Newer direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, and dabigatran offer predictable pharmacokinetics and no routine coagulation monitoring, but both classes carry bleeding risk. A knowledge test that could serve both populations, in the patient's own language and dialect, was the study's central goal. The adaptation followed two internationally recognized frameworks: the ISPOR Task Force's Principles of Good Practice for translating patient-reported outcome measures and the COSMIN taxonomy for health measurement instruments.

Two native Arabic speakers translated the 28-item tool independently, a third blinded translator translated it back into English, and the team reconciled discrepancies to secure conceptual equivalence. A panel of ten cardiovascular and anticoagulation specialists then rated every item for relevance on a five-point scale. A pilot with ten patients refined the language further, producing a mean clarity score of 4.44 out of 5, with roughly ninety percent of items rated clear or very clear.

The revisions were mostly dialectal: Iraqi Arabic handles idioms about diet and bleeding symptoms differently from Modern Standard Arabic, and the team adjusted phrasing so the questions resonated with local vernacular. The validation cohort then enrolled 280 adult outpatients at the Ibn Al-Bitar Center for Cardiac Surgery in Baghdad between mid-October and mid-December 2025, split evenly between 140 warfarin users and 140 DOAC users, matching the recommended ten participants per questionnaire item. Mean age was 54.5 years, with DOAC patients significantly older on average than warfarin patients.

Education levels also differed between the groups, a detail that would prove central to the findings. That central finding is stark: educational attainment was the only sociodemographic variable that significantly predicted knowledge scores in both cohorts. Among DOAC patients, one-way ANOVA yielded p = 0.003 for education; among warfarin patients, p = 0.006.

Patients with college or higher education scored highest (11.00 and 16.65 mean points respectively), while illiterate patients and those with only primary schooling occupied the lowest strata. Sex, age group, and even duration of therapy showed no significant association with knowledge in either group. Neither warfarin nor DOAC users showed any measurable improvement in pharmacological understanding as a function of how long they had been on therapy.

The assumption that patients gradually absorb knowledge through repeated clinic visits and prescription refills does not survive contact with this data. Knowledge of oral anticoagulation, the authors argue, is not acquired passively; it requires active, structured, health-literacy-appropriate education, which points directly at pharmacist-led counseling programs as the intervention of choice. The psychometric structure of the tool turned out to be more intricate than a single reliability number can capture.

For DOAC patients, the 20-item general scale showed acceptable internal consistency with Cronbach's alpha of 0.700. For warfarin patients, the full 28-item scale aggregated to a poor alpha of 0.512 — but that headline number conceals excellent domain-level reliability. Principal component analysis with varimax rotation extracted ten components explaining 75.44 percent of total variance, and the five items covering warfarin-specific INR knowledge loaded between 0.832 and 0.981 on a single factor with an alpha of 0.972.

Bleeding-safety items and healthcare-communication items formed further coherent, independently reliable clusters. The DOAC cohort yielded eight components explaining 70.17 percent of variance, led by a strong adverse-effects-and-bleeding factor with loadings up to 0.935. This pattern makes sense once anticoagulation knowledge is treated as what psychometricians call a formative index rather than a reflective scale.

In a reflective model, all items are driven by one underlying trait and should correlate; in a formative index, distinct factual elements — INR targets, missed-dose protocols, dietary interactions — combine to build the construct, and there is no theoretical reason they must covary. The low global alpha for the warfarin scale is therefore not a failure of the tool but a description of how fragmented real-world medication knowledge actually is, and it is precisely this fragmentation that lets the instrument triage education toward specific deficits. The cross-sectional design cannot track how knowledge evolves, predictive validity against clinical outcomes such as time in therapeutic range or bleeding events was not assessed, and recruitment at a specialized tertiary center in Baghdad may overestimate knowledge relative to resource-constrained rural clinics.

The Iraqi-dialect tuning, while a strength locally, may need cognitive debriefing before use in other Arab countries.

Subject of Research: Cultural adaptation and psychometric validation of the Oral Anticoagulation Knowledge Tool for Arabic-speaking Iraqi patients

Article Title: Cultural adaptation and validation of the Oral Anticoagulation Knowledge Tool in Arabic-speaking Iraqi patients

Article References: Al-Jailawi, Y. T. S., Al-Metwali, B. Z., & Ouj, R. H. (2026). Cultural adaptation and validation of the Oral Anticoagulation Knowledge Tool in Arabic-speaking Iraqi patients. Pharmacia, 73, Article e197938. https://doi.org/10.3897/pharmacia.73.e197938

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e197938

Keywords: oral anticoagulants, warfarin, DOACs, patient knowledge, psychometric validation, cross-cultural adaptation, Iraq, health literacy, INR monitoring, Cronbach's alpha, principal component analysis, clinical pharmacy

The instrument is adapted from the Patient Engagement in Patient Safety within Canadian Healthcare Organizations tool, which was developed to self-assess patient engagement in safety at the systemic level within healthcare organizations. The study did not test whether the tool improves safety outcomes or whether engagement causes reductions in harm. Instead, it examined whether a Canadian organizational assessment could be translated and adapted for use in Brazil without losing equivalence, and whether the resulting content was understandable, relevant and comprehensive for the intended setting.

This distinction places the work within measurement development rather than an evaluation of clinical effectiveness. Cross-cultural adaptation was completed in six stages: preparation, translation, back-translation, pre-test, review and documentation. The pre-test involved nine health organizations.

Equivalences between versions were evaluated using a coefficient of agreement, and items receiving agreement below 90% were discussed until consensus was reached. At the end of this process, 97.9% of the items were considered equivalent by 100% of the evaluators. These figures describe the assessment of equivalence during adaptation; they do not establish the instrument’s repeatability, measurement structure or relationship with safety indicators in routine use.

The second phase used a two-round Delphi technique to assess content validity. A committee of seven experts, including a partner patient, rated the adapted instrument in terms of comprehensiveness, clarity and relevance. Most items met acceptable Content Validity Index and inter-rater agreement values, reported for the study as 99.6% and 99.0%, respectively.

Items with unsatisfactory results were modified, reassessed and, after approval by all experts, incorporated into the finalized instrument. After completion of the adaptation and validation process, the instrument was finalized and made available for use in Brazil. The authors concluded that it provides evidence of cross-cultural adaptation and content validity, as well as preliminary evidence of feasibility and applicability for assessing patient engagement in patient safety within Brazilian healthcare organizations.

Larger and more diverse samples are therefore needed to expand psychometric evaluation and strengthen the evidence for broader use. The study was published as open access in BMC Health Services Research .

Subject of Research: Cross-cultural adaptation and content validation of a Brazilian patient-safety engagement instrument for healthcare organizations

Article Title: First Brazilian instrument for assessing patient engagement in patient safety: a cross-cultural adaptation and content validation study

Article References: Sousa, M. R. G. D., Freitas, J. S. D., Lima, J. C. D., Silva, K. D. C., Pomey, M. P., Aho-glele, U., & Silva, A. E. B. D. C. (2026). First Brazilian instrument for assessing patient engagement in patient safety: a cross-cultural adaptation and content validation study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15377-2

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15377-2

Keywords: patient safety, patient engagement, Brazil, cross-cultural adaptation, content validity, healthcare organizations, measurement development, patient partner, Delphi technique, organizational assessment, First, Brazilian

The study, led by Márta Fekete of Uzsoki Hospital in Budapest together with Patricia Lajko of Semmelweis University and colleagues including corresponding author Xenia Gonda, recruited 223 Hungarian-speaking participants aged 50 and above. Each respondent completed a Hungarian adaptation of the CASP-19 that used a modified agreement-based response format — a seemingly small design decision that, as the authors show, can ripple through the entire measurement. The work was approved by the Scientific and Research Ethics Committee of the Medical Research Council of Hungary, and the team supplemented the CASP-19 with a battery of established quality-of-life instruments to test whether the scale actually measures what it claims to measure.

