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. 2023 Apr 22;10(8):5056–5078. doi: 10.1002/nop2.1742

The psychometric properties of nursing image measurement instruments: A systematic review

Lu Zhou 1,2, Khunanan Sukpasjaroen 2, EnLi Cai 1,✉, Kristiya Moonsri 3, Prakobkiat Imsiri 4, Thitinan Chankoson 5
PMCID: PMC10333846  PMID: 37086148

Abstract

Aim

To identify the measures assessing the nursing image, and to analyse, evaluate and synthesize the psychometric properties of these available instruments.

Design

A systematic review of the psychometric properties of instruments assessing the nursing image. The system review has been registered in the PROSPERO database with the registration number CRD42020221511.

Methods

The systematic review was conducted according to COSMIN guidelines. Search strategies were run in CINAHL, MEDLINE, APA PsycINFO, Web of Science, Scopus, COSMIN systematic review database, Cochrane Library and China National Knowledge Infrastructure (CNKI). Two reviewers independently screened the studies, extracting the psychometric properties of the included study characteristics and instruments. The methodological quality of the studies, instrument measurement performance, risk of bias and grade of evidence were evaluated and disagreements were resolved via discussion.

Results

The search strategy yielded a total of 24 studies and 11 instruments assessing nursing image. None of the measures fulfilled all criteria in the COSMIN Risk of Bias checklist. The Nurses Self‐Concept Instrument (NSCI) and the Nurses Self‐Concept Questionnaire (NSCQ) were recommended for measuring the professional image of nursing, and the Nursing Brand Image Scale (NBIS) have the potential to be recommended for measuring a more comprehensive image of nursing. Every instrument evaluated in this review had different characteristics in the nursing image (e.g. the traditional image, the professional image, and the brand image). Therefore, the selection of the most appropriate instrument depends on the psychometrics, the context and the aim of the assessment.

Keywords: image, nursing, psychometric properties, self‐concept, systematic review

1. BACKGROUND

Nursing image (NI) is a multi‐dimensional concept, which includes four dimensions. Respectively, the nursing image of the media's dissemination, the public's perception of nursing, the perception of nurses' perception of nursing and the perception of nurses (including nursing students and nurse practitioners) on the personal and collective image of their profession (Rezaei‐Adaryani et al., 2012).

Nursing image is related to the decision to enter the nursing industry, and it also provides a basis for the public's career choices (Emeghebo, 2017; Rezaei‐Adaryani et al., 2012; Zarea et al., 2009). The negative nursing image may lead to multiple undesirable consequences, such as workforce shortages, an impediment to interdisciplinary relationships, violence, public trust, low salary and heavy workload and burnout (Appiah et al., 2020; Morris, 2010; Mroczek et al., 2012; Wang et al., 2019). In 2020, the number of Registered Nurses worldwide is less than 28 million, with a gap of 5.9 million (Elmorshedy et al., 2020; Hosseini et al., 2020; Liao et al., 2020). The image of nursing perceived nursing students directly affects the enrollment rate, graduation rate and employment rate within 5 years (John & Park, 2019; Squires et al., 2019). In addition, nurses' self‐perception of the nursing image will directly affect their clinical competence and professional identity, and turnover rate (Strasen, 1989).

Due to the influence of social environment, historical culture and other factors, the nursing industry has always been in a subordinate position. In public, nursing is still a marginalized industry dominated by gender, and its professionalism and dominance have not been accepted (Valiee et al., 2020). Traditional stereotypes of nurses, such as the least educated subordinate of physicians or angels of mercy, have misrepresented the concept of nursing, reduced resource allocation for nursing research and diminished the status of the nursing profession (Godsey et al., 2020). Following the COVID‐19 pandemic, media coverage contributed to the evolution of stereotypical images of nurses, highlighting the ‘heroic’ traits of nurses (Turale & Nantsupawat, 2021) and bolstering nurses' positive reputation (Li et al., 2021). However, the promotion of such virtues as dedication and sacrifice by the media may not last long in boosting the image of the nursing profession, as it does not capture an accurate and consistent image of nursing (Bennett et al., 2020). Over the long term, this highlighting of nurse virtues while ignoring the perception and promotion within professional competence, intelligence and irreplaceability is not only detrimental to the image of nursing but also reduces the attractiveness of the nursing profession (McGinity, 2021).

As erroneous social ideas and outmoded preconceptions have severely affected nurses' images, the value of the nursing profession has frequently been underestimated. To correct inaccurate views and stereotypes, it is necessary for nurses, the public and researchers to understand the gap between perceptions of nursing, the actual image and the ideal self‐image to re‐understand and re‐measure the image of nursing. Assessing different images of nursing relies on measurement instruments with great reliability and validity (Golafshani, 2003). In addition, it is essential that research builds upon past studies in the area. A synthesis of relevant research on nursing image measurement and a comparison between research cohorts to present different nursing image measurement instruments. This will facilitate the clarification of its attributes and characteristics to better understand the image of nursing. Furthermore, it will also inform the development of new nursing image measurement instruments and ensure the credibility of future research findings. There are, however, few systematic reviews that synthetically measure all developed nursing image measurement instruments according to COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN; Mokkink et al., 2018).

Given the above, the aims of this study were to identify nursing image measures that have been used with nurses, nursing, perception of the public and nursing students; and analyse, evaluate and synthesize the psychometric properties of the identified nursing image measures based on COSMIN to make recommendations for nursing image measures to use in further quantitative studies.

2. METHODS

2.1. Protocol and registration

This research is based on Preferred Reporting Items of Systematic Reviews and Meta‐Analyses, PRISMA (Moher et al., 2011) reporting guidelines for project reporting. This systematic review has been registered in the PROSPERO database (CRD42020221511; Booth et al., 2012).

2.2. Eligibility criteria

Inclusion criteria: (1) Psychometric characteristics research or the results of the research report psychometric characteristics; (2) Instrument revision or cross‐cultural adaptation research; (3) The target population of the scale is the nurse group, and there is no restriction on the use of the population; (4) Research on the self‐concept of nurses or overall image of nursing scale and (5) Research in Chinese and English.

Exclusion criteria: (1) Conference papers or review reviews; (2) Research where the scale is only used as an outcome measuring instrument and does not report any measurement characteristics; (3) Relative quality level poor research with obviously wrong data and (4) Repetitive research by the same researcher.

2.3. Information sources

Search CINAHL, MEDLINE, APAPsycINFO, Web Of Science, Scopus, Cosmin database of systematic reviews, Cochrane Library and China National Knowledge Infrastructure (CNKI), the search date ends in April 2021.

