Psychometric evaluation of the Persian version of the school-to-work transition anxiety scale in senior nursing students

Abstract

Background

Senior nursing students frequently encounter transition anxiety during internships, a phenomenon that adversely affects their mental health, academic performance, and the quality of patient care. Although Iran has introduced internship programs to reduce transition shock, their effectiveness remains unclear due to the lack of a validated Persian assessment tool. This study sought to evaluate the validity and reliability of the Persian adaptation of the school-to-work transition anxiety scale in nursing students.

Methods

This methodological research was carried out to examine the structural validity and internal reliability of the scale, utilizing data gathered from October 2024 to May 2025. A total population sampling approach was used. All eligible final-year nursing students were identified using the official enrollment list maintained by the faculty’s education office and were invited to participate. A total of 342 students participated and were divided into two independent samples: 171 participants for exploratory factor analysis (EFA) and 171 participants for confirmatory factor analysis (CFA). EFA, using the maximum likelihood extraction method with Promax rotation, was conducted to identify the latent factor structure. Subsequently, CFA was performed on the second independent sample to verify the proposed model. Convergent validity was assessed following the Fornell and Larcker approach by calculating the average variance extracted (AVE) and composite reliability (CR), while discriminant validity was evaluated using the Heterotrait-Monotrait (HTMT) ratio. Internal consistency was examined using Cronbach’s alpha and McDonald’s omega coefficients, and stability was assessed using the intraclass correlation coefficient (ICC).

Results

The study included 342 nursing students (55.85% male, mean age 22.81 ± 2.16 years, grade point average 16.83 ± 1.31). Qualitative face validity confirmed all items as clear, relevant, and important. Content validity was confirmed, with minor revisions to three items and the removal of five items (CVR > 0.56). EFA extracted four factors (58.71% variance), with two items removed due to low factor loadings. CFA supported model fit (χ²/DF = 1.665, RMSEA = 0.063, CFI = 0.917). Convergent validity was confirmed for “Interpersonal Interactions” and “Fear of Being Infected” factors based on AVE and CR values. Discriminant validity was confirmed, as all HTMT coefficients were below the 0.85 threshold. Internal consistency of all factors was confirmed by Cronbach’s alpha and McDonald’s omega values greater than 0.7, and the stability of the scale was confirmed by evaluation of the ICC with 0.75 acceptable threshold. The final Persian version comprised 24 items across the same four-factor structure as the original 31-item scale.

Conclusion

The school-to-work transition anxiety scale demonstrated strong reliability and validity, confirming its suitability as a self-report instrument for assessing transition-related anxiety among final-year nursing students in Iran.

Background

The “transition” from student to novice nurse represents a critically challenging phase, initially conceptualized by Kramer as “reality shock” to describe the profound dissonance between academic preparation and clinical practice realities [1, 2]. Duchscher’s Theory of Transition Shock significantly expanded this foundation by outlining physical, emotional, intellectual, and socio-developmental dimensions of the shift to independent practice [3]. Within this multifaceted experience, the emotional component of relentless “anxiety” stands out as particularly pervasive and acute among senior nursing students, who face the impending culmination of their academic journey [3]. Anxiety is generally defined as a future-oriented emotional state characterized by apprehension and heightened arousal in anticipation of potential future threats [4]. In contrast, transition anxiety refers to the context-specific emotional response of apprehension, worry, and uncertainty experienced in anticipation of or during a significant life transition involving changes in roles, responsibilities, or environments [5, 6]. Unlike general anxiety, transition anxiety is specifically associated with the anticipation or experience of a particular life transition rather than representing a generalized emotional state across diverse situations [4–6]. Although closely related, transition anxiety should not be considered synonymous with transition shock. Transition shock is a broader multidimensional phenomenon encompassing physical, emotional, intellectual, and sociocultural responses to role transition, whereas transition anxiety can be understood as the emotional component of this broader transition experience [3].

Transition anxiety intensifies due to several converging factors, as senior students face critical career choices, clinical practice, further education, or leaving the profession, each with major personal and professional implications [7]. Concurrently, persistent concerns about clinical knowledge adequacy, practical skill competency, and effective communication with both healthcare teams and patients contribute substantially to their anxiety levels [8]. Addressing this anxiety is vital not only for student wellbeing but also for patient safety, as unmitigated anxiety can impair mental health, academic performance, care quality, and communication, ultimately compromising clinical decisions and increasing medical error risks [9].

Given the critical importance of the transition phase, numerous interventions have been implemented internationally, including residency programs, orientation tracks, extended transition initiatives, mentoring and preceptorship models, internship programs, entry-to-practice schemes, and structured clinical support systems [10]. In Iran, nursing students in their final academic year undertake internship training across multiple hospital departments, where they rotate through morning, evening, and night shifts each month. During this period, they receive a monthly stipend and assume independent responsibility for patient care, while remaining under the supervision of a registered nurse who provides guidance and support when needed [11]. Although this approach—designed to facilitate the transition period—was implemented in 2018 to mitigate transition shock and enhance psychological readiness among future nurses [12], its impact on transition-related anxiety in this population remains unclear.

The existing research gap appears to arise from the absence of evaluations assessing the impact of internship programs on transition anxiety, largely attributable to the lack of a valid and reliable measurement instrument. Although the original version of the school-to-work transition anxiety scale was validated on a heterogeneous sample of healthcare students (including medical students), the transition experience of Iranian nursing students is fundamentally different. For instance, while medical students typically develop autonomy in clinical decision-making gradually over their long training, Iranian nursing students experience a sudden and compressed transition. For the first three years, they practice under close instructor supervision, rarely assuming full patient responsibility. However, in their final year (7th and 8th semesters, as in the current study’s setting at Tehran University of Medical Sciences), they are abruptly placed in clinical settings to independently manage patient care. This sharp shift from a supervised learning role to an autonomous practice role within a short pre-transition period creates a unique set of anxieties. Additionally, these anxieties are distinct from those of students in other healthcare fields who have less direct and critical patient care responsibilities. Therefore, validating the scale for this distinct subgroup is a necessary first step to establish a foundational tool that can accurately identify their specific transition anxiety, which is a prerequisite for developing targeted support interventions.

