Translation and Psychometric Evaluation of the Professional Bereavement Scale - German Version (PBS-D) among Psycho-oncologists in Germany

Translation and Psychometric Evaluation of the Professional Bereavement Scale - German Version (PBS-D) among Psycho-oncologists in Germany | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Translation and Psychometric Evaluation of the Professional Bereavement Scale - German Version (PBS-D) among Psycho-oncologists in Germany Svenja Wandke, Raphael Detchev, Eva Christalle, Mareike Rutenkröger, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8524198/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Professional grief – the emotional response to patient death among healthcare professionals – remains insufficiently understood. To gain better understanding psychometrically sound measures are crucial. The Professional Bereavement Scale (PBS) is the first instrument specifically designed to measure professional grief, but lacks validation beyond Chinese populations. This study aimed to translate, culturally adapt, and validate the PBS into German (PBS-D) and assess its psychometric properties among psycho-oncologists in Germany. Methods: First, the PBS was translated and culturally adapted following the TRAPD methodology. Then, to assess psychometric properties, data were collected using a cross-sectional online survey. Psychometric evaluation included item analysis, internal consistency, structural validity (confirmatory factor analysis), and convergent validity assessed using the Texas Revised Inventory of Grief and the Professional Quality of Life scale. Results: The PBS-D was developed through iterative translation, expert review, and cognitive testing, confirming the presence all three aspects of content validity (relevance, completeness, comprehensiveness). Among 258 eligible participants (91% female; mean age 48 years), the PBS-D demonstrated acceptable overall reliability for both major subscales. However, analyses of inter-item correlations revealed some internal inconsistencies within the scales, ranging from -.091 to .860, including negative correlations suggesting conceptual heterogeneity. The subscale concerning short term bereavement demonstrated robust convergent validity with another grief measure (r = .594). However, confirmatory factor analysis revealed insufficient structural validity. Conclusions: The PBS-D provides a solid foundation for assessing professional grief in German healthcare settings, demonstrating good reliability and convergent validity for core constructs. However, significant challenges regarding structural validity emerged. The instrument requires validation across diverse healthcare professions before it can be used routinely. Until then, subscale scores rather than total scores should be computed, with particular attention to professional role characteristics that influence the relevance of the grief dimension. professional grief psychometric evaluation professional bereavement scale Figures Figure 1 Background Grief is commonly defined as the reaction to losing a significant relationship 1 . Most grief research has focused on personal bereavement, while grief among healthcare professionals (HCPs) following patient deathhas received less attention 2 . In oncology, repeated exposure to patient loss is frequent and emotionally impactful 3,4 . This form of grief, professional grief , distinct from personal grief 5,6 , is typically less intense, confined to the professional sphere, and may involve guilt or perceived failure 5 . Although clinically relevant, professional grief remains insufficiently understood. It may entail both risks (emotional burden, impaired well-being) and resources (professional and personal growth) 6,7 . Research is particularly scarce, particularly among psycho-oncologists, who often form close, long-term relationships with seriously ill and dying patients 2,8 . Quantitative data are limited, especially outside Anglophone contexts such as Germany. A major obstacle to advancing research is the lack of validated instruments specific to professional grief 5,6 . Existing measures focus on personal bereavement and fail to capture its professional dimensions 6,8 . The Professional Bereavement Scale (PBS), developed by Chen and Chow 9 in 2022, represents the first validated instrument for this purpose. Grounded in established theoretical frameworks 10 , the PBS underwent rigorous psychometric testing in a Chinese sample of healthcare professionals 9 , demonstrating good construct validity as well as good internal consistency (α > .80) and split-half reliability 9 . To ensure broader applicability, translations, adaptations and psychometric validations are needed. This study addresses this gap by translating and adapting the PBS into German (PBS-D) and evaluating its psychometric properties psycho-oncologists. Methods Study design The study consisted of two phases. Phase I translated and culturally adapted the original PBS into German (PBS-D); phase II evaluated its psychometric properties in a survey study. This part of the study was conducted and reported in accordance with the COSMIN Reporting guideline 11 (supplementary file 1). The psychometric evaluation of the PBS-D represented the secondary aim of a broader cross-sectional study on professional grief, coping strategies, and unmet support needs of psycho-oncologists in Germany 7 . Overview of the primary instrument: PBS-D The primary instrument was the PBS-D, which consists of 32 items across two subscales: Short-Term Bereavement Reactions (SBR; 17 items) and Accumulated Global Changes (AGC; 15 items). SBR assesses emotional responses during the first week after a patient death, comprising four factors: Frustration & Trauma (SBR 1; Items 5, 12, 13, 14, 15, 16, 17), Guilt (SBR 2; Items 7, 9, 10, 11), Grief (SBR 3; Items 1, 2, 3, 8), and Being Moved (SBR 4; Items 4, 6). Participants rate SBR items on a 5-point Likert scale from 0 = ”not at all” to 4 = ”extremely strong”. For the SBR subscale, participants could additionally indicate if an item was “not applicable” to their most recent patient death experience. AGC captures long-term professional and personal changes following repeated patient losses and comprises five factors: New Insights (AGC 1; Items 1, 2, 3, 8), More Acceptance of Limitations (AGC 2; Items 12, 13, 14), More Death-Related Anxiety (AGC 3; Items 4, 5, 11, 15), Less Influenced by Patient Deaths (AGC 4; 6, 7), and Better Coping with Patient Deaths (AGC 5; Items 9, 10). Items can be rated on a 5-point scale from 0 = ”No (no such change or the change was not induced by experiencing patient deaths)” to 4 = ”Yes, a great deal”. Following the original authors’ applied scoring approach, two total scores were calculated: one for the SBR subscale (sum of Items 1–17) and one for the AGC subscale (sum of Items 18–32). No items require reverse scoring 9 . Phase I: Translation and Cultural Adaptationof the original PBS To enable content validity assessment and cultural adaptation through cognitive interviews and later on psychometric evaluation, the English version of the PBS was first translated into German by the research team. The translation process followed the TRAPD protocol 12 . Independent forward translations were produced by two team members (SW, RD), followed by a third version created by a reviewer (IS). All were proficient in German and English. In a team consensus meeting (IS, SW, RD, MR), final wording for all items, instructions, and response categories was determined. Throughout the process, all translation decisions and their rationales were systematically documented (refer to supplementary files 2 and 3). Assessment of Content Validity To assess content validity, two rounds of cognitive interviews were conducted, to assess the comprehensibility, relevance, and completeness of the translated items. Round 2 especially retested items modified based on Round 1 feedback to confirm content validity. Participants were recruited through the Psycho-Oncology Outpatient Clinic at the University Medical Center Hamburg-Eppendorf (UKE) and via a regional network of psycho-oncologists in the Hamburg metropolitan area ( Psychoonkologie Treffen – POT ). Eligibility criteria included professional engagement with cancer patients and prior experience with at least one patient death. Interviews were conducted by RD in May 2023, either online via Zoom or in person, using a structured guide 13 . There is no standardized procedure for the analysis of data from cognitive interviews 14 . Comprehensibility was assessed for all items using probing techniques and