Validation of the Regret Coping Scale for Healthcare Professionals (RCS-HCP) in Portuguese for Brazil

Background: Assessment of the ability to cope with regret can contribute to support strategies for health professionals. However, in Brazil, there are few instruments that evaluate this ability in the general context. The aim of the study was to adapt and validate the Regret Coping Scale for Healthcare Professionals (RCS-HCP) for Brazilian health professionals. Methods: This is a cross-sectional study carried out with professionals linked to tertiary care hospital institutions. In the validation, the instruments were translated, and the psychometric properties were evaluated for validity and reliability. Validity was assessed using the following validities: content (judges' evaluation), criterion (correlation with Satisfaction With Life Scale – SWLS and Self-Reporting Questionnaire-20 – SRQ-20) and construct validity (exploratory factor analysis using the method of Promax rotation, based on the slope graph and Kaiser criterion and conrmatory using the structural equation model). Reliability was measured using Cronbach's α coecient and the test retested in a maximum period of 30 days. Reproducibility was calculated by intraclass correlation. Results: Three-hundred-forty-one professionals participated, with an average age of 38.6 ± 9.2 years, and 87 participated in a retest survey 30 days later. Exploratory factor analysis showed adequacy of the structure (KMO = 0.786) composed of three factors. In the conrmation, the performance was close to acceptable. Reliability was good for the maladaptive strategies (α = 0.834) and adequate for the problem-focused strategies (α = 0.717), but slightly too low for adaptive strategies (α = 0.595). Test-retest showed lower than expected values, with a Spearman-Brown coecient of 0.703. Conclusions: The RCS-HCP scale showed satisfactory performance in relation to the properties evaluated.


Introduction
During decision-making in clinical practice, health professionals are constantly challenged to make choices that successfully promote the improvement of the patient's health status (1,2). An error can cause repercussions such as guilt, shame, states of anxiety, patient fear, loss of con dence, inability to verbalize, and repentance (3). In addition, emotional distress at the non-development of coping mechanisms can signi cantly compromise the mental health of these professionals (4,5).
The strategies that can be used to deal with feelings of repentance can be either problem-centered or emotion-focused(6). Problem-centered strategies are targeted directly to the patient, while emotionfocused strategies are directed to modify the emotional response to the situation, accepting its own limitations or limitations related to care (7,8). Coping strategies have positive and/or negative results when related to work participation. Coping strategies, such as active problem solving, can increase the chance of participation in work, while passive coping and coping with evasion could decrease the chance of participation (9).
In this sense, the evaluation and monitoring of coping strategies in health professionals is extremely important. For this, there are already several tools used internationally. However, in Brazil, there is a scarcity of validated instruments that assess coping situations in the general context and in a feasible way (10,11). In this context, the Regret Coping Scale for Healthcare Professionals (RCS-HCP) scale addresses the strategy of coping with regret related to care by health professionals. This instrument was validated in French (original version), German, and Danish, with applications in physicians, nurses, and social educators. It has a practical and fast approach since its structure includes 15 items and presented a good performance in relation to internal consistency (7,12,13).
Thus, the present study aims to validate the Regret Coping Scale for Healthcare Professionals in Portuguese for its application in Brazilian health professionals.

Study design and context
This is a cross-sectional study recruited from health-care professionals working with pediatric and adult populations in public, private, and philanthropic hospital institutions in the states of Espírito Santo, Ceará, Pernambuco, Alagoas, Piauí, Bahia, Acre, Minas Gerais, Rio de Janeiro, São Paulo, and the Rio Grande do Sul from October 2018 to April 2019.

Participants
Health professionals participated in the study (physicians, nurses, and physiotherapists), working in direct care to patients and who have at least 6-months experience in the service. The inclusion criterion of the sample was those signing the free and informed consent form for participation in the research by sending the invitation or in person. The professionals answered the questionnaires to collect the sociodemographic variables and later to the other instruments of this research.

Sociodemographic variables
Sociodemographic variables were obtained through structured interviews and included age (years), sex (male or female), and professional designations (title, number of works, work experience time, typical work shift, and state of origin).