Given the clear need for a tool to measure transition anxiety, it is important to review existing Persian instruments in this domain, especially for newly graduated nurses or final-year nursing students. In this regard, Shahsavari et al. (2020) conducted a study on the design and psychometric evaluation of the Perceived Professional Preparedness of Senior Nursing Students (PPPNS). This 19-item questionnaire measures four factors: (a) clinical competency, (b) evidence-based practice, (c) framework-oriented performance, and (d) patient-centered care in senior nursing students [13]. Additionally, Jalali et al. (2023) conducted a study aimed at translating and validating the Persian version of the Nursing Practice Readiness Scale (NPRS) in newly graduated nurses. This 35-item scale measures five factors: (a) clinical judgment and nursing performance, (b) professional attitudes, (c) patient-centeredness, (d) collaborative interpersonal relationships, and (e) self-regulation [14].

Despite their favorable psychometric properties, however, the instruments mentioned above focus on the concept of preparedness rather than anxiety. However, there is a lack of a valid and reliable instrument, in contrast to the PPPNS and NPRS, to measure transition anxiety. The School-to-Work Transition Anxiety Scale for Healthcare Students (StWTA-HS) is one such instrument, designed and validated by Hung et al. (2021) [5]. The original version of this scale not only has favorable psychometric properties for measuring transition anxiety, but no study has yet examined the validity and reliability of the StWTA-HS in other societies, including Iran. On the other hand, the critical role of the transition period in the professional development of nursing students, as well as improving desired care outcomes, highlights the need for a valid and reliable tool to accurately assess the effectiveness of different educational approaches in alleviating this specific type of anxiety, namely transition anxiety. Therefore, since the psychometric properties of this scale in Iranian society, especially among senior nursing students, remain unknown due to linguistic and cultural differences, the present study aimed to evaluate the psychometric properties of the Persian version of this scale in the aforementioned society.

Methods

Design

This methodological study was conducted at the School of Nursing and Midwifery, Tehran University of Medical Sciences. Participants were undergraduate nursing students enrolled during the period from October 2024 and May 2025 (October–December 2024 for exploratory factor analysis (EFA); February–May 2025 for CFA), covering two consecutive academic semesters (Fall 2024 and Winter 2025) to ensure comprehensive access to the eligible target population. The sampling frame comprised all nursing students enrolled in semesters 7 or 8 during the study period. Students who progressed from semester 6 (Fall 2024) to semester 7 (Winter 2025) were also considered eligible to avoid inadvertent exclusion of this cohort. A total population sampling approach was employed. All eligible students were identified through official university enrollment records and contacted using their registered telephone numbers. After the study had been explained and written informed consent had been obtained, participants were screened for eligibility, including self-reported history of serious mental illness and current use of psychiatric medications. Eligible students were subsequently invited to complete the study questionnaires. During the study period, 440 students comprised the accessible population. Following eligibility screening, 438 students met the eligibility criteria, of whom 342 completed the study, yielding a response rate of 78.1%. Inclusion criteria were enrollment in semesters 7 or 8, willingness to participate, self-reported absence of diagnosed serious mental illness (SMI), and self-reported non-use of psychiatric medications. For the purposes of this study, SMI was operationally defined as a diagnosable mental, behavioral, or emotional disorder resulting in serious functional impairment that substantially interferes with or limits one or more major life activities [15]. Eligibility regarding psychiatric disorders and psychiatric medication use was assessed through participant self-report. During participant screening, two potential participants were excluded based on these criteria. According to their self-reports, one was receiving pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD), and the other was receiving pharmacological treatment for an anxiety disorder. Consequently, neither individual was enrolled in the study. Students who had been dismissed from the program or transferred to another institution were also excluded. Completed questionnaires underwent a quality control process. Forms containing more than 15% missing data or response patterns indicating non-engagement were excluded to preserve data integrity. The study was conducted in two sequential phases: initial translation and cross-cultural adaptation of the instrument, followed by a comprehensive psychometric evaluation of the Persian version among Iranian undergraduate nursing students.

Scale

The original StWTA-HS is a self-report instrument developed to assess healthcare students’ anxiety during the transition from school to professional practice. This is a seven-point Likert scale, with 7 signifying ‘strongly agree’ and 1 signifying ‘strongly disagree’. The higher the score, the higher the student’s school-to-work transitional anxiety. The StWTA-HS included four factors: (a) inexperience in professional knowledge and skills (9 items), (b) fear of death (8 items), (c) fear of being infected (8 items), and (d) interpersonal interactions (6 items) [16].

First phase

Translation and cultural adaptation processes

Following authorization from the original developer (Ya-huei Wang, February 2024), the English version of the StWTA-HS was translated into Persian using the standard forward–backward translation method for cross-cultural adaptation of measurement instruments (Fig. 1) [17, 18].

Fig. 1.

Flowchart of translation process and psychometric evaluation of the school-to-work transition anxiety scale

The translation process consisted of six sequential steps: forward translation, synthesis of the translations, back translation, expert committee review, pre-testing of the pre-final version, and submission of documentation to the original developer. First, two bilingual translators whose native language was Persian independently performed forward translation. One translator had expertise in nursing education, while the other had no medical or clinical background to ensure both conceptual and lay linguistic equivalence. The translations were then synthesized into a single version (T12) through discussion and consensus among the translators and a recording observer. In the back-translation phase, two native English-speaking translators, who were blind to the original instrument and had no medical background, independently translated the T12 version back into English (BT1 and BT2). An expert committee consisting of researchers and translators reviewed all versions (T1, T2, T12, BT1, BT2) to ensure semantic, idiomatic, experiential, and conceptual equivalence.

A pre-final version of the scale was then pilot tested on 30 nursing bachelor students to evaluate item comprehensibility and response clarity. This stage was conducted only for preliminary feedback and was not included in the formal validity or reliability analyses. Finally, all documentation was submitted to the original developer and coordinating committee for verification of compliance with recommended cross-cultural adaptation procedures.