rated by the research team following Christalle et al. 15 . Relevance and completeness were evaluated through global probing questions, with additional individual assessment for four items flagged during translation. Detailed methodology for content validity assessment, including specific probing questions and rating procedures, is provided in Supplementary File 4. An overview of the study procedure can be found in Supplementary File 2. A comprehensive summary of all translation modifications and adaptations is provided in Supplementary File 3. The final German version of the PBS (PBS-D) was developed through iterative translation, expert review, and cognitive testing (Supplementary File 5). Phase II: Psychometric Evaluation Sampling and Recruitment Participants were recruited from a range of professional networks relevant to the field of psycho-oncology (Supplementary File 6). These organizations distributed the survey via email and newsletters between August and September 2024. It remained open until November 30, 2024. Additionally, contact details of psycho-oncological services from cancer centers were identified using the online directory of cancer care facilities certified by the German Cancer Society (“Oncomap”), for the three cancer entities with the highest absolute numbers of deaths in Germany (lung, pancreatic, and breast cancer) 16 . From this database, 180 facilities were systematically selected by choosing every fifth center listed within each federal state. Following COSMIN guidelines for structural validity, the target sample size was set as seven times the number of scale items (32 × 7 = 224). Inclusion criteria were professional involvement in psychosocial cancer care and experience with at least one patient death. Participants could enter a draw for one of twenty €15 online vouchers. Data Collection Quantitative data were collected via an anonymous, open online survey administered through LimeSurvey. Before participation, all respondents provided electronic informed consent. The study was preregistered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/CNRUQ). Instruments To assess the PBS-D’s construct validity two additional measures were applied: the German version of the Texas Revised Inventory of Grief – Present Feelings Subscale (TRIG-D) 17 was used to measure grief-related distress, with 16 items rated on a five-point Likert scale ranging from 1 (“completely false”) to 5 (“completely true”). A total sum score is calculated by summing all 16 items, with higher scores indicating greater grief-related emotional distress. No items require reverse scoring. The TRIG-D has demonstrated sound psychometric properties, including good internal consistency (Cronbach's α = .87) and convergent construct validity 17 , although no validated cut-off scores exist. The German version of the Professional Quality of Life Scale (ProQOL) 18 was also included, which consists of 30 items across three subscales: Compassion Satisfaction (10 items), Burnout (10 items), and Secondary Traumatic Stress (10 items) 18 . Items are rated on a five-point Likert scale ranging from 1 (“never”) to 5 (“very often”). For each subscale, a total sum score is calculated. Within the Burnout subscale, items 1, 4, 15, 17, and 29 require reverse scoring prior to calculation. Higher scores indicate higher levels of the respective construct. Validated cut-off scores are available to categorize low, average, and high levels for each subscale 18 . Sociodemographic and professional characteristics were collected for sample description. Statistical Analyses Descriptive statistics (frequencies, means, standard deviations (SD)) described the sample, and Table 1 gives a detailed overview of the applied analysis and criteria for study phase II. Item analyses were done by observing item response distributions (means, SD, minimum and maximum), missing values, item relevance, inter-item correlations, corrected item-total correlations, and item difficulties (see Table 1). Missing values were examined as a proxy indicator of item acceptability 19 . For SBR items, “not applicable” response rates were analyzed as an indicator of item relevance. Structural validity was examined with confirmatory factor analysis (CFA), testing the original nine-factor structure, tested previously by the original authors 9 : a four-factor model for SBR and a five-factor model for AGC (Model 1), and a higher-order two-factor model (SBR total; AGC total) to replicate the recommended but previously untested scoring approach (Model 2). A robust maximum likelihood estimator was used and the Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR) were observed for model fit. Good model fit was defined as CFI >.90, RMSEA and SRMR <.1 9 . Internal consistency was assessed using Cronbach's alpha (α) and McDonald's omega (ω). McDonald's Omega is reported due to its greater accuracy for scales with heterogeneous item structures 20,21 , while Cronbach's alpha is also reported to align with established conventions. Construct validity was evaluated through predefined hypotheses regarding associations with external measures: PBS-SBR was expected to correlate with TRIG-D (r ≥ .30) and ProQOL Burnout (r ≥ .30), while PBS-AGC was anticipated to show correlations with ProQOL Burnout (r ≥ .10), Compassion Satisfaction (r ≥ .50), and Compassion Fatigue (r ≥ .50). These hypotheses were based on the associations the PBS’ original authors found within their sample 9 . For CFA, Cronbach’s alpha and McDonald’s Omega missing values were dealt with by using Full Information Maximum Likelihood (FIML) 22 . For total scores and item-total-correlations up to 30% of missing values per person were imputed by person-centered mean. Cases with more missing values were excluded. CFA and McDonald’s Omega were computed in R Version 4.5.1. All other data preparation and analyses were performed in SPSS Version 29. Results Phase I: Translation and cultural adaptation Sample characteristics A total of n = 10 participants (seven women, three men) took part: seven psycho-oncologists, two physicians, and one nurse. Eight participants were interviewed in Round 1 and two in Round 2. Five were over 50 years old, three were 41-50, one was 31-40, and one under 30. Nine participants (90%) had ≥ 11 years of cancer care experience. All were native German speakers. Translation process Initial challenges (verb tense inconsistencies, ambiguous phrasing, culturally incongruent expressions) were resolved through team discussions and consultation with the PBS authors (supplementary file 3). Assessment of content validity Global relevance was confirmed in both rounds; individual item relevance was additionally evaluated for a few items in Round 1. Most items were rated relevant, though guilt items (SBR 7, 9, 10) were occasionally perceived as less so. Overall, eight of ten participants rated the scale as relevant. Although some items were initially difficult to interpret, the revised version was ultimately understood by most participants (supplementary file 3). Moreover, participants found the scale encompassed a wide spectrum of grief-related experiences, indicating completeness. All three aspects of content validity were thus confirmed. Layout and Response Modifications Based on participant feedback, a “not applicable” option was added to the SBR subscale, since clinicians often had no family contact. This option was visually separated from the rating scale. Similarly, in the AGC subscale, the option 0 = “no” was separated from other response options. The final PBS-D version, subject to psychometric evaluation, can be found in supplementary file 5. Phase II: Psychometric assessment Sample characteristics N = 258 participants were included in the analysis. Complete flow of participants can be followed via figure 1. Table 2 summarizes characteristics: mean age 48 years (SD = 12.27), majority female (91.1%), participants cared for approximately 36 patients monthly (range: 0–200) and encountered approximately 3 patient deaths per month (range: 0–25). PBS-D item analysis Response distributions, missing values, “not applicable” rates, corrected item-total correlations, and item difficulties are presented in Table 3. Missing values per item were minimal, with completion rates exceeding 90% for all items (maximum 5.4% missing values), indicating good item acceptability. Missing values were minimal, with >90% completion for all items (max 5.4%), indicating good acceptability. “Not applicable” rates were low overall, but higher for SBR4 items: Item 4 („I was moved by the patient's family's understanding“; 23.6%) and Item 6 („I was moved