Cross-Cultural Adaptation and Psychometric Evaluation of the Arabic Clinical Reasoning Scale Among Nursing Students

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the opportunity to review your manuscript. The study addresses an important topic, However issues like the title and claims regarding psychometric evaluation should be reconsidered, as construct validity testing (e.g., EFA/CFA) was not performed. Detailed section-wise comments and recommendations are attached for your consideration.

I encourage you to carefully revise the manuscript and provide a detailed point-by-point response to each reviewer comment when resubmitting.

I wish you all the best in strengthening the manuscript and look forward to reviewing a revised version.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

Needs proof reading. 

Author Response

Dear Editor and Reviewer,

We sincerely thank you for the time and effort invested in reviewing our manuscript and for the valuable comments and suggestions provided. We appreciate the constructive feedback, which has helped us improve the quality, clarity, and rigor of the manuscript. We have carefully considered all comments and revised the manuscript accordingly. Detailed responses to each comment are provided below, and all changes made in the revised manuscript have been highlighted for ease of review.

We hope that the revisions satisfactorily address the reviewers' concerns. We are grateful for the opportunity to revise and resubmit our work.

Sincerely,

Minimole Kalarickal Kunjan

 

Response to Reviewers' Comments

1. The title does not fully reflect the scope of the study. While the manuscript refers to a "psychometric evaluation," the assessment was limited to content validity, internal consistency, and test–retest reliability. Key psychometric analyses, particularly Exploratory Factor Analysis (EFA) and/or Confirmatory Factor Analysis (CFA), were not conducted to establish construct validity and confirm the underlying factor structure of the instrument Therefore, I recommend either:
2. Conducting appropriate factor analysis (EFA and/or CFA) to provide a more comprehensive psychometric evaluation and justify the use of the term "psychometric evaluation" in the title; or
3. Revising the title to more accurately reflect the study's scope by focusing on the translation, cultural adaptation, and preliminary validation/reliability testing of the Arabic Clinical Reasoning Scale, rather than a full psychometric evaluation.

Comment addressed: An Exploratory Factor Analysis (EFA) using Principal Axis Factoring with Varimax rotation was conducted to evaluate the construct validity of the Arabic Clinical Reasoning Scale. These findings have been incorporated into the revised manuscript and provided additional psychometric evidence supporting the use of the term “psychometric evaluation” in the title. Page 10; line 375

2. The abstract is overstating the psychometric evaluation. This must be re written based on the title changes.

Comment addressed: The abstract has been revised to accurately reflect the psychometric analyses performed in the study. The revised version now includes the exploratory factor analysis findings in addition to content validity, internal consistency, and test–retest reliability results, ensuring consistency between the title, methodology, results, and conclusions. page 1

3. In the abstract, add the response rate, Main domain scores, Mention that construct validity was not assessed.

Comment addressed: The abstract has been revised to include the response rate and the main domain scores of the Arabic Clinical Reasoning Scale. Page 1; line 34, 43

4. In the introduction, the literature review is somewhat descriptive and lacks critical analysis. State objectives in accordance with the changes in the title as well.

Comment addressed: The literature review has been revised to incorporate a more critical analysis of the existing evidence by comparing and contrasting findings from previous studies and identifying gaps in the literature. These revisions strengthen the rationale for the study and further justify the need for the current research. No changes were made to the title, as the assessment of construct validity and internal consistency was conducted as part of the overall evaluation of the psychometric properties of the instrument. Therefore, the study objectives remain unchanged, as they are consistent with the title and adequately reflect the aims of the study. Page 2-5

5. Again in the intro. more discussion is needed on, existing clinical reasoning instruments, why CRS was chosen over alternative tools. Page 4, line 133

Comment addressed: A discussion of existing clinical reasoning instruments and the rationale for selecting the Clinical Reasoning Scale (CRS) was already included in the Introduction.

6. There are formatting errors in the intro. Part. Proof read if possible.

The Introduction section has been carefully proofread, and the identified formatting errors have been corrected throughout the manuscript.

7. In the methodology, the design is described as a "cross-sectional descriptive methodological study." This should be more clearly defined as: "Methodological instrument validation study with a cross-sectional survey component.

Comments addressed: The methodology section has been revised to describe the study as a "methodological instrument validation study with a cross-sectional survey component." This better reflects the primary aim of instrument validation and the use of a cross-sectional survey for psychometric evaluation. Page 5-line 181

8. There is inconsistency regarding participant eligibility. The inclusion criteria specify only second-year students. However later 365 students from multiple cohorts participated. Justify or correct.

Comments addressed: The inclusion criteria have been revised for clarity. Participants were recruited from medical and surgical nursing clinical courses across three consecutive semesters (January 2024–May 2025) to achieve the required sample size. These courses were selected because they provide opportunities to develop and apply clinical reasoning in patient care. The methodology section has been updated to clearly describe the participant eligibility and recruitment process. page 5

9. Sample size calculation appears inappropriate for psychometric validation. Therefore, also this validation must be removed.

