Translation, cross-cultural adaptation and validation of the Spanish version of “Assessment of Physiotherapy Practice” (APP-S)

RESEARCH Open Access © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 /. Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 https://doi.org/10.1186/s12909-025-08002-z BMC Medical Education *Correspondence: Eleonora Magni [email protected] 1Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 6 Avenzoar ST, Seville 41009, Spain 2Research Group PAIDI-CTS-1158: Development and Evaluation of Interventions in Health and Education (DEISE), Seville, Spain Abstract Background Clinical education is a key component of the undergraduate education of physiotherapy students, as it provides the context for the development of essential clinical competencies. These competencies can be assessed in a variety of ways, with scales being one of the most widely used. Among these, the “Assessment of Physiotherapy Practice” (APP) has demonstrated robust psychometric properties and is used in several countries. The objective of this study is to translate and cross-culturally adapt the APP into Spanish (APP-S) and assess its psychometric properties (reliability, content validity, and structural validity) and edumetric properties (acceptability and feasibility). Methods This study involved 27 clinical educators (CEs) and 145 physiotherapy students (92 students in the fourth year and 53 students in the third year) from two Spanish universities. Students were assessed at the end of a clinical placement period during the last semester of the academic year. Ten CEs and 35 students evaluated content validity in terms of relevance, comprehensiveness and comprehensibility, using the Content Validity Index for each item (I-CVI) and for the entire scale (S-CVI). Structural validity was examined using exploratory factor analysis, while reliability was assessed using Cronbach’s alpha (α). Finally, eight CEs assessed acceptability and feasibility using a 12-item feedback form. Their ratings were then analysed using Aiken’s V coefficient and the percentage of agreement was calculated. Results The scale demonstrated acceptable content validity (I-CVI ≥ 0.89, S-CVI >0.95) and an excellent internal consistency (Cronbach’s α = 0.971). Exploratory factor analysis revealed a two-factor solution: dimension 1, items 6–20; dimension 2, items 1–5. CEs provided positive feedback regarding acceptability and feasibility, with Aiken’s V values ≥ 0.78 and a high percentage of agreement. Conclusions The APP-S is an appropriate tool for assessing students in clinical placement, and it was well accepted and positively rated by CEs. Further studies are needed to consolidate its psychometric properties. Keywords Clinical education, Education measurement, Physical therapy, Students, Clinical clerkship Translation, cross-cultural adaptation and validation of the Spanish version of “Assessment of Physiotherapy Practice” (APP-S) EleonoraMagni1,2* and María DoloresGuerra-Martín1,2 Page 2 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 Background Clinical education represents an important component in the university training of Physiotherapy students, as the part of the curriculum devoted to consolidating or learning the fundamental clinical competencies to effectively manage patients [1, 2]. As the largest global organisation in the Physiotherapy sector, World Physiotherapy (operating name of the World Confederation of Physical Therapy, WCPT) asserts that clinical education should represent at least one-third of the Physiotherapy curriculum, highlighting the importance for hands-on experiences in a clinical environment. This allows students to develop the necessary competencies to manage patients of all ages and in different clinical contexts [3]. In 2021, the “Physiotherapy Education Framework” proposed classifying these competencies into eight key domains, namely: (1) Physiotherapy assessment and intervention; (2) Ethical and professional practice; (3) Communication; (4) Evidence-based practice; (5) Interprofessional teamwork; (6) Reflective practice and lifelong learning; (7) Quality improvement; and (8) Leadership and management [4]. These competencies are assessed by clinical educators (CEs), and such assessment would need to be made by means of standardised instruments [3, 5]. O’Connor et al. (2018) identified a total of 14 clinical performance assessment tools and, when analysing their psychometric properties, they noticed a generalised lack of robustness – only the “Physical Therapy Clinical Performance Instrument” (PT-CPI, 1997 version) and the “Assessment of Physiotherapy Practice” (APP) scales have been used for studies with large samples [6]. Both scales (the APP and the CPI, in all its versions) are the tools with the most studies at the international level and provide a comprehensive assessment of all the competence domains considered fundamental by the WCPT [7]. The APP was developed in Australia [8] and has become the tool used nationwide in Australia and in New Zealand to evaluate Physiotherapy students’ clinical competence in clinical placements (CPs) [9]. It has 20 items divided into 7 domains (1. Professional Behaviour; 2. Communication; 3. Assessment; 4. Analysis and Planning; 