by the patient's family's gratitude“; 19.4%). Corrected item-total correlations revealed mixed patterns across subscales. For the SBR scale, correlations ranged from .245 (Item 13) to .813 (Item 14). Items 3 and 13 fell below the preferred threshold of .3 25 . For AGC correlations were generally good (.421 - .866), with the notable exception of Item 11 (.207). Item difficulty analysis revealed floor effects in SBR, especially SBR2 (“Guilt”, mean .01–.12). Five of seven SBR1 (“Frustration & Trauma”) items also showed low difficulty. SBR3 and SBR4 were appropriate (.46–.68). AGC difficulties were adequate (.20–.75). Inter-item correlations (Tables 4-5) revealed heterogeneity, ranging from −.091 to .860 (SBR) and −.104 to .866 (AGC). Internal consistency Internal consistency was evaluated for both individual subfactors and overall scales using McDonald's Omega (ω) and Cronbach’s alpha (α; see Table 6). was acceptable to excellent overall: SBR (ω = .830, α = .856), AGC (ω = .863, α = .868). Subfactor reliability varied: excellent for AGC5 (ω = .928, α = .925), good for SBR1, SBR4, AGC1, acceptable for SBR2 and AGC2, but insufficient for AGC3 (ω = .591, α = .604). Structural validity CFA tested two models (Table 7). Model 1, testing the nine-factor structure (four SBR, five AGC factors), showed mixed fit. RMSEA (.080) and SRMR (.087) were within acceptable limits (.20; Table 3). Model 2, testing a simplified two-factor structure (SBR and AGC), showed poor fit across all indices: CFI = .526, RMSEA = .123, and SRMR = .125 (Table 7). Despite poor fit, most loadings exceeded .20 (Table 3) Construct validity Construct validity was evaluated by examining whether correlations between PBS-D scales and theoretically related measures fell within pre-specified ranges (Table 8). SBR total correlated strongly with TRIG-D (r = .594) and showed the expected positive correlation with burnout (r = .385), supporting convergent validity. Subfactors SBR1 (“Frustration & Trauma”; r = .503) and SBR3 (“Grief”; r = .510) showed the strongest correlations with TRIG-D; SBR4 weaker (“Being Moved”; r = .270) and SBR2 moderate (“Guilt”; r = .379) correlations. For the AGC scale, construct validity findings were more mixed. While AGC3 („More Death-Related Anxiety“) showed positive correlations with ProQOL Burnout (r = .446) and Secondary Traumatic Stress (r = .441), and a negative correlation with Compassion Satisfaction (r = -.205), the overall AGC scale and other subfactors showed largely weak correlations. Specifically, AGC5 („Better Coping with Patient Deaths“) even demonstrated a negative correlation with Secondary Traumatic Stress (r = -.132) and a positive correlation with Compassion Satisfaction (r = .112), representing inverse relationships compared to AGC3. Discussion This study translated and culturally adapted the PBS into German, assessed content validity, and evaluated psychometric properties. Cognitive interviews confirmed adequate validity: items were generally understood and relevant, with psycho-oncologists affirming comprehensive coverage of professional grief. The PBS-D showed acceptable reliability, though structural validity limitations warrant caution. Structural and Scale-Specific Issues The questionnaire’s structural validity showed mixed findings. The original nine-factor model demonstrated acceptable fit according to RMSEA and SRMR indices, while the CFI fell below the recommended threshold of .90. This suggests that the theoretical structure proposed by Chen and Chow 9 captures important aspects of response patterns in our German psycho-oncologist sample, though refinements may be needed to achieve optimal fit. The simplified two-factor model – applied via subscore calculation but not empirically tested by the original authors – performed considerably worse, indicating a simple two-dimensional structure inadequately represents the scale's complexity. The the wide range of inter-item correlations, including negative values (−.091 to .860 for SBR), reveals substantial heterogeneity within scales: items within the same overall scale may measure conceptually different or even opposing constructs. Consequently, computing overall sum scores for SBR and AGC appears inappropriate; subscores should be calculated and interpreted individually until further evidence is available. The AGC scale exemplifies this complexity, with subfactors AGC3 (“More Death-Related Anxiety”) and AGC5 (“Better Coping with Patient Deaths”) showing opposite relationships with validation measures, reflecting two divergent responses to patient deaths: adaptive coping that protects against burnout versus maladaptive responses characterized by increased anxiety or withdrawal. While both responses have been documented in the literature 6,28–30 , their opposing nature challenges the validity of composite scoring approaches and necessitates careful interpretation of individual subfactors and broader validation studies encompassing diverse professional groups. However, caution is needed especially concerning the interpretation of factor AGC3 (“More Death-Related Anxiety”) since it demonstrated insufficient reliability. Despite these limitations, both total scales showed excellent overall reliability, with several subfactors achieving outstanding reliability coefficients. The SBR scale demonstrated robust convergent validity with the TRIG Present Feelings subscale, particularly for theoretically relevant subfactors. Professional Role and Sample-Specific Considerations Guilt items’ relevance was occasionally questioned during interviews (especially SBR items 7, 9, 10). Marked floor effects (item difficulties .01–.12) likely reflect the specific characteristics of our psycho-oncologist sample. Unlike physicians who bear direct responsibility for treatment decisions, psycho-oncologists typically provide supportive care without primary accountability for medical outcomes 7 . Previous research has identified this professional role as a protective factor against guilt-related grief responses 7 , explaining why guilt-related items showed limited relevance in our sample. Similarly, items incorporating patient family experiences (SBR items 4 and 6) were frequently rated as irrelevant, reflecting setting specificities where family members may not always be known to psycho-oncologists. This highlights the importance of “not applicable” response options rather than indicating problematic item content. These findings suggest that professional role characteristics exert significant influence over grief expression. While Granek et al. 31 propose that the emotional experience of professional grief transcends cultural boundaries, our results indicate that professional culture, may be a more influential factor than geographical culture in determining which grief dimensions are salient. Strengths and Limitations Translation followed a rigorous protocol with input from authors and participants, ensuring cultural appropriateness. Data quality was high, with minimal missing data, and the sample diverse in settings, experience, and age. However, convenience sampling and exclusive focus on German psycho-oncologists limits generalizability to other healthcare professions. Replication across diverse professions is needed. Conclusion The PBS-D offers a solid foundation for assessing professional grief in German healthcare settings, demonstrating good reliability and convergent validity for core grief constructs. However, significant challenges regarding structural validity and professional role specificity require attention before recommending its use in either research or clinical practice. A differentiated approach to the two overarching scales is warranted. The SBR scale demonstrated adequate psychometric properties for assessing short-term grief reactions, whereas the AGC scale, despite acceptable internal consistency, requires cautious interpretation due to validity concerns. Until further psychometric evaluation across diverse HCPs is completed, we recommend computing subscores rather than total scale scores, with particular attention to professional role characteristics that may influence the relevance of specific grief dimensions. By contributing a validated German-language instrument, this study lays the groundwork for future research and supports the systematic investigation of professional grief and its consequences. Future research should prioritize validation in samples including physicians, nurses, and other healthcare professionals to determine whether observed patterns reflect professional role differences or broader applicability issues. This evidence will be crucial