Cross cultural adaptation and psychometric validation of the Persian version of the integral nursing leadership scale

Abstract

Integral leadership emphasizes the interplay between individual leadership traits, performance outcomes, and organizational culture, empowering nurses to effectively address the multifaceted challenges prevalent in modern healthcare environments. By fostering a holistic approach to leadership, integral leadership contributes to the advancement of the nursing profession and the enhancement of patient care quality. This study sought to adapt, translate, and psychometrically evaluate the Integral Nursing Leadership Scale (INLS) in Persian within the Iranian healthcare context. This study utilized a cross-sectional methodological design to recruit a sample of 620 nurses using convenience sampling. The Persian translation of the INLS was developed following the Polit and Yang approach. To assess the scale’s validity and reliability, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and internal consistency measures were conducted. The exploratory and confirmatory factor analyses confirmed the four-factor structure of the Persian INLS, with 30 items accounting for 81.58% of the total variance. The model fit was excellent, with CFI, GFI, TLI, RMSEA, and SRMR values indicating a good fit. The scale demonstrated acceptable internal consistency reliability, as evidenced by Cronbach’s alpha and McDonald’s ω estimates of 0.935 and 0.949, respectively. The findings demonstrated that the Persian version of the INLS is a valid and reliable instrument for assessing integral leadership among Iranian nurses.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-18908-9.

Introduction

Healthcare systems in contemporary societies are experiencing significant transformations across economic, social, and technological domains. The ability of these systems to navigate these challenges and deliver high-quality care heavily depends on effective leadership and management. In this regard, the role of nursing leadership is particularly emphasized, serving as a fundamental backbone of healthcare systems^1,2.

Leadership, a fundamental process of influencing individuals toward shared objectives³, is particularly crucial in the dynamic and complex healthcare environment. One of the most vital manifestations of leadership in the health sector is evident in the nursing profession. Leadership in nursing can be defined as a driving force that enables nursing leaders to effectively unite their followers to set and achieve their goals⁴. Effective leadership by nurses ensures the quality of care and patient safety⁵. Additionally, effective nursing leadership can improve the quality of the nursing work environment⁶, reduce nurse burnout⁷, and ultimately lower overall healthcare costs. Therefore, considering the high significance of the nursing profession and its pivotal role in healthcare systems, it is imperative to address leadership within the nursing profession.

In recent years, nursing has seen increased focus on how leadership styles affect patient outcomes and healthcare professionals’ well-being⁸. Different leadership styles have various strengths and weaknesses, and the style used by nursing leaders impacts both patient and nurse results⁹. Therefore, leaders should choose the most appropriate style for the situation. Effective styles like transformational and authentic leadership emphasize relational skills such as communication and emotional intelligence¹⁰. This approach has been linked to higher job satisfaction, organizational commitment, and better patient outcomes. However, it can be time-consuming and lead to conflicts during crises^11,12. In contrast, task-focused leadership prioritizes efficiency with clearly defined goals and constant monitoring¹³. While it may enhance performance, it tends to result in negative health outcomes for nurses. Given the changing healthcare landscape, an integrated leadership approach is essential.

Motivation and contribution

In the Iranian nursing system, leadership styles predominantly depend on traditional and informal relationships, frequently resulting in the appointment of managers based on seniority or personal connections rather than merit and leadership competencies¹⁴. This approach has contributed to a deficiency in effective leadership, as a significant number of nursing managers lack formal training in leadership and organizational behavior, compounded by a pervasive belief that such training is superfluous. As a consequence, the nursing workforce encounters substantial challenges, including elevated turnover rates, job dissatisfaction, and suboptimal patient care, which are intensified by excessive workloads, inadequate support, and limited opportunities for professional development¹⁵.These issues highlight the pressing need for an integrated approach to nursing leadership capable of addressing the multifaceted challenges within Iran’s healthcare landscape. Integrated leadership, encompassing individual, relational, organizational, and cultural dimensions, provides a comprehensive framework deemed essential for navigating the complexities of contemporary healthcare settings by promoting a holistic understanding of leadership¹⁶.This imperative served as the impetus for this study, which aimed to devise an instrument for evaluating the integrated leadership capabilities of nursing leaders in Iran.

The major contributions of this study are: Developing a Persian version of the INLS that is both linguistically accurate and culturally relevant, providing a tool to identify strengths and areas for improvement in nursing leadership, Demonstrating the process and outcomes of adapting a leadership assessment tool across cultures.

Integral nursing leadership is a comprehensive and multidimensional framework designed to integrate personal, relational, cultural, and systemic perspectives to optimize healthcare outcomes. This approach encourages leaders to cultivate a deep understanding of the interconnectedness of different aspects of leadership by emphasizing a comprehensive and humanistic perspective^17–19. Integral leadership not only fosters personal growth but also enhances external skills and performance. By prioritizing organizational and functional dynamics often overlooked in traditional nursing leadership, this style empowers nurses to address the multifaceted challenges inherent in modern healthcare settings¹⁶.

