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The Compassion Competence Scale Arabic version: A validation study among

student nurses and interns in Saudi Arabia

Article  in  International Journal of Nursing Practice · May 2020

DOI: 10.1111/ijn.12843

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Received: 22 October 2019 Revised: 16 March 2020 Accepted: 15 April 2020
DOI: 10.1111/ijn.12843

RESEARCH METHODOLOGY PAPER

The Compassion Competence Scale Arabic version: A

validation study among student nurses and interns in
Saudi Arabia

Hawa Alabdulaziz PhD, RN, Assistant Professor1 |

2
Nahed Alquwez PhD, RN, Assistant Professor |
Jonas Preposi Cruz PhD, RN, Lecturer2 |
Regie Tumala EdD, RN, Assistant Professor3 |
Abdulrhman Albougami PhD, RN, Assistant Professor4 |
Monirah Albloushi PhD, RN, Assistant Professor3

1
Maternity and Children Department, Faculty
of Nursing King Abdulaziz University, Jeddah, Abstract
Saudi Arabia Aim: The aim of this study is to assess the validity and reliability of the Compassion
2
Nursing Department, College of Applied
Competence Scale Arabic version for Saudi nursing students and interns.
Medical Sciences, Shaqra University, Al
Dawadmi, Saudi Arabia Background: Compassion is an essential element of quality health care in which
3
Medical-Surgical Department, College of training nursing students to deliver compassionate care is important. Assessment of
Nursing, King Saud University, Riyadh, Saudi
Arabia compassion competence of Arabic-speaking nursing students requires a valid and
4
Department of Nursing, College of Applied reliable tool.
Medical Sciences, Majmaah University,
Design: This is a descriptive and cross-sectional study.
Majmaah, Saudi Arabia
Methods: This investigation was conducted from April to May 2019 in two universi-
Correspondence
ties in Saudi Arabia involving nursing students and interns. Cultural adaptation was
Jonas Preposi Cruz, Nursing Department,
College of Applied Medical Sciences, Shaqra performed using a forward–backward translation method. Content validity and
University, Al Dawadmi, Saudi Arabia.
construct validity through exploratory factor analysis were established. Internal con-
Email: [email protected]
sistency, stability and reliability were also determined for the scale.
Funding information
Results: The Arabic version has an excellent content validity. The exploratory factor
Deanship of Scientific Research (DSR), King
Abdulaziz University, Jeddah, Grant/Award analysis supported a three-factor solution that accounts for 50.62% of the scale's
Number: DF-035-668-1441
variance. The Cronbach's alpha of the scale was 0.806, whereas the Cronbach's alpha
of the subscales ranged from 0.739 to 0.797. The intraclass correlation coefficient of
the two-week test–retest scores was 0.84. The university, gender, year level and
family type predicted the students' compassion competence.
Conclusion: The Arabic version can be used to measure Arabic-speaking nursing
students' compassion competence in clinical areas.

KEYWORDS

compassion, compassion competence, nursing, students, psychometric properties, Saudi

Arabia

Int J Nurs Pract. 2020;e12843. wileyonlinelibrary.com/journal/ijn © 2020 John Wiley & Sons Australia, Ltd 1 of 9
https://doi.org/10.1111/ijn.12843
2 of 9 ALABDULAZIZ ET AL.

S U M M A R Y ST A T E M E N T well as compassion. Compassion among nursing students is seen as