for establishing appropriate scoring approaches and interpretation guidelines for the PBS-D. Declarations Ethics statement This study was carried out according to the latest version of the Helsinki Declaration of the World Medical Association and respecting principles of good scientific practice. The local Ethics Committee of the University Medical Center Hamburg-Eppendorf gave approval prior to investigation (approval number: LPEK-0608 and LPEK-0614). Study participation was voluntary and no foreseeable risks for participants resulted from the participation in this study. Participants were fully informed about the aims of the study, data collection and the use of collected data and written informed consent was obtained. Data availability statement The data collected and analyzed are available from the corresponding author on reasonable request. Signing a data use/sharing agreement will be necessary, and data security regulations both in Germany and in the country of the investigator, who proposes to use the data, must be complied with. Preparing data sets for use by other investigators requires substantial work and is thus linked to available or provided resources. Consent for publication Not applicable. Conflict of Interest Statement The authors report there are no competing interests to declare. Funding source information This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. Authorship statement IS is the responsible principal investigator (PI) of the study; MR is the co-PI. IS and SW were involved in planning and preparation of the study. SW and RD translated and RD culturally adapted the Professional Bereavement Scale from English to German. IS, SW, and MR advised the process. SW recruited participants and collected data for the psychometric validation. EC and SW analysed the data. All authors interpreted the results. SW wrote the first draft of the manuscript. MR, RD, EC and IS critically revised the manuscript for important intellectual content. All authors gave final approval of the version to be published and agreed to be accountable for the work. Acknowledgements Generative artificial intelligence (GenAI) tools were utilized to assist in the manuscript’s conceptual organization and linguistic refinement. This included support in restructuring content for logical flow and academic tone. The authors reviewed and substantively edited the final content to ensure accuracy and scholarly integrity. References Hilberdink, C. E. et al. Bereavement issues and prolonged grief disorder: A global perspective. Camb. Prisms Glob. Ment. Health 10 , e32 (2023). Engler-Gross, A., Goldzweig, G., Hasson-Ohayon, I., Laor-Maayany, R. & Braun, M. Grief over patients, compassion fatigue, and the role of social acknowledgment among psycho-oncologists. Psychooncology. 29 , 493–499 (2020). Chen, C., Chow, A. Y. M. & Tang, S. 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Psychooncology. 26 , 960–966 (2017). Tables Table 1 to 8 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files 03table1statisticalanalysismethodsfinal.docx 04table2samplecharacteristicsfinal.docx 05table3descriptivesnewfinal.docx 06table4and5InterItemCorrfinal.docx 07table6internalconsistencyfinal.docx 08table7structuralvalidityfinal.docx 09table8convergentvalidityfinal.docx 10supplementaryfile1COSMINreportingguidelinefinal.doc 11supplementaryfile2TRAPDprocessoverviewfinal.docx 12supplementaryfile3TRAPDdocumentationfinal.docx 13supplementaryfile4contentvalidityassessmentfinal.docx 14supplementaryfile5PBSDfinal.docx 15supplementaryfile6professionalassociationsrecruitment.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8524198","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570959957,"identity":"d1d1cea5-ce46-4477-9c39-9ac1c49a6e5c","order_by":0,"name":"Svenja Wandke","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYNACtgQGfgY2EIMULZINJGsxOECsFvkGHsPPBWVpcsY30hIfMJTZENZicIDHWHrGuRxjsxtphw0YzqURoYWBd4M0b1tF4rYb6W0SjG2HiXEY7+bfQC31m2ekt/9gbPtPWAvDAd5tQFtyEgwk0o4xMLYdIMJhh/m/WfOcSzOcceZZskTCuWQiHNbelnybpyxZnr89zfDDhzI7IhzGjMxJIELDKBgFo2AUjAIiAADTQzSmV7/uVQAAAABJRU5ErkJggg==","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":true,"prefix":"","firstName":"Svenja","middleName":"","lastName":"Wandke","suffix":""},{"id":570959961,"identity":"0a3de427-42f3-4b39-8a42-5649668c0610","order_by":1,"name":"Raphael Detchev","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Raphael","middleName":"","lastName":"Detchev","suffix":""},{"id":570959969,"identity":"77dea7f5-6b9a-4d43-a755-81b1753f6630","order_by":2,"name":"Eva Christalle","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Christalle","suffix":""},{"id":570959974,"identity":"0bab8ff9-279a-4889-86d0-a85a94e9b4e9","order_by":3,"name":"Mareike Rutenkröger","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Mareike","middleName":"","lastName":"Rutenkröger","suffix":""},{"id":570959980,"identity":"f2dce25d-731b-4d66-b89c-25d3282d74b7","order_by":4,"name":"Isabelle Scholl","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Isabelle","middleName":"","lastName":"Scholl","suffix":""}],"badges":[],"createdAt":"2026-01-05 18:38:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8524198/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8524198/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100408407,"identity":"5773efc0-e481-46c3-b702-f74ba7293a48","added_by":"auto","created_at":"2026-01-16 13:06:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50063,"visible":true,"origin":"","legend":"\u003cp\u003eFlow of participants (Figure stemming from: Wandke, S., Lang, K., Härter, M., Oechsle, K., Bokemeyer, C., Rutenkröger, M., \u0026amp; Scholl, I. (2025). 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13:06:40","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":33118,"visible":true,"origin":"","legend":"","description":"","filename":"13supplementaryfile4contentvalidityassessmentfinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-8524198/v1/c1a9558ca9cf157e4e225183.docx"},{"id":100409364,"identity":"86cb18b6-5d71-44d5-bf75-a15fbcf53c92","added_by":"auto","created_at":"2026-01-16 13:07:07","extension":"docx","order_by":12,"title":"","display":"","copyAsset":false,"role":"supplement","size":62429,"visible":true,"origin":"","legend":"","description":"","filename":"14supplementaryfile5PBSDfinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-8524198/v1/d6975fafcf613ffa26a47237.docx"},{"id":100408960,"identity":"9bfbd266-d780-4550-ab06-f88531da584d","added_by":"auto","created_at":"2026-01-16 13:06:41","extension":"docx","order_by":13,"title":"","display":"","copyAsset":false,"role":"supplement","size":31479,"visible":true,"origin":"","legend":"","description":"","filename":"15supplementaryfile6professionalassociationsrecruitment.docx","url":"https://assets-eu.researchsquare.com/files/rs-8524198/v1/879ff1f31a3d87f9a4530a60.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Translation and Psychometric Evaluation of the Professional Bereavement Scale - German Version (PBS-D) among Psycho-oncologists in Germany","fulltext":[{"header":"Background","content":"\u003cp\u003eGrief is commonly defined as the reaction to losing a significant relationship\u003csup\u003e1\u003c/sup\u003e. Most grief research has focused on personal bereavement, while grief among healthcare professionals (HCPs) following patient deathhas received less attention\u003csup\u003e2\u003c/sup\u003e. In oncology, repeated exposure to patient loss is frequent and emotionally impactful\u003csup\u003e3,4\u003c/sup\u003e. This form of grief, \u003cem\u003eprofessional grief\u003c/em\u003e , distinct from personal grief\u003csup\u003e5,6\u003c/sup\u003e, is typically less intense, confined to the professional sphere, and may involve guilt or perceived failure\u003csup\u003e5\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough clinically relevant, professional grief remains insufficiently understood. It may entail both risks (emotional burden, impaired well-being) and resources (professional and personal growth)\u003csup\u003e6,7\u003c/sup\u003e. Research is particularly scarce, particularly among psycho-oncologists, who often form close, long-term relationships with seriously ill and dying patients\u003csup\u003e2,8\u003c/sup\u003e. Quantitative data are limited, especially outside Anglophone contexts such as Germany.