Regret Coping Scale for Healthcare Professionals (RCS-HCP)
The daily strategies for coping with repentance related to the care used by health professionals were measured using the RCS-HCP scale. The scale consists of 15 items that measure strategies for coping with regret that can be focused on the problem or adaptive or maladaptive emotions. The questions assess the change in patient care practices, usually performed after events of regret. Answer options range from 1 (never or almost never) to 4 (always or almost always). The original scale features three domains. The rst domain focused on the problem, and the other focused on adaptive emotion and maladaptive emotion (12). Although the best strategy is situation-speci c, and no single strategy can be described as generally better than others, some strategies in domains focused on maladaptive emotion are more associated with negative results (14). The estimate of the latent trait 'dealing with regret' is obtained through the Average Score; the total score of the instrument is not calculated since it is believed that there are three types of coping strategies and not a global strategy.

Self-Reporting Questionnaire -SRQ-20
The SRQ-20 scale was validated in Brazil (15,16) and assessed the prevalence of Common Mental Disorders (depressive, anxious, and somatic complaints). This instrument has 20 questions, and the nal score can range from zero (null probability) to 20 (high probability) of common mental disorders (15,16).

Instrument Validation
The validation process was composed of two phases, and the methodology adopted for the translation of the scale followed international standards (19,20).

Translation
Translation of the RIS-10 encompassed the following steps: (i) translation by two German-Brazilian Portuguese translators; (ii) harmonization between both Portuguese versions, resulting in a single version in Portuguese; (iii) back-translation of the harmonized version by two Brazilian Portuguese-German translators; (iv) harmonization between both translators, resulting in a single German version; and (v) general harmonization, where the versions resulting from the rst and second harmonization were discussed by the four translators to obtain a consensus version (20).
We also translated the RIS-10 from French into Portuguese by two translators and harmonized these translations to assess the differences between the translated versions of German and French. Given that no differences were found between these translations, we adopted the German-to-Portuguese translation as the o cial translation.
Evaluation of psychometric properties.
Phase II comprised the evaluation of the psychometric properties of validity (content, construct, and criterion) and reliability through eld testing.

Content validation
After the scale was translated, the process of cultural adaptation began. For this, this version of the scale was evaluated in relation to content by judges with clinical experience in the studied latent trait. Six judges who have been working in the health care area for more than 5 years participated from each of the following areas: two physicians, two nurses, one psychologist, and one physiotherapist.
First, the evaluation was done qualitatively to obtain the possible suggestions for a better cultural adaptation of the translated terms. The level of agreement among the judges regarding the relevance and representativeness of the items was evaluated by the Content Validity Index (CVI). A 4-point Likert scale was used, where: 1 = not relevant; 2 = item needs a large revision to be representative (not relevant); 3 = quite clear, but needs a small review (very relevant); and 4 = quite clear and representative (highly relevant) (19). This index is calculated by the sum of the 3-and 4-point answers divided by the total number of judges, yielding a proportion of judges who deemed the item valid. However, 1-and 2-point answers required revision or elimination. To calculate the general CVI of the instrument, the sum of all CVI calculated separately was performed, divided by the number of items (19). A CVI exceeding 0.78 is considered an acceptable agreement rate when six judges participate, which was the case in our study (19,21). The scale's content was evaluated through a pilot study of ten professionals, six nurses, three physicians, and one physiotherapist.

Construct validity
Construct validity testing was performed with exploratory and con rmatory factor analysis. Exploratory factor analysis was performed with the Promax rotation method and used the Kaiser measure to assess the adequacy of the sample to a latent factorial structure. The evaluation of the adequacy of a latent factorial structure to the data was measured using the Kaiser-Meyer-Olkin (KMO) test (22). KMO values exceeding 0.5 were considered adequate (22).

Criterion validity
For criterion validity, the total score of the RCS-HCP scale was correlated with the questionnaires validated in Brazil, namely, the SRQ-20 (15,16) and the Life Satisfaction Scale (17). We hoped that some emotion-centered strategies would be more often associated with negative outcomes, such as a higher prevalence of the common mental disorder, and secondly, that problem-centered, emotion-centered strategies would be associated with greater satisfaction with life. Correlations were evaluated using Spearman's rho (ρ), and values of r 0.3 were considered acceptable (27).