The headline number is impressive. The full 19-item questionnaire achieved a Cronbach’s alpha of 0.91, a statistic that ranges from zero to one and expresses how tightly the items hang together; anything above 0.90 is generally considered excellent for a multi-dimensional scale. In plain terms, when a Hungarian respondent reports a strong sense of control over their life, they are very likely to also report high autonomy, self-realization and pleasure. For researchers and clinicians who want a single summary score of psychosocial quality of life in later life, the Hungarian CASP-19 delivers one they can trust.

But the deeper story lies in the factor analysis — the statistical machinery used to ask how many separate psychological dimensions actually live inside a questionnaire. The team ran a principal axis factoring with varimax rotation, a classical exploratory technique that extracts underlying factors from the correlations among items. This yielded a four-factor solution explaining 53.1 percent of the total variance, superficially matching the theory. Yet when the researchers applied sensitivity analyses — parallel analysis, which compares observed factors against those arising from random noise, and oblique rotation, which allows factors to correlate — the evidence favoured fewer factors. The tidy four-part architecture of the CASP framework, it turns out, is partly in the eye of the beholder.

The most telling detail concerns the boundary between Control and Autonomy, two dimensions that sound distinct in theory but blur in practice. In the Hungarian data, all of the Autonomy items and most of the Control items loaded onto a single common factor, meaning that respondents do not experience these two ideas as psychologically separable. Control, in the CASP framework, refers to the sense of being able to influence one’s own life, while Autonomy concerns freedom from the dictates of others. In the lived experience of Hungarian adults over 50, however, having free choice and having influence apparently merge into one broader feeling of personal agency. Consistent with this, the Autonomy subscale showed the weakest internal consistency of the four, with an alpha of just 0.69 — below the conventional 0.70 threshold that psychometricians typically demand.

To confirm these exploratory findings, the researchers turned to confirmatory factor analysis, the stricter sibling of exploratory methods. Rather than letting the data suggest a structure, CFA tests pre-specified structural models and grades how well each fits. Crucially, the team estimated their models from polychoric correlations using the weighted least squares mean- and variance-adjusted estimator, known as WLSMV — a technical choice that matters enormously here. The CASP-19 uses ordered response categories rather than continuous measurements, and treating such ordinal data with methods designed for continuous variables can distort factor structures. Polychoric correlations and WLSMV respect the ordinal nature of the responses, making this one of the more methodologically careful adaptations of the scale to date.

Validity was assessed from two directions. On the convergent side, the CASP-19 correlated moderately to strongly with three independent measures: the EuroQol 5-Dimension 5-Level questionnaire, the 36-Item Short Form Health Survey, and the Mental Health Quality of Life questionnaire. This pattern is exactly what one hopes to see — the scale tracks other quality-of-life and well-being instruments closely enough to be measuring something real, but not so perfectly that it is redundant with them. The correlations thus anchor the Hungarian CASP-19 within the wider family of health and well-being measures, giving researchers confidence that scores can be compared and integrated across studies.

The study also tackled a practical question that increasingly confronts ageing research: does it matter whether older adults fill in a paper questionnaire or an online version? The authors compared total CASP-19 scores between respondents who completed the paper-based form and those who used the online version, matching participants on background characteristics using propensity scores and then running matched-pair t-tests. The matched subgroups showed no difference in total scores. But the researchers are admirably cautious about this finding: the matched sample consisted of different individuals rather than the same people completing both formats, and it contained only 26 pairs. As they emphasize, this cannot be interpreted as evidence of true measurement equivalence between the two administration modes — a caveat that should temper any rush to digital data collection in later-life surveys.

Why does all this matter beyond Hungary? Populations across Europe and much of the world are ageing rapidly, and instruments like the CASP-19 feed directly into policy decisions about pensions, health services and social care. If a scale’s subscale scores are used to target interventions — say, programmes designed to boost autonomy specifically — but the data show that autonomy and control are empirically inseparable in a given culture, then the theoretical scaffolding behind those programmes wobbles. The Hungarian findings add a cross-cultural data point to a growing international conversation about whether the CASP framework’s four dimensions are universal psychological realities or, at least in part, artefacts of the original British context in which the scale was developed.

The authors’ conclusions are measured. They report that the Hungarian CASP-19 demonstrated high internal consistency and interpretable structural characteristics, supporting its use for assessing psychosocial quality of life in adults aged 50 and over. At the same time, they state plainly that their findings did not support a strictly separated four-dimensional interpretation, particularly with regard to the Control and Autonomy domains. The study also highlights the methodological relevance of response format adaptation — a reminder that how a question is asked, not just what it asks, shapes what researchers discover about the quality of later life. For anyone measuring well-being in ageing populations, the message is clear: trust the total score, but handle the subscales with care.

Subject of Research: Psychometric evaluation of the Hungarian CASP-19 quality-of-life scale in adults aged 50 and over

Article Title: Psychometric evaluation and factor structure of the Hungarian CASP-19: methodological and practical implications from an ageing population

Article References: Fekete, M., Lajko, P., Szekeres, T., Rethy, L. J., & Gonda, X. (2026). Psychometric evaluation and factor structure of the Hungarian CASP-19: methodological and practical implications from an ageing population. BMC Psychology. https://doi.org/10.1186/s40359-026-05810-w

Image Credits: AI Generated

DOI: 10.1186/s40359-026-05810-w

Keywords: CASP-19, quality of life, psychometrics, factor analysis, ageing, older adults, Hungary, internal consistency, confirmatory factor analysis, cross-cultural adaptation, response format, psychosocial well-being

The system, named TL-CDRNet, was developed by Lanxin Zhong of Hainan Vocational University in Haikou, China. Its starting point is a familiar one in modern language technology: a pretrained multilingual encoder-decoder Transformer, in this case the mBART-50 model with roughly 611 million backbone parameters, twelve encoder layers, twelve decoder layers, and a SentencePiece vocabulary of more than 250,000 tokens. But rather than simply fine-tuning this backbone on a rewriting task, the study treats cultural adaptation as a transfer learning problem in which the crucial question is what knowledge can safely move between cultures and what must stay behind. Four newly designed modules wrap around the pretrained model to answer that question at different levels of granularity.

The first module addresses a tension that has long shaped cross-lingual and cross-cultural modeling. Some knowledge is genuinely universal: factual semantics, thematic content, and basic narrative structures transfer well between cultural domains. Other knowledge is deeply local: metaphors, symbolic preferences, value judgments, and pragmatic conventions that can actively harm output quality if forced through a shared channel, a phenomenon known as negative transfer. TL-CDRNet handles this with a shared-specific transfer adapter module that inserts two lightweight bottleneck feed-forward networks into each of the twelve encoder layers. One adapter learns cross-cultural commonalities while the other, conditioned on the target culture, learns culture-specific representations. Learnable weighting parameters then balance the two contributions at every layer, allowing the model to discover dynamically where the boundary between the universal and the local actually lies.

Separating the two knowledge streams, however, is not enough, because the appropriate balance differs from one cultural pair to the next. When the source and target cultures are close, much of the shared representation is useful and should flow freely; when they are distant, aggressive sharing risks importing assumptions that do not belong. The second module therefore learns a 64-dimensional embedding for each cultural-linguistic domain, normalizes it, and computes the Euclidean distance between source and target embeddings as a scalar measure of cultural distance. A sigmoid gating function converts that distance into a transfer coefficient: culturally close pairs receive stronger injection of shared knowledge, while distant pairs shift weight toward target-culture-specific representations. Importantly, the study stresses that these embeddings model corpus-level differences in expression conventions and narrative preferences rather than fixed national or ethnic identities, and no external cultural-index database is used.

