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The relationship between medical students’ attitudes towardscommunication skills learning and their demographic andeducation-related characteristics
Charlotte Rees1 & Charlotte Sheard2
Introduction The General Medical Council (GMC) has
stressed the importance of medical students’ attitudes
towards learning. However, few studies have explored
medical students’ attitudes towards communication
skills learning. This study explores the relationship
between the attitudes of medical students at two dif-
ferent schools and their demographic and education-
related characteristics.
Methods A total of 490 medical students from the
Universities of Nottingham (Years 1 and 2) and
Leicester (Year 1) completed the 26-item Communi-
cation Skills Attitude Scale (CSAS) and a personal
details questionnaire satisfactorily. The relationships
between students’ attitudes and their demographic and
education-related characteristics were analysed sepa-
rately for Nottingham and Leicester students using
both univariate and multivariate statistics.
Results The attitudes of Nottingham and Leicester
medical students towards communication skills learn-
ing were significantly associated with a number of
demographic and education-related characteristics.
Both Nottingham and Leicester students with more
positive attitudes towards communication skills learn-
ing tended to be female, tended to think their commu-
nication skills needed improving and tended not to have
parents who were doctors. Both Nottingham and
Leicester students with more negative attitudes towards
communication skills learning tended to think their
communication skills did not need improving.
Discussion The results indicate that medical students’
attitudes towards communication skills learning are
associated with their demographic and education-
related characteristics. These findings have a number
of implications for educational practice and further
research and these are discussed in this paper.
Keywords education, medical, undergraduate ⁄*standards; *communication; *learning; attitude of
health personnel; interpersonal relations; question-
naires; England.
Medical Education 2002;36:1017–1027
Introduction
Communication skills learning became an integral part
of undergraduate medical education with the publica-
tion of Tomorrow’s Doctors.1 In this report, the General
Medical Council (GMC) stated that by the end of their
training, students should have acquired and demon-
strated a proficiency in communication. The GMC
concluded that doctors should be good listeners and
should be able to provide advice and explanations that
are comprehensible to patients and their relatives. The
GMC also made recommendations regarding medical
students’ attitudes, suggesting that students should
have acquired and demonstrated attitudes consistent
with effective medical practice by the end of their
training. Included in a diverse list of 12 attitudinal
objectives were four that related to attitudes towards
learning (e.g. having an awareness of personal limita-
tions and willingness to seek help where necessary).
The research literature on medical students’ attitudes
towards communication skills learning2–4 has produced
mixed results. One of the first attempts to assess
medical students’ attitudes towards communication
skills learning was a study conducted by Walker et al.2
These authors assessed the attitudes of final year
medical students qualifying in 1978 ⁄79 towards the
content, teaching and assessment of their medical
training at the University of Aberdeen. Of the 101 final
1Institute of Clinical Education, Peninsula Medical School, Plymouth,
UK2Behavioural Sciences Section, Division of Psychiatry, University of
Nottingham, UK
Correspondence: Charlotte Rees, Peninsula Medical School, ITTC
Building, Tamar Science Park, Davy Road, Plymouth PL6 8BX, UK.
Tel.: 00 44 1752 238009; Fax: 00 44 1752 238001; E-mail:
Clinical and communication skills
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027 1017
year students who were sent a 44-item anonymous
postal questionnaire, 75 responded, giving a response
rate of 74Æ3%. In terms of their attitudes towards
communication skills learning, the authors found that
only 45% of the students thought they had been given
sufficient instruction in doctor–patient relationships,
only 59% thought they had received sufficient instruc-
tion in interviewing techniques and 66% believed that
the scientific aspects of the course had been overem-
phasised. These findings suggested that communica-
tion skills learning was valued and that many students
wanted more. However, this study was conducted over
20 years ago and cannot be taken as representative of
final year students qualifying in the year 2002.
More recently, Rosenthal & Ogden3 conducted a
questionnaire survey in June 1994 to elicit the attitudes
of all undergraduate medical students (Years 1–5) at
the Royal Free Hospital School of Medicine concerning
the GMC’s1 recommendations for changing the un-
dergraduate curriculum. Of the 508 medical students
invited to participate, 383 responded satisfactorily,
giving an overall response rate of 75Æ4%. Of these
students, 64Æ8% agreed with the statement: �Greater
emphasis should be placed on communication skills�,suggesting that the majority of students valued com-
munication skills learning. However, response rates
varied according to the year of training. For example,
first, second and fourth year students had higher
response rates (89Æ3%, 78Æ6% and 88Æ8%, respectively)
than third and fifth year students (65Æ4% and 54Æ2%,
respectively). This suggests that the findings may not
be generalisable to a wider population of third and
fifth year students.
