Psychometric evaluation of the Chinese version of the Positive Health Behaviours Scale for clinical nurses: a cross-sectional translation

Abstract

Background
Occupational health is essential for nurses in clinical nursing practice. However, there is no specific tool for measuring the health behaviour of clinical nurses in China. This study aimed to translate the Positive Health Behaviours Scale into Chinese and validate its psychometric properties among clinical nurses.

Design
A cross-sectional design with repeated measures.

Methods
A total of 633 clinical nurses were recruited by convenience sampling from hospitals in Liaoning Province, China. After obtaining the authorization of the original author, the PHBS was translated into Chinese by the Brislin back-translation method. Item analysis was completed to evaluate item discrimination, and the Delphi method was adopted to analyse content validity. Exploratory factor analysis and confirmatory factor analysis were conducted to explore and validate the underlying factor structure. Internal consistency and test-retest reliability were calculated to evaluate reliability.

Results
A total of 29 items were retained in the item analysis, and the content validity index of the translated scale was 0.956. In the EFA, four common factors were extracted (nutrition, physical activity, relaxation and behaviours related to mental health and preventive behaviours), explaining 60.81% of the total variance. The results of the CFA were as follows: χ²/df = 1.363, GFI = 0.902, NFI = 0.909, IFI = 0.974, TLI = 0.971, CFI = 0.974, RMSEA = 0.034, and RMR = 0.023. The results of the EFA and CFA showed that the translated scale had good structural validity. Cronbach’s α coefficient, the split-half reliability and the test-retest reliability of the Chinese version of the PHBS were 0.928, 0.953 and 0.891, respectively. At the same time, the translated scale had good reliability.

Conclusions
The Chinese version of the PHBS for clinical nurses had good psychometric properties. The results of the questionnaire survey effectively and comprehensively reflect the level of health behaviours in clinical nurses, which provides a scientific reference for determining the intervention target.

Full text

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Kong et al. BMC Nursing (2023) 22:296
https://doi.org/10.1186/s12912-023-01453-z BMC Nursing
*Correspondence:
Huijun Zhang
13904069606@163.com
1Departement of Nursing, Jinzhou Medical University, Jinzhou, China
Abstract
Background Occupational health is essential for nurses in clinical nursing practice. However, there is no specic
tool for measuring the health behaviour of clinical nurses in China. This study aimed to translate the Positive Health
Behaviours Scale into Chinese and validate its psychometric properties among clinical nurses.
Design A cross-sectional design with repeated measures.
Methods A total of 633 clinical nurses were recruited by convenience sampling from hospitals in Liaoning Province,
China. After obtaining the authorization of the original author, the PHBS was translated into Chinese by the Brislin
back-translation method. Item analysis was completed to evaluate item discrimination, and the Delphi method was
adopted to analyse content validity. Exploratory factor analysis and conrmatory factor analysis were conducted to
explore and validate the underlying factor structure. Internal consistency and test-retest reliability were calculated to
evaluate reliability.
Results A total of 29 items were retained in the item analysis, and the content validity index of the translated scale
was 0.956. In the EFA, four common factors were extracted (nutrition, physical activity, relaxation and behaviours
related to mental health and preventive behaviours), explaining 60.81% of the total variance. The results of the
CFA were as follows: χ2/df = 1.363, GFI = 0.902, NFI = 0.909, IFI = 0.974, TLI = 0.971, CFI = 0.974, RMSEA = 0.034, and
RMR = 0.023. The results of the EFA and CFA showed that the translated scale had good structural validity. Cronbach’s
α coecient, the split-half reliability and the test-retest reliability of the Chinese version of the PHBS were 0.928, 0.953
and 0.891, respectively. At the same time, the translated scale had good reliability.
Conclusions The Chinese version of the PHBS for clinical nurses had good psychometric properties. The results of the
questionnaire survey eectively and comprehensively reect the level of health behaviours in clinical nurses, which
provides a scientic reference for determining the intervention target.
