From April 2022 to August 2022, a cross-sectional study was conducted to validate the Self-Awareness Scale for Nurses. It consisted of two phases: (1) psychometric assessment of the scale; (2) analysis of factors influencing nurses’ self-awareness.

In April 2022, the method of cross-sectional study was used. Nurses from four hospitals in Liaoning Province participated in the study. Inclusion criteria: Registered nurses working in healthcare facilities, volunteered for the study. Intern nurses were excluded.

The number of nurses required is based on 10 times the number of items, the scale has 18 items and the sample size should be at least 90–180 (20). The survey was anonymous, but we flagged 30 nurses who voluntarily participated in a second experiment for test–retest reliability 2 weeks later.

The survey took place between April and June 2022. We invited the head nurses from each hospital to assist with the investigation. We first sent the questionnaire to the corresponding head nurses, and then they sent the questionnaire to the nurses in the department. In this study, participants were asked to fill in questionnaires according to the actual situation. Filling out the questionnaire is voluntary. A total of 554 nurses participated in this study and finally, 549 questionnaires were retained after data compilation.

In addition, to explore the influencing factors of nurses’ self-awareness, collected another 430 data from six hospitals from July to August 2022.

The study questionnaire consisted of demographic information and original scale, and Kessler 10 psychological distress scale (K10). The demographic information included age, gender, marital status, education levels, average monthly income (yuan), working experience (years), and job title.

The 18-SASN was developed by Rasheed et al. (19) and consists of four subscales: contextual, conscientious, personal, and professional awareness. Each item corresponds to a response ranging from 5 (always) to 0 (never). The overall Cronbach’s alpha coefficient for the original scale was 0.87 and content validity was 0.94 (19).

The Kessler 10 psychological distress scale (K10), used by the World Health Organization in several countries around the world, assesses the level of non-specific psychological distress by asking about the frequency of non-specific psychological symptoms in the past 4 weeks. The K10 was first applied to China by Xu et al. (21), this scale consists of 10 items, including subscales measuring anxiety and depression. The internal consistency coefficient for this scale was 0.80. Each item was rated using a scale of 1 (hardly ever) to 5 (all the time). The total score is divided into four levels, the higher the level, the higher the risk of psychological disorders: 10–19 (low), 20–24 (low-moderate), 25–29 (moderate), and 30–50 (high).

Following the consent of the original author, we conducted our translation process using the Brislin (22) principle, which involves ensuring the accuracy and cultural relevance of the translation without altering the meaning. First, it was translated into Chinese by two experts in English, forming two separate versions (A1 and A2). Next, the two experts and researchers compared the Chinese translations of A1 and A2, discussed and corrected the inconsistencies, and obtained the first draft of the Chinese version (A12). Then, we invited two nursing experts who had no contact with SASN to back-translate the Chinese draft into English to form back-translated versions (B1 and B2). Finally, the experts compared and discussed the original scale, the first draft of the Chinese translation, and the back-translated English scale. Based on the experience, Chinese expression habits, and customary concepts, a tentative draft of the Chinese version was formed (T1).

A pre-test was conducted with 30 nurses, and the final Chinese version (T2) was obtained through a collaborative discussion between team members and translation experts.

Data were statistically analyzed using SPSS 25.0 and Amos 24.0 software. The reliability and validity of 18 items were tested. Quantitative data were represented by (mean, standard deviation), and classified data were represented by frequency and component ratio. Validity evaluation indicators include exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), content validity index (I-CVI), and the average value of all content validity indicators of the scale (S-CVI/Ave), and discriminant validity. Reliability was tested using Cronbach α coefficient and test–retest reliability coefficient. To investigate potential independent variables of the nurses’ self-awareness, a multivariate linear regression analysis was utilized. For all analyses, p < 0.05 was considered statistically significant.

The demographic characteristics of the participants in the cultural adaptation phase of the study are shown in Supplementary materials. In the research phase of the influencing factors analysis, the majority of the nurses were female (91.7%), 48.5% had more than 11 years of work experience, 48.3% of the nurses had the title of Charge Nurse and above, and the other information is shown in Table 1.

Analyzed all items in the SASN (18 items). In this study, the top 27% of the high subgroup and the bottom 27% of the low subgroup cutoff values were 64.0 and 76.0. The results of the independent samples t-test showed statistically significant scores for each item in both groups (p < 0.05) (Table 2).