Reliability
The reliability measures of internal consistency, oor and ceiling effects, test-retest, and Spearman-Brown coe cient were used (27). Cronbach's α was used for internal consistency (28). The oor and ceiling effects were evaluated by determining the lowest and highest percentage of the population in the application of the scale (29,30). The Spearman-Brown coe cient (27) was analyzed by the split method, as detailed in the following strategies. First, the items were randomly divided into two equal halves. A scale mean was computed for each half, and then the two sets of scale means were correlated to estimate a split-half correlation. The split-half correlation was adjusted by the Spearman-Brown formula to create a split-half reliability (31,32). Test-retest reliability was analyzed using the intraclass correlation and Bland-Altman plots (33). Data collection for test-retest analysis was performed within a maximum period of 30 days.
Interpretations of the reliability test items were as follows: Cronbach's α was ≥ 0.7, as recommended 33 , the criterion considered to oor and ceiling effect was > 20% (29,34), the intraclass correlation (CIC) was considered acceptable when ≥ 0.7 (35) and the Spearman-Brown coe cient was > 0.3 (27). The data were analyzed using the statistical software SAS v.9.4 and the Lavann package v.0.6-5 of R. This study uses a p of 0.05 as the statistical threshold of signi cance.

Sample size
Calculation of the sample size was based on the psychometric properties evaluated and aimed for a ratio

Sample characteristics
Of the 500 total questionnaires distributed, 341 were completed (68%). Of the 159 questionnaires that were not returned, 119 (75%) were from the online version of the questionnaire, and 40 (25%) of the printed version.
The average age of the participants was 38.6 ± 9.2 years. Most of the sample was female, 217 (64%) and 190 married (56%). Of the participants, 164 (48%) were nursing professionals, with only one job 186 (56%) and 135 (41%) worked the night shift. The interviewees are predominantly from the state of Espírito Santo (76%; Table 1). The overall average coping score was 2.3 ± 0.39.

Instrument translation and cultural adaptation
The items were consistent in both the translation and back-translation processes. Any terms that translated differently between translators were discussed and resolved to ensure uniformity of the instrument.

Content validity
The level of agreement among the judges regarding the relevance and representativeness of the items evaluated by the CVI was 1.00.

Construct validity
Exploratory factor analysis showed the adequacy and detection of the structure with the KMO index = 0.78 considered adequate according to the parameters established in the study. The analysis allowed the extraction of three factors (the rst being responsible for 57.3% of the total variation), con rmed in the application of the slope graph ( Figure 1).
The correlations of each item to each factor are described in Table 2, according to the suggested factorial structure. The suggested structure of the instrument in the analysis presents the items with distribution in three factors reproducing the version of the original instrument (a measurement of strategies focused on the problem, adaptive and maladaptive) but with alteration in the relationship of the composition of the item to the factor. In factor 1, there was the displacement of an item (Q11) on the scale, increasing the composition of the items that constitute it.  Cronbach's alpha coe cients for the dimensions: focused on the 0.71 problem and maladaptive 0.83 were adequate and close to those presented in validation studies of the instrument in other countries, for adaptive dimension the result was slightly below 0.59. The value of the alpha coe cient increased to 0.69 if the items "I try to accept the situation" and "I try not to value the situation so much" were excluded from the questionnaire (Table 4).    Figure 2 shows the Bland-Altman graph of agreement with the mean difference and the limits according to 95% of the Test and Retest. The mean bias was -0.53 with lower and upper limits from -9.50 to 8. 44, respectively.