Keywords Clinical nurses, Factor analysis, Health behaviours, Occupational health, Psychometric evaluation
Psychometric evaluation of the Chinese
version of the Positive Health Behaviours Scale
for clinical nurses: a cross-sectional translation
LinghuiKong1, TingtingLu1, ChenZheng1 and HuijunZhang1*
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Kong et al. BMC Nursing (2023) 22:296
Background
Nurses play a central role in the health care system and
are one of the main labour forces. Nurses, as health
care providers, protectors, disseminators, coordinators,
decision-makers and teachers, provide dierent health
services in dierent environments [1]. Nurses in China
account for nearly one-fth of the world’s nurses [2, 3].
Nurses are the rst to respond to dierent health-related
conditions and can promote health recovery and pre-
vent diseases [1]. More importantly, nurses’ own health
behaviours can greatly inuence the eectiveness of the
health interventions delivered to their patients [4]. Since
nurses play an indispensable role in the hospital, it is par-
ticularly important to ensure that they do not quit their
jobs due to physical problems.
Health promotion behaviours refer to all behaviours
that guide individuals, families, communities, and soci-
eties to promote peace, happiness, and the realization
of their health potential, including physical behaviours,
such as diet, nutrition, exercise, and health responsibil-
ity, as well as psychological behaviours, such as spiritual
growth, stress management, and interpersonal relation-
ships [5, 6]. e content of health promotion behaviours
is guided by health promotion, which is an indicator of
individuals’ eorts to achieve a healthier state [7]. e
World Health Organization (WHO) points out that there
is a close correlation between health and lifestyle and that
health promotion is about empowering individuals and
populations to make healthier choices and follow life-
styles that promote physical and mental health [8].
In particular, nurses engaged in clinical nursing work
often do not have a healthy lifestyle due to the special
nature of their work [9], so more health promotion pro-
grams are needed to improve their poor lifestyle habits.
Relevant studies [10, 11] have shown that diet, physical
activity or stress interventions for clinical nurses can
improve their well-being, their health status and the
quality of their nursing work.
Heavy workloads, complex interpersonal relation-
ships, negative stimulation due to the pain and death
of patients, stress caused by worrying about errors and
accidents [12] and physical and mental fatigue caused by
frequent shift work [13] are all risk factors aecting the
physical and mental health of nurses. In terms of physi-
cal health, nurses have an increased incidence of insom-
nia, obesity, stomach diseases, endocrine disorders,
varicose veins and even breast cancer due to these risk
factors [14–18]. In terms of mental health, nurses experi-
ence anxiety and depression due to changes in hospital
units or departments, heavy workloads and long-term
work in stressful and uncertain environments [19]. is
not only reduces clinical nurses’ work eciency but also
leads to job errors and the deterioration of interpersonal
relationships, eventually leading to health problems and
job burnout [20]. In addition, studies have shown that
high job burnout and low health levels also increase
the separation rate of nurses [21], which has an impact
on hospital clinical nursing work. Compared with other
populations [22], clinical nurses may have an increased
number of poor lifestyle habits [13–23], such as an unrea-
sonable diet and reduced physical activity levels, which
makes them prone to various health problems [24].
At present, the health promotion behaviours of clini-
cal nurses urgently need to be widely considered, and
interventions are needed to improve the health level and
reduce the incidence of diseases among clinical nurses
[25–27]. Screening and evaluation is the most important
rst step before intervention, so an appropriate evalu-
ation tool is necessary. However, there are few scales to
measure the health behaviours of clinical nurses work-
ing in hospitals in China. Initially, Walker and others [28]
developed Health Promoting Lifestyle Proles (HPLP) to
assess people’s health-promoting lifestyles. Subsequently,
Pender et al. developed the Health Promoting Lifestyle
Prole II (HPLP-II)[29], which is mainly used to assess
whether individuals have a healthy lifestyle in the gen-
eral population. Later, Sun, Huang and Ling developed
an improved Chinese version of the HPLP [30]. Although
the three scales dier in the number of items, what they
measure is relatively similar. In contrast, the existing
health behaviour scales are mostly developed by Western
countries and focus on Western cultural habits and life-
styles, and these scales are universal scales, lacking refer-
ence for occupational specicity and cultural dierences.