Second phase

Face validity

Face validity was assessed qualitatively to ensure the clarity, comprehensibility, and relevance of the items for the target population. Fifteen participants from the target group reviewed the items using a structured evaluation form assessing clarity, wording accuracy, cultural relevance, and perceived difficulty. During face-to-face sessions, each item was read aloud to the participants, and they were asked to consider these specific aspects and provide their feedback. Participants were encouraged to share any comments or suggestions about confusing wording, cultural inappropriateness, or perceived difficulty, which were then systematically recorded in the review form. The collected feedback was carefully compiled and discussed with all members of the research team, and the most appropriate revisions were implemented to improve item clarity, cultural appropriateness, and comprehensibility. This process ensured that the instrument was clear, culturally relevant, and easily understood by the intended population, in line with standard practices for face validity assessment in instrument adaptation studies [19, 20].

Content validity

Content validity was evaluated using both qualitative and quantitative methods. For the quantitative assessment, twelve nursing education experts rated each item for necessity using the Content Validity Ratio (CVR) based on Lawshe’s method. Items with CVR values greater than 0.56 (based on twelve experts) were considered acceptable. In addition, the Content Validity Index (CVI) was calculated to evaluate item relevance, clarity, and simplicity. The Item-Level Content Validity Index (I-CVI) was computed as the proportion of experts rating each item as 3 or 4 on a 4-point Likert scale. An I-CVI value of 0.78 or higher was considered acceptable. The Scale-Level Content Validity Index (S-CVI/Ave) was calculated using the average method, representing the mean of I-CVI values across items, with values of 0.90 or higher indicating excellent content validity [21, 22]. To adjust for the possibility of chance agreement among experts, the modified kappa coefficient (κ) was calculated for each item based on the I-CVI values. The probability of chance agreement (Pc) was first computed, and κ was then derived using the formula: κ = (I-CVI − Pc) / (1 − Pc). According to established criteria, κ values above 0.74 were considered excellent, values between 0.60 and 0.74 as good, and values between 0.40 and 0.59 as fair. Items with κ values below 0.40 were considered for revision or removal [23]. Furthermore, a qualitative approach was employed in which the same twelve nursing education experts were asked to examine the scale and offer feedback, focusing on the relevance, clarity, simplicity, and cultural suitability of each item to establish qualitative content validity. Following these revisions, the updated scale was returned to the experts for final approval.

Construct validity

Construct validity was assessed using EFA, adhering to the guideline of including three to ten participants per item, followed by CFA [24]. A total of 342 students were assessed, corresponding to the sample size required for the full construct validation procedure, which entailed a two-stage factor analysis. The model was initially developed using EFA on data from 171 participants and subsequently tested and confirmed through CFA on an entirely independent sample of 171 participants, with no overlap between the two groups. Student enrollment lists were obtained from the education office and that participation records were systematically monitored to prevent duplicate enrollment based on the “student ID” for each student defined in the institute. Although some methodological recommendations suggest a minimum of 200 participants for CFA [25], simulation studies indicate that smaller samples can be sufficient when the variable-to-factor ratio is at least six and the communality values are moderate to high [26]. The suitability of the sample was verified using the Kaiser–Meyer–Olkin (KMO) measure and Bartlett’s test of sphericity. Prior to the EFA, item analysis was carried out by computing corrected item–total correlations using a 0.30 cut-off [27, 28]. EFA was subsequently performed using the maximum likelihood extraction method with Promax rotation, given that the assumptions of univariate and multivariate normality were met [29]. Items with communalities below 0.2 and factor loadings below 0.3 were considered to be removed [30]. Furthermore, each retained factor was required to comprise at least three items. A factor loading of approximately 0.3 or greater was considered significant for defining a latent factor. This significance threshold was derived from the formula: CV = 5.152 ÷ √(n − 2), where CV represents the critical value for the factor loading and “n” denotes the sample size [31]. The rotated pattern matrix was examined to determine the final factor structure [32]. An eigenvalue (λ) for a given factor is derived from the sum of its squared factor loadings. This value indicates the magnitude of the factor’s influence, quantifying the amount of total variance it captures. The proportion of total variance explained by the factor is subsequently obtained by dividing its eigenvalue by the total number of variables [33]. Then, the CFA was used to confirm the dimensions of the scale and the proposed model of EFA. Model fit was evaluated using several indices, including the Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Adjusted Goodness of Fit Index (AGFI), Parsimony Goodness of Fit Index (PGFI), Tucker-Lewis Index (TLI), and Incremental Fit Index (IFI). The Parsimony Comparative Fit Index (PCFI) and Parsimony Normed Fit Index (PNFI) were also examined. Additionally, the Root Mean Square Error of Approximation (RMSEA), and the minimum discrepancy divided by degrees of freedom (CMIN/DF) were computed [25].

Convergent and discriminant validity

In line with the framework proposed by Fornell and Larcker, convergent validity was measured using Average Variance Extracted (AVE) and Composite Reliability (CR). The established thresholds for acceptability were an AVE > 0.5 and a CR > 0.7. When AVE values fell below the recommended threshold, structural robustness was evaluated using CR, theoretical coherence of the construct, and the adequacy of factor loadings, rather than relying solely on AVE [34, 35]. Also, to evaluate discriminant validity, the Heterotrait-Monotrait (HTMT) ratio was employed, as it is a sensitive measure for this type of assessment. The HTMT ratio, introduced by Henseler et al. (2015), is grounded in the principles of the multitrait-multimethod matrix framework [36]. Results from Monte Carlo simulations have shown that HTMT exhibits superior performance compared to traditional techniques such as the Fornell-Larcker criterion and (partial) cross-loading analysis [37, 38]. In line with this evidence, the current study adopted the HTMT method to evaluate discriminant validity, applying the conventional threshold of 0.85—values below which are considered indicative of conceptually distinct constructs [37]. The convergent and discriminant validity of the measurement model were evaluated using AMOS version 26.

Reliability

To assess the internal consistency of items within the construct, Cronbach’s alpha and McDonald’s omega were calculated (Acceptable value: above 0.70). The assessment of McDonald’s omega further supports the reliability of the findings, as this coefficient provides a more robust estimate than Cronbach’s alpha when the assumption of equal factor loadings (tau-equivalence) is not fully met or the scale has a factor structure with more than one factor [39, 40]. Therefore, McDonald’s omega is considered a practical alternative to Cronbach’s alpha for estimating reliability. Also, in order to provide a more comprehensive assessment of the reliability, the CR was reported (Acceptable value: above 0.7) [41]. The stability of the scale was evaluated using the intraclass correlation coefficient (ICC) using a mixed two-way effects model, with 0.75 considered the minimum acceptable threshold. To assess test–retest reliability, 30 nursing students completed the scale on two occasions separated by a two‑week interval [42].

