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Translation and psychometric evaluation of the Witness Perceived Safety Scale of prehospital emergency care

BMC Emergency Medicine volume 25, Article number: 65 (2025) Cite this article

Abstract

Background

Timely, effective and safety out-of hospital care and transfer to hospital by prehospital emergency medical services significantly impacts patient outcomes. This study aimed at translation and psychometric evaluation of the witness perceived safety scale of prehospital emergency care.

Methods

The methodological design was utilized to verify the validity and reliability of the Witness Perceived Safety Scale across two phases: the translation process and an assessment of its validity and reliability. Construct validity was assessed using confirmatory factor analysis. The convergent validity, discriminant validity, and reliability of the scale were also evaluated.

Results

The Witness Perceived Safety Scale comprises 10 items that were retained following cross-cultural translation. Both face and content validity were deemed acceptable. The fit indices from the confirmatory factor analysis supported the model’s appropriate fit (χ²/df = 2.41; IFI = 0.96; CFI = 0.96; RMSEA = 0.075). Cronbach’s α coefficient for the total scale was 0.899.

Conclusion

The Persian version of the Witness Perceived Safety Scale provides a reliable assessment of witnesses’ perceptions of safety during emergency assistance and transfers.

Clinical trial number

Not applicable.

Peer Review reports

Background

The World Health Organization (WHO) has introduced the “Safer Primary Care” initiative to enhance awareness of primary care and ensure patient safety [1]. Patient safety means preventing harm during healthcare, while monitoring it involves coordinated efforts to avoid risks [2,3,4]. Healthcare organizations must implement effective risk management to identify weaknesses and improve safety [5]. Previously, analysis of adverse events focused on root causes, but now the focus is on preventing risks before they happen [6]. Gathering feedback from patients helps address safety issues that providers may overlook [7]. Patient safety is essential to the healthcare system and a key aspect of care quality. Care quality is multidimensional, with patient safety as a crucial element [8, 9]. Research shows patient perceptions of safety differ, including not just error absence but also communication, trust, ongoing information, consistent care, and psychological support [2, 10, 11]. Thus, measuring patient safety is vital for ensuring care quality and patients’ security [12].

Pre-hospital emergency care operates as a cohesive medical response system, encompassing emergency diagnosis, care delivery, and safe patient transfer by trained personnel [13]. This complex setting requires managing environmental hazards, making quick decisions, following verbal orders, and addressing multiple patients with varying needs [14, 15]. During stressful situations, individuals are vulnerable to physical and psychological harm, emphasizing the unique challenges of pre-hospital care compared to other healthcare environments [16,17,18]. The role of Emergency Medical Technicians (EMTs) has evolved, with patient safety becoming a key focus [19]. Factors influencing patient safety in the Emergency Medical System (EMS) include workplace culture, policies, training, and human factors like communication and judgment [20, 21]. Awareness of safety issues has improved care quality, but differing views on patient safety can lead to cognitive dissonance among EMTs [22]. In cases where patients cannot respond, a reliable measure of patient safety is vital [1]. WHO suggests that witnesses can provide valuable insights into patient safety in these scenarios [23].

Existing investigations indicates that a significant number of the questionnaires utilized to gauge the concept of patient safety tend to be quite general in nature and are predominantly concentrated within the hospital environment. These tools often fail to capture the nuances of patient safety in different healthcare settings. One notable exception to this trend is a specific questionnaire designed to evaluate perceptions of safety in the pre-hospital emergency context. This unique instrument is known as the witness perceived safety scale. It focuses specifically on the evaluation of patient safety as perceived through the eyes of witnesses present during emergency situations. By examining safety from their perspectives, this scale provides valuable insights that are often overlooked in more traditional assessments [22, 24].

Considering the lack of a Persian version of this scale in Iran and the, along with the researcher’s clinical experience in pre-hospital settings and the recognition that pre-hospital emergency conditions differ significantly from hospital environments, the decision has been made to validate the Persian version of the witness perceived safety scale. This aims to quantify witnesses’ perceptions of patient safety, thereby contributing to the enhancement of patient care and safety in pre-hospital emergency settings. Therefore, the objective of this study was translation and psychometric properties of the witness perceived safety scale in prehospital emergency care.