5. Intervention; 6. Evidence-Based Practice; and 7. Risk Management). Each item is assessed through a five-point Likert scale (from 0 = Rarely demonstrates performance indicators to 4 = Demonstrates most performance indicators to an excellent standard) that is used to quantify the students’ performance and provides some examples of performance indicators to assess each item. It also includes a final item used to qualify the students’ overall performance, which is quantified through an ordinal scale with 4 answer levels (Not adequate, Adequate, Good, Excellent) [8]. In a study comparing PT-CPI and APP, the latter was considered more feasible and acceptable both by the CEs and by the students. The APP was assessed as a more practical tool, recording a higher satisfaction percentage. In particular, the CEs consider it faster and easier to apply and highlighted that the performance indicators are simple to understand and useful to offer feedback to the students [10]. From the psychometric point of view and according to the framework proposed by the Accreditation Council for Graduate Medical Education (ACGME), the APP presents high-quality evidence regarding its content and construct validity, as well as consistent quality evidence in terms of internal consistency [6]. In addition, it proved to have a high intra-observer reliability level [11] and that it can be effectively applied in different clinical contexts [9]. Its suitability to be used in CPs has also been verified by means of a Rash analysis [12]. A recent study involving 19 Australian universities with a total of 1,865 students and 9,387 APP assessments remarked upon its psychometric robustness and integrity, extending its applicability at the international level [13]. It should be mentioned that the APP has been translated into Chinese (APP-C), where it has proved to be a tool well-accepted by students and CEs alike [14]; it has also been validated in Turkish (APP-T), showing sufficient psychometric properties to implement it as an evaluation tool in CPs [15]. In Spain, external supervised curricular placements are given the name of “Practicum” [16]; these placements are organised in clinical rotational internships at hospitals and care centres [2] and may not take up more than one-fourth of the total degree course hours, which are between 6,000 and 7,200 h [17]. Unlike the cases of Australia and New Zealand, there is no tool used for this purpose at the national level. Few scales developed in Spanish are reported in the literature. The “Rubric for Competence Assessment in Clinical Physiotherapy Practices” (RECOPC-FIS II) [18] appears to be the only one developed in Spain to assess competencies in CPs. This scale, which is an expansion and validation of RECOPCFIS I [19], is a rubric with 14 items through which the most relevant transversal and specific competencies are assessed, according to national documents and norms [2, 17, 20]. However, no studies have been found in the literature documenting its use in universities other than those in which it was developed and validated. In CP, the students are usually evaluated through multiple methods, such us rubrics or scales prepared ad hoc by each institution. O’Connor et al. (2018) highlighted that, given the excessive number of existing scales in international literature, it would be more efficient to adapt and validate to each country’s context those tools that have already shown Page 3 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 their validity, instead of continuing to develop new scales [6]. Given all of the above, the following objectives are proposed in this study: (1) To translate and cross-culturally adapt the APP scale to Spanish (APP-S); (2) To analyse its psychometric properties (content validity, structural validity, internal consistency); and (3) To assess its acceptability and feasibility. Methods This study was carried out from September 2023 until July 2024 and involved the University of Seville (US) and the Osuna University School (OUS) (Spain). It received approval from the Ethics Committee at the University of Seville (March 9, 2023, code number 0447-N-23). The study adhered to the ethical recommendations of the most recent version of the 1975 World Medical Association Declaration of Helsinki, as well as the Sex and Gender Equity in Research (SAGER) guidelines. This is a validation study comprised of two phases: Phase 1: Translation and cross-cultural adaptation of the APP [8] into Spanish (APP-S) following the guidelines proposed by Sousa and Rojjanasrirat (2011) [21] (protocol available in Additional File 1). Phase 2: Assessment of the APP-S’ psychometric and edumetric properties. Psychometric properties included content and construct validity, and internal consistency, based on COSMIN guidelines for Consensus-Based Standards for the Selection of Health Measurement Instruments [22, 23]. The APP-S’ acceptability and feasibility, as edumetric properties, were determined using a feedback form developed by the author of the original scale and used in previous studies [8, 14]. Phase 1 The translation and cross-cultural adaptation processes are described in Additional File 1. After the first three steps (forward translation, synthesis, and back