Development and psychometric evaluation of an emotional growth questionnaire for university students

Background: Despite the importance of emotional growth promotion among students, there is still a lack of standard emotional growth tools to evaluate the concept while developing interventional programs. The aim of present study was to devise and provide a valid and reliable instrument for measuring students’ emotional growth. Methods: This study was conducted from 2016 to 2017 among university students. A questionnaire containing 79 items was made using focus group discussions with students and studying relevant texts. Exploratory factor analysis (EFA) (n = 188) was used to determine the construct validity of the questionnaire. Confirmatory factor analysis (CFA) (n = 38) was performed to assess the validity of the model. Reliability (n = 56) and repeatability (n = 31) of the questionnaire were assessed. Results: A 4-factor (positive identity, self-esteem, effective communication and motivation)and 21-item solution was found as the best solution, which explained 63.5% of total variancebetween the items. The results of CFA approved the validity of the model (CFI = 0.914, RMSEA= 0.070). Cronbach alpha (0.93) and Intra class correlation coefficient (0.91) approved the reliability and repeatability of questionnaire. Conclusion: The 21 items questionnaire seems to be a valid and reliable instrument to measure emotional growth among university students.


Introduction
Higher education is generally important for developing the scientific knowledge of the students. The university administrators, however, are frequently faced with the criticism that they do not prepare the students for taking various kinds of roles like leadership, which is the essential requirement of organizations. 1 This means that the university graduates do not acquire emotional and social skills along with the scientific knowledge of their field of study. Universities should take into account the all-inclusive growth of the students embracing all aspects (mental, emotional, and social) of their lives in order to better prepare the graduate students for achieving success in the future. This urges the instructors who approach learning as a process, to participate the students in both teaching and learning processes, and to link an effective association between the students and instructors. 2,3 Those students who can develop their capabilities to perceive themselves and their surrounding world may create significant relationships and positive changes in their university, work, and life. 4 According to education theorists, education should approve latent learning, which occurs simultaneously with the routine educational programs. It should also be able to promote and facilitate the development of various human aspects of the students. 5 For example, in modern nursing, nurses are expected to consider comprehensive nursing care in accordance with the biological, mental, and spiritual needs of patients. 6,7 However, official nursing education programs in Iran follow a biomedical approach HPP that is mainly focused on medical problems. 8,9 These official education programs put their focus on conveying the knowledge and mastery of patients' physical carerelated techniques. Besides official programs, students also learn through unofficial latent nursing education curricula. Direct observation of situations such as birth, death, loss, and pain has a significant effect on emotional growth (also referred to as emotional development) and learning among students. 10 In addition, through interacting with each other as well as with instructors and nursing staff, students acquire some experiences that are associated with long-term effects during their lifetime. 11 Self-flourishing is the objective of many humanoriented programs. The main emphasis of such programs is on the fact that learning experiences should provide the students with cognitive and emotional learning processes which are inclined with their current lives. Thus, learning these concepts has been integrated in emotional growth. 12 In emotional growth, the individuals are expected to achieve the ability to control, receive, and recognize feelings and, then, behave accordingly. An emotionally full-grown individual features the capability to properly communicate with others in his/her social life as well as the capability to accept the responsibilities of both himself/herself and others. Moreover, such an individual is successful in interacting with others, is not selfish and self-oriented, and also has the ability to get adapted to the surrounding environment and conditions. 13 Emotional growth means to have a sense of sympathy, confidence, and competency in making relationships with others and accepting roles of others. 14 Furthermore, emotional growth is achievable through "effective relationships", "inducing sense of positive identity", and "loving others", which represent "effective interactions". 15 Considering the importance of promoting students' emotional growth as well as the necessity of assessing interventional programs on the students' emotional growth, it seems definitely essential to have a valid and reliable tool. However, to our knowledge, there is no standard tool for evaluating the emotional growth of university students. Therefore, the present study is aimed to devise and provide a standard, valid, and reliable instrument for measuring students' emotional growth, so that it can be applicable for improving quality of education among university students.

Materials and Methods
This mixed-method study was conducted from 2016 to 2017. The participants in the study were undergraduate students from the faculties of nursing in Tabriz University of Medical Sciences and Baqiyatallh University of Medical Sciences.

Questionnaire development
To prepare the questionnaire, the codes obtained from two performed focus group discussions with 11 students (4 female and 7 males) by using conventional qualitative content analysis were extracted. Applying these codes and the items found after comprehensive review of the literature (including the Hermans achievement motivation questionnaire 16 19 29 questions), a pool of questions containing 79 items was made.

