Reliability and validity study of the Spanish adaptation of the "Educational Practices Questionnaire" (EPQ).

The Educational Practices Questionnaire is an instrument for assessing students perceptions of best educational practices in simulation. As for other countries, in Spain, it is necessary to have validated rubrics to measure the effects of simulation. The objective of this study was to carry out a translation and cultural adaptation of the Educational Practices Questionnaire into Spanish and analyze its reliability and validity. The study was carried out in two phases: (1) adaptation of the questionnaire into Spanish. (2) Cross-sectional study in a sample of 626 nursing students. Psychometric properties were analyzed in terms of reliability and construct validity by confirmatory and exploratory factor analysis. The exploratory and confirmatory factor analyses showed that the one-dimensional model is acceptable for both scales (presence and importance). The results show that the participants' scores can be calculated and interpreted for the general factor and also for the four subscales. Cronbach's alpha and the Omega Index were also suitable for all the scales and for each of the dimensions. The Educational Practices Questionnaire is a simple and easy-to-administer tool to measure how nursing degree students perceive the presence and importance of best educational practices.

Introduction

Using clinical simulation as a tool for teaching both new nursing professionals during their university education and existing professionals during continuing education has grown exponentially in recent years [1]. Simulation is also regarded as an effective educational method for the delivery of clinical scenarios [2].

The literature states that, in order to obtain optimal learning results through simulation associated with the competencies that nurses must master in their clinical practice, it is necessary to use a common international language and these activities must be incorporated throughout the entire Nursing Degree curriculum [3]. In addition, the International Nursing Association for Clinical Simulation and Learning (INACLS), and several studies [4, 5] affirm that it is necessary to establish best practices for the simulation methodology to be effective. In 2005, Pamela Jeffries developed a guide on simulation methodology for nursing education through the National League for Nursing (NLN) along with Laerdal; this consisted of 5 basic components necessary to conduct a simulation session: educational practices, the facilitator, participants, simulation design features and expected results [6].

Based on the seven principles of good practice defined by Chickering & Gamson, educational practices related to simulation were defined [7]. These practices are: 1) Active learning: through simulation, students actively learn, as they have the opportunity to participate directly in the activity, both when performing the scenario and in subsequent debriefing [8]; 2) Feedback: simulation offers immediate feedback, from the instructor and classmates, as well as from the human patient simulator (HPS), on the knowledge and skills demonstrated and the decisions made [9]; 3) Interaction: intercommunication between the university and the student fosters a climate of trust between the instructor and the students. Together they can discuss and reflect on the learning process, in addition to designing individualized improvement action plans according to the needs of each one.[10]; 4) Collaborative learning: simulation promotes collaborative learning as it provides a reality-like environment where all participants work together for the same purpose and share the decision-making process [11]. This can offer several advantages, allowing participants to learn from different disciplines and learn about teamwork and, if they have different levels, novice nurses can even be given the opportunity to learn from experts [12]; 5) High expectations: it is important that the expectations before performing the simulation are high, so that both students and instructors feel empowered to achieve greater learning in a safe environment [13]; 6) Diversity in learning: people have different learning needs depending on their personal characteristics. It is important to implement different teaching methodologies in the curricula, including simulation [14] and 7) Time: through simulation we can give training in techniques to reduce times in real clinical practice [15].

Subsequently, in order to understand how educational practices on high fidelity simulation are perceived by participants, the NLN, along with Laerdal, developed the “Educational Practices Questionnaire” (EPQ) to evaluate perceptions of best educational practices in simulation [16].

In the Spanish educational context there are several valid and reliable tools that can be used to know the level of satisfaction of students about new teaching methodologies; these include the tutorial action [17, 18], or simulation plans [19, 20]. There are also tools to measure nursing competences in a simulation scenario [21-23], to evaluate the debriefing through the DASH report [24]. However, in Spain, as occurs in other countries, there are no validated instruments that evaluate perceptions of best educational practices in simulation [25]. Therefore, it is essential to have validated rubrics in Spain in order to be able to evaluate the effects of simulation activities.

The objective of this study was to carry out a translation and cultural adaptation of the Educational Practices Questionnaire into Spanish and analyze its reliability and validity.

Methods

Design

A two-phase study was conducted. In the first phase, the instrument was adapted to Spanish; and in the second phase, the metric properties of the EPQ questionnaire translated into Spanish were analyzed.

Participants and setting

The study sample consisted of 626 nursing students from the 2018–19 academic year at the Campus Docent Sant Joan de Déu Fundació Privada [Sant Joan de Déu Private Foundation Teaching Campus], a center affiliated with the Universidad de Barcelona [University of Barcelona]. Non-probability convenience sampling was used. Students who had performed a clinical simulation during the course were included and only those who were not present at the time of the simulation were excluded.

To calculate the sample size, the recommendations of Comrey and Lee [26] for validation studies were followed, which consider a good sample to be anything more than 500 participants.

Variables and source of information

All items related to the EPQ questionnaire were collected as variables. It is a questionnaire made up of 16 items that are grouped into four dimensions (active learning, collaboration, different ways of learning, and expectations). For each item, the same questionnaire makes it possible to assess both the presence of best educational practices and the importance of best practices integrated in clinical simulation [16].

Each item is evaluated using a scale with five possible answers, where 1) is strongly disagree, 2) disagree, 3) undecided, 4) agree, and 5) strongly agree. The sum of the scores of all the items represents a greater recognition of best educational practices in simulation.

In the study conducted by Jeffries and Rizzolo [16], 'the presence of educational best practices' obtained a Cronbach's alpha of 0.86 and 'importance of best practices embedded in simulation' obtained 0.91. This reliability was similar to what was found in another study, which was 0.95 [27].

Other variables were also collected such as: age, sex, teaching shift, whether they were working, work shift and whether they had previous work experience in the health field.