Normality, outliers and missing data

Univariate outliers were identified through visual inspection of distribution plots, while multivariate outliers were detected using the Mahalanobis distance (p < 0.001). Normality was assessed at both levels: univariate normality was evaluated using skewness (within ± 3) and kurtosis (within ± 7), and multivariate normality was examined using the Mardia coefficient (< 8) [43]. For CFA, missing data were addressed via listwise deletion, as most non-responses arose from incomplete questionnaires rather than random omissions, making imputation less appropriate. All statistical analyses were performed using SPSS and AMOS, version 26.0.

Ethic

Participants received information about the study through a digital form, which included a preliminary consent item that had to be acknowledged before participation. The study was conducted in accordance with the principles of the Declaration of Helsinki, and both verbal and written informed consent were obtained from all participants. Ethical approval for the research was granted by the Tehran University of Medical Sciences Ethics Committee (Approval No. IR.TUMS.FNM.REC.1403.162). All data collected were maintained with strict confidentiality. In addition, formal permission to translate, culturally adapt, and psychometrically evaluate the instrument was obtained from the original developer (Ya-Huei Wang) prior to the initiation of the study. The original version of the scale was provided directly by the developer, who was kept informed throughout the translation, cultural adaptation, and validation processes. Explicit permission for publication of the adapted version and its psychometric findings was also obtained.

Results

In this study, overall, out of 342 students, 191 (55.85%) were male, and 151 (44.15%) were female. This gender distribution reflects the actual enrollment pattern of final-year nursing students at the study site during the data collection period. The mean score of grade point average (out of 20) of students was 16.83 ± 1.31, and the mean age of participants was 22.81 ± 2.16 years.

Face and content validity

The findings from the qualitative face validity assessment showed that students considered all items to be clear, relevant, and important, with no further recommendations offered. In qualitative content validity, three items [24, 44, 45] were edited according to experts’ suggestions. For assessing quantitative content validity, both the CVR and CVI indices, along with the kappa coefficient for agreement beyond chance, were calculated. According to the proposed method by Lawshe, items with a CVR value greater than 0.56 (for a panel of 12 experts) were considered acceptable [21]. The results showed that items 7, 11, and 19 had a CVR value of 0, while items 20 and 30 had a CVR value of 0.33, all of which were below the acceptable threshold of 0.56. In addition, the item-level content validity index (I-CVI) and modified kappa coefficients were also calculated to evaluate agreement beyond chance. The results demonstrated that items 7, 11, 19, 20, and 30 had not only low CVR values but also low I-CVI scores, indicating insufficient content relevance based on expert consensus. Specifically, items 7, 19, and 20 had I-CVI values of 0.58, and items 11 and 30 had an I-CVI value of 0.50. The kappa coefficients for these items were also within the unacceptable or borderline ranges, with kappa values of 0.483 for items 7, 19, and 20, 0.354 for items 11 and 30. According to established criteria, kappa values below 0.60 indicate weak or marginal agreement beyond chance among experts. In contrast, the remaining items demonstrated excellent content validity, with I-CVI values ranging from 0.83 to 1.00 and kappa coefficients ranging from 0.83 to 1.00, supporting strong expert agreement and confirming the validity of the final instrument. The S-CVI/Ave was first calculated for the initial 31-item scale, yielding a value of 0.87, indicating adequate but not optimal scale-level content validity.

During the content validation process, five items (7, 11, 19, 20, and 30) were removed due to a combination of statistical and conceptual considerations. These items demonstrated low CVR values, indicating insufficient agreement among experts regarding their essentiality. In addition, these items showed low I-CVI and modified kappa coefficients, further confirming weak agreement beyond chance among experts regarding their relevance. From a conceptual and linguistic perspective, the removed items were also associated with redundancy, ambiguity, and lack of specificity. Q7 overlapped with Q2, which more clearly captured perceptions of professional knowledge and performance under pressure, and it was linguistically more complex. Q11 overlapped with Q15, which more precisely addressed emotional responses and anxiety related to patient death, while Q11 was less specific. Q19 was redundant with Q21, which provided a clearer description of students’ anxiety about patients withholding information, and was considered conceptually ambiguous. Q20 overlapped with Q18, which more precisely linked disease risk perception to professional performance, and was considered too vague. Finally, Q30 overlapped with Q27, which more specifically addressed anxiety regarding ineffective communication with patients and families, and was judged overly general. Overall, the removal of these items reduced redundancy, improved clarity, and enhanced conceptual coherence and cultural and semantic equivalence of the Persian version of the instrument. Furthermore, after item removal, the S-CVI/Ave increased to 0.94 for the remaining 25 items, indicating excellent scale-level content validity and improved psychometric quality of the final instrument.

Construct validity

All items showed corrected item–total correlations exceeding the 0.30 threshold (ranging from 0.341 to 0.711), supporting their appropriateness for inclusion in the subsequent EFA. Given that the data met the assumptions of univariate and multivariate normality, the maximum likelihood extraction method was considered appropriate and was therefore applied in the EFA. In the Maximum Likelihood Exploratory Factor Analysis (MLEFA) with Promax rotation, the Kaiser–Meyer–Olkin (KMO) measure was 0.908, and Bartlett’s test of sphericity yielded a value of 2979.174 (P < 0.001), indicating sampling adequacy and suitability for factor analysis. In the model, four factors were extracted based on eigenvalues greater than 1. The initial EFA model accounted for 61.36% of the total variance. Items 13 and 24 were excluded from the analysis due to low factor loadings (0.271 and 0.234, respectively) below the predetermined threshold of 0.30, and following their removal, the final model accounted for 58.7% of the variance. Although this represents a slight decrease in the total variance explained, the final solution yielded a more interpretable factor structure with stronger loadings across the retained items. Table 1 presents the rotated factor pattern matrix following Promax rotation.

Table 1.