the value and affective learning that shapes a robust system of values
What is already known about this topic? during their clinical training (Younas & Maddigan, 2019). Compassion
revolves around connection, care and respect in understanding people
• Compassion is an essential characteristic that nurses must possess as defined by medical and nursing students in the United Kingdom
in order to deliver quality nursing care. (Bickford et al., 2019).
• Nursing education has the responsibility to develop and transform Compassion and competence are intricately bound as concepts of
nursing students into compassionate future nurses. caring to the values and beliefs inherent to essential components of
• The Compassion Competence Scale is a valid and reliable tool nursing practice (Monks & Flynn, 2014). Watson (2008, p. 78)
assessing nurses' compassion competence in nursing practice. described compassion as the “capacity to bear witness to, suffer with,
and hold dear within our heart the sorrow and beauties of the world.”
What this paper adds? Compassion is expressed as showing sensitivity in understanding the
suffering of an individual; these individuals have the will to assist and
• The study delivered cultural and linguistic adaptation of the Com- support another person's well-being by searching for a solution to the
passion Competence Scale to Arabic for Saudi nursing students person's problem (Perez-Bret, Altisent, & Rocafort, 2016). Conse-
and nursing interns. quently, compassion is conveyed when staff nurses genuinely work to
• The Compassion Competence Scale Arabic version exhibited excel- comprehend the suffering of patients, thus becoming sensitive to their
lent content and construct validity, as well as acceptable internal experiences (Younas & Maddigan, 2019). Lee and Seomun (2016)
consistency and stability reliability when used among Saudi nursing have conducted a concept analysis that utilizes a hybrid model to cap-
students and interns. ture the concept of nurses' compassion competence. The results
• The study established the psychometric properties of the Compas- reveal that competence is the capacity of a person to perform the
sion Competence Scale Arabic version, enabling the valid and reli- responsibilities expected of him successfully within the norms of soci-
able assessment of the compassion competence of Saudi nursing ety. Competence is described among professionals as a habit that
students and interns. encompasses the thoughtful utilization of empirical knowledge,
applied skills, clinical reasoning, communication, emotions, reflection
The implications of this paper: and values on a daily basis in one's professional practice. Thus, nurses
must possess not only psychomotor and cognitive competencies but
• This study opens doors for international and cross-country com- also the affective competency to deliver excellent care built on the
parisons of compassion competence of nursing students and burden of suffering patients (Tilley, 2008).
interns. Nursing students and nursing interns are required to deliver
• The tool can be utilized as a routine assessment or screening mea- compassionate and competent care to clients and their families
sure to determine the level of compassion competence of nursing throughout the patient's lifespan during their clinical rotations. Thus,
students and form a basis for educational intervention. training nursing students to deliver compassionate care is essential to
• For clinical applications, the Compassion Competence Scale Arabic undergraduate nursing education (Hofmeyer et al., 2016, 2018). One
version can be used to screen nursing interns' compassion compe- of the policy frameworks proposed for nursing education to promote
tence, which can initiate the creation of in-service education and compassion entails incorporation of information and measures on
training programs to ensure the continuous development of com- how students understand and express themselves in the nursing
passion competence. curriculum (Younas & Maddigan, 2019). It is essential to develop
understanding of compassion and resilience for effective professional
practice among nursing students and nursing interns to ensure future
nurses are competent in providing compassionate care (Hofmeyer
1 | I N T RO D UC TI O N et al., 2016).
Developing compassion competence among undergraduate nurs-
Compassion is an essential element of quality health care, especially in ing students requires a validated tool that is appropriate for them. A
the nursing profession (Bickford, Daley, Sleater, Hebditch, & measurement tool capable of assessing compassion competence,
Benerjee, 2019). Compassion provides sense to what humane care is which was grounded on appropriate knowledge, skills and attitudes
all about. Compassion in the nursing profession is not limited to com- for nursing, has been created by Lee and Seomun (2016). The Com-
miserating with the challenges experienced by patients; it also implies passion Competence Scale is a simple and effective screening instru-
empowering patients through appropriately delivered nursing care ment has been proven to assess nurses' compassion competence in
(Dewar & Cook, 2014). Compassion is rightly anticipated by patients, South Korea (Lee & Seomun, 2016). This tool, however, was only
professional organizations and health care practitioners (Bickford tested among practicing nurses and no attempts had been done to
et al., 2019). Correspondingly, health care practitioners, including test its validity and reliability for nursing students and interns. Fur-
nurses, are expected to perform their roles with expertise and skill as thermore, to the best of our knowledge, no research tools have been
ALABDULAZIZ ET AL. 3 of 9

