CoChat
Sign Up
Cited by 1Clinical Reasoning and Diagnostic SkillsHealth Education and ValidationSimulation-Based Education in Healthcare

Turkish adaptation of the clinical reasoning evaluation simulation tool (CREST-TR): a validity and reliability study

Open access
Bayzat, Cigdem, Dinc, Leyla·2025·BMC Nursing
DOI 10.1186/s12912-025-03503-0PMC PMC12220264
Open this paper in CoChat — free accountOpen PDF

Abstract

BACKGROUND: To enhance the clinical reasoning skills of nursing students, it is essential to assess their level of clinical reasoning using valid and reliable measurement tools. The aim of this study was to adapt Clinical Reasoning Evaluation Simulation Tool to Turkish by ensuring its translation-back translation and content validity, testing its psychological properties, including the construct validity and reliability, and evaluating its usability. METHODS: This methodological study was conducted in three phases. The first phase involved examining the language and content validity of the tool. The second phase focused on assessing the construct validity and reliability of the tool with 26 third-year and 26 fourth-year nursing students enrolled at faculty of nursing of a state university who undertook the simulation-based assessment. The third phase involved evaluating its usability by six educators. RESULTS: After the linguistic validation of the tool, the content validity index (CVI) was calculated as 0.91 based on the opinions of five field experts. Following exploratory factor analysis, items 1 and 8 with factor loadings below 0.30, were excluded from the tool. The first item pertained to the domain of "considering the patient situation", while the eighth item involved to domain of "taking actions" using the "ISBAR" framework for effective communication. The tool was validated as a unidimensional consisting of seven domains and eight items with factor loadings ranging from 0.58 to 0.76. Confirmatory factor analysis revealed that all fit index values showed satisfactory fit. AGFI (0.852) and SRMR (0.058) values were found to have acceptable fits, while χ²/SD (1.091), GFI (0.911), NFI (0.909), NNFI (0.986), CFI (0.991) and RMSEA (0.042) values provided good fits. Cronbach's alpha for the total tool was 0.88. The usability of the tool was positively evaluated by educators, although one educator disagreed regarding its ease of interpretation, clarity of descriptors, and user-friendliness. CONCLUSION: The Turkish version of the Clinical Reasoning Evaluation Simulation Tool was found to be a valid and reliable tool. This tool provides a concrete and objective evaluation of nursing students' clinical reasoning levels during simulation by instructors. In addition, the tool provides feedback on aspects that need improvement in line with the students' clinical reasoning performances. CLINICAL TRIAL NUMBER: Not applicable.

AI snapshot

Written from the paper’s full text.

TL;DR

This methodological study adapted the Clinical Reasoning Evaluation Simulation Tool (CREST) into Turkish and tested its validity and reliability among nursing students. The resulting CREST-TR was supported as a valid and reliable unidimensional tool with seven domains and eight items.

Key findings

  • Content validity index was 0.91 based on five field experts; after EFA, items 1 and 8 were removed because their factor loadings were below 0.30 (0.27 and 0.24, respectively).
  • The final CREST-TR was unidimensional with seven domains and eight items, factor loadings 0.58–0.76, accounting for 55.1% of total variance; CFA fit values included χ²/SD = 1.091, GFI = 0.911, NFI = 0.909, NNFI = 0.986, CFI = 0.991, RMSEA = 0.042, AGFI = 0.852, and SRMR = 0.058.
  • Cronbach’s alpha for the total tool was 0.88; interrater reliability ranged from ICC = 0.73 to 0.97 by item, with total CREST-TR ICC = 0.98.
  • Fourth-year students had higher mean scores than third-year students on several domains and total CREST-TR, but the difference was not statistically significant (total: 20.92 ± 3.969 vs. 20.85 ± 3.936; p = 0.944). Usability was positively evaluated by educators, though one educator disagreed regarding ease of interpretation, clarity of descriptors, and user-friendliness.

Methods

  • Three-phase methodological study conducted October 2022–December 2023: language/content validity, construct validity/reliability, and usability testing.
  • Construct validity and reliability were tested with 52 nursing students (26 third-year and 26 fourth-year) using convenience sampling; students completed a high-fidelity simulation of a critical patient scenario lasting 15 minutes, and two educators rated video-recorded performances using CREST.
  • Analyses included EFA and CFA, Cronbach’s alpha, ICC, independent samples t-tests, and Pearson correlation; usability was assessed by six educators using a 10-item, 4-point Likert questionnaire.

