Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13270 Development and psychometric evaluation of a quality assessment questionnaire for clinical nursing education Muhamad Andika Sasmita Saputra, Tukimin Bin Sansuwito, Faridah Mohd Said Faculty of Nursing, Lincoln University College, Malaysia Abstract This study developed and evaluated a quality assessment questionnaire for clinical nursing education using an exploratory- sequential mixed-method approach. A systematic literature review and expert consultations informed the initial item generation, fol- lowed by psychometric validation involving nursing students and experts in Palembang, Indonesia. The questionnaire was assessed for Content Validity Index (CVI ≥0.83, scale-level CVI = 0.97), construct validity (five factors explained 85.1% variance, factor loadings 0.56–0.91), and reliability (Cronbach’s Alpha = 0.94). The final version consisted of 24 items across five dimensions: quality, constraints, benefits, practicality, and transparency. Unlike existing tools, this questionnaire integrated a comprehensive eval- uation framework tailored for nursing education, ensuring a more structured and contextually relevant assessment. Despite its robustness, the study was limited by its focus on a single geo- graphic and cultural setting. Future research should explore cross- cultural validation and technological integration to enhance its applicability. Introduction Clinical practice is a fundamental component of nursing edu- cation, enabling students to translate theoretical knowledge into real-world healthcare settings. Beyond developing technical skills, clinical practice fosters critical competencies such as communica- tion, professional ethics, and problem-solving, all of which are vital for competent nursing professionals.1–3 Additionally, inter- professional collaboration is strengthened during clinical training, as nursing students engage with multidisciplinary teams, improv- ing the overall quality of patient care.4–6 A supportive learning environment and mentorship play crucial roles in enhancing stu- dents’ satisfaction and competency development, emphasizing the need for well-structured clinical practice evaluation tools.7–9 The evaluation of clinical practice is essential to ensure stu- dents acquire meaningful learning experiences that contribute to their professional growth.10,11 Various assessment methods, includ- ing direct observation, mentor feedback, and self-assessment, are used to evaluate students’ competencies.12 Competency-based assessments are particularly significant as they encompass techni- cal skills, communication, and affective attributes such as empa- thy and ethical behavior.13 Furthermore, technological advance- ments, including digital simulations and electronic portfolios, have been introduced to improve the accuracy and efficiency of clinical evaluations.14,15 While existing tools aim to provide com- prehensive assessments, there remains a need for standardized and reliable evaluation methods across different nursing programs. Despite the availability of various clinical evaluation instru- ments, inconsistencies in assessment criteria and evaluator subjec- tivity persist, compromising the reliability of student evalua- tions.16 The variability in evaluators’ perceptions often results in inconsistent grading, underscoring the necessity for standardized, evidence-based evaluation tools.17 Additionally, while technologi- cal advancements have improved objectivity, issues related to accessibility and implementation in diverse educational settings remain unaddressed.18 Recent research suggests that intensive training for evaluators can significantly reduce bias and enhance assessment consistency. Another critical gap in current evaluation frameworks is the underrepresentation of affective and behavioral competencies. Many existing instruments predominantly focus on cognitive and technical aspects, neglecting crucial interpersonal skills such as empathy, communication, and professional behavior.19 Studies indicate that systematic evaluation of affective competencies can Correspondence: Muhamad Andika Sasmita Saputra, Faculty of Nursing, Lincoln University College, Malaysia. E-mail: andika.phdscholar@lincoln.edu.my Key word: clinical practice, development of instrument, nursing stu- dents, quality of evaluation, validity and reliability Contributions: research, data analysis, interpretation, drafting, and criti- cal article were all done by the authors. Conflict of interest: the author declares no conflict of interest. Ethics approval and consent to participate: this study passed ethical review with the approval number 042-2023. The ethical review was con- ducted by the Medical and Health Research Ethics Committee of the Faculty of Medicine, Sriwijaya University, Palembang, an institution accredited by the government in the South Sumatra Province, Indonesia. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analysed during this study are included in this published article. Acknowledgments: the authors would like to thank you very much to all of those who have supported the researcher in writing this research. Received: 19 October 2024. Accepted: 28 April 2025. Early view: 22 July 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13270 doi:10.4081/hls.2025.13270 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 102] [Healthcare in Low-resource Settings 2025;13(s2):13270] lead to improved nurse-patient interactions and better patient out- comes.20 Additionally, the development of holistic assessment tools that incorporate emotional and social competencies is imper- ative to ensure nursing students are adequately prepared for dynamic clinical environments.21 Furthermore, existing evaluation instruments are typically developed by faculty members and experts, often overlooking the perspectives of students the primary users of these tools. Research indicates that involving students in the design and refinement of assessment instruments enhances their relevance and applicability in real-world settings.14,22,23 Collaborative development between faculty and students has been shown to increase the accuracy of evaluations while fostering student engagement and ownership in the assessment process.24 Clarke et al. (2023)25 emphasize that stu- dent-faculty collaboration ensures a comprehensive evaluation framework that adequately reflects students’ clinical learning experiences. Given these limitations, this study aims to develop a valid, reli- able, and comprehensive questionnaire for evaluating clinical practice quality from the perspective of nursing students. Unlike existing evaluation instruments that primarily assess learning activities and student competencies, this study seeks to create an innovative assessment tool that evaluates the quality of the evalu- ation process itself.26,27 This approach aligns with constructivist learning theories, which advocate for assessments that consider learning outcomes, the learning process, and contextual factors.28 By incorporating diverse stakeholder perspectives, including stu- dents and clinical practitioners, the resulting evaluation tool is expected to be more adaptable across various cultural and educa- tional contexts.29 Furthermore, ensuring the reliability of the instrument will allow for consistent and meaningful evaluations across different clinical settings30. Ultimately, this study con- tributes to the advancement of nursing education by providing a more effective tool for assessing the quality of clinical practice evaluations, thereby supporting improved educational outcomes and better-prepared nursing professionals. Materials and Methods Study design This study designed and developed a questionnaire to assess nursing students’ clinical practice quality using an exploratory- sequential mixed method approach. In the context of this study, the exploratory-sequential method begins with a qualitative explo- ration phase through a systematic literature review to identify key themes related to the quality of clinical practice evaluation, which are subsequently used to develop the questionnaire items. Meanwhile, the quantitative phase is conducted to test whether the developed instrument is valid, reliable, and truly reflects nursing students’ experiences and perceptions regarding the quality of clin- ical practice evaluation.31,32 Population, sample, and sampling The study population comprised nursing students enrolled in a professional nursing education programme in Palembang, South Sumatra, Indonesia. A purposive sampling approach was employed for the qualitative phase, selecting relevant literature based on pre- defined inclusion and exclusion criteria. Inclusion criteria encom- passed books published between 2013 and 2023 and journal arti- cles from 2018 to 2023. Data were extracted by reviewing sources based on author, title, year, type (book or journal), keywords, and topic relevance, focusing on content related to clinical practice evaluation quality. Selected sources met the following: alignment with keywords, relevance to evaluation components, conformity with scope, appropriate publication years, and open-access index- ing (for journals) or valid ISBNs (for books). Books served as pri- mary references, while journals provided supporting insights33. For the quantitative phase, a sample of 168 nursing students was selected using stratified random sampling to ensure representative- ness across different academic levels. Variables The variable analysed in this study is the quality of clinical practice evaluation among nursing students. Instrument development The questionnaire was developed based on findings from the systematic literature review. Each component was translated into five questions, resulting