The item-total correlation coefficient after item correction was 0.250 except for item 11, and the remaining items were greater than a criterion of 0.3 (r = 0.400–0.622) (29, 30). Also conducted a correlation analysis between the items and the total score of the scale, and the results showed that, except for item 11, the remaining items were significantly and positively correlated with the total score and the correlation was high (r = 0.469–0.712, p < 0.001). Meanwhile, initially reliability analysis showed that the overall Cronbach α coefficient was 0.867 (95% CI: 0.851–0.883), by deleting item 11, the internal consistency of the scale can be improved to 0.873. Item 11 was therefore deleted after consideration by the experts. The results are shown in Table 3.

The results of the content validity analysis showed that the I-CVI for item 11 was 0.571 (Table 4), indicating that item 11 was indeed inappropriate for Chinese nurses. The I-CVI values for the remaining items were from 0.857 to 1.000, and the S-CVI/Ave for the scale was 0.921.

The Bartlett’s test (25) for sphericity of exploratory factor analysis (EFA) was significant (χ² = 3883.060, p < 0.001) and the KMO index (26) was 0.889. The EFA results indicated that the factor loadings for the items ranged from 0.536 to 0.961 (Table 5). The 4-factor distribution was based on EFA, the CFA model was constructed using AMOS, and the model fit was analyzed. According to the Modification Index (MI), there was one modification to the original model: e17 and e18. Fit indices of the four-factor model (χ²/df = 2.264, GFI =0.905, CFI = 0.970, TLI = 0.964, RMSEA = 0.066, SRMR = 0.040). The results indicated that the fit of the 4-factor model was statistically acceptable. The regression coefficients are shown in Figure 1.

The SASN overall Cronbach alpha coefficient was 0.873 (95% CI:0.857–0.888), and its four-factor Cronbach coefficients are 0.979, 0.808, 0.820, and 0.918, respectively. Two weeks later, the 30 nurses who participated in the first survey rejoined the survey, and the Spearman correlation coefficient between the retest scores was 0.834 (p < 0.001).

The results of multiple regression analyses showed statistically significant correlations between overall scores on the nurses’ self-awareness scale and gender, age, work experience, and job title (Table 6). The score of the “professional awareness” subscale was related to gender, age, working experience, job title, and psychological distress. While the score of the “contextual awareness” subscale was related to age, average monthly income, working experience, and psychological distress. Gender, age, working experience, and job title were all associated with scores on the “personal awareness” and “consciousness awareness” subscales.

In conclusion, the four subscales and the total score were correlated with age and working experience. However, only some subscales of the four subscales were correlated with age, gender, job title, and psychological distress.

To the best of our knowledge, this study is the first attempt to introduce the scale to measure nurses’ level of self-awareness. After a rigorous cultural adaptation process, we translated the scale into Chinese and validated a scale with sufficient reliability and validity that is particularly suitable for assessing nurses’ self-awareness. Finally, a 17-item Chinese version of the SASN with a four-factor structure was created.

The original scale was a four-factor model containing 18 items. Factor 1 - contextual awareness (including items 1–3), Factor 2 - conscientious awareness (including items 4–7), Factor 3 - personal awareness (including items 8–12), and Factor 4 - professional awareness (including items 13–18). The Chinese version of SASN supports a four-factor model consisting of 17 items. Factor 1-professional awareness (including items 13–18), Factor 2-contextual Awareness (including items 1–4), Factor 3-conscientious awareness (including items 8, 9, 10, 12), and Factor 4-personal awareness (including items 5–7) (Table 5; Figure 1). The number of dimensions is the same as the original scale, but the number of items and the factor attribution of the items are slightly different.

First, this study translated and adapted the items according to the Chinese expressions, which may have affected the structure of the original scale to some extent. Second, self-awareness belongs not only to psychology, but it belongs to a multidisciplinary field of study. For example, in the field of cognition, a high degree of self-awareness may also protect attentional resources and counteract the deleterious effects of chronic stress on working memory (31). Furthermore, data from neuroimaging studies suggest that inducing self-awareness activates prefrontal cortex regions and helps regulate attention in that region related to working memory (32). In the field of psychology, an individual’s self-awareness is a psychological expression based on his or her perceptions, emotions, and will about himself or herself and his or her relationship with the external world (33). Overall, self-awareness describes a person’s understanding and perception of their environment (34). For nurses, Rasheed et al. (7) believe that self-awareness is essentially a subjective feeling like reflection and evaluation of one’s nursing work. Therefore, the understanding of self-awareness may vary across domains and cultural contexts. Meanwhile, the results of this study showed that Cronbach’s alpha coefficient increased significantly after the removal of item 11 (Table 3), and the content validity of the Chinese version of the SASN was assessed by experts, the I-CVI of item 11 was 0.571. Therefore, the expert group decided to remove item 11.