translation) the expert committee reviewed all translations to develop the pilot version of the APP-S, verified the equivalence between Spanish and English versions in terms of semantics, idiomatic, experiential and conceptual aspects [24]. Once the pilot version was developed, it was tested by CEs in a sample of physiotherapy students, leading to the final version of the APPSpanish version (APP-S). The APP-S is provided in Additional File 2. Phase 2 This phase comprised the assessment of the psychometric and edumetric properties of the APP-S. Participants Physiotherapy students in their third or fourth year, along with CEs conducting their CPs in both public and private centres affiliated with the two universities (US and OUS), were invited to participate. A convenience sampling method was used to select the sample. Procedure All the students and the CEs involved in the study were required to provide written informed consent prior to starting the clinical placement where the assessment would take place. Step 1: Preparation of CEs and physiotherapy students on the APP-S Students and the CEs received training to be introduced to APP-S and to become familiar with the scale. All students and the CEs attended a workshop of approximately 90min, during which the APP-S and its administration were explained. The workshop content was developed based on materials used in the training of Australian CEs and provided directly by the author of the original scale. The workshop for the CEs was offered in both face-toface and online formats, and all the CEs received a manual and an explanatory video detailing the scale and its administration. All students attended the workshop in person. Step 2: Sample, instrument, and data collection to Establish content validity Among the recruited sample, the CEs and students were invited to participate in evaluating the relevance, comprehensiveness, and comprehensibility of each APP-S item. All participants who agreed to take part completed a questionnaire developed for this purpose, rating each item on a five-point Likert scale for these aspects (1 = Not relevant, complete, or comprehensible; 5 = Very relevant, complete, or comprehensible). Additionally, the CEs were asked to evaluate the relevance of the performance indicators, proposed as examples by the author of the original scale, with regard to their suitability for the Spanish clinical education context, using a four-point Likert scale (1 = Not relevant; 4 = Very relevant). Step 3: Sample, instrument and data collection to assess structural validity and internal consistency The “Practicum” at both universities consists of clinical rotations that alternate with periods of theoretical and practical classes. During the clinical rotations, students undertake practice in a specific CP under the supervision of a single CE. The organisation and the length of CPs differ throughout the semesters and between the two universities. During this study, students from US completed their CPs in period of two to three weeks, whereas, students from OUS completed theirs in periods of three to four weeks. All students were assessed by their CEs at the end Page 4 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 of a CP, conducted in the final semester of the academic year. The CEs completed the APP-S electronically using Microsoft Form (Additional File 3). Step 4: Sample, instrument and data collection to explore edumetric properties Using a convenience sampling method, the CEs were selected to provide feedback on the edumetric properties of the APP-S. Acceptability and feasibility were assessed using a feedback form developed and provided by the author of the original scale. The form consisted of a 12-item ad hoc questionnaire (Additional File 4), including 10 closed-ended questions rated on a five-point Likert scale (1 = Strongly disagree; 5 = Strongly agree), and two final open-ended questions. Statistical analysis Data analyses were conducted using version 4.4.1 of the free R software (the R project, Auckland, New Zealand) and IBM SPSS® version 29.0 (IBM Corp., Armonk, NY, USA). Descriptive statistical methods were employed to delineate and summarise the attributes of the sample population. Normality assessments were carried out utilising the Shapiro-Wilk test or the Kolmogorov-Smirnov test. Continuous variables were represented as mean values with standard deviation (SD) or median with interquartile range (IQR) depending on the distribution. Categorical variables were reported as frequencies or percentages. Group proportion comparisons were conducted using the chi-square (χ²) test and linear regression analysis, with statistical significance set at p < 0.05. The following psychometric and edumetric properties were assessed: 1. Content validity: a quantitative method was used to test content validity. The Content Validity Index was calculated for each item (I-CVI) and for the overall scale (S-CVI), based on ratings of relevance, comprehensiveness, and comprehensibility. The S-CVI was determined by calculating the average of the I-CVIs. I-CVI values greater than 0.78 and S-CVI values above 0.90 were considered acceptable [25]. Regarding the performance indicators, Aiken’s V Coefficient (V) [26] was used to determine the CE’s agreement, with values ≥ 70 considered acceptable [27]. 