in an initial draft of 45 items. Each evalu- ation component was then divided into positive (3 questions) and negative (2 questions). A five-point Likert scale (1 = strongly dis- agree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree) was employed. Content validity was assessed using the Content Validity Index (CVI), while construct validity was examined through exploratory factor analysis (EFA). Data collection process The study was conducted between January 2023 and June 2024. The qualitative data collection phase involved a systematic literature review to explore and identify key themes and compo- nents influencing the quality of clinical practice evaluation, which served as the basis for developing a valid and empirically ground- ed questionnaire instrument. The literature search was performed using accessible electronic databases and search engines such as Google Books, Google Scholar, ProQuest, PubMed, and ScienceDirect, alongside printed sources. A strategic search approach was applied using Boolean operators (AND/OR/NOT), ensuring precise retrieval of relevant studies. For instance, key- words such as “component” AND “quality of evaluation” AND “clinical practice” AND “among nursing students” were used. The selection criteria included books published within the past decade (2013–2023) and journal articles from the last five years (2018– 2023). Data extraction was systematically conducted by reviewing sources based on the author’s name, title, publication year, type of source (book or journal), keywords, and thematic relevance, specifically focusing on content related to quality components of clinical practice evaluation. Studies were included in the analysis based on the following criteria: i) journal titles and/or abstracts aligning with the chosen keywords, ii) direct relevance to quality components in clinical practice evaluation, iii) correspondence with the scope of clinical practice evaluation, iv) books published from 2013 to 2023 and journals from 2018 to 2023, and v) books with ISBNs and journals indexed in open-access databases. While books provided primary references for the review, journal articles contributed supplementary insights into the essential components influencing the quality of clinical practice evaluation. In the quan- titative phase, nursing students completed the developed question- naire, and data were collected electronically. Data analysis The qualitative phase The journal analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) framework. The data extraction process com- Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13270] [page 103] prised two key stages: i) reviewing the database by identifying details such as the author, title, publication date, year, journal type, keywords, topic, and primary reference sources; and ii) ensuring that the content or subject matter corresponded with the specified keywords.33 The flow chart illustrates the literature selection process using the PRISMA diagram (Figure 1). A total of 12 sources met the inclusion criteria by addressing quality evaluation components, while all others were excluded. The quantitative phase Content validity In the subsequent phase, the researcher assessed content valid- ity by engaging six experts in nursing and education to review the initial questionnaire draft. Using a Content Validity Index (CVI) form, the experts evaluated each item in terms of relevance, clarity, and completeness. The form consisted of four components: instructions, content, language, and questionnaire items (a total of 45), each rated on a 4-point Likert scale from 1 (not relevant) to 4 (highly relevant). Feedback from the experts informed revisions to the questionnaire, and the Content Validity Index (CVI) was used to analyse item validity based on expert judgment.18,34 Content validity was analysed using the Content Validity Index (CVI), involving expert assessment of the relevance of each item in the questionnaire. The analysis was conducted using computer soft- ware by converting expert responses into an ordinal scale (0 and 1), followed by the calculation of the Item-Level Content Validity Index (i-CVI) and the Scale-Level Content Validity Index (s-CVI) to assess the questionnaire’s relevance. The determination of the questionnaire’s acceptability relevance followed validation stan- dards involving 6–8 experts, with an Item-Level Content Validity Index (i-CVI) threshold of ≥0.83. For s-CVI/Ave values of ≥0.90 the category is Excellent, ≤0.80 – <0.90 is Good, and <0.80 is con- sidered to have inadequate content validity and may require sub- stantial revision.18,34 Construct validity Construct validity was analysed using exploratory factor anal- ysis. The sample comprised 168 nursing students from a profes- sional nursing education programme in Palembang, South Sumatra Province, Indonesia. Factor analysis began with the