Wilber’s four-quadrant map has been widely used across fields to understand human experience, yet its use in nursing leadership is still limited. This model, which looks at individual and collective dimensions, offers valuable insights into effective nursing leadership²⁰. Although Noorzad’s integral leadership framework illustrates applying Wilber’s model, studies on integral nursing leadership are limited¹⁸. Therefore, developing a reliable tool based on this theory could enhance research and practice in this area.

While various tools assess nursing leadership, those specifically measuring integral leadership are lacking^6,16,21,22. Ecoff and Stichler created the Nursing Leadership Competency Assessment (LCA) to help identify developmental needs among leaders, including dimensions like leading self and change²¹. Other tools, like the Leadership and Management Inventory and the Advanced Practice Nursing Competency Assessment Instrument, also assess various leadership competencies²³. Still, there’s a need for tools focused on integral nursing leadership. The 360-degree feedback questionnaire is used for evaluating general leadership, but it may not fully capture the specific aspects of nursing leadership¹⁷. To fill this gap, Cho and Choi developed the Integral Nursing Leadership Scale (INLS) to assess nursing-specific leadership traits, informing educational and intervention strategies¹⁶.

In the Iranian nursing system, leadership styles primarily rely on traditional and informal relationships. However, workplace pressures, resource shortages, and nurse burnout have underscored the urgent need for an integrated approach to nursing leadership. Integral leadership, which considers individual, interpersonal, organizational, and cultural dimensions, offers a comprehensive solution to these challenges. Among the various tools available for assessing leadership, the INLS is the only instrument designed to evaluate integral nursing leadership in a holistic and specific manner. Grounded in theoretical foundations, the INLS identifies key leadership traits in nursing, providing a well-rounded perspective on both the internal and external aspects of nursing leadership. Additionally, it serves as a reliable framework for designing and implementing training programs aligned with its established indicators¹⁶.

Despite its merits, the INLS was originally developed and psychometrically validated in South Korea, where the cultural background, leadership styles, and nursing system differ significantly from those in Iran. For instance, while Iran’s predominant leadership style is relationship-oriented²⁴, South Korea employs a range of leadership approaches, including self-leadership, transformational leadership, and authentic leadership^22,25,26. Consequently, adapting the INLS for Iranian use necessitates a rigorous psychometric evaluation. A direct translation that overlooks the cultural characteristics of the target community would fail to adequately, logically, or scientifically capture the nuances essential for meeting local needs. Currently, no validated and reliable instrument exists to comprehensively assess integral nursing leadership among Iranian nurses within Iran’s distinct cultural and social context, posing a significant challenge for researchers and practitioners seeking to explore and evaluate this concept.

Therefore, to address the gap in the literature, this study aimed to adapt, translate, and conduct a psychometric evaluation of the INLS in Persian for application in Iran. Furthermore, it seeks to determine whether the Persian version of the instrument possesses acceptable validity and reliability.

Methods

Study design

This cross-sectional methodological study, undertaken in the second half of 2024, sought to evaluate the psychometric properties of the Persian version of the Integral Nursing Leadership Scale (INLS) among Iranian nurses. The study was conducted in two phases: a transcultural translation of the INLS to the Persian language and a subsequent psychometric evaluation of the translated version.

Participants

The study population comprised all clinical nurses in seven hospitals affiliated with Kermanshah University of Medical Sciences in Western Iran. A convenience sample of 620 nurses was recruited from these hospitals to participate in the psychometric evaluation of the Persian INLS. With ages spanning from 24 to 60 years. The gender distribution indicates that 377 participants (60.8%) were female, and 243 (39.2%) were male, reflecting a predominantly female sample. 351 (56.6%) being single and 269 (43.4%) married. Regarding work shifts, 227 (36.6%) worked daily shifts, 140 (22.6%) worked night shifts only, and 253 (40.8%) had rotating shifts. The majority were employed in surgical departments (37.9% overall), followed by critical care (28.1%), internal (19.2%), and other departments (11.0%). Educationally, 543 (87.6%) held a bachelor’s degree, and 77 (12.4%) had a master’s degree. Detailed demographic characteristics are presented in Table 1.

Table 1.

Demographic characteristics of participants in the study.