Comments addressed: We agree that the original sample size justification was not the most appropriate approach for a psychometric validation study. Accordingly, the sample size section has been revised to reflect recommendations specific to factor analysis, using a participant-to-item ratio approach.  Page 6-line 215

10. Details regarding translator qualifications are insufficient.

Comments addressed: Additional details on the translators' qualifications and expertise have been added to the methodology section. The revised manuscript now specifies the translators' linguistic proficiency, bilingual competency, and professional background relevant to the translation and cultural adaptation process, thereby enhancing the transparency and rigor of the study. Page 7-line 250

11. Have you done a pilot study, if yes, results not reported.

Comments addressed: Before the Arabic CRS was finalized for psychometric evaluation, a pilot study was conducted with 30 nursing students to assess the readability, clarity, and comprehensibility of the translated items. Internal consistency was also assessed. Feedback obtained from the participants was used to confirm the understand ability of the instrument prior to large-scale data collection. Page 7- Line 268. Page 9-line 349

12. You stated p>0.05 was regarded as the cut-off. This is incorrect. It Should be p < 0.05.

Comments addressed: Thank you for identifying this error. We agree that the statement was incorrect. The manuscript has been revised to indicate that a p-value < 0.05 was considered statistically significant. The correction has been made in the data analysis section of the revised manuscript. page 9-line 337

13. In the results, explain why two items received I-CVI=0.90 whereas others were 1.0.

Comments addressed: Items 4 and 8 received an I-CVI of 0.90 because one expert suggested replacing a specific Arabic term with a more appropriate and culturally relevant word to improve clarity and linguistic accuracy. The recommendation was related to wording rather than the relevance of the item content. Following expert review, the suggested modifications were incorporated into the final Arabic version of the scale. A clarification has been added to the Results section of the revised manuscript. page 10-line 367

14. Cronbach's alpha of 0.974 may suggest redundancy. Compare similar studies on your questionnaire and report it. The discussion should address why Cronbach's alpha is substantially higher than in the original study (if so)

Comments addressed: We acknowledge that a Cronbach's alpha coefficient of 0.974 may indicate a high degree of inter-item correlation and potential item overlap. It was done with 30 sample size for the pilot study. Now in the main psychometric evaluation it is revised and done with 365 sample size. We have addressed this concern. Page 17-Line 510

15. Domain-level scores should be presented on a separate table.

Comments addressed: A separate table presenting the domain-level scores of the Arabic Clinical Reasoning Scale has been added to the Results section. Page 15-Line 468

16. Single-center design, Lack of criterion validity testing, Absence of factor analysis. Are all limitations of this study this must be stated clearly.

Comments addressed: We agree that the study limitations should be clearly stated. The limitations section has been revised to acknowledge the single-center study design and the absence of criterion validity testing. In addition, as suggested by the reviewers, exploratory factor analysis was conducted and included in the revised manuscript to provide evidence of construct validity. The limitations section has also been updated to recommend further validation studies, including confirmatory factor analysis and criterion validity testing in diverse populations. Page 21-Line 621

17. The conclusion is generally supported by the data. However, statements such as: "legitimate and trustworthy instrument" should be moderated because full psychometric validation was not completed.

Comments addressed:  The conclusion has been revised to use more cautious language and to avoid overstating the findings. The need for further validation, including confirmatory factor analysis and criterion validity testing, has also been acknowledged. Page 22-Line 661

18. In table 2, "F test with true value 0" needs clarification.

Comments addressed: The table has been revised by replacing the heading "F test with true value 0" with "F-test for ICC" to improve clarity and readability while preserving the intended statistical meaning. Page 13-Line 432

19. Table 5 Incorrect numbering. The manuscript labels it as: Table 1. Comparison of Clinical Reasoning Scores by Age Group

Comments addressed:  Thank you for identifying this error. The table numbering has been reviewed and corrected throughout the manuscript. The table previously mislabeled as has been renumbered appropriately to ensure consistency between the table citations in the text and the corresponding table titles. Page 16-Line 481

20. Table 6; Include effect size (η²).

Comments addressed: Table 9 (before table 6) has been revised to include the effect size (η²) for the ANOVA analysis. In addition, a brief interpretation of the effect size has been added to the Results and discussion section to complement the statistical significance findings and provide insight into the practical importance of the observed group differences. Page 16-498

21. Extensive English editing is required throughout.

Comments addressed: The manuscript has undergone comprehensive English language editing and proofreading to improve grammar, clarity, sentence structure, and overall readability throughout the text.