Limitations

  • The paper states the study was conducted with a small sample of third- and fourth-year students from one university, which may limit generalizability.
  • The paper states predictive validity could not be examined because no suitable Turkish criterion tool was available.
  • The paper states students engaged in the simulation only once and recommends further studies with larger samples in national and international contexts; the text also makes evident that the convenience sample and single-scenario design may constrain broader claims.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12912-025-03503-0

Cites

44 of 44 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

10 of 28 cited sources checked · 2 supported · 1 flagged · accuracy not yet measured

  • Premisecitation

    The Lasater Clinical Judgement Rubric (LCJR) focuses on assessing clinical judgement, not the broader spectrum of nursing students' clinical reasoning.

    “The LCJR focuses on assessing clinical judgement, not the broader spectrum of nursing students’ clinical reasoning [19].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Brentnall J, Thackray D, Judd B. Evaluating the clinical reasoning of student health professionals in placement and simulation settings: A systematic review. Int J Env Res Pub He. 2022;19(2):1–15. https://doi.org/10.3390/ijerph19020936. source

      The Results (§3.1) describe the LCJR as assessing nursing students’ clinical judgement. But the Discussion (§4.4; page not available in our copy) says the rubric addresses multiple components consistent with broad definitions of clinical reasoning, contrary to the claim that it does not assess that broader spectrum. (LLM, conf=0.87)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Study design and conductcitation

    A minimum sample size of 52 nursing students was calculated based on a significance level of 0.05, an effect size (d) of 0.8, and 80% power.

    “A minimum sample size of 52 nursing students was calculated based on a significance level of 0.05, an effect size (d) of 0.8, and 80% power [33].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [33] Faul F, Erdfelder E, Lang AG, Buchner A. G* power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–91. source

      The Program Handling section (page unavailable) explains that G*Power calculates a required sample size from inputs including effect size, significance level, and desired power. It does not report a calculation yielding 52 nursing students, so the cited paper supports the calculation method but not that study-specific result. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Findingown data

    The evaluation of outcomes score had a low positive and significant linear relationship with the overall academic score (r = 0.292; p < 0.05).

    “While it was observed that there was a low positive significant linear relationship between the evaluation of outcomes score and the overall academic score (r = 0.292; p < 0.05)”
    Quote in the paperNot a substantial claim
  • Findingown data

    Cronbach's alpha for the total CREST-TR tool was 0.88.

    “Cronbach’s alpha for the total tool was 0.88.”
    Quote in the paperSubstantial claim
  • Findingown data

    The content validity index (CVI) of the Turkish CREST was 0.91 based on the opinions of five field experts.

    “After the linguistic validation of the tool, the content validity index (CVI) was calculated as 0.91 based on the opinions of five field experts.”
    • Also stated in: § Content validity · plain
      “Subsequently, the content validity index for each item was calculated to be 0.91.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 19
  • May combine two claims. 24

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The CRCS's validity and reliability have been confirmed, but further testing of its psychometric properties is recommended due to unanalysed item difficulty levels.

    “While its validity and reliability have been confirmed, further testing of its psychometric properties is recommended due to unanalysed item difficulty levels.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Bae, et al. [24] Bae J, Lee J, Choi M, Jang Y, Park CG, Lee YJ. Development of the clinical reasoning competency scale for nurses. BMC Nurs. 2023;22(1):138. https://doi.org/10.1186/s12912-023-01244-6. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Nurse Clinical Reasoning Scale (NCRS) evaluates the clinical reasoning levels of nurses and nursing students nearing graduation.

    “Another tool, the Nurse Clinical Reasoning Scale (NCRS), developed by Liao, et al. [22], evaluates the clinical reasoning levels of nurses and nursing students nearing graduation.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Liao, et al. [22] Liao HC, Yang YM, Li TC, Cheng JF, Huang LC. The effectiveness of a clinical reasoning teaching workshop on clinical teaching ability in nurse preceptors. J Nurs Manage. 2019;27(5):1047–54. https://doi.org/10.1111/jonm.12773. source

      Section 3.4 (Instruments; page unavailable) identifies the study's instruments as the Knowledge and Self-efficacy of Clinical Reasoning Teaching questionnaire (KSECRT) and the Cleveland Clinics Teaching Effectiveness Instrument (CCTEI). Searches for the Nurse Clinical Reasoning Scale and NCRS found no passage saying that Liao et al. developed it or that it evaluates nurses and nursing students nearing graduation. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    An insufficient level of clinical reasoning ability is a primary cause of cognitive errors in patient care and poses threats to patient safety, such as unnecessary pain, treatments, or procedures, and increased healthcare costs.

