New Persian Scale Measures ICU Nurses’ Confidence in Fighting Delirium

Delirium is one of the most feared complications of intensive care. It strikes suddenly, clouding consciousness and cognition in patients who are already fighting for their lives, and it can affect as many as 80 percent of mechanically ventilated patients. In Iranian hospitals, the burden is substantial: a recent meta-analysis reported an overall delirium prevalence of 22 percent among hospitalized patients, rising to 44.3 percent among the elderly, while a cross-sectional study of Iranian intensive care units found that 22.43 percent of patients developed the condition during admission. The consequences reach far beyond the bedside, with delirium independently linked to prolonged mechanical ventilation, longer hospital stays, higher costs, long-term cognitive deficits, and increased mortality. Yet a striking gap persists between what guidelines recommend and what actually happens in clinical practice, and a new study from Ardabil, Iran, offers a fresh tool to close it.

International guidelines call for routine delirium monitoring using validated instruments such as the Confusion Assessment Method for the ICU or the Intensive Care Delirium Screening Checklist. Nurses, with their continuous 24-hour bedside presence, are uniquely positioned to catch the acute and fluctuating onset of delirium symptoms that periodic physician rounds may miss. But detection is genuinely difficult in this population. Up to 75 percent of ICU patients are mechanically ventilated, many are deeply sedated, and the interplay of metabolic disturbances, polypharmacy, and severe underlying illness can mask symptoms or lead clinicians to attribute them to the critical illness itself. Recognizing delirium early and delivering appropriate pharmacological and non-pharmacological interventions is vital to limiting its damage.

The Iranian data on nursing practice reveal why a new measurement approach is needed. One recent study found that 81 percent of ICU nurses had a poor perception of delirium assessment, 79.9 percent never performed delirium screening, and 93.1 percent had never participated in a delirium training course. In the region more broadly, 83 percent of nurses in Iraq reported no delirium-related training at all. Screening tools exist in Persian, but no instrument measured what psychologists consider a critical determinant of clinical behavior: self-efficacy, the belief in one’s own ability to perform essential tasks. According to Bandura’s social cognitive theory, self-efficacy is a powerful predictor of performance. Nurses with higher self-efficacy are more likely to engage in complex clinical behaviors, persist through challenges, and achieve better patient outcomes.

Existing generic instruments fall short of this task. The Generalized Self-Efficacy Scale addresses confidence in a broad context and does not target the unique challenges of delirium management, while the Nursing Professional Self-Efficacy Scale, though focused on critical care skills, omits the nuanced psychological and emotional dimensions of delirium care in high-pressure environments. Because Bandura argued that self-efficacy is domain-specific, a general measure cannot adequately capture nurses’ confidence in the particular skills of delirium assessment and management. The Delirium Care Self-Efficacy Scale for ICU nurses, developed by Chang and colleagues in Taiwan and later validated in mainland China, was designed to fill exactly this gap, measuring the attitudes, skills, and behaviors crucial for effective delirium care through 13 items across two factors.

A team of Iranian researchers led by investigators at Ardabil University of Medical Sciences has now translated, culturally adapted, and psychometrically validated the Persian version of this scale, known as the P-DCSE-I. Writing in Nursing Open, they report a methodological study conducted from February to August 2025 across four educational-therapeutic centers in Ardabil, following the COSMIN checklist for instrument validation. The translation followed the established forward-backward procedure of Beaton and colleagues: two bilingual translators independently produced Persian versions, the team synthesized them, two other blinded translators back-translated into English, and an expert committee resolved semantic, idiomatic, and conceptual inconsistencies before finalizing the version.

The sample consisted of 209 ICU nurses drawn from a census of 230 invited participants, a response rate of 90.9 percent that exceeded the minimum of 200 required for robust confirmatory factor analysis. Most participants were female, held bachelor’s degrees, and had a mean age of 33.84 years with roughly six and a half years of ICU experience. Notably, 73.2 percent had never completed a formal delirium education course, yet 69.4 percent expressed willingness to use delirium assessment tools, a combination that underscores both the unmet educational need and the latent motivation within the workforce. A pilot study with 20 nurses confirmed the questionnaire’s clarity and feasibility, with average completion times of five to ten minutes.