Procedure

The study was conducted in two phases, the first of which consisted of translating and adapting the English version into Spanish through an independent bilingual English—Spanish, Spanish—English committee.

Fig 1 shows the entire translation and back-translation process that was performed following the Standards for Educational and Psychological Testing [28]. Table 1 shows the semantic equivalence of items from English to Spanish.

Fig 1

Description of phase: Adaptation to Spanish of the “Educational Practices Questionnaire” (EPQ).

Table 1

Shows the semantic equivalence of items from English to Spanish that were metrically validated.

	English	Spanish
Item 1	I had the opportunity during the simulation activity to discuss the ideas and concepts taught in the course with the teacher and other students.	Durante la actividad de simulación tuve la oportunidad de debatir sobre ideas y conceptos presentados con el instructor/facilitador y el resto de los estudiantes.
Item 2	I actively participated in the debriefing session after the simulation.	Participé activamente en el debriefing posterior a la simulación.
Item 3	I had the opportunity to put more thought into my comments during the debriefing session.	Durante el debriefing tuve la oportunidad de reflexionar más sobre mis comentarios.
Item 4	There were enough opportunities in the simulation to find out if I clearly understand the material.	Durante la simulación hubo suficientes oportunidades de saber si entendía bien el material.
Item 5	I learned from the comments made by the teacher before, during, or after the simulation.	Aprendí de los comentarios del instructor/facilitador, antes, durante o después de la simulación.
Item 6	I received cues during the simulation in a timely manner.	A lo largo de la simulación recibí indicaciones puntuales.
Item 7	I had the chance to discuss the simulation objectives with my teacher.	Tuve la oportunidad de hablar de los objetivos de la simulación con el instructor/facilitador.
Item 8	I had the opportunity to discuss ideas and concepts taught in the simulation with my instructor.	Tuve la oportunidad de debatir sobre ideas y conceptos presentados en la simulación con el instructor/facilitador.
Item 9	The instructor was able to respond to the individual needs of learners during the simulation.	El instructor/facilitador pudo responder a las necesidades individuales de los estudiantes durante la simulación.
Item 10	Using simulation activities made my learning time more productive.	Gracias a las actividades de simulación, mi tiempo de aprendizaje fue más productivo.
Item 11	I had the chance to work with my peers during the simulation.	Tuve la oportunidad de trabajar con mis compañeros durante la simulación.
Item 12	During the simulation, my peers and I had to work on the clinical situation together.	Durante la simulación, mis compañeros y yo tuvimos que trabajar juntos en la situación clínica.
Item 13	The simulation offered a variety of ways in which to learn the material.	La simulación ofreció varias maneras de aprender el material.
Item 14	This simulation offered a variety ways of assessing my learning.	La simulación ofreció varias maneras de valorar el aprendizaje.
Item 15	The objectives for the simulation experience were clear and easy to understand.	Los objetivos de la experiencia de simulación eran claros y fáciles de comprender.
Item 16	My instructor communicated the goals and expectations to accomplish during the simulation	El instructor/facilitador comunicó los objetivos y expectativas que había que alcanzar durante la simulación.

Finally, a pilot test was done, and the participants (n = 15) concluded that it required little time for completion (5 to 10 minutes) and that it was easy to understand. At second phase, the questionnaire was administered to the nursing students who had performed a simulation to analyze the psychometric properties of the Spanish version. The Spanish version was named EPQ-Sp.

Statistical analysis

Confirmatory factorial analysis (CFA) models were estimated using structural equation modelling on the polychoric correlation matrix (EQS 6.2 for Windows, Multivariate Software, Inc., Encino, CA, USA). It is important to note that Presence and Importance in Simulation scales were analyzed as separated scales (i.e., factorial analyses were computed first for the 16 items related to Presence scale, and then for the 16 items related to the Importance in Simulation scale).

A CFA was performed to analyze the validity of the construct using the generalized least squares method. The goodness of the fit was examined in terms of the standardized Chi-square, defined as the ratio between the value of the Chi-square and the number of degrees of freedom (χ2/df), Adjusted Goodness of Fit Index (AGFI), Goodness of Fit Index (GFI), Comparative Fit Index (CFI), Bentler Bonnet Non-Normed Fit Index (BBNNFI), Bentler Bonnet Normed Fit Index (BNNFI), Root Mean Standard Error Standardized (RMRS) and Root Mean Standard Error of Approximation (RMSEA). A good overall adjustment was considered if the adjustment values were: X2/df between 2 and 6 [29]; AGFI, GFI, CFI, BBNNFI, BBNFI ≥ .90 and RMRS, RMSEA ≤ .06 [30-32]. Reliability was analyzed using Cronbach's alpha coefficient [33] as well as the Omega Index [34] since this latter index makes it possible to analyze the degree of internal consistency based on the factorial loads and does not depend on the number of items, as the alpha coefficient does, which is appropriate given that three of the four dimensions (D2. Collaboration, D3. Diverse ways of learning and D4. High expectations) have two items.

The following were considered acceptable values: Cronbach's alpha values greater than 0.70 [33, 35] and Omega Index values greater than 0.80 [34].

The inspection of the estimated parameters of the CFA suggested that a unidimensional factor solution could also be a plausible option. In order to assess whether the scale could be considered as essentially unidimensional, we computed Explained Common Variance (ECV) and Unidimensional Congruence (UniCo) indices to assess the degree of dominance of the general factor or closeness to unidimensionality [36]. The ECV index essentially measures the proportion of common variance of the item scores that can be accounted for by the first canonical factor (i.e. the factor that explains most common variance). The UniCo index is the congruence between the actual loading matrix and the loading matrix that would be obtained if the unidimensional model is true: the closer to the value of 1, the more the actual loading matrix looks like the unidimensional loading matrix. To conclude that a scale is essentially unidimensional, ECV and UniCo values should be larger than 0.850 for ECV [36], and 0.950 for UniCo [37]. Finally, we also computed Optimal Implementation of Parallel Analysis (PA) [38].

