The development of a scale to measure medical students' attitudes towards communication skills learning: the Communication Skills Attitude Scale (CSAS)

The development of a scale to measure medical students'attitudes towards communication skills learning: theCommunication Skills Attitude Scale (CSAS)

Charlotte Rees, Charlotte Sheard & Susie Davies

Introduction There is little research identifying medical

students' attitudes towards communication skills

learning. This pilot study outlines the development of a

new scale to measure attitudes towards communication

skills learning.

Methods First- and second-year medical students (n =

490) completed the 26-item Communication Skills

Attitude Scale (CSAS) and 39 students completed the

CSAS on a second occasion. Factor analysis was con-

ducted to determine the factors underpinning the scale.

The internal consistency of the subscales was deter-

mined using a coef®cients. The test-retest reliability of

the individual scale items were determined using

weighted kappa coef®cients and the test-retest reliab-

ility of the subscales were established using intraclass

correlation coef®cients.

Results Maximum likelihood extraction with direct

oblimin rotation resulted in a 2-factor scale with 13

items on each subscale. Factor I represented positive

attitudes towards communication skills learning and

factor II represented negative attitudes. Subscale I had

an internal consistency of a � 0á873 and an intraclass

correlation of 0á646 (P < 0á001). Subscale II had an

internal consistency of a � 0á805 and an intraclass

correlation of 0á771 (P < 0á001). The majority of items

on the positive (n � 9, 69á2%) and the negative attitude

subscales (n � 8, 61á5%) possessed moderate test-retest

reliability.

Discussion The development of a new and reliable scale

to identify medical students' attitudes towards

communication skills learning will enable researchers to

explore the relationships between medical students'

attitudes and their demographic and education-related

characteristics. Further work is needed to validate this

scale among a broader population of medical students.

Keywords Attitude, attitude of health personnel;

education, medical, undergraduate; students, medical;

communication skills, interpersonal communication.

Medical Education 2002;36:141±147

Introduction

In 1993, the General Medical Council (GMC)1 pro-

vided recommendations on undergraduate medical

education. In terms of communication skills, the GMC

stated that by the end of their undergraduate course,

medical students should have acquired and demon-

strated their pro®ciency in communication. In partic-

ular, doctors must be able to provide advice and

explanations to patients and their relatives in a form

they can understand and doctors should be good lis-

teners.1 The recommendations also required that

medical students should have acquired and demon-

strated appropriate attitudes by the end of the medical

course. Included in a diverse list of 12 attitudinal

objectives were having respect for patients, being a self-

directed learner and having an awareness of personal

limitations.

As a result of the GMC's report, many medical

educators have developed new communication curri-

cula and others are already using well-developed pro-

grammes.2 However, despite the wealth of literature

regarding communication curricula within the under-

graduate degree,3±5 few studies6,7 have explored medi-

cal students' attitudes within a communication skills

learning and teaching context.

In a study conducted by Hajek et al.6 139 third-year

medical students rated 16 concerns regarding

communicating with patients at two time points:

(1) before the students had any contact with patients

Division of Psychiatry, University of Nottingham, UK

Correspondence: Charlotte Rees, Behavioural Sciences Section, Division

of Psychiatry, University of Nottingham, A Floor South Block, Queen's

Medical Centre, Nottingham, NG7 2UH, UK. Tel.: 0115 970 9338;

Fax: 0115 970 9495; E-mail: [email protected]

Research papers

Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:141±147 141

and before communication skills teaching began; and

(2) after students had completed four communication

skills sessions and had an opportunity to practise cler-

king patients. The authors found that at both time

points, students' main concerns involved communica-

ting with patients who were in pain and who showed

strong negative emotions.

Batenburg & Smal7 measured second- and third-year

medical students' (n � 676) attitudes towards patients,

illness and care at three time points to measure attitude

change during and after a communication skills teach-

ing intervention. Participants' attitudes were measured:

(1) just before the course; (2) just after the course; and

(3) six months after the course. The authors found that

medical students' attitudes did not change substantially

as a result of the communication skills teaching inter-

vention, suggesting that students' attitudes towards

patients, illness and care were very stable and consid-

erable effort was needed to initiate a change in

attitudes.