Thank you for the comments.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the time spent creating and submitting this work. The manuscript in its current version presents a series of limitations that need to be reviewed. Below I present my suggestions, hoping they are useful:
-The title and keywords chosen are appropriate.
-SUMMARY: In the results, differences are noted depending on CGPA. What does CGPA refer to? Using the complete concepts instead of acronyms would improve the understanding of the summary.
-INTRODUCTION: The introduction is brief. However, it clearly reflects the need to carry out the study as well as its starting point. I recommend that authors update the bibliographic references that support the introduction. Since the origins or starting theoretical models are not discussed in depth, the introduction should be supported by very current references (around 40% should be from the last 2 years).
-METHOD: 
-Section 2.1.: The first time you refer to an abbreviation, indicate its meaning (e.g.: CV). Although there is a section on abbreviations, the fluency of reading will appreciate this small clarification.
-Describe better how the CGPA variable was collected. In the results section, they point out that this variable was distributed in very good (60%), good (26.6%), excellent (11.5%), and satisfactory (1.9%). However, the criteria for each of the groupings have not been indicated in the manuscript.
RESULTS:
-The manuscript evaluates the reliability of the adapted version. However, to demonstrate the validity of cultural adaptation, it is necessary to check the factor structure and invariance of the tool. It is suggested that the authors include an invariance analysis of the questionnaire to check the performance of the adapted version before purchasing and interpret the differences between groups.
-Although the results show adequate levels of internal consistency, the psychometric evaluation of the instrument is limited as it has focused exclusively on reliability indicators. Reliability is a necessary condition, but not sufficient to guarantee the psychometric quality of a measure.
DISCUSSION AND CONCLUSIONS
-A psychometric analysis that does not include analysis of the internal structural, convergent, discriminant and measurement invariance validity is incomplete. Therefore, conclusions about the adequacy of the version should be made cautiously. Furthermore, sincerely, I believe that it is totally necessary to complete the psychometric analysis and base the discussion and conclusions with the new findings.

Author Response

Dear Editor and Reviewer,

We sincerely thank you for the time and effort invested in reviewing our manuscript and for the valuable comments and suggestions provided. We appreciate the constructive feedback, which has helped us improve the quality, clarity, and rigor of the manuscript. We have carefully considered all comments and revised the manuscript accordingly. Detailed responses to each comment are provided below, and all changes made in the revised manuscript have been highlighted for ease of review.

We hope that the revisions satisfactorily address the reviewers' concerns. We are grateful for the opportunity to revise and resubmit our work.

Sincerely,

Minimole Kalarickal Kunjan

 

Response to Reviewers' Comments

-SUMMARY: In the results, differences are noted depending on CGPA. What does CGPA refer to? Using the complete concepts instead of acronyms would improve the understanding of the summary.

Comment addressed: The acronym CGPA in the result part of the abstract has been replaced with its full term, Cumulative Grade Point Average. Page 2-Line 45

-INTRODUCTION: The introduction is brief. However, it clearly reflects the need to carry out the study as well as its starting point. I recommend that authors update the bibliographic references that support the introduction. Since the origins or starting theoretical models are not discussed in depth, the introduction should be supported by very current references (around 40% should be from the last 2 years).

Comment addressed: The Introduction has been revised to include a more comprehensive discussion of the theoretical foundations underpinning clinical reasoning and the development of the Clinical Reasoning Scale. In addition, the literature included recent and relevant studies, to ensure that the introduction reflects current evidence and developments in the field.

Page 2-4

-METHOD: 
-Section 2.1.: The first time you refer to an abbreviation, indicate its meaning (e.g.: CV). Although there is a section on abbreviations, the fluency of reading will appreciate this small clarification.

Comment addressed:  We agree that defining abbreviations at their first appearance improves readability and facilitates understanding. Accordingly, the manuscript has been revised to provide the full term followed by the abbreviation at its first mention in Section 2.5.1 and throughout the manuscript where applicable. Page 6-Line 230

-Describe better how the CGPA variable was collected. In the results section, they point out that this variable was distributed in very good (60%), good (26.6%), excellent (11.5%), and satisfactory (1.9%). However, the criteria for each of the groupings have not been indicated in the manuscript.

Comment addressed:  Additional information has been added to the result section describing how CGPA data were collected and categorized. The criteria used for each category have now been clearly stated in the manuscript. Page 75Line 245

RESULTS:
-The manuscript evaluates the reliability of the adapted version. However, to demonstrate the validity of cultural adaptation, it is necessary to check the factor structure and invariance of the tool. It is suggested that the authors include an invariance analysis of the questionnaire to check the performance of the adapted version before purchasing and interpret the differences between groups.

-Although the results show adequate levels of internal consistency, the psychometric evaluation of the instrument is limited as it has focused exclusively on reliability indicators. Reliability is a necessary condition, but not sufficient to guarantee the psychometric quality of a measure.

