Translation and cross-cultural adaptation of the Clinical Competence Questionnaire for use in Brazil

ABSTRACT Objective: translating and transculturally adapting the Clinical Competence Questionnaire to Brazilian senior undergraduate Nursing students, as well as measuring psychometric properties of the questionnaire. Method: a methodological study carried out in six steps: translation of the Clinical Competence Questionnaire instrument, consensus of the translations, back-translation, analysis by an expert committee, pre-testing and then presentation of the cross-cultural adaptation process to the developers. Psychometric properties were measured using Cronbach's alpha, intraclass correlation coefficient and content validity index. Results: the instrument was translated, transculturally adapted and its final version consisted of 48 items. Cronbach's alpha coefficient was 0.90, and the agreement index of the items was 99% for students and 98% for evaluators. Conclusion: the Clinical Competence Questionnaire was translated and adapted to Brazilian students, and the psychometric properties of the Portuguese version of the questionnaire presented satisfactory internal consistency regarding the studied sample.


Introduction
In the international scenario of nursing education, it is currently a requirement that students master the skills necessary for their training. To ensure the development of knowledge, skills and attitudes for professional practice, it is imperative that an evaluation method be implemented before graduation.
An accurate, reliable and valid evaluation allows for verifying clinical performance and their preparation/readiness for professional exercise. In general, assessments that rely on knowledge-based tests reflect the effectiveness of teaching, but fail to demonstrate how students could apply knowledge in clinical situations (1) .
Thus, education has evolved from teaching the profession based on tested experience to teaching it based on scientific evidence, and currently the assessment of nursing students should be able to gauge whether the desired learning outcomes are achieved, and whether the competencies of the course were achieved in order to ensure safe and competent care.
Although there are innovative methods in nursing that guarantee an evaluation of clinical skills' learning, many others lack scientific evidence or present gaps (2) .
On the one hand, nursing education in several parts of the world leads a dynamic, critical and reflective profile, involving complex clinical knowledge and the graduate's ability to act in the face of the unexpected.
On the other hand, however, it focuses on assessments aimed toward psychomotor skills, to the detriment of a multidimensional assessment that encompasses attributes of clinical competence (3) .
Thus, assessing the clinical competence of nursing students/graduates has demonstrated problems of reliability, subjectivity, validity and bias in their processes (3)(4) , which prevents them from achieving their real objectives, noting that this evaluation must also converge to knowledge, skills and attitudes, which can be misconceived when evaluating one or two isolated elements (1,5) .
The Clinical Competence Questionnaire (CCQ) was constructed and validated in Taiwan in 2013 in order to measure the perception of undergraduate nursing students' clinical competence. The CCQ construction was based on the model "From Novice to Expert", by Patrícia Benner, which ranks nurses in six levels of competence: novice, beginner, advanced, competent, proficient and expert (5) .
The CCQ assesses the skills of nursing students acquired in their training. Usually, new graduates enter the job market as a novice nurse, ideally having the possibility of a rapid progression in their career until reaching a competent level. The questionnaire is composed of 47 items, divided into domains that converge to the required competencies of the bachelor's degree in nursing, including professional behaviors, specific skills, general performance, and advanced skills; evaluating aspects such as safe care, professional ethics, clinical thinking, collaboration and communication, basic nursing routines, and technical skills (5) .
In order to assess the instrument's stability, the Intraclass Correlation Coefficient (ICC) was measured in order to guarantee its reproducibility. The following criteria were adopted: values between 0 (zero) and 0.20 = poor; between 0.21 and 0.40 = reasonable; between 0.41 and 0.60 = good; between 0.61 and 0.80 = very good; between 0.81 and 1.00 = excellent (8) .
The relevance and representativeness of the items were evaluated through the Content Validity Index (CVI), which measures agreement among the evaluators.
The adequacy of each item ranged from adequate to unsuitable in a Likert scale. A minimum value of 0.90, or 90% was considered (9) .

Results
The final instrument totaled 48 items, since item 40 in the Skills and Abilities domain unfolded into items 40 and 41 after the experts suggested that it would be appropriate for "oxygen therapy" to be separated from "performing postural drainage and percussion." Thus, the total score went from 235 to 240.

CCI †
Means Do not have a clue (1) Is known in theory, but not confident at all in practice (2) Is known in theory, can perform some parts in practice Is known in theory, competent in practice, need Supervision  Rev. Latino-Am. Enfermagem 2017;25:e2898.

Discussion
The analysis of items 1 to 13 of the Nursing Professional Behaviors axis showed an important relationship between this axis and the "decisionmaking" competence of the National Curricular Guidelines of Nursing Undergraduate Courses (DCENF). (10) This axis refers to the safe care referred to in the original instrument, which suggests that professionals' performance must be anchored in their ability to make decisions that lead to effectiveness and adequate cost-effectiveness of the workforce related to equipment, medicines, procedures and practices (10) .
Decision-making by nurses is a complex, dynamic and inseparable process of their training; its commitment is considering factors that, when combined, potentiate the quality of the decision and can affect the patient's prognosis and safety; these being: psychological, cognitive, and analytical aspects, information, situations and intuition (11) .
Another aspect to be considered is that nursing constitutes as the largest health workforce in Brazil, concentrating an estimated 1,500,000 professionals.
This expressive number indicates how much a direct relation of the category is necessary for patient safety strategies and error prevention (12) .
In order to prevent errors, the ability of nurses to carry out prevention, promotion, protection and rehabilitation in health. Moreover, they are related to general/overall competency of the DCENF, which is "healthcare" (10) .
General competence of healthcare points to the training of critical and reflexive professionals engaged in seeking and solving health problems of the individual, the family and the community, respecting ethical and bioethical principles (10) . In this care, clinical reasoning helps the professional to recognize patient priorities and to select the relevant care. We believe that nurses use problem-solving skills in their professional practice on a daily basis, and that these assist them in interventions in the current health context.

Modification of item 4 was based on the concern
of one of the specialists regarding a lack of definition is considered a high value, therefore demonstrating that the test items are correlated (7) . Thus, the instrument demonstrated validity and precision with a high degree of internal consistency, a result corroborated by the original instrument (5) .
Regarding the intraclass correlation coefficient, 46 items were classified as very good and reasonable, thus inferring that the instrument has stability ranging from moderate to significant (8) . On the other hand, two items obtained poor correlation, which is justified by the fact that their competencies are related to specific clinical practices, suggesting that these are uncommon during students' practical training.
In turn, content validity obtained 99% agreement between the students and 98% among the experts.
Mean scores for each domain found in the Brazilian version were similar to the original study scores of the instrument. Judges' analysis and semantics are part of the construction procedures of measuring an instrument, as well as the initial validity stage (23) ; therefore, in complying with this construction step, we assure the scale's content validity.

Conclusion
The CCQ was translated and transculturally adapted into the Portuguese language and some of its psychometric properties were tested. However, it is necessary to finalize the validation process through further appropriate sampling and statistical tests in order for it to be used by graduating undergraduates in nursing.
The availability of this questionnaire may allow for the self-assessment of student's clinical competence, which is considered to be an essential component of nursing since it assists in obtaining new knowledge, better learning and safer patient care.
We can also consider that the questionnaire may provide teachers and supervisors of nursing practices with parameters regarding the clinical competence progression of future nurses, pointing out what can be developed in the clinical steps. This is a time when students can demonstrate their knowledge, skills and attitudes, considering that the instrument evaluates both behaviors and skills. In health institutions, the QCC could be a useful and viable tool for nursing managers to evaluate novice and beginner nurses.