Distance at the domain level is still a coarse signal, so a third module works at the level of individual tokens. A transferability-aware knowledge selection mechanism scores every hidden representation, estimating how applicable each piece of content is to the target-culture task. Factual information, core thematic elements, and universal expressions earn high transferability scores and pass through largely intact; content tightly bound to the source cultural context is blended with a local adaptation representation instead. This token-level filtering proved essential for semantic preservation in the experiments: removing it dropped the semantic consistency score from 0.918 to 0.892, indicating that without it the model drifts further from the original meaning while chasing cultural fit.

The fourth and arguably most distinctive module makes cultural discount itself a trainable objective. A discriminator network mean-pools the decoder’s hidden states and passes them through a three-layer multilayer perceptron to output a cultural discount score between zero and one, where higher values signal greater risk of communication loss in the target culture. The training loss then demands that the generated text score lower than the original unadapted text by at least a safety margin, a hinge-style formulation that turns reduction of cultural discount into a differentiable goal rather than a hoped-for side effect. Combined with standard generation loss, a semantic consistency loss based on cosine similarity of sentence embeddings, and a distribution alignment loss, this feedback closes the loop between transfer, generation, and cultural evaluation.

To test the framework, the researchers assembled a dataset of 9,000 samples across three culturally demanding scenarios: film synopsis adaptation, tourism promotional text rewriting, and descriptions of cultural creative and intangible heritage products. Each sample pairs a source text with source and target cultural-linguistic labels, a human-written target-culture reference adaptation, and a cultural discount annotation. Bilingual and multilingual annotators produced the reference rewrites, and target-domain reviewers then assessed fluency, semantic preservation, and cultural appropriateness, with three annotators per sample and disagreements sent back for revision. Inter-annotator agreement measured by Krippendorff’s alpha reached 0.742, and the data were split 80/10/10 into training, validation, and test sets with texts from the same original item kept together to prevent leakage.

The results show consistent gains over a range of baselines including direct fine-tuning of mBART, LoRA adapters, and a culture-aware BART variant. Against the strongest competitor, TL-CDRNet raised BLEU from 29.6 to 31.4, ROUGE-L from 44.0 to 46.1, BERTScore from 88.9 to 89.8, and semantic consistency from 0.900 to 0.918. The task-oriented metrics improved more dramatically: the cultural discount score fell from 0.361 to 0.298, and the cultural discount reduction rate climbed from 33.5 percent to 43.7 percent, an improvement of 10.2 percentage points. Performance held steady across all three scenarios, with reduction rates of 43.5, 41.9, and 40.3 percent for film, tourism, and heritage content respectively, while semantic consistency stayed between 0.897 and 0.922 throughout.

Ablation and transfer-strategy comparisons reveal where the gains come from. Moving from training from scratch through pretrained initialization, direct fine-tuning, bridging domain transfer, multi-stage transfer, and finally the complete model produced a monotonic rise in performance, with the full system lifting the reduction rate from 24.6 percent under direct fine-tuning to 43.7 percent, a transfer gain of 77.6 percent. Removing the shared-specific adapters cut the reduction rate to 34.6 percent; removing the cultural distance gate lowered it to 36.1 percent, with the sharpest degradation under distant-culture pairs; and removing the discount feedback loop caused the most severe decline of all. The framework also proved resilient under scarcity: with only five target-domain examples it achieved a reduction rate of 16.8 percent versus 8.3 percent for direct fine-tuning, and with one hundred examples it reached 39.8 percent against 22.4 percent. In cross-domain tests, where the model trained on one scenario and was evaluated on another, it maintained semantic consistency above 0.898 and reduction rates between 36.9 and 40.4 percent. A further analysis showed that although transfer gains decline as cultural distance grows for all methods, the slope is markedly gentler for TL-CDRNet than for LoRA, suggesting the distance-aware mechanisms genuinely mitigate the risks of long-range cultural transfer.

The study is candid about its limits. The cultural discount score and reduction rate are produced by a learned discriminator and cannot fully replace human judgment of appropriateness, emotional resonance, and audience acceptance; the author notes that future work should incorporate evaluations from target-culture participants. The baselines also exclude the newest instruction-tuned multilingual large language models, and the framework currently handles text only, leaving multimodal formats such as short video scripts and image-text generation for later exploration. There are ethical considerations too: aggressive adaptation to a target culture can erode the source culture’s distinctiveness, and biased training data risks producing stereotyped cultural portrayals, which is why the paper recommends review of culturally sensitive outputs by experts from both sides. Even so, the core demonstration stands: by teaching a model not just what cultures say but how far apart they sit, transfer learning can turn cultural adaptation from an afterthought of translation into an explicit, optimizable goal, offering a practical technical pathway for film distribution, tourism promotion, and the international reach of cultural products.

Subject of Research: Transfer learning for reducing cultural discount in cross-cultural AI text adaptation

Article Title: Transfer learning guided by cultural distance enables effective cross cultural content adaptation

Article References: Zhong, L. (2026). Transfer learning guided by cultural distance enables effective cross cultural content adaptation. Discover Artificial Intelligence, 6(1), Article 1225. https://doi.org/10.1007/s44163-026-02267-z

Image Credits: AI Generated

DOI: 10.1007/s44163-026-02267-z

Keywords: transfer learning, cultural discount, cross-cultural adaptation, multilingual NLP, Transformer, mBART, machine translation, negative transfer, cultural distance, semantic consistency, low-resource learning, intangible cultural heritage

The instrument at the center of the study is the ATRAI-14, short for Attitude Toward Radiology Artificial Intelligence, a 14-item questionnaire originally designed to capture how radiologists feel about AI implementation along three conceptual domains: Trust, Implementation Perspectives, and Hopes and Fears. Because residents’ attitudes are widely regarded as central to whether AI tools actually get adopted in clinical practice, the authors — Erdem Ozkan of Kastamonu Training and Research Hospital and Mehtap Balaban of Yıldırım Beyazıt University in Ankara — set out to adapt the scale into Turkish and examine whether its three-domain structure replicates in a different language and a different health system. The adaptation followed established cross-cultural methodology: the questionnaire was translated into Turkish and content-validated by a panel of eight expert radiologists, achieving an item-content validity index of 0.875, a figure indicating strong expert agreement that the translated items preserved the meaning of the originals.

The survey itself was national in scope and cross-sectional by design, administered as a web-based questionnaire to radiology residents across Türkiye. Psychometric evaluation was thorough and multi-pronged: confirmatory factor analysis to test whether the original three-factor structure reproduced itself, exploratory factor analysis to see what structure the data actually preferred, Cronbach’s alpha and McDonald’s omega to quantify internal consistency, item–total correlations to flag misbehaving questions, and criterion validity assessed against a visual analog scale of overall attitude. Group differences and predictors of the total score were examined with non-parametric tests and regression modeling. This is the full battery one would want before declaring a translated instrument fit for research use — and it is precisely this battery that produced the study’s most instructive negative results.

The headline psychometric finding is that the three-factor model fitted inadequately in the Turkish cohort. The comparative fit index came in at 0.82, well below conventional thresholds for acceptable model fit, and the root mean square error of approximation was 0.075, sitting at the edge of what researchers typically tolerate. In plain terms, the data from Turkish residents did not organize themselves into the three neat conceptual boxes the scale was designed around. Only the Trust domain reached borderline-acceptable internal consistency, with a Cronbach’s alpha of 0.69 — just under the 0.70 line most psychometricians treat as the minimum for group-level comparisons. The other two domains collapsed entirely: Implementation Perspectives returned an alpha of 0.07 and Hopes and Fears an alpha of 0.06, values so close to zero that they indicate the items within those domains share essentially no common signal. Two items even loaded negatively, pulling in the opposite direction from their intended constructs.