Comment addressed: In response to the reviewer's suggestion, exploratory factor analysis (EFA) was conducted and added to the revised manuscript to examine the underlying factor structure of the Arabic Clinical Reasoning Scale and provide evidence of construct validity. Accordingly, the psychometric evaluation is no longer limited to reliability indicators alone. However, measurement invariance analysis was beyond the scope of the current study and was not performed. We have also acknowledged in the limitations section that further validation studies, including confirmatory factor analysis, measurement invariance testing, and criterion validity assessment, are warranted to provide additional evidence of the instrument's psychometric properties. Page 10-Line 374

DISCUSSION AND CONCLUSIONS
-A psychometric analysis that does not include analysis of the internal structural, convergent, discriminant and measurement invariance validity is incomplete. Therefore, conclusions about the adequacy of the version should be made cautiously. Furthermore, sincerely, I believe that it is totally necessary to complete the psychometric analysis and base the discussion and conclusions with the new findings.

Comment addressed: We agree that a comprehensive psychometric evaluation ideally includes additional forms of validity evidence, such as confirmatory factor analysis, convergent validity, discriminant validity, criterion validity, and measurement invariance testing. In response to the reviewer's comments, EFA was conducted and included in the revised manuscript to provide evidence of construct validity. However, we acknowledge that the psychometric evaluation remains preliminary and does not encompass all aspects of validation. Therefore, the discussion and conclusions have been revised to adopt a more cautious interpretation of the findings, and the need for further validation studies has been emphasized in the limitations and recommendations sections. Page 17-Line 525

Thank you for the comments.

 

Reviewer 3 Report

Comments and Suggestions for Authors

I thoroughly enjoyed reading this manuscript and congratulate the authors on tackling such an important topic; however, the document requires some major revisions to enhance its quality so it can effectively serve a large audience across Arabic-speaking nursing colleges and healthcare systems in general.

1. Reduce the overuse of transitional adjuncts throughout the paper (e.g., "further", "moreover").
2. Provide a very concise and distinct definition for clinical reasoning, clinical decision-making, and clinical competency, as they are currently used almost interchangeably.
3. Add the appropriate citation for "Huang et al." on Line 76.
4. Briefly describe the medium of instruction for nursing students in the study setting. If the medium of instruction is English, provide a strong justification for why translating the scale was necessary.

1. Justify using 2^nd-year students to evaluate clinical reasoning. Clarify whether 2nd-year students in the KSA curriculum have had any actual clinical exposure yet, and look back at the original scale to verify participant eligibility criteria.
2. Provide a clear justification for why students in their 1st, 3rd, and 4th years of study were excluded from the sample.
3. Please give heavy emphasis to the fact that excluding senior-year students (3rd and 4th years) will significantly affect the generalizability of the report. Senior students possess the highest level of clinical exposure and reasoning skills in an undergraduate program, making their exclusion a major limitation for a tool validation study.
4. Clarify the exact sampling strategy, as the current description makes it look like a census or convenience sample.
5. Correct the definition of your exclusion criteria. Unwillingness to participate should not be listed as an exclusion criterion; instead, report it transparently as part of your recruitment/response rate. This should be also part of the tool validation criteria, not a simple exclusion
6. Since the study population was pre-determined to be 2nd-year students, remove the mention of 1st, 3rd, and 4th-year students from the exclusion criteria entirely, as they were never part of the source population.
7. Explicitly state at what stage of the study the STROBE guidelines were utilized.
8. Explain how and why this specific scale was selected over other existing tools that measure the same variable.
9. Provide a detailed description of the original scale, including its background, original development setting, and contexts.
10. Expand on the reported reliability and validity scores of the original Clinical Reasoning Scale (CRS) by indicating its original target population, setting, language, country, and time period.
11. Specify the exact criteria of the international guideline used for translation, detailing how this tool guided your translation process.
12. Address the methodological limitation that a cross-sectional design cannot fully cover the entire translation and validation process, and ensure psychometric statistical tests go beyond simple descriptive analysis.
13. Clarify the exact sample size used for the test-retest reliability calculation, as it is currently unclear whether data was taken from 30 or 365 students.
14. Provide a clear methodological justification for choosing a two-week time gap between the test and the retest.
15. Explicitly explain what is meant by single ICC versus average ICC in the context of your results.
16. Justify why this study ignores the individual domains of the original scale to test only the overall scale. Note that the study appears to have a large enough sample size to run a formal Factor Analysis.
17. Verify if Mokkink et al., 2016 is the correct citation for both the COSMIN framework and your specific cutoff threshold for an acceptable Cronbach’s alpha score.
18. Clarify the logic behind how the CGPA categories were determined and categorized (e.g., very good (60%), followed by good (26.6%), excellent (11.5%)).
19. Correct the misalignment between the description of the Content Validity Average (CVA) scoring (which mentions a 4-point scale from 1 to 4) and the data presented in Table 1.