Finally, Rees & Garrud4 conducted a qualitative pilot
study in May 2000 with five medical students from the
University of Nottingham to establish their attitudes
towards communication skills learning. This study
found that some medical students held positive
attitudes towards communication skills learning. For
example, some students thought that in order to
become a �good� doctor, they had to possess good
communication skills. They also thought that commu-
nication skills were lifelong skills and helped them to
work in teams. One student suggested that communi-
cation skills learning was fun, interesting, useful and
applicable to medicine. However, some students had
negative attitudes towards communication skills learn-
ing. Negative attitudes included communication skills
learning not being viewed as a valuable part of the
undergraduate curriculum and being viewed as too
easy. In addition, some students felt unable to vocalise
their personal limitations in this area, a finding that is
inconsistent with the attitudinal objectives of the
GMC.1 Finally, some of the participants suggested
that medical students’ attitudes were related to other
factors like their previous educational experiences, their
age and their communicative abilities. However, given
the small sample size of this study, it is impossible to
extrapolate its findings to a wider population of medical
students.
Although studies have started to explore medical
students’ attitudes towards communication skills learn-
ing, it is difficult to draw any firm conclusions about
medical students’ attitudes because of the limitations
associated with these studies. For example, none of
these studies has used a reliable scale to measure
attitudes. To combat these limitations and to address
gaps in the research literature, the current study aims
to identify the attitudes of medical students at two
different schools using a reliable attitude scale, and to
consider their relationships with medical students’
demographic and education-related characteristics.
The Nottingham and Leicester Schools were chosen
for this study because they offer different communica-
tion skills courses. Although the content of the courses
at Nottingham and Leicester are similar (e.g. both the
Nottingham and Leicester Year 1 courses focus on
information gathering in the medical interview), the
teaching methods differ, as has been found with
other universities.5 The Nottingham courses use more
instructional teaching methods compared to the
Leicester course (e.g. the Nottingham Year 1 course
includes four lectures compared to one lecture at
Leicester). In addition, the Leicester course uses more
experiential methods of learning, such as observed
interviews with simulated patients and feedback,
Key learning points
Both Nottingham and Leicester medical students’
attitudes are associated with their demographic
characteristics (e.g. gender and whether they have
doctor parents).
Both Nottingham and Leicester medical students’
attitudes are associated with their education-
related characteristics (e.g. whether they think
their communication skills need improving).
Further research is needed to establish which
aspects of communication skills courses are asso-
ciated with attitudes.
Further research is necessary to determine whether
medical students’ attitudes change as a result of
communication skills learning.
Attitudes towards communication skills learning • C Rees & C Sheard1018
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
compared to the Nottingham Year 1 course (e.g. three
2-hour workshops at Leicester compared to one 2-hour
workshop in the Nottingham Year 1 course). In
addition, the Leicester course is more fully integrated
with clinical examination skills and family placement
sessions than are the Nottingham courses, which are
more stand-alone in structure with some integration
with early clinical skills sessions. The use of two
different schools not only enabled us to explore
students’ attitudes towards different communication
skills courses but also allowed us to explore the
differences between the demographic and education-
related characteristics of the undergraduate populations
of Nottingham and Leicester.
Methods
Recruitment procedures
After receiving approval from the Medical School
Ethics Committee at the University of Nottingham,
all Year 1 and 2 medical students at the University of
Nottingham and all Year 1 medical students at the
University of Leicester were invited to participate in
this study. Year 1 students from Nottingham and
Leicester 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 collec-
ted them during the seminars. The facilitators then
returned the completed questionnaires to the authors in
freepost envelopes provided. Year 2 medical students at
Nottingham were initially recruited by internal mail and
email in October 2000. However, this led to a poor
response (n ¼ 43, 21Æ8%) within a 2-week period.
Therefore, additional Year 2 students (n ¼ 87, 44Æ2%)
were recruited during a 50-minute lecture 2 weeks after
being invited by internal mail and email. The study
materials were distributed during the lecture and
completed questionnaires were collected at the end of
the lecture.
Materials
Communication Skills Attitude Scale
The first author (CR) designed the Communication
Skills Attitude Scale (CSAS) using the findings of an
earlier qualitative pilot study that explored medical
students’ attitudes towards communication skills learn-
ing.4 The scale consists of 26 items with two subscales,
each with 13 items. The first subscale (items 4, 5, 7, 9,
10, 12, 14, 16, 18, 21, 22, 23 and 25) represents
positive attitudes towards communication skills learn-
ing, such as: �Developing my communication skills is
just as important as developing my knowledge of
medicine� (item 4). In a previous study6 this subscale
was found to possess satisfactory internal consistency
with 490 medical students (a ¼ 0Æ873) and satisfactory
test-retest reliability with 39 medical students (intra-
class correlation ¼ 0Æ646, P < 0Æ001). The second
subscale (items 1, 2, 3, 6, 8, 11, 13, 15, 17, 19, 20,
24 and 26) represents negative attitudes towards
communication skills learning, such as: �I can�t be
bothered to turn up to sessions on communication
skills’ (item 8). This subscale has also been found
to possess satisfactory internal consistency (a ¼ 0Æ805)
and test-retest reliability (intraclass correlation ¼0Æ771, P < 0Æ001).6
All the 26 items are accompanied by 5-point Likert
scales ranging from 1 (strongly disagree) to 5 (strongly
agree). Two scores can be determined from the CSAS:
the total positive attitude scale (PAS) score and the
total negative attitude scale (NAS) score. After
reversing the scores of items 1 and 22, both the PAS
and NAS scores are established by summing the
scores for the 13 items of each subscale. Both scores
range from 13 to 65, with higher scores indicating
stronger attitudes.