2.4. Search

Two researchers did their respective searches. The search strategy consisted of a combination of the following five traits in relation to the search construct proposed by Terwee et al.: #1 construct search AND #2 population search AND #3 instruments search AND #4 filter for measurement properties AND #5 ‘NOT’ exclusion filter (Gutiérrez‐Sánchez et al., 2020; Terwee et al., 2009). In accordance with Terwee's criteria, the exclusion filters mainly confine the type of publication, the subject grouping and the language (limited to full research articles published in English and Mandarin). References uncovered by the search strategy were imported into the Endnote bibliographic software to screen the selected publications. Additionally, the reference lists of the screened publications were reviewed to identify other relevant works (Gutiérrez‐Sánchez et al., 2020). The electronic search strategy was detailed in the Appendix S1.

2.5. Data selection

A researcher (TC) runs the above search strategy in all databases. Two investigators (ZL and CEL) independently searched the above‐mentioned database, selected eligible titles and abstracts through a determined search strategy, and screened the results again. Disagreements were settled via discussion with a third reviewer. The following information was extracted from each of the included studies: author, published year, target population, setting, instrument characteristics, measurement properties and COSMIN ratings.

2.6. The methodological quality and result rating of each single study

The COSMIN Risk of Bias checklist (Mokkink et al., 2018) is used to assess the methodological quality and the psychometric properties of every single study. The list is composed of 10 boxes: instrument development, content validity, structural validity, internal consistency, cross‐cultural validity, reliability (test–retest, inter‐rater and intra‐rater), measurement error, criterion validity, hypothesis testing and responsiveness; every box is evaluated with items assessed on a four‐point rating scale [very good (V), adequate (A), doubtful (D) and inadequate (I)], and the final evaluation of each property is assessed on a ‘worst score counts’ principle.

Significantly, in contrast to the original universe checklist (Mokkink et al., 2012), content validity was extended from assessing only face validity to instrument development and content validity (relevance, comprehensibility and comprehensiveness). The most important changes are as follows: a reordering of the measurement attributes to be assessed; the removal of criteria that do not necessarily lead to biased results; the integration of general criteria for item response theory research with those for specific measurement attributes; an emphasis on proposing construct validity hypotheses; and the optimization of the labels for the four‐point rating system (i.e., Excellent, Good, Fair or Poor) for greater clarity and certainty (Mokkink et al., 2018).

The updated criteria for good measurement properties (Gutiérrez‐Sánchez et al., 2020; Prinsen et al., 2018) were employed to rate the quality of the measurement properties reported by each study. This refers specifically to the actual result of the measurement performance (Charette et al., 2020). Each property is rated as sufficient (+), insufficient (−) or indeterminate (?).

2.7. Synthesis

Each measurement property had its evidence summarized and rated as either ‘high’, ‘moderate’, ‘low’ or ‘very low’ (Prinsen et al., 2018). In this step, the summarized evidence was graded using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) quality of evidence method (Guyatt et al., 2008; Prinsen et al., 2018). The focus is here on each instrument. Quantitatively pooled or qualitatively summarized measurement properties for each instrument were conducted and compared against the criteria for good measurement properties to determine whether overall the measurement property of the instrument is sufficient (+), insufficient (−), inconsistent (±) or indeterminate (?) (Prinsen et al., 2018).

The included instruments are categorized into three categories of recommendations: (A) instruments that have the potential to be recommended as the most suitable instrument for the construct and population of interest (i.e., instruments with evidence for sufficient content validity (any level) and at least low evidence for sufficient internal consistency); (B) instruments that may have the potential to be recommended, but further validation studies are needed (i.e., instruments categorized not in A or C) and (C) instruments that should not be recommended (i.e., instruments with high‐quality evidence for an insufficient measurement property; de Freitas et al., 2022; Prinsen et al., 2018). The step is formulated concerning the quality of the evidence, construct of interest and study population.

All three of the above quality assessments (risk of bias, outcome quality and quality of evidence) were completed independently by two authors.

3. RESULTS

3.1. Study selection

A total of 3342 articles were retrieved, 1020 duplicate articles were removed and 205 articles were re‐screened. Two reviewers evaluated the title and abstract based on the inclusion criteria. A total of 205 articles are included for full‐text review. Among them, 23 studies met the search criteria shown in the PRISMA flowchart (Moher et al., 2011), as shown in Figure 1.

FIGURE 1.

FIGURE 1

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PRISMA literature screening flowchart.

3.2. Study characteristics

Twenty‐four instruments were included in this review, detailed in Table 1. Eleven original instruments (Angel et al., 2012; Arthur, 1995; Cowin, 2001; Dagenais & Meleis, 1982; Godsey et al., 2018; Porter & Porter, 1991; Siebens et al., 2006; Toth et al., 1998; Tzeng, 2006) and 13 culturally adapted and revised (Cao et al., 2013; Chang & Yeh, 2016; Cukljek et al., 2017; De Braganca & Nirmala, 2021; Guirong et al., 2008; Olsson & Gullberg, 1987; Onyeizugbo & Nwafor, 2010; Qiuhuan & Xiuzhen, 2008; Ryu & Kim, 2017; Takase et al., 2006; Yan et al., 2012; Miao et al., 2020; Zencir et al., 2019). Before 2018, these original instruments almost were only focused on one characteristic of nursing images, such as the virtuous features of nurses or professional image of a nurse. Three instruments developed by Godsey et al. (2018) were the only instruments that incorporated the concept of the brand image of nursing measuring a more integrated and multi‐dimensional image of nursing. The rest of the original instruments were almost based on self‐concept theory, role theory and socialization theory. Focus groups are the most common research method for developing scales. All original instruments were extracted from English studies. Translations were most often validated using a cross‐sectional study design.

TABLE 1.

Characteristics of included scales.

Instrument Reference, country Population/language Item generation Conceptual model/theoretical framework Characteristics and subscales (number of items) Response options Measuring range

Porter

Nursing Image Scale, PNIS

 Porter and Porter (1991), USA 363 nurses, English Literature review Self‐concept model

3 dimensions, 30 bipolar adjectives:

1. Interpersonal power: 13

2. Interpersonal relations: 10

3. Intrapersonal ability: 7

 Likert 7 The self‐image of nurses and the public's perception of nursing
Takase et al. (2006), Australia 300 Registered Nurses, English / /

2 dimensions, 17 bipolar adjectives:

1. Leadership aptitudes: 12

2. Caring aptitudes: 5

 Likert 6 The self‐image of nurses and their perception of the public image of nurses
De Braganca and Nirmala (2021), India 749 nurses, English / / 3 dimensions, 14 bipolar adjectives Likert 5

Self‐reports from Registered Nurses

regarding their perception about doctors' image of a nurse,

patients' image of a nurse, other hospital staffs' image of a

nurse, and self‐perception about a nurse using nurses' perception about stakeholders' image of a nurse scale.
Tzeng (2006), Taiwan, China 488 undergraduates, postgraduates and university faculty and staff, Chinese &English Based on PNIS /

5 dimensions, 19 items:

1. Angel of mercy aspect (7)

2. Romantic aspect (4)

3. Careerist aspect (4)

4. Obedient aspect (2)

5.Bureaucratic aspect (2)

Likert 5: The perception items: From 1 (very much disagree) to 5 (very much agree).