Variables		N (%)
		EFA (200)	CFA (420)
Age (year)		7.27 ± 30.64	6.34 ± 31.007
History of attending the department (year)		6.72 ± 6.13	6.39 ± 5.57
Gender	Male	73 (36.5)	170 (40.5)
	Female	127 (63.50)	250 (59.5)
Marital status	Single	114 (57)	237 (56.4)
	Married	86 (43)	183 (43.6)
Shift work	Daily	63 (31.5)	164 (39)
	Only Night	50 (25)	90 (21.4)
	Circular	87 (43.5)	166 (39.5)
Educational level	BSc	184 (92)	359 (85.5)
	MSc	16 (8)	61 (14.5)
Department	Internal	52 (26)	67 (15.95)
	Surgical	41 (20.5)	219 (52.14)
	Critical Care	84 (42)	88 (20.95)
	Other	23 (11.5)	46 (10.95)

Inclusion criteria required participants to be willing to participate and have at least six months of clinical experience. Questionnaires with more than 10% missing data were excluded from the analysis²⁷. To ensure adequate statistical power for exploratory and confirmatory factor analyses, recommended sample sizes are generally 100–250 individuals (or 2–20 individuals per item) for exploratory analysis²⁸ and 150–500 individuals for confirmatory analysis²⁹. Given these guidelines and the importance of separating samples for different stages of construct validation^30,31, the 620 participating nurses were randomly divided into two groups: a group of 200 for exploratory factor analysis and a group of 420 for confirmatory factor analysis.

Integral nursing leadership scale (INLS)

The INLS, initially developed by Cho and Choi¹⁶, is a 30-item instrument assessing four dimensions of nursing leadership: individual leadership qualities (9 items, 1–9), individual performance (9 items, 10–17 and 19), influencing organizational culture (7 items, 18 and 20–25), and organizational excellence (5 items, 26–30).

Respondents rate their agreement with each item on a 6-point Likert scale, ranging from 1 (strongly disagree) to 6 (strongly agree), with higher scores indicating greater integral nursing leadership. The original English version demonstrated strong internal consistency, with a Cronbach’s alpha of 0.97 and a McDonald’s ω of 0.98¹⁶. The complete version of the INLS is available in Supplementary File 1.

Part I: the translation and cultural adaptation phase

With the original author’s permission, the INLS underwent a translation process following the Polit and Yang approach³². This seven-step process involved translating the scale from English to Persian, combining different translations, back-translating the Persian version to English, reviewing the back-translated version, conducting a pilot study, making necessary modifications, and finalizing the translated questionnaire. Two bilingual translators with expertise in healthcare services initially translated the INLS into Persian. Subsequently, the two translations were compared and merged to create a unified Persian version. To identify potential ambiguities and issues, the translated INLS was administered to a pilot group of 15 nurses. Based on the feedback received, necessary modifications were made to the questionnaire. Subsequently, the revised Persian version was back-translated into English by two bilingual individuals. The final version was then submitted to the original scale developer for review and approval, with minor revisions made as needed. In the present study, all changes were made under the supervision of the research team who had sufficient experience in this field, and assistance was also taken from skilled translators and Persian literature experts in this regard.

Part II: psychometric evaluation

This phase of the study focused on assessing the validity (face, content, and construct) and reliability (internal consistency) of the Persian version of the instrument.

Face validity assessment

After completing the translation of the questionnaire and producing a single version in Persian, we conducted interviews with a convenience sample of 10 nurses who resembled the target population to assess qualitative face validity. These nurses evaluated each item for clarity, difficulty, and relevance.

Content validity assessment

After confirming the face validity of the items in the Persian version of the questionnaire, we conducted an assessment of content validity. This assessment utilized both qualitative and quantitative methods. For qualitative content validity, a panel of 14 nursing experts was consulted, including five nursing faculty members, five nursing managers with master’s degrees, and four clinical nurses with master’s degrees. These experts evaluated the scale’s items based on grammatical correctness, language appropriateness, item placement, clarity, scoring methods, and cultural relevance to Iran. To quantitatively evaluate content validity, we employed the Content Validity Ratio (CVR) and Content Validity Index (CVI) based on the assessments from 14 experts. For the CVR calculations, experts rated the necessity of each item on a 3-point Likert scale: necessary, useful but not necessary, or not necessary^33,34. The resulting CVR was evaluated using Lawshe’s table, with a minimum acceptable value of 0.49 for a panel of 14 experts³⁵.

To further assess content validity, the CVI was calculated by having experts rate the relevance of each item on a 4-point Likert scale: not relevant, somewhat relevant, quite relevant, or very relevant³⁶. Polit and Beck state that a CVI of 0.79 or higher is considered excellent, regardless of the number of experts involved in the evaluation³³.

Construct validity

Exploratory and confirmatory factor analysis are standard methods for assessing construct validity³⁷. In the EFA, the aim is to identify latent factors that explain the organization and underlying structure of measured items³⁸. In this study, we conducted the analysis twice due to the differing cultural contexts of the Iranian nursing community and the Korean nurses used in the original version. CFA evaluates how effectively the items designed to measure a construct represent that construct. This method essentially determines whether the questionnaire items selected for each factor are appropriate^39,40.

The study employed both EFA and CFA to assess the construct validity. EFA was conducted to identify the underlying factor structure using the Principal Component Analysis and Direct Obliging rotation. The following criteria were used to determine an optimal structure: eigenvalues greater than 1.0, factor loadings greater than 0.50^41,42, and total variance explained of over 40%⁴³. Before conducting EFA, the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test were used to assess the adequacy of the sample. A KMO value greater than 0.7 and Bartlett’s test P-value less than 0.05 were considered acceptable⁴⁴.