Given that teaching programmes within the social

sciences often encounter varying degrees of student

resistance,8 it is important to identify medical students'

attitudes towards communication skills learning. This

paper presents the ®ndings of a pilot study, which

aimed to develop a new and reliable measure of medical

students' attitudes towards communication skills

learning. It is part of a larger study to look at commu-

nication skills at the University of Nottingham. This

research began with a qualitative pilot study to explore

the views and experiences of 5 ®rst-year medical stu-

dents.9 This study showed that some medical students

had very positive attitudes towards communication

skills learning, e.g. they thought it was interesting, fun,

useful and applicable to medicine. However, some

students had very negative attitudes towards commu-

nication skills learning, e.g. they thought it was too easy

and not worth investing time in compared with other

subjects that were assessed by written examinations.

Some participants suggested that medical students'

attitudes towards communication skills learning were

related to other factors such as their previous educa-

tional experiences, their age, and their communicative

abilities.

In order to explore these ®ndings in a systematic way

with a wider population of medical students, it was

necessary to design a new and reliable scale to identify

medical students' attitudes towards communication

skills learning. This paper presents the development of

the Communication Skills Attitude Scale (CSAS).

Methods

Participants

Of the 585 medical students invited to participate in this

study, 490 (83á8%) completed the study materials

satisfactorily. They ranged in age from 17 to 35 years

(median � 19, interquartile range � 18±19). The

majority were female (n � 281, 57á3%), white (n � 352,

72á1%) and came from non-manual socioeconomic

groups10 (n � 473, 96á9%). Finally, the majority spoke

English as their ®rst language (n � 411, 83á9%).

Procedures

After receiving approval from the Medical School Ethics

Committee at the University of Nottingham, all ®rst-

and second-year medical students at the University of

Nottingham and all ®rst-year medical students at the

University of Leicester were invited to participate in this

study. First-year students from Nottingham (n � 213)

and Leicester (n � 175) were invited to take part during

small group seminar teaching in November and

December 2000. The authors distributed the study

materials to the seminar facilitators who handed them

out and collected them during the seminars. The facil-

itators then returned the completed questionnaires to

the authors in the Freepost envelopes provided. Second-

year medical students at Nottingham (n � 197) were

initially recruited by internal mail and E-mail in October

2000. However, this led to a poor response (n � 43,

21á8%) within a 2-week period. Therefore, additional

second-year students (n � 87, 44á2%) were recruited

during a 50-minute lecture 2 weeks after being invited

by internal mail and E-mail. The study materials were

distributed during the lecture and completed question-

naires were collected at the end of the lecture.

Although the study instruments were anonymous, 73

second-year students from the University of Notting-

ham wrote their names on the ®rst set of questionnaires,

indicating that they were happy to receive a second copy

of the CSAS to complete. Of these students, 39 (53á4%)

completed the second copy of the CSAS satisfactorily

(with a 2-week interval between tests).

Key learning points

A new measure of medical students' attitudes

towards communication skills learning is described.

Evidence for its factor structure and reliability is

presented.

Further research is needed to evaluate the validity

of this scale.

Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:141±147

Communication Skills Attitude Scale · C Rees et al.142

Instruments

The Communication Skills Attitude Scale (CSAS) con-

sists of 26 items, 13 of which are written in the form of

positive statements and 13 negative statements about

communication skills learning. Each item is accom-

panied by a 5-point Likert scale, ranging from 1

(strongly disagree) to 5 (strongly agree). Brief instruc-

tions for the completion of this scale are included to

ensure that the scale can be self-administered (see

Appendix).

Participants also completed a demographic ques-

tionnaire, which included items on their age, gender,

ethnicity, and ®rst language. This questionnaire also

asked for the employment histories of their parents (to

determine their socioeconomic groups).

Data analysis

Data were analysed using the Statistical Package for the

Social Sciences (SPSS version 9á0). Exploratory data

analysis was conducted to establish the distribution of

all continuous variables. Parametric statistics were

determined for normally distributed continuous varia-

bles and non-parametric statistics were established for

non-normally distributed continuous variables. In order

to determine the structure underlying the CSAS, the

scale was factor analysed using maximum likelihood

extraction with direct oblimin (oblique) rotation. Sub-

scales were constructed on the basis of the factor

loadings, with scores being reversed where necessary.

The internal consistency of the subscales were identi-

®ed using Cronbach's alpha (a) coef®cients. The test-

retest reliability of the individual items on the CSAS

were measured by weighted kappa (j) coef®cients using

the statistical program SAS (Release 6á12). The test-

retest reliability of the subscales was measured using

intraclass correlation coef®cients.

Results

Factor structure

Six factors possessed eigenvalues greater than 1,

accounting for 56á74% of the variance in the data (see

Table 1).