2. Structural validity: exploratory factor analysis (EFA) was carried out to explore structural validity. For EFA the compliance with three fundamental assumptions was verified: the distribution of scale scores was confirmed to be normal; a preliminary item analysis indicated a moderate degree of correlation among items, as evidenced by a corrected item-total correlation exceeding 0.3; and the suitability of the data for factor analysis was further supported by Bartlett’s Test of Sphericity and a Kaiser-Meyer-Olkin (KMO) measure exceeding 0.8. Factor extraction employed principal component analysis with Varimax rotation, retaining factors with eigenvalues greater than one and ensuring cross-loadings above 0.4, with the requirement that the explained variance exceeds 60% [28]. “Pairwise deletion” option was used in SPSS to include all the sample. 3. Internal consistency: this was quantified using Cronbach’s alpha (α), with a value range from 0 to 1. Alpha values between 0.7 and 0.8 indicate acceptable consistency, values between 0.8 and 0.9 indicate good consistency, and values above 0.9 indicate excellent consistency [29]. Furthermore, an internal consistency was considered satisfactory when the corrected item-to-total correlation was ≥ 0.30 [30]. To ensure a complete dataset for the internal consistency analysis in SPSS, NA were imputed using the median of adjacent values. 4. Acceptability and feasibility: Aiken’s V Coefficient (V) [26] was used to determine the level of agreement among CEs, with values ≥ 70 considered acceptable [27]. Additionally, based on previous studies [12, 14], the percentage of agreement between the scores of 4 (‘agree’) and 5 (‘strongly agree’) was calculated. Results A total of 27 CEs and 145 physiotherapy students participated in this study. Participant characteristics are presented in Table1. The CEs (81.48% female; median age 46, IQR: 41.5–48) had a median of 7 years (IQR:4-9.5) of experience as a CE. Most were affiliated with the US (n = 21, 77.7%) and worked in the public healthcare sector, primarily hospitals (n = 23, 85.1%). The physiotherapy students (50.3% female; median age 22, IQR: 22–24) were predominantly from the US (81.3%, n = 118). A total of 62.7% (n = 91) were in their fourth year, while the remaining 37.2% (n = 54) were in their third year. The CPs were mainly in neurological settings (n = 66, 45.5%) attended exclusively by fourth-year students, and orthopaedic settings (n = 48, 33.1%) attended exclusively by third-year students. More than half of the students (n = 79, 54.4%) were assessed after completing at least three weeks of CP. The APP-S mean total score was 65.68 ± 11.77. Linear regression analysis revealed that neither the academic year (p = 0.138) nor the number of weeks of CP (p = 0.425) had a significant effect on the APP-S global score. Not all items could be assessed for every student. The CEs marked “No Assessment” (NA) for items whose Page 5 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 performance could not be observed within the specific clinical context of the placement. The items with the highest number of NA responses were item 18 (NA = 51) and item 6 (NA = 15). Table A1 in Additional File 5 shows the score for each item, along with their corresponding NA counts and the overall APP-S test scores. Regarding the overall APP-S score, more than half of the students (56.55%, n = 82) were rated as “excellent,” while only one student received a rating of “not adequate.” No significant differences were observed between the “excellent” category and the grouping of the other three categories with respect to the academic year (p = 0.85). Translation, cross-cultural adaptation and content validity The translation and cross-cultural adaptation processes were completed without incident. The pilot version of the APP-S was tested by eight CEs (62.5% female; median age 48, IQR: 46.75–49.75) in a group of 10 students (40% female; median age 22, IQR: 22–24) from the US. Both reported being comfortable with the scale. To assess the content validity of the APP-S, 10 CEs (60% female; median age 46, IQR:42-49.75) and 35 students (48.57% female; median age 24, IQR: 22–26) completed the questionnaire evaluating the relevance, comprehensiveness and comprehensibility. Table A2 (Additional File 5) presents the I-CVI and S-CVI scores. Among the CEs, I-CVI scores reached perfect agreement (1.0), while among students, values ranged from 0.89 to 1.0. Items 6, 8, and 18 received the lowest scores in the three aspects, with values of 0.89, 0.92 and 0.92, respectively. All S-CVI were greater than or equal to 0.95. Therefore, content validity is considered acceptable, supporting the final version on the APP-S. Regarding the relevance of the performance indicators proposed as examples by the author of the original scale, Additional File 6 shows the V value for each indicator. The list of performance indicators of each item that reached an acceptable level of agreement is included in Additional File 2 following the APP-S scale. Structural validity The sample was adequate for conducting the factor analysis, as indicated by the Kaiser-MeyerOlkin (KMO = 0.925) and Bartlett’s test