New 19-Item Scale Measures How ICU Nurses Reflect Critically on Delirium Care

Delirium remains one of the most feared and costly complications of intensive care, an acute brain dysfunction that strikes critically ill patients with alarming frequency and leaves a trail of consequences ranging from prolonged hospital stays and soaring healthcare costs to increased mortality and persistent cognitive impairment after discharge. For the nurses who staff intensive care units around the world, preventing, detecting, and managing delirium is among the most demanding tasks in modern medicine. Yet until now, no validated instrument has existed to measure a crucial ingredient of that capability: the capacity for critical reflection, the disciplined habit of examining one’s own clinical experiences against evidence, theory, and ethics to improve future decisions. A new study published in Nursing Open changes that, introducing and rigorously testing the Critical Reflection Competency in Delirium Care Scale, or CRCDCS, among Iranian ICU nurses.

Critical reflection is more than casual thinking about a difficult shift. Researchers define it as a structured, analytical learning process in which nurses systematically analyse clinical experiences, evaluate evidence-based practices, reconsider weaknesses in their own performance, and weigh ethical dimensions of care in complex situations. In the delirium context, this competency takes on particular urgency. Delirium is dynamic, unpredictable, and often distressing, requiring nurses to interpret biological, psychological, social, and ethical dimensions simultaneously while preserving patient dignity, minimising restrictive interventions, and staying within the bounds of clinical safety. Existing tools, such as the Critical Reflection Competency Scale developed by Shin and colleagues, the California Critical Thinking Disposition Inventory, and the Delirium Care Critical-Thinking Scale developed by Chang and colleagues in 2024, capture related but distinct constructs. None was designed to assess delirium-specific critical reflection, leaving a genuine measurement gap.

The research team, led by Fahimeh Magsoodi and Fatemeh Ghaffari of Babol University of Medical Sciences, conducted an exploratory mixed-methods study between June 2025 and March 2026, following the eight-step scale development framework of DeVellis and Thorpe. The construct was operationally defined as the ICU nurse’s ability to integrate scientific evidence, professional experience, ethical values, and theoretical knowledge through reflection-on-action and reflection-in-action, with the aim of sharpening clinical decision-making, improving care quality, and safeguarding the safety and dignity of patients with delirium. This definition deliberately spans cognitive, ethical, and anticipatory dimensions of practice rather than reducing reflection to a purely intellectual exercise.

Item generation combined deductive and inductive strategies. A systematic search of PubMed, CINAHL, Scopus, Web of Science, ProQuest, and Google Scholar identified 130 records, of which 21 studies ultimately met inclusion criteria and yielded 10 preliminary items through content analysis. To ground the instrument in real clinical behaviour, the team also conducted semi-structured interviews with 15 ICU nurses, each with at least a year of intensive care experience and direct care of at least five delirious patients in the preceding six months. Interviews lasting roughly 35 to 40 minutes explored how nurses reassessed clinical decisions, recognised gaps between evidence and practice, evaluated patient dignity and privacy, communicated with families, and interpreted early warning signs. Conventional content analysis of the transcripts produced 20 items organised into seven subcategories and three principal categories: Analytical-Evaluative Clinical Reflection, Person-Centered Ethical Reflection, and Risk-Oriented Preventive Reflection.

The qualitative work was conducted with careful attention to trustworthiness, following the criteria of Guba and Lincoln. Credibility was supported by purposive sampling with maximum variation, member checking with eight participants, and independent review of portions of the coding process. Transferability, dependability, confirmability, and authenticity were each addressed through detailed documentation, transparent tracing of items back to raw data, and secure archiving of research files. One illustrative example shows how a participant’s description of covering a patient’s body during procedures, limiting unnecessary visitors, and documenting lapses in dignity was distilled into a final item asking nurses to evaluate the extent to which respect, privacy, and physical comfort of delirious patients were maintained.

Expert review then tightened the instrument. A panel of 10 nursing faculty members with critical care and instrument-development experience evaluated 30 initial items for relevance, clarity, and linguistic transparency. Content validity ratios ranged from 0.40 to 1.00, and nine items falling below the Lawshe threshold of 0.62 were removed. Item-level content validity indices for retained items ranged from 0.80 to 1.00, with scale-level averages of 0.93 and 0.86 by the averaging and universal-agreement methods respectively. Face validity testing with 10 ICU nurses using the impact score formula eliminated two further items whose abstract concepts invited inconsistent interpretations, leaving a preliminary version that was then administered to 700 ICU nurses employed at hospitals affiliated with Babol and Mazandaran Universities of Medical Sciences. Following the Nunnally and Bernstein rule of at least 10 participants per item, the sample was randomly split into equal halves of 350 for exploratory and confirmatory factor analysis.