The CFA was conducted to validate the factor structure identified in the EFA. The model fit was evaluated using several goodness-of-fit indices, including the chi-square test, chi-square-to-degrees-of-freedom ratio, GFI, CFI, NFI, RFI, IFI, TLI, SRMR, and RMSEA. Acceptable cutoff values for these indices were generally set at χ2/df < 3, GFI > 0.9, CFI > 0.9, NFI > 0.9, IFI > 0.9, TLI > 0.9, SRMR < 0.09, and RMSEA < 0.08⁴⁵.

Reliability (Internal consistency and Stability)

The scale’s internal consistency was assessed using Cronbach’s alpha and McDonald’s omega coefficients. Both coefficients were deemed acceptable if they exceeded 0.70^28,46. Test-retest reliability was evaluated using the intra-class correlations on 10% (n = 62) of the sample size based on a two-week interval⁴⁷.

Data analysis

Data analysis was conducted using SPSS version 27 and LISREL version 8. Descriptive statistics were used to summarize demographic data. The Waltz & Bausell index was employed to evaluate quantitative content validity⁴⁸. Construct validity was verified using both exploratory and confirmatory factor analyses. Statistical significance was determined at a p-value of less than 0.05. The normality of the data distribution was evaluated using skewness and kurtosis. Cronbach’s alpha and test-retest reliability were used to assess the instrument’s reliability.

Data collection

Prior to data collection, the study protocol obtained ethical approval from the Ethics Committee of Kermanshah University of Medical Sciences. Two researchers conducted on-site visits to the participating hospitals on different weekdays, covering morning, evening, and night shifts. Questionnaires were distributed directly to nurses, who completed them voluntarily and returned them to the researchers. Ethical principles were rigorously adhered to throughout the data collection process. Nurses were informed of the study’s objectives and assured of the confidentiality of their responses. Informed consent was secured from all participating nurses before questionnaire distribution. The final sample included 620 nurses, achieving a 94% response rate. In total, 40 individuals were excluded from the study in two stages due to missing more than 10% of the questionnaire items.

Results

Descriptive results

The EFA phase involved 200 nurses with an average age of 30.64 years (SD = 7.27) and a range of 24 to 60 years. Of the participants, 63.5% were female, 43% were married, 92% had bachelor’s degrees in nursing, and 26% were employed in internal departments (Table 1). The CFA phase included 420 nurses with an average age of 31.007 years (SD = 6.34) and a range of 24 to 60 years. Of the participants, 40.5% were male, 85.5% had bachelor’s degrees in nursing, and 20.95% worked in critical care units (Table 1).

Face validity

The qualitative assessment of face validity indicated that items 7 and 21 needed revisions to address ambiguity, which were subsequently implemented.

Content validity

Qualitative content validity was conducted by fourteen experts, who identified three items^9,17,25 that needed revisions to improve clarity and comprehension. These revisions were implemented. The quantitative content validity was evaluated using the Content Validity Ratio (CVR), yielding a score of 0.86, which falls within the acceptable range of 0.71 to 1.00. Furthermore, the Scale-Level Content Validity Index (S-CVI), calculated using the method described by Waltz and Bausell⁴⁸, was 0.94, with individual item scores ranging from 0.86 to 1.00, as illustrated in Table 2.

Table 2.

CVR, CVI, and item factor loadings from exploratory factor analysis in the integral nursing leadership scale.