The authors are refreshingly candid about what this means, and their caution is worth emphasizing because it changes how the rest of the findings should be read. Because Implementation Perspectives and Hopes and Fears did not form coherent constructs in this population, findings touching those domains should be interpreted as observations about individual items rather than as measurements of the intended underlying dimensions, and they should not be used to compare groups. The total score, however, fared better: its criterion validity against the visual analog scale was acceptable, with a Spearman correlation of 0.56, meaning the overall number does track meaningfully with residents’ self-reported global attitude even if the sub-domains do not cohere. This is a genuinely useful contribution to the literature on cross-cultural instrument validation — a reminder that a scale validated in one linguistic and health-system context cannot simply be translated and assumed to measure the same things elsewhere.

So what do Turkish radiology residents actually think about AI? The mean total score was 20.99 with a standard deviation of 3.60, sitting 2.99 points above the scale midpoint of 18 — a modestly positive attitude overall. The item-level pattern is where the story gets vivid. On the collaborative side, 90.6% of residents said they would re-examine a study when AI disagreed with their reading, a striking endorsement of AI as a second pair of eyes worth taking seriously. Expectations about workload were similarly optimistic: 79.7% expected AI to reduce their workload. But the appetite for autonomy stops hard at the boundary of machine independence — only 22.0% of residents expressed comfort with AI operating autonomously. The residents want a colleague, not a replacement.

Not every sentiment was rosy. A majority — 60.8% — feared that AI would diminish the prestige of their profession, a concern that speaks to identity as much as to employment. And perhaps the most practically consequential number in the study is one of the smallest: only 21.7% of residents had actual access to AI tools at work. That gap between opinion and experience is the study’s quiet bombshell. Nearly four in five residents are forming attitudes about a technology they have almost never touched, which raises an obvious question about what those attitudes are actually measuring — informed judgment, or accumulated rumor, media coverage, and anxiety about the future of the specialty.

Equally telling is what did not predict attitudes. Residents’ scores did not differ by AI access, seniority, institution type, or research involvement. In a more mature adoption environment, one might expect hands-on users to diverge from outsiders, or senior residents with more clinical experience to view automation differently from juniors. The absence of any such differences in this cohort reinforces the impression that AI in Turkish radiology training remains largely an abstraction — everyone is weighing in from roughly the same distance. The authors are careful here too: they suggest that incorporating supervised, hands-on AI experience into residency training could help align expectations with practice, but they explicitly frame this as a hypothesis warranting direct evaluation rather than a conclusion drawable from cross-sectional data.

The study received no specific funding, was approved by the Kastamonu University Clinical Research Ethics Committee, and collected electronic informed consent from all participants. Its methodological honesty may prove to be its most exportable contribution. As AI attitude surveys proliferate across specialties and countries, this paper demonstrates both the necessity and the difficulty of proper psychometric validation: a translation that experts judged highly faithful (an item-content validity index of 0.875) still produced a scale whose two of three domains dissolved in a new population. For researchers hoping to track how the next generation of radiologists feels about AI, the message is clear — trust the Trust domain, treat the rest with caution, and above all, get residents their first real hands-on encounter with the algorithms everyone is already opining about.

Subject of Research: Cross-cultural adaptation and psychometric validation of the Turkish ATRAI-14 questionnaire measuring radiology residents' attitudes toward artificial intelligence

Article Title: Cross-cultural adaptation and psychometric evaluation of the Turkish ATRAI-14 among radiology residents: a multicenter national survey

Article References: Ozkan, E., & Balaban, M. (2026). Cross-cultural adaptation and psychometric evaluation of the Turkish ATRAI-14 among radiology residents: a multicenter national survey. BMC Medical Education, 26(1), Article 1653. https://doi.org/10.1186/s12909-026-10415-3

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10415-3

Keywords: artificial intelligence, radiology, psychometrics, ATRAI-14, cross-cultural adaptation, medical education, radiology residents, survey research, factor analysis, Türkiye, attitude measurement, clinical training

The original Patient-Centered Survivorship Care Index was developed from the stated priorities of cancer survivors regarding the care they receive after treatment. It asks respondents to rate items across domains such as health monitoring, coordination of care, information and education, and support for daily living and emotional wellbeing, all framed from the survivor’s perspective. Translating such an instrument is not a matter of dictionary substitution. Health care concepts are embedded in cultural expectations: how patients in Korea relate to physicians, what they consider appropriate follow-up, and how they express unmet needs may differ substantially from the settings where the original tool was built. The research team, led by Ol Han of Ewha Womans University with colleagues from the National Cancer Center and the Dongnam Institute of Radiological and Medical Sciences, therefore undertook a full cross-cultural adaptation before any statistical testing.

The adaptation followed the canonical sequence used in modern instrument validation. First, the source questionnaire underwent forward translation into Korean, followed by expert review to resolve ambiguities and adapt wording to Korean health-system realities. The Korean version was then back-translated into the source language so that the original developers’ intent could be checked against the reverse rendering. A pilot group of survivors completed the draft under cognitive debriefing, a technique in which respondents think aloud and explain how they interpret each item, exposing phrasing that reads naturally to clinicians but confusingly to patients. Finally, a panel assessed content validity item by item. The outcome was striking: of the original 36 items, 34 were retained, and the scale-level content validity index averaged 0.98, a value indicating near-unanimous expert agreement that the items remain relevant and clearly worded in Korean.

With the adapted instrument in hand, the team moved to the psychometric core of the study. They recruited adult cancer survivors from three hospitals across South Korea using convenience sampling, distributing 220 questionnaires and analyzing 198 completed responses. The central question was structural validity: does the seven-factor architecture of the original index, in which each domain represents a distinct facet of patient-centered survivorship care, hold up in the Korean data? To answer it, the researchers used confirmatory factor analysis with robust maximum-likelihood estimation, a method chosen because survivor-reported data often deviate from perfect normality. The prespecified seven-factor simple-structure model served as the primary test, with two additional models examined as sensitivity analyses to probe how the data behaved when plausible refinements were allowed.

The results tell a nuanced story. The prespecified seven-factor model achieved moderate fit, with a robust comparative fit index of 0.913, a Tucker-Lewis index of 0.904, a root mean square error of approximation of 0.075, and a standardized root mean square residual of 0.060. In conventional interpretation, these values sit in the acceptable-to-borderline range: the model captures the broad architecture of the data but leaves room for local misfit. A sensitivity model informed by the original development study, which permitted specific residual covariances suggested by prior research, improved fit modestly, and a further data-informed model with four substantively interpretable within-factor residual covariances improved it again, reaching a comparative fit index of 0.937 and an RMSEA of 0.064. The authors are appropriately cautious here: this most parsimonious refined model fits well but requires independent replication before it can be treated as the definitive structure.

The item-level statistics were reassuring. Standardized factor loadings ranged from 0.70 to 0.94, meaning each item correlates strongly with its intended domain, and average variance extracted ranged from 0.64 to 0.81, indicating that each subscale explains the majority of the variance in its own items. Discriminant validity, assessed with the heterotrait-monotrait ratio, produced values between 0.675 and 0.896, below the thresholds that would suggest problematic overlap between domains, although the upper end of that range hints at partial domain overlap that the residual-covariance analyses also detected. Reliability was strong throughout: subscale Cronbach’s alpha ranged from 0.85 to 0.94, McDonald’s omega from 0.86 to 0.94, and the total scale alpha reached 0.98, an exceptionally high internal consistency for a 34-item multidimensional instrument.