Personal details questionnaire
The personal details questionnaire contained six
demographic items and four education-related items.
Demographic items included age, gender, ethnicity,
first language and the employment history of respond-
ents’ fathers and mothers (to calculate socio-economic
status). Education-related items included what sub-
jects respondents studied before studying medicine,
whether respondents thought their communication
skills needed improving and the mark (out of 20) that
respondents received for their last communication
skills Objective Structured Clinical Examination
(OSCE). Participants were also asked to rate their com-
munication skills on a 5-point scale where 1 ¼ poor
and 5 ¼ excellent.
Data analysis
Data were analysed using SPSS version 10Æ0. Explor-
atory data analysis was conducted first to establish the
distribution of continuous variables. Non-parametric
statistics were used for continuous variables that were
non-normally distributed and parametric statistics were
used for continuous variables that were normally
distributed.
Attitudes towards communication skills learning • C Rees & C Sheard 1019
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
Descriptive statistics (e.g. frequencies, percentages,
etc.) were used to identify the demographic and
education-related details of the total sample and then
the Nottingham and Leicester students separately.
Univariate statistics (e.g. Mann–Whitney Z statistics
or chi-squared statistics) were used to establish whether
the Nottingham and Leicester samples differed signifi-
cantly in terms of their demographic and education-
related characteristics. Univariate statistics were also
used to establish the relationship between the depend-
ent variables (DVs) (i.e. scores on the PAS and NAS)
and individual independent variables (IVs) (i.e. demo-
graphic and education-related characteristics of partic-
ipants) for Nottingham and Leicester students
separately.
Multivariate statistics (i.e. stepwise multiple regres-
sion) were used to establish the best linear combination
of IVs to predict the DVs for Nottingham and Leicester
students separately. However, some of the DVs
were transformed before running the stepwise multiple
regression procedures. The PAS score for Nottingham
students was negatively skewed and was therefore
transformed using a reflect procedure and a square root
transformation.7 The NAS score for Nottingham and
Leicester students was positively skewed and was there-
fore transformed using a square root transformation.7
Results
Participants’ demographic and education-related
characteristics
Of the 585 medical students invited to participate
in this study, 490 completed the CSAS satisfactorily,
giving a response rate of 83Æ8%. Overall, the sample
ranged in age from 17 to 35 years (median ¼ 19,
interquartile range ¼ 18–19). The majority were
female (n ¼ 281, 57Æ3%), white (n ¼ 352, 72Æ1%) and
came from non-manual socio-economic backgrounds
(n ¼ 473, 96Æ9%). Most of the students spoke English
as their first language (n ¼ 411, 83Æ9%), did not have
parents who were doctors (n ¼ 400, 82Æ0%) and had
studied only pure science subjects before studying
medicine (n ¼ 251, 54Æ3%). Students’ ratings of their
own communication skills ranged from 1 (poor) to 5
(excellent) (median ¼ 3, interquartile range ¼ 3–4)
and nearly all of them thought that their communica-
tion skills needed improving (n ¼ 471, 96Æ3%). Finally,
the majority were studying medicine at the University
of Nottingham (n ¼ 326, 66Æ5%). As students were
recruited from two different schools, their demographic
and education-related characteristics are presented
separately in Table 1.
Relationships between students’ positive attitudes and
their demographic and education-related characteristics
Nottingham students
Scores for the positive attitude subscale (PAS) for
Nottingham students ranged from 14 to 65
(median ¼ 48Æ5, interquartile range ¼ 44–53). Of the
relationships explored between the dependent variable
(PAS score) and the 10 independent variables, three
(30%) were found to be statistically significant at the
P < 0Æ05 level and one (10%) showed a trend towards
significance (Table 2).
The four variables with a significant or a trend
towards a significant relationship with the dependent
variable (PAS score) were entered into a stepwise
multiple regression model. Of these four variables, all
except the OSCE assessment mark were found to be
significantly associated with scores on the PAS. Whe-
ther students had parents who were not doctors seemed
to be the biggest predictor of positive attitudes towards
communication skills learning for Nottingham students
(Table 3).
Leicester students
PAS scores for Leicester students ranged from 34 to 64
(mean ¼ 52Æ38, SD ¼ 6Æ53). Of the relationships
explored between the dependent variable (PAS score)
and the nine independent variables, two (22Æ2%) were
found to be statistically significant at the P < 0Æ05 level
and two (22Æ2%) showed a trend towards significance
(Table 2).
The four variables with a significant or a trend
towards a significant relationship with the dependent
variable (PAS score) were entered into a stepwise
multiple regression model. Of these four variables, all
except whether students thought their communication
skills needed improving were found to be significantly
associated with scores on the PAS. The age of students
(i.e. the younger they were) seemed to be the biggest
predictor of positive attitudes towards communication
skills learning for Leicester students (Table 3).
Relationships between students’ negative attitudes
and their demographic and education-related
characteristics
Nottingham students
Scores for the negative attitude subscale (NAS) for
Nottingham students ranged from 14 to 51
(median ¼ 27, interquartile range ¼ 24–31). Of the
relationships explored between the dependent variable
(NAS score) and the 10 independent variables, one
(10%) was found to be statistically significant at the
Attitudes towards communication skills learning • C Rees & C Sheard1020
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
P < 0Æ05 level and two (20%) showed a trend towards
significance (Table 4).
