Cross-cultural adaptation and validation of the Nursing Student Satisfaction Scale for use with Brazilian nursing students

ABSTRACT Objective: to cross-culturally adapt and validate the Nursing Student Satisfaction Scale (NSSS) for use with nursing students in the Brazilian context. Method: this was a quantitative exploratory and descriptive study using a cross-sectional design conducted with 123 undergraduate nursing students studying at a public university in the south of Brazil. The cross-cultural adaptation was performed according to international guidelines. Validation for use in a Brazilian context was performed using factor analysis and Cronbach's alpha. Results: based on the expert committee assessment and pre-test, face and content validity were considered satisfactory. Factor analysis resulted in three constructs: curriculum and teaching; professional social interaction, and learning environment. The internal consistency of the instrument was satisfactory: the value of Cronbach's alpha coefficient was 0.93 for the instrument as a whole, and between 0.88 and 0.89 for the constructs. Conclusion: the Brazilian version of the Nursing Student Satisfaction Scale was shown to be reliable and validated for the evaluation of student satisfaction with undergraduate nursing programs, considering the aspects teaching activities, curriculum, professional social interaction, and learning environment.


Introduction
Satisfaction can be understood as an individual's subjective perception of meeting his/her expectations in relation to various aspects of life (1) . The constant and dynamic state of change in modern society is driving a growing demand for qualified professionals with specialist knowledge and skills.
One of the reflexes of this state of change is that the labor market has become more demanding. More rigorous qualification requirements mean that workers must constantly review, update and develop their knowledge, skills and competencies (2) . In addition, the educational landscape has undergone various changes in order to adapt to new global challenges. This reshaping of education aims to adapt teaching to the needs of society, resulting in structural changes in management models that lead to a constant need to rethink teaching strategies (3) .
In this respect, student satisfaction can be viewed as an essential factor for motivating and involving students, thus enhancing the benefits of learning and, consequently, the professional competence of future professionals (4) . Student satisfaction involves the student's unique perception of the value of his/ her educational experience during the degree program.
Thus, satisfaction can be described as the level of harmony between what is demanded of the individual and what he/she expects or, in other words, as an individual's perception of whether his/her expectations are being met (3) .
University can promote significant changes to the life of students, while increasing demands and responsibilities may lead to feelings of anguish and fear caused by difficulties in adapting to a new social and cultural environment (5) . Academic demands and living in a new, and often hostile, environment, together with constant market pressure for increasingly efficient workers, can overburden students and lead to a perception of failure and lack of achievement of goals and expectations (2) . These limitations lead to demotivation and students begin to feel uninterested and dissatisfied. Satisfaction is the result of the complex and dynamic interaction between general living conditions, work relationships, the work process and an individual's perception of control over his/her living and working conditions (5). The fast pace of life and lack of concern with the personal needs of individuals are therefore intimately related to the perception of satisfaction.
However, the detection of factors that lead to student dissatisfaction can be complex due to their multifaceted nature: curriculum, teaching, professional social interaction, and learning environment (6) . The use of tools to measure student satisfaction and gain an insight into its different dimensions is therefore essential for evaluating educational programs with a view to improving the quality of education, adapting it to student needs and consequently reducing dropout rates.
The Nursing Student Satisfaction Scale (NSSS) was developed for use in quantitative studies to measure nursing student satisfaction with nursing programs (6) .
The instrument was validated in the United States with a sample of 303 nursing students and consists of questions that address curriculum and teaching, professional social interaction, and the learning environment.
In Brazil, few studies exist on student satisfaction in the specific context of nursing. It is therefore essential to develop instruments that help us to understand the factors that affect student satisfaction with nursing programs in order to improve the quality of education and adapt programs to students' needs, thus enhancing student satisfaction and reducing dropout rates.
The justification for this study is thus based on the need to analyze the factors that caused the demotivation during the degree program, thereby making it possible to improve the processes for meeting needs with a view to increasing the satisfaction of Brazilian nursing academics, exploring the dimensions of teaching, curriculum, professional social interaction and the learning environment. This study therefore aims to validate and cross-culturally adapt the Nursing Student Satisfaction Scale (NSSS) to the specific context of Brazilian nursing students.