Recently, Woynarowska-Sołdan et al. developed a vali-
dated instrument called the Positive Health Behaviours
Scale [31], which evaluates the health promotion behav-
iours of clinical nurses from four aspects: nutrition, phys-
ical activity, relaxation and behaviours related to mental
health, and preventive behaviours. Each dimension of the
scale comprehensively presents dierent aspects of health
promotion behaviours. According to the background of
low self-care consciousness and high prevalence rate of
clinical nurses, the scale fully considered the preventive
behavior and lifestyle of clinical nurses, and the nurses’
health behaviours scale was reasonably constructed. At
present, there is no study reporting on the reliability and
validity of the translated version of this scale. e results
of the evaluation of this scale will be helpful for clinical
nursing managers to develop interventions to improve
the health behaviours of clinical nurses and compare dif-
ferences before and after interventions.
e aim of this study was to translate the PHBS into
Chinese and further cross-culturally adaptation and to
validate its psychometric properties in clinical nurses.
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Kong et al. BMC Nursing (2023) 22:296
Methods
Study design and participants
A cross-sectional survey was adopted to evaluate the
Chinese version of the PHBS. A total of 633 nurses from
3 Grade A hospitals in Liaoning Province were selected
by convenience sampling from September 2021 to March
2022. e inclusion criteria were registered nurses with
at least 1 year of clinical work experience who provided
informed consent and volunteered to participate in the
study. e exclusion criteria were as follows: practice,
study, and rotation nurses (practice nurses refer to nurs-
ing graduates who work in hospitals for 9 months before
taking the national nurse practice exam and do not have
the right to work independently during this period; study
nurses are students who go to the hospital to study dur-
ing the school year due to course needs; and rotating
nurses are nurses who rotate throughout the wards).
e respondents were interviewed face-to-face in the
department by the investigator. According to the rough
estimation method to determine sample size, the sample
size required for scale reliability and validity tests must
be 5 ~ 10 times [32] the number of scale items. To ensure
the stability of the factor structure, CFA should include
at least 300 participants [33], and a larger sample size
should be considered. In this study, there were 29 items
in the Chinese version of the PHBS. e reference sample
size should be 10 times the number of items in the scale,
but considering that the sample loss rate may be 20%, it
was estimated that 348 nurses should be included in this
study. A total of 633 clinical nurses were recruited for
this study.
Instruments
General demographic characteristics questionnaire
According to the purpose of the study, the researchers
designed a general demographic characteristics ques-
tionnaire, including age, educational level, marital status,
number of working years, position titles, personnel rela-
tions and self-assessed health.
Positive health behaviors scale (PHBS)
e Positive Health Behaviours Scale for clinical nurses
developed by Woynarowska-Sołdan et al. [31] consists of
29 items covering four dimensions: nutrition (nine items),
physical activity (four items), relaxation and behaviours
related to mental health (seven items), and preventive
behaviours (nine items). Participants’ behaviour is scored
on a four-point scale ranging from 0 for “never or almost
never” to 3 for “always or almost always”. e PHBS total
score ranges from 0 to 87, and the higher the score is,
the higher the level of healthy behaviours. Cronbach’s α
coecient of the original scale was 0.844, while that for
each dimension ranged from 0.623 to 0.761. In the origi-
nal scale, four common factors were forcibly extracted
to explain 38% of the total variance, with GFI = 0.87 and
RMSEA = 0.07.
Procedures
Scale translation and cross-cultural adaptation procedure
With the permission of Professor Woynarowska-Sołdan
[31], we translated and cross-culturally adjusted the
scale. e PHBS was translated into Chinese by the Bris-
lin method [34]. e specic steps are as follows: (1)
Translation: the researcher and a nursing graduate stu-
dent translated the original scale to form a translated ver-
sion; (2) Correction: another researcher retranslated the
Chinese version into English, and two nursing experts
compared the translated version, discussed and evalu-
ated the translation quality, and revised the professional
terms to form the rst draft; and (3) Back translation: to
achieve semantic equivalence, a nonmedical researcher
was invited to back translate the rst draft into English
and form the nal Chinese version of the PHBS. Subse-
quently, 30 community clinical nurses were randomly
selected to evaluate the clarity and agreement of the Chi-
nese version of the PHBS.