While this work holds immense potential, addressing these major revisions is essential to elevate the study's scientific rigor and maximize its impact for nursing education throughout the region.

Author Response

Dear Editor and Reviewer,

We sincerely thank you for the time and effort invested in reviewing our manuscript and for the valuable comments and suggestions provided. We appreciate the constructive feedback, which has helped us improve the quality, clarity, and rigor of the manuscript. We have carefully considered all comments and revised the manuscript accordingly. Detailed responses to each comment are provided below, and all changes made in the revised manuscript have been highlighted for ease of review.

We hope that the revisions satisfactorily address the reviewers' concerns. We are grateful for the opportunity to revise and resubmit our work.

Sincerely,

Minimole Kalarickal Kunjan

 

Response to Reviewers' Comments

1. Reduce the overuse of transitional adjuncts throughout the paper (e.g., "further", "moreover").

 

Comment addressed: The manuscript has been carefully revised to reduce the overuse of transitional adjuncts and improve the overall flow, readability, and conciseness of the text.

 

Throughout done

 

1. Provide a very concise and distinct definition for clinical reasoning, clinical decision-making, and clinical competency, as they are currently used almost interchangeably.

Comment addressed: We agree that the terms clinical reasoning, clinical decision-making, and clinical competency were not sufficiently differentiated in the original manuscript. To improve conceptual clarity, concise definitions of each construct have been added to the Introduction. Page 97-Line 3

 

1. Add the appropriate citation for "Huang et al." on Line 76.

 

 

Comment addressed: Thank you for this comment. The appropriate reference to Huang et al. (2023), the developers of the Clinical Reasoning Scale, has been added on Line 76 to ensure proper attribution and support for the statement. Page 4-Line 144

 

 

1. Briefly describe the medium of instruction for nursing students in the study setting. If the medium of instruction is English, provide a strong justification for why translating the scale was necessary.

Comment addressed:  Additional information has been added to the methodology section describing the medium of instruction in the nursing program. Page 7-Line 250

 

5. Justify using 2^nd-year students to evaluate clinical reasoning. Clarify whether 2nd-year students in the KSA curriculum have had any actual clinical exposure yet, and look back at the original scale to verify participant eligibility criteria.

 

Comment addressed:  The participant eligibility criteria have been clarified in the revised manuscript. In addition to second year, the study included third year nursing students also, they had already received theoretical instruction, nursing skills laboratory training, simulation-based learning experiences, and supervised clinical exposure through medical and surgical nursing clinical courses. These educational and clinical experiences provided opportunities to develop and apply clinical reasoning skills in patient care situations. The methodology section has been revised accordingly to clarify the clinical preparedness of the study participants. In addition, the participant eligibility criteria were reviewed in relation to the original Clinical Reasoning Scale study, which was conducted among nursing students during the last semester of the study. This is reflected in the discussion section opf the manuscript. Page 5-Line 194

 

1. Provide a clear justification for why students in their 1st, 3rd, and 4th years of study were excluded from the sample.

 

Comment addressed:  Thank you for this important observation. Third-year nursing students were eligible for participation and were included in the study; the previous statement excluding them was incorrect and has been corrected in the revised manuscript. First-year and fourth-year students were excluded because the study focused on assessing clinical reasoning related to the nursing management of patients with medical and surgical disorders. First-year students had not yet undertaken relevant clinical courses, while fourth-year students were enrolled in advanced specialty and internship-related courses that differed from the target population of the study. Page 5-Line 210

 

1. Please give heavy emphasis to the fact that excluding senior-year students (3rd and 4th years) will significantly affect the generalizability of the report. Senior students possess the highest level of clinical exposure and reasoning skills in an undergraduate program, making their exclusion a major limitation for a tool validation study.

Comment addressed:  We would like to clarify that third-year nursing students were not excluded from the study and were included among the participants. The statement indicating their exclusion was an error in the manuscript and has been corrected in the revised version. First-year students were excluded because they had not yet undertaken medical and surgical nursing clinical courses, while fourth-year students were excluded because the study specifically focused on students enrolled in medical and surgical nursing clinical courses. We acknowledge that the exclusion of fourth-year students may limit the generalizability of the findings to students with more advanced clinical exposure and reasoning skills. This limitation has been acknowledged in the revised manuscript. Page 5-Line 201, 212

 

1. Clarify the exact sampling strategy, as the current description makes it look like a census or convenience sample.

Comment addressed:  Comment addressed:  The sampling strategy has been clarified in the revised manuscript. A consecutive sampling approach was used, whereby all eligible nursing students enrolled in the selected medical and surgical nursing clinical courses during the study period were invited to participate until the required sample size was achieved. The methodology section has been revised accordingly. Page 5-Line 189

 

1. Correct the definition of your exclusion criteria. Unwillingness to participate should not be listed as an exclusion criterion; instead, report it transparently as part of your recruitment/response rate. This should be also part of the tool validation criteria, not a simple exclusion

 

Comment addressed:  Thank you for this important comment. We agree that unwillingness to participate should not be considered an exclusion criterion. Accordingly, this statement has been removed from the exclusion criteria. The manuscript has been revised to indicate that only students who provided informed consent were enrolled in the study, while those who declined participation were accounted for as part of the recruitment process rather than as exclusions.