    “An insufficient level of clinical reasoning ability is identified as a primary cause of cognitive errors in patient care and poses threats to patient safety, such as unnecessary pain, treatments, or procedures, as well as increased healthcare costs [9, 10].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [9] Parodis I, Andersson L, Durning SJ, Hege I, Knez J, Kononowicz AA, et al. Clinical reasoning needs to be explicitly addressed in health professions curricula: recommendations from a European consortium. Int J Env Res Pub He. 2021;18(21):11202. https://www.mdpi.com/1660-4601/18/21/11202. source

      The Introduction (page not provided) says inadequate clinical reasoning threatens patient safety and may lead to inappropriate treatment or procedures and suboptimal use of societal resources. Results §3.5 (page not provided) addresses cognitive errors in clinical reasoning, but the paper does not identify insufficient ability as a primary cause of those errors or specifically mention unnecessary pain or increased healthcare costs. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [10] The DID-ACT. Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators 2022. https://did-act.eu/. Accessed February 8, 2024.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    A pilot application was conducted with ten nursing students to assess the critical patient scenario's appropriateness and equipment adequacy before the construct validity and reliability study.

    “Prior to the construct validity and reliability study, a pilot application was conducted with ten nursing students to assess the scenario’s appropriateness and equipment adequacy [34].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [34] Watts PI, McDermott DS, Alinier G, Charnetski M, Ludlow J, Horsley E, et al. Healthcare simulation standards of best practicetm simulation design. Clin Simul Nurs. 2021;58:14–21. https://doi.org/10.1016/j.ecns.2021.08.009. source

      Criterion 11 (Required Elements, pp. 14–21) recommends pilot-testing simulation experiences before full implementation to assess whether they meet their intended purpose. It does not report a pilot application with ten nursing students, an assessment of equipment adequacy, or the stated sequence before a construct-validity and reliability study. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Adaptation and testing of measurement instruments across different international contexts saves time, facilitates quantitative comparisons between cultures over time, increases the generalizability of data, and contributes evidence for evaluating outcomes and developing effective interventions.

    “The adaptation and testing of measurement instruments across different international contexts not only saves time required to develop a new measurement, but also facilitates quantitative comparisons between cultures over time. This helps to increase the generalizability of data and contribute to evidence for evaluating outcomes and developing effective interventions [27–29].”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [27] Arafat SMY, Chowdhury HZR, Qusar MMAS, Hafez MA. Cross-cultural adaptation and psychometric validation of research instruments: A methodological review. J Behav Health. 2016;5(3):129–36. https://doi.org/10.5455/jbh.20160615121755. source
    • cites [28] Çapık C, Gözüm S, Aksayan S. Kültürlerarası Ölçek Uyarlama aşamaları, Dil ve kültür Uyarlaması: güncellenmiş Rehber. Flor Nightingale J Nurs. 2018;26(3). https://doi.org/10.26650/FNJN397481. source

      The Extended Abstract (page unavailable) says adapted scales save time, increase the generalizability of collected data, and enable comparisons between societies. It also says valid and reliable tools help measure nursing-care outcomes. It does not specifically support comparisons over time or the development of effective interventions. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [29] Cruchinho P, López-Franco MD, Capelas ML, Almeida S, Bennett PM, Miranda da Silva M, et al. Translation, Cross-Cultural adaptation, and validation of measurement instruments: A practical guideline for novice researchers. J Multidiscip Healthc. 2024;17:2701–28. https://doi.org/10.2147/JMDH.S419714. source

      The Introduction (page unavailable) says cross-cultural adaptation facilitates comparisons between cultures, measurement of outcomes over time, and identification of factors relevant to effective interventions. It does not say adaptation saves time compared with developing a new instrument or specifically increases the generalizability of data. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Clinical Reasoning Competency Scale (CRCS) includes items for planning, organising intervention strategies, and self-education.

