Psychometric properties of instruments used to measure the competence of operating room nurses: A COSMIN-based systematic review

Psychometric properties of instruments used to measure the competence of operating room nurses: A COSMIN-based systematic review | 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 Psychometric properties of instruments used to measure the competence of operating room nurses: A COSMIN-based systematic review Xinxin Xu, Yuanyuan Mou, Shiyu Zhuo, Weizhen Bai, Lingli Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8671837/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Objective: This systematic review aimed to evaluate competence instruments for operating room nurses,in order to provide evidence-based support for selecting the most appropriate instrument for specific populations. Background: The operating room nurses’ competence significantly affects the quality of nursing care, as well as the outcomes of surgical treatments and patient prognosis.Despite the development of various instruments designed to assess the operating room nurses’ competence, a comprehensive and rigorous systematic review that provides an overview and critical appraisal of these instruments is currently lacking. Consequently,a systematic review of the measurement properties of such instruments is essential. Design: Systematic review of measurement properties following the COSMIN guidelines. Methods： Relevant studies were searched on seven English databases and four Chinese databases from inception to October 2025.The eligible studies were reviewed to identify the competence measured by the instruments for operating room nurses. The psychometric properties of instruments in development and psychometric testing design studies were also examined. The COSMIN checklist was used to assess the studies' methodological quality. Results: A total of 16 instruments were included,and included instruments assessed only two to four psychometric properties.No studies report measurement error and responsiveness.The PPCS-R and the SPLINTS were rated as A recommendations, while the remaining instruments were rated as B recommendations. Conclusion: The study identified the PPCS-R and the SPLINTS as appropriate measures for assessing the competence of operating room nurses.Future research should adhere to the COSMIN methodological standards to strengthen the development and validation of competence assessment tools. Instruments Systematic review Measurement properties Operating room nurse competence Evaluation tools Figures Figure 1 1. Introduction Quality of care and patient safety are arguably the dominant themes of the modern healthcare agenda.Approximately 12% of preventable patient harm causes permanent disability or patient death and is mostly related to therapeutic management,and invasive clinical procedures[ 1 ].Enhance nursing competencies in therapeutic management and procedural safety.Decrease in preventable harm,disability and death,improving overall patient safety[ 2 , 3 ].Competence has been described in various ways; as a combination of specific knowledge, skills, concepts, and values to meet performance standards in a particular context[ 4 , 5 ].After the concept of competence was introduced into the nursing field, the International Council of Nurses (ICN) defined the competence of the generalist nurse as the knowledge, skills, judgment, and personal attributes required for nurses to fulfill their job responsibilities[ 6 ].The cultivation of competence is an important topic in the development of global nursing education.The competence of operating room(OR) nurses significantly affects the quality of nursing care,as well as the outcomes of surgical treatments and patient prognosis[ 7 , 8 ]. The Association of PeriOperative Registered Nurses (AORN) established evaluation criteria for the competence of operating room nurses at the end of the 20th century, providing reference for other countries around the world[ 9 ]. At the beginning of the 21st century, the Australian College of Operating Room Nurses (ACORN) focused on the requirements for the competence of scrub nurses.The competence of OR nurses, also known as perioperative nurses,were divided into technical skills and non-technical skills. Technical skills (TS) include theoretical practical knowledge, mastery of aseptic techniques, and strict adherence to various operational procedures, while non-technical skills (NTS), also known as soft skills, mainly include holistic nursing, situation awareness, empathy, collaboration, communication, task management, and teamwork[ 10 , 11 ]. NTS have significant individual differences but are crucial in OR nursing work. The lack of NTS can lead to interruptions in surgery, retained surgical objects, and other adverse events, threatening the safety of surgical patients and even endangering their lives[ 11 ]. Despite the existence of several instruments designed to assess the competence of OR nurses, these tools have been developed in disparate contexts.Consequently, there is no consensus on which tool is the most appropriate and reliable, which has led to confusion among researchers and OR managers when selecting it.To our knowledge,there is no systematic review to summarize all the OR nurses’ competence assessment tools and report their psychometric properties.Therefore, this study adopt the COSMIN guideline to evaluate instruments,and adopt the GRADE guideline to form recommendations.This study evaluated OR nurses’ competence instruments using the COSMIN guidelines,and aim to provide an evidence-based assessment tool for the competence of OR nursing teams and lay the foundation for future research. 2. Method This study used the COSMIN guideline for quality assessment of included studies[ 12 , 13 ],and was registered on PROSPERO(CRD42024627674) 2.1Search strategy We conducted primary searches in PubMed using both MeSH terms and free terms to develop search words.The identified search strategy was confirmed by our research group.This study systematically searched PubMed,Embase,Web of Science,CINAHL,PsycInfo,China National Knowledge Infrastructure(CNKI) and Wanfang Database using the identified search strategy, with the search period from database inception to October 2025.And manually trace the references and related studies to supplement this research.Our search included keywords such as“operating room nurs*,”“theatre nurs*,”“competenc*,”“perioperative nurs*,”“scrub nurs*,”“circulating nurs*,”“capacit*,”“abilit*,”“questionnaire*,” “instrument*,” “tool*,”“assess*,” “measure*”and“scale*.” The search strategies provided in Supplemental Appendix A, NoteExpress was used to export and manage the retrieved studies. 2.2. Inclusion and exclusion criteria The inclusion criteria were as follow: (1) the study was conducted with OR nurses, including circulating nurses and scrub nurses; (2) Research involving the development or validation of measurement instrument of OR nurses’ competence and evaluate one or more psychometric properties;and(3)studies published in English or Chinese.Exclusion criteria for this study were as follow: (1) unavailability of the full text; (2)non-English or non-Chinese literature; (3)duplicate publications. 2.3Literature screening and data extraction According to the inclusion and exclusion criteria, two researchers trained in evidence-based methodology independently screened the literature and extracted data,If a consensus could not be reached,a third researcher was consulted to resolve the disagreement.All studies were imported into the NoteExpress software, where they were processed through a series of deduplication, initial screening, and full-text screening steps.The research team determined whether to include them through group discussions.s. We extracted data on (1) Characteristics of the included studies.(Table 1 ); (2)Methodological quality and measurement properties evaluation of the included instruments(Table 2 ); and(3)Summary of results for psychometric properties and evidence(Table 3 ) 2.4.Assessment of methodological quality COSMIN risk of bias checklist is a consensus-based standard for the selection of health measurement instruments,which can evaluate the methodological quality and measurement properties,and provide recommendations for instrument selection[ 12 , 13 ].The COSMIN risk of bias checklist has 10 domains and 116 items, including patient-reported outcome measure(PROM) development, content validity, structural validity, internal consistency,cross-cultural validity/measurement invariance, reliability, measurement error, criterion validity, hypotheses testing for construct validity,and responsiveness. Each item has five options, including “very good”,“adequate”, “doubtful”, “inadequate”, and “not applicable”. The “worst score counts” principle was used to determine the overall quality of the study[ 12 ]. 2.5.Measurement properties quality assessment With the COSMIN criteria for good measurement properties,Content validity and other measurement properties could be rated as sufficient(+),insufficient(-),or indeterminate(?). 2.6.Evidence Level Assessment The modified Grading of Recommendations Assessment,Development,and Evaluation (GRADE) system [ 12 , 13 ]is used to grade the quality of evidence; the evaluation tools are downgraded based on four criteria: risk of bias, inconsistency, indirectness, and imprecision, with evidence levels being "high," "moderate," "low," or "very low";Content validity is "sufficient" (any level of evidence),with adequate internal consistency (at least low-quality evidence) was rated as Category A,which is recommended for use.Its measurement attributes are 'inadequate'(at high-quality evidence) was rated as Category C,which is not recommended for use.All others were not in Category A or Category C rated as Category B,which has potential for application, but further research is required to evaluate its quality. 3. Results 3.1. Literature search As shown in Fig. 1 .,a total of 11154 articles were initially retrieved from the seven databases searching, of which 9527 remained after the removal of duplicates. Subsequently, 9412 articles were excluded after review of their titles and abstracts, and an additional 115 articles were excluded after full-text review. Ultimately, a total of 16 articles were included in the present study after screening for eligibility.The literature screening flowchart is shown in Fig. 1 ,The basic characteristics of the included literature are shown in Table 1 .This study included a total of 8 evaluation tools, consisting of 4 comprehensive competence evaluation tools and 4 specialized competence evaluation tools. Table 1 Characteristics of the included studies. Reference item Instrument name Developer/year country Original language Theoretical model Population(N) Content and/or subscales (items) Response options [ 14 ] comprehensive competency evaluation tools The core competency scale for ORNs(CCS_ORN) Na Mei/2022 China Chinese — 300 1.Emergency and problem-solving skills(5 items) 2.Specialist knowledge and skills (12 items) 3.Collaboration and interpersonal communication skills (5 items) 4.Teaching and research capacity (8 items) 5.Laws and regulations and relevant expertise (5 items) 6.Management capabilities and basic skills (7 items) 5-point scale 0 = not competent at all) ;4 = very competent [ 15 ] the Revised Perioperative Competence Scale(PPCS-R) Brigid M. Gillespie/2012 Australia English — 1122 1.Foundational Knowledge & Skills(9 items) 2.Leadership(8 items) 3.Collaboration(6 items) 4.Proficiency(6 items) 5.Empathy(5 items) 6.Professional Development(6 items) 5-point Likert response scale ; 1 = never;5 = always [ 16 ] The PPCS-R in the United States context 2024 the United States English — 1581 1.Foundational Knowledge and Skills(9 items) 2.Leadership(8 items) 3.Collaboration(6 items) 4.Proficiency(6 items) 5.Empathy(5 items) 6.Professional Development(6 items) Likert scale;“never” = 1, “sometimes” = 2, “often” = 3, “very often” = 4, and “always” = 5. [ 17 ] the PPCS-R in the Swedish context 2018 Swiss Swedish — 1033 1.Foundational Knowledge and Skills(9 items) 2.Leadership(8 items) 3.Collaboration(6 items) 4.Proficiency(6 items) 5.Empathy(5 items) 6.Professional Development(6 items) five-point Likert response scale;never = 1,always = 5. [ 18 ] the Persian PPCS-R Neda Mirbagher Ajorpaz/2017 Iran Persian — 357 1.Foundational Skills and Knowledge (nine items) 2.Leadership (eight items) 3.Collaboration (six items), 4.Proficiency (six items) 5.Empathy (five items) 6.Professional Development (six items) 5-point Likert scale;strongly disagree = 1,strongly agree = 5 [ 19 ] the Turkish version PPCS 2019 Turky Turkish — 206 1.foundational knowledge and skills(9 items) 2.leadership(8 items) 3.collaboration(6 items) 4.proficiency (6 items) 5.empathy(5 items) 6.professional development(6 items) 5-point Likert scale [ 20 ] The Chinese Perceived Perioperative Competence Scale-Revised (C-PPCS-R) 2022 China Chinese — 480 1.Foundational Skills and Knowledge (8 items) 2.Leadership (7 items) 3.Collaboration (5 items), 4.Proficiency (4 items) 5.Empathy (5 items) 6.Professional Development (5 items) four-point Likert scale;not relevant = 1,very relevant = 2 [ 21 ] the Perceived Perioperative Competence Scale-Revised Short Form(PPCS-R-SF) 2023 Australia English — 649 1.Foundational Skills and Knowledge (3 items) 2.Leadership (3 items) 3.Collaboration (3 items), 4.Proficiency (3 items) 5.Empathy (3 items) 6.Professional Development (3 items) five-point frequency scale;never = 1,always = 5 [ 22 ] the Perceived Perioperative Competence Scale–Revised instrumen into Italian(PPCS-R ITA) 2025 Italy Italian - 509 1.Foundational Skills and Knowledge(9 items) 2.Leadership(8 items) 3.Empathy(5 items) 4.Professional Development(6 items) 5.Communication(6 items) 6.Proficiency(6 items) Five-point Likert scale (1 = never; 5 = always) [ 23 ] Competency Evaluation Index System for Nurses in Operating Room Wang Yumei/2015 China Chinese Icebery model,onion model 60 1.specialized knowledge(8 items) 2.professional ability(5items) 3.personality(8 items) 4.self-motivation(3 items) 1–10 [ 24 ] Operating Room Professional Nurses Core Competency Evaluation Scale Mu Li/2019 China Chinese — 433 1.professional development ability(12 items) 2.professional cooperation ability(12 items) 3.professional management ability (10 items) 4.perioperative assessment ability (6 items)5.basic professional ability(5 items). 