of sphericity (X²=1753.943, p < 0.001). EFA revealed a two-factor solution, accounting for 72.5% of the variance. The two dimensions were as follows: dimension 1 included items 6 through 20, while dimension 2 comprised items 1 through 5 (Table2). These two dimensions can be defined as ‘Clinical’ (Dimension 1) and ‘Professional’ (Dimension 2). Table 1 Characteristics of CEs and students Characteristics Clinical Educator (n = 27) Student (n = 145) Gender 22F, 5M 73F, 72M Age (years) (Median, IQR) 46 (41.5–48) 22 (22–24) Professional Experience (years) (Median, IQR) 24 (18.5–26) Clinical education experience (years) (Median, IQR) 7 (4-9.5) Course 4th 19 92 3rd 8 53 University Seville 20 118 Osuna 7 27 Healthcare facility Public (Hospital) 21 132 Private 6 13 Clinical setting Neurological 11 66 (4th) Paediatric 3 19 (4th) Respiratory 3 8 (3rd) Orthopaedic 8 48 (3rd) Hydrokinetic 1 2 (4th) Acute care 1 2 (4th) Period of CP 2 wks 66 3 wks 73 4 wks 6 *CP Clinical Placement, F Female, IQR Interquartile range, M Male, wks Weeks, 3rd Third-year, 4th Four-year Table 2 Factor analysis: rotated component matrix Items Factor 1 Factor 2 Item 1 0.833 Item 2 0.463 0.714 Item 3 0.872 Item 4 0.753 Item 5 0.492 0.691 Item 6 0.614 0.540 Item 7 0.769 Item 8 0.743 Item 9 0.717 0.436 Item 10 0.792 Item 11 0.731 0.509 Item 12 0.734 0.421 Item 13 0.688 0.580 Item 14 0.712 0.435 Item 15 0.673 0.514 Item 16 0.720 0.499 Item 17 0.761 0.480 Item 18 0.718 Item 19 0.798 Item 20 0.669 0.487 Proportion of Variance Explained 43.01% 31.50% Total Variance 72.5% Loadings < 0.40 were removed Page 6 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 Reliability Total Cronbach’s α was 0.971, while Cronbach’s α for the dimension-1 and dimension-2, were 0.966 and 0.908, respectively, indicating an excellent internal consistency. Item-total correlations ranged from 0.607 (item 18) to 0.878 (item 17), demonstrating that all items contribute coherently to the construct measured by the scale. Table3 presents the internal consistency analysis of each item of the APP-S. Acceptability and feasibility A total of eight CEs (75% female; median age 46.5, IQR: 39.5–53.5) completed the feedback form. Table4 shows the V values and the percentages of agreement in the CE’s responses to the questionnaire. All questions received scores between 4 and 5, with acceptable V values (> 0.70), showing the acceptability and feasibility of the APP-S. The final four questions, which assess feasibility, obtained the highest possible score (5), agreement (100%) and V value (1). In contrast, the questions related to performance indicators (questions 3 and 6) received the lowest scores, showing lower agreement rates (12.5% and 25%) and reduced V values (0.78 and 0.81, respectively). Discussion This study suggests that the APP-S is a suitable tool to evaluate physiotherapy students in CPs. The APP-S presents acceptable content validity and excellent internal consistency, which supports its suitability to assess the competencies acquired by the students in this context. The factor analysis reveals a two-factor solution (“Clinical” and “Professional”), which indicates a possible two-dimension structure for the APP-S. The tool is well assessed and accepted by the CEs, who consider it comprehensive and easy to use. Translation, cross-cultural adaptation and content validity As in the APP-T validation study conducted by Çelik et al. (2024) [15], the APP translation and cross-cultural adaptation process into Spanish was performed in a satisfactory way, with no difficulties and with the active participation of both the CEs and the physiotherapy students, who were involved in content validation. As reported by these authors [15], the CVI values for relevance and comprehensiveness obtained the maximum score of 1 among the CEs, which indicated the contribution of each scale item to a comprehensive assessment of the students in the CPs. This finding supports the APP as a tool that allows a thorough evaluation of student’s clinical competency [7], assessing all the competencies Table 3 Internal consistency for the items of the APP-S (20 items)* ItemsTotal Statistics Scale Mean if Item Removed Scale Variance if Item Removed Corrected Item-Total Correlation Cronbach’s Alpha if Item Removed Item 1 64.80 117.576 0.666 0.971 Item 2 64.83 116.265 0.761 0.970 Item 3 64.76 116.918 0.746 0.970 Item 4 64.79 116.316 0.739 0.970 Item 5 64.90 114.763 0.793 0.969 Item 6 64.99 115.985 0.742 0.970 Item 7 65.12 114.774 0.784 0.969 Item 8 65.15 114.245 0.758 0.970 Item 9 65.00 114.096 0.808 0.969 Item 10 65.10 113.735 0.839 0.969 Item 11 65.06 111.193 0.873 0.968 Item 12 65.11 112.992 0.811 0.969 Item 13 65.11 112.473 0.813 0.969 Item 14 65.02 114.418 0.809 0.969 Item 15 65.01 113.325 0.825 0.969 Item 16 65.10 113.202 0.854 0.969 Item 17 65.10 112.467 0.878 0.968 Item 18 65.13 119.269 0.607 0.971 Item 19 65.19 116.602 0.662 0.971 Item 20 65.10 113.639 0.794 0.969 *0% missing value Table 4 V values and the percentages ofagreement in the CEs’ responses to the feedback form exploring acceptability andfeasibility Acceptability Feedback form themes Percentage of agreement (4 vs. 5) V Mean ±SD Felt confident with. Rating scale to judge the student’s performance (Q1) 62.5% 0.91 4.825 ± 