Method
This was a quantitative exploratory and descriptive study using a cross-sectional design. The cross-cultural adaptation and validation of the NSSS for use in the Brazilian context was performed drawing on concepts from relevant international scientific literature (7) .
The validation process involved the translation and retranslation of the items of the original English version of the instrument into Brazilian Portuguese to test its face and content validity, while the description of the psychometric properties related to its construct validity and reliability was measured using factor analysis and Cronbach's alpha. Hirsch CD, Barlem ELD, Tomaschewski-Barlem JG, Dalmolin GL, Pereira LA, Ferreira AG.

The original instrument
The original version of the NSSS in English is composed of 30 questions and aims to measure student satisfaction with educational programs. Thirty questions in three subscales were validated by administering the NSSS among a sample of 303 nursing students: 14 items concerning curriculum and teaching; nine items concerning professional social interaction, and six items related to the learning environment. The scale also contains a specific item that assesses student satisfaction. The NSSS uses a 6-point Likert scale scored from 1 (not at all satisfied), to 6 (very satisfied).

Cross-cultural adaptation: face and content validity
According to international cross-cultural adaptation guidelines, cross-cultural adaptation was performed in six stages in order to obtain semantic, linguistic, experiential and conceptual equivalence: initial translation; synthesis; back translation; expert committee; pretesting; and review of the adaptation process by the researchers (7) .
For the first stage, the instrument was translated from English to Portuguese by two bilingual translators.  (7) . Finally, the cross-cultural adaption process was reviewed, whereby the researchers made the necessary changes to the scale in order to facilitate its understanding by the selected sample.
After following these cross-cultural adaptation procedures, the final Brazilian version of the NSSS was approved for use in the Brazilian context.

Location and study participants
The final version of the scale was administered in a federal university in the south of Brazil that offers free education and whose purpose is to promote higher education, research and extension. Convenience sampling was used to select the study sample, whereby study participants were selected according to their presence and availability in the location at the time of data collection (8) . A specific formula was used to determine the minimum sample size needed for statistical analysis (9) . Based on a previously known population of 187 nursing students, the formula resulted in a minimum study sample of 123 study participants.

Data collection
The scale was administered collectively during the normal lecture period with the authorization of the nursing faculty. After the procedures related to the ethical aspects of the study were undertaken, the scales were placed in a brown envelope and handed directly to the participants, who completed the questionnaire anonymously.

Construct validation of the scale
After administering the questionnaire, statistical tests were performed using the SPSS (Statistical Package for Social Sciences) version 22.0 to measure the clarity and reliability of the Brazilian version. Two tests were performed to measure construct validity: factor analysis, and Cronbach's alpha (10) .
With respect to factor analysis, the data was summarized by identifying factors common to each question and grouping the questions into categories (constructs) based on the average of the answers.
Cronbach's alpha was used to estimate the reliability of the instrument by assessing the characteristics of each group of questions to determine whether the questions contained in the scale consistently measured the phenomenon in question (10) .
Principal component analysis was used as the extraction method. Varimax orthogonal rotation was used to determine the relevance of the variables to the identified components. The formation of the factors was based on two criteria: the degree of relationship between the variables, determined by the factor loadings (>.400); and degree of subjectivity (10) .

Results
With respect to face validity, there was a consensus among the expert committee that all items were relevant and demonstrated semantic, cultural, linguistic and conceptual equivalence. All items and question formulation were understandable and therefore changes to the questions were limited to how they were written.
It was also suggested that question 16 -"Eu

Discussion
The inclusion of student satisfaction as a course evaluation indicator can provide important information and insights into students' expectations and perceptions of the educational experience, which can be used to promote teaching and program development and enhancement (11) . Therefore, the validated Portuguese version of the NSSS is an important tool for identifying the factors that determine nursing student satisfaction in the Brazilian context.
The findings show that the three constructs of the Brazilian version have slight differences to those of the original version in terms of structure and conceptual definition (6) . The instrument provides a theory-based approach to measuring student satisfaction by revealing the association between its dimensions and student satisfaction with the course. It is also important to highlight that this version of the NSSS is the first to be made available in Brazil and as such other versions that address the specific context of Brazilian students do not exist in the literature.
With respect to the structure of the instrument, the expert committee suggested that the Likert scale be reduced from six to five points to create a midpoint response for respondents to be able to express neutrality The final version of the instrument was therefore composed of three constructs made up of 22 items: curriculum and teaching; professional social interaction, and learning environment, as shown in Figure 1.