5-point Likert [ 25 ] specialized competency evaluation tools the Imperial College Assessment of Technical Skill for Nurses (ICATS-N) Nick Sevdalis/2009 United Kingdom English — 21 1.Gowning and Cloving(3 items) 2.Setting up instrumentation(5 items) 3.Draping(3 items) 4.Maintaining sterile field(4 items) 6-point Likert;1 = Not done well;6 = Done very well [ 26 ] the Scrub Practitioners’ List of Intraoperative Non-Technical Skills(SPLINTS) Lucy Mitchel/2011 United Kingdom English — 34 1.Situation awareness(3 items) 2.Communication and teamwork(3 items)3.ask management(3 items) 4-point scale;1 = poor, 2 = marginal, 3 = acceptable and 4 = good [ 27 ] The Chinese Version of Scrub Practitioners' List of Intraoperative Non-Technical Skills(C-SPLINTS) 2021 China Chinese 一 118 1.Situation awareness(3 items) 2.Communication and teamwork(3 items)3.ask management(3 items) 4-point scale;1 = poor, 2 = marginal, 3 = acceptable and 4 = good [ 28 ] the Non-technical Skills for Operating Room Nurses behavioural marker system (NOTSORN) Irene Sirevåg/2024 Norway Norwegian and English — 25 1.Professional accountability(2 items) 2. Situational awareness and decision making(4items) 3. Teamwork and communication(3 items) 4. Leadership and task management(3 items) four-point scale [ 29 ] The circulating practitioner’s list of non-technicalskills(CPLNTS) Reza Kalantari/2021 Iran English — 316 1.task management(13 items) 2.teamwork(7 items) 3.situational awareness(7 items) 4.communication(9 Items) 5.leadership(7 items) Fivepoint scoring system;zero (necessary but not observed) to four (excellent) “—”Indicates that there is no report. 3.2.Study description The characteristics of the included studies are delineated in Table 1 .A total of 7,244 study subjects were included, with sample sizes ranging from 21 to 1,581.Among the included studies, only three were published in Chinese, with the remainder in English.This table lists nine original tools and seven culturally adapted tools.The Revised Perioperative Competence Scale (PPCS-R) is the most widely culturally adapted questionnaire, having been validated in six countries.[ 16 – 19 , 22 , 30 ].All research constructs were the competence of OR nurses,including ST and NST.The original and translated versions of a category of instruments were evaluated individually as separate instruments due to the variations in their items and sub-instrument compositions. 3.3. Quality assessment 3.3.1 Methodological quality assessment As presented in Table 2 , of the 16 included studies, only two studies explored more than five psychometric properties[ 15 , 31 ]. However, there was insufficient information on cross-cultural validity,measurement error and responsiveness. Content validity were consistently reported across all studies. 3.3.2 Quality of measurement properties The quality of PROM development was assessed as “adequate” in one studies[ 15 , 28 ],which had representative sample of the target population.A total of fifteen studies rated the PROM development study as ‘doubtful,’ of which ten conducted cognitive interviews with professionals or researchers only[ 14 , 15 , 17 , 19 , 23 – 25 , 27 – 29 ];three conducted cognitive interviews or pre-tests with the target population, but it was unclear whether they asked about comprehensibility and comprehensiveness[ 16 , 22 , 30 ]༛two did not describe the research process in detail[ 18 , 31 ].Content validity was evaluated through cognitive interviews or pilot tests.The quality of content validity was rated as “adequate” in three studies[ 15 , 26 , 28 ],where both target population and professionals were consulted regarding the relevance and comprehensiveness of the constructs;these studies employed a sufficiently representative target population and professionals and used appropriate methods to analyze the data.Furthermore,thirteen studies did not provide detailed descriptions of their research designs or data analysis processes for content validity, resulting in the methodological quality of content validity being rated as ‘doubtful.’ The structural validity of the instruments was assessed across 13 studies.In this studies,confirmatory factor analysis (CFA) is the most frequently used method.Two studies employed exploratory factor analysis (EFA).[ 14 , 15 , 22 , 24 , 27 ],six studies used both CFA and EFA[ 14 , 15 , 17 , 27 , 29 , 30 ],and only one applied item response theory[ 16 ].Five studies which used both CFA and EFA with adequate sample sizes and no other significant methodological flaws, so the methodological quality was assessed as ‘very good’,the Chinese version of SPLINTS had a sample size of less than five times the required amount and was rated as ‘inadequate’[ 27 ].The PPCS-R in the United States context used item response theory demonstrated sufficient model and sample size, thus resulting in an assessment of its methodological quality as ‘very good’[ 16 ].Four studies received an ‘doubful’ rating, primarily due to their limited focus on EFA and inadequate sample size[ 18 , 19 , 22 , 24 ].The remaining three studies were characterised by adequate sample sizes and the absence of any other significant methodological weaknesses,consequently they were rated as 'adequate'.Internal consistency was evaluated except NOTSORN,and this study report Cronbach’s alpha,and the quality was consistently rated as ‘very good’.However,four studies did not report Cronbach’s alpha or item-total correlations calculated,and so were consequently rated as ‘doubful’[ 22 , 25 , 26 , 29 ].Only one study assess measurement invariance by categorizing perioperative nurses into participants with perioperative nursing experience,used multi-group confirmatory factor analysis framework,and did not have other important methodological flaws,so it was rated as ‘very good’.[ 16 ] Reliability was assessed in eight studies, which calculated intragroup correlation coefficients (ICC) or Pearson's correlation.Nonetheless, these studies were rated as 'doubful' ,because insufficient information of detailed formula descriptions and information about whether the target population was stable or not and whether the measurement conditions were similar[ 14 , 15 , 18 , 19 , 23 , 25 , 29 , 31 ].The criterion validity of the PPCS-R-SF was based on other commonly used scales and rated as ‘doubful’[ 31 ].In terms of hypothesis testing, one study adequately described most of the important characteristics of the known-groups,had no other methodological flaws and was therefore rated as ‘adequate’[ 15 ]. The criterion validity of the PPCS-R-SF was based on the previously validated 40-item PPCS-R and meet the COSMIN guideline criteria,therefore it was rated as ‘very good.’[ 31 ]In terms of hypothesis testing,one study adequately described most of the important characteristics of the subgroup and had no other methodological flaws,PPCS-R was rated as ‘adequate.’[ 15 ] 3.3.2 Quality of measurement properties Table 2 shows the quality of psychometric properties retrieved from included studies.Content validity was assessed for all instruments in sixteen studies, and three instruments were rated as ‘sufficient (+)’[ 15 , 23 , 26 , 28 ].Thirteen instruments received an ‘inconsistent (±)’rating[ 14 , 16 – 20 , 22 – 24 , 29 – 32 ].Structural validity was assessed for thirteen instruments in sixteen studies, with six instruments received a ‘sufficient (+)’ rating[ 15 , 17 , 22 , 26 , 29 , 30 ],and four were rated as ‘insufficient (-)’[ 16 , 19 , 21 , 29 ] and three instruments received an ‘indeterminate (?)’ rating[ 14 , 18 , 24 ].Internal consistency was assessed for fifteen instruments in sixteen studies,with seven instruments rated as ‘sufficient (+)’[ 15 , 16 , 19 , 22 , 26 , 30 , 31 ],and seven studies were assigned a rating of ‘indeterminate (?)’[ 17 , 23 – 27 , 29 , 33 , 34 ] and only one study rated as ‘indeterminate (?)[ 18 ]. Reliability was assessed for eight instruments in sixteen studies, with four instruments rated as ‘sufficient (+)’[ 18 , 19 , 29 , 31 ],three instruments rated as ‘indeterminate (?)’[ 15 , 23 , 25 ],and one instrument rated as ‘sufficient (+)’[ 14 ].Only one study assessed measurement invariance,and PPCS-R in the United States context was rated as ‘sufficient (+)’[ 16 ].The criterion validity was rated as ‘sufficient(+)’ for PPCS-R-SF[ 31 ],and hypotheses testing for construct validity was rated as ‘indeterminate (?)’ for PPCS-R[ 15 ]. Table 2 Methodological quality and measurement properties evaluation of the included instruments. Instrument PROM development Content validity Structural validity Internal consistency Reliability Measurement invariance Criterion validity Hypotheses testing for construct validity MQ MQ QR MQ QR MQ QR MQ QR MQ QR MQ QR MQ QR CCS_ORN[ 14 ] D D ? V ? V ? A - PPCS-R[ 15 ] A A + V + V + D ? A ? PPCS-R in the United States context[ 16 ] D D ? V - V + V + Persian PPCS-R[ 18 ] I D ? D ? V - A + PPCS-R in the Swedish context[ 17 ] D D ? V + V ? Turkish PPCS-R[ 19 ] D D ? D - V + A + C-PPCS-R[ 30 ] D D ? V + V + PPCS-R-SF[ 31 ] D D ? A - V + D + V + PPCS-R ITA[ 22 ] D D ? D + D + Competency Evaluation Index System for Nurses in Operating Room[ 23 ] D D ? V ? V ? Operating Room Professional Nurses Core Competency Evaluation Scale[ 24 ] D D ? A ? V ? ICATS-N[ 25 ] D D ? D ? D ? SPLINTS[ 26 ] D A + A + D + C-SPLINTS[ 27 ] D D ? I - V ? NOTSORN[ 28 ] A A + CPLNTS[ 29 ] D D ? V + D ? A + Comments: MQ, Methodological quality; QR, Quality of he results rated,V: very good, A: adequate, D: doubtful, I: inadequate; “+ ”: sufficient; “-”: insufficient, “?”. .Empty cells indicate that the measurement property was not assessed in the study 3.3.3. Evidence grading and recommendations Table 3 summarizes the evidence quality of all PROMs, rated as ‘high,’ ‘moderate,’ ‘low,’ or ‘very low’ based on downgrading factors including risk of bias, inconsistency, imprecision and indirectness.None of the PROMs were downgraded for inconsistency, imprecision, or indirectness.For risk of bias,the PPCS-R,the SPLINTS and the NOTSORN were rated ‘adequate’[ 15 , 28 , 35 ],so they were not downgraded,while the rest instruments were downgraded one level due to the methodological quality of ‘doubtful’ for content validity.The methodological quality rating for the structural validity of the Persian PPCS-R,the Turkish PPCS-R and the PPCS-R ITA were ‘doubtful’[ 18 , 19 , 22 ], so they was downgraded by one level.The C-SPLINTS was rated ‘inadequate’[ 27 ],so it was downgraded by two level,while the rest of the instruments were rated ‘adequate’ or ‘very good’, so they were not downgraded. The methodological quality of the internal consistency of the PPCS-R ITA,the ICATS-N,the SPLINTS and the CPLNTS was ‘doubful’ and the above four instruments were downgraded one level[ 22 , 25 , 29 , 35 ]. The rest of the instruments were not downgraded, due to the ‘adequate’ or ‘very good’ rating. The methodological quality of the reliability of the PPCS-R and the PPCS-R-SF was rated as ‘doubtful’ and were therefore downgraded one level[ 15 , 31 ]. The remaining instruments are rated ‘adequate’ or ‘very good’ and do not require downgrading. The methodological quality of the measurement invariance of the PPCS-R in the United States context[ 16 ], the criterion validity of the PPCS-R-SF[ 31 ],and the hypotheses testing for construct validity of the PPCS-R[ 15 ] were ‘adequate’ or ‘very good’ and they were not downgraded.For inconsistency, we considered each different language versions of a PROM a unique PROM. In terms of imprecision, the ICATS-N reporting reliability had retest sample sizes of less 50 and were therefore downgraded two level[ 25 ].AND sample sizes of 50–100 of the competence Evaluation Index System for Nurses in OR,therefore downgraded one level[ 23 ]. None of the studies were indirect, so no downgrading. The recommended grades for the sixteen instruments are presented in Table 3 . According to the COSMIN guidelines, the content validity and internal consistency of the PPCS-R and the SPLINTS are ‘sufficient’[ 15 , 35 ],and the level of evidence is no less than ‘moderate’,making it an A recommendation[ 15 , 35 ].Furthermore, none of the PROMs have high-level evidence indicating insufficiency(-),resulting in none of the C recommendations. The other fourteen instruments were all category B recommendations with potential for application, but further research is needed to evaluate their psychometric properties. Table 3 Summary of results for psychometric properties and evidence. Instrument Content validity Structural validity Internal consistency Reliability Measurement invariance Criterion validity Hypotheses testing for construct validity Recommended grade QR QE QR QE QR QE QR QE QR QE QR QE QR QE CCS_ORN[ 14 ] ? Moderate ? High ? High - High B PPCS-R[ 15 ] + High + High + High ? Moderate ? High A PPCS-R in the United States context[ 16 ] ? Moderate - High + High + High B Persian PPCS-R[ 18 ] ? Moderate ? Moderate - High + High B PPCS-R in the Swedish context[ 17 ] ? Moderate + High ? High B Turkish PPCS-R[ 19 ] ? Moderate - Moderate + High + High B C-PPCS-R[ 30 ] ? Moderate + High + High B PPCS-R-SF[ 31 ] ? Moderate - High + High + Moderate + High B PPCS-R ITA[ 22 ] ? Moderate + Moderate + Moderate B Competency Evaluation Index System for Nurses in Operating Room[ 23 ] ? Moderate ? High ? Low B Operating Room Professional Nurses Core Competency Evaluation Scale[ 24 ] ? Moderate ? High ? High B ICATS-N[ 25 ] ? Moderate ? Moderate ? Very low B SPLINTS[ 35 ] + High + High + Moderate A C-SPLINTS2020[ 27 ] ? Moderate - Low ? High B NOTSORN[ 28 ] + High B CPLNTS[ 29 ] ? Moderate + High ? Moderate + High B Comments: (1) Overall rating rated as Sufficient (+), Intermediate (?), Insufficient (−). (2) MQ:Methodological quality; QR:Quality of he results rated,(3) Empty cells indicate that the measurement property was not assessed in the study. 