In order to explore the loading values of the items in a unidimensional solution, an exploratory factor analysis (EFA) was computed. Item scores were treated as ordered-categorical variables and the EFA was fitted to the inter-item polychoric correlation matrix [39]. The chosen fitting function was robust unweighted least squares, with mean-and-variance corrected fit statistics [40]. A single factor was extracted.

We were also interested in assessing a bifactor model for the Presence scale. Factor analysis applications to item are generally based on one of these two models: (a) the unidimensional (Spearman) model or (b) the correlated-factors model. The bifactor model combines both previous models: it allows the hypothesis of a general dimension to be maintained, while the additional common variance among the scores is modelled using group factors that are expected to approach a simple structure [41]. In particular, we computed Pure Exploratory Bifactor (Pebi) proposed by Lorenzo-Seva & Ferrando and implemented in Factor software [42]. As the scale was aimed at measuring four factors that were expected to approach a simple structure, these factors were rotated using Robust Promin rotation [42].

Ethical considerations

The study was approved by the Clinical Investigation Ethics Committee of the Sant Joan de Déu Foundation with CEIC research code PIC-42-19. All participants were informed of the purpose of the study and they freely gave their verbal and written consent to participate in the study as volunteers. The translation has been completed with the consent of the National League for Nursing (NLN), but NLN is not responsible for its accuracy. NLN holds the copyright to the original (English language) and the translated instrument in Spanish. Any request related to the translated instrument in Spanish must be addressed to NLN. More information about research instruments and copyright is available in NLN website [http://www.nln.org/professional-development-programs/research/tools-and-instruments]

Results

Demographic characteristics

Finally, a total of 626 nursing students were included in the study. The mean age was 22.9 (SD 5.1), 83.4% were women. More than half of the students (57.7%) were enrolled in the morning study schedule. 74.4% of the students declared that they were working at that time and of these 62.4% had temporary employment (Table 2).

Table 2

Sociodemographic characteristics of the study population.

	n	%
Age (SD)	22.9 (SD 5.1)
Sex
Women	522	83.4
Men	104	16.6
Study schedule.
Morning	361	57.7
Afternoon	265	42.3
Currently employed
Yes	466	74.4
Not	160	25.6
Type of contract
Permanent employment	175	37.6
Temporary employment	291	62.4

Construct validity

In the following subsections, we present the different analyses that we computed to assess construct validity: Confirmatory Factor Analysis (CFA), Essential Unidimensionality, and Exploratory Bifactor (PEBI).

Confirmatory Factor Analysis (CFA)

The confirmatory factorial analysis was used to verify the internal structure of the questionnaire, in which a 4-dimensional model identical to the structure of the original version of the questionnaire was proposed. Parameter estimation was performed using the least squares method. This method is usually used primarily for ordinal measurement items and has the same properties as the maximum likelihood method, although under less stringent multivariate normality considerations [43].

Dimensions 2, 3 and 4 have the highest factor loads or saturations for both assessments (presence and importance of simulation). All saturations were greater than 0.50. The correlations between the factors for the presence and importance of the simulation were high (Figs 2 and 3, respectively).

Fig 2

Standardized model parameters for the presence of educational best practices.

Fig 3

Standardized model parameters for the importance of educational best practices.

The Chi square test was statistically significant but the fit ratio was 4.17 (presence of good practices) and 5.32 (importance), so if it is between 2–6 the fit is reasonably good [43]. Likewise, the rest of the indices analyzed present the same trend, so it can be concluded that the model correctly fits (Table 3).

Table 3

Indices of goodness of fit of the confirmatory model.

	Assess perceptions of educational best practices
	Presence	Importance in simulation
INDEX	VALUE	VALUE
BBNFI	.895	.899
BBNNFI	.900	.897
CFI	.918	.916
GFI	.918	.900
AGFI	.886	.861
RMSR	.047	.046
RMSEA	.071 (90% CI: .064 -.078)	.083 (90% CI: .076 - .090)
α Cronbach	.894	.915
Goodness of fit test	χ2 = 408.723; gl = 98; P < 0.0001	χ2 = 522,125; gl = 98; P < 0.0001
Reason for fit	χ2 / gl = 4.17 between 2–6	χ2 / gl = 5.32 between 2–6

BBNFI: Bentler Bonnet Normed Fit Index. BBNNFI: Bentler Bonnet Non-Normed Fit Index CFI: Comparative Fit Index. GFI: Goodness of Fit Index. AGFI: Adjusted Goodness of Fit Index. RMSR: Root Mean Standard Error Standardized. RMSEA: Root Mean Standard Error of Approximation. CI Confidence Interval

Essential unidimensionality

As can be observed in Figs 2 and 3, the CFA model was adjusted for a model where the factors were strongly correlated between themselves. This outcome was observed for both the Presence and Importance in Simulation scales. As the correlations were large, a unidimensional factor model could also be expected to fit properly. To evaluate this hypothesis, we computed an analysis to assess essential unidimensionality. For the Presence scale, the ECV and UniCo values were 0.845 and 0.973, respectively. For the Importance in Simulation scale, the ECV and UniCo values were 0.849 and 0.979, respectively. The values of both indices suggested that there is a dominant factor running through all the 16 items in both scales. In addition, the first eigenvalue of the Presence and Importance in Simulation scales accounted for 50.9% and 58.2% of the common variance, respectively. PA suggested that the unidimensional solution is the most replicable in both cases.