In addition, item 4 also changed the original dimension, probably because items 1–4 were patient-centered. Clinical care was patient-centered, so patient-centered situational awareness was essential. Finally, the nurses in our study had a high level of self-awareness. The possible reason for this is that a large percentage of nurses in this study had more than 11 years of professional experience (45.9%) and had undergraduate education (78.5%) (Supplementary materials). Similar studies have pointed out that the more experienced and educated nurses are the more significant the positive effect on their self-awareness (12, 19).

Self-awareness is an important tool to measure the professional development of nurses [7]. Professional awareness is described as being related to the recognition of one’s profession and the response to different nursing challenges (19). Nurses now assume many roles, which require them to continuously improve their professional knowledge and skills to ensure the safety of patients (35). As the largest group of nursing staff, nurses undertake important medical tasks such as patient assessment and 24-h nursing care (36). To a large extent, this requires nurses to have certain professional skills and expertise, such as being able to judge a patient’s condition promptly based on vital signs, thereby promoting better care. To a certain extent, this reflects the professional awareness of nurses. Based on the available literature and results, we still named factor 1 “professional awareness” and explained 36.936% of the total variance, indicating that it was the most important part of nurses’ self-awareness.

Contextual awareness involves an awareness of the personal and interpersonal factors that influence a situation (19). Meanwhile, results from a mixed study of nursing students suggest that being a good nurse is related to relationships and communication (37). Factor 2 has a patient-centered component, so we still name it “contextual awareness.” In Rasheed’s et al. (12) qualitative study, nurses considered contextualization to be part of self-awareness. Thomson et al. (36) interviewed six psychiatric nurses and concluded that situational awareness has an important role in contextualized care. If nurses are not aware of the underlying factors that affect them personally, interpersonally, this may hinder their ability to provide truly effective patient-centered care (38). Clinical nurses’ workloads, work time constraints, and personal stressors may affect their ability to understand contextualization. For this reason, future research may place more emphasis on this aspect of contextualization (9, 12, 36, 38).

Self-awareness is also a tool to measure nurses’ personal development and is described as the process of examining an individual’s thoughts, feelings, and emotions, all of which can affect their overall health and relationships with others (12). Stovall (39) suggests that everyone should emphasize the role of professional self-awareness by understanding their role, and their career. Self-awareness is essential for personal and professional development and for the development of a genuine nurse–patient relationship (10, 40). It is important to experience self-awareness and then use it healthily. It is the first step to taking better care of yourself and helping you to be resilient (7). So the personal awareness was within the scope of self-awareness and was closely related to it.

As clinical workers, nurses need to have a sense of responsibility. A sense of responsibility helps them to know their role and responsibilities in a given situation and to be able to act accordingly in their care (8). Self-awareness requires an awareness of responsibilities as an individual, each of which requires a different potential to manage the situation (12). Therefore, factor 4 was still named “conscientiousness awareness.”

In this study, nurses’ self-awareness was related to gender (Table 6). According to a related article (41), gender differences in self-awareness are primarily brought on by differences in people’s upbringing, social roles, and other factors due to cultural influences, rather than by biological differences between men and women. In traditional Chinese culture, women are frequently advised to be kind, avoid disagreement, demand cooperation, and maintain modesty when being socialized. The intention is for women to become more self-aware than men through maintaining healthy relationships, improving their capacity to comprehend others’ emotions during the socialization process, and valuing self-expression in public. In this culture, women also need to exercise more restraint, stillness, and reflection (41).

This study is consistent with previous findings (9, 19) that nurses’ self-awareness is affected by age, which may be since older clinical nurses tend to have more work and life experience, and greater self-awareness. Furthermore, this study found that self-awareness can have an impact on mental health. This may be attributed to the fact that self-awareness itself can help to understand and change one’s mental state (42–44).

Limitations that should be considered in this study include: (1) The study participants were part of the Northeast China nurses. Due to the differences between the north and south of China, these results are not fully representative of all nurses in China. (2) Measures of self-awareness can only reflect a subjective judgment of the participant at the time, so the results of the study should be interpreted with caution.