4. Discussion This review evaluated 16 OR nurses’ competence assessment instruments based the COSMIN guidelines. To our knowledge,our study is the first to comprehensively assess the psychometric properties of competence assessment tools for operating room nurses. This systematic review provides the first comprehensive synthesis and critical evaluation of the operating room nurse competence assessment instruments. Content validity is the most important psychometric characteristic in the evaluation process, and evaluators should first assess content validity[ 12 , 36 ]. The COSMIN guidelines evaluate content validity from the relevance, comprehensiveness, and understand ability of the study.The methodological quality OF development is predominantly rated as ‘doubtful’,and issues include item generation based on the opinions of professional nurses but limitations in the representativeness of the sample,lack experienced or trained interviewers, appropriate interview outlines, at least two researchers independently coding, analyzing interview data,which raises concerns about the consistency and reliability of the findings.The present study is limited by the fact that it is based solely on the findings of related studies which interviewed professional OR nurses or managers. In addition,the work of OR nurses is characterised by team cooperation with surgeons, anesthesiologists and others,and teamwork in the OR necessitates a comprehensive understanding of the competence required of OR nurses, as determined by their teamwork members rather than solely by the competencies stipulated by OR nurses themselves.In order to address the aforementioned issues, the utilisation of standardised qualitative methodologies, in conjunction with the meticulous delineation of the developmental process and content evaluation procedure of PREMs, has the potential to augment the scientific rigour of these instruments.The comprehensive competence assessment tools for OR nurses vary in evaluation dimensions and content, but the dimensions of evaluation mostly revolve around the ICN nurse competence theoretical framework.The ICN defines nurse competence as the knowledge, skills, judgment, and personal qualities nurses need to provide safe and ethical services to patients[ 37 ]; Specialized competence assessment tools predominantly concentrate on the TS and NTS of scrub nurses, the NTS of circulating nurses and both.It is evident that research on non-technical skills is gradually increasing, and researchers have found that NTS have a significant impact on the safety of surgical patients and the quality of surgical procedures[ 11 ].Nevertheless, the available assessment tools remain inadequate and require further development and refinement. Structural validity refers to the degree of fit between the scale dimensions and the dimensions of the construct being measured, and is also a prerequisite for explaining internal consistency analysis[ 13 ].Structural validity preferred statistical methods based on item response theory(IRT) analyses,but only the PPCS-R in the United States context used IRT,The COSMIN guidelines prescribe the use of factor analysis for the appraisal of structural validity, considering that CFA is better than EFA.CFA is suitable for situations where the dimensions of the construct being measured are determined, while EFA is suitable for situations where the dimensions of the construct being measured are uncertain. The evaluation tools included in this study mainly applied EFA,and eight studies implemented CFA, this limitation has affected the evaluation of the structural validity of the study. It is recommended that in future development studies of OR nurse competence assessment tools, confirmatory factor analysis should be adopted, and the sample size should be ensured to be sufficient to improve the structural validity of the assessment tools and the methodological quality of their internal consistency.Internal consistency was reported for most instruments except NOTSORN in this study. However, the authors noted that many studies relied solely on Cronbach alpha to assess reliability, which is not sufficient. Just PPCS-R in the United States context,Persian PPCS-R and SPLINTS used other internal consistency indices like Omega coefficient, Pearson’s correlation coefficient.This multidimensional approach facilitates a more comprehensive evaluation of the measurement instrument's reliability, thereby enhancing the credibility of the study results. According to the COSMIN guidelines, there is no gold standard for PROM instruments in principle, except when the original scale is simplified, where case the original scale can be used as the gold standard for newly developed brief scales. the PPCS-R-SF criterion validity study used the PPCS-R as the gold standard, which meet the COSMIN guidelines.criterion validity was assessed through Spearman’s rank correlation analysis ,which was conducted to assess the relationships between the PPCS-R or PPCS-R-SF scores and external variables,like self-efficacy, years of experience in the OR, postgraduate education and previous perioperative speciality training received.Regarding reliability, studies have not clarified whether OR nurses are stable between repeated measurement intervals and whether measurement conditions are similar.Consequently, it is recommended that subsequent studies are appraised in accordance with the COSMIN guidelines, thereby ensuring the integrity and comprehensiveness of the study design and analytic process. This review can inform the selection of appropriate instruments to measure the competence in OR nursing,and we systematically reviewed the 16 assessment instruments following COSMIN guidelines.According to GRADE,the instruments that were incorporated were subsequently categorized into various levels of recommendation..The PPCS-R and the SPLINTS had sufficient (+) ratings.Evidence synthesis identified two strongly recommended: the PPCS-R and the SPLINTS is grade A, and they are recommended for use.The remaining instruments possess the potential for application; however, further research is necessary to assess their quality. The PPCS-R found two groups of competencies in the PPCS-R scale: technical and nontechnical competencies.Technical competencies are represented by the domains Foundational Knowledge and Skills and Proficiency, while nontechnical competencies include Leadership, Collaboration/Collegiality, Empathy, and Professional Development.As a self-assessment tool, the PPCS-R scale focuses on the assessment of the competencies perceived by OR nurses, emphasizing how the perception of competence, which is an integral part of the self-professional image, directly and indirectly influences the role, care performance, job satisfaction, and maintenance of competencies[ 38 ].This scale is the first internationally widely used assessment tool for evaluating perioperative competence.By considering each version and each subscale of a PROM a unique PROM, the ones with the highest quality can be recommended for use in the future[ 13 ],so it is useful to evaluate the measurement properties per different language versions PPCS-R.It has been translated into Arabic, Chinese, Spanish, Swedish, and Turkish, and has conducted cross-sectional surveys in four countries[ 38 ],besides it has developed a brief version of the scale for clinical research.The SPLINTS offer structured observation, rating and feedback on the OR nurses' behaviors during surgery and aims to accelerate the development of NTS in OR nurses ,and is customized for scrub nurses.It has three categories of NTS: situation awareness, communication and teamwork, and task management, and each category has three elements concretizing the NTS. In addition,as an observational instrument, it provided examples of good and poor practice[ 26 ].However, the existing evidence on the measurement properties of these two scales is inconsistent, with significant limitations regarding sample size, cross-cultural validity and responsiveness. These methodological constraints reflect the wider challenge of measuring the competence of OR nurses, and highlight the need to continually generate new evidence based on COSMIN guideline, even for scales currently classified as highly recommended.Future research on competence for OR nurses should advance at both the conceptual and methodological levels simultaneously.Future studies should clarify the content and value of OR nurses’ competence, particularly NTS,which builds a solid theoretical foundation that is crucial for perioperative nurses' future education.Methodologically, future studies should closely follow the COSMIN recommendations for designing research and thoroughly testing psychometric validity.Establishing a measuring system based on strong theoretical foundations and rigorous methodology is a vital step in moving research on OR nurse competence forward. The findings of our study have important implications for nursing education, particularly in the education of operating room nurses. The availability of competence assessment instruments with relatively robust psychometric evidence supports their use in competency-based education to inform curriculum design, identify learning needs, and evaluate educational outcomes.This is particularly evident in non-technical skills such as communication, teamwork, and situational awareness.These skills are imperative for ensuring patient safety,but numerous educational programs do not adequately assess them.Furthermore, the limitations of existing tools underscore the importance for nurse educators to prioritize assessment instruments developed and validated using rigorous standards, such as those recommended by COSMIN. This approach ensures meaningful and reliable evaluation of learners' competencies. 5. Limitations This review has several limitations. First, the analysis was restricted to studies published in Chinese and English, potentially leading to the omission of competence assessment instruments for OR nurses developed and validated in other languages. Second, several of the included instruments were self-reported measures, so discrepancies between self-perceived and actual competencies may exist, which could introduce bias into the assessment results. Finally, the psychometric properties of some instruments were evaluated in only one study, which limits the robustness and generalizability of the available evidence. 6. Conclusion This study systematically evaluated the psychometric properties of instruments used to assess competence of OR nurses in accordance with the COSMIN framework. Based on the available evidence, the PPCS-R and the SPLINTS were identified as the most appropriate instruments and were recommended for use. Future research is encouraged to be guided by the methodological framework outlined in the COSMIN Risk of Bias checklist when developing, refining, and evaluating assessment tools, in order to strengthen the quality and transparency of measurement property evidence.Robust competency assessment is essential for advancing competency-based perioperative nursing education. Declarations Ethics approval and consent to participate Not applicable Consent for publication All authors have read and agreed to the published version of the manuscript. Funding This work was supported by the National Natural Science Foundation of China (No. 52373237) Authors' contributions Xin-xin Xu:Conceptualization, Writing – original draft, Supervision,Methodology, Validation. Yuanyuan Mou:Methodology, Validation. Shiyu Zhou:Methodology, Validation. Weizhen Bai:Methodology, Validation. Lin-li Li:Funding acquisition, Supervision, Writing –review & editing, Project administration. Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements ： We would like to extend our appreciation to all members of the study team for their stimulating discussions and a supportive research environment. Clinical trial number: not applicable. References Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ et al : Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis . BMJ-BRIT MED J 2019, 366 :l4185. McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P: Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals . LANCET 2021, 397 (10288):1905-1913. Aiken LH, Sloane DM, Brom HM, Todd BA, Barnes H, Cimiotti JP, Cunningham RS, McHugh MD: Value of Nurse Practitioner Inpatient Hospital Staffing . MED CARE 2021, 59 (10):857-863. Prahalad CK, Hamel G: Chapter 3 - The Core Competence of the Corporation . In Knowledge and Strategy . Boston: Butterworth-Heinemann; 1999:41-59. Prahalad CK, Hamel G: The Core Competence of the Corporation . HARVARD BUS REV 1990, 68 (3):79-91. ALEXANDER M, RUNCIMAN P: ICN Framework of Competencies for the Generalist Nurse: Report of the Development Process and Consultation . Geneva: Jean-Marteall; 2003. Thomasson BG, Fuller D, Mansour J, Marburger R, Pukenas E: Efficacy of surgical safety checklist: Assessing orthopaedic surgical implant readiness . HEALTHCARE-J DEL SCI 2016, 4 (4):307-311. Jung JJ, Elfassy J, Juni P, Grantcharov T: Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review . WORLD J SURG 2019, 43 (10):2379-2392. Conner R: Perioperative care coordinator nurse competency statements. Nursing Practice Committee. Association of periOperative Registered Nurses . AORN J 1999, 70 (4):618, 621-624, 626. Falk-Brynhildsen K, Jaensson M, Gillespie BM, Nilsson U: Swedish Operating Room Nurses and Nurse Anesthetists' Perceptions of Competence and Self-Efficacy . J PERIANESTH NURS 2019, 34 (4):842-850. Siu J, Maran N, Paterson-Brown S: Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents . SURG-J R COLL SURG E 2016, 14 (3):119-128. Prinsen C, Mokkink LB, Bouter LM, Alonso J, Patrick DL, de Vet H, Terwee CB: COSMIN guideline for systematic reviews of patient-reported outcome measures . QUAL LIFE RES 2018, 27 (5):1147-1157. Mokkink LB, Elsman E, Terwee CB: COSMIN guideline for systematic reviews of patient-reported outcome measures version 2.0 . QUAL LIFE RES 2024, 33 (11):2929-2939. Mei N, Chang L, Zhu Z, Dong M, Zhang M, Zeng L: Core competency scale for operating room nurses in China: Scale development, reliability and validity evaluation . NURS OPEN 2022, 9 (6):2814-2825. Gillespie BM, Polit DF, Hamlin L, Chaboyer W: Developing a model of competence in the operating theatre: psychometric validation of the perceived perioperative competence scale-revised . INT J NURS STUD 2012, 49 (1):90-101. Maio S, Stobinski JX, Gillespie BM: Psychometric evaluation of the United States-adapted perceived perioperative competence scale-revised: A national survey . INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2024, 6 . Jaensson M, Falk-Brynhildsen K, Gillespie BM, Wallentin FY, Nilsson U: Psychometric Validation of the Perceived Perioperative Competence Scale-Revised in the Swedish Context . J PERIANESTH NURS 2018, 33 (4):499-511. Ajorpaz NM, Tafreshi MZ, Mohtashami J, Zayeri F, Rahemi Z: Psychometric Testing of the Persian Version of the Perceived Perioperative Competence Scale--Revised. J NURS MEAS 2017, 25 (3):E162-E172. Sönmez B, Ayoğlu T: Validity and reliability of the Perceived Perioperative Competence Scale-Revised . NURS HEALTH SCI 2019, 21 (4):428-435. Yu Q, Wei R, Wei Y, Wu X, Liang T: Psychometric evaluation of the perceived perioperative competence scale-revised among the Chinese operating room nurses: a methodological research. BMC NURS 2022, 21 (1):79. Gillespie BM, Harbeck E, Sutherland-Fraser S, Nicholson P, Boric T: Psychometric validation of the Perceived Perioperative Competence Scale-Revised Short Form . J ADV NURS 2023, 79 (12):4732-4746. Giammaria C, Panattoni N, Terrenato I, Spano A, De Leo A, Tomei B, Di Simone E, Petrone F: Cross-cultural Adaptation and Validation of the Italian Version of the Revised Perceived Perioperative Competence Scale . J PERIANESTH NURS 2025. Yumei W: Development of Competency Evaluation Index Development of Competency Evaluation Index System for Nurses in Operating Room . 硕士 . Huazhong University of Science and Technology, 护理学; 2015. Li M, Zheng W, Luping J, Qingxin F: Development of the Operating Room Professional Nurses Core Competency Evaluation Scale . Chinese Journal of Modern Nursing 2019, 25 (3):294-298. Sevdalis N, Undre S, Henry J, Sydney E, Koutantji M, Darzi A, Vincent CA: Development, initial reliability and validity testing of an observational tool for assessing technical skills of operating room nurses . INT J NURS STUD 2009, 46 (9):1187-1193. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson G: Development of a behavioural marker system for scrub practitioners' non-technical skills (SPLINTS system) . J EVAL CLIN PRACT 2013, 19 (2):317-323. yin S: Reliability and validity of the Chinese Version of Scrub Practitioners' List of Intraoperative Non-Technical Skills . 硕士 . Tongji University, 护理; 2020. Sirevag I, Hansen BS, Tjoflat I, Gillespie BM: Bi-lingual content validation of the Non-Technical Skills for Operating Room Nurses (NOTSORN) tool: A Delphi study . Int J Nurs Stud Adv 2024, 7 :100218. Kalantari R, Zamanian Z, Hasanshahi M, Jamali J, Faghihi AA, Niakan H, Abbasi J: Development and psychometric evaluation of a behavioral marker system for circulating nurse ’ s non-technical skills . Perioperative Care and Operating Room Management 2021, 23 :100167. Yu Q, Wei R, Wei Y, Wu X, Liang T: Psychometric evaluation of the perceived perioperative competence scale-revised among the Chinese operating room nurses: a methodological research . BMC NURS 2022, 21 (1):79. Gillespie BM, Harbeck E, Sutherland Fraser S, Nicholson P, Boric T: Psychometric validation of the Perceived Perioperative Competence Scale ‐ Revised Short Form. Journal of Advanced Nursing (John Wiley & Sons, Inc.) 2023, 79 (12):4732-4746. Mundt AS, Spanager L, Lyk-Jensen HT, Østergaard D: Adaptation of a tool to assess non-technical skills of scrub practitioners in Denmark . J Perioper Pract 2017, 27 (9):180-185. Mei N, Chang L, Zhu Z, Dong M, Zhang M, Zeng L: Core competency scale for operating room nurses in China: Scale development, reliability and validity evaluation. NURS OPEN 2022, 9 (6):2814-2825. 杨文俊: CDIO 教学模式在手术室专科护士核心能力与自我效能培养中的应用研究 . 硕士 . 遵义医科大学, 护理; 2020. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson G: Evaluation of the Scrub Practitioners' List of Intraoperative Non-Technical Skills system . INT J NURS STUD 2012, 49 (2):201-211. Terwee CB, Prinsen CAC, Chiarotto A, Westerman MJ, Patrick DL, Alonso J, Bouter LM, de Vet HCW, Mokkink LB: COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study . Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 2018, 27 (5):1159-1170. Liu M, Kunaiktikul W, Senaratana W, Tonmukayakul O, Eriksen L: Development of competency inventory for registered nurses in the People's Republic of China: scale development . INT J NURS STUD 2007, 44 (5):805-813. Gillespie BM, Harbeck EB, Falk-Brynhildsen K, Nilsson U, Jaensson M: Perceptions of perioperative nursing competence: a cross-country comparison . BMC NURS 2018, 17 :12. Additional Declarations No competing interests reported. Supplementary Files SupplementalAppendixASearchStrategyandSearchHistory.docx SupplementalAppendixBchecklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 05 Mar, 2026 Editor assigned by journal 04 Mar, 2026 Editor invited by journal 10 Feb, 2026 Submission checks completed at journal 06 Feb, 2026 First submitted to journal 06 Feb, 2026 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8671837","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602673546,"identity":"81c666be-ef07-4080-af8d-def988a27181","order_by":0,"name":"Xinxin Xu","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xinxin","middleName":"","lastName":"Xu","suffix":""},{"id":602673547,"identity":"ec6fde01-66da-43a0-87aa-69e06d995856","order_by":1,"name":"Yuanyuan Mou","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"Mou","suffix":""},{"id":602673548,"identity":"00f446e0-f7f6-42db-9d35-b63964d29a49","order_by":2,"name":"Shiyu Zhuo","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Shiyu","middleName":"","lastName":"Zhuo","suffix":""},{"id":602673549,"identity":"5418099d-1be3-4e42-afa9-af1aa0a71fd5","order_by":3,"name":"Weizhen Bai","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Weizhen","middleName":"","lastName":"Bai","suffix":""},{"id":602673550,"identity":"e528bc07-f315-48f3-b422-79cc7a6b8b14","order_by":4,"name":"Lingli Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie2RMQrCQBBFZ1lImolpR5ScYSEQLAJexSCkChLwAhFBm2Adb+ERlMVUHiCtNwjYBAnoJpWVm1JwXzPNf+z8WQCD4QcZcZ6dAWbocpadaxF6WsXqkgCE4/32ci/S2NcrwDI1CMStXPpYy0iv2Gwj0ydNoUqCSSj4Amx5PekWk8cDISuUkghrBRjHlVZxckJOvYJr1SsYplidMhMUZYMUbAgRVX0QYqDiqBjZ6si5WPiWrovrSvnANpzPpfqgpn15ri3Lr0oP232+q433tMNiBoPB8Ke8AbnWQ0qZuJmxAAAAAElFTkSuQmCC","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Lingli","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2026-01-22 16:24:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8671837/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8671837/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104395242,"identity":"7c88a745-8d70-48a9-a9a0-c4066384ec30","added_by":"auto","created_at":"2026-03-11 11:04:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31139,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram for systematic review.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8671837/v1/1efd7005ef192b7269290a0a.png"},{"id":104406335,"identity":"142b68df-725b-4e91-819b-2922f8f9fd53","added_by":"auto","created_at":"2026-03-11 12:25:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3080376,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8671837/v1/71b2c288-d84c-406f-88f2-d853de03402c.pdf"},{"id":104395243,"identity":"ecce6ff7-52d6-4049-8aa5-26e23b270147","added_by":"auto","created_at":"2026-03-11 11:04:20","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27277,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalAppendixASearchStrategyandSearchHistory.docx","url":"https://assets-eu.researchsquare.com/files/rs-8671837/v1/ae23137806a76d6614ab1c3b.docx"},{"id":104395244,"identity":"c1a0c962-6f22-4088-9603-6ed001bd0be5","added_by":"auto","created_at":"2026-03-11 11:04:20","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":87601,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalAppendixBchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8671837/v1/374f36b3850a0f3c7073b070.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychometric properties of instruments used to measure the competence of operating room nurses: A COSMIN-based systematic review","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eQuality of care and patient safety are arguably the dominant themes of the modern healthcare agenda.Approximately 12% of preventable patient harm causes permanent disability or patient death and is mostly related to therapeutic management,and invasive clinical procedures[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].Enhance nursing competencies in therapeutic management and procedural safety.Decrease in preventable harm,disability and death,improving overall patient safety[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].Competence has been described in various ways; as a combination of specific knowledge, skills, concepts, and values to meet performance standards in a particular context[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].After the concept of competence was introduced into the nursing field, the International Council of Nurses (ICN) defined the competence of the generalist nurse as the knowledge, skills, judgment, and personal attributes required for nurses to fulfill their job responsibilities[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].The cultivation of competence is an important topic in the development of global nursing education.The competence of operating room(OR) nurses significantly affects the quality of nursing care,as well as the outcomes of surgical treatments and patient prognosis[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Association of PeriOperative Registered Nurses (AORN) established evaluation criteria for the competence of operating room nurses at the end of the 20th century, providing reference for other countries around the world[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. At the beginning of the 21st century, the Australian College of Operating Room Nurses (ACORN) focused on the requirements for the competence of scrub nurses.The competence of OR nurses, also known as perioperative nurses,were divided into technical skills and non-technical skills. Technical skills (TS) include theoretical practical knowledge, mastery of aseptic techniques, and strict adherence to various operational procedures, while non-technical skills (NTS), also known as soft skills, mainly include holistic nursing, situation awareness, empathy, collaboration, communication, task management, and teamwork[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. NTS have significant individual differences but are crucial in OR nursing work. The lack of NTS can lead to interruptions in surgery, retained surgical objects, and other adverse events, threatening the safety of surgical patients and even endangering their lives[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the existence of several instruments designed to assess the competence of OR nurses, these tools have been developed in disparate contexts.Consequently, there is no consensus on which tool is the most appropriate and reliable, which has led to confusion among researchers and OR managers when selecting it.To our knowledge,there is no systematic review to summarize all the OR nurses\u0026rsquo; competence assessment tools and report their psychometric properties.Therefore, this study adopt the COSMIN guideline to evaluate instruments,and adopt the GRADE guideline to form recommendations.This study evaluated OR nurses\u0026rsquo; competence instruments using the COSMIN guidelines,and aim to provide an evidence-based assessment tool for the competence of OR nursing teams and lay the foundation for future research.