Goodness of fit indices for the single factor model are printed in Table 4. As can be observed in the table, the fit is not so good as the multidimensional model tested in CFA, but it is still acceptable. Finally, Expected at Posteriori reliability [44] of the single factor was 0.926 and 0.947 for the Presence and Importance in Simulation scales, respectively.

Table 4

Indices of goodness of fit of the exploratory unidimension to the model.

INDEX	Assess perceptions of educational best practices'
	Presence		Importance in simulation
	VALUE	95% CI	VALUE	95% CI
CFI	.968	(.958 - .982)	.973	(.962 - .983)
GFI	.970	(.963 - .981)	.973	(.964 - .983)
AGFI	.966	(.957 - .978)	.969	(.957 - .978)
RMSEA	.083	(.069 - .089)	.094	(.078 - .105)
Goodness of fit test	χ2 = 554.578; gl = 104; P < .0001		χ2 = 680.538; gl = 104; P < .0001
Reason for fit	χ2 / gl = 5.3 between 2–6		χ2 / gl = 5.8 between 2–6

CFI: Comparative Fit Index. GFI: Goodness of Fit Index. AGFI: Adjusted Goodness of Fit Index.

RMSEA: Root Mean Standard Error of Approximation CI: Confidence Interval

Exploratory bifactor (PEBI)

While the unidimensional solution is acceptable for both the Presence and Importance in Simulation scales, the fit indices inspected in the previous subsection show that the fit to the unidimensional solution is slightly worse in the case of the Presence scale. This means that, while the general factor for Presence is strong, the four group factors can still play a substantial role in the factor model. To test this hypothesis, we fitted an exploratory bifactor model related to the Presence scale. Goodness of fit indices for the bifactor model are printed in Table 5. As can be observed in the table, the fit was actually very good. In addition, all items had a salient loading in the general factor and in the expected group factor (see the loading matrix printed in Table 6). It must be pointed out that some items expected to measure Active learning (i.e., items 4, 5, 7 and 9) also loaded in High expectation. The correlation among group factors ranged from 0.04 to 0.20. Finally, Orion reliabilities of factors [44] ranged from 0.712 (for High expectation) to 0.920 (for Active learning). The general factor showed an Orion reliability of 0.881.

Table 5

Indices of goodness of fit of the exploratory bifactor model of Presence scale.

INDEX	Assess perceptions of educational best practices
	Presence
	VALUE	95% CI
CFI	.998	(.998 - .999)
GFI	.998	(.998 - .999)
AGFI	.995	(.995 - .997)
RMSEA	.029	(.012 - .029)
Goodness of fit test	χ2 = 36.514; gl = 50; P < .0001
Reason for fit	χ2 / gl = 5.3 between 2–6

CFI: Comparative Fit Index. GFI: Goodness of Fit Index. AGFI: Adjusted Goodness of Fit Index.

RMSEA: Root Mean Standard Error of Approximation CI: Confidence Interval

Table 6

Loading matrix related to the exploratory bifactor solution.

Items	General factor	Active learning	Collaboration	Learning diversity	High expectation
1	.570	.508	-.021	-.097	-.056
2	.579	.449	-.155	-.139	-.195
3	.623	.486	-.177	-.155	-.187
4	.466	.317	-.038	.052	.323
5	.516	.278	.100	-.071	.308
6	.356	.281	-.010	-.017	.249
7	.427	.568	-.015	.058	.297
8	.485	.640	.029	-.018	.145
9	.421	.406	.022	-.044	.391
10	.590	.305	-.068	.105	.171
11	.606	.050	.476	.081	.082
12	.692	-.010	.704	.012	-.085
13	.640	-.013	-.022	.759	.058
14	.670	.019	-.079	.400	.113
15	.634	-.154	-.083	-.041	.493
16	.705	-.101	-.063	-.110	.594

Loading values larger than .250 are printed in bold.

Conclusion of construct validity analyses

The conclusion is that both models (unidimensional and multidimensional) are acceptable. From a practical point of view, this means that researchers can compute the overall scale score (i.e., the score that is obtained using the responses to the all items), but also the score in four subscales when a more detailed description of participant responses may be needed.

Reliability

Cronbach's alpha internal consistency coefficient for the total of the Assess perceptions of educational best practices presence and importance and simulation questionnaire was 0.894 and 0.915, respectively. The Omega (ω) coefficient for the questionnaire total was 0.922 (presence) and 0.945 (Importance and simulation). All values obtained for each dimension and each coefficient were greater than 0.762 (Table 7).

Table 7

Internal consistency coefficient (Cronbach’s alpha and Omega) for the Educational Practices Questionnaire (EPQ).

Item contents summarized	Cronbach’s alpha		Omega (ω)
	Assess perceptions of educational best practices'		Assess perceptions of educational best practices'
	Presence	Importance in simulation	Presence	Importance in simulation
Active learning	.860	.891	.896	.930
Collaboration	.762	.832	.865	.908
Learning diversity	.774	.832	.863	.913
High expectation	.769	.836	.849	.911
Total questionnaire	.894	.915	.922	.945

Discussion

This study describes the adaptation to Spanish and the psychometric analysis of the “Educational Practices Questionnaire” (EPQ). It is a questionnaire made up of 16 items designed to evaluate both the presence of best educational practices and the importance of best practices integrated in simulation. The results show that the Spanish EPQ has adequate psychometric properties in terms of internal consistency and the validity of the construct. Internal consistency calculated with Cronbach's alpha coefficient was adequate (α ≥ 0.70) for the total of the questionnaire and for each of the dimensions [35]. The highest alpha value was found for dimension D1. Active Learning. For the rest of the dimensions (D2. Collaboration, D3 Learning diversity and D4. High expectation) the alpha varied between 0.762 and 0.836. Since several dimensions (D2, D3 and D4) only have two items, the Omega index was also calculated. Internal consistency according to McDonald (2013) was adequate (ω ≥ 0.85). This instrument has been translated into different languages and countries (Turkish and Portuguese) and reported values similar to those found in our study [27, 45, 46].