The expectation items: From 1 (very little needed) to 5 (very much needed).

 Perceived images and expected images of nurses and public groups of Taiwanese nurses, the scope of nursing image, and the difference in concept between nurses and non‐nursing employees
Yan et al. (2012), China 511 clinical nurses, Chinese / /

5 dimensions, 19 items:

1. Angel of mercy aspect (7)

2. Romantic aspect (4)

3. Careerist aspect (4)

4. Obedient aspect (2)

5. Bureaucratic aspect (3)

Likert5:The perception items: From 1 (very much disagree) to 5 (very much agree).

The expectation items: From 1 (very little needed) to 5 (very much needed).

 Measuring the self‐image of nurses
Nursing Attitudes/image Questionnaire, NAQ/NIQ Toth et al. (1998), USA 388 nurses and nursing students, English Literature review Socialization and role theory

5 dimensions, 30 items: Items 6 and 24 have been adjusted due to cultural adaptability

1. Role (10)

2. Values (7)

3. Stereotype (views by society; 6)

4. Professionalism (4)

5. Characteristics of nurses/nursing (3)

 Likert5: from 1 (strongly disagree) to 5 (strongly agree) How do individuals view the role, values and professional activities of nurses
Cukljek et al. (2017), Croatia 725 nursing students, English/Croatian / /

5 dimensions, 30 items:

1. Role (10)

2. Values (7)

3. Stereotype (views by society; 6)

4. Professionalism (4)

5. Characteristics of nurses/nursing (4)

 Likert5: from 1 (strongly disagree) to 5 (strongly agree) How do individuals view the role, values and professional activities of nurses
BELgian professional self‐IMAGE instrument for nursing students, BELIMAGE Siebens et al. (2006), Belgium 9638 nurses, Dutch & French Focus groups, literature reviews and triangulation /

3 dimensions, 52 items:

1. Competence (?)

2. Nursing care (?)

3. Team (?)

1. Competence (incompetent, rather incompetent, rather competent, competent, very competent)

2. Nursing care (less important, important, very important, priority)

3. Team (?)

 Assessing the professional self‐image of nurses in Belgian hospitals
Professional Self‐Concept of Nurses Instrument, PSCNI Arthur (1995), Australia 170 junior nursing students, English Interview, questionnaire survey and literature review Self‐concept theory

3 dimensions, 5 sub‐dimensions, 27 items:

1. Professional practice (16)

1.1 Leadership

1.2 Flexibility

1.3 Skill

2. Satisfaction (7)

3. Communication (4)

 Likert 4 Assess the professional self‐image of the nurse community
Guirong et al. (2008), China 833 sophomore to senior nursing students, English/Chinese / /

5 dimensions, 30 items:

1. Leadership (4)

2. Flexibility (7)

3. Skill (5)

4. Satisfaction (9)

5. Communication (5)

 Likert 4
Nurses Self‐Concept Instrument, NSCI Angel et al. (2012), Australia 253 undergraduate nursing students, English Literature review and Cowin's NSCQ scale Self‐concept theory

4 dimensions, 14 items:

1. Care (3)

2. Knowledge (4)

3. Staff relations (3)

4. Leadership (4)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Measuring the professional self‐concept of nursing students in Australia and abroad
Chang and Yeh (2016), Taiwan, China 540 nursing students, English/Chinese / /

2 dimensions, 14 items:

1.Care (10)

2. Leadership (4)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Evaluating the professional self‐concept of Chinese nursing undergraduates
Ryu and Kim (2017), South Korea 159 long‐term Care Hospitals nurses, English/Korean / /

4 dimensions, 14 items:

1. Care (3)

2. Knowledge (4)

3. Staff relations (3)

4. Leadership (4)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Evaluate the self‐concept of Registered Nurses in Korean nursing homes
Miao et al., (2020), China 1284 nursing students, English/Chinese / /

3 dimensions, 14 items:

1. Care (7)

2. Staff relations (3)

3. Leadership (4)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Evaluating the professional self‐concept of Chinese nursing undergraduates
Nurses Self‐Concept Questionnaire, NSCQ Cowin (2001), Australia, Afghanistan, Zimbabwe, USA, New Zealand, and other countries 506 fresh graduate nursing students and 528 nurses, English Interview, expert consultation and literature review Multi‐dimensional self‐concept model

6 dimensions, 36 items:

1. General nursing (6)

2. Care (6)

3. Staff relations (6)

4. Communication (6)

5. Knowledge (6)

6. Leadership (6)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Measuring the self‐concept of nurses
Cao et al. (2013), China 1374 Registered Nurses, English/Chinese / /

6 dimensions, 36 items:

1. General nursing (8)

2. Care (6)

3. Staff Relations (5)

4. Communication (6)

5. Knowledge (5)

6. Leadership (6)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Assessing the professional self‐concept of Chinese nurses
Zencir et al. (2019), Turkey 335 nursing students and 380 Registered Nurses, English/Turkish / /

6 dimensions, 36 items:

1. General nursing (6)

2. Care (6)

3. Staff Relations (6)

4. Communication (6)

5. Knowledge (6)

6. Leadership (6)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Assessing the professional self‐concept of nurses in Turkey
Onyeizugbo and Nwafor (2010), Nigeria 100 nursing students and 70 Registered Nurses, English / /

6 dimensions, 36 items:

1. General nursing (6)

2. Care (6)

3. Staff Relations (6)

4. Communication (6)

5. Knowledge (6)

6. Leadership (6)

 Likert 8: ranging from 1 (definitely false) to 8 (definitely true) Assessing the professional self‐concept of nurses in Nigeria
Nurse Self‐Description Form, NSDF Dagenais and Meleis (1982), USA 188 senior nursing students, English NASA's assessment of staff self‐concept /

3 dimensions, 19 items:

1. Professionalism (11)

2. Empathy (4)

3. Work ethic (4)

 Likert 7: From 1 (definitely less than others) to 7 (absolutely more than others) Self‐assessment of the nurses' perception of their relationship with others, their enthusiasm, and their nursing role
Olsson and Gullberg (1987), Sweden 30 Registered Nurses, English/Swedish / /

4 dimensions, 19 items:

1. Professionalism (8)

2. Empathy (7)

3. Work ethic (10)

4. Leadership (2)

 Likert 7: From 1 (definitely less than others) to 7 (absolutely more than others) Cross‐cultural revision of the Swedish version
Qiuhuan and Xiuzhen (2008), China 81 nursing students, English/Chinese / / unknown, 19 items Likert 5: from 1 (strongly disagree) to 7 (strongly agree) Cross‐cultural revision of the Chinese version
Nursing Brand Image Scale, NBIS Godsey et al. (2018), USA 286 nursing graduates, English Focus group Brand strategy theory