Rotated pattern matrix of the scale obtained through exploratory factor analysis

Factors	Qn. Item	Factor Loading	Item Communality (h2)	Eigenvalue (λ)	%Variance
Inexperience professional knowledge and skills	2. I experience pressure while thinking that my professional knowledge and skills are not good enough for caring for patients.	0.872	0.630	4.312	17.967
	4. The unsettled conflicts between the ideal and the reality in the healthcare system lead me to begin to doubt about whether I am able to be a qualified medical/healthcare professional.	0.803	0.639
	3. I feel anxious and stressful while thinking that I do not yet familiarize myself with medical/healthcare equipment, technology, and facilities.	0.799	0.570
	1. I often feel very frustrated and want to give up the job while thinking of my immaturity in medical/healthcare professionalism.	0.727	0.588
	5. My pressure comes from the lack of professional knowledge and skills.	0.706	0.466
	6. I experience anxiety while thinking that my immaturity in medical/healthcare professional knowledge and skills may lead to me making errors or bring trouble to someone.	0.686	0.521
	9. I feel exhausted: physically and spiritually, after entering the healthcare workplace and realizing that there is a lot of room for improvement in my healthcare knowledge and skills.	0.658	0.624
	8. After keeping making mistakes all the time, I become so scared of caring for patients or providing any healthcare service.	0.581	0.484
Interpersonal interactions	27. I experience anxiety once thinking that I may not be able to communicate effectively with patients and patients’ families.	0.987	0.832	3.639	15.163
	26. Having poor communication skills, I am afraid of facing patients and patients’ families.	0.932	0.860
	28. Thinking of having to communicate with patients and patients’ families in the future makes me uneasy and restless.	0.897	0.796
	29. The interpersonal interaction in the healthcare workplace is a source of pressure for me.	0.799	0.733
	31. I feel nervous and anxious when I have to face my bosses and my supervisors.	0.594	0.575
Fear of being infected	18. The risk of being infected makes me unable to demonstrate my specialties and professionalism in caring for patients.	0.859	0.696	3.100	12.917
	22. I become anxious once thinking of the increasing possibility of being infected in the current healthcare system.	0.823	0.680
	21. Thinking that patients may conceal their medical history makes me uneasy and restless, hence failing to concentrate on my healthcare job.	0.796	0.651
	23. At any moment, I feel anxious about the possibility of being infected.	0.787	0.632
	25. I don’t know how to deal with the patients with infectious diseases, so while dealing with them, I feel very nervous and my heart beats faster.	0.657	0.591
Fear of death	14. I feel anxious when thinking of the possibility of facing patient deaths in the future.	0.849	0.784	3.039	12.663
	15. My past experience in facing death has let me afterwards feel uncomfortable and anxious in facing patients’ deaths.	0.805	0.570
	16. I don’t know how to tell patients that they are going to die, and hence I experience anxiety.	0.794	0.604
	12. Death telling is a very unpleasant emotional experience; I really don’t know how to deal with it.	0.758	0.567
	10. I feel guilty or even fail to fall asleep while thinking that I may not be able to save patients’ lives.	0.533	0.553
	17. Thinking that I have to face the deaths of my patients makes me feel like I am not ready yet to be a healthcare professional.	0.425	0.525

Confirmatory factor analysis

CFA was conducted to evaluate the proposed four-factor structure of the scale. Standardized factor loadings for all items are presented in Table 2, ranging from 0.527 to 0.857, all exceeding the commonly recommended threshold of 0.50, indicating that each item adequately represents its respective construct. During the analysis, modification indices suggested correlating the error terms of a few pairs of theoretically related items within the same factor (e.g., W3 ↔ W6, W27 ↔ W26, W29 ↔ W31, W22 ↔ W23, W16 ↔ W12). These correlations were allowed, which improved model fit without altering the underlying factor structure. Model modification indices indicated that improved fit could be attained by permitting correlations among the residuals of items with conceptual similarity. Accordingly, based on theoretical justification and content overlap, error covariances were freed for the item pairs W3–W6 (limited knowledge and skills in healthcare and clinical practice), W27–W26 (interactions with patients and their families), W29–W31 (communication with colleagues and managerial staff), W23–W22 (perceived risk of disease infection), and W16–W12 (delivering bad news related to death). These modifications reflect potential shared method variance attributable to similarities in item wording and thematic content. Following these adjustments, all fit indices indicated an acceptable model fit: χ2 = 401.383; DF = 241, P < 0.001, CMIN/DF = 1.66, PCFI = 0.80, PNFI = 0.71, RMSEA = 0.06 (CI 90%: 0.052–0.073), IFI = 0.91, TLI = 0.90, CFI = 0.91, GFI = 0.93, AGFI = 0.79, PGFI = 0.97) (Fig. 2). In Fig. 2, the letter “W” was used to label the items corresponding to the “Workplace Transition Anxiety”.

Table 2.

Standardized factor loadings of the scale based on confirmatory factor analysis

Factor	Item	Standardized Loading
Inexperience professional knowledge and skills	W2	0.706
	W4	0.628
	W3	0.683
	W1	0.682
	W5	0.588
	W6	0.654
	W9	0.631
	W8	0.527
Interpersonal interactions	W27	0.786
	W26	0.766
	W28	0.857
	W29	0.762
	W31	0.729
Fear of being infected	W18	0.761
	W22	0.689
	W21	0.751
	W23	0.690
	W25	0.705
Fear of death	W14	0.757
	W15	0.689
	W16	0.640
	W12	0.573
	W10	0.638
	W17	0.641

“W” refers to individual items of the StWTA-HS. Each item is labeled according to its corresponding construct.

Fig. 2.

The model structure of the scale based on the CFA

Convergent and discriminant validity

Given that the AVE values for the factors “Interpersonal Interactions” and “Fear of Being Infected” exceeded 0.50, convergent validity was supported for these factors. In contrast, for the factors “Inexperience in professional knowledge and skills” and “Fear of death,” AVE values were below the recommended threshold of 0.50, indicating that convergent validity was not supported for these two factors, despite CR values exceeding 0.70 (Table 3). Furthermore, the HTMT ratio findings showed that all obtained ratios were lower than 0.85, thus confirming the discriminant validity in all factors (Table 4).

Table 3.