culturally adapted to assess compassion competence in nursing stu- 2.4 | Data collection
dents and nursing interns in Saudi Arabia. Hence, the study is relevant
in providing evidence on the psychometric properties of the Compas- A demographic data sheet collected information on students' age, sex,
sion Competence Scale Arabic version (SSC-A) when used among academic year level, type of family (nuclear or extended) and type of
nursing students and interns to allow accurate assessment of nursing living community (rural or urban).
students' compassion competence. It will also enable the creation of TThe Compassion Competence Scale by Lee and Seomun (2016)
educational interventions that are focused on students in terms of was created as a measure to screen nurses' compassion compe-
compassionate care. The study may also pave the way to more studies tence. The tool has 17 items, which can be responded as a five-
and cross-cultural studies on compassionate care and compassion point Likert scale (1 = strongly disagree to 5 = strongly agree). The
competence among nursing students and interns, thus, enriching the scale comprises three subscales: communication, sensitivity and
literature on this topic. insight. Dimension scores can be obtained by calculating the means
of the item-scores in each dimension. The total mean for the entire
scale can also be calculated. A high mean indicates a high level of
2 | METHODS compassion competence. The Cronbach's alpha of the scale was
0.91, whereas the subscale communication, sensitivity and insight
2.1 | Aim were 0.88, 0.77 and 0.73, respectively. The test–retest reliability
was 0.80. The exploratory factor analysis (EFA) supported the
The study examined the validity and reliability of the CCS-A and three-factor solution of the tool, with a cumulative percentage of
explored the demographic factors influencing the students' compas- variance of 55.94%. For convergent validity, the scale and its three
sion competence. subscales correlated strongly with other scales measuring compas-
sion (Lee & Seomun, 2016).
TA forward–backward translation method was used to translate
2.2 | Design the CCS-A (Beaton, Bombardier, Guillemin, & Ferraz, 2000). First,
two bilingual Saudis produced separate translations from English to
This is a quantitative and cross-sectional study. Arabic; both translators were assistant professors in nursing. Sec-
ond, a certified translator combined the two translations to create
an Arabic version. Third, this version was translated back to English
2.3 | Sample by two translators (unrelated to nursing), each producing separate
versions. Fourth, the translated and back-translated versions were
The investigation was conducted in two state universities in Saudi evaluated by five experts who judged the cultural and linguistic
Arabia. Both universities (referred as University A and B in this equivalence of the scale's items. The panel was also tasked to
study) are situated in Riyadh, Saudi Arabia. The baccalaureate pro- appraise the content validity by assessing each item's relevance to
gramme in nursing (BSN) in the country comprises 4 years of theo- the construct compassion competence (1 = not relevant to 4 = highly
retical and clinical nursing courses and a year of internship relevant; Polit & Beck, 2016). Fifth, the CCS-A was distributed to
programme after completion of the academic requirements. The first 50 nursing students (excluded in the main study) for pilot test. Con-
year of the programme is considered a preparatory year where stu- sequently, the Cronbach's alpha of the whole scale was 0.849,
dents are required to take basic courses. The nursing proper starts whereas its subscales were as follows: communication = 0.708, sen-
in the second year. sitivity = 0.807 and insight = 0.739. No item was reported to have
The sample size for this study was guided by the required sam- any problem.
ples for conducting factor analysis. Costello and Osborne (2005) The researchers coordinated with the heads of each depart-
stated that a ratio of 10 respondents for each item of the tool is ment to secure the schedule of the potential respondents. Upon
recommended. Hence, the required sample size for this study was securing the schedule, the researchers planned for the recruitment
170 nursing students. The students were deemed qualified to be a and data collection. The recruitment of participants was performed
respondent if they (1) were Saudi nationals, (2) registered full-time as by the researchers before the collection of data. The qualified stu-
sophomore, junior or senior BSN students in the two universities or dents were approached during their break. Students who agreed
registered in the internship programme and (3) had or were having to participate were given the survey with a cover letter with
clinical duties during the conduct of the study. Freshmen were regard to the study. Codes were included in the survey to allow
excluded because the preparatory programme did not have nursing the comparison of the test and retest scores. The students submit-
courses and clinical duties. To ensure the adequacy of the sample, a ted the filled-out questionnaires in the drop boxes that were set
universal sampling technique was employed. A total of 369 students up in various areas around the campus. Two weeks after the pre-
were deemed eligible to participate. However, only 317 question- liminary collection, a similar questionnaire was dispensed following
naires were returned and included in the analysis (response the codes. The data collection period lasted from April to May
rate = 85.9%). 2019.
4 of 9 ALABDULAZIZ ET AL.

2.5 | Ethical considerations TABLE 1 Demographic characteristics of the respondents

(n = 317)

This study is part of the protocol approved by an Ethical Review Com- n %

mittee (Reference Number: 1F-04). Administrative permissions were University
also sought from the management of the two universities. During the
University A 156 49.2
recruitment process, the information of the study, including the rights
University B 161 50.8
of the participants (i.e., voluntary participation and right to withdraw
Sex
participation) and the required participation of the students, were
Male 141 44.5
thoroughly explained to the respondents. A clarification was made to
Female 176 55.5
the students that participation was voluntary, and participation or
Academic level
nonparticipation did not have any bearing on their academic perfor-
mance. An informed consent was signed by those who agreed to First year 75 23.7