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cp\u003eThis study used the COSMIN guideline for quality assessment of included studies[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e],and was registered on PROSPERO(CRD42024627674)\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1Search strategy\u003c/h2\u003e \u003cp\u003eWe conducted primary searches in PubMed using both MeSH terms and free terms to develop search words.The identified search strategy was confirmed by our research group.This study systematically searched PubMed,Embase,Web of Science,CINAHL,PsycInfo,China National Knowledge Infrastructure(CNKI) and Wanfang Database using the identified search strategy, with the search period from database inception to October 2025.And manually trace the references and related studies to supplement this research.Our search included keywords such as\u0026ldquo;operating room nurs*,\u0026rdquo;\u0026ldquo;theatre nurs*,\u0026rdquo;\u0026ldquo;competenc*,\u0026rdquo;\u0026ldquo;perioperative nurs*,\u0026rdquo;\u0026ldquo;scrub nurs*,\u0026rdquo;\u0026ldquo;circulating nurs*,\u0026rdquo;\u0026ldquo;capacit*,\u0026rdquo;\u0026ldquo;abilit*,\u0026rdquo;\u0026ldquo;questionnaire*,\u0026rdquo; \u0026ldquo;instrument*,\u0026rdquo; \u0026ldquo;tool*,\u0026rdquo;\u0026ldquo;assess*,\u0026rdquo; \u0026ldquo;measure*\u0026rdquo;and\u0026ldquo;scale*.\u0026rdquo; The search strategies provided in Supplemental Appendix A, NoteExpress was used to export and manage the retrieved studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eThe inclusion criteria were as follow: (1) the study was conducted with OR nurses, including circulating nurses and scrub nurses; (2) Research involving the development or validation of measurement instrument of OR nurses\u0026rsquo; competence and evaluate one or more psychometric properties;and(3)studies published in English or Chinese.Exclusion criteria for this study were as follow: (1) unavailability of the full text; (2)non-English or non-Chinese literature; (3)duplicate publications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3Literature screening and data extraction\u003c/h2\u003e \u003cp\u003eAccording to the inclusion and exclusion criteria, two researchers trained in evidence-based methodology independently screened the literature and extracted data,If a consensus could not be reached,a third researcher was consulted to resolve the disagreement.All studies were imported into the NoteExpress software, where they were processed through a series of deduplication, initial screening, and full-text screening steps.The research team determined whether to include them through group discussions.s. We extracted data on (1) Characteristics of the included studies.(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e); (2)Methodological quality and measurement properties evaluation of the included instruments(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); and(3)Summary of results for psychometric properties and evidence(Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4.Assessment of methodological quality\u003c/h2\u003e \u003cp\u003eCOSMIN risk of bias checklist is a consensus-based standard for the selection of health measurement instruments,which can evaluate the methodological quality and measurement properties,and provide recommendations for instrument selection[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].The COSMIN risk of bias checklist has 10 domains and 116 items, including patient-reported outcome measure(PROM) development, content validity, structural validity, internal consistency,cross-cultural validity/measurement invariance, reliability, measurement error, criterion validity, hypotheses testing for construct validity,and responsiveness. Each item has five options, including \u0026ldquo;very good\u0026rdquo;,\u0026ldquo;adequate\u0026rdquo;, \u0026ldquo;doubtful\u0026rdquo;, \u0026ldquo;inadequate\u0026rdquo;, and \u0026ldquo;not applicable\u0026rdquo;. The \u0026ldquo;worst score counts\u0026rdquo; principle was used to determine the overall quality of the study[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5.Measurement properties quality assessment\u003c/h2\u003e \u003cp\u003eWith the COSMIN criteria for good measurement properties,Content validity and other measurement properties could be rated as sufficient(+),insufficient(-),or indeterminate(?).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6.Evidence Level Assessment\u003c/h2\u003e \u003cp\u003eThe modified Grading of Recommendations Assessment,Development,and Evaluation (GRADE) system [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]is used to grade the quality of evidence; the evaluation tools are downgraded based on four criteria: risk of bias, inconsistency, indirectness, and imprecision, with evidence levels being \"high,\" \"moderate,\" \"low,\" or \"very low\";Content validity is \"sufficient\" (any level of evidence),with adequate internal consistency (at least low-quality evidence) was rated as Category A,which is recommended for use.Its measurement attributes are 'inadequate'(at high-quality evidence) was rated as Category C,which is not recommended for use.All others were not in Category A or Category C rated as Category B,which has potential for application, but further research is required to evaluate its quality.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Literature search\u003c/h2\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.,a total of 11154 articles were initially retrieved from the seven databases searching, of which 9527 remained after the removal of duplicates. Subsequently, 9412 articles were excluded after review of their titles and abstracts, and an additional 115 articles were excluded after full-text review. Ultimately, a total of 16 articles were included in the present study after screening for eligibility.The literature screening flowchart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e,The basic characteristics of the included literature are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.This study included a total of 8 evaluation tools, consisting of 4 comprehensive competence evaluation tools and 4 specialized competence evaluation tools.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the included studies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eitem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstrument name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDeveloper/year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOriginal\u003c/p\u003e \u003cp\u003elanguage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTheoretical model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePopulation(N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eContent and/or subscales (items)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eResponse options\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003ecomprehensive competency evaluation tools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe core competency scale for ORNs(CCS_ORN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNa Mei/2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Emergency and problem-solving skills(5 items) 2.Specialist knowledge and skills (12 items) 3.Collaboration and interpersonal communication skills (5 items) 4.Teaching and research capacity (8 items) 5.Laws and regulations and relevant expertise (5 items) 6.Management capabilities and basic skills (7 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5-point scale 0\u0026thinsp;=\u0026thinsp;not competent at all) ;4\u0026thinsp;=\u0026thinsp;very competent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Revised Perioperative\u003c/p\u003e \u003cp\u003eCompetence Scale(PPCS-R)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBrigid M. Gillespie/2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Foundational Knowledge \u0026amp; Skills(9 items) 2.Leadership(8 items) 3.Collaboration(6 items) 4.Proficiency(6 items) 5.Empathy(5 items) 6.Professional Development(6 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5-point Likert response scale ; 1\u0026thinsp;=\u0026thinsp;never;5\u0026thinsp;=\u0026thinsp;always\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe PPCS-R in the United States context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ethe United States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Foundational Knowledge and Skills(9 items) 2.Leadership(8 items) 3.Collaboration(6 items) 4.Proficiency(6 items) 5.Empathy(5 items) 6.Professional Development(6 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eLikert scale;\u0026ldquo;never\u0026rdquo; = 1, \u0026ldquo;sometimes\u0026rdquo; = 2, \u0026ldquo;often\u0026rdquo; = 3, \u0026ldquo;very often\u0026rdquo; = 4, and \u0026ldquo;always\u0026rdquo; = 5.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe PPCS-R in the Swedish context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSwiss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSwedish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Foundational Knowledge and Skills(9 items) 2.Leadership(8 items) 3.Collaboration(6 items) 4.Proficiency(6 items) 5.Empathy(5 items) 6.Professional Development(6 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003efive-point Likert response scale;never\u0026thinsp;=\u0026thinsp;1,always\u0026thinsp;=\u0026thinsp;5.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Persian PPCS-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeda Mirbagher Ajorpaz/2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePersian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Foundational Skills and Knowledge (nine items) 2.Leadership (eight items) 3.Collaboration (six items), 4.Proficiency (six items) 5.Empathy (five items) 6.Professional Development (six items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5-point Likert scale;strongly disagree\u0026thinsp;=\u0026thinsp;1,strongly agree\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Turkish version PPCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTurky\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTurkish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.foundational knowledge and skills(9 items) 2.leadership(8 items) 3.collaboration(6 items) 4.proficiency (6 items) 5.empathy(5 items) 6.professional development(6 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5-point Likert scale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe Chinese Perceived Perioperative Competence Scale-Revised (C-PPCS-R)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Foundational Skills and Knowledge (8 items) 2.Leadership (7 items) 3.Collaboration (5 items), 4.Proficiency (4 items) 5.Empathy (5 items) 6.Professional Development (5 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003efour-point Likert scale;not relevant\u0026thinsp;=\u0026thinsp;1,very relevant\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Perceived Perioperative Competence Scale-Revised Short Form(PPCS-R-SF)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Foundational Skills and Knowledge (3 items) 2.Leadership (3 items) 3.Collaboration (3 items), 4.Proficiency (3 items) 5.Empathy (3 items) 6.Professional Development (3 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003efive-point frequency scale;never\u0026thinsp;=\u0026thinsp;1,always\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Perceived Perioperative Competence Scale\u0026ndash;Revised instrumen into Italian(PPCS-R ITA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eItaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eItalian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Foundational Skills and Knowledge(9 items) 2.Leadership(8 items) 3.Empathy(5 items) 4.Professional Development(6 items) 5.Communication(6 items) 6.Proficiency(6 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFive-point Likert scale (1\u0026thinsp;=\u0026thinsp;never; 5\u0026thinsp;=\u0026thinsp;always)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCompetency Evaluation Index System for Nurses in Operating Room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWang Yumei/2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIcebery model,onion model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.specialized knowledge(8 items) 2.professional ability(5items) 3.personality(8 items) 4.self-motivation(3 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOperating Room Professional Nurses Core Competency Evaluation Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMu Li/2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e433\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.professional development ability(12 items) 2.professional cooperation ability(12 items) 3.professional management ability (10 items) 4.perioperative assessment ability (6 items)5.basic professional ability(5 items).