\u003c/p\u003e\n\u003cp\u003eA major obstacle to advancing research is the lack of validated instruments specific to professional grief\u003csup\u003e5,6\u003c/sup\u003e. Existing measures focus on personal bereavement and fail to capture its professional dimensions\u003csup\u003e6,8\u003c/sup\u003e. The \u003cem\u003eProfessional Bereavement Scale\u003c/em\u003e (PBS), developed by Chen and Chow\u003csup\u003e9\u003c/sup\u003e in 2022, represents the first validated instrument for this purpose. Grounded in established theoretical frameworks\u003csup\u003e10\u003c/sup\u003e, the PBS underwent rigorous psychometric testing in a Chinese sample of healthcare professionals\u003csup\u003e9\u003c/sup\u003e, demonstrating good construct validity as well as good internal consistency (\u0026alpha; \u0026gt; .80) and split-half reliability\u003csup\u003e9\u003c/sup\u003e. To ensure broader applicability, translations, adaptations and psychometric validations are needed. This study addresses this gap by translating and adapting the PBS into German (PBS-D) and evaluating its psychometric properties psycho-oncologists.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThe study consisted of two phases. Phase I translated and culturally adapted the original PBS into German (PBS-D); phase II evaluated its psychometric properties in a survey study. This part of the study was conducted and reported in accordance with the COSMIN Reporting guideline\u003csup\u003e11\u003c/sup\u003e (supplementary file 1). The psychometric evaluation of the PBS-D represented the secondary aim of a broader cross-sectional study on professional grief, coping strategies, and unmet support needs of psycho-oncologists in Germany\u003csup\u003e7\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eOverview of the primary instrument: PBS-D\u003c/h2\u003e\n\u003cp\u003eThe primary instrument was the PBS-D, which consists of 32 items across two subscales: Short-Term Bereavement Reactions (SBR; 17 items) and Accumulated Global Changes (AGC; 15 items). SBR assesses emotional responses during the first week after a patient death, comprising four factors: Frustration \u0026amp; Trauma (SBR 1; Items 5, 12, 13, 14, 15, 16, 17), Guilt (SBR 2; Items 7, 9, 10, 11), Grief (SBR 3; Items 1, 2, 3, 8), and Being Moved (SBR 4; Items 4, 6). Participants rate SBR items on a 5-point Likert scale from 0 = \u0026rdquo;not at all\u0026rdquo; to 4 = \u0026rdquo;extremely strong\u0026rdquo;. For the SBR subscale, participants could additionally indicate if an item was \u0026ldquo;not applicable\u0026rdquo; to their most recent patient death experience. AGC captures long-term professional and personal changes following repeated patient losses and comprises five factors: New Insights (AGC 1; Items 1, 2, 3, 8), More Acceptance of Limitations (AGC 2; Items 12, 13, 14), More Death-Related Anxiety (AGC 3; Items 4, 5, 11, 15), Less Influenced by Patient Deaths (AGC 4; 6, 7), and Better Coping with Patient Deaths (AGC 5; Items 9, 10). Items can be rated on a 5-point scale from 0 = \u0026rdquo;No (no such change or the change was not induced by experiencing patient deaths)\u0026rdquo; to 4 = \u0026rdquo;Yes, a great deal\u0026rdquo;. Following the original authors\u0026rsquo; applied scoring approach, two total scores were calculated: one for the SBR subscale (sum of Items 1\u0026ndash;17) and one for the AGC subscale (sum of Items 18\u0026ndash;32). No items require reverse scoring\u003csup\u003e9\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePhase I: Translation and Cultural Adaptationof the original PBS\u003c/h2\u003e\n\u003cp\u003eTo enable content validity assessment and cultural adaptation through cognitive interviews and later on psychometric evaluation, the English version of the PBS was first translated into German by the research team.\u0026nbsp;The translation process followed the TRAPD protocol\u003csup\u003e12\u003c/sup\u003e. Independent forward translations were produced by two team members (SW, RD), followed by a third version created by a reviewer (IS). All were proficient in German and English. In a team consensus meeting (IS, SW, RD, MR), final wording for all items, instructions, and response categories was determined. Throughout the process, all translation decisions and their rationales were systematically documented (refer to supplementary files 2 and 3).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAssessment of Content Validity\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eTo assess content validity, two rounds of cognitive interviews were conducted, to assess the comprehensibility, relevance, and completeness of the translated items. Round 2 especially retested items modified based on Round 1 feedback to confirm content validity. Participants were recruited through the Psycho-Oncology Outpatient Clinic at the University Medical Center Hamburg-Eppendorf (UKE) and via a regional network\u0026nbsp;of psycho-oncologists in the Hamburg metropolitan area (\u003cem\u003ePsychoonkologie Treffen \u0026ndash; POT\u003c/em\u003e). Eligibility criteria included professional engagement with cancer patients and prior experience with at least one patient death. Interviews were conducted by RD in May 2023, either online via Zoom or in person, using a structured guide\u003csup\u003e13\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is no standardized procedure for the analysis of data from cognitive interviews\u003csup\u003e14\u003c/sup\u003e. Comprehensibility was assessed for all items using probing techniques and rated by the research team following Christalle et al.\u003csup\u003e15\u003c/sup\u003e. Relevance and completeness were evaluated through global probing questions, with additional individual assessment for four items flagged during translation. Detailed methodology for content validity assessment, including specific probing questions and rating procedures, is provided in Supplementary File 4. An overview of the study procedure can be found in Supplementary File 2. A comprehensive summary of all translation modifications and adaptations is provided in Supplementary File 3. The final German version of the PBS (PBS-D) was developed through iterative translation, expert review, and cognitive testing (Supplementary File 5).\u003c/p\u003e\n\u003ch2\u003ePhase II: Psychometric Evaluation\u003c/h2\u003e\n\u003ch3\u003eSampling and Recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited from a range of professional networks relevant to the field of psycho-oncology (Supplementary File 6). These organizations distributed the survey via email and newsletters between August and September 2024. It remained open until November 30, 2024. Additionally, contact details of psycho-oncological services from cancer centers were identified using the online directory of cancer care facilities certified by the German Cancer Society (\u0026ldquo;Oncomap\u0026rdquo;), for the three cancer entities with the highest absolute numbers of deaths in Germany (lung, pancreatic, and breast cancer)\u003csup\u003e16\u003c/sup\u003e. From this database, 180 facilities were systematically selected by choosing every fifth center listed within each federal state.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing COSMIN guidelines for structural validity, the target sample size was set as seven times the number of scale items (32 \u0026times; 7 = 224). Inclusion criteria were professional involvement in psychosocial cancer care and experience with at least one patient death. Participants could enter a draw for one of twenty \u0026euro;15 online vouchers.\u003c/p\u003e\n\u003ch3\u003eData Collection\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eQuantitative data were collected via an anonymous, open online survey administered through LimeSurvey. Before participation, all respondents provided electronic informed consent. The study was preregistered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/CNRUQ).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cp\u003eTo assess the PBS-D\u0026rsquo;s construct validity two additional measures were applied: the German version of the Texas Revised Inventory of Grief \u0026ndash; Present Feelings Subscale (TRIG-D)\u003csup\u003e17\u003c/sup\u003e was used to measure grief-related distress, with 16 items rated on a five-point Likert scale ranging from 1 (\u0026ldquo;completely false\u0026rdquo;) to 5 (\u0026ldquo;completely true\u0026rdquo;). A total sum score is calculated by summing all 16 items, with higher scores indicating greater grief-related emotional distress. No items require reverse scoring. The TRIG-D has demonstrated sound psychometric properties, including good internal consistency (Cronbach\u0026apos;s \u0026alpha; = .87) and convergent construct validity\u003csup\u003e17\u003c/sup\u003e, although no validated cut-off scores exist.