Development and psychometric validation of a culturally adapted instrument to assess nurses’ competence in delivering bad news to families of patients nearing end-of-life

BACKGROUND: This study developed and validated a culturally grounded instrument to assess Iranian nurses' competence in delivering bad news to families of patients nearing end-of-life. METHODS: Using a sequential exploratory mixed-methods design, qualitative interviews with 18 nurses and a systematic review of 37 studies identified three core domains: Preparation, Conveying the Bitter Truth, and Consolation. Psychometric analyses were subsequently conducted within this mixed-methods framework to validate the developed instrument. These informed a 26-item scale, psychometrically tested with 284 nurses. RESULTS: The final instrument demonstrated strong content validity (S-CVI/Ave = 0.915), a clear three-factor structure explaining 66.82% of total variance (KMO = 0.934, P < 0.001), and high reliability (Cronbach's α = 0.945; ICC = 0.95). Items captured culturally specific strategies such as gradual truth-telling, strategic timing, non-distressing language, and empathic consolation. CONCLUSION: This validated scale provides a contextually relevant tool for evaluating and improving nurses' communication in end-of-life care, with implications for education, clinical practice, and cross-cultural research in palliative and death-related contexts. Future studies should apply confirmatory factor analysis and evaluate predictive validity across diverse settings.