Data collection procedure
Before distributing the questionnaires on site, the
researcher rst obtained the consent of the manager of
the nursing department and the head nurses of related
Table 1 Frequency distribution of demographic characteristics
(n = 633)
Factors Group n %
Age 20~ 435 68.7
30~ 169 26.7
40~ 29 4.6
Educational level Junior college education 59 9.3
Undergraduate education 511 80.7
Postgraduate education or above 63 10.0
Marital status Unmarried 444 70.1
Married 189 29.9
Working years 1~ 488 77.1
10~ 127 20.1
20~ 18 2.8
Positional titles Primary nurse 372 58.8
Nurse practitioner 166 26.2
Nurse-in-charge or above 95 15.0
Personnel
relations
Contract nurses* 368 58.1
Formal nurses* 209 33.0
Other 56 8.8
Health self-
assessment
status
Particularly good 360 56.9
Good 238 37.6
Poor 29 4.6
Particularly poor 6 0.9
Note: *Contract nurses are hospitals and nurses sign labor contracts. Formal
nurses are re cruited by the local hea lth bureau, and the work is s table.
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Kong et al. BMC Nursing (2023) 22:296
departments and avoided the department’s busy work
hours. With the assistance of the nursing department
manager, the researcher and two other trained investiga-
tors went to 3 Grade A hospitals in Liaoning Province.
A convenience sampling method was used to distribute
questionnaires to nurses in the departments who met
the inclusion and exclusion criteria and to inform the
nurses of the purpose and signicance of the study and
matters that should be paid attention to when lling out
the questionnaires. After completing the questionnaire,
the data were collected. A total of 640 nurses completed
the questionnaire. Abnormal questionnaires with obvi-
ous regularity or confusing logic were eliminated from
the data (for example, the answers had the same choices
or the answers were contradictory). Ultimately, 633 valid
questionnaires were collected, with an eective recovery
rate of 98.9%. Two weeks later, 60 nurses were randomly
selected for a second survey to assess the retest reliability
of the scale.
Data analysis
SPSS 26.0 and Amos 22.0 were used for statistical anal-
ysis. e measurement data are represented by mean
values (standard deviation, SD), and the enumeration
data are described by percentages. Data were consid-
ered normally distributed when the skewness and kur-
tosis values of the items were between − 2 and + 2 [35].
Item analysis, validity analysis, and reliability analysis of
the Chinese version of the PHBS were performed in our
study.
Items analysis
e total scores of the Chinese version of the PHBS were
ranked from high to low and divided into low and high
subgroups by 27% and 73% quantile boundaries. e
independent-samples T test was used to compare the dif-
ferences in each item between the high-score group and
the low-score group. A critical ratio > 3.000 [36] indicated
that the discriminability of the item was high. Whether
each item of the Chinese version of the PHBS could be
retained was assessed by analysing the item-total correla-
tion and Cronbach’s alpha coecient of the deleted item.
e item-total correlation was judged with 0.4 as the
inclusion criterion [37].
Table 2 Mean (SD) scores with skewness and kurtosis, item analysis for Chinese version of the positive health behaviours scale
Item Item score (SD) Critical ratio Item-total correlation Cronbach’s Alpha if item deleted Skewness Kurtosis
1 2.1(0.7) 17.577 0.614 0.925 -0.175 -0.781
2 2.1(0.7) 18.042 0.611 0.925 -0.351 -0.610
3 2.1(0.8) 19.957 0.621 0.925 -0.152 -1.105
4 2.2(0.7) 18.228 0.612 0.925 -0.310 -0.645
5 1.9(0.8) 19.956 0.614 0.925 -0.018 -1.004
6 1.9(0.7) 19.636 0.649 0.925 0.011 -0.906
7 2.0(0.7) 19.133 0.636 0.925 -0.102 -0.777
8 2.0(0.7) 18.168 0.638 0.925 -0.122 -0.689
9 2.0(0.8) 16.099 0.577 0.926 -0.099 -1.036
10 1.6(0.8) 10.628 0.463 0.928 0.120 -0.605
11 1.6(0.9) 12.108 0.489 0.927 0.038 -0.679
12 1.7(0.8) 12.084 0.489 0.927 -0.005 -0.566
13 1.6(0.9) 12.004 0.460 0.928 0.002 -0.708
14 2.1(0.7) 13.746 0.510 0.927 -0.164 -0.821
15 1.9(0.7) 16.397 0.590 0.926 -0.052 -0.622