0.52 Global rating scale (Q2) 87.5% 0.97 4.875 ± 0.35 Utility of. Performance indicators (Q3) 12.5% 0.78 4.125 ± 0.35 Scoring rules (Q4) 62.5% 0.91 4.625 ± 0.52 Definition of competency level expected of a beginning physiotherapist (Q5) 50% 0.88 4.5 ± 0.53 Feasibility Performance indicators easy to understand (Q6) 25% 0.81 4.25 ± 0.46 APP as a practical instrument (Q7) 100% 1 5 ± 0.00 Acceptable time to complete (Q8) 100% 1 5 ± 0.00 Compressive information on how complete (Q9) 100% 1 5 ± 0.00 APP-S online form versus the paper format (Q10) 100% 1 5 ± 0.00 *Q Question, SD Standard deviation Page 7 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 considered fundamental according to the international standards [4]. With respect to the S-CVI scores provided by the students, despite the considerably larger sample size (35 vs. 10), the values for the APP-S were slightly lower than those for the APP-T (0.95 vs. 1) [15]. The items that obtained the lowest scores were item 6 (“Demonstrates clear and accurate documentation”), 8 (“Selects and measures relevant health indicators and outcomes”) and 18 (“Undertakes discharge planning”). This may be attributable to the lack of standardisation among the protocols followed by each CE when requesting written tasks to the students. In the two centres where the data were collected (US and OUS), the CEs could freely decide to ask that the patient’s medical history was prepared or that a written presentation of clinical cases was provided; in addition, there are few standardised protocols for data collection in patient assessment. Such variability could lead to confusion among students in the evaluation of items 6 and 8 due to the lack of a clear definition of “documentation” or “health indicators” in the educational clinical context. Regarding item 18, the results suggest that it cannot always be assessed in the students, which may contribute to its lower perceived relevance. An additional contribution apported by this study is the assessment of the comprehensibility for each item, whose values are in line with the other two aspects analysed and help consolidate the APP-S content validity. Compared with the RECOPC-FIS II rubric [18], the APP-S covered all the aspects evaluated in that tool, which suggests its suitability as an instrument to evaluate competencies according to the established national criteria [2, 20]. In addition, the APP is used in several countries and is aligned with the international standards [7], which may enhance the evaluation of Spanish students from an international perspective. Structural validity In relation to structural validity, several studies have been conducted over the years to examine the dimensionality of the APP in order to identify the structure most suitable for assessing students’ competencies in CPs. To this end, both factor analyses [9, 13] and Rash analyses [12, 31] were employed, concluding that, although the APP structure can be considered feasible both in a one-dimension and two-dimension model, the two-factor model presents more solid validity [13]. In the current study the EFA revealed and evidenced a two-factor representation for the APP-S, aligned with the findings just described. This method was also used by Çelik et al. (2024) [15] in the APP-T’s validation. In contrast, they identified a one-dimensional structure, which they justified by the differences in the statistical methods employed and by the different study populations analysed in the other validation studies. In accordance with the perspective proposed by these authors, the variability in the scale structure and its translated versions might be attributed to the differences across the samples recruited in the various studies, such as the numbers of CEs and students. In addition, the different organisation of clinical education across countries and institutions [3] might influence this aspect. With respect to the dimensions, the analysis grouped items 6–20 in Dimension 1 and items 1–5 in Dimension 2. According to Reubenson et al. (2025) [13], the two dimensions identified can be respectively defined as “Clinical” (items 6–20) and “Professional” (items 1–5), in disagreement with these authors regarding the inclusion of item 5 (“Communicates effectively and appropriately - Verbal/Non-verbal”) in the “Professional” dimension. Reubenson et al. (2020) [9] stated that communication is a complex concept that can give rise to different interpretations regarding its inclusion as a professional or clinical skill. These authors, whose analysis included the items from the “Communication” domain (item 5: “Communicates effectively and appropriately - Verbal/Nonverbal” and item 6: “Demonstrates clear and accurate documentation”) in the “Clinical” dimension, reported that the performance indicators provided along with the APP (such as “Provides clear instructions” [8]), support the clinical nature of this domain. According to their interpretation, communication is developed in a clinical context characterised by the physiotherapist-patient relationship, where students require clinical knowledge to appropriately collect patient information (by conducting an adequate clinical interview, for example) and to guide them in their recovery process. However, although