Kaiser-Meyer- Olkin (KMO) test to assess sampling adequacy, where values above 0.90 are considered excellent, while values below 0.50 indi- cate that the data are unsuitable for factor analysis.35,36 To ensure adequate item correlation, Bartlett’s test of sphericity (p<0.05) and Anti-image analysis were also conducted. The Anti-image matrix helped determine the suitability of each variable in the factor model using the Measure of Sampling Adequacy (MSA).37 Items with an MSA value above 0.50 were deemed acceptable, while those with MSA ≤0.50 were removed due to their minimal contri- bution.37,38 Subsequently, Promax rotation was applied during the exploratory factor analysis to examine inter-factor correlations.37 Factor loadings >0.50 were interpreted as strong contributors to the factor structure, whereas loadings <0.50 were considered weak and potentially irrelevant.39–41 Reliability A reliability test was conducted to measure the internal consis- tency of each scale in the questionnaire. The analysis compared Cronbach’s Alpha coefficient value to a constant value. Cronbach’s α >0.90 was categorised as Excellent, <0.80 – ≤0.90 as Good, <0.70 – ≤0.80 as Adequate, <0.60 – ≤0.70 as Mediocre, <0.50 – Pathways of Change, Part II [page 104] [Healthcare in Low-resource Settings 2025;13(s2):13270] Figure 1. Flow chart of the literature review selection stage. ≤0.60 as Poor, and <0.50 as Very Poor. This reliability test was cru- cial to ensure that the questionnaire consistently measured what it was intended to measure, thereby making the data produced trust- worthy35,36. Ethical considerations Ethical approval was obtained from the Medical and Health Research Ethics Committee of the Faculty of Medicine, Sriwijaya University, Palembang, an institution accredited by the govern- ment in the South Sumatra Province, Indonesia (Approval No. 042-2023). Participation was voluntary, and informed consent was obtained from all respondents prior to data collection. Confidentiality and anonymity of participants were maintained throughout the study. Results In the qualitative phase, nine essential elements that can be used as a foundation for gauging the calibre of clinical practice evaluation among nursing students were identified by the literature review analysis. Validity, reliability, practicability, objectivity, fea- sibility, understandability, continuity, propriety, and efficiency are some of these elements. These were found to be essential factors to take into account in order to effectively and consistently measure student skills and significantly improve their clinical competencies throughout the design and implementation of clinical practice eval- uations. After that, each element was converted into five questions, yielding a preliminary questionnaire draft with 45 questions. Each assessment item was separated into two categories: positive (3 questions) and hostile (2 questions). A Likert scale with the follow- ing scores was used for each questionnaire item: 1 denotes strong disagreement, two disagreement, three neutrality, four agreement, and five strong agreements. In the quantitative phase, demographic data were gathered to outline the characteristics of the nursing stu- dents participating in the study. These data serve to contextualise the findings and ensure the representativeness and appropriateness of the sample for the research objectives. Table 1 shows that the respondents in this study were nursing students enrolled in the pro- fessional nurse programme, with ages ranging from 21 to 32 years. The mean age was 23.99 years, with a standard deviation of 1.860, indicating that the respondents’ ages were relatively uniform and did not vary significantly from the average. The majority of respondents are female (72.6%), with clinical practice experience of ≥6 months (62.5%). Additionally, the academic year of the Pathways of Change, Part II Table 1. Demographic characteristics of the respondents. Variable Min-Max = 21-32 (year) Mean = 23.99 Std. Deviation = 1.860 Age Variable n % Gender Male 46 27.4 Female 122 72.6 Clinical Practic Experience <6 Month 63 37.5 ≥6 Month 105 62.5 Academic Year 2023/2024 79 47.0 2022/2023 89 53.0 Table 2. Component structure and factor loading of each item using a promax rotation. Components’ name Items Factor loading Component 1: Quality Q1. The instructions in the clinical practice evaluation instrument are easy to understand 0.91 Q2. The clinical practice evaluation instrument comprehensively covers all clinical activities 0.83 and focuses on assessing clinical competence Q3. Each activity/competency/skill has its own evaluation instrument 0.82 Q4. The clinical practice evaluation instrument produces consistent scores when used repeatedly 0.82 Q5. The clinical practice evaluation instrument aligns with the competencies/skills that have been learned 0.69 Q6. The clinical practice evaluation process is