The statistical results were striking. Sampling adequacy was excellent, with a Kaiser-Meyer-Olkin value of 0.912 and a highly significant Bartlett’s test. Exploratory factor analysis using principal axis factoring with Promax rotation confirmed a clean three-factor structure matching the qualitative categories, with all 19 items loading between 0.633 and 0.853 and no substantial cross-loadings. The three factors explained 20.38, 19.37, and 17.59 percent of variance respectively, for a cumulative 57.34 percent. Parallel analysis supported the three-factor solution. Confirmatory factor analysis on the independent subsample, using the WLSMV estimator appropriate for ordinal data, produced excellent fit: a chi-square to degrees-of-freedom ratio of 1.14, RMSEA of 0.029, CFI of 0.986, TLI of 0.984, and SRMR of 0.041. A second-order model loading the three dimensions onto a single overarching competency yielded identical fit indices, a mathematical necessity when exactly three first-order factors are specified, so the authors caution that this equivalence confirms correlated dimensions rather than proving a hierarchical structure.

Reliability and validity evidence was equally robust. Cronbach’s alpha for the total scale was 0.876 and McDonald’s omega 0.861, with dimension-level coefficients ranging from 0.845 to 0.878. Test-retest reliability over a two-week interval with 30 participants produced an intraclass correlation coefficient of 0.85 for the total score. Average variance extracted exceeded 0.50 for all three factors and composite reliability exceeded 0.70, while the Fornell-Larcker criterion confirmed that each dimension was empirically distinct, with square roots of AVE between 0.732 and 0.746 exceeding inter-factor correlations of 0.350 to 0.420. Standard errors of measurement were low, between 0.42 and 0.51, indicating precise scores. In a methodological departure from conventional validation studies, the team also applied exploratory graph analysis, whose network estimation with the graphical LASSO algorithm and Walktrap clustering reproduced exactly the three theoretical communities, and random forest regression, which identified analytical-evaluative reflection as the strongest contributor to the internal score structure, followed by person-centered ethical and risk-oriented preventive reflection.

The authors are careful about what these findings do and do not establish. Because predictors and outcome in the random forest analysis came from the same item set, the results describe internal score structure rather than external predictive validity, and the convergent validity evidence is model-based rather than criterion-related, since no external instrument was administered alongside the CRCDCS. Limitations include the cross-sectional design, a sample drawn exclusively from teaching hospitals of two Iranian universities, reliance on self-report vulnerable to social desirability bias, and the absence of measurement invariance testing across subgroups. The three-level score interpretation bands, spanning low, moderate, and high competency across the possible 19 to 95 range, are conventional equal-range divisions rather than clinically validated cut-offs.

Even with those caveats, the study represents a significant advance for critical care nursing. The CRCDCS is the first instrument designed specifically to measure, in a multidimensional way, how intensively care nurses reflect critically on delirium care, and its development blended theory, qualitative clinical experience, classical psychometrics, network science, and machine learning in a single coherent pipeline. Pending further validation against external criteria and longitudinal outcomes, the 19-item scale offers hospital managers, educators, and policymakers a practical tool for identifying performance gaps, benchmarking professional preparedness, and evaluating training programmes aimed at strengthening reflective thinking in delirium care. Given that delirium affects a large share of ICU patients and that early recognition depends heavily on nursing vigilance, a reliable measure of the reflective competency behind that recognition could ultimately translate into better outcomes for some of the most vulnerable patients in medicine.

Subject of Research: Development and psychometric validation of a scale assessing ICU nurses' critical reflection competency in delirium care

Article Title: Development and Psychometric Evaluation of the Critical Reflection Competency in Delirium Care Scale (CRCDCS) Among Iranian ICU Nurses

Article References: Magsoodi, F., & Ghaffari, F. (2026). Development and Psychometric Evaluation of the Critical Reflection Competency in Delirium Care Scale (CRCDCS) Among Iranian ICU Nurses. Nursing Open, 13(9), Article e70818. https://doi.org/10.1002/nop2.70818

Image Credits: AI Generated

DOI: 10.1002/nop2.70818

Keywords: delirium, ICU nursing, critical reflection, scale development, psychometric validation, factor analysis, nursing competency, patient safety, reflective practice, network analysis, Iran, critical care