16 2.0(0.7) 14.906 0.534 0.926 -0.147 -0.687
17 2.0(0.7) 15.217 0.552 0.926 0.022 -0.902
18 2.0(0.7) 15.197 0.565 0.926 -0.003 -0.634
19 2.0(0.7) 15.317 0.550 0.926 -0.003 -0.907
20 2.0(0.8) 13.940 0.521 0.927 -0.108 -0.884
21 1.9(0.8) 14.195 0.536 0.926 -0.416 -0.326
22 2.1(0.7) 17.414 0.610 0.925 -0.209 -0.762
23 2.3(0.7) 17.691 0.590 0.926 -0.426 -0.856
24 2.0(0.8) 20.880 0.636 0.925 -0.295 -0.826
25 2.0(0.7) 18.242 0.645 0.925 -0.302 -0.442
26 2.1(0.7) 19.144 0.632 0.925 -0.326 -0.571
27 2.0(0.8) 19.749 0.639 0.925 -0.183 -0.881
28 2.0(0.8) 18.800 0.643 0.925 -0.244 -0.543
29 2.2(0.7) 16.698 0.578 0.926 -0.316 -0.837
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Kong et al. BMC Nursing (2023) 22:296
Validity analysis
Seven nursing specialists were invited to access each item
in the translated scale from the perspective of content
importance. e Delphi method was used to calculate
the item content validity index (I-CVI) and scale content
validity index (S-CVI). A 4-point Likert scale was used to
evaluate the content correlation of each item of the Chi-
nese version of the PHBS, ranging from 1 = irrelevant to
4 = highly relevant. e I-CVI refers to the proportion of
the number of experts who gave a score of 3 or 4 points
for an item to the total number of experts; the S-CVI is
the mean I-CVI of all items in the scale. An I-CVI > 0.780
and an S-CVI > 0.900 indicated better content validity
[38].
e total sample was randomly divided into sample 1
and sample 2 by a simple random method. Exploratory
factor analysis (EFA) and conrmatory factor analysis
(CFA) were performed to evaluate the structural validity.
Factor analysis was performed on the data, and the appli-
cable conditions were as follows: the calculated value of
the Bartlett sphericity test was signicant (P < 0.05) and
the KMO value was > 0.60 [36]. e principal compo-
nent analysis method was used to extract common fac-
tors with eigenvalues > 1 by rotating through the varimax
method and deleting items with factor loads < 0.50 [36].
CFA was implemented to conrm the hypothesized fac-
tor model, and the maximum likelihood method was
used for estimation.
Reliability analysis
Cronbach’s α coecients, Guttman split-half reliability
and test-retest reliability were analysed to validate the
reliability of the translated scale. Cronbach’s α coe-
cients of the total scale and each dimension of the scale
were calculated, and a value of 0.70 was taken as the
acceptable standard for the reliability coecient [39].
Split-half reliability was assessed by dividing the scale
items into two halves in parity order and calculating the
correlation between the scores of the two parts. Two
weeks later, 60 clinical nurses were retested using the
translated scale and the correlation with the results of the
rst measurement was analysed to evaluate the stability
and consistency throughout the data collection period.
Since the Pearson correlation coecient is often higher
than the true reliability, the intraclass correlation coe-
cient (ICC) was also used to calculate the consistency of
the two measurements.
Results
Scale translation and cross-cultural adaptation
According to experts’ opinions, the Chinese version of
the PHBS was revised and improved. e details were
as follows: Item 5, “I drink at least 2 glasses of milk, ker
or yogurt daily” was changed to “I drink at least two
glasses of milk or yogurt every day”. In China, it is widely
believed that ker is a type of yogurt, so it was deleted.
Item 28, “I have a smear test at least once every 3 years
or more often as prescribed by a physician” was changed
Fig. 1 Screen plot of exploratory factor analysis for Chinese version of the Positive Health Behaviours Scale
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Kong et al. BMC Nursing (2023) 22:296
to “I have a smear (females) or PSA blood test (males)
at least every 3 years or less”. In the original scale, only
female nurses were included; in China, the number of
male nurses accounted for a certain proportion of nurses
working in the hospital. We made certain modications
to this item to make it applicable to male nurses.