Two findings deserve particular attention from a measurement-science standpoint. First, six items showed ceiling proportions above 40 percent, meaning that large shares of survivors gave the same top response. Ceiling effects compress variability and can obscure differences between patient groups or changes over time, so future users of the K-PC-SCI should interpret those items carefully, especially in samples where care quality is uniformly high. Second, the team examined convergent evidence by relating K-PC-SCI scores to the Korean Cancer Survivors’ Unmet Needs scale, a well-established instrument measuring what survivors feel is missing from their care. The results were illuminating rather than disappointing: K-PC-SCI scores showed essentially no association with the simple count of unmet needs, with a Spearman’s rho of 0.072 and a confidence interval spanning zero, but a small positive association with severity-weighted unmet-needs intensity, rho of 0.162 with a confidence interval excluding zero.

That dissociation is conceptually meaningful. Counting unmet needs treats every gap in care as equal, whereas the PC-SCI asks survivors to evaluate care against their own priorities, so a survivor with few but severe unmet needs may rate patient-centeredness poorly while one with many trivial gaps rates it well. The modest correlation with intensity-weighted unmet needs suggests the two instruments measure related but distinct constructs, which is precisely what one would want from a new tool rather than a redundant copy of an existing one. In other words, the K-PC-SCI appears to capture something the unmet-needs literature has been missing: the survivor’s own weighting of what matters, which is the definitional core of patient-centered care.

The authors are candid about the limits of their evidence. The sample was drawn from three hospitals by convenience sampling, which may not represent the full diversity of Korean cancer survivors, particularly those years past treatment who receive care in community settings rather than specialized cancer centers. The moderate fit of the primary model, the residual local dependence revealed in sensitivity analyses, and the partial overlap among some domains all point to the need for further validation in independent samples, especially post-treatment and community-based cohorts. The study also received no specific external funding, and the authors declare no competing interests, with ethical approval obtained from all three participating institutions and written informed consent from every participant in accordance with the Declaration of Helsinki.

Even with those caveats, the practical significance is considerable. South Korea has one of the world’s most rapidly aging cancer survivor populations, and its national cancer control program has invested heavily in survivorship services. Until now, evaluating whether those services reflect survivors’ own priorities required instruments validated elsewhere. The K-PC-SCI, with 34 items across seven domains, strong reliability, and preliminary structural validity, gives Korean researchers a foundation for national surveys, intervention trials, and quality-improvement programs grounded in what survivors themselves say matters. More broadly, the study is a model of methodological transparency: rather than reporting only the best-fitting model, the team presents the prespecified test, the theory-informed refinements, and the data-driven alternatives side by side, letting readers see exactly where the instrument is solid and where replication is needed. In a field where measurement tools often cross borders with little scrutiny, that kind of honesty is itself a form of patient-centeredness.

Subject of Research: Cross-cultural validation of the Korean Patient-Centered Survivorship Care Index among adult cancer survivors

Article Title: Cross-cultural validation of the Korean version of the patient-centered survivorship care index (K-PC-SCI) among adult cancer survivors

Article References: Han, O., Baek, J. B., Moon, C. S., & Kim, Y. E. (2026). Cross-cultural validation of the Korean version of the patient-centered survivorship care index (K-PC-SCI) among adult cancer survivors. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15859-3

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15859-3

Keywords: cancer survivors, survivorship care, patient-centered care, psychometric validation, cross-cultural adaptation, confirmatory factor analysis, Korea, health services research, unmet needs, questionnaire validation, reliability, content validity

The research was led by first and corresponding author Vaia Pappa of the Aristotle University of Thessaloniki, working alongside co-authors Diomidis Antoniadis, Konstantinos Fountoulakis and Nikitas Arnaoutoglou from the same institution. Their starting point was a practical gap: although the CASS was originally developed to measure several distinct dimensions of cancer stigma, including avoidance, blame, policy opposition, personal responsibility, financial discrimination and perceptions of cancer severity, it had never been validated in Greek. Without a psychometrically sound Greek adaptation, researchers in Greece could not systematically assess how stigmatizing attitudes toward cancer are distributed in the population, how they vary across groups, or whether anti-stigma programs are actually changing minds. The new study was designed to close that gap and, in doing so, to test a broader theoretical idea: that stigma toward different illnesses may share common psychological roots.

To adapt the instruments for Greek participants, the team used a standardized forward-backward translation process involving independent bilingual experts and a separate back-translator. This approach, considered standard practice in cross-cultural scale validation, helps ensure that translated items preserve the original meaning rather than merely the original wording. Once the Greek versions were finalized, the researchers assessed internal consistency, construct validity and convergent validity using a battery of statistical techniques: Cronbach’s alpha for reliability, exploratory factor analysis for structural validity, Spearman correlations and regression analysis for convergent relationships, and receiver operating characteristic analysis, commonly abbreviated as ROC, for discriminatory performance.

The study sample consisted of 176 undergraduate, postgraduate and doctoral students recruited in Thessaloniki through convenience sampling. Participants had a mean age of 23.5 years, and 60.8 percent were women. Importantly for the study’s aims, approximately 39.8 percent reported a personal or family history of cancer, while 35.2 percent reported a personal or family history of mental illness. Each participant completed both the Greek CASS and the Community Attitudes toward the Mentally Ill scale, known as CAMI, allowing the researchers to examine whether attitudes toward cancer were associated with broader forms of health-related stigma rather than existing in isolation.

The psychometric results were encouraging. The Greek CASS demonstrated high overall internal consistency, with a Cronbach’s alpha of 0.89, a value well above the conventional threshold of 0.70 that researchers typically use to indicate acceptable reliability. Reliability across the individual subscales ranged from 0.72 to 0.86, suggesting that each dimension of the scale held together coherently in the Greek context. Exploratory factor analysis generally supported the scale’s original multidimensional structure, with most items loading onto their theoretically expected factors. Taken together, these findings provide evidence for the structural coherence and construct validity of the Greek version, meaning that the instrument appears to measure the same underlying dimensions of cancer stigma in Greek speakers that it measures in the populations where it was originally developed.

Perhaps the most conceptually striking findings emerged from the comparison with mental illness attitudes. Cancer-related stigma showed moderate to strong positive correlations with the CAMI dimensions of authoritarianism and social restrictiveness, with Spearman correlation coefficients ranging from 0.42 to 0.57. In practical terms, participants who endorsed authoritarian or socially restrictive views about people with mental illness also tended to endorse stigmatizing views about cancer. The authors interpret these relationships as evidence that different forms of health-related stigma may share underlying mechanisms involving fear, stereotyping, blame and social distancing. As the researchers state, the present findings further support the conceptualization of stigma as a generalized psychosocial construct operating across different health conditions, rather than a set of illness-specific attitudes that must be studied entirely separately.

Not every statistical result was equally strong, however, and the authors are candid about this. The regression model was not statistically significant and explained only 9.6 percent of the variance in cancer stigma scores. The ROC analyses showed limited to moderate discriminatory ability across most dimensions, with two CAMI dimensions performing acceptably: Authoritarianism achieved an area under the curve, or AUC, of 0.770, while Community Mental Health Ideology reached an AUC of 0.780. These values indicate moderate discrimination, above the chance level of 0.500 but far from perfect classification. The authors argue that such results reinforce the view that stigma is better understood as a complex, multidimensional construct than as a simple binary characteristic that people either possess or lack.