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5-point Likert\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003especialized competency evaluation tools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Imperial College Assessment of\u003c/p\u003e \u003cp\u003eTechnical Skill for Nurses (ICATS-N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNick Sevdalis/2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Gowning and Cloving(3 items) 2.Setting up instrumentation(5 items) 3.Draping(3 items) 4.Maintaining sterile field(4 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6-point Likert;1\u0026thinsp;=\u0026thinsp;Not done well;6\u0026thinsp;=\u0026thinsp;Done very well\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Scrub Practitioners\u0026rsquo; List of Intraoperative Non-Technical Skills(SPLINTS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLucy Mitchel/2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Situation awareness(3 items) 2.Communication and teamwork(3 items)3.ask management(3 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4-point scale;1\u0026thinsp;=\u0026thinsp;poor, 2\u0026thinsp;=\u0026thinsp;marginal, 3\u0026thinsp;=\u0026thinsp;acceptable and 4\u0026thinsp;=\u0026thinsp;good\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe Chinese Version of Scrub Practitioners' List of Intraoperative Non-Technical Skills(C-SPLINTS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e一\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Situation awareness(3 items) 2.Communication and teamwork(3 items)3.ask management(3 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4-point scale;1\u0026thinsp;=\u0026thinsp;poor, 2\u0026thinsp;=\u0026thinsp;marginal, 3\u0026thinsp;=\u0026thinsp;acceptable and 4\u0026thinsp;=\u0026thinsp;good\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe Non-technical Skills for Operating Room Nurses behavioural marker system (NOTSORN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIrene Sirev\u0026aring;g/2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNorwegian and English\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.Professional accountability(2 items) 2. Situational awareness and decision making(4items) 3. Teamwork and communication(3 items) 4. Leadership and\u003c/p\u003e \u003cp\u003etask management(3 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003efour-point scale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe circulating practitioner\u0026rsquo;s list of non-technicalskills(CPLNTS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReza Kalantari/2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.task management(13 items) 2.teamwork(7 items) 3.situational awareness(7 items) 4.communication(9\u003c/p\u003e \u003cp\u003eItems) 5.leadership(7 items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFivepoint scoring system;zero (necessary but not observed) to four\u003c/p\u003e \u003cp\u003e(excellent)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026mdash;\u0026rdquo;Indicates that there is no report.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2.Study description\u003c/h2\u003e \u003cp\u003eThe characteristics of the included studies are delineated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.A total of 7,244 study subjects were included, with sample sizes ranging from 21 to 1,581.Among the included studies, only three were published in Chinese, with the remainder in English.This table lists nine original tools and seven culturally adapted tools.The Revised Perioperative Competence Scale (PPCS-R) is the most widely culturally adapted questionnaire, having been validated in six countries.[\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].All research constructs were the competence of OR nurses,including ST and NST.The original and translated versions of a category of instruments were evaluated individually as separate instruments due to the variations in their items and sub-instrument compositions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Quality assessment\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Methodological quality assessment\u003c/h2\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, of the 16 included studies, only two studies explored more than five psychometric properties[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, there was insufficient information on cross-cultural validity,measurement error and responsiveness. Content validity were consistently reported across all studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Quality of measurement properties\u003c/h2\u003e \u003cp\u003eThe quality of PROM development was assessed as \u0026ldquo;adequate\u0026rdquo; in one studies[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e],which had representative sample of the target population.A total of fifteen studies rated the PROM development study as \u0026lsquo;doubtful,\u0026rsquo; of which ten conducted cognitive interviews with professionals or researchers only[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e];three conducted cognitive interviews or pre-tests with the target population, but it was unclear whether they asked about comprehensibility and comprehensiveness[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]༛two did not describe the research process in detail[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].Content validity was evaluated through cognitive interviews or pilot tests.The quality of content validity was rated as \u0026ldquo;adequate\u0026rdquo; in three studies[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e],where both target population and professionals were consulted regarding the relevance and comprehensiveness of the constructs;these studies employed a sufficiently representative target population and professionals and used appropriate methods to analyze the data.Furthermore,thirteen studies did not provide detailed descriptions of their research designs or data analysis processes for content validity, resulting in the methodological quality of content validity being rated as \u0026lsquo;doubtful.\u0026rsquo;\u003c/p\u003e \u003cp\u003eThe structural validity of the instruments was assessed across 13 studies.In this studies,confirmatory factor analysis (CFA) is the most frequently used method.Two studies employed exploratory factor analysis (EFA).[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e],six studies used both CFA and EFA[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e],and only one applied item response theory[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].Five studies which used both CFA and EFA with adequate sample sizes and no other significant methodological flaws, so the methodological quality was assessed as \u0026lsquo;very good\u0026rsquo;,the Chinese version of SPLINTS had a sample size of less than five times the required amount and was rated as \u0026lsquo;inadequate\u0026rsquo;[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].The PPCS-R in the United States context used item response theory demonstrated sufficient model and sample size, thus resulting in an assessment of its methodological quality as \u0026lsquo;very good\u0026rsquo;[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].Four studies received an \u0026lsquo;doubful\u0026rsquo; rating, primarily due to their limited focus on EFA and inadequate sample size[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].The remaining three studies were characterised by adequate sample sizes and the absence of any other significant methodological weaknesses,consequently they were rated as 'adequate'.Internal consistency was evaluated except NOTSORN,and this study report Cronbach\u0026rsquo;s alpha,and the quality was consistently rated as \u0026lsquo;very good\u0026rsquo;.However,four studies did not report Cronbach\u0026rsquo;s alpha or item-total correlations calculated,and so were consequently rated as \u0026lsquo;doubful\u0026rsquo;[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].Only one study assess measurement invariance by categorizing perioperative nurses into participants with perioperative nursing experience,used multi-group confirmatory factor analysis framework,and did not have other important methodological flaws,so it was rated as \u0026lsquo;very good\u0026rsquo;.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eReliability was assessed in eight studies, which calculated intragroup correlation coefficients (ICC) or Pearson's correlation.Nonetheless, these studies were rated as 'doubful' ,because insufficient information of detailed formula descriptions and information about whether the target population was stable or not and whether the measurement conditions were similar[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].The criterion validity of the PPCS-R-SF was based on other commonly used scales and rated as \u0026lsquo;doubful\u0026rsquo;[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].In terms of hypothesis testing, one study adequately described most of the important characteristics of the known-groups,had no other methodological flaws and was therefore rated as \u0026lsquo;adequate\u0026rsquo;[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe criterion validity of the PPCS-R-SF was based on the previously validated 40-item PPCS-R and meet the COSMIN guideline criteria,therefore it was rated as \u0026lsquo;very good.\u0026rsquo;[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]In terms of hypothesis testing,one study adequately described most of the important characteristics of the subgroup and had no other methodological flaws,PPCS-R was rated as \u0026lsquo;adequate.\u0026rsquo;[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Quality of measurement properties\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the quality of psychometric properties retrieved from included studies.Content validity was assessed for all instruments in sixteen studies, and three instruments were rated as \u0026lsquo;sufficient (+)\u0026rsquo;[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].Thirteen instruments received an \u0026lsquo;inconsistent (\u0026plusmn;)\u0026rsquo;rating[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].Structural validity was assessed for thirteen instruments in sixteen studies, with six instruments received a \u0026lsquo;sufficient (+)\u0026rsquo; rating[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e],and four were rated as \u0026lsquo;insufficient (-)\u0026rsquo;[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and three instruments received an \u0026lsquo;indeterminate (?)\u0026rsquo; rating[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].Internal consistency was assessed for fifteen instruments in sixteen studies,with seven instruments rated as \u0026lsquo;sufficient (+)\u0026rsquo;[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e],and seven studies were assigned a rating of \u0026lsquo;indeterminate (?)\u0026rsquo;[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and only one study rated as \u0026lsquo;indeterminate (?)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Reliability was assessed for eight instruments in sixteen studies, with four instruments rated as \u0026lsquo;sufficient (+)\u0026rsquo;[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e],three instruments rated as \u0026lsquo;indeterminate (?)\u0026rsquo;[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e],and one instrument rated as \u0026lsquo;sufficient (+)\u0026rsquo;[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].Only one study assessed measurement invariance,and PPCS-R in the United States context was rated as \u0026lsquo;sufficient (+)\u0026rsquo;[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].The criterion validity was rated as \u0026lsquo;sufficient(+)\u0026rsquo; for PPCS-R-SF[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e],and hypotheses testing for construct validity was rated as \u0026lsquo;indeterminate (?)\u0026rsquo; for PPCS-R[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMethodological quality and measurement properties evaluation of the included instruments.