participate. Second year 86 27.1

Third year 94 29.7
Nursing interns 62 19.6
2.6 | Data analysis Family type
Nuclear family 186 58.7
The content validity of items (I-CVI) and the whole scale were calcu- Extended family 131 41.3
lated using averaging technique (S-CVI/Ave). Given that five experts
Community type
evaluated the content validity, the accepted values were one for the I-
Rural area 135 42.6
CVI and more than or equal to 0.90 for the S-CVI (Polit &
Urban area 182 57.4
Beck, 2016). The estimation of the tool's corrected item–total correla-
Mean (SD) Range
tion (ITC) for internal construct validity was done. An item with ITC
Age 21.15 (1.73) 18–27
less than 0.30 and greater than 0.80 was removed. In addition, items
were deleted if they caused more than 10% decrease in the
Cronbach's α of the overall scale. An EFA through principal compo- (SD = 0.79). The computed ITCs had a range of 0.30 to 0.57. None of
nent analysis (PCA) with varimax rotation was conducted in the scale. the items caused more than a 10% drop in the Cronbach's alpha of the
The criteria used in the EFA was eigenvalue >1 and factor loading of scale.
>0.40 (DeVellis, 2016). A Kaiser–Meyer–Olkin (KMO) test determined The results of the EFA were summarized in Table 3. The KMO
that the sample was adequate (KMO value ≥0.60), whereas Barlett's value was 0.745, and Bartlett's test was significant (P < 0.001). The
test of sphericity determined the correctness of the factor model. analysis revealed three distinct factors with a cumulative percentage
Internal consistency and test–retest reliability were achieved by of variance of 50.62%. Eight items loaded onto factor
Cronbach's alpha (≥0.70; Nunnally & Bernstein, 1994) and intraclass 1 (0.413–0.757) with an explained variance of 24.84%, five items
correlation coefficient (ICC; ≥0.80; Vincent, 2012). To examine the were loaded onto Factor 2 (0.683–0.773) with an explained variance
demographic variables associated with the students' compassion com- of 14.47%, and four items were loaded onto Factor 3 (0.657–0.774)
petence, a multiple regression analysis was conducted. Dummy vari- with an explained variance of 11.30%. Item 6 was loaded onto two
ables were created before entering the data in the analysis. factors, factor 1 (factor loading = 0.521) and Factor 3 (factor
P values < 0.05 denoted significance. loading = 0.437).
The Cronbach's α of the entire scale was 0.806, whereas the
subscales were as follows: (1) communication = 0.797, (2) sensitiv-
3 | RESULTS ity = 0.788, and (3) insight = 0.739. The ICC of the two-week test and
retest score was 0.84.
Among the 317 respondents, 156 (49.2%) were from University A and The overall mean score of the students in the CCS-A was entered
161 (50.8%) were from University B. More than half of the students into a regression analysis with the demographic variables as the pre-
were females (55.5%), belonging to a nuclear family (58.7%) and living dictor variables. The multiple regression model was statistically signifi-
in an urban area (57.4%). The students were fairly distributed across cant (F[8, 308] = 9.09, P < 0.001), explaining 17.0% of the variance of
various academic levels, with the highest proportion of respondents the students' compassion competence. Table 4 shows the regression
belonging to the junior level (29.7%), whereas the lowest proportion model results. Students from University B reported higher levels of
comprised nursing interns (19.6%). The average age of the students compassion competence compared with students from University A
was 21.15 years (SD = 1.73; Table 1). (ß = 0.20, P < 0.001, 95% CI [0.12, 0.28]). Moreover, female nursing
I-CVI and S-CVI/Ave values were computed. The computed I-CVI students exhibited higher levels of compassion competence compared
of the items were all 1, whereas the S-CVI/Ave was 1. As reflected in with male nursing students (ß = 0.16, P < 0.001, 95% CI [0.08, 0.24]).
Table 2, the item means ranged from 1.96 (SD = 1.19) to 3.85 Junior nursing students had a higher compassion competence score of
ALABDULAZIZ ET AL. 5 of 9

TABLE 2 Item mean, corrected item-total correlations and Cronbach's alpha if item is deleted (n = 317)

Corrected item-total Cronbach's alpha if

Item Mean SD correlation item is deleted
1. I can express my compassion towards patients through 3.23 1.02 0.39 0.795
communication with them
2. I am aware of how to communicate with patients to 3.85 0.79 0.33 0.797
encourage them
3. In conversation, I have a sense of humour to induce a 2.81 0.99 0.48 0.787
good mood in patients
4. Patients express their concerns and difficulties about 2.84 0.91 0.48 0.787
diseases to me
5. I try to support patients through nursing to help them 3.33 0.67 0.57 0.784
overcome their problems
6. When communicating with patients, I respond to them 1.96 1.19 0.47 0.789
with proper nonverbal presentation
7. I participate in education to develop interpersonal 2.92 0.98 0.48 0.787
relationship skills with patients, colleagues, and so forth
8. I can provide the required emotional support to patients 3.51 0.79 0.41 0.792
appropriately
9. I am careful in my speech and behaviours so as to avoid 3.66 0.76 0.30 0.799
hurting my patient's feelings
10. I always pay attention to what patients say 3.85 0.67 0.31 0.798
11. I promptly respond to patients when they ask for 3.24 0.73 0.32 0.798
attention
12. I am tolerant of others' opinions 3.44 0.67 0.34 0.797
13. I am well aware of changes in patients' emotional 3.63 0.64 0.32 0.798
condition
14. I am intuitive about patients because of my diverse 3.25 0.72 0.39 0.794
clinical experience
15. I offer customized care to patients by taking their 3.25 0.64 0.32 0.798
characteristics into consideration
16. I look after patients without being influenced by 3.19 0.68 0.44 0.791
personally challenging situations
17. I can empathize well with patients' difficulty 3.72 0.65 0.35 0.796