Demographic patterns added further nuance. Younger participants tended to report higher cancer-related stigma, while participants with personal or family experience of illness showed lower stigma levels. The authors suggest that familiarity with serious illness may reduce negative stereotypes and encourage more empathetic attitudes, a pattern consistent with established theories proposing that interpersonal contact can reduce stigma. The Greek cultural context may also shape how cancer stigma is expressed. The authors discuss the importance of family-centered approaches to illness, communication practices and religious or fatalistic beliefs. While family ties and spiritual beliefs can provide important sources of support for patients, certain patterns of silence or fatalistic interpretation may simultaneously contribute to fear, avoidance or reluctance to openly discuss a cancer diagnosis. These observations argue for culturally sensitive approaches to stigma reduction rather than assuming that attitudes toward cancer operate identically across populations.

The validated Greek CASS now offers researchers and clinicians a practical instrument for assessing cancer-related stigma in both community and clinical settings. The authors suggest that identifying stigmatizing attitudes can help inform psychoeducational programs, supportive counseling and public-awareness initiatives, and that the observed relationship between cancer and mental illness stigma points toward integrated approaches that address health-related stigma more broadly rather than condition by condition. The findings, they note, highlight the persistence of stigma and underscore the importance of culturally tailored interventions targeting both cancer-related and mental illness stigma.

Important limitations temper these conclusions. The study relied primarily on a young, highly educated university-based sample, which limits generalizability to older adults, oncology patients and people from more diverse socioeconomic backgrounds. Its cross-sectional design prevents causal conclusions about the relationships observed, and variance-explained indices from the exploratory factor analysis were not retained in the archived statistical outputs, limiting the completeness of the construct-validity evaluation. Future validation in larger and more diverse populations, including cancer patients, caregivers, healthcare professionals and rural communities, will therefore be essential. Even so, the study supports the Greek version of the CASS as a reliable and valid tool for assessing cancer-related stigma and establishes a foundation for broader studies of cancer stigma in Greece and for the development and evaluation of culturally informed anti-stigma interventions.

Subject of Research: Validation of the Greek Cancer Stigma Scale and its relationship to mental illness stigma attitudes

Article Title: Greek version of cancer stigma scale validated for assessing cancer-related stigma

Article References: Greek version of cancer stigma scale validated for assessing cancer-related stigma. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: cancer stigma, Cancer Stigma Scale, CASS, psychometric validation, Greece, mental illness stigma, CAMI, psycho-oncology, cross-cultural adaptation, Cronbach's alpha, social stigma, Aristotle University of Thessaloniki

The seven-item instrument at the center of this study did not appear from nowhere. It descends from a longer questionnaire built around the knowledge–attitude–practice framework, a structure long favored in health services research because it separates what clinicians know from what they believe and what they actually do at the bedside. The original version asked respondents to work through a substantial battery of items covering drainage system management, infection prevention, complication surveillance, and the practical mechanics of cerebrospinal fluid handling. That depth is a strength when the goal is comprehensive profiling, but it becomes a liability when the goal is rapid screening across large nursing workforces. Long instruments compete with clinical duties, inflate respondent fatigue, and invite careless answering patterns that quietly corrupt the data. Compressing the assessment to seven carefully chosen statements is therefore not merely a convenience; it reflects a deliberate trade-off between measurement breadth and the practical realities of administering knowledge assessments in busy hospital environments.

The translation process used to bring the instrument into Chinese deserves attention because cross-cultural adaptation is often the weakest link in imported measurement tools. The Brislin forward–backward translation method, employed here, works by having one translator render the source items into the target language and a second, independent translator render that version back into the original language without sight of the source text. Discrepancies between the back-translated version and the original reveal ambiguities, idioms, or culturally loaded phrasing that could distort meaning. For an instrument touching on technical nursing procedures, this iterative reconciliation matters enormously: a poorly translated item about drainage bag positioning or aseptic technique could measure linguistic confusion rather than clinical knowledge. The researchers’ use of this established method, followed by pilot testing before the main survey, aligns with recommended practice for achieving semantic and conceptual equivalence across languages.

The choice of the Rasch Rating Scale Model as the analytic framework signals a particular philosophy of measurement. Classical test theory, the traditional approach, treats every item as contributing equally to a total score and evaluates reliability through internal consistency coefficients. Rasch measurement, by contrast, models the probability of each response as a function of the difference between the respondent’s ability or knowledge level and the difficulty of the item. This produces interval-level measures from ordinal rating data and allows researchers to examine whether each item actually functions as intended for the population being tested. When a seven-item instrument is the entire measurement payload, a single misbehaving item carries disproportionate weight, so the item-level scrutiny that Rasch analysis provides is not a statistical luxury but a structural necessity.

Several of the reported findings illustrate what this scrutiny looks like in practice. The Infit and Outfit mean-square statistics both fell within conventional acceptable boundaries, with Infit values between 0.94 and 1.16 and Outfit values between 0.94 and 1.07. These statistics compare observed response patterns with those predicted by the model: values substantially above 1.0 indicate erratic, unpredictable responding, while values substantially below 1.0 suggest redundancy, where an item merely echoes information already captured by its neighbors. The narrow range observed here indicates that all seven items contribute distinct, model-consistent information. The point-measure correlations, ranging from 0.63 to 0.70, reinforce this picture by showing that respondents who scored higher on the instrument overall also tended to endorse each individual item in the expected direction, with no item behaving anomalously relative to the latent construct.

The unidimensionality evidence addresses a question that haunts any short instrument: does it really measure one coherent thing? With only seven items, there is little room for hidden subdimensions, yet the principal components analysis of residuals provides a formal check. The 55.1% of variance explained by the measures exceeds the threshold often cited for Rasch-based instruments, and the eigenvalue of the first residual contrast, at 1.4, falls comfortably below the value of 2.0 that would suggest a meaningful secondary dimension. In plain terms, the residuals left over after the primary measurement dimension is extracted contain no strong competing structure, which supports treating the total score as a summary of a single underlying attribute: self-reported awareness of recommended EVD care practices.

Equally instructive is the behavior of the five-point rating scale itself. Rating categories are only useful if respondents actually use them in the intended order. The Rasch framework tests this through threshold ordering: the step from one category to the next should represent progressively more knowledge or confidence. The finding that observed average measures increased monotonically across categories and that thresholds were sequentially ordered means that respondents who chose higher categories genuinely demonstrated higher measures, and that no category was so underused or disordered that it needed to be merged with a neighbor. The clearly peaked category probability curves confirm that each response option had a region of the knowledge continuum where it was the most probable choice. This is a nontrivial achievement, since collapsing categories is one of the most common remedial actions required in Rasch analyses of Likert-type instruments.

The test information function adds a practical dimension to the psychometric results. Measurement precision in Rasch models is not uniform across the trait continuum; it concentrates where item difficulties cluster. The reported pattern, with higher precision near the average level of the construct and diminishing information at the extremes, means the instrument is most accurate for identifying nurses whose knowledge sits in the middle range of the distribution. This has direct implications for how the tool should be deployed. It is well suited to routine screening and to detecting the typical variation across a general nursing workforce, which is precisely the use case the authors envision. However, it will be less reliable for distinguishing among the very small number of nurses with extremely high or extremely low self-reported knowledge, and programs hoping to identify exceptional outliers should interpret scores at the tails with corresponding caution.

The single-site design of the study shapes what the results can and cannot support. All 242 participants were drawn from one hospital in Liaoning Province, which means the sample reflects the training programs, protocols, and patient mix of a single institution. Rasch parameters are known to be sample-sensitive to some degree, so item difficulty estimates and category functioning observed here may shift in populations with different educational backgrounds, different exposure to neurosurgical patients, or different institutional guidelines. The authors’ call for multicenter validation is therefore not a formality but a necessary next step. Nurses in community hospitals, emergency departments, or general wards encounter EVDs far less frequently than neurosurgical intensive care staff, and differential item functioning analysis in more diverse samples would reveal whether any item behaves differently across these subgroups.