7 dimensions, 42 phrases:

1. Influential leaders/interprofessional partners (12)

2. Qualified for advanced nursing practice (7)

3. Qualified caregivers (6)

4. Strong interpersonal skills (4)

5. Lack authority/professional identity (7)

6. Expert healthcare providers and partners (3)

7. Valued by society (2)

 Likert 10: From 1 (Does Not Apply At All) to 10 (Perfectly Applies) Understand how nurses evaluate self‐brand image and determine how the industry currently views self‐image
Nursing's Current Brand Position Scale, NCPBS Godsey et al. (2018), USA 286 nursing graduates, English Focus group Brand strategy theory

3 dimensions, 10 items:

1. Influential leaders (5)

2. Patient‐centered health/wellness (2)

3. Caring advocates for patients/public (3)

 Likert 10: 1 (Does Not Describe At All) to 10 (Perfectly Describes) Describe the current brand positioning in the nursing industry
Nursing's Desired Brand Position Scale, NDBPS Godsey et al. (2018), USA 286 nursing graduates, English Focus group Brand strategy theory

2 dimensions, 10 items:

1. Influential leaders (6)

2. Patient‐centered health/wellness (4)

 Likert10: 1 (Very unappealing to 10 appealing) Describe the desired brand positioning for the nursing industry
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3.3. Methodological quality and ratings of measurement properties

The measurement properties, methodological quality, results ratings of measurement performance and GRADE quality of evidence for each study and the instruments measuring the image of nursing are detailed in Table 2. There were no psychometric data on the measurement error and responsiveness of any of the included instruments. Therefore, the properties are omitted in the presentation of results. Additionally, all of the included cross‐cultural studies did not conduct Multiple‐group CFA to validate the translated versions.

TABLE 2.

Methodological quality, quality of results and ratings of measurement properties.

Instrument Reference, country Content validity Structural validity Internal consistency Cross‐cultural validity\measurement invariance Reliability Criterion validity Hypotheses testing for construct validity
M Q QE M Q QE M Q QE M Q QE M Q QE M Q QE M Q QE
PROM development; target population/experts EFA; CFA Cronbach's alpha Details of translation and adaptation; CFA ICC/kappa Sensitivity and specificity Convergent validity/discriminant validity; correlations
Porter Nursing Image Scale, PNIS Porter and Porter (1991), USA D Clinical and Nursing Education Expert Panel Evaluation (−) L I Cronbach's alpha (subscales) 0.88 ~ 0.57(−) L
Takase et al. (2006), Australia D Expert (n =?) reviewed relevance (CVI not reported). Nurses (n = 16) reviewed Comprehensiveness (?) NA A

Cronbach's alpha (subscales) 0.85–0.87:leadership aptitudes 0.87, caring aptitudes 0.85;

(overall tool) 0.89 (n = 343)(+)

 L
De Braganca and Nirmala (2021), India I Expert (n = 11) in nursing and management reviewed the scale (CVI was 0.982); No target population involved (−) L I Cronbach's alpha (overall tool) 0.851 (n = 749) (+) L
The Nursing Image Scale, NIS Tzeng (2006), Taiwan, China D Expert (n = 3) reviewed comprehensiveness (CVI not reported). Nurses (n = 71) reviewed comprehensibility (+) L A EFA:62.66% of the variance was explained (n = 488) (+); pseudo‐R2 Nagelkerke = 0.433 M A Cronbach's alpha (subscales) perception (a) & expectation (b): Angel of mercy aspect (a = 0.867, b = 0.817), Romantic aspect (a = 0.720, b = 0.796), Careerist aspect (a = 0.802, b = 0.697), Obedient aspect (a = 0.601, b = 0.758), Bureaucratic aspect (a = 0.670, b = 0.568); (overall tool) a = 0.849, b = 0.806(n = 488) (+) L
(Yan et al., 2012), China I Nurses (n = 123) reviewed comprehensibility (?) NA I Logistic:coxsnell = o.623, Nagelkerkel = 0.650, McFadden R 2 = 0.624 (?) NA I Cronbach's alpha (overall tool) 0.867 (n = 135) (?) NA A A month, r = 0.89 (n = 511) (+) H
The Nursing Attitudes/image Questionnaire, NAQ/NIQ Toth et al. (1998), USA A Expert (n = 11) reviewed relevance and comprehensiveness (CVI not reported). Nurses (n = 45) reviewed comprehensibility (+) L D Cronbach's alpha (overall tool)0.75 ~ 0.80(?) NA A 4 weeks, Spearman'r = 0.77 (n = 12) (+) L D Concurrent Validity: RNs score t(88) = 6.7, p < 0.001; no report convergent and discriminant validity (−) L
Cukljek et al. (2017), Croatia D Nurses (n = 20) tested comprehensiveness and Comprehensibility (?) NA I EFA:36% of the variance was explained (−) L I Cronbach's alpha (overall tool) 0.63 ~ 0.70(?) NA I Expert (n = 2) translation and back translation; The process not mentioned; Multiple‐group CFA not applied (?) L
BELgian professional self‐IMAGE instrument for nursing students, BELIMAGE Siebens et al. (2006), Belgium D Expert (n = 3) reviewed relevance and academic (n =?) reviewed relevance of items (2 round). (−) L
The Professional Self‐concept of Nurses Instrument, PSCNI Arthur (1995), Australia A Nursing teachers (n = 35) test the comprehensiveness (?) NA A EFA: 40%–57.30% of the variance was explained (n = 170) (+) M A Cronbach's alpha (subscales) 0.59–0.85; Cronbach's alpha (overall tool) 0.89 (+) H D PSCNI and CAQ (r = 0.51); PSCNI and TIQ (r = 0.13), no report hypotheses (?) NA
Guirong et al. (2008), China I Lack of expert evaluation process and CVI; No target population involved (−) L D EFA:54.06% of the variance was explained (n = 833), orthogonal (+) M A Cronbach's alpha (subscales) 0.32–0.8; Cronbach's alpha (overall tool) 0.84 (+) H A Half‐reliability (subscale) r = 0.46\0.54\0.61\0.53\0.87, overall sacle r = 0.75 (+) L
The Nurses Self‐Concept Instrument, NSCI Angel et al. (2012), Australia D Experts (n = 2) in educational psychology review the comprehensibility and comprehensiveness (−) M A CFA showed good fit of the original factor structure, RMSEA = 0.066 (95% CI: 0.051–0.080), NNFI = 0.98, CFI = 0.99, x2 = 148.89, df = 71, p‐value for test of close fit = 0.025.(n = 253) (+) H A Cronbach's alpha (subscales) 0.81–0.88: Knowledge 0.81, Care 0.86, Staff relations 0.86, Leadership 0.88; Cronbach's alpha (overall tool)0.94 (+) H
Chang and Yeh (2016), Taiwan, China A Expert (n = 3) in nursing education and clinical practice reviewed relevance and comprehensiveness (I‐CVI = 1, S‐CVI = 0.81). Nurses (n = 5) reviewed comprehensibility (+) M A EFA:69.04% of the variance was explained (n = 298). M A Cronbach's alpha (subscales) 0.89–0.94:care0.94, leadership 0.89; Cronbach's alpha (overall tool)0.94 (492) (+) H D Expert (n = 2) in english translation and back translation differences in factor structure via CFA (?) NA V 2 weeks, Spearman's r = 0.87 (n = 48) (+) M I Concurrent Validity: mean (freshman)84.71 ± 13.24, 78.83 ± 9.82 (undergraduate) , p < 0.05 (−) L
CFA showed good fit of the original factor structure, RMSEA = 0.08, CFI = 0.92, x 2 = 183.56, X 2/df = 2.66, AGFI = 0.88, RMR = 0.08, CN = 170 (n = 149) (+)
Ryu and Kim (2017), South Korea I Professors (n = 2) reviewed comprehensiveness (CVI not reported);Nursing postgraduates (n = 3) in elderly care reviewed comprehensibility (+); L I EFA: 78.81% of the variance was explained (n = 159), orthogonal (−) VL A Cronbach's alpha (subscales) 0.77–0.91: knowledge 0.87, care 0.78, staff relation 0.77, leadership 0.91; Cronbach's alpha (overall tool) 0.94 (n = 159) (+) H I 2 round in translation and back translation; Multiple‐group CFA not applied (?) NA I Elderly care performance scale (p < 0.01)(−) L
Miao et al., (2020), China A Expert (n = 6) in nursing education, clinical practice and psychology reviewed relevance and comprehensiveness (I‐CVI = 0. 84–1. 00, S‐CVI = 0.954). Nurses (n = 30) reviewed comprehensibility (+) M D EFA:67. 11% of the variance was explained (n = 630), orthogonal; (−) L V Cronbach's alpha (subscales)0.742–0.884: care0.881, staff relation 0.742, leadership 0.884; Cronbach's alpha (overall tool)0.918 (n = 1284) (+) H A Expert (n = 7); translation and back translation; nursing students and teachers (n = 6) reviewed Comprehensibility; Multiple‐group CFA not applied (?) NA D 2 weeks; r = 0.736–0.943 (n = 126) (+) H D PSCNI: Cronbach's alpha = 0.84; split‐half reliability = 0.86 (+) L
CFA showed good fit of the original factor structure, RMSEA = 0.076, GFI = 0.875, NFI = 0.902, CFI = 0.927, IFI = 0.926,x 2 = 268.72, df = 74 (n = 654) (+)
The Nurses Self‐Concept Questionnaire, NSCQ Cowin (2001), Australia, Afghanistan, Zimbabwe, USA, New Zealand, and other countries D Expert (n = 9) in nursing and self‐concept reviewed relevance (CVI not reported); No target population involved (−) L V