0.16 (P = 0.047, 95% CI [0.00, 0.32]) than nursing interns. Nursing stu- The findings revealed that the content validity of the CCS-A was
dents that belonged to an extended type of family reported higher excellent. The five-member panel of experts concurred that each item
scores of 0.17 (P < 0.001, 95% CI [0.09, 0.24) than those belonging to in the scale was in agreement in gauging the compassion competence
a nuclear type of family. of Saudi nursing students. The creation of the tool items was centred
on the conceptual analysis of compassion competence and the inter-
views of nurses about compassion competence. The results reported
4 | DISCUSSION that respect and empathy for patients, emotional connection and
communication with patients with warmth and insight, responsibility
Compassion has been thought as one of the essential assets of the to acquire extensive nursing knowledge and constant efforts to
nursing profession and is a critical component of quality nursing care develop one's self were the key concepts of compassion competence
(Lee & Seomun, 2016). Compassion adds value to how nurses deliver among nurses, which served as the basis in constructing the items on
quality nursing care through understanding and recognizing patient's the scale (Lee & Seomun, 2016). The panel agreed that the scale items
holistic needs and delivering care that is considerate, respectful and were conceptually appropriate for nursing students and was in agree-
accepting. Measuring compassion competence among nursing stu- ment with the cultural background of the nursing students. Further-
dents and interns is the first step to understanding areas on this con- more, by looking at the item analysis results, the ITC values were
struct that needs to be enhanced to ensure the development of within the acceptable range, and none of the items caused more than
compassionate future nurses. The present investigation has proven 10% decrease in the scale's Cronbach's α when deleted. These find-
the validity and reliability of such measure among Saudi nursing ings indicated that all the items correlated well with the scale score,
students. and each item contributed to the internal consistency of the scale.
6 of 9 ALABDULAZIZ ET AL.

TABLE 3 Results of factor analysis (n = 371) following reasons: (a) it had a stronger correlation with factor 1 (Nun-

Item Factor 1 Factor 2 Factor 3 nally & Bernstein, 1994) and (b) the latent nature of the items was
related to the construct of the factor (Yong & Pearce, 2013).
8 0.757
Factor 1 was labelled as “communication,” following the original
2 0.690
scale. Communication was defined as “expressing understanding and
5 0.685
compassion toward patients and their families” (Lee & Seomun, 2016,
3 0.667
p. 80). The factor contained items with regard to nurses' use of com-
4 0.659
munication to express compassion and to encourage patients, such as
7 0.548 sense of humour, patient's expression of concerns and challenges and
6 0.521 0.437 the use of nonverbal cues when communicating to patients. Previous
1 0.413 studies underscored the importance of communication in compassion-
11 0.773 ate care. Ortega-Galán et al. (2019) stated that effective communica-
13 0.747 tion; active listening; and attentive, calm and unpressured interaction
9 0.731 with patients could create effective communication, which was essen-

12 0.698 tial to end of life care. Nurses' communication skills were vital in
ensuring compassionate care. Similar to the original scale, factor
10 0.683
2 was named “sensitivity.” Lee and Seomun (2016) reported that sen-
16 0.774
sitivity entailed carefully observing and recognizing and appropriately
14 0.688
reacting to the changing emotions of patients. Nurses must have the
15 0.686
ability to sense and acknowledge a patient's feelings, difficulties and
17 0.657
challenges to provide compassionate care effectively. The concepts of
Variance explained 24.84 14.47 11.30
being mindful of actions and reactions towards the patient, paying
Cumulative variance explained 24.84 39.32 50.62 attention to the patient, responding to patients promptly, being toler-
ant and being aware of the patient's emotional changes were the
The EFA supported a three-factor solution to the scale, which items that loaded into the factor. In the qualitative study that was
was similar to the original scale factor solution (Lee & Seomun, 2016). conducted among patients' experience, the patients recognized com-
The explained variance of the three factors was adequate, indicating passionate care when nurses show awareness and understanding
that the three factors had substantial contribution to predicting the about the suffering of the patients; thus, nurses must show sensitivity
compassion competence of nursing students (Brown, 2015; to the patients' condition (Bramley & Matiti, 2014). The third factor
Kline, 2014). The items had high factor loadings on the factor that was labelled as “insight.” Lee and Seomun (2016) reported that insight
they loaded, signifying that each factor was considerably accounted was the act of having a clear understanding of the patient and identi-
for by their items (Yong & Pearce, 2013). However, item 6 was split- fying and recognizing the patient's needs and condition with profes-
loaded into factors 1 and 3. A higher factor loading was recorded in sional knowledge. This factor showed that being compassionate was
factor 1 than in factor 3. Item 6 was consistent with the construct of not only about being sensitive to the situation of the patient or about
the items in factor 1. Thus, this item was retained in factor 1 for the communicating effectively with them. Compassion was also about

TABLE 4 Result of the regression analysis on the overall compassion competence (n = 317)