The CFA revealed an adequate adjustment of the 4-factor structure consistent with the original version [16].

In our study, a confirmatory factorial analysis was carried out using the generalized least squares method in order to determine whether the scores reproduced the four-dimensional structure on which the original questionnaire is based. The confirmatory factorial analysis showed that all the items presented an adequate factorial load. With respect to the fit indices analyzed for the model, both the absolute fit indices: GFI, RMSR, RMSEA, and the incremental fit indices: AGFI, BBNFI, BBNNFI, CFI and the parsimony indices such as the normed Chi-square all present an acceptable fit. The fit of the model was adequate in relation to the study by Franklin et al. (2014) [27]. In addition, we computed an exploratory factor analysis and observed that the unidimensional factor solution is also acceptable for both scales (Presence and Importance in Simulation) of the test. In the case of the Presence scale, it is interesting that a bifactor model can be fitted: this means that, while the scale seems to be essentially unidimensional, the four group factors still play a substantial role in the factor model. Our outcomes reinforce the idea that participants’ scores can be computed and interpreted for the general factor, but also for the four subscales.

Limitations

Our study has several limitations. First of all, we selected a sample of convenience from a single university in Barcelona, and therefore, it is possible that our results cannot be generalized to all nursing students. However, the socio-demographic and work characteristics of the students in this study are similar to other universities in Spain and Europe.

Secondly, there is response bias. In other words, the power of the facilitator over the nursing student may also have an impact on the response. This bias has been minimized by conducting the questionnaire anonymously and additionally none of the investigators participated in the simulation activity.

Finally, future studies should investigate the predictive capacity (sensitivity and specificity) of the EPQ-Sp questionnaire, as well as its temporal stability.

Conclusions

The Educational Practices Questionnaire is a simple and easy-to-administer tool to measure the perception of nursing degree students of the presence of best educational practices and the importance of best practices integrated into clinical simulation. The statistical techniques used in this study enable the addition of solid evidence to support the use of the EPQ questionnaire in Spanish and ensure that simulation judgments are reliable and valid.

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7 Jul 2020

PONE-D-20-16146

Reliability and validity study of the Spanish adaptation of the “Educational Practices Questionnaire” (EPQ).

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Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The article covers the following technical aspects:

1.- The study presents the results of primary scientific research.

2.- Results reported have not been published elsewhere.

3.- Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail.

4.- Conclusions are presented in an appropriate fashion and are supported by the data.

5.- The article is presented in an intelligible fashion and is written in standard English.

6.- The research meets all applicable standards for the ethics of experimentation and research integrity.

7.- The article adheres to appropriate reporting guidelines and community standards for data availability.

The article satisfies the requirements of PlosOne magazine. On the other hand, there are some issues that require clarification from the authors, as well as some suggestions to improve the article.

Abstract

The summary is concrete and adequate. As a suggestion, if the authors consider it appropriate, the results of Cronbach's Alpha and Omega index could be added.

It is exposed that in Spain it is necessary to have validated rubrics that can show the effects of simulation. Is this only in Spain or is it also in other countries?. I propose something similar to this: "As in other countries, in Spain..."

Introduction

This section is correct. It puts the manuscript in context, includes a brief review of the key literature and defines the problem and the need.

I think the aim of the study is not precise enough. The authors’ purpose was “... to translate into Spanish and analyse the reliability and validity of the Educational Practices Questionnaire”. The first part: "Translating into Spanish", the methodology used by the authors has not only been to translate the Educational Practices Questionnaire (EPQ), but also the transcultural adaptation. In fact, both the methodology and Figure 1 describe the realization of the cross-cultural adaptation of the EPQ. I propose to modify it to: "translation and cultural adaptation".

Materials and Methods

Both the population and the methodology used are well justified. Some issues are proposed for the authors' consideration:

In the paragraph: “Others variables:… academic year”. I do not understand why this variable is included, since previously in the “Participants and setting” section, it is stated that the study is carried out from the 2018-2019 academic year. Perhaps you're referring to the nursing course does each student belong to? (1st, 2nd, 3rd, 4th year of the nursing degree)

The pilot test realization time is not well explained in the text, it is only described in the Figure 1. I suggest adding "finally a pilot test was done" in the Procedure section.

Statistical analysis

In the first paragraph, the term CFA models appears, but has not been previously described. A description of this term is given in the next paragraph.

“… Analyse the validity of the construct (CFA)…”

I recommend that you review this aspect and describe it before using it.

In the paragraph: “The following were considered acceptable values: a Crombach´s Alpha of between 0,70 and 0.9 …”. I do not understand why you put this range. If the value is greater than 0.9, how is it considered?

Discussion

In relation to the Fit Indices, the acronyms are set out in the methodology. I believe that to detail them again in the discussion is to fill in the article without providing more content.

References

It is important to check the format of the references. PLOS uses the reference style outlined by the International Committee of Medical Journal Editors (ICMJE), (Vancouver style). References such as 3, 6, 7, 10, 16, 17, 25, 29, 33, 35, 39 are incorrect. Quotations 4 and 5 are incomplete.

In the main text, reference numbers should appear in square brackets [] and not in parentheses. Also, there are some small errors in citations. Example: in paragraph 1, section “Variables and resource of information”. “…integrated in clinical simulation (Jeffries and Rizzolo, 2006).” is in the APA format style.

Figures

In order for the figure to be better understood by itself, it would be good to explain the acronyms that appear on the figures.

Example: figure 1. T1, T2, RTV, etc.

Tables

Tables are self-explanatory. In table 1 the description of the confidence interval is missing at the bottom of the table.