The three variableswith a significant or a trend towards
a significant relationship with the dependent variable
(NAS score) were entered into a stepwise multiple
regression model. Of these three variables, all except
ethnicity were found to be significantly associated with
scores on the NAS. Students reporting that their com-
munication skills did not need improving seemed to be
the biggest predictor of negative attitudes towards
communication skills learning for Nottingham students
(Table 5).
Leicester students
Scores for the negative attitude subscale (NAS) for
Leicester students ranged from 13 to 40 (median ¼ 24,
interquartile range ¼ 21–27). Of the relationships
explored between the dependent variable (NAS score)
Table 1 Demographic and education-related characteristics of the sample by school
Frequency (valid percentage)*
Variables Nottingham Leicester Test statistic, P-value**
Age
Median (interquartile range) 19 (18–20) 19 (18–19)
Range 17–35 18–33 Z ¼ ) 2Æ131, P ¼ 0Æ033
Gender
Male 129 (39Æ6%) 80 (48Æ8%)
Female 197 (60Æ4%) 84 (51Æ2%) v2 ¼ 3Æ417, d.f. ¼ 1, P ¼ 0Æ065
Ethnicity�White 245 (75Æ4%) 107 (65Æ6%)
Non-white 80 (24Æ6%) 56 (34Æ4%) v2 ¼ 4Æ650, d.f. ¼ 1, P ¼ 0Æ031
Socio-economic status�Non-manual occupations (I, II, IIIN) 321 (98Æ8%) 150 (92Æ0%)
Manual occupations (IIIM, IV, V) 4 (1Æ2%) 13 (8Æ0%) v2 ¼ 12Æ75, d.f. ¼ 1, P < 0Æ001
Do students have doctor parent(s)?�Yes 57 (17Æ5%) 31 (19Æ0%)
No 268 (82Æ5%) 132 (81Æ0%) v2 ¼ 0Æ076, d.f. ¼ 1, P ¼ 0Æ782
First language
English 288 (88Æ3%) 123 (75Æ0%)
Non-English 38 (11Æ7%) 41 (25Æ0%) v2 ¼ 13Æ396, d.f. ¼ 1, P < 0Æ001
Subjects studied prior to medicine�Pure science subjects only 173 (55Æ8%) 78 (51Æ3%)
Non-pure science subject(s) 137 (44Æ2%) 74 (48Æ7%) v2 ¼ 0Æ658, d.f. ¼ 1, P ¼ 0Æ417
Students ratings of their own
communication skills
Median (interquartile range) 3 (3–4) 3 (3–3Æ75)
Range 1–5 2–5 Z ¼ ) 3Æ218, P ¼ 0Æ001
Do students think their
communication skills need improving?��Yes 313 (96Æ0%) 158 (96Æ9%)
No 13 (4Æ0%) 5 (3Æ1%) v2 ¼ 0Æ065, d.f. ¼ 1, P ¼ 0Æ799
Communication skills OSCE mark
(Nottingham Year 2 students only)
Median (interquartile range) 17 (16–18)
Range 12–20
Positive attitude subscale (PAS) score
Central tendency (distribution) 48Æ5 (44–53)§ 52Æ38 (6Æ53)§§
Range 14–65 34–64 Z ¼ ) 6Æ386, P < 0Æ001
Negative attitude subscale (NAS) score
Median (interquartile range) 27 (24–31)§ 24 (21–27)§
Range 14–51 13–40 Z ¼ ) 6Æ705, P < 0Æ001
*Except age, students’ ratings of their communication skills, communication skills OSCE mark, PAS and NAS scores.
**Non-parametric statistics were used, i.e. Mann–Whitney Z statistics and Chi-squared statistics.
�2 missing cases; � 28 missing cases; �� 1 missing case; § median (interquartile range); §§mean (standard deviation).