Descriptive Statistics
A total of 640 questionnaires were collected in this study,
and 633 valid questionnaires were ultimately obtained
after the elimination of 7 invalid questionnaires. A total
of 68.7% of the participants were aged 20 to 29 years. e
number of participants with an undergraduate education
accounted for 80.7% of the sample. Participants who were
unmarried accounted for 70.1% of the sample; 77.1%
of the participants had been engaged in clinical nurs-
ing work for 1 to 9 years. ere were more participants
(58.8%) who obtained the professional title of primary
nurse. A total of 58.1% of the participants were contract
nurses; 56.9% of the participants thought that their self-
assessed health status was particularly good. Table1 lists
all the characteristics of the participants.
Item Analysis
e critical ratio of 29 items in the translated scale
ranged from 10.628 to 20.880, and the dierences in each
item in the high-score and low-score groups were statis-
tically signicant (P < 0.001). e correlation coecient
between the score of each item and the total score of the
translated scale was 0.460~0.649. Cronbach’s α coe-
cient of the translated scale was 0.928, and after deleting
any item, Cronbach’s α coecient of the translated scale
ranged from 0.925 to 0.928, without any specic value.
e mean (SD) item score and skewness and kurtosis
values of the Chinese version of the PHBS are shown in
Table2. e skewness and kurtosis values showed that
the detected dataset conformed to a normal distribution.
Validity analysis
Content Validity Analysis
Seven experts were invited to rate the importance of each
item on the scale. e results showed that the content
validity index at the scale level was 0.956, and the content
validity index at the item level was 0.857 ~ 1.000.
Exploratory factor analysis
e KMO value was 0.928, χ2 = 4905.714, and P < 0.001
using the Bartlett sphericity test, which indicated that
the partial correlation between items was weak, and EFA
could be performed in this study. Four common factors
with eigenvalues > 1 were extracted by principal compo-
nent analysis and orthogonal rotation of factors by the
varimax method. e explained variances were 18.80%,
18.70%, 13.54% and 9.83%, respectively, explaining
Table 3 Factor loadings of exploratory factor analysis for the
Chinese version of the Positive Health Behaviours Scale
Item Fac-
tor 1
Fac-
tor 2
Fac-
tor 3
Fac-
tor
4
21. In autumn and winter, I will supple-
ment vitamin D
0.593 - - -
22. I will avoid excessive sun exposure 0.687 - - -
23. I brush my teeth at least twice a day 0.776 - - -
24. I check my teeth every six months 0.795 - - -
25. I measure my blood pressure every
three months
0.775 - - -
26. I will be vaccinated against inuenza
to prevent disease
0.739 - - -
27. I have a breast self-examination once
a month
0.825 - - -
28. I have a smear test (female) or blood
test for prostate specic antigen (male)
at least every 3 years or less
0.784 - - -
29. When I am ill, I will follow the doc-
tor’s advice and receive treatment
0.733 - - -
1. I have regular meals every day - 0.713 - -
2. I have the habit of eating breakfast - 0.719 - -
3. I eat fruit every day - 0.771 - -
4. I eat vegetables every day - 0.718 - -
5. I drink at least two glasses of milk or
yogurt every day
- 0.798 - -
6. I limit the intake of animal fat every
day
- 0.762 - -
7. I limit my intake of salt every day - 0.729 - -
8. I limit my sugar intake every day - 0.751 - -
9. I don’t eat snacks between meals - 0.696 - -
14. I sleep at least 6–7 hours every night - - 0.710 -
15. I work and rest regularly every day - - 0.723 -
16. I spend at least 20 minutes a day
relaxing
- - 0.735 -
17. I can cope with pressure well - - 0722 -
18. Facing myself and the outside world,
I can always maintain a positive attitude
- - 0.650 -
19. When I encounter diculties, I will
ask others for help
- - 0.733 -
20. I get together with my friends or
colleagues once a month
- - 0.639 -
10. I do at least 30 minutes of moderate
or vigorous exercise every day
- - - 0.837
11. I do strength exercises of major
muscle groups at least twice a week
(e.g. sweeping the oor, carrying heavy
bags, climbing stairs, exercising abdomi-
nal muscles)
- - - 0.835
12. In daily life, I will take the initiative
to increase physical activity or physical
labor (for example, walking instead of
taking a car, climbing stairs instead of
taking an elevator)
- - - 0.775
13. I limit the time I watch TV every day - - - 0.766
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Fig. 2 Standardized four-factor structural model of the Chinese version of the Positive Health Behaviours Scale (n = 317)
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Kong et al. BMC Nursing (2023) 22:296
60.81% of the total variance in the variables. e load-
ing of each item on its factor was > 0.50, so no item was
deleted. e factor loading for each item is shown in
Table3. Four principal component factors were selected
according to the descending slope of the eigenvalues in
the scree plot. Figure1 shows the scree plot.