Predictor variables B SE Beta t P 95% confidence interval

Lower Upper
***
University 0.20 0.04 0.26 4.86 <0.001 0.12 0.28
Gender 0.16 0.04 0.22 4.06 <0.001*** 0.08 0.24
Age −0.01 0.02 −0.02 −0.18 0.860 −0.04 0.04
Academic level (Reference group: Nursing interns)
Second year 0.00 0.10 0.00 −0.00 0.998 −0.20 0.20
Third year 0.16 0.08 0.19 2.00 0.047* 0.00 0.32
Fourth year 0.11 0.07 0.13 1.52 0.130 −0.03 0.24
Family type 0.17 0.04 0.22 4.10 <0.001*** 0.09 0.24
Community type −0.05 .039 −0.06 −1.14 0.257 −0.12 0.03
2 2
Note: R = 0.191, adjusted R = 0.170.
*
Significant at 0.05.
***
Significant at 0.001.
ALABDULAZIZ ET AL. 7 of 9

understanding the situation of the patient and providing appropriate result might be explained by parenting and attachment styles, which
and customized care suitable to their condition based on empirical were critical in the development of one's empathy later in life (Essays,
knowledge. This kind of care could be achieved if nurses were able to UK, 2018). A previous study argued that children in a supportive fam-
build a rapport with the patient, which enables nurses to have a deep ily and those who had parents who support the emotional expression
assessment of the patients' condition and engage the patient in the of children were highly emphatic (Taylor, Eisenberg, Spinrad, Eggum, &
nursing care process (Lown, Rosen, & Marttila, 2011). Sulik, 2013). Being in an extended family exposes the individual to
The scale and its factors' Cronbach's alpha were above the social events and interactions, which could further shape the emo-
accepted cut-off. This indicated that the internal consistency of the tional reactions of the person.
scale was good, signifying the coherence of the items in the scale
(Nunnally & Bernstein, 1994). Similarly, the original scale had good
internal consistency (Lee & Seomun, 2016). To support the scale's reli- 4.1 | Study limitations
ability, the ICC of the two-week test and retest scores were obtained,
and the value was higher than the acceptable value of 0.80 (Vincent, The validity test was only limited to EFA. Future studies should be
1999). This finding implied that the CCS-A was efficient in the mea- conducted using other validity tests, such as convergent, divergent
surement of compassion competence of Saudi nursing students with and discriminant validity tests. In addition, the study was only con-
consistency over time (Boateng, Neilands, Frongillo, Melgar- ducted in one region in the country. Hence, future studies should
Quiñonez, & Young, 2018). The same ability of consistent measure- include a wider range of study settings. This study focused on nursing
ment was reported by Lee and Seomun (2016) in the original version students only. Another study must test the scale's validity and reliabil-
of the scale. ity among practicing nurses in Saudi Arabia.
With regard to the relationship between the students' demo-
graphic profile and compassion competence, the analysis revealed
that the university, gender, academic level and family types were 5 | C O N CL U S I O N
associated with the respondents' compassion competence. Differ-
ences in compassion competence were observed between the stu- The study was carried out to examine the psychometric properties of
dents from the two universities, with students from University B a culturally and linguistically adapted tool in measuring Saudi nursing
reporting higher levels of compassion competence than the students students' compassion competence. The study concludes that the
from University A. A plausible explanation for this was that environ- CCS-A is a valid and reliable tool that can be used in measuring Saudi
mental factors, such as organizational and individual factors, could nursing students and interns' compassion competence. The study pro-
play an important role in creating a caring environment, which would vides evidence that compassion competence varies between students
allow compassionate care (Christiansen, O'Brien, Kirton, Zubairu, & depending on the university, gender, year-level and type of family.
Bray, 2015). Studies reported that compassion could be learned Ensuring that future nurses possess the necessary competence
(e.g., Hofmeyer et al., 2016, 2018). Strategies and methods of teach- to deliver quality nursing care is a critical function of nursing schools.
ing and learning might vary from one institution to another, which Similarly, nursing students must develop and maintain compassion
may lead to varying levels of development of compassion. Similarly, competence as they navigate through their years in the nursing
nursing students often struggle with compassionate care, and often- school, as well as when they transition to the clinical settings. In
times, their compassion deteriorate as they become more immersed in order to develop such competence, nursing educators, both in the
the demanding clinical environment (Booth, 2016). classroom and clinical settings, must plan and implement interven-
Female students reported higher levels of compassion compe- tions and activities to foster compassion among students. A valid and
tence than male students. Similar results were reported among nurs- reliable tool is essential to assess the areas concerning compassion of
ing students in Korea (Kim, 2018) and medical students in Saudi students that needs to be improved or sustained. Hence, this study
Arabia (Hamed, Alahwal, Basri, & Bukhari, 2015). Some studies argued provided evidence that the CCS-A could be used to provide valid and
that sex differences with regard to compassion were highly depen- reliable assessments of Saudi nursing students' compassion
dent on the social context, in which societal norms dictate gender competence.
roles and expectations (Michalska, Kinzler, & Decety, 2013; O'Brien, The results of the study have opened plenty of opportunities for
Konrath, Grühn, & Hagen, 2012). These factors might explain the dif- nursing research, education and practice. For nursing research, the
ferences in the findings. Saudi Arabia is known to have a patriarchal CCS-A can be employed to measure the compassion competence of
society, where men are perceived and expected to be strong and students in this part of the world accurately, thus contributing to the
dominant. In Saudi society, showing weak emotions is uncommon for literature. This study will also open doors for international and cross-
Arab men. Alghowinem, Goecke, Wagner, and Alwabil (2019) reported country comparisons of compassion competence. For nursing educa-
that women were found to be emotionally expressive, whereas men tion, the tool can be utilized as a routine assessment or screening
manifested strong emotions. measure to determine the level of compassion competence of nursing
Furthermore, students belonging to extended families reported students and interns and form a basis for educational intervention.
higher compassion competence than those from nuclear families. This This method can also be used to evaluate the effectiveness of existing
8 of 9 ALABDULAZIZ ET AL.