The psychometric results are strikingly strong. Face validity testing produced impact scores between 2.5 and 3.8, all above the retention threshold of 1.5. Content validity, judged by an independent panel of ten specialists, yielded item-level content validity indices between 0.8 and 1.0 and content validity ratios between 0.8 and 1.0, both exceeding accepted cutoffs. Exploratory factor analysis, conducted after confirming sampling adequacy with a Kaiser-Meyer-Olkin measure of 0.921, recovered a clean two-factor structure matching the original scale: confidence in delirium assessment, explaining 41.7 percent of variance, and confidence in delirium management, explaining 31.9 percent, for a cumulative 73.6 percent. Every item loaded above 0.715 on its intended factor with no meaningful cross-loadings, a cleaner solution than the Chinese adaptation, which had reported cross-loadings on three items.

The confirmatory phase set this validation apart from its predecessors. Neither the original Taiwanese study nor the Chinese version reported confirmatory factor analysis, but the Iranian team did, and the two-factor model fit the data well: the ratio of chi-square to degrees of freedom was 2.341, the root mean square error of approximation was 0.047, and the comparative fit index reached 0.948, all within accepted criteria. Because Likert-scale data departed from multivariate normality, the researchers applied a Bollen-Stine bootstrap correction with 2,000 samples to ensure unbiased estimates. Convergent validity was established with composite reliability above 0.7 and average variance extracted above 0.5 for both factors, while discriminant validity was confirmed because the maximum shared variance of 0.04 fell well below each factor’s average variance extracted, showing that the two subscales capture genuinely distinct dimensions. Common method bias was ruled out through Harman’s single-factor test, which attributed only 34.8 percent of variance to a single factor, and a common latent factor analysis that explained just 2.9 percent.

Reliability was equally convincing. Cronbach’s alpha reached 0.86 for the total scale, with subscale values of 0.82 and 0.84, complemented by McDonald’s omega and maximal reliability indices that confirmed high internal consistency. Test-retest stability over a two-week interval, assessed in 40 participants using a two-way random-effects intraclass correlation model, produced values of 0.84 to 0.86, indicating excellent reproducibility. The authors acknowledge limitations: the sample came from a single province, self-reported data may inflate scores in a collectivist culture where admitting low confidence carries social cost, the two-week retest window was short, and exploratory and confirmatory analyses used the same dataset rather than independent subsamples, a pragmatic choice given the specialized population but one that leaves the model awaiting true cross-validation.

The practical implications are considerable. Nurse managers and clinical educators can now use the P-DCSE-I to pinpoint exactly where confidence falters, whether in distinguishing hypoactive delirium from depression or in coordinating with physicians about sleep quality, and to design targeted training rather than generic instruction. Administering the scale before and after educational interventions or new delirium protocols provides quantitative evidence of effectiveness. Because self-efficacy is a modifiable psychological state rather than a fixed trait, the researchers envision the scale as a dynamic monitoring tool, integrated into quality frameworks, nursing curricula, and future multicenter studies that could establish national benchmarks. In a healthcare system where delirium affects roughly one in five hospitalized patients and most ICU nurses have never received formal delirium education, a rigorously validated measure of the confidence that drives clinical behavior may prove to be a deceptively simple instrument with far-reaching consequences for patient outcomes.

Subject of Research: Psychometric validation of the Persian Delirium Care Self-Efficacy Scale for intensive care unit nurses

Article Title: Psychometric Properties of the Persian Version of the Delirium Care Self‐Efficacy Scale for Intensive Care Unit Nurses: A Methodological Study

Article References: Fadaei, H., Shahmari, M., Nemati‐Vakilabad, R., & Belil, F. E. (2026). Psychometric Properties of the Persian Version of the Delirium Care Self‐Efficacy Scale for Intensive Care Unit Nurses: A Methodological Study. Nursing Open, 13(9), Article e70800. https://doi.org/10.1002/nop2.70800

Image Credits: AI Generated

DOI: 10.1002/nop2.70800

Keywords: delirium, ICU nursing, self-efficacy, psychometrics, scale validation, confirmatory factor analysis, Iran, nursing education, cross-cultural adaptation, reliability, construct validity, critical care