Conrmatory factor analysis
Figure2 shows the results of CFA. In Amos, the maxi-
mum likelihood method was used to conduct CFA on
another part of the data of the scale (n = 317), and the
initial model was revised according to the modica-
tion indices (MIs) as follows: e14 and e17, e23 and e29,
respectively. e tness index model modication is
shown in Table4. e results of each tted indicator after
correction showed that the χ2/df was 1.363, the GFI was
0.902, the NFI was 0.909, the TLI was 0.971, the CFI was
0.974, and the IFI was 0.974. e RMSEA was 0.034, and
the RMR was 0.023. Each tted indicator of CFA was
within the reference range.
Reliability analysis
Cronbach’s α coecient of the translated scale was 0.928,
and the values of the four dimensions ranged from 0.860
to 0.920. e split-half reliability value was 0.953. Sixty
clinical nurses were randomly selected for a retest 2
weeks later; the retest reliability value was 0.891 (Table5)
and the ICC was 0.885.
Discussion
According to relevant studies [40], due to the existence
of multidimensional stress, nurses may adopt ineective
coping mechanisms (such as overeating, reducing physi-
cal activity, etc.) to deal with work-related stressors, and
these unhealthy behaviours seriously aect their physi-
cal and mental health, thus leading to the occurrence of
diseases. Healthy lifestyles among nurses are receiving
increasing attention from managers. In China, scales
used to measure nurses’ health behaviours are all uni-
versal, and a large number of items may increase nurses’
workloads. erefore, accurate and appropriate tools
that can be applied to evaluate healthy lifestyle behav-
iours in clinical nurses are necessary. e Positive Health
Behaviours Scale (PHBS) was developed by Woyn-
arowska-Soredan in 2018. It is a research tool developed
to evaluate healthy lifestyles among clinical nurses, and
it comprehensively evaluates positive health behaviours
from four aspects: nutrition, physical activity, preven-
tive behaviours, and relaxation and behaviours related to
mental health. e content of preventive behaviour was
added to this scale, which can more accurately measure
the health status of clinical nurses under the continuous
development of the current era and meet the require-
ments of China’s advocacy for a prevention-oriented
healthy lifestyle. e Chinese version of the PHBS strictly
followed the Brislin principle [34] in the translation pro-
cess and literal translation, back translation and cultural
adjustment procedures were carried out. After statisti-
cal analysis, the results showed that the Chinese version
of the PHBS has good reliability and validity and can be
used to evaluate nurses’ health behaviours and improve
their health awareness. It provides a reliable assessment
tool for further in-depth and comprehensive understand-
ing of nurses’ health promotion behaviours and their
impact on nurses and can help guide clinical nursing
managers to develop eective intervention measures.
Item analysis
e critical ratios of the Chinese version of the PHBS
were all within the standard range [36], indicating that
each item of the scale had the ability to identify the health
behaviour level of dierent survey subjects. e results of
the correlation coecient method showed that each item
had a high correlation with the dimension [37]. After
deleting items, the Cronbach’s α coecient of the transla-
tion scale did not increase, indicating a strong correlation
between items and high internal consistency. is means
that all 29 items in the Chinese version of the PHBS can
be retained with good discrimination.