 

Page 5-Line 197

 

1. Since the study population was pre-determined to be 2nd-year students, remove the mention of 1st, 3rd, and 4th-year students from the exclusion criteria entirely, as they were never part of the source population.

Comment addressed:  We agree that exclusion criteria should be defined in relation to the source population. In the revised manuscript, the participant eligibility criteria have been clarified to indicate that the study included both second- and third-year nursing students enrolled in medical and surgical nursing clinical courses. The exclusion criteria have been revised accordingly, and references to academic levels not relevant to the source population have been removed to avoid confusion. Page 5-Line 197

 

1. Explicitly state at what stage of the study the STROBE guidelines were utilized.

Comment addressed: The manuscript has been revised to clarify the use of the STROBE guidelines. Specifically, the STROBE statement was used during the preparation and reporting of the manuscript to ensure comprehensive and transparent reporting of the study methods and findings. A statement indicating this has been added to the methodology section. Page 6-Line 222

 

1. Explain how and why this specific scale was selected over other existing tools that measure the same variable.

Comment addressed: Additional justification has been added to the manuscript introduction section regarding the selection of the Clinical Reasoning Scale (CRS). Page 4-Line 133

 

• Provide a detailed description of the original scale, including its background, original development setting, and contexts.

 

Comment addressed: Additional information regarding the background, development, and original validation of the Clinical Reasoning Scale (CRS) has been added to the manuscript. Specifically, the revised text now describes the theoretical basis of the instrument, its development among nursing students enrolled in different nursing education programs in Taiwan, its factor structure, scoring system, and intended use for assessing clinical reasoning competence in nursing students. Page 4-Line 144

 

1. Expand on the reported reliability and validity scores of the original Clinical Reasoning Scale (CRS) by indicating its original target population, setting, language, country, and time period.

 

Comment addressed: Additional information regarding the original Clinical Reasoning Scale (CRS) has been added to the manuscript under methodology -Clinical Reasoning Scale (CRS)-survey tool. The revised text now describes the scale's development background, target population, setting, language, country of origin, data collection period, psychometric properties, and intended use among nursing students enrolled in different nursing education programs. Page 7-Line 225

1. Specify the exact criteria of the international guideline used for translation, detailing how this tool guided your translation process.

 

Comment addressed: The manuscript has been revised to specify the translation guideline used and to describe how it informed the translation process. Specifically, the translation and cultural adaptation of the Clinical Reasoning Scale followed the WHOQOL Group (1998) guidelines, which include forward translation, expert review, back translation, comparison with the original version, and pretesting to ensure conceptual, semantic, and cultural equivalence between the source and target versions.

 

          Page 7-Line 254

 

1. Address the methodological limitation that a cross-sectional design cannot fully cover the entire translation and validation process, and ensure psychometric statistical tests go beyond simple descriptive analysis.

 

Comment addressed: We acknowledge that a cross-sectional design has limitations in establishing certain psychometric properties that require longitudinal follow-up. However, the present study extended beyond descriptive analysis and included content validity assessment, exploratory factor analysis for construct validity, internal consistency reliability, and test–retest reliability. The limitations section has been revised to acknowledge that psychometric properties such as predictive validity, responsiveness to change, and longitudinal measurement invariance were not evaluated and should be examined in future studies. Page 21-Line 629

 

1. Clarify the exact sample size used for the test-retest reliability calculation, as it is currently unclear whether data was taken from 30 or 365 students.

Comment addressed: We apologize for the lack of clarity regarding the sample sizes used for different psychometric analyses. The test–retest reliability assessment was conducted using a pilot subsample of 30 nursing students who completed the Arabic Clinical Reasoning Scale on two occasions, separated by a two-week interval. In contrast, the main psychometric evaluation, including exploratory factor analysis and internal consistency reliability assessment (added based on reviewer comments), was performed using data from 365 participants. The manuscript has been revised to clearly distinguish between the pilot study sample and the main validation sample. Page 8-Line 297

 

1. Provide a clear methodological justification for choosing a two-week time gap between the test and the retest.

Comment addressed: The manuscript has been revised to provide a methodological justification for the two-week interval used in the test–retest reliability assessment. Consistent with recommendations by Streiner, Norman, and Cairney, a two-week interval was selected because it is sufficiently long to minimize recall of previous responses while being short enough to reduce the likelihood of genuine changes in the construct being measured. Therefore, the interval was considered appropriate for assessing the temporal stability of the Arabic Clinical Reasoning Scale. Page 8-Line 301