Factor	Items	CVR	CVI	Mean	SD	Factor				Commonality
						1	2	3	4
Individual leadership qualities	Q1	0.86	0.93	4.23	1.65	0.849	− 0.074	− 0.068	0.046	0.795
	Q2	0.86	0.93	4.02	1.71	0.868	− 0.057	− 0.010	− 0.006	0.804
	Q3	1.00	1.00	4.00	1.62	0.904	0.037	− 0.032	0.059	0.809
	Q4	0.71	1.00	3.67	1.73	0.906	− 0.056	− 0.048	− 0.006	0.838
	Q5	0.86	0.93	3.78	1.61	0.958	0.000	0.001	− 0.055	0.860
	Q6	0.86	0.93	3.84	1.76	0.876	0.077	0.008	0.078	0.775
	Q7	0.86	0.86	3.81	1.65	0.893	0.028	0.052	0.021	0.840
	Q8	1.00	0.71	3.81	1.69	0.846	0.007	0.108	− 0.002	0.812
	Q9	0.71	0.86	3.58	1.65	0.709	− 0.133	0.186	− 0.064	0.771
Individual performance	Q10	0.57	0.93	3.74	1.69	0.034	− 0.881	0.032	− 0.005	0.842
	Q11	0.86	1.00	3.97	1.52	0.019	− 0.878	− 0.059	0.060	0.803
	Q12	0.86	0.93	3.91	1.56	0.085	− 0.821	− 0.048	0.073	0.808
	Q13	1.00	0.93	3.84	1.57	0.107	− 0.866	− 0.004	− 0.103	0.768
	Q14	0.71	. 93	3.57	1.69	− 0.044	− 0.883	− 0.017	0.076	0.798
	Q15	0.86	0.93	3.77	1.58	0.020	− 0.918	− 0.022	− 0.046	0.799
	Q16	0.86	1.00	3.64	1.63	− 0.013	− 0.901	0.017	− 0.016	0.796
	Q17	0.86	1.00	3.73	1.66	− 0.013	− 0.911	0.025	− 0.018	0.820
	Q18	1.00	0.93	3.77	1.69	− 0.020	− 0.865	0.074	0.018	0.817
	Q19	0.71	0.93	3.97	1.69	− 0.073	− 0.802	0.119	0.116	0.805
Influencing organizational culture	Q20	0.86	0.86	3.69	1.77	− 0.007	− 0.215	0.740	0.062	0.817
	Q21	0.86	0.93	3.72	1.63	0.037	− 0.095	0.780	0.124	0.859
	Q22	0.86	0.93	3.77	1.70	0.122	− 0.038	0.799	0.065	0.861
	Q23	1.00	1.00	3.63	1.70	0.119	− 0.062	0.788	0.074	0.875
	Q24	0.86	1.00	3.59	1.66	0.129	0.009	0.793	0.115	0.859
	Q25	0.71	0.86	4.46	1.40	− 0.069	0.065	0.822	− 0.084	0.530
Organizational excellence	Q26	1.00	1.00	3.92	1.77	0.093	0.017	0.049	0.854	0.859
	Q27	1.00	1.00	3.94	1.71	− 0.008	− 0.007	− 0.037	0.948	0.867
	Q28	0.86	0.93	3.86	1.67	− 0.007	0.029	0.047	0.913	0.837
	Q29	. 86	0.93	3.71	1.75	− 0.007	− 0.074	− 0.015	0.914	0.900
	Q30	1.00	1.00	3.77	1.77	0.011	− 0.031	0.033	0.881	0.850
Eigenvalue						17.936	2.542	2.076	1.920
Percentage of the variance (%)						59.788	8.473	6.92	6.4

Exploratory factor analysis

An EFA was performed on a sample of 200 participants. The KMO index for sampling adequacy was 0.954, indicating a suitable sample size for factor analysis. Additionally, the Bartlett’s test of sphericity was significant (p < 0.001). Since the KMO value surpassed the recommended threshold of 0.7, it is appropriate to proceed with the factor analysis⁴⁹. Using the Principal Component Analysis (PCA) and Direct Oblimin (DO) rotation, the EFA identified a four-factor solution with eigenvalues greater than 1.0, explaining 81.58% of the total variance. This exceeds the standard threshold of 40%. The scree plot (Fig. 1) supported this four-factor solution. As illustrated in Table 2, each of the 30 items on the scale had factor loadings exceeding 0.5, demonstrating their strong association with the identified factors. No items were eliminated.

Fig. 1.

Scree plot of the extracted components of the Integral Nursing Leadership Scale.

Confirmatory factor analysis

A four-factor model was tested using CFA on a sample of 420 nurses. The model showed a satisfactory fit, as indicated by the following fit indices: χ² = 1051.26, p-value = 0.0001, RMSEA = 0.063, NNFI/TLI = 0.96, CFI = 0.98, GFI = 0.98, SRMR = 0.043, df = 399, χ²/df = 2.63. The path diagram and factor loadings from the CFA are illustrated in Fig. 2. Additionally, Table 3 shows significant and positive correlations between the subscales and the overall scale, as assessed by Pearson’s correlation coefficient. All first and second-order factor loadings were found to be significant at the 95% confidence level, with calculated values exceeding 1.96. The Lambda coefficient which represents the standardized factor loading of each item on a given factor was also calculated (Table 4). Given the model results and the model’s good fit indices, no corrective actions were required.

Fig. 2.

Final measurement model of the Integral Nursing Leadership Scale from confirmatory factor analysis.

Table 3.

The integral nursing leadership scale.

Factor	1	2	3	4
Individual leadership qualities	1
Individual performance	0.687**	1
Influencing organizational culture	0.61**	0.653**	1
Organizational excellence	0.63**	0.652**	0.546**	1

**P < 0/01.

Note. Correlations are latent factor correlation estimates from the CFA model. All correlations were statistically significant at p < .001.

Table 4.

T-value, pearson correlation coefficient, factor loadings, Macdonald ῶ, and Cronbach alpha of the integral nursing leadership scale.