Validity analysis
Content validity refers to the extent to which a concept
measured by a researcher is reected by questionnaire
Table 4 Fit indices of the Chinese version of the Positive Health Behaviours Scale model
Fit indices χ2/df RMSEA RMR GFI NFI TLI CFI IFI
Model modication 1.363 0.034 0.023 0.902 0.909 0.971 0.974 0.974
range [43]< 3.000 < 0.080 < 0.050 > 0.900 > 0.900 > 0.900 > 0.900 > 0.900
Note: RMSEA = the root mean square error of approximation, RMR = root mean residual, GFI = goodness-of-t index, NFI = the normed t index,TLI = the tucker lewis
index, CFI = the comparative t inde x, IFI = the incremental t index
Table 5 Reliability analysis for the Chinese version of the Positive
Health Behaviours Scale
The scale and its dimension Cron-
bach’s
Alpha
Split-half
reliability
Test-
retest
reliability
The Positive Health Behaviors Scale 0.928 0.953 0.891
Nutrition 0.920
Physical activity 0.864
Relaxation and behaviors related to
mental health
0.860
Preventive behaviours 0.919
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Kong et al. BMC Nursing (2023) 22:296
items [41]. In this study, the I-CVI and S-CVI were
within the reference value range [38], indicating that this
scale has good content validity. erefore, the results
showed that the items of the scale could better reect the
measured content. Structural validity refers to whether
the multi-index measurement of an objective thing has
a professional ideal structure [42]. When the factor load
value of each item to the corresponding common factor
is appropriate and the cumulative explanatory variation
is > 40%, the structure validity can be considered to be
good. e orthogonal rotation method of maximum vari-
ance was used in this study, and a factor load ≥ 0.50 was
the test standard. In this study, 4 common factors were
extracted from the EFA without deleting any item, and
the items of each dimension were in accordance with the
original scale [31]. e EFA results divided 29 items in
the translated scale into four factors, and the cumulative
variance contribution rate was 60.81%, which is higher
than that of the original scale (38%), indicating that the
extracted common factors had good interpretability
for the dimensions. CFA is a measurement of whether
the relationship between a factor and its corresponding
index conforms to the research’s design theory. e CFA
results in this study showed that χ2/df ≤ 3, RMSEA < 0.08,
RMR < 0.05 and other relative tting indices > 0.90, and
the tting value reached the ideal tting standard [43].
Further CFA results indicated that the scale structure
was scientic and stable and had good structural validity.
Reliability analysis
Reliability refers to the reliability of the measured data
[44], and common indicators include internal consis-
tency and test-retest reliability. It is generally considered
that a Cronbach’s α coecient above 0.7 is acceptable,
and 0.8~0.9 indicates good reliability [39, 41]. In this
study, Cronbach’s α coecient of the Chinese version of
the PHBS was 0.928, which was higher than the results
of the Polish version [31], indicating that the scale has
good internal consistency and high credibility. Moreover,
the test-retest reliability was also good, which proved the
cross-time stability of the Chinese version of the PHBS.
Consequently, the Chinese version of the PHBS has good
reliability.
Limitations
ere are some drawbacks in this study that need to be
considered. First, only part of the nursing population
completed the scale, which may aect the representative-
ness and universality of the survey results. Second, due to
the heavy workload of nurses, this study failed to measure
the predictive validity of the scale and could not evaluate
the impact of nurses’ health behaviours. ird, conve-
nience sampling was used in this study, which may make
the determination of sample units unrepresentative.
Finally, this study relied on principal component factor
analysis, which has a certain ambiguity in its interpreta-
tion, which may lead to overestimation of the number of
common factors.
Conclusions
In conclusion, the Chinese version of the PHBS formed
in this study has a clear description, a short completion
time, and moderate reliability and validity in hospitals.
is method can eectively evaluate the level of positive
health behaviours in clinical nurses and has strong oper-
ability. It can be applied to clinical scientic research.
Clinical nursing managers can understand the health
behaviours of nurses according to the measurement
results of the scale and take corresponding measures to
improve nurses’ awareness of disease prevention and
health care to improve the quality of nursing work.
Acknowledged
Thank all participants who provided data for this study, and thank professor
Woynarowska-Sołdan for providing the PHBS.
Author contributions
LK drafted the manuscript after data collection and analysis, TL and CZ
collected the data, and HZ made key modications to the manuscript in order
to obtain important academic content. All authors read and approved the
nal manuscript.
Funding
No funding was obtained for this study.
Data Availability
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Before lling in the questionnaire, all participants obtained informed consent
to the content and signicance of this study, and then lled in anonymously.
All procedures were carried out in accordance with the 1964 Helsinki
declaration, and the research proposal was approved by the Ethics Committee
of Jinzhou Medical University (JZMULL2022043).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 26 March 2023 / Accepted: 16 August 2023
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