Convergent validity and internal consistency of the Persian version of the school-to-work transition anxiety scale

Indices Factors	CR	AVE	MSV	α	Ω	ICC (95% CI)
Inexperience professional knowledge and skills	0.846	0.409	0.459	0.881	0.880	0.933 (0.865–0.967)
Interpersonal interactions	0.886	0.610	0.413	0.916	0.915	0.753 (0.748–0.768)
Fear of being infected	0.843	0.518	0.413	0.878	0.877	0.881 (0.768–0.942)
Fear of death	0.820	0.434	0.459	0.861	0.861	0.954 (0.905–0.978)

CR Composite Reliability, AVE Average Variance Extracted, MSV Maximum Shared Squared Variance, ICC Intraclass Correlation Coefficient, CI Confidence Interval

Table 4.

Discriminant validity assessment using the HTMT criterion

Inexperience professional knowledge and skills	Inexperience professional knowledge and skills	Interpersonal interactions	Fear of being infected	Fear of death
Interpersonal interactions	0.493
Fear of being infected	0.466	0.615
Fear of death	0.671	0.574	0.500

HTMT Heterotrait-Monotrait

Reliability

The reliability analysis demonstrated acceptable internal consistency for all factors, with both Cronbach’s alpha (ranging from 0.861 to 0.916) and McDonald’s omega (ranging from 0.877 to 0.915) falling within established acceptable thresholds, as well as satisfactory stability (ranging from 0.709 to 0.954) (Table 3). The obtained Cronbach’s alpha and McDonald’s omega coefficients, all exceeding the 0.70 threshold, indicate adequate internal consistency for each factor, confirming that their items reliably measure a single underlying construct. Additionally, the CR values above 0.7 in all factors indicated appropriate construct reliability, further supporting the reliability of the scale (ranging from 0.820 to 0.886).

Final structure

The original version of the scale contained 31 items. Five items (7, 11, 19, 20, and 30) were eliminated during the content validity phase, as their individual CVR values fell below the critical threshold of 0.56 for a 12-member expert panel. Additionally, two items (13 and 24) were removed during the EFA phase due to low factor loadings. The finalized Persian version of the scale consists of 24 items grouped into four factors: (a) Inexperience in professional knowledge and skills (8 items), (b) Interpersonal interactions (5 items), (c) Fear of being infected (5 items), and (d) Fear of death (6 items). Overall, the original 31-item scale was reduced to 26 items after the content validity assessment and finally to 24 items following exploratory factor analysis. The rating format follows the original version, a seven-point Likert scale ranging from 1 (‘strongly disagree’) to 7 (‘strongly agree’). Higher scores indicate greater levels of school-to-work transitional anxiety among senior nursing students.

Discussion

The present study aimed to conduct a cultural adaptation and psychometric evaluation of the Persian version of the school-to-work transition anxiety scale among Iranian senior nursing students. EFA of the Persian version of this scale extracted four factors, namely: (a) Inexperience in professional knowledge and skills, (b) Interpersonal interactions, (c) Fear of being infected, and (d) Fear of death, which accounted for 17.967%, 15.163%, 12.917%, and 12.663% of the total variance, respectively. Collectively, these four factors explained 58.710% of the total variance of the scale. CFA also confirmed the acceptable fit of this four-factor structure.

Consistent with the present study, the original version of this scale also assessed four factors: (a) Inexperience in professional knowledge and skills, (b) Fear of death, (c) Fear of being infected, and (d) Interpersonal interactions, which together explained 66.80% of the total variance. The four-factor structure of the original scale also demonstrated an acceptable fit [16].

Regarding the first factor, lack of experience in professional knowledge and skills, it can be explained that new graduates, despite intensive clinical internship programs and extensive orientation sessions, still experience a lack of confidence during the transition phase when they are expected to work independently in hospital settings [44]. On the other hand, Najafi and Nasiri (2023) identified insufficient knowledge as one of the key factors contributing to the weak professional confidence of novice nurses [46]. Clark and Springer (2012) also highlighted knowledge gaps and the fear of harming patients as influential factors in reducing nurses’ self-confidence [45]. Thus, it appears that the lack of confidence among final-year nursing students stems from their inexperience in professional knowledge and skills, which plays a crucial role in their transition-related anxiety from academic settings to the workplace.

The second factor, interpersonal interactions, reflects concerns that novice nurses may experience apprehension when exercising clinical judgment due to perceived evaluation by experienced colleagues. Prematurely seeking assistance may result in perceptions of clinical inadequacy and potential criticism from colleagues [47]. However, the implications of interpersonal dynamics extend further. The reciprocal self-other relationship underscores the evolving interaction between novice nurses and their patients, wherein responding to patient needs allows new nurses to engage with the deeper values of the nursing profession. By transcending task-based care, they develop an awareness of each patient’s individuality and assume responsibility for addressing their needs. This process cultivates their role as a “subject for the other”—a perspective shaped by empathy and professional accountability [48]. Achieving equilibrium between responsibility and empathy hinges on interpersonal competence, yet this very dynamic can also exacerbate anxiety among novice nurses [49]. Consequently, the complexities of interpersonal interactions and their potential ramifications for final-year nursing students warrant careful consideration.

The third factor, Fear of being infected, reflects final-year nursing students’ concerns about occupational exposure to viruses and potential transmission to their families. This phenomenon was particularly salient during the COVID-19 pandemic, as the rapid surge in cases heightened anxiety among healthcare students regarding viral contraction. Their direct contact with confirmed or suspected COVID-19 patients significantly increased exposure risk [50]. Consequently, students feared that their own infection might subsequently endanger family members and loved ones [16].

Beyond infection-related anxiety, healthcare professionals - particularly young trainees - may experience death anxiety, constituting the fourth factor [51]. Newly graduated nurses often lack adequate preparation to cope with patient mortality [49]. In reality, it is advancing age that enhances both life experiences and clinical exposure, enabling nurses to effectively manage patient deaths [52]. When caring for critically ill patients, novice nurses report heightened anxiety as they bear dual responsibilities: providing competent healthcare while enduring the psychological strain of life-threatening situations. Furthermore, for healthcare providers, patient death represents not merely a biological event but may also signify perceived clinical failure or inadequacy in healthcare delivery [53].