not supported on psychometric results, other authors [32] included these items in the “Professional” dimension, referring to it as “Professional Behaviour”. According to Reubenson et al. (2020), item 6 (“Demonstrates clear and accurate documentation”) is appropriately included in the “Clinical” dimension of the APP-S as it evaluates the written collection and preparation of a patient’s clinical information. On the other hand, item 5 (“Communicates effectively and appropriately - Verbal/ Non-verbal”) covers multiple communication aspects that extend beyond the clinical domain. Along with the clinical aspects evidenced by performance indicators provided by Reubenson et al. (2020) [9], effective communication requires personal skills such as empathy, active listening and verbal clarity [33]. Examples of this aspect are represented by the following performance indicators: “Gives appropriate, positive reinforcement”, “Greets others appropriately” or “Recognises barriers to optimal communication” [8], which mainly assess personal values linked to professional skills rather than to Page 8 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 strictly clinical ones. This might justify the inclusion of item 5 in the APP-S “Professional” dimension. Reliability Regarding reliability, the APP-S showed excellent internal consistency (0.971), along with good Item-Total correlations, suggesting that it is a suitable tool to assess the students’ clinical competency, the construct under investigation. Previous psychometric studies on the original scale did not include an analysis of this property [9, 11–13], thereby making a comparison with the original version is no feasible. However, Cronbach’s α and ItemCorrelation analyses were performed in the APP-T validation [15], obtaining similar values to those found in the current study. In particular, Cronbach’s α was slightly higher in the APP-S (0.971) than in the APP-T (0.935), whereas the Item-Total correlations range had a lower limit in the APP-S (0.607) when compared to the APP-T (0.820). The greater sample size in the APP-T confers greater robustness to the Çelik et al. (2024) findings [15], and the lower values observed in the Item-Total correlations range in the APP-S may also be explained by the different sample size. The internal consistency of the APP-S is also in line with that reported for the RECOPC-FIS II [18], with both scales reaching nearly identical values (0.971 vs. 0.976), supporting the suitability of the APP-S to assess the students’ clinical performance in the Spanish context. Acceptability and feasibility Concerning the edumetric properties, the findings are in accordance with previous studies [8, 14, 15]. The results indicate that the APP-S is an acceptable and feasible tool, considered practical and easy/quick to apply. As in the APP-T validation study [15], only the CEs were involved in this process, therefore not exploring the students’ perspective, an aspect that was indeed investigated for the original scale [8] and for the Chinese version [14]. Nevertheless, as in these two studies [8, 14], the feedback form provided by the author of the original scale was used, which allowed exploring those aspects in a more standardised way. According to He et al. (2020) [14], the CEs stated their preference for the scale’s electronic format, suggesting that this modality represents a more feasible and efficient way to administer it. The questions asking for opinions about the performance indicators were the ones that obtained the lowest mean scores, which evidences the need to continue adapting the examples of performance indicators to the Spanish clinical context reality. In addition, this may represent another factor explaining the inability to assess all the items in some CPs. Strengths, limitations and future directions A considerable number of CEs participated in this study, contributing diverse professional perspectives from different clinical settings. The final feedback provided by these professionals has also contributed to consolidating the APP-S applicability from the perspective of one of the key actors involved in the CPs evaluation process. On the other hand, the sample included thirdand fourth-year physiotherapy students, which may represent a possible limitation of the study. However, the linear regression analysis did not find a significant influence of course year on the APP-S scores, supporting the feasibility of using the APP-S throughout the entire development of CPs. Of note, the patients’ complexity increases progressively throughout the “Practicum” in both centres, with orthopaedic and neurological settings prevailing in third and fourth years, respectively. Consequently, the APP-S appears to be suitable for use in both basic and complex clinical setting. Among the study’s limitations, the recruitment of the sample represents a challenge, as each academic year includes a relatively small number of students (around 100 at US and 75 at UOS), which has hindered the possibility of reaching a larger sample in which the psychometric properties could be verified more robustly. Another limitation concerns the variability of the CP rotation. Each CE had from 1 to 3 students assigned, supervising them