In the methodology reference is made to "Other Variables", I cannot find in the text or in any table the description of the variables: age, sex, teaching shift, academic year, whether they were working, work shift and whether they had previous work experience in the health field. It would be good to make a table with the results obtained.

Reviewer #2: Thank you for giving me the opportunity to review this article. The manuscript is well written and relevant in an educational context (Spanish) where clinical simulation is booming. Congratulations for the excellent work done in adapting the questionnaire to the Spanish context.

Introduction:

As the authors say, it is necessary to have tools to evaluate the effectiveness of the sessions from the point of view of students and facilitators. In your work you carry out an adaptation of a scale on the perception of the participants about the simulation. You say that in Spain there are no validated instruments to evaluate simulated practices, however, this aspect is not completely correct.

There are various scales that have been used in the Spanish educational context to assess student satisfaction with simulation, the assessment of debriefing-DASH- and even the acquisition of skills. Some examples that you can cite in the introduction and/or in the discussion section are the following:

1. Linguistic Validation of the Debriefing Assessment for Simulation in Healthcare in Spanish and Cultural Validation for 8 Spanish Speaking Countries (Muller-Botti et al., 2020)

2. Clinical Simulation as a Learning Tool in Undergraduate Nursing: Validation of a Questionnaire (Alconero-Camarero et al., 2016)

3. To assess the competences of the students, scales such as Clinical Simulation in Nursing Assessment Questionnaire (CLISINAQ) and the Knowledge Management Scale (KMS) have been used in Spain (Díaz Agea, Megías Nicolás, et al., 2019; Sánchez Expósito et al., 2018)

4. To evaluate satisfaction with a simulation methodology, a specific questionnaire was designed for that method (Díaz Agea, Ramos-Morcillo, et al., 2019)

I recommend removing the bold highlighting from the text.

Methods and results.

In the analysis of the internal structure, the authors first present the CFA with the original structure of the scale (4 oblique dimensions). Subsequently, they perform an EFE to analyze the one-dimensional and two-dimensional structure. This is very confusing. It is normally recommended to make sequential use of both types of analysis, whenever the sample size allows it. It is a matter of dividing the sample randomly into two subsamples and exploring the factorial structure underlying the items in the first sample (with an exploratory factor analysis), and then trying to confirm that structure in the other half of the sample, this time by confirmatory factor analysis. The authors must justify why they have carried out the internal structure analyzes first by carrying out a CFA with the original structure of the questionnaire (4 oblique dimensions), and why they then carry out an EFE to analyze the one-dimensional and two-dimensional structure of the questionnaire.

On the other hand, the authors comment that the fit of the model with the original structure of the scale (4 oblique dimensions) in the CFA was good. However, there are fit indices <0.90 and the RMSEA> 0.06. The authors must justify these results or indicate that the model fit was acceptable and not good.

References

Alconero-Camarero, A. R., -Romero, A. G., Sarabia-Cobo, C. M., & Arce, A. M.-. (2016). Clinical simulation as a learning tool in undergraduate nursing: Validation of a questionnaire. Nurse Education Today, 39, 128-134. https://doi.org/10.1016/j.nedt.2016.01.027

Díaz Agea, J. L., Megías Nicolás, A., García Méndez, J. A., Adánez Martínez, M. de G., & Leal Costa, C. (2019). Improving simulation performance through Self-Learning Methodology in Simulated Environments (MAES©). Nurse Education Today, 76, 62-67. https://doi.org/10.1016/j.nedt.2019.01.020

Díaz Agea, J. L., Ramos-Morcillo, A. J., Amo Setien, F. J., Ruzafa-Martínez, M., Hueso-Montoro, C., & Leal-Costa, C. (2019). Perceptions about the Self-Learning Methodology in Simulated Environments in Nursing Students: A Mixed Study. International Journal of Environmental Research and Public Health, 16(23), 4646. https://doi.org/10.3390/ijerph16234646

Muller-Botti, S., Maestre, J. M., del Moral, I., Fey, M., & Simon, R. (2020). Linguistic Validation of the Debriefing Assessment for Simulation in Healthcare in Spanish and Cultural Validation for 8 Spanish Speaking Countries. Simulation in Healthcare, Publish Ahead of Print. https://doi.org/10.1097/SIH.0000000000000468

Sánchez Expósito, J., Leal Costa, C., Díaz Agea, J. L., Carrillo Izquierdo, M. D., & Jiménez Rodríguez, D. (2018). Ensuring relational competency in critical care: Importance of nursing students’ communication skills. Intensive and Critical Care Nursing, 44, 85-91. https://doi.org/10.1016/j.iccn.2017.08.010

Reviewer #3: 1. The study presents the results of original research. Yes

2. Results reported have not been published elsewhere. No

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail.

Yes, the statistical analyzes are robust, detailed, and very well-grounded.

But, consider this - always use the same rule to report numbers ex: 0, 43, or 0,425 (tenths or hundredths) .

4. Conclusions are presented in an appropriate fashion and are supported by the data. Yes, conclusions are robust and consistent with the results and presented in an appropriate fashion way.

5. The article is presented in an intelligible fashion and is written in standard English.

Yes, the article is presented in a clear, rigorous, and easy to read. But the manuscript needs a careful review of English (USA).

6. The research meets all applicable standards for the ethics of experimentation and research integrity.

Yes.

7. The article adheres to appropriate reporting guidelines and community standards for data availability. The article follows the appropriate reporting guidelines and community standards for data availability.

Yes, but the titles and graphics of the tables can be improved.

The manuscript has great relevance for the teaching practice in nursing. Objectives and methodology are consistent with the object of study and the study complies with all formal and ethical standard requirements.

The sample is robust and adequate, and the treatment and statistical analysis of the data is also robust, detailed and very well based on recent evidence, so it allows conclusions to be drawn, also robust and secure.

But the manuscript needs a careful review of English (USA).