conducted ethically and respects my rights and dignity 0.63 Q7. The assessment in clinical practice evaluation is based on clear criteria 0.58 Component 2: Constraints Q8. The clinical practice evaluation instrument is difficult to access and use 0.91 Q9. The clinical practice evaluation instrument is not well stored and/or cannot be accessed again 0.87 Q10. Clinical practice evaluation is not conducted with consistent procedures 0.85 Q11. During evaluation, the Clinical Instructor (CI)/Academic Supervisor does not immediately 0.80 fill in/write the scores Q12. The assessment by the CI/Academic Supervisor is influenced by personal closeness to me 0.67 Q13. The assessment by the CI/Academic Supervisor does not cover all the required competencies 0.64 Q14. The language used in the clinical practice evaluation instrument is too technical and difficult to understand 0.64 Q15. The aspects included in the clinical practice evaluation instrument are too difficult to achieve 0.62 Component 3: Benefits Q16. The clinical practice evaluation instrument greatly helps me achieve the best results 0.89 Q17. The evaluation aspects are easy to implement without complicated procedures or excessive preparation 0.69 Component 4: Practicality Q18. The language and structure of the clinical practice evaluation instrument are well-organised and use standard terminology 0.68 Q19. The clinical practice evaluation process is simple and not confusing 0.66 Q20. The clinical evaluation instrument and aspects are available in the form of a handbook/e-book/technology 0.65 and can be studied in advance Q21. The evaluation aspects are well-presented and clearly readable 0.56 Component 5:Transparency Q22. The evaluation process and criteria are clear and accessible to all involved parties 0.76 Q23. The assessment results can be viewed in real time 0.66 Q24. The clinical practice evaluation instrument and aspects reflect my duties and responsibilities 0.65 [Healthcare in Low-resource Settings 2025;13(s2):13270] [page 105] respondents is fairly evenly distributed between the 2022/2023 (53%) and the 2023/2024 (47%). The content validity analysis of the 45 questions showed that the i-CVI for seven items was 0.83, while the other 38 items had a value of 1.00. The i-CVI for the questionnaire instructions and lan- guage was 1.00 each, and for content, it was 0.83. The s-CVI for the questionnaire instructions, content, and language was 0.94, while for all items combined, it was 0.97, indicating that all items were within the excellent range. These results concluded that all items were valid, requiring no deletions, and overall, all questions were excellent and could proceed to the next phase. The content validity analysis began with sampling adequacy testing, indicated by a KMO value of 0.708, which confirmed the data’s suitability for factor analysis. Bartlett’s test of sphericity showed a significant result (p=0.000), supporting the appropriate- ness of the data. The Anti-image Correlation Matrix revealed nine items with MSA values <0.5, which were excluded from further analysis, leaving 36 items. Subsequently, 12 items with factor loadings <0.5 were also removed. The final analysis showed an improved KMO value of 0.812, and Bartlett’s test yielded a chi- square value of 5,655.415 (df = 276; p = 0.000), indicating that the data were highly suitable for factor analysis. Based on the scree plot results, five dominant factors exist (Figure 2). These five factors collectively account for 85.1% of the variance. The factor loadings for each item are significant and range from 0.56 to 0.91 (Table 2). In Table 2, each component is named according to the theme of the questions. The first component is named “Quality”, with seven question items encompassing validity, reliability, objectivity, understandability, and propriety (items 1-7). The second compo- nent is named “Constraints” and includes eight questions: validity, reliability, practicability, objectivity, and understandability (items 8-15). The third component, named “Benefits”, has two question items that involve elements of feasibility (items 16-17). The fourth component is named “Practicality”, with three question items cov- ering practicability and understandability (items 18-21). The fifth component is named “Transparency”, with three question items that include elements of propriety and efficiency (items 22-24). These five components or factors are verified with acceptable cor- relation values (Table 3). Table 3 presents the factor correlation matrix, illustrating the relationships among the five components identified in the evalua- tion of clinical practice. The strongest positive correlation is observed between the factors of “Practicality” and “Transparency” (0.494), indicating that as the evaluation process becomes more practical, transparency in clinical assessment also tends to improve. Similarly, the “Quality” factor exhibits a moderate posi- tive correlation with “Practicality” (0.471) and “Transparency” (0.458), suggesting that an enhancement in quality standards is associated with increased feasibility and openness in the evalua- tion process. Conversely, the “Benefits” factor shows the weakest correlation with “Transparency” (0.154), implying that while ben- efits exist within clinical evaluation, they do not necessarily enhance transparency in assessment procedures. The “Constraints” factor demonstrates a relatively moderate correlation with “Transparency” (0.434) and “Practicality” (0.318), indicating that although challenges exist in the evaluation process, they may still coexist with efforts to maintain clarity and efficiency in practice. Pathways of Change, Part II Table 3. Factor correlation matrix. Factor Quality Constraints Benefits Practicality Transparency Quality 1.000 0.180 0.299 0.471 0.458 Constraints 0.180 1.000 0.204 0.318 0.434 Benefits 0.299 0.204 1.000 0.237 0.154 Practicality 0.471 0.318 0.237 1.000 0.494 Transparency 0.458 0.434 0.154 0.494 1.000 Figure 2. The factor analysis scree plot. [page 106] [Healthcare in Low-resource Settings 2025;13(s2):13270] Thus, these findings indicate that the interrelation among the fac- tors supports the effectiveness of clinical practice evaluation, where improvements in quality, practicality, and transparency enhance the evaluation process, while constraints still offer oppor- tunities for targeted improvements. Table 3 is referenced to clarify these relationships. The reliability of this questionnaire was evaluated by compar- ing the Cronbach’s Alpha coefficient value to a constant value. It is considered acceptable if the Cronbach’s Alpha coefficient is higher than the fixed value of 0.60. Table 4 demonstrates that the reliability of all dimensions in the questionnaire shows excellent internal consistency, with Intraclass Correlation Coefficient (ICC) values exceeding 0.60 and statistically significant (p <0.05). The highest ICC was found in the Quality dimension (0.95), while the lowest was in the Benefit dimension (0.76), with an overall ICC of 0.94. These results indi- cate that the developed questionnaire is sufficiently reliable and consistent in assessing nursing students’ perceptions of clinical practice evaluation, making it suitable for use in nursing education contexts. The final version of the clinical practice evaluation qual- ity questionnaire among nursing students can be seen in Supplementary materials, Table 1. Discussion This study aimed to develop and examine the validity and reli- ability of a questionnaire designed to evaluate the quality of clini- cal practice among nursing students. The instrument was con- structed based on nine essential components identified through a comprehensive literature review, namely: validity, reliability, prac- ticability, objectivity, feasibility, understandability, continuity, pro- priety, and efficiency, which were operationalised into 45 struc- tured items. Content validity analysis indicated that the majority of items achieved an i-CVI score of 1.00, with an overall s-CVI of 0.97, reflecting a very high level of expert consensus. Factor anal- ysis revealed five dominant dimensions, thereby confirming the structural validity and strong construct underpinning of the instru- ment. Consequently, the questionnaire was demonstrated to be both reliable and valid for assessing clinical practice in nursing education. Moreover, this instrument presents notable distinctions from existing evaluation scales, as it not only assesses clinical competence but also encompasses dimensions such as quality, con- straints, benefits, practicality, and transparency. Whereas most conventional instruments predominantly focus on skill perfor- mance, this tool broadens the assessment scope by incorporating student experiences, ease of use, clarity of evaluation criteria, and fairness throughout the evaluation process. The inclusion of these additional dimensions is intended to more comprehensively mea- sure and enhance the quality of clinical evaluation, while better reflecting the real-world experiences of nursing students during their clinical placements. The results align with previous research highlighting the sig- nificance of validity and reliability in clinical evaluation instru- ments. Sellberg et al. (2019)18 and Shrestha et al. (2021)41 empha- sised that high CVI values indicate expert agreement on an instru- ment’s relevance. The importance of factor analysis in confirming structural validity has also been established in research by Andersson et al. (2020),40 where high factor loadings suggested strong construct validity. Additionally, Saqr & López-Pernas (2022)42 argued that intercorrelations among factors in an evalua- tion tool reinforce its conceptual soundness, which is reflected in the factor correlation matrix