EFA:72.9% of the variance was explained (n = 506)

CFA showed good fit, TLI = 0.911, RNI = 0.887, GFI = 0.906,x 2 = 787.05, df = 120 (n = 528) (+)

 H V Cronbach's alpha (subscales) 0.83–0.93: General Nursing 0.93, Care 0.89, Staff Relations 0.89, Communication 0.92, Knowledge0.83, Leadership 0.93; Cronbach's alpha (overall tool) 0.90 (n = 1034)(+) H I Time interval not mentioned; neither ICC/weighted kappa nor Pearson's r determined (?) VL I Concurrent Validity: statistically significant differences in 4 dimensions of nursing care, colleague relations, communication and leadership among nursing students and nurses (−) VL
Cao et al. (2013), China A Expert (n = 8) in nursing education and clinical practice reviewed relevance and comprehensiveness (I‐CVI = 0.881); Nurses (n = 18) reviewed comprehensibility and time (+) M V

EFA:61.66% of the variance was explained (n = 347)

CFA showed good fit, x 2 = 2615.55; df = 579; x 2/df = 4.52; RMSEA = 0.06; TLI = 0.90; CFI = 0.91; GFI = 0.87 (n = 1017) (+)

 H V Cronbach's alpha (subscales) 0.83–0.88:General nursing 0.88, Care 0.86, staff relations 0.83, communication 0.84, knowledge 0.86, leadership 0.87; Cronbach's alpha (overall tool) 0.95 (n = 347) (+) H A Expert (n = 6) translation and back translation; Nurses (n = 18) reviewed comprehensibility; Multiple‐group CFA not applied (?) NA A 2 weeks, 0.73–0.83 (n = 25) (+) M D AVE < 0.6; The outcomes demonstrated a favourable discriminant validity of the C‐NSCQ among staff nurses and head nurses; no report the relationship between the square root of AVE and the highest shared variance with any other factors; MBI and NSCQ (β = 0.58; p = 0.00) (?) NA
Zencir et al. (2019), Turkey D Experts (n = 10) including 2 specialist nurses, 5 assistant professors in nursing, 2 clinical nursing managers, and 1 Registered Nurse reviewed relevance and comprehensiveness (CVI0.78); No target population involved (−) M V

EFA:65.76% of the variance was explained (n = 673)

CFA showed good fit, RMSEA = 0.081, NNFI[TLI] = 0.97, CFI = 0.97, SRMR = 0.072, except GFI = 0.80, χ 2: 3110; df: 579 and χ 2/df = 5.37 (n = 170) (+)