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"16\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInstrument\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePROM\u003c/p\u003e \u003cp\u003edevelopment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eContent validity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eStructural validity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eInternal consistency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eReliability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003eMeasurement invariance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e \u003cp\u003eCriterion validity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003eHypotheses testing for construct validity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003eMQ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c16\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCS_ORN[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R in the United States context[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersian PPCS-R[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R in the Swedish context[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurkish PPCS-R[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-PPCS-R[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R-SF[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R ITA[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency Evaluation Index System for Nurses in Operating Room[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating Room Professional Nurses Core Competency Evaluation Scale[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICATS-N[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPLINTS[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-SPLINTS[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNOTSORN[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPLNTS[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"16\"\u003eComments: MQ, Methodological quality; QR, Quality of he results rated,V: very good, A: adequate, D: doubtful, I: inadequate; \u0026ldquo;+ \u0026rdquo;: sufficient; \u0026ldquo;-\u0026rdquo;: insufficient, \u0026ldquo;?\u0026rdquo;. .Empty cells indicate that the measurement property was not assessed in the study\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3. Evidence grading and recommendations\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the evidence quality of all PROMs, rated as \u0026lsquo;high,\u0026rsquo; \u0026lsquo;moderate,\u0026rsquo; \u0026lsquo;low,\u0026rsquo; or \u0026lsquo;very low\u0026rsquo; based on downgrading factors including risk of bias, inconsistency, imprecision and indirectness.None of the PROMs were downgraded for inconsistency, imprecision, or indirectness.For risk of bias,the PPCS-R,the SPLINTS and the NOTSORN were rated \u0026lsquo;adequate\u0026rsquo;[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e],so they were not downgraded,while the rest instruments were downgraded one level due to the methodological quality of \u0026lsquo;doubtful\u0026rsquo; for content validity.The methodological quality rating for the structural validity of the Persian PPCS-R,the Turkish PPCS-R and the PPCS-R ITA were \u0026lsquo;doubtful\u0026rsquo;[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], so they was downgraded by one level.The C-SPLINTS was rated \u0026lsquo;inadequate\u0026rsquo;[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e],so it was downgraded by two level,while the rest of the instruments were rated \u0026lsquo;adequate\u0026rsquo; or \u0026lsquo;very good\u0026rsquo;, so they were not downgraded. The methodological quality of the internal consistency of the PPCS-R ITA,the ICATS-N,the SPLINTS and the CPLNTS was \u0026lsquo;doubful\u0026rsquo; and the above four instruments were downgraded one level[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The rest of the instruments were not downgraded, due to the \u0026lsquo;adequate\u0026rsquo; or \u0026lsquo;very good\u0026rsquo; rating. The methodological quality of the reliability of the PPCS-R and the PPCS-R-SF was rated as \u0026lsquo;doubtful\u0026rsquo; and were therefore downgraded one level[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The remaining instruments are rated \u0026lsquo;adequate\u0026rsquo; or \u0026lsquo;very good\u0026rsquo; and do not require downgrading. The methodological quality of the measurement invariance of the PPCS-R in the United States context[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the criterion validity of the PPCS-R-SF[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e],and the hypotheses testing for construct validity of the PPCS-R[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] were \u0026lsquo;adequate\u0026rsquo; or \u0026lsquo;very good\u0026rsquo; and they were not downgraded.For inconsistency, we considered each different language versions of a PROM a unique PROM. In terms of imprecision, the ICATS-N reporting reliability had retest sample sizes of less 50 and were therefore downgraded two level[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].AND sample sizes of 50\u0026ndash;100 of the competence Evaluation Index System for Nurses in OR,therefore downgraded one level[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. None of the studies were indirect, so no downgrading.\u003c/p\u003e \u003cp\u003eThe recommended grades for the sixteen instruments are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. According to the COSMIN guidelines, the content\u003c/p\u003e \u003cp\u003evalidity and internal consistency of the PPCS-R and the SPLINTS are \u0026lsquo;sufficient\u0026rsquo;[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e],and the level of evidence is no less than \u0026lsquo;moderate\u0026rsquo;,making it an A recommendation[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].Furthermore, none of the PROMs have high-level evidence indicating insufficiency(-),resulting in none of the C recommendations. The other fourteen instruments were all category B recommendations with potential for application, but further research is needed to evaluate their psychometric properties.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of results for psychometric properties and evidence.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"16\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInstrument\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eContent validity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eStructural\u003c/p\u003e \u003cp\u003evalidity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eInternal\u003c/p\u003e \u003cp\u003econsistency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eReliability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eMeasurement\u003c/p\u003e \u003cp\u003einvariance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003eCriterion validity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003eHypotheses\u003c/p\u003e \u003cp\u003etesting for construct validity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c16\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRecommended\u003c/p\u003e \u003cp\u003egrade\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eQE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eQE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eQE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003eQE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCS_ORN[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R in the United States context[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersian PPCS-R[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R in the Swedish context[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurkish PPCS-R[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-PPCS-R[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R-SF[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPCS-R ITA[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency Evaluation Index System for Nurses in Operating Room[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating Room Professional Nurses Core Competency Evaluation Scale[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICATS-N[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVery low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPLINTS[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-SPLINTS2020[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNOTSORN[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPLNTS[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComments: (1) Overall rating rated as Sufficient (+), Intermediate (?), Insufficient (\u0026minus;). (2) MQ:Methodological quality; QR:Quality of he results rated,(3) Empty cells indicate that the measurement property was not assessed in the study.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis review evaluated 16 OR nurses\u0026rsquo; competence assessment instruments based the COSMIN guidelines. To our knowledge,our study is the first to comprehensively assess the psychometric properties of competence assessment tools for operating room nurses. This systematic review provides the first comprehensive synthesis and critical evaluation of the operating room nurse competence assessment instruments.\u003c/p\u003e \u003cp\u003eContent validity is the most important psychometric characteristic in the evaluation process, and evaluators should first assess content validity[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The COSMIN guidelines evaluate content validity from the relevance, comprehensiveness, and understand ability of the study.The methodological quality OF development is predominantly rated as \u0026lsquo;doubtful\u0026rsquo;,and issues include item generation based on the opinions of professional nurses but limitations in the representativeness of the sample,lack experienced or trained interviewers, appropriate interview outlines, at least two researchers independently coding, analyzing interview data,which raises concerns about the consistency and reliability of the findings.The present study is limited by the fact that it is based solely on the findings of related studies which interviewed professional OR nurses or managers. In addition,the work of OR nurses is characterised by team cooperation with surgeons, anesthesiologists and others,and teamwork in the OR necessitates a comprehensive understanding of the competence required of OR nurses, as determined by their teamwork members rather than solely by the competencies stipulated by OR nurses themselves.In order to address the aforementioned issues, the utilisation of standardised qualitative methodologies, in conjunction with the meticulous delineation of the developmental process and content evaluation procedure of PREMs, has the potential to augment the scientific rigour of these instruments.The comprehensive competence assessment tools for OR nurses vary in evaluation dimensions and content, but the dimensions of evaluation mostly revolve around the ICN nurse competence theoretical framework.The ICN defines nurse competence as the knowledge, skills, judgment, and personal qualities nurses need to provide safe and ethical services to patients[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]; Specialized competence assessment tools predominantly concentrate on the TS and NTS of scrub nurses, the NTS of circulating nurses and both.It is evident that research on non-technical skills is gradually increasing, and researchers have found that NTS have a significant impact on the safety of surgical patients and the quality of surgical procedures[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].Nevertheless, the available assessment tools remain inadequate and require further development and refinement.\u003c/p\u003e \u003cp\u003eStructural validity refers to the degree of fit between the scale dimensions and the dimensions of the construct being measured, and is also a prerequisite for explaining internal consistency analysis[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].Structural validity preferred statistical methods based on item response theory(IRT) analyses,but only the PPCS-R in the United States context used IRT,The COSMIN guidelines prescribe the use of factor analysis for the appraisal of structural validity, considering that CFA is better than EFA.CFA is suitable for situations where the dimensions of the construct being measured are determined, while EFA is suitable for situations where the dimensions of the construct being measured are uncertain. The evaluation tools included in this study mainly applied EFA,and eight studies implemented CFA, this limitation has affected the evaluation of the structural validity of the study. It is recommended that in future development studies of OR nurse competence assessment tools, confirmatory factor analysis should be adopted, and the sample size should be ensured to be sufficient to improve the structural validity of the assessment tools and the methodological quality of their internal consistency.Internal consistency was reported for most instruments except NOTSORN in this study. However, the authors noted that many studies relied solely on Cronbach alpha to assess reliability, which is not sufficient. Just PPCS-R in the United States context,Persian PPCS-R and SPLINTS used other internal consistency indices like Omega coefficient, Pearson\u0026rsquo;s correlation coefficient.This multidimensional approach facilitates a more comprehensive evaluation of the measurement instrument's reliability, thereby enhancing the credibility of the study results. According to the COSMIN guidelines, there is no gold standard for PROM instruments in principle, except when the original scale is simplified, where case the original scale can be used as the gold standard for newly developed brief scales. the PPCS-R-SF criterion validity study used the PPCS-R as the gold standard, which meet the COSMIN guidelines.criterion validity was assessed through Spearman\u0026rsquo;s rank correlation analysis ,which was conducted to assess the relationships between the PPCS-R or PPCS-R-SF scores and external variables,like self-efficacy, years of experience in the OR, postgraduate education and previous perioperative speciality training received.Regarding reliability, studies have not clarified whether OR nurses are stable between repeated measurement intervals and whether measurement conditions are similar.Consequently, it is recommended that subsequent studies are appraised in accordance with the COSMIN guidelines, thereby ensuring the integrity and comprehensiveness of the study design and analytic process.