Content validity
At first, a questionnaire with 36 items was prepared by the research team from the pool of questions. Then, to determine its validity, qualitative and quantitative content validity assessment were used. So, the designed questionnaire attached with an answer sheet for the opinions on relevancy and clarity of the questionnaire were sent to the following experts: 7 experts in the field of nursing education (content expert), 3 experts on the questionnaire designing and methodology (methodology expert), 3 lecturer and mentor experts in the field of nursing education and 8 alert students (as lay experts). For the purpose of assessing the relevancy of the questionnaire, individuals were asked to answer the following question: "How much this question is associated with the measured parameter? In other words, how appropriate is this question?" The proposed answers were ranked as follows: 1-not suitable, 2-moderately suitable, 3-suitable and 4-completely suitable. For examining the clarity of the questionnaire, they were asked to answer the following question: "How clear is the meaning of this question?" The proposed answers were categorized as follows: 1-ambiguous, 2-moderately ambiguous, 3-clear and 4-completely clear. Answers 3 and 4 were considered as favorable and answers 1 and 2 were considered as unfavorable, then the relevancy and clarity percentages for two groups (experts and lay experts) were separately measured.
According to the results of this phase, 8 questions were deleted and a 28-items questionnaire was developed. The answer choices for the questionnaire was based on a 6-point scaling: "completely agree" (6), "agree" (5), "somewhat agree" (4), "somewhat disagree" (3), "disagree" (2) and "completely disagree" (1). Three examples of the questions were as follow: 1-I feel particularly pleased with the way I am, 2-My life is purposeful, and 3-I have a good effect on others.

Construct validity
Exploratory factor analysis (EFA) was used to determine the constructs of the questionnaire. Kaiser-Meyer-Olkin (KMO) and Bartlett's test of Sphericity tests were used to verify the sampling adequacy and to determine construct validity and appropriateness of data, respectively. Principle component analysis (extraction method) with Varimax rotation and cut-off values ≥0.5 was considered in this analysis. The sample size for this analysis was 188 students (115 females and 75 males). This analysis was performed in SPSS-22 (IBM Corp. Released 2013) software.
Confirmatory factor analysis (CFA) was performed using Stata 14 (StataCorp., College Station, TX, USA) to assess the validity of the EFA model. The sample size for this analysis was 238 students (140 females and 98 males).

Reliability
The reliability and repeatability of the questionnaire was assessed using Cronbach's alpha as measure of internal consistency in a sample of 56 students and intra-class correlation coefficient (ICC) as a measure of repeatability in a sample of 31 students within a two-week interval.

Results
In terms of content validity, the percentage of item relevancy for the scale was 100%. The level of clarity among the experts and lay experts were 85% and 91%, respectively.
The researchers had no prior idea about which or how many underlying factors could be found to explain the data. Therefore, EFA was considered to be conducted. In the correlation matrix, 28 items were inter-correlated with Pearson coefficient scores of r = 0.132-0.764. KMO measure of sampling adequacy of 0.912 and Bartlett's test of Sphericity (χ 2 value 2658.6, df = 378, P < 0.001) indicated that the EFA was possible. Table 1 shows the items, their mean and standard deviation, and factor loading of four-factor structure of the student emotional growth questionnaire. This 21-item structure was found to explain 63.5% of the variance (See Figure S1, Supplementary materials). The items were extracted in four factors: positive identity, self-esteem, effective communication and motivation.

Confirmatory factor analysis
Considering the emotional growth as a latent variable with four sub-scales and 21 items, as observed items, we performed CFA (Figure 1). The modified CFA output illustrated in Figure 1 showed that the solution was appropriate. The following values of absolute fit indices showed an acceptable level of fit: (1) the chi-square test with χ 2 value of 360.8, df = 178, P = 0.416, indicated a smaller difference between expected and observed covariance matrices; (2) CFI = 0.914, RMSEA = 0.070 (90% CI: 0.060-0.081) indicated acceptable level of fit. Table 2 shows the results of internal consistency (Cronbach α) and test-retest reliability (ICC) of four factors and total questionnaire of emotional growth. The results indicated acceptable levels of reliability and repeatability for the questionnaire.

Discussion
Based on a holistic model of health care, human beings have biological, psychological, social and spiritual dimensions. 20 Scholars in nursing education should approve latent learning, which occurs simultaneously with the routine educational programs. They should also be able to promote and facilitate the development of various human aspects of the students. 5 One of the barriers for human growth in nursing students is emotional growth. 21 Regarding the importance of promoting students' emotional growth and lack of standard tools for evaluating the emotional growth of students, this study was conducted to devise and provide a standard, valid,  and reliable instrument for measuring students' emotional growth.
In this study, a questionnaire with 21 items was developed. The results of content validity of the questionnaire showed its high relevancy and clarity. EFA was used to assess construct validity using principal component analysis extraction method and Varimax rotation. 22,23 Based on the EFA, four factors were extracted as follow: positive identity, self-esteem, effective communication and motivation. The factor-structure of the emotional growth questionnaire explained 65.3% of the total variance. Also, the modified CFA showed that the solution was appropriate and in an acceptable level of fit. The intra-class correlation coefficient was used to assess the reliability for numeric items. The ICC 0.61 to 0.8 were considered as good and >0.8 as excellent. 24 According to the results, all factors approved to be reliable (the ICC value was above 0.64 for the factors).
The study sample size was large enough to conduct a valid EFA. 25,26 However, the study samples were limited to nursing students; thus, generalizability of the results is limited.

Conclusion
The developed 21 items questionnaire seems to be a valid and reliable instrument for measuring students' emotional growth which could be used as a research instrument to evaluate emotional growth educational interventions among university students.