However, only two factors were extracted because

the researchers wanted to use only demonstrably reli-

able factors11 and retain enough factors for an adequate

®t but not extract so many that parsimony was lost11

and because the scree plot suggested that two factors be

extracted. After direct oblimin rotation, the pattern

matrix for each item was examined (see Table 2). Items

with loadings less than 0á01 were suppressed in the

rotated pattern matrix.

Of the 26 items, 12 (46á2%) items making positive

statements about communication skills learning loa-

ded positively on factor I (items 4, 5, 7, 9, 10, 12,

14, 16, 18, 21, 23 and 25), with weightings ranging

from 0á246 (item 18) to 0á883 (item 14). In addition,

these 12 items either loaded negatively (n � 8,

66á7%), failed to load (n � 2, 16á7%) or loaded very

weakly on factor II (n � 2, 16á7%). The remaining

positive statement about communication skills learn-

ing (item 1) did not load on factor I but did load

highly and negatively (± 0á503) on factor II, suggest-

ing that its score should be reversed and added to

subscale II.

Of the 26 items, 12 (46á2%) items making negative

statements about communication skills learning (items

2, 3, 6, 8, 11, 13, 15, 17, 19, 20, 24 and 26) and 2

(7á7%) items making positive statements (items 5 and

14) loaded positively on factor II, with weightings ran-

ging from 0á128 (item 5) to 0á696 (item 26). In addition,

the 12 negative attitude items either loaded negatively

(n � 7, 58á3%) or failed to load (n � 5, 41á7%) on

factor I. The remaining negative statement about

communication skills (item 22) failed to load on factor

II but did load negatively (±0á394) on factor I, sug-

gesting that its score should be reversed and added to

subscale I. With the exception of items 5 and 14, none

of the variables could be considered complex variables,

i.e. variables that loaded positively on both factors.11

The correlation between factors I and II was )0á552.

Internal consistency

After reversing the scores for items 1 and 22, the

internal consistency of the 13 items of subscale I (items

4, 5, 7, 9, 10, 12, 14, 16, 18, 21, 22, 23 and 25) was

a � 0á873 and subscale II (items 1, 2, 3, 6, 8, 11, 13,

15, 17, 19, 20, 24 and 26) was a � 0á805.

Table 1 Total variance explained by the factors with eigenvalues

greater than 1

Factor

Initial

eigenvalues

% of

variance

Cumulative %

of variance

1 8á205 31á56 31á56

2 1á784 6á86 38á42

3 1á443 5á55 43á97

4 1á213 4á67 48á64

5 1á102 4á24 52á88

6 1á006 3á87 56á74

Communication Skills Attitude Scale · C Rees et al. 143


Test-retest reliability

The weighted kappa coef®cients between the items on

tests 1 and 2 ranged from 0á361 (item 25) to 0á611

(item 18) on subscale I and 0á204 (item 1) to 0á526

(item 11) on subscale II. The index of agreement for

the 13 items on the ®rst and second subscale is

summarised in Table 3.

In addition, test-retest analysis for the ®rst subscale,

as measured by an intraclass correlation coef®cient was

0á646 (P < 0á001). Test-retest analysis for the second

subscale, as measured by an intraclass correlation

coef®cient was 0á771 (P < 0á001).