    “The Clinical Reasoning Competency Scale (CRCS) developed by Bae, et al. [24] includes items for planning, organising intervention strategies, and self-education.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Bae, et al. [24] Bae J, Lee J, Choi M, Jang Y, Park CG, Lee YJ. Development of the clinical reasoning competency scale for nurses. BMC Nurs. 2023;22(1):138. https://doi.org/10.1186/s12912-023-01244-6. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A sufficient sample size for a one-factor CFA with eight items and factor loadings of 0.8 could be at least 30 respondents for meaningful patterns of association between variables.

    “The study by Wolf, et al. [42] revealed that a sufficient sample size for a one-factor CFA with eight items and factor loadings of 0.8 could be at least 30 respondents for meaningful patterns of association between variables.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Wolf, et al. [42] Wolf EJ, Harrington KM, Clark SL, Miller MW. Sample size requirements for structural equation models: an evaluation of power, bias, and solution propriety. Educ Psychol Meas. 2013;73(6):913–34. https://doi.org/10.1177/0013164413495237. source

      The Method section says the study evaluated one-factor CFAs with eight indicators loading at .80, and the Discussion reports a minimum of 30 cases for a one-factor CFA. But the Discussion assigns that 30-case figure to four indicators, not eight; the Results instead report 60 for four indicators and do not state a minimum for eight indicators at .80. Our copy therefore does not establish the claimed eight-item, 30-respondent threshold. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    The usability of the CREST-TR was positively evaluated by educators, although one educator disagreed regarding its ease of interpretation, clarity of descriptors, and user-friendliness.

    “The usability of the tool was positively evaluated by educators, although one educator disagreed regarding its ease of interpretation, clarity of descriptors, and user-friendliness.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The confirmatory factor analysis of the CREST-TR measurement model showed acceptable fit for AGFI (0.852) and SRMR (0.058), and good fit for χ2/sd (1.091), GFI (0.911), NFI (0.909), NNFI (0.986), CFI (0.991), and RMSEA (0.042).

    “goodness-of-fit index (AGFI = 0.852) and standardised root mean square residual (SRMR = 0.058) values were found to have acceptable fits, while χ²/sd (1.091), goodness-of-fit index (GFI = 0.911), normed fit index (NFI = 0.909), non-normed fit index (NNFI = 0.986), comparative fit index (CFI = 0.991) and root mean square of error approximation (RMSEA = 0.042) values provided good fits.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Fourth-year students achieved higher average scores than third-year students on identifying problems, establishing goals, taking actions, evaluating outcomes, reflecting on the process and new learning, and on the total CREST-TR score.

    “The fourth-year students achieved higher average scores than the third-year students in items such as identifying problems, establishing goals, taking actions, evaluating outcomes, reflecting on the process and new learning. Additionally, the total mean CREST-TR score for the fourth-year students was higher than that of the third-year students.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In this study with 52 nursing students, exploratory factor analysis showed that the Turkish version of the Clinical Reasoning Evaluation Simulation Tool was one-dimensional and had eight items after removal of two items with factor loadings below 0.30.

    “In this study conducted with 52 nursing students, exploratory factor analysis revealed that the Turkish version of the Clinical Reasoning Evaluation Simulation Tool was one-dimensional and the number of items was eight after the removal of two items with factor loadings below 0.30.”
    • Also stated in: § Conclusion · plain
      “Two items in the original tool were excluded from the CREST-TR.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    All educators who evaluated the usability of the CREST-TR affirmed their intention to employ the tool for assessing students' performance and emphasised its flexibility in evaluating clinical reasoning, its utility in offering formative feedback, and its effectiveness in assessing performance and clinical reasoning.

    “All educators who evaluated the usability of the CREST-TR affirmed their intention to employ the tool for assessing students’ performance. At same time, all of them emphasised its flexibility in evaluating clinical reasoning, its utility in offering formative feedback, and its effectiveness in assessing performance and clinical reasoning.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The CREST-TR, consisting of 8 items, was found to be highly reliable with a Cronbach's alpha of 0.88.

    “As a result of the reliability analysis, the CREST-TR, consisting of 8 items, was found to be highly reliable (Cronbach’s alpha of 0.88).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The CREST-TR was validated as a unidimensional tool consisting of seven domains and eight items, with factor loadings ranging from 0.58 to 0.76.