 H V Cronbach's alpha (subscales)0.83–0.91:General Nursing0.91, care0.86, staff relations0.83, communication0.89, knowledge0.85, leadership0.87; Cronbach's alpha (overall tool) 0.95 (n = 673) (+) H A Expert (n = 12) in public health and English and Turkish inventories translation and back translation; Multiple‐group CFA not applied (?) NA A Overall T‐NSCQ was 0.87. The subscales had a high coefficient (for leadership r = 0.87; NGSC r = 0.84; knowledge r = 0.83; caring r = 0.77; communication r = 0.76) except staff relations (r = 0.69) (+) M D RSES and T‐NSCQ (r = 0.147 ~ 0.375); The staff relations (p = 0.002), communication (p = 0.004), knowledge (p = 0.001), and leadership (p = 0.022) subscale scores were higher among nurses compared to nursing students (?) NA
Onyeizugbo and Nwafor (2010), Nigeria I Experts (n = 5) in clinical practice reviewed relevance and comprehensiveness (CVI not reported); No target population involved (−) L D Explained variance not mentioned; CFA showed good fit, CFI = 0.91, NNFI = 0.91, IFI = 0.91, RMSEA = 0.06 and x 2 = 982.09, df = 579, p = 0.0 (n = 170) (+) H A Cronbach's alpha (subscales) 0.70–0.75: General nursing 0.75, care 0.72, staff relations 0.70, communication 0.75, knowledge 0.70, leadership 0.74; Cronbach's alpha (overall tool) 0.95 (n = 170) (+) H I Cultural‐adaptation process not mentioned; Multiple‐group CFA not applied (?) NA D MSQ and NSCQ (r = 0.37, p < 0.001, r = 0.32, p < 0.001 and r = 0.33, p < 0.001); NSCQ and MBI (r = −0.34, p < 0.001, r = −0.33, r = −0.24, r = −0.30, p < 0.001) (?) NA
The Nurse Self‐Description Form, NSDF Dagenais and Meleis (1982), USA I Western Council of Higher Education in Nursing (WCHEN) reviewed relevance; No target population involved (?) NA A EFA:62.5% of the variance was explained (n = 188) (+) L A Cronbach's alpha (subscales) 0.80–0.92:Professionalism 0.92, Empathy 0.80, Work ethic 0.82; Cronbach's alpha (overall tool) 0.93(n = 188) (+) M I The powerlessness scale; the self‐esteem test; the omnibus personality inventory; the honesty scale, the correlation not mentioned (?) NA
Olsson and Gullberg (1987), Sweden I Nurses (n = 30) reviewed comprehensibility (−) L I EFA:70.1% of the variance was explained (n = 30) (+) L D 1 round in translation and back translation; Multiple‐group CFA not applied (?) NA
Qiuhuan and Xiuzhen (2008), China I Nursing students (n = 5) reviewed comprehensibility (?) NA I The author translation; student (n = 1) back translation and verification; Multiple‐group CFA not applied (?) NA
The Nursing Brand Image Scale, NBIS Godsey et al. (2018), USA A

A total of three in‐person and webinar

focus group meetings (n = 27); experts (n = 16); target population (n = 11) (+)

 M A EFA:61.6% of the variance was explained (n = 286) (+) L D Cronbach's alpha (overall tool) = 0.925 (n = 286) (?) L
Nursing's Current Brand Position Scale, NCPBS Godsey et al. (2018), USA A Ditto M A EFA:68.4% of the variance was explained (n = 286) (+) H D Cronbach's alpha (overall tool) = 0.86 (n = 286) (?) L
Nursing's Desired Brand Position Scale, NDBPS Godsey et al. (2018), USA A Ditto M A EFA:68.3% of the variance was explained (n = 286) (+) H D Cronbach's alpha (overall tool) = 0.906 (n = 286) (?) L
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The Porter Nursing Image Scale was assessed in three studies (De Braganca & Nirmala, 2021; Porter & Porter, 1991; Takase et al., 2006). Only Content validity and Internal consistency were reported in the three studies. High scores of internal consistency in the study of Takase et al. (2006), while this property was scored as ‘inadequate’ in the rest of the studies because Cronbach's alphas of each dimensionality were not determined. Content validity was scored as ‘doubtful’ and ‘inadequate’ in the three studies because of no target population involvement and unclear description.

The Nursing Image Scale was evaluated in two studies. Content validity was scored as ‘doubtful’ in the study conducted in Taiwan (Tzeng, 2006) because the authors do not report the values of the content validity index (CVI), and only 3 experts were invited to the validation process. The content validity of the Mandarin version was deemed of doubtful methodological quality because a clear description of the translation process is lacking. Both Structural validity and internal consistency were scored as ‘inadequate’ in the Mandarin version since exploratory or confirmatory factor analysis was not performed, and Cronbach's alphas of each dimensionality are unclear.

The Nursing Attitudes/image Questionnaire was assessed in two studies (Cukljek et al., 2017; Toth et al., 1998). Four measurement properties were evaluated in the study of Toth et al. (1998), scoring as ‘adequate’ for content validity and reliability. The questionnaire scored as ‘doubtful’ in internal consistency and construct validity due to Cronbach's alphas were not clearly described and convergent validity/discriminant validity were not evaluated. The content validity of the Croatian translation was deemed of doubtful methodological quality because no expert was recruited for the cross‐cultural adaptation. In addition, the Croatian version only can explain <50% of the variance. Thus, validity was rated low for the Croatian version, as well as internal consistency.

The BELgian professional self‐IMAGE instrument was assessed content validity (Siebens et al., 2006), scoring as ‘doubtful’ due to no target population involvement.

The Professional Self‐concept of Nurses Instrument was evaluated in two studies (Arthur, 1995; Guirong et al., 2008). Four measurement properties were evaluated for the original instrument, scoring as ‘adequate’ for content validity, structural validity and internal consistency. The instrument scored as ‘doubtful’ in construct validity due to hypotheses was not clearly described and convergent validity/discriminant validity was not evaluated. The content validity and structural validity of the Chinese version were deemed as ‘inadequate’ and ‘doubtful’ methodological quality study since the target population and experts were not involved in the translation and adaptation, and an inappropriate rotation method is employed (i.e. orthogonal rotation).

The Nurses Self‐Concept Instrument was evaluated in four studies (Angel et al., 2012; Chang & Yeh, 2016; Ryu & Kim, 2017; Miao et al., 2020). Overall, the NSCI is outperformed by the instruments already mentioned in terms of methodological quality, quality of results and quality of evidence. However, content validity scored as ‘doubtful’ in the study of Angel et al. (2012) because the authors do not report the values of the content validity index (CVI), the target population was not involved in item selection, and only a small sample of experts (n = 2) were involved in the validation process. Cross‐cultural validity and construct validity were scored as ‘doubtful’ and ‘inadequate’ in the study of Chang and Yeh (2016) because of differences in factor structure via CFA and unclear descriptions of hypotheses. The methodological qualities of the Mandarin version were deemed doubtful methodological quality because a clear description of the translation process is lacking. Except for internal consistency, all other methodological qualities (i.e. content validity, structural validity, cross‐cultural validity and construct validity) of the Korean version were deemed doubtful because of lacking a sufficient sample of the target population and experts, convergent validity/discriminant validity for hypotheses testing, as well as an inappropriate rotation method. Criterion validity was scored as ‘doubtful’ in the study of Miao et al. (2020) because it was unclear if the Professional Self‐concept of Nurses Instrument (p < 0.01) could be considered an adequate gold standard.

The Nurses Self‐Concept Questionnaire was evaluated in four studies (Cao et al., 2013; Cowin, 2001; Onyeizugbo & Nwafor, 2010; Zencir et al., 2019). Similar to the NSCI and PSCNI, the NSCQ focuses on measuring the perceived professional image of the nurse group. Content validity was scored as ‘doubtful’ in the study of Cowin (2001) because the target population was not involved in item selection, while structural validity and internal consistency were scored highly. The reliability of the Chinese translation was deemed of doubtful methodological quality because neither ICC/weighted kappa nor Pearson's r was determined. The Chinese version of the NSCQ is the only study to assess convergent validity by average variance extracted (AVE), even though the AVE is lower than the recommended value. Content validity and construct validity scored as ‘doubtful’ in the study of Turkey translation because the authors do not report the target population and hypotheses. The internal consistency of the Nigerian version is adequate, but the rest of the psychometric properties were deemed doubtful or inadequate methodological quality.