Table 2 Rotated pattern matrix

Item Factor loading I Factor loading II

1. In order to be a good doctor I must have good communication skills )0á503

2. I can't see the point in learning communication skills )0á197 0á524

3. Nobody is going to fail their medical degree for having poor communication skills )0á241 0á161

4. Developing my communication skills is just as important as developing my knowledge

of medicine

0á493 )0á196

5. Learning communication skills has helped or will help me respect patients 0á735 0á128

6. I haven't got time to learn communication skills )0.339 0á340

7. Learning communication skills is interesting 0á536 )0á138

8. I can't be bothered to turn up to sessions on communication skills )0á238 0á446

9. Learning communication skills has helped or will help facilitate my team-working skills 0á510 )0á125

10. Learning communication skills has improved my ability to communicate with patients 0á444 )0á237

11. Communication skills teaching states the obvious and then complicates it )0á325 0á281

12. Learning communication skills is fun 0á525

13. Learning communication skills is too easy )0á107 0á367

14. Learning communication skills has helped or will help me respect my colleagues 0á883 0á239

15. I ®nd it dif®cult to trust information about communication skills given to me by

non-clinical lecturers

0á503

16. Learning communication skills has helped or will help me recognise patients' rights

regarding con®dentiality and informed consent

0á641

17. Communication skills teaching would have a better image if it sounded more like a

science subject

0á363

18. When applying for medicine, I thought it was a really good idea to learn

communication skills

0á246 )0á334

19. I don't need good communication skills to be a doctor 0á585

20. I ®nd it hard to admit to having some problems with my communication skills 0á227

21. I think it's really useful learning communication skills on the medical degree 0á380 )0á451

22. My ability to pass exams will get me through medical school rather than my

ability to communicate

)0á394

23. Learning communication skills is applicable to learning medicine 0á286 )0á431

24. I ®nd it dif®cult to take communication skills learning seriously )0á410 0á273

25. Learning communication skills is important because my ability to communicate

is a lifelong skill

0á311 )0á497

26. Communication skills learning should be left to psychology students, not medical students 0á696

Table 3 Test-retest reliability of the items on subscales I and II of the CSAS

Weighted

Kappa (j)

Levels of

agreement*

Subscale I

Frequency (%)

Item

number

Subscale II

Frequency (%)

Item

number

0á61±0á80 Substantial 1 (7á7) 18

0á41±0á60 Moderate 9 (69á2) 4, 5, 7, 9, 10, 12, 14, 21, 22 8 (61á5) 2, 3, 8, 11, 17, 19, 20, 24

0á21±0á40 Fair 3 (23á1) 16, 23, 25 4 (30á8) 6, 13, 15, 26

0á00±0á20 Slight 1 (7á7) 1

*levels of agreement according to Landis & Koch13.



Discussion

All of the variables loading positively on factor I were

positive statements about communication skills learn-

ing, suggesting that factor I re¯ected medical students'

positive attitudes towards communication skills. Inter-

estingly, these items clustered together in three groups:

(a) students' beliefs that communication skills learning

would facilitate their interpersonal skills with both their

colleagues and with patients; (b) students' beliefs that

communication skills learning was fun and interesting;

and (c) students' beliefs that communication skills

learning was important within a medical context, atti-

tudes consistent with those advocated by the GMC.1 In

addition, these variables generally loaded negatively or

failed to load on factor II, suggesting that factor II may

represent negative attitudes towards communication

skills learning. The remaining positive statement about

communication skills learning (item 1) did not load on

factor I but did load highly and negatively with factor II,

suggesting that its score should be reversed and added

to subscale II.

The hypothesis that factor II represented negative

attitudes towards communication skills learning was

given further weight by the ®nding that 12 of the 13

negative attitude statements loaded positively on

factor II. Interestingly, these items clustered together

in four groups: (a) medical students' negative atti-

tudes towards communication skills learning as a so-

cial science subject, a ®nding consistent with previous

research;8 (b) students' apathy towards learning

communication skills, a ®nding inconsistent with the

attitudes recommended in Tomorrow's Doctors;1

(c) students' negative beliefs that communication

skills learning was dif®cult to take seriously; and (d)

students' negative attitudes towards communication

skills assessment. In addition, these variables generally

loaded negatively or failed to load on factor I, sug-

gesting that factor I did indeed represent positive

attitudes towards communication skills learning. The

remaining negative statement (item 22) did not load

on factor II but did load negatively with factor I,

suggesting that its score should be reversed and added

to subscale I.

The a value for the positive and negative attitude

subscales were both above 0á8, indicating that the

subscales possessed satisfactory internal consistency.12

In addition, the majority (n � 18, 69á2%) of items

possessed substantial or moderate kappa coef®cients,

indicating satisfactory test-retest reliability.13 Finally,

test-retest analysis for both subscales, as measured by

intraclass correlations, indicated that the subscales

possessed satisfactory test-retest reliability.

This pilot study has a number of methodological

weaknesses that must be taken into consideration when

interpreting the results. Kline14 suggested that a mini-

mum sample size of 100 participants was necessary

when assessing the test-retest reliability of a scale. This

®gure is greater than the 39 test-retest participants used

in this study. Kline14 also recommended that there

should be at least a 3-month interval between tests to

establish a reliable estimate of test-retest reliability.

However, due to time constraints, the interval between

tests was approximately 2 weeks. Thus, the test-retest

reliability may have been in¯ated if participants were

able to remember their answers from the ®rst test.

Therefore, the ®ndings associated with test-retest reli-

ability must be treated with caution. In addition,

although the response rate for this study was high

(83á8%), nonresponders may have possessed different

(e.g. poorer) attitudes towards communication skills

learning compared to responders, thus biasing the

sample.