educational programs in the country, which aim to encourage compas- Brown, T. A. (2015). Confirmatory factor analysis for applied research (2nd
sionate care among nursing students and interns. The tool can also be ed.). London: The Guilford Press.
Christiansen, A., O'Brien, M. R., Kirton, J. A., Zubairu, K., & Bray, L. (2015).
used by nursing instructors to assess the areas on providing compas-
Delivering compassionate care: the enablers and barriers.
sionate care that needs to be improved in the students. For clinical British Journal of Nursing, 24, 833-837. https://doi.org/10.12968/bjon.
applications, the CCS-A can be used to screen nursing interns' 2015.24.16.833.
compassion competence, which can initiate the creation of in-service Costello, A. B., & Osborne, J. W. (2005). Best practices in exploratory
factor analysis: Four recommendations for getting the most from your
education and training programs to ensure the continuous develop-
analysis. Practical Assessment, Research, and Evaluation, 10, 1-9.
ment of compassion competence. Available online: http://pareonline.net/getvn.asp?v=10&n=7.
DeVellis, R. F. (2016). Scale development theory and applications (4th ed.).
FUND ING INFORMATION Thousand Oaks: Sage Publications.
Dewar, B., & Cook, F. (2014). Developing compassion through a
This work was funded by the Deanship of Scientific Research (DSR),
relationship centered appreciative leadership programme. Nurse
King Abdulaziz University, Jeddah, Saudi Arabia, under grant No.(DF- Education Today, 34, 1258–1264. https://doi.org/10.1016/j.nedt.
035-668-1441). The authors, therefore, acknowledge with thanks 2013.12.012
DSR technical and financial support. Essays, UK. (November 2018). Factors Affecting Empathy: Theories Analy-
sis. Retrieved from https://www.ukessays.com/essays/psychology/
factors-affecting-empathy-theories-6059.php?vref=1
CONF LICT OF IN TE RE ST
Hamed, O. A., Alahwal, A. M., Basri, A. H., & Bukhari, B. M. (2015). Per-
The authors declare no conflict of interest. sonal, cultural and academic factors affecting empathy score in third
year medical students. International Journal of Education and Research,
AUTHORS' CONTRIBUTI ON S 3, 727–740.
Hofmeyer, A., Toffoli, L., Vernon, R., Taylor, R., Fontaine, D.,
All authors contributed equally to the conception or design of the
Klopper, H. C., & Coetzee, S. K. (2016). Teaching the practice of com-
work. The acquisition of data were done by NA, JPC and AA. The passion to nursing students within an online learning environment: A
analysis and interpretation of data were performed by HA, NA and Qualitative Study Protocol. Contemporary Issues in Education Research,
JPC. Drafting the work was performed by HA, NA, JPC and 9, 201–222.
Hofmeyer, A., Toffoli, L., Vernon, R., Taylor, R., Klopper, H. C.,
RT. Revising it critically for important intellectual content was done by
Coetzee, S. K., & Fontaine, D. (2018). Teaching compassionate
all authors. Final approval of the version to be published was care to nursing students in a digital learning and teaching
employed by all authors. environment. Collegian, 25, 307–312. https://doi.org/10.1016/j.
colegn.2017.08.001
Kim, J. (2018). Factors influencing nursing students' empathy. Korean Jour-
ORCID
nal of Medical Education, 30, 229–236. https://doi.org/10.3946/kjme.
Hawa Alabdulaziz https://orcid.org/0000-0002-1120-9438 2018.97
Jonas Preposi Cruz https://orcid.org/0000-0002-3758-1414 Kline, P. (2014). An easy guide to factor analysis. New York, NY: Routledge.
Regie Tumala https://orcid.org/0000-0002-0558-1751 Lee, Y., & Seomun, G. (2016). Development and validation of an
instrument to measure nurses' compassion competence. Applied
Nursing Research, 30, 76–82. https://doi.org/10.1016/j.apnr.2015.
RE FE R ENC E S 09.007
Alghowinem, S., Goecke, R., Wagner, M., & Alwabil, A. (2019). Evaluating Lown, B. A., Rosen, J., & Marttila, J. (2011). An agenda for improving com-
and validating emotion elicitation using English and Arabic movie clips passionate care: A survey shows about half of patients say such care is
on a Saudi sample. Sensors, 19, 2218. https://doi.org/10.3390/ missing. Health Affairs, 30(9), 1772–1778. https://doi.org/10.1377/
s19102218 hlthaff.2011.0539
Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz, M. B. (2000). Michalska, K. J., Kinzler, K. D., & Decety, J. (2013). Age-related sex
Guidelines for the process of cross-cultural adaptation of self-report differences in explicit measures of empathy do not predict
measures. Spine, 25, 3186–3191. https://doi.org/10.1097/00007632- brain responses across childhood and adolescence. Developmental
200012150-00014 Cognitive Neuroscience, 3, 22–32. https://doi.org/10.1016/j.dcn.2012.
Bickford, B., Daley, S., Sleater, G., Hebditch, M., & Benerjee, S. (2019). 08.001
Understanding compassion for people with dementia in medical and Monks, J., & Flynn, M. (2014). Care, compassion and competence in critical
nursing students. BMC Medical Education, 19, 35. https://doi.org/10. care: A qualitative exploration of nurses' experience of family
1186/s12909-019-1460-y witnessed resuscitation. Intensive and Critical Care Nursing, 30,
Boateng, G. O., Neilands, T. B., Frongillo, E. A., Melgar-Quiñonez, H. R., & 353–359. https://doi.org/10.1016/j.iccn.2014.04.006
Young, S. L. (2018). Best practices for developing and Nunnally, J., & Bernstein, I. (1994). Psychometric theory. New York:
validating scales for health, social, and behavioral research: a primer. McGraw-Hill.
Frontiers in Public Health, 6, 149. https://doi.org/10.3389/fpubh.2018. O'Brien, E., Konrath, S. H., Grühn, D., & Hagen, A. L. (2012). Empathic
00149 concern and perspective taking: Linear and quadratic effects of age
Booth, L. (2016). Compassion: a universal language. Contemporary across the adult life span. Journals of Gerontology Series B: Psychological
Nurse, 52, 366–368. https://doi.org/10.1080/10376178.2016. Sciences and Social Sciences, 68, 168–175. https://doi.org/10.1093/
1221325 geronb/gbs055
Bramley, L., & Matiti, M. (2014). How does it really feel to be in my shoes? Ortega-Galán, A.  M., Ruiz-Fernández, M. D., Carmona-Rega, M. I.,
Patients' experiences of compassion within nursing care and Cabrera-Troya, J., Ortíz-Amo, R., & Ibáñez-Masero, O. (2019).
their perceptions of developing compassionate nurses. Journal of Competence and compassion: Key elements of professional care at
Clinical Nursing, 23, 2790–2799. https://doi.org/10.1111/jocn.12537 the end of life from caregiver's perspective. American Journal of
ALABDULAZIZ ET AL. 9 of 9