Methods

Design

A methodological study was conducted to examine the translation and psychometric properties of the Witness Perceived Safety Scale in prehospital emergency care [23, 25].

Reseach sample

The research population consisted of witnesses to the assistance and hospital transfers of patients who called for emergency medical help via the “115” number in Ardabil province, Iran. The province’s emergency medical services comprise 36 road bases and 24 urban bases that transport patients to five general hospitals. Participants were selected through convenience sampling from October 2023 to March 2024. Between all the assistances of the province of Ardabil, in such a way as to ensure the representation in the sample of the different types of assistance and transfers that appear daily, with a variability similar to that of the population under study. The selected subjects were given the questionnaire 15–30 days after the emergency care. Requesting informed consent so that the responses and data could be used for this study, guaranteeing the anonymity and confidentiality of the data. Inclusion criteria included voluntary participation and informed consent, while exclusion criteria encompassed individuals under legal age, those facing language or sensory barriers, individuals with intellectual disabilities, and those who refused to participate. The translation phase involved two proficient Persian and English translators for forward translation and two for back translation. To establish face validity, 10 witnesses assessing perceived safety were chosen, and for content validity, 10 specialists were selected using purposive sampling [26]. The appropriate sample size for confirmatory factor analysis is 20–30 times the number of scale items [27]. In this study, 250 witnesses were selected for confirmatory factor analysis.

Translation procedure

After obtaining permission from the author, the Witness Perceived Safety Scale was translated into Persian. Initially, two Iranian translators fluent in both languages translated the scale. This was followed by a review from experts to consolidate the translations. Two more knowledgeable translators then re-evaluated the version, unaware of the main items. With expert consultation, the English translation was finalized [18]. The updated version was submitted to the scale’s developer for approval.

Instruments

Demographic information

The questionnaire aimed to gather personal details including age, gender, marital status, education level, and transfer status.

Witness Perceived Safety Scale

The witness perceived safety scale (ESPT10, as abbreviated in Spanish), developed by Peculo-Carrasco et al. in 2019, assesses the safety perception of witnesses during emergency assistance and transfers [22]. It consists of 10 items, scored on a 6-point Likert scale, from 0 (totally disagree) to 5 (totally agree), leading to a total score range of 0 to 50 points. A higher score reflects greater confidence. The exploratory factor analysis detected a component that explained 61.1% of the total variance. The intraclass correlation coefficient was 0.933 with 95% confidence interval between 0.900 and 0.954. The corrected item-scale correlation coefficient was greater than 0.596, and the Cronbach α coefficient was 0.927 (95% confidence interval, 0.919–0.934).

Data analysis

Data were analyzed using SPSS 26 and AMOS 24. Descriptive statistics presented the participants’ demographic characteristics, with means and standard deviations computed for measurement data and percentages for categorical data. Content validity was assessed through the scale-level and item-level content validity index (CVI), while internal consistency was evaluated using Cronbach’s Alpha coefficient [27,28,29]. CFA assessed the scale’s construct validity via various fit indices, including the chi-square/degrees of freedom ratio (χ²/df), goodness of fit index (GFI), incremental fit index (IFI), comparative fit index (CFI), Tucker-Lewis’s index (TLI), and root-mean-square error of approximation (RMSEA). A satisfactory model fit is indicated by χ²/df values ≤ 5 and RMSEA values between 0.05 and 0.08 [30]. For GFI, AGFI, IFI, TLI, and CFI, values > 0.9 indicate excellent fit, and values between 0.7 and 0.9 recommend acceptable fit [31, 32].

To assess discriminant and convergent validity, standardized factor loadings, composite reliability (CR), and average variance extracted (AVE) were evaluated. Standardized factor loadings exceeded 0.5, CR ranged from 0.70 to 0.95, and AVE was ≥ 0.50, confirming the questionnaire’s validity [27]. The Cronbach’s α coefficient was > 0.7, indicating satisfactory internal consistency reliability for the Witness Perceived Safety Scale [33]. Statistical significance was set at P < 0.05.

Results

Table 1 summarizes the participants’ characteristics, with an average age of 45.18 ± 18 years. The majority of the participants were university studies. 65.2% of witnessed nonassisted transfer of patients.