In the present study, CR values exceeded this threshold for all four factors, confirming acceptable internal consistency. However, convergent validity, as assessed by AVE, was fully supported only for the factors “Interpersonal Interactions” and “Fear of Being Infected,” with AVE values exceeding 0.50. According to the Fornell–Larcker criteria, convergent validity was not supported for the factors “Inexperience in professional knowledge and skills” and “Fear of death,” as their AVE values fell below the recommended threshold of 0.50. Although the CR values were satisfactory, they do not compensate for the insufficient AVE in evaluating convergent validity. Alternative factor structures (e.g., three-factor, two-factor, or second-order models) were considered. However, given the strong theoretical foundation of the original four-factor model and the acceptable overall model fit indices in the CFA, no further model re-specification was undertaken in the present study. Future research with larger samples is recommended to further explore alternative factorial structures. In the original version of the scale, although AVE values were also lower than CR for some factors, overall convergent validity was considered acceptable [5].

On the other hand, values less than 0.85 of the HTMT matrix suggest satisfactory discriminant validity of the Persian version of the scale. In contrast, AVE square root values greater than the correlation coefficients between factors also indicate excellent discriminant validity of the original version of this scale [5]. Therefore, the limitations regarding the convergent validity of the Persian version of this scale, namely the AVE values less than 0.5 for the factors “Inexperience in professional knowledge and skills” and “fear of death”, as well as the difference in the approach used to assess discriminant validity, highlight the need for further studies to determine the convergent and discriminant validity of the Persian version of this scale. This could be achieved by determining the correlation of this scale with existing instruments in this field, such as PPPNS and NPRS.

Finally, excellent internal consistency and construct reliability of the Persian version of the school-to-work transition anxiety scale were confirmed, with both Cronbach’s alpha and McDonald’s omega coefficients exceeding 0.8, along with CR values above 0.8 for all factors. Similarly, the original version of the scale demonstrated strong reliability, with Cronbach’s alpha and CR values surpassing 0.8 for all factors, thereby establishing its internal consistency and construct reliability [16].

A key methodological distinction between the present study and the original instrument development study lies in our additional calculation of McDonald’s omega alongside Cronbach’s alpha to assess internal consistency. Unlike Cronbach’s alpha, which can be influenced by the number of items and sample size, McDonald’s omega remains unaffected by these parameters [54]. Nevertheless, both the original and Persian versions of the scale demonstrated excellent internal consistency and construct reliability, supporting their psychometric robustness.

Items 7, 11, 19, 20, and 30 (a total of 5 items) were removed during the content validity stage due to CVR values lower than the threshold of 0.56. Additionally, items 13 and 24 (a total of 2 items) were removed during the construct validity stage due to factor loadings lower than the threshold of 0.3. Possible reasons for the exclusion of these items include the differing nursing education systems in China and Iran, as well as the distinct conditions governing the healthcare systems of these two countries. The diverse value systems of Chinese and Iranian students, along with their varying perspectives on issues such as death due to differing religious beliefs, may also partially justify the removal of some items.

Within the Iranian context, religion and spirituality constitute integral components of everyday life and healthcare delivery. Consequently, nursing students in Iran may demonstrate greater familiarity with the spiritual dimensions of care compared to their Chinese counterparts, which could contribute to elevated levels of spiritual well-being. In this regard, Nassehi et al. (2025) observed a positive and significant relationship between spiritual well-being and positive attitudes toward death among nursing students [55]. Korzebor et al. (2021) also identified spiritual well-being as one of the factors associated with positive attitudes towards death and dying, as well as reduced anxiety [56]. Therefore, it is possible that the removal of items 11 (Because of some bad experience in the past, I am scared of dealing with death issues.) and 13 (I feel very uncomfortable once thinking that someone may die because of my unprofessional healthcare knowledge or skills.) from the “fear of death” factor stems from the different perspectives of Chinese and Iranian students towards death. Meanwhile, the removal of item 30 (How to interact with patients and patient families always brings me anxiety.) from the “interpersonal interactions” factor may be attributed to lower anxiety resulting from the higher spiritual well-being of Iranian students.

Like many developing countries, the Iranian nursing education system was introduced by Western missionaries and is largely influenced by the educational systems of the United States and the United Kingdom [57]. However, in the past decades, the Iranian nursing education system has undergone significant changes to adapt to the country’s conditions [58]. These changes have addressed the growing complexities of healthcare systems, such as increasing the quality of nursing care, promoting nursing authority and competence, improving the social image of the nursing profession, and implementing evidence-based nursing care [57, 59, 60]. Thus, the improvement of the Iranian nursing education system following these changes may be a possible reason for the removal of item 7 (Thinking that I am not qualified enough to be a medical/healthcare professional makes me begin to think about whether I can be a medical/healthcare worker after graduation.) from the factor “Inexperience in professional knowledge and skills” and items 19 (I am too anxious to fall asleep due to thinking that patients may conceal their medical history.), 20 (The possibility of having the risk of being infected makes me hesitate to be a healthcare provider.), and 24 (I don’t think Iran’s medical system can provide medical personnel with a secured working environment, so I feel uneasy about it.) from the factor “Fear of being infected” in the Persian version.

These cases may not only be possible reasons for the removal of the mentioned items but also may clarify the difference in factor loading and item communalities, as well as the different organization of items in each factor between the original and Persian versions. However, the proposed explanations are merely theoretical hypotheses and the present study was not designed to directly test them. Therefore, future comparative and cross-cultural research could clarify the role of these factors in the observed differences with greater precision.

Although items 7, 11, 19, 20, and 30 were removed during the content validity stage, and items 13 and 24 during the construct validity stage of the cultural adaptation and psychometric evaluation process, these decisions were not made solely to enhance statistical indicators. Instead, they were based on a comprehensive set of theoretical, cultural, and psychometric considerations to ensure that the final items would possess the greatest conceptual relevance, semantic clarity, and psychometric efficiency for the target population. In such studies, the removal or modification of certain items is common and does not necessarily imply a weakening of the construct being measured. Rather, if theoretical coherence and appropriate coverage of the construct dimensions are preserved, it can lead to increased validity and suitability of the instrument within a new cultural context [61, 62]. Consequently, the remaining items in the Persian version of the aforementioned scale still adequately represent the primary dimensions of transition anxiety from school to work and are conceptually aligned with the theoretical framework of the original version. However, the reduction in the number of items may somewhat limit the coverage of various aspects of this construct. Thus, this difference should be considered when directly comparing findings from the Persian version with those from the original or other language versions. Moreover, conducting additional studies in different cultural contexts can further clarify the degree of retention of the conceptual coverage of the construct and the cross-cultural comparability of the aforementioned scale.