Discussion
In the present study, the German version of the Regret Coping Scale for Healthcare Professionals (RCS-HCP), translated and adapted for the Portuguese, presented an adequate performance and was a valid and reliable measure. The clarity and familiarity of the translated items might have contributed to this performance of the questionnaire in the Brazilian population.
The factorial composition of the repentance scale indicated dimensions, analogous to the results observed in the studies that performed translation and validation of the RCS-HCP (7,12,13). Most items remained in the factors as in the original study. The item that the analysis suggested a different domain was item 11, "I try to distance myself", being conditioned to the Domain focused on the disadaptive emotion. This result underlines the theory that coping strategies can occur differently in each individual; each would present their own style (37), which might in uence the use of each one are personal characteristics, re ecting on the psychological balance about their experiences (12,38) or the rationale for preparing professional practice (39). The interaction of previous individual and contextual characteristics affects emotional reactions through stressful events and can present themselves in positive or negative ways in the short and long term (40).
The scale of coping with repentance presented in relation to the maladaptive domain an association with the mental health of professionals evidencing a higher prevalence of common mental disorders according to the original studies in French (12), German (7), and Danish (13) and was signi cantly related to lower life satisfaction (12). The set of coping strategies can help in the satisfaction and quality of life of the professional, ensuring their capacity in the realization of care (41). Considering the disadaptive coping -a strategy related to emotion -might infer that these professionals have di culty in regulating them. This result was observed in another study (13), where the authors describe an association of mental health problems with a worse coping or coping with maladaptive regret. The emotion-focused coping strategy refers to the management of emotional response through defensive behaviors to protect censorship(8). Thus, the greater use of the coping strategy with a focus on emotion can be seen as a negative aspect.
The use of problem-focused strategies was positively correlated with life satisfaction, according to studies using the French (12) and German (7)  Counseling and discussion can be important functions in coping focused on the problem and emotions, allowing for the analysis of the situation, structuring strategies, and constructive processing of negative feelings (45).
Regarding the adaptive response, resilience is highlighted as an aid within institutions to learn from mistakes and have exibility and professionals as a way to deal with daily stress as well as adaptation to changes(46). Conceptually, resilience is correlated with coping, and both are stress-conditioned. The divergence occurs once that coping is directed to a strategy used to deal with the situation regardless of the result obtained, and resilience is concerned with successful adaptation (47). Resilience is associated with positive coping strategies (dealing with the problem, optimism), improving the well-being of health professionals (48) and would be a protective factor against the development of mental disorder (49).
Regarding reliability, Cronbach's overall alpha presented the scale with a value lower than the versions already validated (7,12,13) and when compared to other instruments that measure repentance strategies validated in Brazil (11,37,44), but it is discussed that the acceptability of the Cronbach's alpha coe cient is not determined by its statistical signi cance, which could be considered acceptable coe cients >0.6(50). The consistency for dimensions (domains) of the scale proved to be adequate as in the original German and Danish versions (7,12,13), being the lowest value in relation to the adaptive domain. Higher reliability coe cients in the scales of immediate and long-term emotional reaction support the conclusion that these aspects are more similar among professionals (40).
In this study, there was a divergence in relation to the veri cation of the oor and ceiling effect in the German study (7), since a percentage of responses with higher prevalence in responses with the lowest levels of measurement was evidenced. Uniformity of the distribution of responses was observed, even as evidenced by the ground effect, which could infer that this factor was in uenced not by a random response pattern, but through a reality presented in the study population. The presence of ceiling and oor effects can in uence sensitivity and responsiveness(51) based on the longitudinal distribution of the sample(52).
The results of the RCS-HCP test and retest analyses were below the expected. This might have occurred due to the difference in the time interval of the application of the questionnaires between the professionals, the performance of the questionnaire during the workday or other sources of error. In the literature, there is still no consensus on the ideal time between the applications of the questionnaires(53,54), but it is recommended to be neither overly short nor long, so that it has not memorized the responses or interference of personal and environmental factors(54,55) .
A limitation of this study is that the sample was random, but there were participants from several regions of the country, which contributed to the validation process of this instrument due to the greater scope. The sample presented higher representativeness in the states of Espírito Santo and Porto Alegre, respectively. However, the study included participants from different regions of Brazil (Southeast, Northeast, and South) who represent 83% of the population index(56). The self-report methodology used in this questionnaire-based study might be subject to bias since the reassessment is related to emotional regulation strategies; some strategies should be analyzed at the time of their occurrence. However, it makes it feasible to evaluate repentance in several scenarios because it does not measure speci c events, but rather measures the overall experience of regrets, and can be used to evaluate strategies for coping with repentance to different events.
Another important consideration is related to the participation of professionals working only in the hospital environment, which can be declared as another limitation, considering that the generalization for professionals in other environments in direct care also needs to be clari ed, and perhaps the target of future studies. Additional studies could evaluate the coping of repentance and the presence/insertion of programs within health services that can assist these professionals in recognizing and implementing coping strategies.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The author(s) declared no potential con icts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no nancial support for the research, authorship, and/or publication of this article. 5 . IBGE -Instituto Brasileiro de Geogra a e Estatística. Estimativas populacionais para os municípios e para as Unidades da Federação brasileiros em 01.07.2020. 2020. Figure 1