It is also worth emphasizing the distinction the authors draw between self-reported knowledge and demonstrated competence. The instrument asks nurses to rate their own awareness of recommended practices, which is a subjective judgment that can diverge from objectively verified understanding. Research on self-assessment across the health professions has repeatedly shown that confidence and accuracy are only moderately correlated, and that individuals with the least knowledge are sometimes the most confident. A nurse who rates herself highly on EVD care awareness may nonetheless mishandle a drainage system leveling error in practice. The instrument’s value lies in efficiently flagging perceived knowledge levels and guiding educational targeting, not in certifying that a nurse can safely manage an EVD without direct observation or skills-based assessment. Hospital educators who adopt the tool should pair it with simulation, direct observation, or objective structured assessments when high-stakes competence decisions are involved.

Within those limits, the practical appeal of a seven-item, psychometrically vetted tool is considerable. Infection related to external ventricular drainage remains one of the most feared complications in neurocritical care, with ventriculitis carrying substantial morbidity, and the evidence base consistently links adherence to care bundles—aseptic handling, appropriate drainage height, minimal system opening, and prompt complication recognition—with reduced infection rates. Identifying which knowledge elements are weakest across a nursing staff allows education departments to concentrate scarce training time where it will matter most, rather than delivering uniform refresher content to everyone regardless of need. A brief instrument that can be administered in minutes, repeated over time to track learning, and analyzed with modern measurement methods offers a realistic mechanism for closing the loop between assessment and targeted education. The present study provides the initial psychometric foundation for that mechanism in a Chinese nursing context, and its findings will gain weight as replication accumulates across the diverse settings where external ventricular drains are actually managed.

Subject of Research: Psychometric validation of a seven-item self-reported knowledge test for external ventricular drain care among Chinese nurses using the Rasch model.

Article Title: Psychometric properties of a short knowledge test to evaluate awareness of external ventricular drain care practices among Chinese nurses: a Rasch model analysis of an efficient 7-item self-reported assessment tool

Article References: Wen, L., Sun, Y., & Du, X. (2026). Psychometric properties of a short knowledge test to evaluate awareness of external ventricular drain care practices among Chinese nurses: a Rasch model analysis of an efficient 7-item self-reported assessment tool. Frontiers in Public Health, 14, Article 1963782. https://doi.org/10.3389/fpubh.2026.1963782

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1963782

Keywords: external ventricular drainage, nursing knowledge, Rasch model, psychometrics, neurocritical care, cross-cultural adaptation, questionnaire validation, patient safety, nursing education, differential item functioning, self-reported knowledge, China

The research team, led by Reyhane Sefidkar, Mahla Kermani, and Fatemeh Keshmiri of Shahid Sadoughi University of Medical Sciences in Yazd, conducted a two-phase cross-sectional study in 2025. Their goal was twofold: first, to establish that a Persian-language PIQ could measure professional identity with acceptable validity and reliability among Iranian nursing students; and second, to see what the instrument reveals when administered to nurses who have recently entered clinical practice. The distinction matters, because the authors are careful to frame the second phase as exploratory rather than as additional validation — a methodological honesty that is often missing from questionnaire studies.

The first phase followed a well-established playbook for cross-cultural instrument adaptation. The researchers translated the PIQ into Persian and culturally adapted it according to Beaton’s guidelines, the standard framework for translating health-status questionnaires. This process is not simple word substitution. It involves forward translation, synthesis, back-translation by independent translators, and review by an expert committee to resolve discrepancies and ensure that each item reads naturally and retains its intended meaning in the target culture. Face validity — whether the items appear to measure what they claim — and content validity — whether they comprehensively cover the construct — were assessed using both qualitative and quantitative approaches. All items met the predefined criteria, meaning the adapted questionnaire passed the first gate of psychometric scrutiny.

The heart of the validation work was structural validity, examined with confirmatory factor analysis (CFA) in a sample of 226 undergraduate nursing students. CFA is a statistical technique that tests whether the pattern of correlations among questionnaire items matches a theoretically predicted structure. In this case, the hypothesized structure was a two-factor model comprising Professional Identity Formation Attachment (PIF-A) and Professional Identity Formation Detachment (PIF-D) — essentially, the degree to which a person bonds with the professional role versus the degree to which they feel detached from it. The results were strikingly good. The model fit indices were excellent: the ratio of chi-square to degrees of freedom was 1.08, the root mean square error of approximation (RMSEA) was 0.01, the comparative fit index (CFI) and incremental fit index (IFI) were both 0.99, the goodness-of-fit index (GFI) was 0.97, and the standardized root mean square residual (SRMR) was 0.04. In practical terms, values of CFI and IFI above 0.95, RMSEA below 0.06, and SRMR below 0.08 are conventionally considered evidence of good fit, and this model comfortably cleared every threshold. Standardized factor loadings — the strength of the relationship between each item and its factor — ranged from 0.30 to 0.90.

Reliability, the consistency of measurement, was assessed in two complementary ways. Internal consistency, which reflects how well items within a scale hang together, was evaluated with Cronbach’s alpha. The total PIQ achieved an alpha of 0.86, generally regarded as good, with the attachment dimension reaching 0.93 — very high — and the detachment dimension at 0.78, which is acceptable for a shorter subscale. Stability over time was tested in an independent sample of 100 nursing students who completed the questionnaire on two occasions, with agreement quantified using the intraclass correlation coefficient (ICC). The total scale achieved an ICC of 0.79 (95% confidence interval: 0.71 to 0.85), which the authors describe as satisfactory. Together, these results indicate that the Persian PIQ produces scores that are both coherent and reasonably stable when the underlying construct has not changed.

With the instrument validated in students, the team turned to the clinical world. In the second phase, the Persian PIQ was administered to a separate sample of 110 early-career nurses to describe their professional identity and examine how it relates to demographic and occupational characteristics. The mean total professional identity score was 38.67 with a standard deviation of 6.77 on a scale where the possible range runs from 10 to 50 — a moderately high average that suggests a generally positive sense of professional identity in this group, though with meaningful individual variation.

The most intriguing finding from the exploratory phase concerned work experience. The number of years worked showed a small positive association with the reverse-scored detachment dimension (r = 0.250, p = 0.008). Because the detachment scale is reverse-scored, this pattern can be read as suggesting that nurses with more work experience reported somewhat less detachment from their professional role — a tentative hint that identity may consolidate with time in practice. In a multiple linear regression analysis, work experience remained positively associated with this dimension (β = 0.250, B = 0.644, 95% CI: 0.164 to 1.125, p = 0.009). However, the authors urge caution, and for good reason: the overall regression model was not statistically significant (R² = 0.063, adjusted R² = 0.037, p = 0.073), meaning the predictors together explained only a small fraction of the variance and the model as a whole did not reach conventional significance. Age and sex were not significantly associated with professional identity outcomes.

The authors are explicit about the limits of their evidence, and their caveats deserve emphasis. The association between work experience and the detachment dimension is modest in magnitude, embedded in a nonsignificant overall model, and derived from a cross-sectional design — a snapshot that cannot establish whether experience causes identity change or whether other unmeasured factors drive the pattern. Furthermore, the exploratory application among early-career nurses provided descriptive and associative evidence but did not constitute additional psychometric validation; the reliability and validity findings formally apply to the student sample in which they were established. The researchers also note that further validation in larger and more diverse nursing populations is warranted, including formal measurement-invariance testing — a procedure that verifies whether a questionnaire measures the same construct in the same way across different groups — and additional sources of validity evidence before the instrument is used for broad comparisons or intervention studies.