Factor	No	valuea t	b(λ)	R c	Macdonald ῶ	Cronbach alpha
Individual leadership qualities	Q1	17.25	0.74***	0.69**	0.933	0.969
	Q2	16.35	0.71***	0.66**
	Q3	16.68	0.72***	0.66**
	Q4	21.28	0.85***	0.77**
	Q5	19.3	0.80***	0.70**
	Q6	16.23	0.71***	0.66**
	Q7	21.43	0.86***	0.79**
	Q8	17.74	0.75***	0.71**
	Q9	20.84	0.84***	0.78**
Individual performance	Q10	18.74	0.79***	0.71**	0.868	0.972
	Q11	7.58	0.37***	0.43**
	Q12	15.68	0.69***	0.65**
	Q13	11.48	0.54***	0.53**
	Q14	19.47	0.81***	0.77**
	Q15	16.08	0.71***	0.63**
	Q16	16.95	0.73***	0.67**
	Q17	19.28	0.80***	0.75**
	Q18	15.44	0.65***	0.68**
	Q19	17.18	0.74***	0.69**
Influencing organizational culture	Q20	18.8	0.80***	0.71**	0.819	0.945
	Q21	9.49	0.46***	0.44**
	Q22	18.39	0.78***	0.69**
	Q23	21.01	0.86***	0.73**
	Q24	16.57	0.73***	0.64**
	Q25	9.21	0.45***	0.37**
Organizational excellence	Q26	19.47	0.82***	0.67**	0.879	0.94
	Q27	17.42	0.76***	0.62**
	Q28	17.08	0.75***	0.64**
	Q29	18.44	0.75***	0.72**
	Q30	16.83	0.74***	0.63**
The Integral Nursing Leadership Scale					0.949	0.935

***P < 0/001; **P < 0/01; * P < 0/05.

(a) The calculated values for all first- and second-order factor loadings are greater than 1.96, indicating statistical significance at the 95% confidence level. (b) The Lambda coefficient (λ) represents the standardized factor loading of each item on a given factor. (c) Pearson correlation coefficient.

Reliability (Internal consistency and Stability)

Internal Consistency

The Persian INLS demonstrated strong internal consistency. Cronbach’s alpha coefficients for the total scale and four subscales ranged from 0.935 to 0.972, indicating excellent reliability. Similarly, McDonald’s omega coefficients ranged from 0.819 to 0.949, further supporting the scale’s internal consistency (Table 4).

Stability

The test-retest result for the total score on the INLS was 0.927, indicating the excellent stability of the scale.

Discussion

In the present study, the Integral Nursing Leadership Scale (INLS) developed by Cho and Choi¹⁶ was culturally adapted and validated into Persian for use in the Iranian context. The emergence of four distinct factors—individual performance, individual leadership qualities, influencing organizational culture, and organizational excellence—aligns with the multidimensional nature of leadership as conceptualized in integral theory, which considers both internal and external, as well as individual and collective, dimensions of leadership. The high content validity indices observed in this study highlight the cultural and conceptual relevance of the scale items within the Iranian healthcare context. These values are closely aligned with the original study¹⁶, suggesting strong cross-cultural applicability of the INLS framework. These results collectively support the content validity of the Persian INLS and its suitability for measuring integral leadership in nursing within the Iranian healthcare setting.

In this study, the four factors collectively accounted for 81.58% of the variance, demonstrating a strong model fit. In the original study¹⁶, the explained variance was slightly lower at 68.7%. A comparative analysis of the two studies suggests that the INLS has demonstrated cross-cultural generalizability, effectively measuring the target construct in both Iranian and South Korean contexts.

Among the study components, ‘Individual Performance’ emerged as a significant predictor of the variance explained by the instrument. This finding aligns with the original study¹⁶, which also identified ‘Individual Performance’ as a significant contributor to variance (20.48%). The substantial contribution of ‘Individual Performance’ to the explained variance underscores its critical role in integral nursing leadership. The ‘Individual Performance’ component, comprising ten items, assesses a nursing leader’s ability to innovate, leverage digital technologies, analyze data, adapt to changing healthcare environments, manage resources effectively, ensure adequate staffing, balance workload with staff preferences and patient needs, maintain up-to-date nursing knowledge, apply evidence-based practices, and communicate effectively with staff. In the study by Cho and Choi¹⁶, the ‘Individual Performance’ dimension included nine items. Item 18, “communicate effectively with staff members,” was initially identified as a core aspect of individual performance based on literature reviews and interviews. However, their study placed this item within the ‘Influencing organizational culture’ dimension, as determined by EFA¹⁶. In contrast, our study, employing both exploratory and confirmatory factor analysis, consistently classified item 18 as a key component of ‘Individual Performance.’ The high correlations observed between the four dimensions of the scale and individual items suggest that the items may not be entirely distinct, aligning with Wilber’s integral theory^20,50. Additionally, cultural differences between the Iranian and South Korean nursing samples likely influenced these findings. Leadership and management in any country are shaped by cultural, social, and economic contexts. While both Iran and South Korea have strong healthcare histories, significant cultural variations in nursing management approaches exist, impacting service quality, patient and staff satisfaction, and overall healthcare system performance. In Iran, nursing leadership is predominantly relationship-oriented²⁴, whereas South Korea exhibits a diverse range of leadership styles, including self-leadership, transformational leadership, and authentic leadership^22,25,26. Consequently, effective communication with staff, while considered a core aspect of individual performance in Iranian nursing leadership, is perceived as a key influencer of organizational culture in South Korea.