Attitudes towards communication skills learning • C Rees & C Sheard 1021
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
Ta
ble
2U
niv
ari
ate
rela
tion
ship
sbet
wee
nsc
ore
son
the
posi
tive
att
itu
de
subsc
ale
(PA
S)
an
dd
emogra
phic
an
ded
uca
tion
-rel
ate
dch
aract
eris
tics
by
school
Dem
ogra
ph
ican
d
edu
cati
on
-rel
ate
dch
ara
cter
isti
cs
Nott
ingham
Lei
cest
er
Med
ian
PA
Ssc
ore
(in
terq
uart
ile
ran
ge)
Tes
tst
ati
stic
P-v
alu
e*
Mea
nP
AS
score
(SD
)
Tes
tst
ati
stic
,P
-valu
e�
Age
–r¼
)0Æ0
79,
P¼
0Æ1
55
–r¼
)0Æ2
15,
P¼
0Æ0
06
Gen
der
Male
47
(42–51Æ5
)51Æ2
6(6Æ9
8)
Fem
ale
49
(45–54)
Z¼
)2Æ3
30,
P¼
0Æ0
20
53Æ4
5(5Æ9
2)
T¼
)2Æ1
71,
d.f
.¼
162,
P¼
0Æ0
31
Eth
nic
ity
Wh
ite
48
(43–53)
52Æ1
4(6Æ4
7)
Non
-whit
e49
(45–53)
Z¼
)0Æ8
01,
P¼
0Æ4
23
52Æ8
8(6Æ7
4)
T¼
)0Æ6
79,
d.f
.¼
161,
P¼
0Æ4
98
Soci
o-e
con
om
icst
atu
s
Non
-man
ual
48
(44–53)
52Æ4
3(6Æ3
9)
Man
ual
occ
up
ati
on
s50
(47Æ5
–54Æ7
5)
Z¼
)0Æ8
77,
P¼
0Æ3
81
52Æ3
8(8Æ3
3)
T¼
0Æ0
22,
d.f
.¼
161,
P¼
0Æ9
82
Fir
stla
ngu
age
En
glish
48
(43–53)
52Æ0
5(6Æ2
5)
Non
-En
glish
49Æ5
(46Æ7
5–52Æ2
5)
Z¼
)1Æ3
19,
P¼
0Æ1
87
53Æ3
9(7Æ3
0)
T¼
)1Æ1
40,
d.f
.¼
162,
P¼
0Æ2
56
Do
stu
den
tshave
doct
or
pare
nts
(on
eor
both
)?
Yes
47
(40Æ5
–52Æ5
)50Æ5
5(7Æ4
7)
No
49
(45–53)
Z¼
)1Æ7
59,
P¼
0Æ0
79
52Æ8
6(6Æ2
4)
T¼
)1Æ7
88,
d.f
.¼
161,
P¼
0Æ0
76
Su
bje
cts
stu
die
dpri
or
tom
edic
ine
Pu
resc
ien
ces
on
ly48
(43–52)
52Æ9
7(6Æ3
9)
Non
-sci
ence
subje
ct(s
)49
(44Æ5
–53Æ5
)Z
¼)
0Æ6
78,
P¼
0Æ4
98
51Æ3
5(6Æ8
0)
T¼
)1Æ5
17,
d.f
.¼
150,
P¼
0Æ1
31
Stu
den
ts’
rati
ngs
of
thei
r
ow
nco
mm
un
icati
on
skills
–r¼
0Æ0
46,
P¼
0Æ4
12
–r¼
0Æ0
26,
P¼
0Æ7
36
Do
stu
den
tsth
ink
thei
rco
mm
un
icati
on
skills
nee
dim
pro
vin
g?
Yes
49
(44–53)
52Æ5
4(6Æ4
0)
No
45
(33–48)
Z¼
)2Æ4
43,
P¼
0Æ0
15
47Æ2
0(9Æ7
8)
T¼
1Æ8
09,
d.f
.¼
161,
P¼
0Æ0
72
OS
CE
mark
(Nott
ingh
am
Yea
r2
stu
den
tson
ly)
–r¼
)0Æ2
18,
P¼
0Æ0
23
––
*N
on
-para
met
ric
stati
stic
sw
ere
use
d,
i.e.
Man
n–W
hit
ney
Zst
ati
stic
sor
Spea
rman
’sr
stati
stic
s.
�Para
met
ric
stati
stic
sw
ere
use
d,
i.e.
Ind
epen
den
tT
-tes
tsor
Pea
rson
’sr
stati
stic
s.
Attitudes towards communication skills learning • C Rees & C Sheard1022
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
and the nine independent variables, four (44Æ4%) were
found to be statistically significant at the P < 0Æ05 level
(Table 4).
The four variables with a significant relationship with
the dependent variable (NAS score) were entered into a
stepwise multiple regression model. Of these four
variables, two were found to be significantly associated
with scores on the NAS: ethnicity and whether students
thought their communication skills needed improving.
Students’ non-white ethnicity seemed to be the biggest
predictor of negative attitudes towards communication
skills learning for Leicester students (Table 5).
Discussion
As can been seen from Table 1, Nottingham and
Leicester students differed significantly in terms of their
age, ethnicity, socio-economic status, first language,
how they rated their communication skills and their
positive and negative attitudes towards communication
skills learning. There was also a trend towards a signi-
ficant difference between Nottingham and Leicester
students in terms of their gender.
A number of demographic and education-related
variables were found to have significant relationships
with scores on the positive (PAS) and negative atti-
tude subscales (NAS) for Nottingham and Leicester
students.
The relationship between attitudes and demographic
variables
Age was found to have a significant univariate and
multivariate relationship with PAS scores for Leicester
students. As age increased, PAS scores decreased,
suggesting that younger students had more positive
attitudes towards communication skills learning than
older students. A possible explanation for this finding is
that older students at Leicester University may have
utilised their communication skills in a wide variety of
settings outside their academic education, e.g. in
previous employment. As a result, they may not value
the opportunities afforded by a communication skills
course to the same degree as younger students, who
may have less experience communicating with people
they do not know. However, this finding is inconsistent
with previous research,4 which suggested that mature
students were more positive towards learning commu-
nication skills than younger students. This inconsistent
finding may have resulted from the Rees & Garrud4
study, only optimising a small sample size which is
unlikely to be representative of a wider population of
medical students. In addition, all participants in the
Rees & Garrud4 study were students at the University
of Nottingham, so may have had a different demo-
graphic profile to the Leicester students in the current
study. The relationship between age and students’
attitudes needs further exploration in a longitudinal
study.