\u003c/p\u003e\n\u003cp\u003eThe German version of the Professional Quality of Life Scale (ProQOL)\u003csup\u003e18\u003c/sup\u003e was also included, which consists of 30 items across three subscales: Compassion Satisfaction (10 items), Burnout (10 items), and Secondary Traumatic Stress (10 items)\u003csup\u003e18\u003c/sup\u003e. Items are rated on a five-point Likert scale ranging from 1 (\u0026ldquo;never\u0026rdquo;) to 5 (\u0026ldquo;very often\u0026rdquo;). For each subscale, a total sum score is calculated. Within the Burnout subscale, items 1, 4, 15, 17, and 29 require reverse scoring prior to calculation. Higher scores indicate higher levels of the respective construct. Validated cut-off scores are available to categorize low, average, and high levels for each subscale\u003csup\u003e18\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSociodemographic and professional characteristics were collected for sample description.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eStatistical Analyses\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics (frequencies, means, standard deviations (SD)) described the sample, and Table 1 gives a detailed overview of the applied analysis and criteria for study phase II. Item analyses were done by observing item response distributions (means, SD, minimum and maximum), missing values, item relevance, inter-item correlations, corrected item-total correlations, and item difficulties (see Table 1). Missing values were examined as a proxy indicator of item acceptability\u003csup\u003e19\u003c/sup\u003e. For SBR items, \u0026ldquo;not applicable\u0026rdquo; response rates were analyzed as an indicator of item relevance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStructural validity was examined with confirmatory factor analysis (CFA), testing the original nine-factor structure, tested previously by the original authors\u003csup\u003e9\u003c/sup\u003e: a four-factor model for SBR and a five-factor model for AGC (Model 1), and a higher-order two-factor model (SBR total; AGC total) to replicate the recommended but previously untested scoring approach (Model 2). A robust maximum likelihood estimator was used and the Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR) were observed for model fit. Good model fit was defined as CFI \u0026gt;.90, RMSEA and SRMR \u0026lt;.1\u003csup\u003e9\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInternal consistency was assessed using Cronbach\u0026apos;s alpha (\u0026alpha;) and McDonald\u0026apos;s omega (\u0026omega;). McDonald\u0026apos;s Omega is reported due to its greater accuracy for scales with heterogeneous item structures\u003csup\u003e20,21\u003c/sup\u003e, while Cronbach\u0026apos;s alpha is also reported to align with established conventions.\u003c/p\u003e\n\u003cp\u003eConstruct validity was evaluated through predefined hypotheses regarding associations with external measures: PBS-SBR was expected to correlate with TRIG-D (r \u0026ge; .30) and ProQOL Burnout (r \u0026ge; .30), while PBS-AGC was anticipated to show correlations with ProQOL Burnout (r \u0026ge; .10), Compassion Satisfaction (r \u0026ge; .50), and Compassion Fatigue (r \u0026ge; .50). These hypotheses were based on the associations the PBS\u0026rsquo; original authors found within their sample\u003csup\u003e9\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor CFA, Cronbach\u0026rsquo;s alpha and McDonald\u0026rsquo;s Omega missing values were dealt with by using Full Information Maximum Likelihood (FIML)\u003csup\u003e22\u003c/sup\u003e. For total scores and item-total-correlations up to 30% of missing values per person were imputed by person-centered mean. Cases with more missing values were excluded. CFA and McDonald\u0026rsquo;s Omega were computed in R Version 4.5.1. All other data preparation and analyses were performed in SPSS Version 29.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003ePhase I: Translation and cultural adaptation\u0026nbsp;\u003c/h2\u003e\n\u003ch3\u003eSample characteristics\u003c/h3\u003e\n\u003cp\u003eA total of n = 10 participants (seven women, three men) took part: seven psycho-oncologists, two physicians, and one nurse. Eight participants were interviewed in Round 1 and two in Round 2. Five were over 50 years old, three were 41-50, one was 31-40, and one under 30. Nine participants (90%) had \u0026ge; 11 years of cancer care experience. All were native German speakers.\u003c/p\u003e\n\u003ch3\u003eTranslation process\u003c/h3\u003e\n\u003cp\u003eInitial challenges (verb tense inconsistencies, ambiguous phrasing, culturally incongruent expressions) were resolved through team discussions and consultation with the PBS authors (supplementary file 3).\u003c/p\u003e\n\u003ch3\u003eAssessment of content validity\u003c/h3\u003e\n\u003cp\u003eGlobal relevance was confirmed in both rounds; individual item relevance was additionally evaluated for a few items in Round 1. Most items were rated relevant, though guilt items (SBR 7, 9, 10) were occasionally perceived as less so. Overall, eight of ten participants rated the scale as relevant.\u003c/p\u003e\n\u003cp\u003eAlthough some items were initially difficult to interpret, the revised version was ultimately understood by most participants (supplementary file 3).\u003c/p\u003e\n\u003cp\u003eMoreover, participants found the scale encompassed a wide spectrum of grief-related experiences, indicating completeness. All three aspects of content validity were thus confirmed.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eLayout and Response Modifications\u003c/h3\u003e\n\u003cp\u003eBased on participant feedback, a \u0026ldquo;not applicable\u0026rdquo; option was added to the SBR subscale, since clinicians often had no family contact. This option was visually separated from the rating scale. Similarly, in the AGC subscale, the option 0 = \u0026ldquo;no\u0026rdquo; was separated from other response options. The final PBS-D version, subject to psychometric evaluation, can be found in supplementary file 5.\u003c/p\u003e\n\u003ch2\u003ePhase II: Psychometric assessment\u003c/h2\u003e\n\u003ch3\u003eSample characteristics\u003c/h3\u003e\n\u003cp\u003eN = 258 participants were included in the analysis. Complete flow of participants can be followed via figure 1.\u003c/p\u003e\n\u003cp\u003eTable 2 summarizes characteristics: mean age 48 years (SD = 12.27), majority female (91.1%), participants cared for approximately 36 patients monthly (range: 0\u0026ndash;200) and encountered approximately 3 patient deaths per month (range: 0\u0026ndash;25).\u003c/p\u003e\n\u003ch3\u003ePBS-D item analysis\u003c/h3\u003e\n\u003cp\u003eResponse distributions, missing values, \u0026ldquo;not applicable\u0026rdquo; rates, corrected item-total correlations, and item difficulties are presented in Table 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMissing values per item were minimal, with completion rates exceeding 90% for all items (maximum 5.4% missing values), indicating good item acceptability.\u003c/p\u003e\n\u003cp\u003eMissing values were minimal, with \u0026gt;90% completion for all items (max 5.4%), indicating good acceptability. \u0026ldquo;Not applicable\u0026rdquo; rates were low overall, but higher for SBR4 items: Item 4 (\u0026bdquo;I was moved by the patient\u0026apos;s family\u0026apos;s understanding\u0026ldquo;; 23.6%) and Item 6 (\u0026bdquo;I was moved by the patient\u0026apos;s family\u0026apos;s gratitude\u0026ldquo;; 19.4%).\u003c/p\u003e\n\u003cp\u003eCorrected item-total correlations revealed mixed patterns across subscales. For the SBR scale, correlations ranged from .245 (Item 13) to .813 (Item 14). Items 3 and 13 fell below the preferred threshold of .3\u003csup\u003e25\u003c/sup\u003e. For AGC correlations were generally good (.421 - .866), with the notable exception of Item 11 (.207).\u003c/p\u003e\n\u003cp\u003eItem difficulty analysis revealed floor effects in SBR, especially SBR2 (\u0026ldquo;Guilt\u0026rdquo;, mean .01\u0026ndash;.12). Five of seven SBR1 (\u0026ldquo;Frustration \u0026amp; Trauma\u0026rdquo;) items also showed low difficulty. SBR3 and SBR4 were appropriate (.46\u0026ndash;.68). AGC difficulties were adequate (.20\u0026ndash;.75).\u003c/p\u003e\n\u003cp\u003eInter-item correlations (Tables 4-5) revealed heterogeneity, ranging from \u0026minus;.091 to .860 (SBR) and \u0026minus;.104 to .866 (AGC).