    “The tool was validated as a unidimensional consisting of seven domains and eight items with factor loadings ranging from 0.58 to 0.76.”
    • Also stated in: § Construct validity · plain
      “The tool was validated as a unidimensional consisting of seven domains and eight items with factor loadings ranging between 0.58 and 0.76.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Interrater reliability of the CREST-TR was excellent for collecting cues (ICC = 0.96), identifying problem (ICC = 0.95), taking actions (ICC = 0.97), overall rating (ICC = 0.94), and total CREST-TR (ICC = 0.98); high for processing information (ICC = 0.88); and good for establishing goals (ICC = 0.81), evaluating outcomes (ICC = 0.76), and reflecting on the process and new learning (ICC = 0.73).

    “collecting cues (ICC = 0.96; confidence interval 0.93–0.98), identifying problem (ICC = 0.95; confidence interval 0.92–0.97), taking actions (ICC = 0.97; confidence interval 0.95–0.98), overall rating (ICC = 0.94; confidence interval 0.89–0.96), and total CREST-TR (ICC = 0.98; confidence interval 0.96–0.99) level of compliance was excellent in terms of scores”
    • Also stated in: § Interrater reliability · plain
      “processing information (ICC = 0.88; confidence interval 0.80–0.93) compliance level was high; establishing goals (ICC = 0.81; confidence interval 0.69–0.89) and evaluating outcomes (ICC = 0.76; confidence interval 0,58 − 0,86), reflecting on the process and new learning (ICC = 0.73; confidence interval 0.73–0.91) compliance level was good in terms of scores (p < 0.001).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    The CREST-TR consists of seven domains and eight items.

    “CREST-TR consists of seven domains and eight items.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For the CREST-TR CFA model, AGFI (0.852) and SRMR (0.058) had acceptable fits.

    “AGFI (0.852) and SRMR (0.058) values were found to have acceptable fits”
    • Also stated in: § Construct validity · plain
      “the adjusted goodness-of-fit index (AGFI = 0.852) and standardised root mean square residual (SRMR = 0.058) values were found to have acceptable fits”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The original CREST has established construct validity, concurrent validity, and predictive validity, with high internal consistency (Cronbach's alpha 0.92) and interrater reliability (ICC 0.88).

    “Construct validity, concurrent validity, and predictive validity have been established, with high internal consistency (Cronbach’s alpha of 0.92) and interrater reliability (intraclass correlation coefficient of 0.88) [25].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, et al. Development and psychometric testing of a clinical reasoning evaluation simulation tool (CREST) for assessing nursing students’ abilities to recognize and respond to clinical deterioration. Nurs Educ Today. 2018;62:74–9. https://doi.org/10.1016/j.nedt.2017.12.009. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The original CREST includes 11 items, with the first 10 items grouped under eight domains using a five-point Likert scale (1-5).

    “It includes a total of 11 items. Of which the first 10 items are grouped under the eight domains using a five-point Likert scale (1–5).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, et al. Development and psychometric testing of a clinical reasoning evaluation simulation tool (CREST) for assessing nursing students’ abilities to recognize and respond to clinical deterioration. Nurs Educ Today. 2018;62:74–9. https://doi.org/10.1016/j.nedt.2017.12.009. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The script concordance test (SCT) is designed primarily for diagnostic medical scenarios and scores examinees based on their agreement with expert panel answers.

    “The SCT is designed primarily for diagnostic medical scenarios, scoring examinees based on their agreement with expert panel answers.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Charlin B, Roy L, Brailovsky C, Goulet F, van der Vleuten C. The script concordance test: A tool to assess the reflective clinician. Teach Learn Med. 2000;12(4):189–95. https://doi.org/10.1207/S15328015TLM1204_5. source

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The acceptable goodness-of-fit level for AGFI, GFI, NFI, NNFI, and CFI is ≥ 0.90, with ≥ 0.95 considered good; for SRMR and RMSEA it is below 0.08, with below 0.05 indicating good fit.

    “The acceptable goodness-of-fit level for the AGFI, GFI, NFI, NNFI and CFI is ≥ 0.90, and a value of ≥ 0.95 is considered good. The acceptable goodness-of-fit level for the SRMR and RMSEA is below 0.08, and a value below 0.05 indicates good fit [50].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [50] Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model: Multidisciplinary J. 1999;6(1):1–55. https://doi.org/10.1080/10705519909540118. source

  • May combine two claims.

    Interpretationown data

    The Turkish version of the Clinical Reasoning Evaluation Simulation Tool is a valid and reliable tool.