Despite some methodological limitations in the

study, this new scale does appear to be a consistent and

stable measure of medical students' attitudes towards

communication skills learning. Further research is

necessary with larger groups of students to con®rm

these study ®ndings and to evaluate the validity of this

scale. We are currently using this scale to establish

whether signi®cant associations exist between medical

students' attitudes and their demographic and educa-

tion-related characteristics. These ®ndings will help us

establish the construct validity of this scale.

Contributors

All the authors contributed to the writing of the

preliminary version of this paper. The ®rst and second

author wrote the ®nal version of the paper. The ®rst

author designed the Communication Skills Attitude

Scale and the ®rst and third author designed the study.

All authors participated in the data collection, data

entry and data analysis for this study.

Acknowledgements

We would like to thank the students who participated in

this study and our colleagues at the Universities of

Nottingham and Leicester who helped us collect data

for this study. From the University of Nottingham

Division of Psychiatry we would like to thank (in

alphabetical order) Drs Kim Cornish and Paul Garrud

and Ms Amy McPherson. From the University of

Leicester Department of General Practice and Primary

Health Care we would like to thank (in alphabetical



order) Drs Aram, Cole, Coleman, de Caestecker,

Hastings, Hay, Heap, Lazarus, Professor Lindsey, Dr

McKinley, Professor Petersen, Drs Preston-Whyte,

Robinsen, Scarborough, Stokes, Sutton and Turner.

We would also like to thank Dr Paul Garrud for peer-

reviewing the revised manuscript.

Funding

The Division of Psychiatry at the University of Not-

tingham funded this study.

References

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General Medical Council; 1993.

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Received 5 December 2000; editorial comments to authors 13 March

2001; accepted for publication 21 June 2001

Appendix (continued overleaf)

Communication Skills Attitudes Scale (CSAS)

Please read the following statements about communication skills learning. Indicate whether you agree or disagree with all of the

statements by circling the most appropriate response. Remember,

1 � strongly disagree

2 � disagree

3 � neutral

4 � agree

5 � strongly agree

1. In order to be a good doctor I must have good communication skills 1 2 3 4 5

2. I can't see the point in learning communication skills 1 2 3 4 5

3. Nobody is going to fail their medical degree for having poor communication skills 1 2 3 4 5

4. Developing my communication skills is just as important as developing my knowledge of medicine 1 2 3 4 5

5. Learning communication skills has helped or will help me respect patients 1 2 3 4 5

6. I haven't got time to learn communication skills 1 2 3 4 5

7. Learning communication skills is interesting 1 2 3 4 5

8. I can't be bothered to turn up to sessions on communication skills 1 2 3 4 5

9. Learning communication skills has helped or will help facilitate my team-working skills 1 2 3 4 5

10. Learning communication skills has improved my ability to communicate with patients 1 2 3 4 5

11. Communication skills teaching states the obvious and then complicates it 1 2 3 4 5

12. Learning communication skills is fun 1 2 3 4 5

13. Learning communication skills is too easy 1 2 3 4 5

14. Learning communication skills has helped or will help me respect my colleagues 1 2 3 4 5

15. I ®nd it dif®cult to trust information about communication skills given to me by non-clinical lecturers 1 2 3 4 5

16. Learning communication skills has helped or will help me recognise patients' rights regarding

con®dentiality and informed consent

1 2 3 4 5



Appendix (Continued)

17. Communication skills teaching would have a better image if it sounded more like a science subject 1 2 3 4 5

18. When applying for medicine, I thought it was a really good idea to learn communication skills 1 2 3 4 5

19. I don't need good communication skills to be a doctor 1 2 3 4 5

20. I ®nd it hard to admit to having some problems with my communication skills 1 2 3 4 5

21. I think it's really useful learning communication skills on the medical degree 1 2 3 4 5

22. My ability to pass exams will get me through medical school rather than my ability to communicate 1 2 3 4 5

23. Learning communication skills is applicable to learning medicine 1 2 3 4 5

24. I ®nd it dif®cult to take communication skills learning seriously 1 2 3 4 5

25. Learning communication skills is important because my ability to communicate is a lifelong skill 1 2 3 4 5

26. Communication skills learning should be left to psychology students, not medical students 1 2 3 4 5



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The development of a scale to measure medical students' attitudes towards communication skills learning: the Communication Skills Attitude Scale (CSAS)