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eInternal consistency\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eInternal consistency was evaluated for both individual subfactors and overall scales using McDonald\u0026apos;s Omega (\u0026omega;)\u0026nbsp;and Cronbach\u0026rsquo;s alpha (\u0026alpha;; see Table 6). was acceptable to excellent overall: SBR (\u0026omega; = .830, \u0026alpha; = .856), AGC (\u0026omega; = .863, \u0026alpha; = .868). Subfactor reliability varied: excellent for AGC5 (\u0026omega; = .928, \u0026alpha; = .925), good for SBR1, SBR4, AGC1, acceptable for SBR2 and AGC2, but insufficient for AGC3 (\u0026omega; = .591, \u0026alpha; = .604).\u003c/p\u003e\n\u003ch3\u003eStructural validity\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eCFA tested two models (Table 7). Model 1, testing the nine-factor structure (four \u0026nbsp;SBR, five AGC factors), showed mixed fit. RMSEA (.080) and SRMR (.087) were within acceptable limits (\u0026lt; .10), though CFI (.812) did not reach the conventional threshold of .90. Item loadings were generally acceptable ( \u0026gt;.20; Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eModel 2, testing a simplified two-factor structure (SBR and AGC), showed poor fit across all indices: CFI = .526, RMSEA = .123, and SRMR = .125 (Table 7). Despite poor fit, most loadings exceeded .20 (Table 3)\u003c/p\u003e\n\u003ch3\u003eConstruct validity\u003c/h3\u003e\n\u003cp\u003eConstruct validity was evaluated by examining whether correlations between PBS-D scales and theoretically related measures fell within pre-specified ranges (Table 8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSBR total correlated strongly with TRIG-D (r = .594) and showed the expected positive correlation with burnout (r = .385), supporting convergent validity. Subfactors SBR1 (\u0026ldquo;Frustration \u0026amp; Trauma\u0026rdquo;; r = .503) and SBR3 (\u0026ldquo;Grief\u0026rdquo;; r = .510) showed the strongest correlations with TRIG-D; SBR4 weaker (\u0026ldquo;Being Moved\u0026rdquo;; r = .270) and SBR2 moderate (\u0026ldquo;Guilt\u0026rdquo;; r = .379) correlations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the AGC scale, construct validity findings were more mixed. While AGC3 (\u0026bdquo;More Death-Related Anxiety\u0026ldquo;) showed positive correlations with ProQOL Burnout (r = .446) and Secondary Traumatic Stress (r = .441), and a negative correlation with Compassion Satisfaction (r = -.205), the overall AGC scale and other subfactors showed largely weak correlations. Specifically, AGC5 (\u0026bdquo;Better Coping with Patient Deaths\u0026ldquo;) even demonstrated a negative correlation with Secondary Traumatic Stress (r = -.132) and a positive correlation with Compassion Satisfaction (r = .112), representing inverse relationships compared to AGC3.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study translated and culturally adapted the PBS into German, assessed content validity, and evaluated psychometric properties. Cognitive interviews confirmed adequate validity: items were generally understood and relevant, with psycho-oncologists affirming comprehensive coverage of professional grief. The PBS-D showed acceptable reliability, though structural validity limitations warrant caution.\u003c/p\u003e\n\u003ch2\u003eStructural and Scale-Specific Issues\u003c/h2\u003e\n\u003cp\u003eThe questionnaire\u0026rsquo;s structural validity showed mixed findings. The original nine-factor model demonstrated acceptable fit according to RMSEA and SRMR indices, while the CFI fell below the recommended threshold of .90. This suggests that the theoretical structure proposed by Chen and Chow\u003csup\u003e9\u003c/sup\u003e captures important aspects of response patterns in our German psycho-oncologist sample, though refinements may be needed to achieve optimal fit. The simplified two-factor model \u0026ndash; applied via subscore calculation but not empirically tested by the original authors \u0026ndash; performed considerably worse, indicating a simple two-dimensional structure inadequately represents the scale\u0026apos;s complexity.\u003c/p\u003e\n\u003cp\u003eThe the wide range of inter-item correlations, including negative values (\u0026minus;.091 to .860 for SBR), reveals substantial heterogeneity within scales: items within the same overall scale may measure conceptually different or even opposing constructs. Consequently, computing overall sum scores for SBR and AGC appears inappropriate; subscores should be calculated and interpreted individually until further evidence is available.\u003c/p\u003e\n\u003cp\u003eThe AGC scale exemplifies this complexity, with subfactors AGC3 (\u0026ldquo;More Death-Related Anxiety\u0026rdquo;) and AGC5 (\u0026ldquo;Better Coping with Patient Deaths\u0026rdquo;) showing opposite relationships with validation measures, reflecting two divergent responses to patient deaths: adaptive coping that protects against burnout versus maladaptive responses characterized by increased anxiety or withdrawal. While both responses have been documented in the literature\u003csup\u003e6,28\u0026ndash;30\u003c/sup\u003e, their opposing nature challenges the validity of composite scoring approaches and necessitates careful interpretation of individual subfactors and broader validation studies encompassing diverse professional groups.\u003c/p\u003e\n\u003cp\u003eHowever, caution is needed especially concerning the interpretation of factor AGC3 (\u0026ldquo;More Death-Related Anxiety\u0026rdquo;) since it demonstrated insufficient reliability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Despite these limitations, both total scales showed excellent overall reliability, with several subfactors achieving outstanding reliability coefficients. The SBR scale demonstrated robust convergent validity with the TRIG Present Feelings subscale, particularly for theoretically relevant subfactors.\u003c/p\u003e\n\u003ch2\u003eProfessional Role and Sample-Specific Considerations\u003c/h2\u003e\n\u003cp\u003eGuilt items\u0026rsquo; relevance was occasionally questioned during interviews (especially SBR items 7, 9, 10). Marked floor effects (item difficulties .01\u0026ndash;.12) likely reflect the specific characteristics of our psycho-oncologist sample. Unlike physicians who bear direct responsibility for treatment decisions, psycho-oncologists typically provide supportive care without primary accountability for medical outcomes\u003csup\u003e7\u003c/sup\u003e. Previous research has identified this professional role as a protective factor against guilt-related grief responses\u003csup\u003e7\u003c/sup\u003e, explaining why guilt-related items showed limited relevance in our sample.\u003c/p\u003e\n\u003cp\u003eSimilarly, items incorporating patient family experiences (SBR items 4 and 6) were frequently rated as irrelevant, reflecting setting specificities where family members may not always be known to psycho-oncologists. This highlights the importance of \u0026ldquo;not applicable\u0026rdquo; response options rather than indicating problematic item content.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings suggest that professional role characteristics exert significant influence over grief expression. While Granek et al.\u003csup\u003e31\u003c/sup\u003e propose that the emotional experience of professional grief transcends cultural boundaries, our results indicate that professional culture, may be a more influential factor than geographical culture in determining which grief dimensions are salient.\u003c/p\u003e\n\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\n\u003cp\u003eTranslation followed a rigorous protocol with input from authors and participants, ensuring cultural appropriateness. Data quality was high, with minimal missing data, and the sample diverse in settings, experience, and age.\u003c/p\u003e\n\u003cp\u003eHowever, convenience sampling and exclusive focus on German psycho-oncologists limits generalizability to other healthcare professions. Replication across diverse professions is needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe PBS-D offers a solid foundation for assessing professional grief in German healthcare settings, demonstrating good reliability and convergent validity for core grief constructs. However, significant challenges regarding structural validity and professional role specificity require attention before recommending its \u0026nbsp;use in either research or clinical practice.\u003c/p\u003e\n\u003cp\u003eA differentiated approach to the two overarching scales is warranted. The SBR scale demonstrated adequate psychometric properties for assessing short-term grief reactions, whereas the AGC scale, despite acceptable internal consistency, requires cautious interpretation due to validity concerns. Until further psychometric evaluation across diverse HCPs is completed, we recommend computing subscores rather than total scale scores, with particular attention to professional role characteristics that may influence the relevance of specific grief dimensions.