Table 1 Demographic characteristics of participants (N = 250)
Full size table

Face and content validity

The examination of witness perceptions regarding prehospital emergency care revealed that all components of the scale were clear and unequivocal, resulting in no required modifications. Overall, the “Witness Perceived Safety Scale” demonstrates strong alignment with the cultural context of Iranian witnesses in prehospital emergency situations. Accordingly, the Persian version of this measure has been assessed as conceptually clear, suitable, and acceptable.

Content validity was assessed by a panel of 10 pre-hospital emergency care experts using a 4-point Likert scale (4 = completely related, 3 = related but needs revision, 2 = somehow related, 1 = not related). The item content validity index (I-CVI) was calculated as the proportion of items rated 3 or 4, while the scale-level content validity index (S-CVI) was the average of all I-CVIs [27]. To ensure adequate content validity, the S-CVI had to be ≥ 0.90 and the I-CVI ≥ 0.78 [34]. The results showed I-CVI values ranging from 0.82 to 1.00, with an S-CVI of 0.935, indicating strong content validity. Thus, all items were retained in the scale.

Construct validity

Confirmatory factor analysis (CFA) was used to check the construct of the scale. In this study, CFA was performed with the assistance of AMOS. The values of fit indices in the CFA showed the suitable fit of the model (Table 2).

Table 2 Goodness of fit indices of scale (n = 250)
Full size table

The outcomes of the CFA, based on the model’s factor statistics, showed that the factor loading of all components exceeded 0.4. Therefore, the inclusion of all examined factors in this variable has been validated (Fig. 1).

Fig. 1
figure 1

The structure model of the Persian version of Witness Perceived Safety Scale

Full size image

Convergent and discriminant validity

Convergent validity is affirmed when composite reliability values meet or exceed 0.7, standardized factor loadings reach a minimum of 0.5, and average variance extracted (AVE) values are 0.5 or higher [27]. In this study, the composite reliability (CR) was determined to be 0.90, standardized factor loadings ranged from 0.4 to 0.8, and the AVE was recorded at 0.5, thereby confirming both convergent validity and establishing discriminant validity (Table 3).

Table 3 Results of convergent, discriminant validity of Witness Perceived Safety Scale (N = 250)
Full size table

Reliability

The reliability of the measure was evaluated by internal consistency method. Internal consistency was determined using Cronbach’s alpha coefficient method. The Cronbach’s alpha reliability coefficient of Witness Perceived Safety Scale was 0.89. Based on this result, the Persian version of Witness Perceived Safety Scale confirmed acceptable internal consistency (Table 4).

Table 4 Internal reliability of Persian version of Witness Perceived Safety Scale
Full size table

Discussion

A valid and reliable measurement scale for patient safety in pre-hospital care can provide new insights and knowledge. This knowledge can be instrumental in understanding patients’ rights and protective behaviors in pre-hospital emergency care. The absence of a valid and reliable scale for assessing patient safety in pre-hospital care within the Iranian cultural context motivated the decision to translate, culturally adapt, and validate the “Witnesses Perceived Safety Scale.”

The findings of this study indicate that the Persian version of the “Witnesses Perceived Safety Scale” can serve as a valid and reliable tool for measuring perceived safety in out-of-hospital care, especially in situations where the patient is unable to respond [35].

The results indicate that the Persian translation of the scale is satisfactory. Using existing tools instead of developing new ones facilitates data collection that can be compared with validated questionnaires, and enhances information sharing within the scientific community.

Face validity plays a crucial role in the assessment of validity, especially for instruments designed for particular populations [36]. In evaluating the face validity of the Persian version of the “Witnesses Perceived Safety Scale,” it was determined that all items were comprehensively understood by the respondents. This finding is consistent with other studies that have emphasized the importance of cultural adaptation in ensuring face validity, such as the adaptation of the Safety Organizing Scale (SOS) in non-Western contexts.

The content validity assessment results confirmed the content validity of the scale. At this stage, necessary revisions were made based on the experts’ opinions. The process of evaluating clarity and content equivalence further supported the conceptual, semantic, and content alignment, as well as the structure of the sentences used in the translated version [36]. This rigorous process mirrors the approach taken in the validation of other safety scales, such as the Modified Stanford Instrument (MSI), which also underwent extensive expert review to ensure content validity across diverse populations.