Gender was found to have statistically significant
univariate and multivariate relationships with PAS
scores for both Nottingham and Leicester students. In
addition, gender was found to have a statistically
significant multivariate relationship with NAS score
for Nottingham students. Female students had higher
PAS scores and lower NAS scores compared to male
students, suggesting that women had more positive
attitudes towards communication skills learning. This
finding is consistent with earlier research,8 which has
found that female students scored the same or higher
Table 3 Multiple regression: dependent variable positive attitude subscale (PAS) score by school
Variable Coefficient B SE (B) Beta t Significance
Nottingham
Constant 5Æ599 0Æ420 13Æ335 0Æ000
DOCPARENT ) 0Æ663* 0Æ220 ) 0Æ277* ) 3Æ014* 0Æ003*
CSIMPROVE 0Æ701* 0Æ334 0Æ194* 2Æ099* 0Æ038*
GENDER 0Æ375* 0Æ184 0Æ187* 2Æ037* 0Æ044*
Leicester
Constant 62Æ523 4Æ829 12Æ948 0Æ000
AGE ) 0Æ685 0Æ237 ) 0Æ218 ) 2Æ884 0Æ004
GENDER 2Æ317 0Æ986 0Æ177 2Æ349 0Æ020
DOCPARENT ) 2Æ535 1Æ270 ) 0Æ151 ) 1Æ997 0Æ048
*Because the DV has been reflected and square root transformed for the Nottingham sample, the direction of the output has been reversed7
DOCPARENT: whether students have doctor parents (one or both); CSIMPROVE: whether students think their communication skills
need improving; GENDER: whether students are female; AGE: students’ ages.
Attitudes towards communication skills learning • C Rees & C Sheard 1023
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
Ta
ble
4U
niv
ari
ate
rela
tion
ship
sbet
wee
nsc
ore
son
the
neg
ati
ve
att
itu
de
subsc
ale
(NA
S)
an
dd
emogra
phic
an
ded
uca
tion
-rel
ate
dch
ara
cter
isti
csby
school
Nott
ingham
Lei
cest
er
Dem
ogra
ph
ican
d
edu
cati
on
-rel
ate
dch
aract
eris
tics
Med
ian
PA
Ssc
ore
(in
terq
uart
ile
ran
ge)
Tes
tst
ati
stic
P-v
alu
e*
Mea
nP
AS
score
(SD
)
Tes
tst
ati
stic
,P
-valu
e*
Age
–r¼
0Æ0
67,
P¼
0Æ2
30
–r¼
0Æ0
99,
P¼
0Æ2
06
Gen
der
Male
27
(25–32)
24
(21–28)
Fem
ale
27
(23–30)
Z¼
)1Æ7
41,
P¼
0Æ0
82
23
(20Æ2
5–26)
Z¼
)1Æ5
68,
P¼
0Æ1
17
Eth
nic
ity
Wh
ite
27
(24–31)
23
(20–26)
Non
-wh
ite
28
(25–31)
Z¼
)1Æ7
06,
P¼
0Æ0
88
26
(22–28)
Z¼
)3Æ3
52,
P¼
0Æ0
01
Soci
o-e
con
om
icst
atu
s
Non
-man
ual
27
(24–31)
24
(21–27)
Man
ual
occ
upati
on
s23
(20Æ2
5–29Æ5
)Z
¼)
1Æ3
20,
P¼
0Æ1
87
23
(21Æ5
–30)
Z¼
)0Æ2
00,
P¼
0Æ8
42
Fir
stla
ngu
age
En
glish
27
(24–31)
23
(20–26)
Non
-En
glish
29
(26–31Æ5
)Z
¼)
1Æ4
85,
P¼
0Æ1
38
26
(22–28)
Z¼
)2Æ7
07,
P¼
0Æ0
07
Do
stu
den
tshave
doct
or
pare
nts
(on
eor
both
)?
Yes
28
(24–32Æ5
)27
(22–31)
No
27
(24–31)
Z¼
)0Æ9
91,
P¼
0Æ3
21
23
(20Æ2
5–26)
Z¼
)2Æ4
08,
P¼
0Æ0
16
Su
bje
cts
stu
die
dpri
or
tom
edic
ine
Pu
resc
ien
ces
on
ly27
(24–31)
23Æ5
(20Æ7
5–27)
Non
-sci
ence
subje
ct(s
)27
(24–31)
Z¼
)0Æ7
87,
P¼
0Æ4
31
24
(21–27)
Z¼
)0Æ2
05,
P¼
0Æ8
37
Stu
den
ts’
rati
ngs
of
thei
row
n
com
mu
nic
ati
on
skills
–r¼
)0Æ0
20,
P¼
0Æ7
24
–r¼
)0Æ0
02,
P¼
0Æ9
76
Do
stu
den
tsth
ink
thei
r
com
mu
nic
ati
on
skills
nee
dim
pro
vin
g?