Curriculum and Teaching
Questions concerning factors related to the faculty qualifications, use of appropriate methodologies and teaching approach, as well as the content and structure of the curriculum, consistency of the subjects and similarity between taught content with practical reality (6) .

Professional Social Interaction
Questions related to interpersonal relationships in educational settings, interaction between individuals, mutual respect and trust, as well as freedom to question and actively participate in the teaching-learning process (6) .
Learning environment Questions relating to teaching resources and facilities, as well as the acquisition and maintenance of equipment (6) . Hirsch CD, Barlem ELD, Tomaschewski-Barlem JG, Dalmolin GL, Pereira LA, Ferreira AG.
between satisfaction and dissatisfaction, which is not possible in six-point scales.
Given the importance of the expert committee assessment, it is vital to select professionals who have adequate knowledge to enable them to examine not only the semantic content of the questions, but also other aspects of the instrument such as structure and layout (12) .
The original NSSS was composed of three constructscurriculum and teaching, professional social interaction, and learning environment (6) (2) .
The characteristics of the validation process differ depending on the purpose of the validation, which can be classified in two ways: validation of the instrument for use in a new context; and validation for cultural studies involving different versions of the same instrument (12) .
The first construct of the Brazilian version of the NSSS, professional social interaction, was made up of items that were included in the first and second subscales of the original NSSS (6) , curriculum and teaching and professional social interaction. The relational problems evident in the training environment affect students' perceptions of satisfaction with the course and are reflected in difficulties in adapting to teaching methods and practices (13) . The items in this construct group address the social interaction among students and faculty and how this affects the teaching-learning process. This construct was shown to be relevant given that negative student-faculty interactions lead to dissatisfaction and make students think about dropping out of the course (3) .
The construct curriculum and teaching was shown to be directly related to the subscale curriculum and teaching of the original NSSS (6) , comprising of questions relating to qualifications and preparedness for teaching, use of appropriate methodologies and teaching approach, as well as the content and structure of the curriculum, consistency of the subjects and similarity between taught content with practical reality. However, in the original NSSS, the curriculum and teaching subscale also includes items that address social interaction among students and faculty and how this affects teachinglearning, whereas in the Brazilian version this construct is restricted to questions that address only curriculum and teaching. These other factors were grouped into the first construct or excluded from the instrument. Therefore, this dimension was consistent with the literature since issues relating to curriculum are seen by students as important factors affecting general satisfaction with the educational programs (6)(7)(8)(9)(10)(11)(12)(13)(14) .
With respect to the final construct, learning environment, the validated items were the same as those in the original version, except for two items: one excluded because it had low factor loading; and an item that was added because it was conceptually related to the construct. The items of this construct address learning environment resources and facilities and the modernization of technological learning methods that enhance information sharing (14) . This construct was also consistent with the literature, since adequate resources and facilities support students and enhance the theoretical and practical knowledge acquired throughout educational programs (15) .
The results obtained with respect to reliability were very satisfactory when compared to the validation of the original version (6) , .88 for the three constructs (6) .

Conclusion
The findings show that the Brazilian version of the Nursing Students Satisfaction Scale is a sound approach for measuring student satisfaction with educational programs and understanding the factors that may demotivate students during the teaching-learning process. It was possible to identify three factors that affect student satisfaction with a nursing program within the Brazilian context: Professional social interaction; Curriculum and teaching, and learning environment.
The Portuguese version of the NSSS is an important tool and the validation process provided important insights into the factors that potentially affect the satisfaction of students with the course and the attractiveness of universities to students in a Brazilian context.
The primary limitations of this study were the lack of NSSSs adapted and validated for use in other countries, which made further comparisons impossible, and the fact that the study was limited to a specific group of students in a public university in the south of Brazil.
Finally, it is recommended that this version of the NSSS be evaluated in other locations in Brazil to determine whether there are significant differences in