of developing successful interventions, as they are able to test and use their competences more easily (5) . Despite appropriate knowledge and skills, nurses are generally reluctant to start certain interventions, unless they feel confident to do so (6) .
According to the theory of self-efficacy (4) , individuals with a greater sense of self-efficacy or self-confidence are more willing to accept challenges and recover faster from failure (5) .
The development of self-confidence is the main component of correct decision making in the clinical context and for the associated judgment processes (7) .
In fact, the use of simulation as a teaching/ learning strategy reveals different gains for the students, particularly the development of knowledge and competences for clinical judgment, priority setting, decision making, accomplishment of correct actions, teamwork and correction of errors without impairing the patients; and, associated with all these, gains in self-confidence levels (3) . Other studies (16)(17) , centered on outcomes related to the use of highfidelity simulation, also indicate gains in the level of self-confidence.
In emergency interventions, studies also demonstrate the importance of self-confidence.
Examples are the relation between self-confidence and nurses' ability to recognize and appropriately respond to an emergency situation (7) or, in trauma emergency interventions, the higher self-confidence levels of students submitted to simulation training when compared to others who only participate in seminar training (8) .
Another example is how a structured simulation training program improves the students' confidence to identify signs of worsening in a patient (18) . The analysis of the most common errors during the cardiorespiratory reanimation of a patient and its causes shows that, in different nurses, errors are related to high levels of anxiety and low levels of self-confidence (19) .
A study shows that the relation between self-

confidence and the result of emergency interventions
can be transferred to practice (11) .
No scientific evidence exists yet, however, regarding the effectiveness of simulated practice. It knowingly contributes to increase self-confidence levels when compared to mere theoretical education, but there are no statistically significant differences when compared to clinical practice (5) . In the same study (5) , simulated practice did not significantly contribute to greater knowledge retention and clinical performance. The combination of clinical practice and simulation obtained better outcomes than any of the two individually.

Objective
To develop the cultural adaptation and validation of a Portuguese version of the Self-confidence Scale.

Method
Methodological adaptation and validation study of a measuring instrument. For the study, a minimum of 120 participants was estimated, attending to the target of 10 participants for each scale item (20) . The sample According to the students' answers, the average time needed to answer the SCS vp was three minutes and a half.
The Self-confidence Scale (SCS) was developed by The scale consists of a list of 12 items with five-point Likert answers: "not confident", "hardly confident", "confident", "very confident" and "extremely confident".
The different items identify the student's ability to: (1) recognize signs and symptoms of changes in the referred areas, (2) assess the patient precisely, (3) intervene appropriately and (4) assess the effectiveness of the interventions implemented in the respiratory, cardiac and neurological areas.
To adapt the instrument, the following phases were undertaken (21) : For the purpose of the study, the minimum number of participants was estimated at 120, complying with the target of 10 participants for each scale item (21) .

Data analysis
The data were analyzed using SPSS software (version 19 for Windows). For all tests, statistical significance was set at p<0.05.
The answers to the different items were scored between 1 ("not confident") and 5 ("extremely confident").

Results
The matrix revealed correlation coefficients between  As a suitability criterion of the factor analysis, the  Bartlett's sphericity test (χ 2 =1390.084 with p<0.001), whose value shows that the variables can be related (22) .
The presented solution proposed the division of the items in three factors, which in total explain 71.4% of the variance. The factor loadings of the three factors can be observed in Table 2. The analysis of the item distribution showed that the mathematically proposed grouping divides the scale in three dimensions, with items focused on breathing, circulation and neurological dysfunction.

Items
Although the proposed solution differs from the original scale author's proposal, it also has a rational meaning, by dividing the items into the breathing, cardiac and neurological areas and grouping the identification of signs and symptoms of severity, the patient assessment, the intervention and the assessment of the outcomes associated with the intervention in each of these dimensions.
Thus, the SCSvp consists of three factors. Factor 1, which includes the items related to the "neurological dysfunction" dimension of the scale; factor 2, which includes the items related to the "breathing" dimension of the scale; and factor 3, which includes the items related to the "circulation" dimension of the scale.

Discussion
The

Conclusions
The self-confidence to intervene in an emergency situation indicates the nurses' pro-activeness. To intervene in an emergency situation, in which each second matters, it is fundamental for nurses to feel confident that they are capable of acting appropriately, while low self-confidence can take the form of delayed help, higher levels of anxiety and more errors. Simulated practice is a strategy that can enhance the self-confidence to intervene in an emergency situation.
The Self-confidence Scale showed good psychometric properties, which reveals the high potential use of the SCSvp, whether in research or as a tool to assess the quality of the trainers' work in simulated training contexts.
The limitations, such as the specific nature of the sample and the (also specific) context need to be considered in future studies, as well as the lack of concurrent validity and test-retest analyses in order to consolidate the validity of the SCSvp, as well as to strengthen its potential use.