    “The Turkish version of the Clinical Reasoning Evaluation Simulation Tool was found to be a valid and reliable tool.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Students’ clinical reasoning level can be validly assessed from their performance in a high-fidelity simulation scenario.
    • Rests on an assumption: The critical patient scenario devised for the study adequately elicits the clinical reasoning domains measured by CREST-TR.

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The intra-class correlation coefficient (ICC) was used to evaluate intra/inter-rater reliability.

    “The intra-class correlation coefficient (ICC) was used to evaluate intra/inter-rater reliability [35].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] Alpar R, Spor. Sağlık ve Eğitim bilimlerinden Örneklerle Uygulamalı İstatistik ve Geçerlik-Güvenirlik. Detay Yayıncılık. 2022.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    Kolmogorov‒Smirnov normality test was applied to all scores, and since all scores met the assumption of normality, parametric tests were used for comparisons.

    “In order to decide on the analyses to be applied, Kolmogorov‒Smirnov normality test was applied to all scores. Since all scores met the assumption of normality, parametric tests were utilised for comparisons.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Items with factor loadings below 0.30 should be removed from the tool.

    “In the literature, items with factor loadings below 0.30 should be removed from the tool [35].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] Alpar R, Spor. Sağlık ve Eğitim bilimlerinden Örneklerle Uygulamalı İstatistik ve Geçerlik-Güvenirlik. Detay Yayıncılık. 2022.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    The CREST was translated from English to Turkish independently by three experts, and a professional translator back-translated the Turkish version into English to ensure alignment with the original tool.

    “The CREST was initially translated from English to Turkish independently by three different experts.”
    • Also stated in: § First phase: language and content validity · plain
      “Subsequently, a professional translator back-translated the Turkish version into English to ensure alignment with the original tool.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Cross-cultural adaptation of psychometric instruments is crucial to ensure their validity and reliability across different cultural settings.

    “Cross-cultural adaptation of psychometric instruments is crucial to ensure their validity and reliability across different cultural settings [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] World Health Organization. WHO guidelines on translation: process of translation and adaptation of instruments 2019. http://www.who.int/substance_abuse/research_tools/translation/en/. Accessed April 27, 2025.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The NCRS consists of 15 items based on the clinical reasoning model and lacks metacognitive attributes that assess the cognitive process in problem-solving.

    “The NCRS, which consists of 15 items based on the clinical reasoning model, lacks metacognitive attributes that assess the cognitive process in problem-solving, which is crucial for clinical reasoning competence [23].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] Holder AG. Clinical reasoning: a state of the science report. Int J Nurs Educ Scho. 2018;15(1). https://doi.org/10.1515/ijnes-2016-0024. source

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    CREST measures students' clinical reasoning level during simulations and provides feedback to students, recognizing and responding to patient condition deterioration.

    “CREST measures the students ‘clinical reasoning level during simulations and provides feedback to students, recognizing and responding to patient condition deterioration.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Liaw, et al. [25] Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, et al. Development and psychometric testing of a clinical reasoning evaluation simulation tool (CREST) for assessing nursing students’ abilities to recognize and respond to clinical deterioration. Nurs Educ Today. 2018;62:74–9. https://doi.org/10.1016/j.nedt.2017.12.009. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Clinical Reasoning Evaluation Simulation Tool (CREST) was developed by Liaw et al. and is based on Levett-Jones et al.'s clinical reasoning cycle.

    “The Clinical Reasoning Evaluation Simulation Tool (CREST) was developed by Liaw, et al. [25] and is based on Levett-Jones, et al. [4]’s clinical reasoning cycle.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Liaw, et al. [25] Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, et al. Development and psychometric testing of a clinical reasoning evaluation simulation tool (CREST) for assessing nursing students’ abilities to recognize and respond to clinical deterioration. Nurs Educ Today. 2018;62:74–9. https://doi.org/10.1016/j.nedt.2017.12.009. source
    • cites Levett-Jones, et al. [4] Levett-Jones T, Hoffman K, Dempsey J, Jeong SYS, Noble D, Norton CA, et al. The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurs Educ Today. 2010;30(6):515–20. https://doi.org/10.1016/j.nedt.2009.10.020. source

  • Classified as probably not a substantial claim.

    Premisecitation

    Cronbach's alpha is interpreted as not reliable (0-0.39), low reliability (0.40-0.59), reliable (0.60-0.79), and highly reliable (0.80-1.00).