exclusively during a CP rotation. These dynamics precluded the collection of data necessary to calculate interand intra-observer reliability. Regarding the length of the CP rotation, the linear regression analysis showed that the number of weeks had no significant influence on the final APP-S scores. Despite this, to align with previous studies [14, 15], standardised CP rotation to a minimum duration of four weeks would be more appropriate. The shorter duration of the CP rotation (two weeks in some cases) limited the observation of representative performances, possibly explaining why some students could not be assessed in certain items. Moreover, the findings show the heterogeneity present across the different CPs and CEs when assessing certain items. This supports the need to reach consensus (at least at the institutional level) on the procedures and competencies that should be taught or reinforced in the patient management (for example: assessment, discharge planning), as well as on the aspects that require greater emphasis, such as professional ethics or evidence-based practice. Another limitation has been the impossibility to assess construct validity. Although there is a rubric in Spanish available (RECOPC-FIS II), it is not implemented in the US and OUS CPs evaluation procedures. Its application requires specific training for the CEs, which would have needed to be added to the APP-S training, thereby Page 9 of 10Magni and Guerra-Martín BMC Medical Education (2025) 25:1421 overloading the CEs and demanding an extremely high level of involvement. A future line of research might consider conducting a Delphi study with a national panel of experts, aimed at reaching consensus on the essential procedures and competencies that should be taught in physiotherapy clinical education, in line with the international standards proposed by the WCPT. Moreover, APP-S validation studies with larger samples are required. These studies should reinforce the twodimension structure of the scale by means of a Confirmatory Factor Analysis, as well as evaluating its interand intra-observer reliability. Likewise, conducting an invariance analysis would be relevant to reinforce the validity of using the APP-S at different stages of training and in diverse clinical settings. Finally, studies that also collect the students’ opinions and satisfaction levels should be conducted in order to explore more thoroughly the educational impact of the scale. Conclusions The Assessment of Physiotherapy Practice-Spanish version (APP-S) is a suitable tool to assess physiotherapy students in clinical placements. It proved to have a twodimension structure where items 1–5 are grouped in the “Professional” dimension and items 6–20 fall into the “Clinical” dimension. It has shown acceptable content validity and excellent internal consistency. It was well accepted and assessed by clinical educators, who consider it an easyand quick-to-use tool. However, it is necessary to conduct studies with larger samples to generalise its use to all clinical environments, in addition to consolidating the findings obtained in this study and assessing other psychometric properties such as intraand inter-observer reliability. Supplementary Information The online version contains supplementary material available at h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 0 9 - 0 2 5 - 0 8 0 0 2 - z. Supplementary Material 1. Supplementary Material 2. Supplementary Material 3. Supplementary Material 4. Supplementary Material 5. Supplementary Material 6. Acknowledgements Acknowledgement is given to the Department of Physiotherapy at the University of Seville and the “Practicum” coordinators, as well as to Osuna University School. Gratitude is also extended to all the students and clinical educators from both universities who contributed to this study. Their collaboration was essential, and the completion of this work would not have been possible without their support. Authors’ contributions Conceptualization, E.M. and M.D.G.-M.; methodology, E.M., M.D.G.-M.; formal analysis, E.M.; investigation, E.M. and M.D.G.-M.; data curation, E.M.; writing— original draft preparation, E.M.; writing—review and editing, E.M. and M.D.G.-M.; visualization, E.M. and M.D.G.-M.; supervision, M.D.G.-M. All authors have read and agreed to the published version of the manuscript. Funding This article represents a part of a Doctoral Thesis whose main author benefits from a Training University Professors Program grant (FPU21/01814) from the Ministry of Universities of the Government of Spain. Data availability Data analysed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate All procedures involving human participants were conducted in compliance with the ethical principles of the institutional research committee and the Declaration of Helsinki (1964), including its subsequent revisions or equivalent ethical guidelines. The study also adhered to the Sex and Gender Equity in Research (SAGER) guidelines to ensure appropriate consideration of sex and gender during the development of investigation. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Received: 6 July 2025 / Accepted: 15 September 2025 References 1. 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