The factor structure of the questionnaire was examined through confirmatory factor analysis. The CFA results indicated that the goodness-of-fit indices demonstrated acceptable alignment between the proposed model and the data. The English version of the “Witnesses Perceived Safety Scale” was found to be unidimensional with 10 items, which was confirmed [22]. The values of the fit indices were as follows: the Root Mean Square Error of Approximation (RMSEA) was 0.075, the Chi-square to degrees of freedom ratio (𝑋²/df) was 2.414, the Comparative Fit Index (CFI) was 0.96, the Incremental Fit Index (IFI) was 0.96, and the Normed Fit Index (NFI) was 0.93.

Convergent validity refers to how well different indicators that aim to measure the same concept align with each other. The results of this study established the fulfillment of criteria for convergent validity, as demonstrated by the CR (Composite Reliability), standardized factor loadings, and AVE (Average Variance Extracted) values, which were 0.501, ranged from 0.47 to 0.88, and 0.90, respectively. Consequently, the convergent validity of the Persian version of the “Witnesses Perceived Safety Scale” was established.

The acceptability of an instrument is one of the most critical criteria that reflect its quality. The outcomes of the internal consistency assessment, calculated using Cronbach’s alpha, showed a value of 0.899 for the “Witnesses Perceived Safety Scale.” [22] Based on these outcomes, it can be claimed that the Persian version of the scale establishes excellent internal consistency. This level of reliability is comparable to other widely used safety instruments, such as the Safety Climate Scale (SCS), which reported Cronbach’s alpha values ranging from 0.85 to 0.92 in various validation studies.

Limitations

This study presents several limitations. It relied on self-administered measures for data collection, which may introduce social desirability bias. Furthermore, as the tool was newly developed in English and only subsequently translated and validated in Persian, the researcher encountered challenges in locating pertinent literature for a more comprehensive discourse. The sample population was primarily drawn from Ardabil, potentially restricting the generalizability of the findings to broader populations. Additionally, the use of convenience sampling may introduce bias and compromise the representativeness of the sample. Future research should aim to address these limitations to enhance the understanding and application of the scale.

Conclusion

This particular study provided strong evidence to support the idea that the Persian daptation of the “Witness Perceived Safety Scale” serves as a dependable and accurate instrument for evaluating the safety perceptions held by witnesses who are involved in the urgent transfer of patients by prehospital Emergency Medical Services (EMS) within the context of Iran. The process of psychometric validation demonstrated that the Persian version exhibits satisfactory levels of reliability, ensuring that users can trust the results it generates. In addition to this strong reliability, it is important to note that this tool is designed to be user-friendly, allowing individuals to complete it in a brief period of time. This aspect makes it particularly advantageous for use in situations where time may be of the essence, such as in emergencies. Overall, the findings suggest that this scale is not only effective but also convenient for those who need to report their perceptions of safety in such critical scenarios.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author [S. M] upon reasonable request.

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Acknowledgements

The authors would like to express their gratitude for the contribution of the study participants.

Funding

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Author information

Authors and Affiliations

  1. Department of Emergency Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran

    Farzad Vagrimogadam & Saeid Mehri

  2. Department of Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran

    Mansoore Karimollahi

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  1. Farzad Vagrimogadam
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Contributions

All the authors were involved in designing the study. FV; carried out the data collection and data entry, SM; performed the statistical analyses and interpretations, and FV; MK; SM; wrote the final report and manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Saeid Mehri.

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Ethical approval

This study approved in the ethics committee of Ardabil University of Medical Sciences withe the ethical code IR.ARUMS.REC.1402.199. Prior to data collection, participants were informed about the study’s purpose, procedures, and data anonymity. They provided written consent and could choose to participate or withdraw. All methods followed applicable guidelines.

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The authors declare no competing interests.

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Vagrimogadam, F., Karimollahi, M. & Mehri, S. Translation and psychometric evaluation of the Witness Perceived Safety Scale of prehospital emergency care. BMC Emerg Med 25, 65 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12873-025-01226-8

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Keywords

BMC Emergency Medicine

ISSN: 1471-227X

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