Why does this matter beyond the statistics? Nursing systems worldwide face chronic shortages and high early-career attrition, and professional identity is increasingly viewed as a protective factor that helps newly qualified nurses weather the difficult transition from classroom to ward. A validated Persian-language instrument gives Iranian educators, hospital administrators, and researchers a practical tool to track how identity forms during training and how it holds up in the first years of practice. It also opens the door to cross-cultural research, allowing findings from Iran to be compared with those from other countries once equivalent validated versions exist. The study, funded by Shahid Sadoughi University of Medical Sciences and approved by its ethics committee, with written informed consent obtained from all participants, was published open access on 13 October 2026 in BMC Nursing under DOI 10.1186/s12912-026-05497-9. As the first rigorously validated Persian version of the PIQ, it represents a small but concrete step toward understanding — and ultimately strengthening — the professional self that nurses carry with them from their first lecture to their thousandth shift.

Subject of Research: Psychometric validation of the Persian Professional Identity Questionnaire among nursing students and early-career nurses

Article Title: Psychometric validation and exploratory application of the Professional Identity Questionnaire (PIQ) among nursing students and early-career nurses

Article References: Sefidkar, R., Kermani, M., & Keshmiri, F. (2026). Psychometric validation and exploratory application of the Professional Identity Questionnaire (PIQ) among nursing students and early-career nurses. BMC Nursing. https://doi.org/10.1186/s12912-026-05497-9

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05497-9

Keywords: professional identity, psychometrics, questionnaire validation, nursing education, confirmatory factor analysis, cross-cultural adaptation, early-career nurses, reliability, BMC Nursing, Iran, workforce retention, measurement invariance

The research, conducted by Xiao Wang of the University of Macau, Fengshi Ren and Ruining Jin of Beijing University of Technology, Yongqi Xu of Minzu University of China, and Jie Wei of Guangxi University and China University of Political Science and Law, examined Chinese international students who had developed a pro-host-nation cultural identity during their time abroad. These are students who, by conventional measures of acculturation, succeeded: they adopted the values, social styles, and everyday practices of their host societies, often feeling more at home in Melbourne, Toronto, or London than they had in Beijing or Chengdu. Yet the study reveals that their trajectories of departure, adaptation, return, and reentry cannot be understood without reference to Confucian values, pragmatism, and the pressures of contemporary individualization in Chinese society.

The team carried out in-depth interviews with 14 Chinese international student returnees, tracing how each participant moved through the full cycle of transnational mobility: the motivations that pushed them overseas, the acculturation strategies they adopted while abroad, the identity shifts they experienced, the calculations that eventually brought them home, and the challenges they faced when they tried to reintegrate into Chinese society. The study was reviewed and approved by the Ethics Committee of China University of Political Science and Law, with written informed consent obtained from all participants, who were assured anonymity through the use of pseudonyms and were offered mental health resources given the potentially sensitive nature of the topics discussed.

Acculturation research has long treated adaptation as a relatively linear process. Classic models, most famously John Berry’s fourfold framework, describe how migrants can integrate, assimilate, separate, or marginalize depending on whether they maintain their heritage culture and engage with the host culture. Return migration, when it is studied at all, is often framed as a simple reversal: the returnee readjusts to a familiar home culture. The new study complicates this picture substantially. Its central finding is that traditional hierarchical and pragmatic values can simultaneously prompt cultural alienation and the pursuit of autonomy abroad, while also shaping the motivations that drive students to return and the difficulties they encounter once they arrive back.

This dual role of tradition is the study’s most striking insight. Confucian norms emphasize hierarchy, family obligation, and the pursuit of achievement as a form of filial devotion. For some participants, these same norms generated a sense of alienation from Chinese social life, with its intense competition, rigid social ladders, and expectations of deference. Studying abroad offered an escape route, a chance to experience societies perceived as more egalitarian and to pursue personal autonomy that felt constrained at home. In other words, the desire to leave was not simply a pull toward the West but a push away from a normative order that these students found suffocating, even as that order had shaped their ambitions in the first place.

Yet the story does not end with liberation overseas. The pragmatic strand of Chinese cultural tradition, which treats education and mobility as instruments for family advancement and long-term security, reasserted itself in the decision to return. Career prospects, aging parents, and the sense that one’s ultimate obligations lay back home combined to draw even the most enthusiastically assimilated students back to China. The return was thus not a failure of adaptation but, in many cases, an expression of the same traditional values that had motivated the original departure. Tradition, the study suggests, operates on both ends of the migration arc, pulling students out and drawing them back.

The reacculturation phase proved to be the most painful. Students who had internalized host-nation norms of directness, individual choice, and flatter social hierarchies returned to workplaces and family structures that operated by very different rules. Their pro-host-nation identity, once an asset abroad, became a liability at home, marking them as different, sometimes as arrogant, sometimes as naive. The mirage of belonging in the study’s title captures this experience: the returnees discovered that the home they remembered no longer matched the home they re-entered, and that their years abroad had transformed them in ways that Chinese society was not always prepared to accommodate. Belonging, which had felt achievable overseas, remained elusive on both sides of the Pacific.

The study also situates these individual experiences within a broader sociological transformation. Contemporary Chinese society is characterized by increasing individualization, a process in which personal choice and self-development have gained legitimacy even within a collectivist framework. The returnees in this study were not simply caught between two static cultures; they were navigating a Chinese society that is itself in flux, where traditional norms coexist with, and are renegotiated by, individualized aspirations. This dynamic helps explain why the participants’ identities did not settle into any of the neat categories offered by classical acculturation theory. Their sense of self remained multi-dimensional, shifting with context and life stage rather than converging on a single cultural orientation.

Methodologically, the research demonstrates the value of qualitative depth in a field dominated by large-scale surveys. Fourteen interviews cannot establish prevalence, but they can illuminate mechanisms, and here the mechanism is clear: traditional norms are not a fixed baseline that migrants shed or retain, but an active force that shapes motivation, adaptation, and reentry at every stage. The authors argue that this finding calls for more nuanced, multi-dimensional models of acculturation and reacculturation, models that treat culture as a dynamic resource rather than a static inventory of traits, and that follow migrants across the entire transnational circuit rather than studying departure and return in isolation.

The implications extend well beyond academia. Universities that recruit Chinese students invest heavily in supporting their adaptation abroad but rarely think about their reentry. Employers in China hiring returnees, and families welcoming them home, may misread the friction these graduates experience as personal failing rather than a predictable outcome of deep cultural negotiation. As international student mobility continues at massive scale, and as geopolitical tensions complicate the calculus of studying abroad, understanding why students leave, why they come back, and why coming back can feel like arriving in a foreign country has never been more relevant. The greener grass, this research suggests, was never really the point; the point was the long, tradition-laden journey between two versions of home.

Subject of Research: The influence of traditional Chinese sociocultural norms on the identity and reacculturation of Chinese international student returnees

Article Title: Greener grass or the mirage of belonging: How Chinese traditional norms impact the identity and (re)acculturation of Chinese international students

Article References: Wang, X., Ren, F., Xu, Y., Wei, J., & Jin, R. (2026). Greener grass or the mirage of belonging: How Chinese traditional norms impact the identity and (re)acculturation of Chinese international students. Humanities and Social Sciences Communications. https://doi.org/10.1057/s41599-026-09223-3

Image Credits: AI Generated

DOI: 10.1057/s41599-026-09223-3

Keywords: acculturation, Chinese international students, Confucian values, return migration, cultural identity, reacculturation, individualization, qualitative interviews, transnational mobility, cultural alienation, pragmatism, belonging