The central role of “Individual Performance” in nursing leadership carries significant practical implications. It is crucial for nursing leaders to effectively navigate the rapidly evolving healthcare environment, adopt new technologies, manage resources efficiently, and create a supportive, empowering atmosphere for their teams. The prominence of this dimension suggests that nursing leaders should prioritize the development of personal competencies such as innovation, digital literacy, and robust communication skills. These competencies not only enhance job satisfaction among nurses but also contribute to better patient outcomes^51,52. Consequently, training and development programs focused on strengthening Individual Performance could be highly effective in improving overall leadership effectiveness and ensuring that nursing leaders are well-equipped to address the complex challenges of contemporary healthcare settings.

The ‘Individual Leadership Qualities’ component is an important factor in assessing integral nursing leadership. This component comprised nine items that evaluated a leader’s self-awareness, role clarity, performance evaluation, value articulation, emotional intelligence, interpersonal skills, sense of responsibility, and ability to empower staff. The ‘Intentional’ dimension in Wilber’s integral theory aligns with these internal and mental characteristics of a leader, which significantly influence their thought processes, emotions, and actions. In Wilber’s integral theory, the ‘Behavioral’ dimension encompasses a leader’s observable actions and practical skills employed in interpersonal interactions and task performance. The ‘Intentional’ and ‘Behavioral’ dimensions are intricately interconnected^20,50. For nursing leaders, cultivating and strengthening both dimensions is essential^26,53,54. Leaders with strong internal qualities and requisite practical skills can effectively lead their teams, enhance healthcare quality, and foster a positive and motivating work environment.

The “Influencing Organizational Culture” component evaluates a leader’s capacity to cultivate a positive and values-driven organizational environment. This dimension emphasizes key leadership behaviors, including encouraging employee engagement, fostering collaboration, creating a respectful and inclusive workplace, resolving conflicts effectively, demonstrating strong communication skills, and prioritizing patient safety as a core organizational value. In the context of Wilber’s Integral Theory, this component aligns with the “Cultural” dimension, which highlights the importance of shaping shared values, vision, and team culture. Wilber asserts that effective leadership must address not only external systems and individual performance but also the collective interior realm—the interpersonal relationships, group norms, and cultural dynamics that influence how teams think, feel, and function. In healthcare settings, this cultural layer is particularly critical, as it directly impacts clinical decision-making, staff morale, and patient outcomes^20,50. Nursing leaders, as central figures in healthcare organizations, have a profound influence on organizational culture through their leadership style, communication practices, and modeled behaviors^55,56. By reinforcing shared values such as respect, collaboration, and safety, and by skillfully navigating interpersonal dynamics, they help shape the unwritten norms and emotional climate of the workplace. This cultural leadership fosters an environment in which staff feel empowered, supported, and aligned with the organization’s mission. Ultimately, cultivating a positive organizational culture is essential not only for enhancing team performance but also for ensuring the delivery of high-quality patient care in increasingly complex healthcare environments.

The ‘Organizational Excellence’ component assesses a leader’s ability to contribute to organizational success. This component focused on strategic planning, operational knowledge, internal and external management involvement, effective decision-making, and quality care improvement initiatives. In Wilber’s integral theory, the ‘Social’ dimension emphasizes a leader’s influence on the external environment and organizational outcomes^20,50. This dimension is crucial for delivering safe and high-quality patient care and improving nursing structures within healthcare systems, encompassing the leader’s social impact, negotiation skills, networking abilities, and systems thinking^55,56. By strengthening both the cultural and social dimensions of nursing leadership, leaders can positively impact not only nursing organizations but also the entire healthcare system, fostering a more efficient, satisfying, and high-quality environment for patients, nurses, and other staff.

When comparing the findings of this study with other leadership tools and studies conducted in similar cultural contexts, several key similarities and differences emerge. For example, tools like the Nursing Leadership Competency Assessment (LCA)²¹ and the Leadership and Management Inventory (LaMI) have been used to assess leadership competencies across various dimensions. However, these tools tend to focus more on general leadership skills and do not capture the holistic and integrated aspects of nursing leadership as effectively as the INLS. Our study highlights the importance of contextualizing leadership assessments to account for specific cultural and organizational settings. In particular, the significant weight of Individual Performance in Iranian nursing leadership may reflect cultural factors such as the high value placed on interpersonal relationships and direct communication in the Iranian context.