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

1 Aug 2020

RESPONSE TO REVIEWERS

Reference: PONE-D-20-16146

Title: Reliability and validity study of the Spanish adaptation of the “Educational Practices Questionnaire” (EPQ).

Journal Requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

We have revised the style requirements of the journal and we have made adjustments.

2. Please clarify in your Methods section whether the questionnaire is published under a CC-BY license, or whether you obtained permission from the publisher to reproduce the questionnaire in this manuscript. Please explain any copyright or restrictions on this questionnaire.

We are not able to publish the scale as the copyright belongs to NLM. However, we have full permission to carry out the study and publish the results and metrics of the items. We have added a table detailing the translation of the items from English to Spanish. For ethical reasons, we have included a section explaining these aspects. We also enclose the formal authorization by the authors of the original tool for the validation in Spanish as a complementary file.

3. Please amend your current ethics statement to address the following concerns:

a) Did participants provide their written or verbal informed consent to participate in this study?.

b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure.

We thank the reviewer for this precision. We obtained written informed consent from each participant and we have modified the manuscript accordingly.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

We apologize for this oversight and we have uploaded the anonymized data set that will enable others to replicate our findings as per the instructions by the journal.

RESPONSES TO REVIEWER 1

General comments: The study addresses an important subject that was studied using an appropriate design but the number with outcomes was small and follow up was short. The authors did well to recommend future studies with longer follow up but should also add big sample size.

Abstract

The summary is concrete and adequate. As a suggestion, if the authors consider it appropriate, the results of Cronbach's Alpha and Omega index could be added.

Thank you for these comments. The authors have considered adding the results of Cronbach’s Alpha and Omega index, but there are a lot of values and we have decided that it would not be appropriate /would not add sufficient value to warrant it.

It is exposed that in Spain it is necessary to have validated rubrics that can show the effects of simulation. Is this only in Spain or is it also in other countries?. I propose something similar to this: "As in other countries, in Spain..."

We thank the reviewer for this point and have amended the manuscript accordingly.

Introduction

This section is correct. It puts the manuscript in context, includes a brief review of the key literature and defines the problem and the need.

We thank the reviewer for these comments.

I think the aim of the study is not precise enough. The authors’ purpose was “... to translate into Spanish and analyse the reliability and validity of the Educational Practices Questionnaire”. The first part: "Translating into Spanish", the methodology used by the authors has not only been to translate the Educational Practices Questionnaire (EPQ), but also the transcultural adaptation. In fact, both the methodology and Figure 1 describe the realization of the cross-cultural adaptation of the EPQ. I propose to modify it to: "translation and cultural adaptation".

We thank the reviewer for this useful indication about the cultural dimension. We have adapted the text accordingly.

Materials and Methods

Both the population and the methodology used are well justified. Some issues are proposed for the authors' consideration:

In the paragraph: “Others variables:… academic year”. I do not understand why this variable is included, since previously in the “Participants and setting” section, it is stated that the study is carried out from the 2018-2019 academic year. Perhaps you're referring to the nursing course does each student belong to? (1st, 2nd, 3rd, 4th year of the nursing degree)

The authors accept this point that this variable could lead to errors and we have eliminated it from the text.

The pilot test realization time is not well explained in the text, it is only described in the Figure 1. I suggest adding "finally a pilot test was done" in the Procedure section.

We thank the reviewer for pointing this out; we have now included the pilot test in the text to make this part clearer.

Statistical analysis

In the first paragraph, the term CFA models appears, but has not been previously described. A description of this term is given in the next paragraph.

“… Analyse the validity of the construct (CFA)…”

I recommend that you review this aspect and describe it before using it.

We thank the reviewer for pointing out this oversight and we have corrected it.

In the paragraph: “The following were considered acceptable values: a Crombach´s Alpha of between 0,70 and 0.9 …”. I do not understand why you put this range. If the value is greater than 0.9, how is it considered?

We take the reviewer’s point and we have rewritten this paragraph. We believe it is now clearer.

Discussion

In relation to the Fit Indices, the acronyms are set out in the methodology. I believe that to detail them again in the discussion is to fill in the article without providing more content.

We have eliminated the description of the acronyms from the discussion.

In the main text, reference numbers should appear in square brackets [] and not in parentheses. Also, there are some small errors in citations. Example: in paragraph 1, section “Variables and resource of information”. “…integrated in clinical simulation (Jeffries and Rizzolo, 2006).” is in the APA format style.

We apologize for this omission and we have checked all the references and corrected the errors.

Figures

In order for the figure to be better understood by itself, it would be good to explain the acronyms that appear on the figures.

Example: figure 1. T1, T2, RTV, etc.

We have added the description of the acronyms to the figures to improve clarity.

Tables

Tables are self-explanatory. In table 1 the description of the confidence interval is missing at the bottom of the table.

We apologize for this omission and we have added the description of the confidence interval (Ci).

In the methodology reference is made to "Other Variables", I cannot find in the text or in any table the description of the variables: age, sex, teaching shift, academic year, whether they were working, work shift and whether they had previous work experience in the health field. It would be good to make a table with the results obtained.

We have included a table with the descriptions of the variables as recommended by the reviewer.

RESPONSES TO REVIEWER 2

Introduction:

As the authors say, it is necessary to have tools to evaluate the effectiveness of the sessions from the point of view of students and facilitators. In your work you carry out an adaptation of a scale on the perception of the participants about the simulation. You say that in Spain there are no validated instruments to evaluate simulated practices, however, this aspect is not completely correct.