1. Explicitly explain what is meant by single ICC versus average ICC in the context of your results.

Comment addressed: The manuscript has been revised to clarify the interpretation of the single-measures and average-measures Intraclass Correlation Coefficients (ICC). Specifically, single-measures ICC reflects the reliability of an individual administration of the instrument, whereas average-measures ICC reflects the reliability of the average score obtained across repeated administrations. Explanatory notes have been added to the table and results section to improve clarity for readers. Page 13-Line 433

 

 

1. Justify why this study ignores the individual domains of the original scale to test only the overall scale. Note that the study appears to have a large enough sample size to run a formal Factor Analysis.

 

Comment addressed: In response, domain-level analyses have been added to the revised manuscript. Specifically, descriptive statistics (mean and standard deviation) for each domain of the Clinical Reasoning Scale are now presented and discussed. Also, the alpha value of each domain is reported. In addition, exploratory factor analysis was conducted using the full validation sample to evaluate the underlying factor structure of the Arabic version. These analyses provide evidence regarding both the overall scale and its individual domains, thereby addressing the dimensional structure of the instrument. Page 14-Line 440, Page 15-Line 468

 

1. Verify if Mokkink et al., 2016 is the correct citation for both the COSMIN framework and your specific cutoff threshold for an acceptable Cronbach’s alpha score.

Comment addressed: We reviewed the cited references and agree that Mokkink et al. (2016) is primarily associated with the COSMIN framework for evaluating the methodological quality of studies on measurement properties. Accordingly, Mokkink et al. (2016) has been retained as the reference for the COSMIN framework. The reference supporting the interpretation of Cronbach's alpha coefficients has been revised, and Taber (2018) is now cited for the recommended threshold values for internal consistency reliability. Page 7-Line 227

1. Clarify the logic behind how the CGPA categories were determined and categorized (e.g., very good (60%), followed by good (26.6%), excellent (11.5%)).

Comment addressed: Additional information has been added to the manuscript to clarify the categorization of cumulative grade point average (CGPA). CGPA data were obtained from the participants and categorized according to the academic grading system used by the institution. The corresponding CGPA ranges for each category have been included in the methodology and results sections to facilitate interpretation of the findings. Page 6-Line 245

 

1. Correct the misalignment between the description of the Content Validity Average (CVA) scoring (which mentions a 4-point scale from 1 to 4) and the data presented in Table 1.

Comment addressed: We agree that the procedure used to calculate the Content Validity Index (CVI) was not described in sufficient detail. The manuscript has been revised to clarify that expert ratings were obtained using a 4-point relevance scale and subsequently dichotomized for CVI calculation. Ratings of 3 or 4 were considered relevant and coded as 1, whereas ratings of 1 or 2 were considered not relevant and coded as 0, in accordance with established recommendations for content validity assessment. Page 7-Line 284

 

           Thank you for the comments.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Revisions are satisfactory

Author Response

Dear Editor and Reviewers,

We would like to express our sincere gratitude to the editor and reviewers for their valuable comments and constructive suggestions regarding our manuscript. We appreciate the time and effort invested in reviewing our work.

We have carefully considered all comments and revised the manuscript accordingly. The revisions have helped improve the clarity, methodological rigor, and overall quality of the manuscript. In addition, the manuscript has undergone further language editing, reference verification, and formatting revisions to ensure compliance with the journal's requirements.

A detailed, point-by-point response to each comment is provided below.

We hope that the revised manuscript satisfactorily addresses all concerns and is now suitable for publication in Nursing Reports.

Thank you for your consideration.

Sincerely,

Corresponding author

_______________________________________________________________________________

Comment 1: Revisions are satisfactory

Response 1: Thank you for your comment. We are pleased that the revisions satisfactorily addressed the concerns raised.

Reviewer 2 Report

Comments and Suggestions for Authors

The revisions introduced by the authors have substantially improved the quality and clarity of the manuscript. Nevertheless, a thorough review of the reference list is recommended, as certain inconsistencies with the journal's citation and formatting guidelines are still present.

Author Response

Dear Editor and Reviewers,

We would like to express our sincere gratitude to the editor and reviewers for their valuable comments and constructive suggestions regarding our manuscript. We appreciate the time and effort invested in reviewing our work.

We have carefully considered all comments and revised the manuscript accordingly. The revisions have helped improve the clarity, methodological rigor, and overall quality of the manuscript. In addition, the manuscript has undergone further language editing, reference verification, and formatting revisions to ensure compliance with the journal's requirements.

A detailed, point-by-point response to each comment is provided below.

We hope that the revised manuscript satisfactorily addresses all concerns and is now suitable for publication in Nursing Reports.