Yes
27
(24–31)
24
(21–27)
No
30
(27Æ5
–36)
Z¼
)2Æ6
36,
P¼
0Æ0
08
31
(27–32Æ5
)Z
¼)
2Æ7
40,
P¼
0Æ0
06
OS
CE
mark
(Nott
ingh
am
yea
r
2st
ud
ents
on
ly)
–r¼
0Æ0
57,
P¼
0Æ5
58
––
*N
on
-para
met
ric
stati
stic
sw
ere
use
d,
i.e.
Man
n–W
hit
ney
Zst
ati
stic
sor
Sp
earm
an
’sr
stati
stic
s.
Attitudes towards communication skills learning • C Rees & C Sheard1024
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
than male students in a study to measure professional
attitudes before and after a communication skills
course. Additionally, in his review of the literature
surrounding communication skills learning in medi-
cine, Aspegren9 cited four studies,10–13 all of which
found that male students were slower at learning
communication skills than female students. This may
account for the less positive attitudes held by male
students in this study.
Although PAS and NAS scores were not found to be
significantly associated with socio-economic status, a
significant multivariate relationship was found for both
Nottingham and Leicester students between PAS
scores and whether students had parents (one or both)
who were doctors. Students with doctor parents had
lower scores on the PAS and higher scores on the NAS,
suggesting that they had less positive attitudes towards
communication skills learning than students who did
not have doctor parents. One possible explanation for
this finding is that doctor parents have poor attitudes
towards communication skills learning, possibly
because communication skills were not taught when
they were undergraduates, and that their children
are socialised into adopting these negative attitudes.
Indeed, several researchers14,15 have suggested that
poor attitudes are transferred from practising and
experienced health care professionals to students and
other less experienced workers.
First language was found to have a statistically
significant univariate relationship with NAS score for
Leicester students. Students whose first language was
not English had significantly higher NAS scores,
suggesting that their attitudes towards communication
skills learning were poorer. A possible explanation for
this finding was that non-English speaking students
(n ¼ 13, 31Æ7%) were significantly more likely to have
parents who were doctors (and thus poorer attitudes)
compared with students who were English-speakers
(n ¼ 18, 14Æ8%) (v2 ¼ 4Æ679, d.f. ¼ 1, P ¼ 0Æ031).
Indeed, when controlling for whether students had
parents who were doctors or not, no significant
relationship remained between first language and
NAS score for students who had doctor parents
(Z ¼ ) 1Æ428, P ¼ 0Æ153) or those who did not
(Z ¼ ) 1Æ741, P ¼ 0Æ082). This finding suggested that
the �doctor parent� variable was acting as a confounding
variable.
Ethnicity was found to have a statistically significant
univariate and multivariate relationship with NAS
scores for Leicester students. Students whose ethnicity
was non-white had significantly higher scores on the
NAS, suggesting that their attitudes towards commu-
nication skills learning were poorer. A possible explan-
ation for this finding was that non-white students
(n ¼ 17, 30Æ4%) were significantly more likely to have
parents who were doctors compared to students who
were white (n ¼ 14, 13Æ2%) (v2 ¼ 5Æ900, d.f. ¼ 1,
P ¼ 0Æ015). However, when controlling for whether
students had doctor parents or not, a significant
relationship still remained between ethnicity and
NAS score for students without doctor parents
(Z ¼ ) 2Æ478, P ¼ 0Æ013).
One reason for this finding may be that non-white
students at Leicester have different cultural beliefs
about the importance of communication skills within
medical practice. For example, a greater proportion
of non-white students at Leicester (compared to
Nottingham) may be international students who have
been socialised into a paternalistic model of medical
practice, which does not value the doctor–patient
relationship to the same extent as scientific knowledge.
In addition, Leicester students may not feel that their
specific communication needs are being catered for
appropriately in their communication skills course.
Although they have a module on cultural diversity,
unlike Nottingham students, they do not have sessions
Table 5 Multiple regression: dependent variable negative attitude subscale (NAS) score by school
Variable Coefficient B SE (B) Beta t Significance
Nottingham
Constant 5Æ838 0Æ178 32Æ853 0Æ000
CSIMPROVE ) 0Æ381 0Æ156 ) 0Æ134 ) 2Æ447 0Æ015
GENDER ) 0Æ137 0Æ063 ) 0Æ120 ) 2Æ196 0Æ029
Leicester
Constant 5Æ085 0Æ249 20Æ433 0Æ000
ETHNIC 0Æ277 0Æ082 0Æ254 3Æ373 0Æ001
CSIMPROVE ) 0Æ572 0Æ224 ) 0Æ192 ) 2Æ552 0Æ012
CSIMPROVE: whether students think their communication skills need improving; GENDER: whether students are female; ETHNIC,
whether students are non-white.
Attitudes towards communication skills learning • C Rees & C Sheard 1025
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
within the communication skills course that explicitly
cover communication issues with people of different
ethnic origins and with different first languages. This is
a particularly important issue given that over a third of
Year 1 students at Leicester are of non-white ethnic
origin.