\u003c/p\u003e \u003cp\u003eThis review can inform the selection of appropriate instruments to measure the competence in OR nursing,and we systematically reviewed the 16 assessment instruments following COSMIN guidelines.According to GRADE,the instruments that were incorporated were subsequently categorized into various levels of recommendation..The PPCS-R and the SPLINTS had sufficient (+) ratings.Evidence synthesis identified two strongly recommended: the PPCS-R and the SPLINTS is grade A, and they are recommended for use.The remaining instruments possess the potential for application; however, further research is necessary to assess their quality.\u003c/p\u003e \u003cp\u003eThe PPCS-R found two groups of competencies in the PPCS-R scale: technical and nontechnical competencies.Technical competencies are represented by the domains Foundational Knowledge and Skills and Proficiency, while nontechnical competencies include Leadership, Collaboration/Collegiality, Empathy, and Professional Development.As a self-assessment tool, the PPCS-R scale focuses on the assessment of the competencies perceived by OR nurses, emphasizing how the perception of competence, which is an integral part of the self-professional image, directly and indirectly influences the role, care performance, job satisfaction, and maintenance of competencies[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].This scale is the first internationally widely used assessment tool for evaluating perioperative competence.By considering each version and each subscale of a PROM a unique PROM, the ones with the highest quality can be recommended for use in the future[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e],so it is useful to evaluate the measurement properties per different language versions PPCS-R.It has been translated into Arabic, Chinese, Spanish, Swedish, and Turkish, and has conducted cross-sectional surveys in four countries[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e],besides it has developed a brief version of the scale for clinical research.The SPLINTS offer structured observation, rating and feedback on the OR nurses' behaviors during surgery and aims to accelerate the development of NTS in OR nurses ,and is customized for scrub nurses.It has three categories of NTS: situation awareness, communication and teamwork, and task management, and each category has three elements concretizing the NTS. In addition,as an observational instrument, it provided examples of good and poor practice[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].However, the existing evidence on the measurement properties of these two scales is inconsistent, with significant limitations regarding sample size, cross-cultural validity and responsiveness. These methodological constraints reflect the wider challenge of measuring the competence of OR nurses, and highlight the need to continually generate new evidence based on COSMIN guideline, even for scales currently classified as highly recommended.Future research on competence for OR nurses should advance at both the conceptual and methodological levels simultaneously.Future studies should clarify the content and value of OR nurses\u0026rsquo; competence, particularly NTS,which builds a solid theoretical foundation that is crucial for perioperative nurses' future education.Methodologically, future studies should closely follow the COSMIN recommendations for designing research and thoroughly testing psychometric validity.Establishing a measuring system based on strong theoretical foundations and rigorous methodology is a vital step in moving research on OR nurse competence forward.\u003c/p\u003e \u003cp\u003eThe findings of our study have important implications for nursing education, particularly in the education of operating room nurses. The availability of competence assessment instruments with relatively robust psychometric evidence supports their use in competency-based education to inform curriculum design, identify learning needs, and evaluate educational outcomes.This is particularly evident in non-technical skills such as communication, teamwork, and situational awareness.These skills are imperative for ensuring patient safety,but numerous educational programs do not adequately assess them.Furthermore, the limitations of existing tools underscore the importance for nurse educators to prioritize assessment instruments developed and validated using rigorous standards, such as those recommended by COSMIN. This approach ensures meaningful and reliable evaluation of learners' competencies.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis review has several limitations. First, the analysis was restricted to studies published in Chinese and English, potentially leading to the omission of competence assessment instruments for OR nurses developed and validated in other languages. Second, several of the included instruments were self-reported measures, so discrepancies between self-perceived and actual competencies may exist, which could introduce bias into the assessment results. Finally, the psychometric properties of some instruments were evaluated in only one study, which limits the robustness and generalizability of the available evidence.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThis study systematically evaluated the psychometric properties of instruments used to assess competence of OR nurses in accordance with the COSMIN framework. Based on the available evidence, the PPCS-R and the SPLINTS were identified as the most appropriate instruments and were recommended for use. Future research is encouraged to be guided by the methodological framework outlined in the COSMIN Risk of Bias checklist when developing, refining, and evaluating assessment tools, in order to strengthen the quality and transparency of measurement property evidence.Robust competency assessment is essential for advancing competency-based perioperative nursing education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation of China (No. 52373237)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXin-xin Xu:Conceptualization, Writing \u0026ndash; original draft, Supervision,Methodology, Validation.\u003c/p\u003e\n\u003cp\u003eYuanyuan Mou:Methodology, Validation.\u003c/p\u003e\n\u003cp\u003eShiyu Zhou:Methodology, Validation.\u003c/p\u003e\n\u003cp\u003eWeizhen Bai:Methodology, Validation.\u003c/p\u003e\n\u003cp\u003eLin-li Li:Funding acquisition, Supervision, Writing \u0026ndash;review \u0026amp; editing, Project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eWe would like to extend our appreciation to all members of the study team for their stimulating discussions and a supportive research environment.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical trial number:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePanagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003ePrevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eBMJ-BRIT MED J\u003c/em\u003e 2019, \u003cstrong\u003e366\u003c/strong\u003e:l4185.\u003c/li\u003e\n\u003cli\u003eMcHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P: \u003cstrong\u003eEffects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals\u003c/strong\u003e. \u003cem\u003eLANCET\u003c/em\u003e 2021, \u003cstrong\u003e397\u003c/strong\u003e(10288):1905-1913.\u003c/li\u003e\n\u003cli\u003eAiken LH, Sloane DM, Brom HM, Todd BA, Barnes H, Cimiotti JP, Cunningham RS, McHugh MD: \u003cstrong\u003eValue of Nurse Practitioner Inpatient Hospital Staffing\u003c/strong\u003e. \u003cem\u003eMED CARE\u003c/em\u003e 2021, \u003cstrong\u003e59\u003c/strong\u003e(10):857-863.\u003c/li\u003e\n\u003cli\u003ePrahalad CK, Hamel G: \u003cstrong\u003eChapter 3 - The Core Competence of the Corporation\u003c/strong\u003e. 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List of Intraoperative Non-Technical Skills system\u003c/strong\u003e. \u003cem\u003eINT J NURS STUD\u003c/em\u003e 2012, \u003cstrong\u003e49\u003c/strong\u003e(2):201-211.\u003c/li\u003e\n\u003cli\u003eTerwee CB, Prinsen CAC, Chiarotto A, Westerman MJ, Patrick DL, Alonso J, Bouter LM, de Vet HCW, Mokkink LB: \u003cstrong\u003eCOSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study\u003c/strong\u003e. \u003cem\u003eQuality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation\u003c/em\u003e 2018, \u003cstrong\u003e27\u003c/strong\u003e(5):1159-1170.\u003c/li\u003e\n\u003cli\u003eLiu M, Kunaiktikul W, Senaratana W, Tonmukayakul O, Eriksen L: \u003cstrong\u003eDevelopment of competency inventory for registered nurses in the People\u0026apos;s Republic of China: scale development\u003c/strong\u003e. \u003cem\u003eINT J NURS STUD\u003c/em\u003e 2007, \u003cstrong\u003e44\u003c/strong\u003e(5):805-813.\u003c/li\u003e\n\u003cli\u003eGillespie BM, Harbeck EB, Falk-Brynhildsen K, Nilsson U, Jaensson M: \u003cstrong\u003ePerceptions of perioperative nursing competence: a cross-country comparison\u003c/strong\u003e. \u003cem\u003eBMC NURS\u003c/em\u003e 2018, \u003cstrong\u003e17\u003c/strong\u003e:12. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Instruments, Systematic review, Measurement properties, Operating room nurse, competence, Evaluation tools","lastPublishedDoi":"10.21203/rs.3.rs-8671837/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8671837/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003c/em\u003eThis systematic review aimed to evaluate competence instruments for operating room nurses,in order to provide evidence-based support for selecting the most appropriate instrument for specific populations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/em\u003eThe operating room nurses’ competence significantly affects the quality of nursing care, as well as the outcomes of surgical treatments and patient prognosis.Despite the development of various instruments designed to assess the operating room nurses’ competence, a comprehensive and rigorous systematic review that provides an overview and critical appraisal of these instruments is currently lacking. Consequently,a systematic review of the measurement properties of such instruments is essential.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDesign: \u003c/strong\u003e\u003c/em\u003eSystematic review of measurement properties following the COSMIN guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods：\u003c/strong\u003e\u003c/em\u003eRelevant studies were searched on seven English databases and four Chinese databases from inception to October 2025.The eligible studies were reviewed to identify the competence measured by the instruments for operating room nurses. The psychometric properties of instruments in development and psychometric testing design studies were also examined. The COSMIN checklist was used to assess the studies' methodological quality.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003eA total of 16 instruments were included,and included instruments assessed only two to four psychometric properties.No studies report measurement error and responsiveness.The PPCS-R and the SPLINTS were rated as A recommendations, while the remaining instruments were rated as B recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003e\u003c/em\u003eThe study identified the PPCS-R and the SPLINTS as appropriate measures for assessing the competence of operating room nurses.Future research should adhere to the COSMIN methodological standards to strengthen the development and validation of competence assessment tools.\u003c/p\u003e","manuscriptTitle":"Psychometric properties of instruments used to measure the competence of operating room nurses: A COSMIN-based systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 11:04:12","doi":"10.21203/rs.3.rs-8671837/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-06T04:36:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T08:01:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T02:49:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-06T08:41:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-02-06T08:11:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4088b2bc-627c-4e25-bec4-76ae3f3427f0","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T11:04:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 11:04:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8671837","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8671837","identity":"rs-8671837","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}