of this study. The findings further val- idate the applicability of reliability theory, where high Cronbach’s Alpha values indicate good internal consistency.43 One notable unexpected result was the emergence of an addi- tional factor in the factor analysis that was not initially hypothe- sised. This factor, which may reflect an underlying aspect of clini- cal evaluation not fully captured in previous models, suggests the need for further investigation. Similar findings were reported by Hung et al. (2021),44 who observed that certain evaluation dimen- sions can emerge as distinct constructs during empirical testing. Understanding this unexpected factor may provide deeper insights into the complexities of clinical evaluation in nursing education.45 Despite its strengths, this study has certain limitations. The sample size, though adequate for factor analysis, may limit the generalisability of the findings across different nursing education settings. Previous studies, such as LoBiondo-Wood & Haber (2019),46 have emphasised the importance of diverse and multi- institutional sampling to enhance external validity. Additionally, the reliance on self-reported responses could introduce biases, as students may provide socially desirable answers rather than reflecting actual experiences.47 Future studies should consider employing mixed-method approaches, integrating objective clini- cal performance measures with survey responses to enhance valid- ity. The validated questionnaire has significant practical implica- tions for improving clinical evaluation in nursing education. It pro- vides educators with a structured tool to assess students’ competen- cies more accurately and identify areas needing improvement. Moreover, the instrument could be adapted for use in other health- care education fields, such as medical and allied health training programs, to standardise clinical assessment methodologies.48 Future research should explore the applicability of this question- naire across different cultural and educational contexts to enhance its universality. Additionally, integrating digital platforms for data collection and analysis could improve efficiency and usability, as suggested by Tobón and Luna-Nemecio (2021).43 In conclusion, this study contributes to the development of a Pathways of Change, Part II Table 4. The score and the Interclass Correlation Coefficient (ICC) values of the Clinical Practice Evaluation Quality Questionnaire among Nursing Students. Factor Dimensions ICC (>0.60) Confidence interval 95% p (<0.05) 1 Quality 0.95 0.93-0.96 0.00 2 Constraints 0.93 0.91-0.94 0.00 3 Benefits 0.76 0.68-0.83 0.00 4 Practicality 0.89 0.86-0.92 0.00 5 Transparency 0.91 0.88-0.93 0.00 Total 0.94 0.93-0.96 0.00 [Healthcare in Low-resource Settings 2025;13(s2):13270] [page 107] valid and reliable clinical evaluation tool for nursing students. The findings confirm that the instrument effectively captures key eval- uation dimensions, supporting structured and continuous assess- ments. While the questionnaire has demonstrated strong psycho- metric properties, further research is recommended to refine its applicability and address its limitations. Future studies should investigate its integration with digital assessment platforms and expand its validation in broader educational settings to ensure its long-term relevance and impact. Conclusions The findings of this study indicate that the developed question- naire has been proven to be valid, reliable and effective in evaluat- ing clinical practice among nursing students, with five key factors comprising Quality, Constraints, Benefits, Practicality and Transparency, which offer valuable insights for enhancing stu- dents’ clinical competence. From a practical perspective, the ques- tionnaire serves as a robust tool to support decision-making in nursing education by offering a structured and standardised approach to evaluation; therefore, its use should be accompanied by training for educational institutions and clinical supervisors to ensure accurate and consistent interpretation of scores. The practi- cal implications of this study extend to the development of more transparent and systematic evaluation strategies, and encourage the implementation of intervention programmes such as targeted men- toring, feedback-based learning approaches and improved supervi- sion models. Future research is recommended to further validate this questionnaire across various educational and clinical contexts to ensure broader and cross-cultural applicability, and to reconsider the excluded items to better accommodate the complexity of nurs- ing practice. 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Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13270] [page 109] Online supplementary materials Table 1. Final version of the clinical practice evaluation quality questionnaire among nursing students.