The Nurse Self‐Description Form was evaluated in three studies (Dagenais & Meleis, 1982; Olsson & Gullberg, 1987; Qiuhuan & Xiuzhen, 2008). Four measurement properties were evaluated for the original instrument, scoring as ‘adequate’ for structural validity and internal consistency. However, inappropriate designs or methods were used to validate content validity and hypotheses. The methodological quality, the quality of the results and the quality of the evidence for the psychometric properties of the Swedish and Chinese versions are poor.

The Nursing Brand Image Scale, the Nursing's Current Brand Position Scale and the Nursing's Desired Brand Position Scale were all developed by Godsey et al. (2018). The three scales are aimed to measure a more comprehensive and objective image of nursing and to position the current and future image of nursing. Three measurement properties were evaluated for the three original instruments in the study of Godsey et al. (2018), scoring as ‘adequate’ for content validity and structural validity. But Cronbach's alphas were not calculated for each subscale. There was also a lack of reporting on the rest of the psychometric properties.

3.4. Synthesis

Within the instruments included in this systematic review, seven instruments were validated in multiple studies and the remaining instruments were all tested in only one study (i.e. BELIMAGE, NBIS, NCPBS and NDBPS). Moreover, categories of recommendations were formulated concerning the quality of the evidence, construct of interest and study population. Overall, as only NSCI and NSCQ meet the criterion that instruments with evidence for sufficient content validity (any level) and at least low evidence for sufficient internal consistency, the recommended category is (A). PSCNI was rated in category (C) due to high‐quality evidence for insufficient internal consistency. The remaining instruments have the potential to be recommended, but further validation studies are needed. The results of the evidence synthesis are detailed in Table 3.

TABLE 3.

Summary of findings.

Instruments Synthesis Overall rating Quality of evidence Recommendation
Porter Nursing Image Scale, PNIS Content validity ? NA B
Relevance ?
Comprehensiveness ?
Comprehensibility ±
Internal consistency − Lowbcd
The Nursing Image Scale, NIS Content validity ± Lowa B
Relevance −
Comprehensiveness ?
Comprehensibility ?
Structural validity − Lowac
Internal consistency ± Moderateb
Reliability + High
The Nursing Attitudes/image Questionnaire, NAQ/NIQ Content validity ± Lowabc B
Relevance ?
Comprehensiveness ±
Comprehensibility ±
Structural validity − Lowa
Internal consistency ? NA
Cross‐cultural validity\measurement invariance ? NA
Reliability + Moderatea
Hypotheses testing for construct validity − Lowac
BELgian professional self‐IMAGE instrument for nursing students, BELIMAGE Content validity − Lowac B
Relevance −
Comprehensiveness −
Comprehensibility −
The Professional Self‐concept of Nurses Instrument, PSCNI Content validity ? NA C
Relevance ?
Comprehensiveness +
Comprehensibility ?
Structural validity − Lowac
Internal consistency − High
Reliability − High
Construct validity ? NA
The Nurses Self‐Concept Instrument, NSCI Content validity + Moderatea A
Relevance +
Comprehensiveness +
Comprehensibility +
Structural validity ± Lowabc
Internal consistency + High
Cross‐cultural validity\measurement invariance ? NA
Reliability + High
Criterion validity + Moderatea
Hypotheses testing for construct validity ? NA
The Nurses Self‐Concept Questionnaire, NSCQ Content validity + Moderated A
Relevance +
Comprehensiveness +
Comprehensibility +
Structural validity + High
Internal consistency + High
Cross‐cultural validity\measurement invariance ? NA
Reliability + Moderateac
Construct validity ? NA
The Nurse Self‐Description Form, NSDF Content validity ? NA B
Relevance ?
Comprehensiveness ?
Comprehensibility ?
Structural validity ? NA
Internal consistency + Moderatea
Cross‐cultural validity\measurement invariance ? NA
Construct validity ? NA
The Nursing Brand Image Scale, NBIS Content validity + Moderatea B
Relevance +
Comprehensiveness +
Comprehensibility +
Structural validity ? NA
Internal consistency ? NA
Nursing's Current Brand Position Scale, NCPBS Content validity + Moderatea B
Relevance +
Comprehensiveness +
Comprehensibility +
Structural validity ? NA
Internal consistency ? NA
Nursing's Desired Brand Position Scale, NDBPS Content validity + Moderatea B
Relevance +
Comprehensiveness +
Comprehensibility +
Structural validity ? NA
Internal consistency ? NA
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Note: Quality of the results rated as + = positive rating, ? = indeterminate rating, ± = inconsistent rating, − = negative rating.

“a” downgrading for Risk of Bias; “b” downgrading for inconsistency; “c” downgrading for imprecision; “d” downgrading for indirectness.

Abbreviations: CFA, confirmatory factor analysis; DIF, differential item functioning; EFA, exploratory factor analysis; ICC, interclass correlation coefficient; MGCFA, multi‐group confirmatory factor analysis; PCA, principal components analysis; SEM, standard error of measurement.

4. DISCUSSION

4.1. Instruments for measuring nursing image

This is the first and most‐updated systematic review that contrasts the measurement properties of the instruments measuring nursing images in accordance with the updated COSMIN guideline (Mokkink et al., 2018; Prinsen et al., 2018).

To correct inaccurate stereotypes and eliminating role ambiguity are crucial to nurses group, the healthcare system, and even the society in the workforce shortage situation, and the nursing image plays an essential role in the process of changing in self‐perception of nurses and the public (Godsey et al., 2020). Different instruments for measuring the image of nursing can provide quantitative and more comprehensive insight into subjective impressions of nursing images that are difficult to observe directly and measure objectively, particularly in terms of measuring the different levels and characteristics of attitudes and perceptions (McGinity, 2021).

The main aim of this systematic review was to identify instruments for measuring the nursing image and to assess the measurement performance of these instruments according to the COSMIN checklist. Tewnty‐four studies were included, and 11 instruments for assessing the nursing image were identified. The instruments assessing nursing image were based on different models and theoretical frameworks, and the emphasis on the image of nursing has also changed from a biased image (i.e. virtuous features or professional image) to a more integrated image (i.e. brand image).