The relationship between attitudes and education-
related variables
The variable �school� (i.e. communication skills courses
attended) had a statistically significant association with
both PAS and NAS scores. Leicester students had
higher scores on the PAS and lower scores on the NAS
than Nottingham students, suggesting that their atti-
tudes were better than Nottingham students. There are
two possible explanations for these findings. Firstly, the
differences between students’ attitudes may have resul-
ted from the different courses offered at each medical
school. As already mentioned, the teaching methods at
each school differ, with Nottingham using more didac-
tic teaching than Leicester. Interestingly, other research-
ers9,16 have suggested that lecture-based teaching is less
effective in terms of communication skills learning than
more practically oriented and problem-based learning.
Secondly, the differences between students’ attitudes
may have resulted from their different levels of experi-
ence regarding communication skills learning at the
time of survey completion. For example, Year 1
students at Leicester were surveyed at the start of their
communication skills course, Nottingham Year 1 stu-
dents were surveyed at the end of their first year course
and Nottingham Year 2 students were halfway through
their second year course. This suggests that students
may be developing more negative attitudes towards
communication skills learning as a result of attending a
communication skills course. Indeed, several research-
ers14,15 suggest that students’ attitudes can become
more negative as a result of teaching. However, this
data is cross-sectional and would need further explo-
ration in a longitudinal study.
Responses to the question �Do your communication
skills need improving?� were shown to have statistically
significant univariate and multivariate relationships
with PAS scores for Nottingham students and NAS
scores for Nottingham and Leicester students. Students
who felt their communication skills needed improving
had more positive and less negative attitudes towards
communication skills learning. A significant relation-
ship was also found between OSCE marks and PAS
scores for Nottingham Year 2 students. As OSCE
marks decreased, positive attitudes towards communi-
cation skills learning increased. Both these findings
suggest that students who felt their communication
skills were lacking (or who received poorer OSCE
marks) valued the opportunities afforded by commu-
nication skills learning more than students who felt
their communication skills did not need improving (or
who received good OSCE marks). These findings
contradict previous research4 that suggested that stu-
dents with better communication skills have more
positive attitudes towards communication skills learn-
ing than students with poorer communication skills. In
addition, a recent study by Cronholm et al.17 found
that biochemistry students who scored highly in their
written examination possessed significantly better atti-
tudes towards their biochemistry course than students
who did less well in their examinations. These incon-
sistent findings need investigating in further research.
This study possesses a number of methodological
limitations that must be taken into consideration when
interpreting the results. Firstly, the response rates for
Year 2 students at Nottingham University (66Æ0%) were
lower than those for Year 1 students at both Nottingham
(92Æ0%) and Leicester (93Æ7%). This poorer response
rate may have biased the results for Nottingham Year 2
students, with responders possibly having better or
poorer attitudes towards communication skills learning
than non-responders. Secondly, some of the variables
(e.g. language) are confounded with other variables (e.g.
whether students had parents who were doctors),
making some of the findings difficult to interpret.
Despite the methodological limitations of this study,
a number of findings have implications for educational
practice and further research. In terms of educational
practice, the findings suggest that positive attitudes
may be associated with more problem-based and self-
directed methods of learning in comparison with the
didactic teaching of communication skills. This sug-
gests that co-ordinators should reduce the level of
lecture-based teaching in their communication skills
courses. However, these conclusions can only be
tentative at this stage, and more research needs to be
conducted to determine which aspects of communica-
tion skills courses, e.g. content, teaching methods or
methods of assessment, are associated with students’
attitudes. This data can then be used to help
co-ordinators develop more successful communication
skills courses. The findings also suggest that commu-
nication skills courses should be designed with the
demographic and education-related profiles of the
medical students attending the course in mind. This
is particularly important for courses that have a high
proportion of students from ethnic minority groups.
In terms of further research, this study has suggested
that medical students’ attitudes towards communication
Attitudes towards communication skills learning • C Rees & C Sheard1026
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027
skills learning may change (i.e. get worse) over time,
perhaps as a result of studying communication skills.
However, this data is cross-sectional and may be due
to cohort effects, so we are currently conducting a
longitudinal study to assess medical students’ attitudes
before and after a communication skills intervention.
Contributors
Both authors contributed to the writing of the prelim-
inary and revised versions of this paper. CR designed
the study. Both authors participated in data collection,
data entry and data analysis.
Acknowledgements
Firstly, we would like to thank the students who
participated in this study. Secondly, we would like to
thank Susan Davies, a Year 4 medical student at the
University of Nottingham, for her help in entering study
data onto SPSS and conducting preliminary analyses.
Thirdly, we would like to thank Dr Paul Lazarus from
the University of Leicester for his help in organizing data
collection at Leicester and also for the information he
gave us about the Leicester communication skills
course. Finally, we would like to thank our colleagues
at the Universities of Nottingham and Leicester who
helped us collect data for this study. From the Univer-
sity of Nottingham Division of Psychiatry we would like
to thank (in alphabetical order) Drs Kim Cornish and
Paul Garrud and 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, Professor Lindsey,
Dr McKinley, Professor Petersen, Drs Preston-Whyte,
Robinsen, Scarborough, Stokes, Sutton and Turner.
Funding
This study was funded by the Division of Psychiatry at
the University of Nottingham.
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Received 24 July 2001; editorial comments to authors 22 October
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Attitudes towards communication skills learning • C Rees & C Sheard 1027
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027