In addition to EFA, CFA was performed to validate the instrument’s underlying structure. The findings confirmed a four-factor structure consistent with the original instrument’s content. Each item loaded onto a single factor as hypothesized, indicating strong relationships between the items and their respective dimensions. These results are consistent with previous studies, such as those by Cho and Choi¹⁶, which reported satisfactory fit indices, indicating robust validation of the instrument. The strong relationships observed between the items and their respective dimensions in this study also align with the principles of sound scale development as outlined by Ebadi et al.⁵⁷, which emphasize the importance of internal consistency and theoretical coherence in instrument design. Furthermore, these findings support the principles of integral theory^20,50. This theoretical and methodological alignment reinforces the validity of the INLS as a comprehensive tool for assessing nursing leadership.

The internal consistency was assessed using Cronbach’s alpha and McDonald’s omega coefficients, yielding excellent reliability estimates of 0.935 and 0.949, respectively. All subscales demonstrated Cronbach’s alpha coefficients above 0.94, further supporting the instrument’s internal consistency. In line with these findings, Cho and Choi¹⁶ also found high-reliability coefficients of 0.97 and 0.98 for Cronbach’s alpha and McDonald’s omega, respectively. These results suggest that the Persian version of the INLS is a highly reliable tool for assessing integral nursing leadership.

The INLS is a specialized tool designed to assess leadership attributes within the nursing field. However, certain items within this scale, particularly those concerning managerial competencies, may overlap with multiple dimensions, making precise categorization challenging. As noted by Cho and Choi¹⁶, items related to the cultural and social facets of nursing leadership may share commonalities with items related to individual performance. Moreover, the INLS may not fully encompass essential leadership traits, skills, and behaviors (e.g., visibility, agility for quick response, and willingness to learn and adapt) that are increasingly vital for contemporary nursing leaders operating in complex environments⁵⁸. Therefore, further research is necessary to refine its items, especially those associated with the dimensions of ‘influencing organizational culture’ and ‘organizational excellence’ to enhance the scale’s effectiveness.

Limitations

This cross-sectional study, utilizing a convenience sample of nurses from a Western Iranian university, investigated the psychometric properties of the INLS. The measurement model was data-driven. Consequently, caution should be exercised when generalizing the findings. The scale primarily focuses on individual characteristics and managerial skills, with fewer items addressing the cultural and social aspects of nursing leadership. Moreover, some items may be influenced by varying work and cultural contexts, leading to divergent responses. While the scale’s content and structural validity have been examined, its criterion validity, including concurrent and predictive validity, remains unexplored. Future research should investigate the INLS’s applicability across diverse cultural contexts and countries to enhance its validation and adaptation for measuring integral nursing leadership within a broader range of nursing leadership systems.

Conclusion

This study conducted a rigorous psychometric evaluation of the Integral Nursing Leadership Scale (INLS), resulting in a valid and reliable instrument specifically adapted to the Iranian cultural and healthcare context. Grounded in integral theory, the INLS offers a comprehensive framework for assessing nursing leadership by capturing both internal characteristics and external behaviors across diverse leadership roles, including clinical nurses, head nurses, nurse managers, and supervisors. Given the complex interplay of cultural, social, economic, and systemic factors that shape nursing leadership in Iran, the INLS emerges as a contextually relevant tool capable of identifying leadership strengths and developmental needs. It enables a deeper understanding of how various leadership roles contribute to the broader organizational culture and performance. Importantly, the INLS not only facilitates evaluation but also provides a practical foundation for designing targeted leadership development and training programs. Its multidimensional approach supports the advancement of nursing leadership competencies essential for improving the quality of patient care, enhancing team dynamics, and fostering organizational effectiveness. In addition, the INLS serves as a valuable resource for researchers seeking to explore nursing leadership within culturally specific frameworks. By integrating theoretical, practical, and cultural dimensions, this tool contributes meaningfully to both academic inquiry and the ongoing professionalization of nursing leadership in Iran and potentially other similar contexts.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CVI

Content Validity Index

CVR

Content Validity Ratio

KMO

Kaiser Meyer Olkin

EFA

Exploratory Factor Analysis

CFA

Confirmatory Factor Analysis

TLI

Tucker-Lewis Index

NFI

Normed Fit Index

GFI

Goodness of Fit Index

RMSEA

Root Mean Square Error of Approximation

PC

Principal Components

SRMR

Standardized Root Mean Square Residual

KUMS

Kermanshah University of Medical Sciences

Author contributions

All authors participated and approved the study design. KH, M; A, S and A, J contributed to designing the study. K, M; K, B; A, N and M, B collected the data, and data analyses were done by A, J. The final report and article were written by A, J; KH, M; K, M; K, B; A, N and M, B and all authors read and approved the final manuscript.

Funding

This study was funded by the Kermanshah University of Medical Sciences in Iran.

Data availability

The data analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Written permission was secured from the developer of the scale and the ethics committee of the Kermanshah University of Medical Sciences approved the study under the ethics code: IR.KUMS.REC.1403.356. All participants completed informed written consent to participate in the study. In addition, the principles of the Helsinki Declaration were observed. All methods were performed per the relevant guidelines and regulations.

were statistically significant at p < 0.001.