\u003c/p\u003e\n\u003cp\u003eBy contributing a validated German-language instrument, this study lays the groundwork for future research and supports the systematic investigation of professional grief and its consequences. Future research should prioritize validation in samples including physicians, nurses, and other healthcare professionals to determine whether observed patterns reflect professional role differences or broader applicability issues. This evidence will be crucial for establishing appropriate scoring approaches and interpretation guidelines for the PBS-D.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was carried out according to the latest version of the Helsinki Declaration of the World Medical Association and respecting principles of good scientific practice. The local Ethics Committee of the University Medical Center Hamburg-Eppendorf gave approval prior to investigation (approval number: LPEK-0608 and LPEK-0614). Study participation was voluntary and no foreseeable risks for participants resulted from the participation in this study. Participants were fully informed about the aims of the study, data collection and the use of collected data and written informed consent was obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collected and analyzed are available from the corresponding author on reasonable request. Signing a data use/sharing agreement will be necessary, and data security regulations both in Germany and in the country of the investigator, who proposes to use the data, must be complied with. Preparing data sets for use by other investigators requires substantial work and is thus linked to available or provided resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report there are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding source information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIS is the responsible principal investigator (PI) of the study; MR is the co-PI. IS and SW were involved in planning and preparation of the study. SW and RD translated and RD culturally adapted the Professional Bereavement Scale from English to German. IS, SW, and MR advised the process. SW recruited participants and collected data for the psychometric validation. EC and SW analysed the data. All authors interpreted the results. SW wrote the first draft of the manuscript. MR, RD, EC and IS critically revised the manuscript for important intellectual content. All authors gave final approval of the version to be published and agreed to be accountable for the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGenerative artificial intelligence (GenAI) tools were utilized to assist in the manuscript\u0026rsquo;s conceptual organization and linguistic refinement. This included support in restructuring content for logical flow and academic tone. The authors reviewed and substantively edited the final content to ensure accuracy and scholarly integrity.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHilberdink, C. E. \u003cem\u003eet al.\u003c/em\u003e Bereavement issues and prolonged grief disorder: A global perspective. \u003cem\u003eCamb. Prisms Glob. Ment. Health\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e, e32 (2023).\u003c/li\u003e\n \u003cli\u003eEngler-Gross, A., Goldzweig, G., Hasson-Ohayon, I., Laor-Maayany, R. \u0026amp; Braun, M. Grief over patients, compassion fatigue, and the role of social acknowledgment among psycho-oncologists. \u003cem\u003ePsychooncology.\u003c/em\u003e \u003cstrong\u003e29\u003c/strong\u003e, 493\u0026ndash;499 (2020).\u003c/li\u003e\n \u003cli\u003eChen, C., Chow, A. Y. M. \u0026amp; Tang, S. 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A., Melgar-Qui\u0026ntilde;onez, H. R. \u0026amp; Young, S. L. Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. \u003cem\u003eFront. Public Health\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, (2018).\u003c/li\u003e\n \u003cli\u003eLee, M., Choe, K., Kim, S. \u0026amp; Shim, Y. How Do Oncology Nurses Cope With the Psychological Burden of Caring for Dying Patients? \u003cem\u003eCancer Nurs.\u003c/em\u003e \u003cstrong\u003e46\u003c/strong\u003e, E245\u0026ndash;E252 (2023).\u003c/li\u003e\n \u003cli\u003eStokar, Y. N. \u0026amp; Pat-Horenczyk, R. Themes of end-of-life care in memorable cases of medical health professionals: A mixed methods approach. \u003cem\u003eCurr. Psychol.\u003c/em\u003e \u003cstrong\u003e42\u003c/strong\u003e, 13721\u0026ndash;13732 (2023).\u003c/li\u003e\n \u003cli\u003eGranek, L., Mazzotta, P., Tozer, R. \u0026amp; Krzyzanowska, M. K. Oncologists\u0026rsquo; Protocol and Coping Strategies in Dealing with Patient Loss. \u003cem\u003eDeath Stud.\u003c/em\u003e \u003cstrong\u003e37\u003c/strong\u003e, 937\u0026ndash;952 (2013).\u003c/li\u003e\n \u003cli\u003eGranek, L., Ben-David, M., Shapira, S., Bar-Sela, G. \u0026amp; Ariad, S. Grief symptoms and difficult patient loss for oncologists in response to patient death. \u003cem\u003ePsychooncology.\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 960\u0026ndash;966 (2017).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 8 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"professional grief, psychometric evaluation, professional bereavement scale","lastPublishedDoi":"10.21203/rs.3.rs-8524198/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8524198/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Professional grief – the emotional response to patient death among healthcare professionals – remains insufficiently understood. To gain better understanding psychometrically sound measures are crucial. The Professional Bereavement Scale (PBS) is the first instrument specifically designed to measure professional grief, but lacks validation beyond Chinese populations. This study aimed to translate, culturally adapt, and validate the PBS into German (PBS-D) and assess its psychometric properties among psycho-oncologists in Germany.\u003c/p\u003e\n\u003cp\u003eMethods: First, the PBS was translated and culturally adapted following the TRAPD methodology. Then, to assess psychometric properties, data were collected using a cross-sectional online survey. Psychometric evaluation included item analysis, internal consistency, structural validity (confirmatory factor analysis), and convergent validity assessed using the Texas Revised Inventory of Grief and the Professional Quality of Life scale.\u003c/p\u003e\n\u003cp\u003eResults: The PBS-D was developed through iterative translation, expert review, and cognitive testing, confirming the presence all three aspects of content validity (relevance, completeness, comprehensiveness). Among 258 eligible participants (91% female; mean age 48 years), the PBS-D demonstrated acceptable overall reliability for both major subscales. However, analyses of inter-item correlations revealed some internal inconsistencies within the scales, ranging from -.091 to .860, including negative correlations suggesting conceptual heterogeneity. The subscale concerning short term bereavement demonstrated robust convergent validity with another grief measure (r = .594). However, confirmatory factor analysis revealed insufficient structural validity.\u003c/p\u003e\n\u003cp\u003eConclusions: The PBS-D provides a solid foundation for assessing professional grief in German healthcare settings, demonstrating good reliability and convergent validity for core constructs. However, significant challenges regarding structural validity emerged. The instrument requires validation across diverse healthcare professions before it can be used routinely. Until then, subscale scores rather than total scores should be computed, with particular attention to professional role characteristics that influence the relevance of the grief dimension.\u003c/p\u003e","manuscriptTitle":"Translation and Psychometric Evaluation of the Professional Bereavement Scale - German Version (PBS-D) among Psycho-oncologists in Germany","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 11:06:58","doi":"10.21203/rs.3.rs-8524198/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8941f8f3-fa31-46a6-b3e1-5aa1a4608f78","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T11:06:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 11:06:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8524198","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8524198","identity":"rs-8524198","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}