    “Cronbach’s alpha value of a measurement tool is interpreted as “not reliable,” “low reliability,” “reliable,” and “highly reliable” when it has a range of 0–0.39, 0.40–0.59, 0.60–0.79, and 0.80–1.00, respectively [35].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] Alpar R, Spor. Sağlık ve Eğitim bilimlerinden Örneklerle Uygulamalı İstatistik ve Geçerlik-Güvenirlik. Detay Yayıncılık. 2022.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The study used the International Test Commission Guidelines for Translating and Adapting Tests Checklist as a basis during the adaptation process.

    “During the adaptation process, the principles of the International Test Commission Guidelines for Translating and Adapting Tests Checklist was taken as a basis [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] International Test Commission (ITC). ITC guidelines for translating and adapting tests. Internation J Test. 2018;18(2):101–34. https://doi.org/10.1080/15305058.2017.1398166. source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Two educators evaluated the clinical reasoning performance of 52 students using CREST by watching video recordings of each student.

    “Two educators evaluated the clinical reasoning performance of 52 students using CREST by watching video recordings of each student.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The CREST-TR is a valid and reliable measurement tool that can be used to evaluate the clinical reasoning level of nursing students in simulation.

    “According to the study results, it was found that the CREST-TR is a valid and reliable measurement tool that can be used to evaluate the clinical reasoning level of nursing students in the simulation.”
    Quote in the paperSubstantial claim
34 of 34

  • The paper relies on this without support.

    Students’ clinical reasoning level can be validly assessed from their performance in a high-fidelity simulation scenario.

    “The clinical reasoning level of the students is determined by the evaluators during the simulation using the tool.”

  • The paper relies on this without support.

    The critical patient scenario devised for the study adequately elicits the clinical reasoning domains measured by CREST-TR.

    “To assess students’ clinical reasoning, a critical patient scenario necessitating intensive nursing care was devised, utilising the CREST.”

  • The paper relies on this without support.

    No prior validity and reliability study adapting the CREST to a different language had been carried out, making this the first cultural adaptation study of the tool.

    “When the literature was examined, it was seen that the validity and reliability study to adapt the tool to a different language has not yet been carried out.”
    “This is the first cultural adaptation study of the tool, and it is an important resource for future studies in different languages.”

  • The paper relies on this without support.

    In Turkey, there are limited studies on structured communication methods such as ISBAR, and nursing students receive limited instruction on this subject during undergraduate education.

    “In our country, there are limited number of studies on structured communication methods such as ISBAR in the literature and students are provided with limited instruction on this subject during their undergraduate education.”

  • The paper relies on this without support.

    There is no Turkish tool suitable for use as a criterion for examining the predictive validity of the CREST-TR.

    “due to the absence of a Turkish tool suitable for use as a criterion.”
5 of 5

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • AGFI is called acceptable despite falling below the stated cutoff

    Minor

    The paper calls an AGFI of 0.852 acceptable, but later states that acceptable AGFI is at least 0.90.

  • GFI and NFI are called good despite falling below the stated cutoff

    Minor

    The paper classifies GFI of 0.911 and NFI of 0.909 as good fits, but its stated threshold for good fit on both indices is at least 0.95.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Secer I. Psychological test development and adaptation process: SPSS and LISREL applications. Ankara: Anı Yayıncılık; 2020.
  2. Tabachnick BG, Fidell LS. Using multivariate statistics 6th edition ed. Boston: MA: Pearson; 2013.
  3. Levett-Jones T, Smith J. Clinical reasoning: what it is and why it matters. In: Levett-Jones T, editor. Clinical reasoning: learning to think like a nurse. 3th ed. Pearson. 2023. pp. 2–14.

Cited by

Sorted by citations

Related

Authors
Bayzat, C., & Dinc, L.
ORCID
Venue
BMC Nursing
Publisher
Springer Science and Business Media LLC
Published
2025-07-02
Volume
24
Issue
1
Pages
819-819
ISSN
1472-6955 (ISSN-L)
DOI
10.1186/s12912-025-03503-0
PMC
PMC12220264
OpenAlex
W4411924620
Cited by
1
References
43
Citations by year
2026: 1
FWCI
1.33
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Nursing (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
  • Social Sciences › Education › Health Education and Validation
  • Health Sciences › Medicine › Physiology › Simulation-Based Education in Healthcare
Keywords
CREST, clinical reasoning, nursing students, simulation-based assessment, Turkish adaptation, psychometric validation, construct validity, reliability statistics, usability, nursing education

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-29.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-29.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review