There are various scales that have been used in the Spanish educational context to assess student satisfaction with simulation, the assessment of debriefing-DASH- and even the acquisition of skills. Some examples that you can cite in the introduction and/or in the discussion section are the following:

1. Linguistic Validation of the Debriefing Assessment for Simulation in Healthcare in Spanish and Cultural Validation for 8 Spanish Speaking Countries (Muller-Botti et al., 2020)

2. Clinical Simulation as a Learning Tool in Undergraduate Nursing: Validation of a Questionnaire (Alconero-Camarero et al., 2016)

3. To assess the competences of the students, scales such as Clinical Simulation in Nursing Assessment Questionnaire (CLISINAQ) and the Knowledge Management Scale (KMS) have been used in Spain (Díaz Agea, Megías Nicolás, et al., 2019; Sánchez Expósito et al., 2018)

4. To evaluate satisfaction with a simulation methodology, a specific questionnaire was designed for that method (Díaz Agea, Ramos-Morcillo, et al., 2019) studies with larger sample size

We thank the reviewer for this excellent summary of available scales and we have edited the introduction to include the references mentioned.

Methods and results.

In the analysis of the internal structure, the authors first present the CFA with the original structure of the scale (4 oblique dimensions). Subsequently, they perform an EFE to analyze the one-dimensional and two-dimensional structure. This is very confusing. It is normally recommended to make sequential use of both types of analysis, whenever the sample size allows it. It is a matter of dividing the sample randomly into two subsamples and exploring the factorial structure underlying the items in the first sample (with an exploratory factor analysis), and then trying to confirm that structure in the other half of the sample, this time by confirmatory factor analysis. The authors must justify why they have carried out the internal structure analyzes first by carrying out a CFA with the original structure of the questionnaire (4 oblique dimensions), and why they then carry out an EFE to analyze the one-dimensional and two-dimensional structure of the questionnaire.

We agree with the reviewer that the usual procedure when first analyzing a questionnaire is: (1) to randomly divide the sample in two halves; and (2) to compute an EFA in the first subsample, and a CFA in the second subsample. However, this is the procedure when researchers do not have a hypothesis about the factor structure underlying the questionnaire, which his was not the case here. As the questionnaire has already been analyzed extracting four factors (with a well-defined set of items defining each factor), our hypothesis was that in the Spanish population the same factor model would be a valid one. This is the reason why we computed a CFA first in order to test the expected hypothesis. We could not accept that the four-factor model was valid for the Spanish population.

Because of this we needed to abandon our four factor-hypothesis and to explore our sample in order to decide which model should be expected in the Spanish population. In order to do so, we computed an EFA, and we concluded that the most appropriate factor model is a mixture of unidimensional model (a single general factor), and a two-factor highly correlated model. This is the reason why we explored our data in the context of a bifactor model (that combines both, a single general factor and two group factors).

On the other hand, the authors comment that the fit of the model with the original structure of the scale (4 oblique dimensions) in the CFA was good. However, there are fit indices <0.90 and the RMSEA> 0.06. The authors must justify these results or indicate that the model fit was acceptable and not good.

We thank the reviewer for this observation. We have made the correction and adapted our text to take this into account.

RESPONSES TO REVIEWER 3

Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail.

Yes, the statistical analyzes are robust, detailed, and very well-grounded.

But, consider this - always use the same rule to report numbers ex: 0, 43, or 0,425 (tenths or hundredths).

We thank the reviewer for this comment and we have taken it into account in our results section.

The article is presented in an intelligible fashion and is written in standard English.

Yes, the article is presented in a clear, rigorous, and easy to read. But the manuscript needs a careful review of English (USA).

We thank the reviewer for these comments. We have had the manuscript edited by an English speaking editor and we hope the manuscript is now more uniform regarding the use of English.

The article adheres to appropriate reporting guidelines and community standards for data availability. The article follows the appropriate reporting guidelines and community standards for data availability.

Yes, but the titles and graphics of the tables can be improved.

We accept these comments. We have made adjustments according to suggestions of all three reviewers and we think that the tables have now been improved.

25 Aug 2020

PONE-D-20-16146R1

Reliability and validity study of the Spanish adaptation of the “Educational Practices Questionnaire” (EPQ).

PLOS ONE

Dear Dr. Merino,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 09 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

César Leal-Costa, Ph. D

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

The article has improved considerably. The authors have made the changes eloquently. There are only 2 details more to be considered:

1.- In my opinion, in the Abstract the objective is incomplete in relation to the general work. (translation and cultural adaptation).

2.- There is a lack of homogenization in the pagination of some references. Most of them show the complete initial and final number, but the references: 1, 14, 15, 40, 43, 44, 45. They show an abbreviated model.

Thank you very much for your efforts.

kind regards.

Reviewer #2: The authors have adequately responded to the reviewer's concerns. The changes proposed by the reviewer have been partially complied with.

Reviewer #3: The authors improved the manuscript according to the three reviewers' recommendations, so the manuscript can now be accepted as is.

Also, the manuscript presents a robust validation study of a relevant instrument to support nurse teaching practice in Spain.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

26 Aug 2020

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

The article has improved considerably. The authors have made the changes eloquently. There are only 2 details more to be considered:

1.- In my opinion, in the Abstract the objective is incomplete in relation to the general work. (translation and cultural adaptation).

We thank the reviewer for this useful indication. We have adapted the text accordingly.

2.- There is a lack of homogenization in the pagination of some references. Most of them show the complete initial and final number, but the references: 1, 14, 15, 40, 43, 44, 45. They show an abbreviated model.

We apologize for this omission and we have checked all the references.

Submitted filename: Response_to_reviewers.doc

Click here for additional data file.

28 Aug 2020

Reliability and validity study of the Spanish adaptation of the “Educational Practices Questionnaire” (EPQ).

PONE-D-20-16146R2

Dear Dr. Merino,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Reviewers' comments:

3 Sep 2020

PONE-D-20-16146R2

Reliability and validity study of the Spanish adaptation of the “Educational Practices Questionnaire” (EPQ).

Dear Dr. Roldán-Merino:

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