4.2. COSMIN methodological quality and quality of evidence

Content validity, structural validity and internal consistency were three psychometric properties that were evaluated most commonly, as well as the most important psychometric properties following the recommendations of the most up‐to‐date COSMIN methodology (Mokkink et al., 2018; Prinsen et al., 2018). The findings of the systematic review indicated that content validity, cross‐cultural validity and construct validity obtained the lowest scores of the psychometric properties that were evaluated with the COSMIN Risk of Bias checklist. Particularly with regard to construct validity, almost all studies did not measure convergent or discriminant validity. The limitations of the currently available nursing image measurement instruments are the absence of psychometric evidence for responsiveness and criterion validity, and no studies were found that assessed measurement error or provided the necessary discussion of missing properties, therefore causing a low‐quality rating. Additionally, the language and culture of the original version of the measurement instrument must be considered (Prinsen et al., 2018) but none of the cross‐cultural studies in this systematic review applied multi‐group CFA or differential item function analysis to validate cross‐cultural validity.

The Nurses Self‐Concept Instrument and the Nurses Self‐Concept Questionnaire were the most frequently tested instruments (Angel et al., 2012; Cowin, 2001), both of which have been adapted and revised cross‐culturally in each of four psychometric studies. Contrastingly, the psychometric properties of the Nursing Brand Image Scale, the Nursing's Current Brand Position Scale and the Nursing's Desired Brand Position Scale were all derived from the original scale development studies and have not been assessed in any cross‐cultural revision studies (Godsey et al., 2018). The Chinese version of the Nurse Self‐Concept Instrument is the measure that contains the most complete range of psychometric properties (seven attributes were tested).

This systematic review recommended two instruments for measuring nursing image among nurses or nursing students that have demonstrated more robust measurement performance than other instruments, the Nurses Self‐Concept Instrument (NSCI) and the Nurses Self‐Concept Questionnaire (NSCQ) namely, but the cross‐cultural validity/measurement invariance, measurement error, criterion validity and responsiveness of the two instruments should be tested more often. Compared to NSCQ, the communication dimension previously identified by Cowin was specifically omitted from the NSCI as it was anticipated that it may be biased towards domestic nursing students. With the exception of the Professional Self‐concept of Nurses Instrument (PSNCI), which was not recommended due to insufficient internal consistency, the remaining included instruments have the potential to be recommended and require further testing of their reliability, particularly their content validity and internal consistency. In addition, researchers and health care providers need to select instruments based on their target population and characteristics; for example, the Porter Nursing Image Scale (PNIS) is more focused on the femininity of nurses, while the Nursing Attitudes/image Questionnaire (NAQ), for example, focuses on the image of the nursing profession. Significantly, the Nursing Brand Image Scale (NBIS) is the first instrument to be concerned with the image of the nursing brand, and it is able to measure a more comprehensive image of nursing, including not only the above‐mentioned image traits, which can contribute to a change in nursing stereotypes.

The different characteristics of nursing image measurement instruments, such as the various image profiles (e.g. professionalized image and brand image) and the target population using the instrument (e.g. nursing practitioners or the public), as well as its dimensions, the number of items, its adequacy to the contemporary context, the methodological quality and psychometric evidence, ought to be considered by practitioners such as nursing managers and researchers to decide which instrument is the best to measure the nursing image.

4.3. Limitations and future directions

This systematic review only included Chinese and English studies, and failed to assess the psychometric characteristics of other languages, resulting in publication bias. Many studies were published before the COSMIN checklist was developed (Prinsen et al., 2018), so it failed to meet all its standards. Another limitation is that we deliberately did not contact the study authors to add the missing information. While a measurement instrument may have been rigorously and comprehensively tested for psychometric properties, the reports of psychometric properties are the basis for the practitioner's selection of the instrument, so the comprehensive systematicity, rigour and accuracy of the study reports are also essential.

Further psychometric examination of each of the selected measures is crucial to the interpretation of future research, as shown by the findings of the present study. Evidence on the psychometric properties of these nursing image instruments requires high‐quality, well‐conducted research. Thus, we call for future research on psychometric properties of instrument development to be reported according to guidelines.

5. CONCLUSIONS

This psychometric review provides a rigorous synthesis of the developed nursing image measurement instruments, which could be a reference for practitioners in selecting the appropriate instrument, clarify the current state of the nursing image, facilitate the development of strategies to enhance the attractiveness of the nursing profession and contribute to the transformation of negative stereotypes of the nursing profession.

Eleven instruments measuring nursing image were identified. There is no perfect instrument, especially since the nursing image is a complex, dynamic concept, and there was no instrument assessing the nursing image for which all of the measurement properties were assessed. Every original instrument, as well as their cross‐cultural version, evaluated in this review was focused on different characteristics of the nursing image. Thus, the selection of the most appropriate instrument depends on the context and purpose of the assessment, including which image of nursing to assess. The methodological quality of the studies was ‘doubtful’ for most of the measurement properties analysed. The quality of the evidence was ‘low’ for most of the measurement properties analysed. The COSMIN methodological quality rating was ‘poor’ for most of the measurement properties analysed. Further studies could be conducted based on the findings of this systematic review.

Currently, the development and use of instruments are lacking in rigour. Further research should focus on generating more evidence regarding the measurement properties of instruments with the nursing image for correcting inaccurate stereotypes, eliminating role ambiguity, and stimulating the professional cohesiveness of the evolving nurse leaders. Researchers also should focus on refining existing scales by cross‐culturally validating them and bringing new evidence to the validity, reliability and responsiveness of existing scales.

AUTHOR CONTRIBUTIONS

Conceptualization and research design L.Z, EL.C. and T.C.; methodology and formal analysis, L.Z., K.S. and T.C.; software and investigation, L.Z., K.S. and T.C.; writing – original draft preparation, L.Z., K.S., K.M., P.I., EL.C. and T.C.; writing – review and editing, L.Z., K.S., K.M., P.I., EL.C. and T.C.; visualization and supervision, T.C. and EL.C.; Correspondence, T.C. and EL.C. All authors have approved the final version of the manuscript.

ACKNOWLEDGEMENT

Thanks to the library of Yunnan University of Chinese Medicine for assistance with the search.

FUNDING INFORMATION

The study was supported by the Yunnan University of Chinese Medicine Research Program (202101AZ070001‐221).

CONFLICT OF INTEREST STATEMENT

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

INFORMED CONSENT

All authors approved and contributed to the final manuscript.

ETHICS STATEMENT

Ethical permission for this research is not required as the review will only use information from previously published research. The findings of this research will be submitted for publication in an international, peer‐reviewed journal. Abstracts will also be submitted for national and international conference presentations.

Supporting information

Appendix S1

Click here for additional data file. (14.2KB, docx)

Zhou, L. , Sukpasjaroen, K. , Cai, E. , Moonsri, K. , Imsiri, P. , & Chankoson, T. (2023). The psychometric properties of nursing image measurement instruments: A systematic review. Nursing Open, 10, 5056–5078. 10.1002/nop2.1742

DATA AVAILABILITY STATEMENT

This content has been supplied by the author(s).

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