After the removal of seven items, 24 items remain in the Persian version of the StWTA-HS, scored on a seven-point Likert scale ranging from “strongly agree” (7 points) to “strongly disagree” (1 point). The lowest and highest possible scores are 24 (indicating the least transition anxiety) and 168 (indicating the most transition anxiety), respectively, with higher scores denoting greater transition anxiety in senior nursing students and vice versa. The Persian version of this scale, while demonstrating desirable validity and reliability, assesses four factors: (a) Inexperience in professional knowledge and skills (8 items, score range 8–56), (b) Interpersonal interactions (5 items, score range 5–35), (c) Fear of being infected (5 items, score range 5–35), and (d) Fear of death (6 items, score range 6–42) among Iranian senior nursing students.

Implications for nursing education, practice, and research

The Persian version of this scale can be employed as a tool to monitor transition anxiety in senior nursing students as they enter the profession. These findings can also be used in curriculum review, educational needs assessment, and design of supportive interventions to facilitate the transition from education to employment. In clinical settings, the Persian version of the StWTA-HS can help identify new nurses who are at risk of transition anxiety and provide a basis for planning organizational supports, preventive programs, mentoring, and other strategies to facilitate professional adjustment. The Persian version of the aforementioned scale provides a suitable platform for conducting various studies on transition anxiety to determine its predictors and consequences in different nursing groups. It can also be used to evaluate the effectiveness of interventions, conduct longitudinal studies, and compare findings across different cultural contexts and educational systems.

Strengths and limitations

There are several major strengths to the current study. First, it is the initial psychometric testing of the scale used among Iranian nursing students and helps fill an important research gap in transition anxiety literature in non-Western countries. The process was highly construct-driven, involving qualitative (expert reviews) and quantitative (content validity indices, exploratory/confirmatory factor analyses) validation steps, leading to a strong adaptation of the scale. The inclusion of both Cronbach’s alpha and McDonald’s omega improves the assessment of internal consistency, as omega is less influenced by the number of items or sample size. Stability was also evaluated using the ICC. In addition, the inclusion of various types of validity checks (e.g., Fornell-Larcker criterion, HTMT ratios) collectively presents strong evidence for both convergent and discriminant validity, aligning with contemporary psychometric standards.

However, several limitations should be considered. First, the present study utilized self-report instruments to collect data, which may have introduced social desirability bias, whereby participants may have provided responses that were perceived as socially acceptable rather than fully reflecting their true feelings or behaviors. In addition, eligibility regarding serious mental illness and psychiatric medication use was determined solely through participant self-report. Independent verification through psychiatric or counseling records was not feasible because access to these records was restricted due to confidentiality regulations. Consequently, some degree of misclassification of psychiatric status cannot be ruled out. The sample size, while sufficient for factor analysis, was limited to students in a nursing program at a single Iranian university, so the findings may not be generalizable to other health or cultural contexts. During the convergent validity assessment, while the two factors demonstrated acceptable CR values, their AVE values were below the 0.50 threshold. It is therefore acknowledged that the AVE criterion was not fully met for these factors, indicating a limitation in their convergent validity according to the stricter standards defined by COSMIN guidelines [35]. To achieve an acceptable model fit in the CFA, covariances between error terms were specified based on theoretical justification. Although these modifications were conceptually justified, they may limit the generalizability of the model and should ideally be cross-validated in an independent sample in future studies. Prospective studies with multicenter recruitment and longitudinal designs that compare with behavioral measures would be useful in future research.

Conclusions

The Persian version of the school-to-work transition anxiety scale consists of 24 items measuring four factors: (a) Inexperience in professional knowledge and skills, (b) Interpersonal interactions, (c) Fear of being infected, and (d) Fear of death. These factors explain more than half of the variance in transition anxiety among senior nursing students. The Persian version of this scale demonstrated acceptable psychometric performance and may serve as a practical tool for assessing transition anxiety among senior nursing students.

Abbreviations

AGFI

Adjusted Goodness of Fit Index

AVE

Average Variance Extracted

CFI

Comparative Fit Index

CFA

Confirmatory Factor Analysis

CMIN/DF

Minimum Discrepancy Divided by Degrees of Freedom

CR

Composite Reliability

CVR

Content Validity Ratio

EFA

Exploratory Factor Analysis

GFI

Goodness of Fit Index

HTMT

Heterotrait-Monotrait

IFI

Incremental Fit Index

KMO

Kaiser–Meyer–Olkin

MLEFA

Maximum Likelihood Exploratory Factor Analysis

NPRS

Nursing Practice Readiness Scale

PCFI

Parsimony Comparative Fit Index

PGFI

Parsimony Goodness of Fit Index

PNFI

Parsimony Normed Fit Index

PPPNS

Perceived Professional Preparedness of Senior Nursing Students

RMSEA

Root Mean Square Error of Approximation

StWTA-HS

School-to-Work Transition Anxiety Scale for Healthcare Students

TLI

Tucker-Lewis Index

Authors' contributions

H. S., S. M., and A. D. contributed to the conceptualization and design of the study J. N., S. G., S. M., S. A., and A. D. were involved in the data gathering and data cleaning. S. M. designed and performed data analysis and interpretation of the results. Study supervision: H. S.; Manuscript writing: (H. S., S. M., J. N, S. G, L.S, S. M., S. A. and A.D). All authors All authors contributed to the article and approved the submitted version.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s)).

Declarations

Ethics approval and consent to participate

Participants received information about the study through a digital form, which included a preliminary consent item that had to be acknowledged before participation. The study was conducted in accordance with the principles of the Declaration of Helsinki, and both verbal, and written informed consent were obtained from all participants. Ethical approval for the research was granted by the Tehran University of Medical Sciences Ethics Committee (Approval No. IR.TUMS.FNM.REC.1403.162). All data collected were maintained with strict confidentiality.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.