Thank you for your consideration.

Sincerely,

Corresponding author

___________________________________________________________________________

Comment 1: The revisions introduced by the authors have substantially improved the quality and clarity of the manuscript. Nevertheless, a thorough review of the reference list is recommended, as certain inconsistencies with the journal's citation and formatting guidelines remain.

Response 1: Thank you for your positive assessment of the revised manuscript and for highlighting the remaining inconsistencies in the reference list. In response, we have thoroughly reviewed and revised all references and in-text citations to ensure compliance with the journal's requirements. Specifically, the reference list has been reformatted from Vancouver style to the ACS style specified in the Nursing Reports’ author guidelines. In addition, journal abbreviations, author formatting, punctuation, and reference details were checked and corrected for consistency throughout the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors 
Thank you for the revision.
Most of comments I provided are well addressed. However, the manuscript can be stronger with the following points addressed.

1. There are too many abbreviations in the abstract.
2. There are unnecessary details in the abstract sections, such as the items' mean scores 
3. Lack of comparison with the validation CRS-A and the original (Chinese) scale. I suggest you discuss what the main revisions (changes) made from the original version. As the title also suggests, this manuscript should not have done only a simple language translation and run the statistical tests. Cultural components are lacking.  
   1. I suggest either ton down the concept of "cultural adaptation"   Or discuss cultural differences between Taiwan and KSA, modifications made on the scale, and how this change can enhance the tool.
4. CRS-A just appeared in this version; if authors believe this naming is important, it should be clearly defined and consistently used.  
5. Several places lack proper citations, like sample size determination.  
   
   With these minor revisions, the manuscript can meet the publication criteria.

Author Response

   

Dear Editor and Reviewers,

We would like to express our sincere gratitude to the Editor and Reviewers for their valuable comments and constructive suggestions regarding our manuscript. We appreciate the time and effort invested in reviewing our work.

We have carefully considered all comments and revised the manuscript accordingly. The revisions have helped improve the clarity, methodological rigor, and overall quality of the manuscript. In addition, the manuscript has undergone further language editing, reference verification, and formatting revisions to ensure compliance with the journal's requirements.

A detailed, point-by-point response to each comment is provided below.

We hope that the revised manuscript satisfactorily addresses all concerns and is now suitable for publication in Nursing Reports.

Thank you for your consideration.

Sincerely,

Corresponding author

________________________________________________________

                 

Comment 1: There are too many abbreviations in the abstract.

Response 1: Thank you for this valuable suggestion. The abstract has been revised to reduce the number of abbreviations and improve readability. Specifically, the abbreviation "CR" has been replaced with the full term "clinical reasoning" throughout the abstract to improve clarity and readability. Only essential abbreviations have been retained in accordance with the journal's guidelines.

 

Comment 2: There are unnecessary details in the abstract sections, such as the items' mean scores 

 

Response 2: Thank you for this insightful comment. The abstract has been revised to improve conciseness by removing item-level mean scores. These revisions provide a clearer and more focused summary of the study. Page 2. Line 41

 

Comment 3: Lack of comparison with the validation CRS-A and the original (Chinese) scale. I suggest you discuss what the main revisions (changes) were made to the original version. As the title also suggests, this manuscript should not have limited itself to a simple language translation and to running the statistical tests. Cultural components are lacking.  

I suggest either tone down the concept of "cultural adaptation" or discuss cultural differences between Taiwan and KSA, modifications made to the scale, and how this change can enhance the tool.

Response 3: Thank you for this important observation. We agree that cross-cultural adaptation extends beyond linguistic translation and requires consideration of cultural relevance and contextual appropriateness. In response, we have expanded the discussion to compare the Arabic Clinical Reasoning Scale (CRS-A) with the original Taiwan version and highlighted the cultural adaptation process undertaken during translation. Page-7, line 252 (methodology)/page 19-linr 578 (discussion)

 

Comment 4: CRS-A just appeared in this version; if authors believe this naming is important, it should be clearly defined and consistently used.  

Response 4: Thank you for this valuable observation. We agree that the abbreviation CRS-A should be clearly introduced and used consistently throughout the manuscript. The term has now been defined as the Arabic Clinical Reasoning Scale (CRS-A), as explained in the methodology, and the manuscript has been carefully reviewed to ensure consistent use of this abbreviation across all relevant sections.

Page 5-line 182

Comment 5: Several places lack proper citations, like sample size determination.  

Response 5: Thank you for highlighting this issue. We have carefully reviewed the manuscript and verified all citations and references for accuracy and completeness. Appropriate references have been added where needed, including in the sample size determination section, to support the methodological approach. Furthermore, the entire reference list and in-text citations were thoroughly cross-checked to ensure consistency and compliance with the journal's citation and formatting requirements. Page 6, line 214