Hospice and Palliative Medicine, 36, 485–491. https://doi.org/10. nursing classics: An essential resource (pp. 243–264). USA, Boulder, CO:
1177/1049909118816662 University Press of Colorado.
Perez-Bret, E., Altisent, R., & Rocafort, J. (2016). Definition of Yong, A. G., & Pearce, S. (2013). A beginner's guide to factor analysis:
compassion in healthcare: A systematic literature review. International Focusing on exploratory factor analysis. Tutorials in Quantitative
Journal of Palliative Nursing, 22, 599–606. https://doi/10.12968/ijpn. Methods for Psychology, 9, 79–94. https://doi.org/10.20982/tqmp.09.
2016.22.12.599 2.p079.
Polit, D. F., & Beck, C. T. (2016). Nursing research: Generating and assessing Younas, A., & Maddigan, J. (2019). Proposing a policy framework for nurs-
evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott ing education for fostering compassion in nursing students: A critical
Williams & Wilkins. review. Journal of Advanced Nursing, 75, 1621–1636. https://doi.org/
Taylor, Z. E., Eisenberg, N., Spinrad, T. L., Eggum, N. D., & Sulik, M. J. 10.1111/jan.13946
(2013). The relations of ego-resiliency and emotion socialization to
the development of empathy and prosocial behavior across early
childhood. Emotion, 13(5), 822–831. https://doi.org/10.1037/
a0032894 How to cite this article: Alabdulaziz H, Alquwez N, Cruz JP,
Tilley, D. D. S. (2008). Competency in nursing: A concept analysis.The Jour-
Tumala R, Albougami A, Albloushi M. The Compassion
nal of Continuing Education in Nursing, 39(2), 58–64.
Vincent, W. J. (1999). Statistics in Kinesiology. Champaign, IL: Human Competence Scale Arabic version: A validation study among
Kinetic. student nurses and interns in Saudi Arabia. Int J Nurs Pract.
Vincent, W. J. (2012). Statistics in kinesiology. Champaign, IL: Human 2020;e12843. https://doi.org/10.1111/ijn.12843
Kinetic.
Watson, J. (2008). Nursing: the philosophy and science of caring (revised
edition). In M. C. Smith, M. C. Turkel, & Z. R. Wolf (Eds.), Caring in

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