Research papers

The development of a scale to measure medical students'

attitudes towards communication skills learning: the
Communication Skills Attitude Scale (CSAS)

Charlotte Rees, Charlotte Sheard & Susie Davies

Introduction There is little research identifying medical factor II represented negative attitudes. Subscale I had
students' attitudes towards communication skills an internal consistency of a ˆ 0á873 and an intraclass
learning. This pilot study outlines the development of a correlation of 0á646 (P < 0á001). Subscale II had an
new scale to measure attitudes towards communication internal consistency of a ˆ 0á805 and an intraclass
skills learning. correlation of 0á771 (P < 0á001). The majority of items
Methods First- and second-year medical students (n = on the positive (n ˆ 9, 69á2%) and the negative attitude
490) completed the 26-item Communication Skills subscales (n ˆ 8, 61á5%) possessed moderate test-retest
Attitude Scale (CSAS) and 39 students completed the reliability.
CSAS on a second occasion. Factor analysis was con- Discussion The development of a new and reliable scale
ducted to determine the factors underpinning the scale. to identify medical students' attitudes towards
The internal consistency of the subscales was deter- communication skills learning will enable researchers to
mined using a coef®cients. The test-retest reliability of explore the relationships between medical students'
the individual scale items were determined using attitudes and their demographic and education-related
weighted kappa coef®cients and the test-retest reliab- characteristics. Further work is needed to validate this
ility of the subscales were established using intraclass scale among a broader population of medical students.
correlation coef®cients. Keywords Attitude, attitude of health personnel;
Results Maximum likelihood extraction with direct education, medical, undergraduate; students, medical;
oblimin rotation resulted in a 2-factor scale with 13 communication skills, interpersonal communication.
items on each subscale. Factor I represented positive Medical Education 2002;36:141±147
attitudes towards communication skills learning and

medical students should have acquired and demon-

Introduction
strated appropriate attitudes by the end of the medical
In 1993, the General Medical Council (GMC)1 pro- course. Included in a diverse list of 12 attitudinal
vided recommendations on undergraduate medical objectives were having respect for patients, being a self-
education. In terms of communication skills, the GMC directed learner and having an awareness of personal
stated that by the end of their undergraduate course, limitations.
medical students should have acquired and demon- As a result of the GMC's report, many medical
strated their pro®ciency in communication. In partic- educators have developed new communication curri-
ular, doctors must be able to provide advice and cula and others are already using well-developed pro-
explanations to patients and their relatives in a form grammes.2 However, despite the wealth of literature
they can understand and doctors should be good lis- regarding communication curricula within the under-
teners.1 The recommendations also required that graduate degree,3±5 few studies6,7 have explored medi-
cal students' attitudes within a communication skills
learning and teaching context.
Division of Psychiatry, University of Nottingham, UK
In a study conducted by Hajek et al.6 139 third-year
Correspondence: Charlotte Rees, Behavioural Sciences Section, Division medical students rated 16 concerns regarding
of Psychiatry, University of Nottingham, A Floor South Block, Queen's
Medical Centre, Nottingham, NG7 2UH, UK. Tel.: 0115 970 9338; communicating with patients at two time points:
Fax: 0115 970 9495; E-mail: [Link]@[Link] (1) before the students had any contact with patients

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142 Communication Skills Attitude Scale · C Rees et al.

tional experiences, their age, and their communicative

Key learning points abilities.
In order to explore these ®ndings in a systematic way
A new measure of medical students' attitudes
with a wider population of medical students, it was
towards communication skills learning is described.
necessary to design a new and reliable scale to identify
Evidence for its factor structure and reliability is medical students' attitudes towards communication
presented. skills learning. This paper presents the development of
the Communication Skills Attitude Scale (CSAS).
Further research is needed to evaluate the validity
of this scale.
Methods
and before communication skills teaching began; and
Participants
(2) after students had completed four communication
skills sessions and had an opportunity to practise cler- Of the 585 medical students invited to participate in this
king patients. The authors found that at both time study, 490 (83á8%) completed the study materials
points, students' main concerns involved communica- satisfactorily. They ranged in age from 17 to 35 years
ting with patients who were in pain and who showed (median ˆ 19, interquartile range ˆ 18±19). The
strong negative emotions. majority were female (n ˆ 281, 57á3%), white (n ˆ 352,
Batenburg & Smal7 measured second- and third-year 72á1%) and came from non-manual socioeconomic
medical students' (n ˆ 676) attitudes towards patients, groups10 (n ˆ 473, 96á9%). Finally, the majority spoke
illness and care at three time points to measure attitude English as their ®rst language (n ˆ 411, 83á9%).
change during and after a communication skills teach-
ing intervention. Participants' attitudes were measured:
Procedures
(1) just before the course; (2) just after the course; and
(3) six months after the course. The authors found that After receiving approval from the Medical School Ethics
medical students' attitudes did not change substantially Committee at the University of Nottingham, all ®rst-
as a result of the communication skills teaching inter- and second-year medical students at the University of
vention, suggesting that students' attitudes towards Nottingham and all ®rst-year medical students at the
patients, illness and care were very stable and consid- University of Leicester were invited to participate in this
erable effort was needed to initiate a change in study. First-year students from Nottingham (n ˆ 213)
attitudes. and Leicester (n ˆ 175) were invited to take part during
Given that teaching programmes within the social small group seminar teaching in November and
sciences often encounter varying degrees of student December 2000. The authors distributed the study
resistance,8 it is important to identify medical students' materials to the seminar facilitators who handed them
attitudes towards communication skills learning. This out and collected them during the seminars. The facil-
paper presents the ®ndings of a pilot study, which itators then returned the completed questionnaires to
aimed to develop a new and reliable measure of medical the authors in the Freepost envelopes provided. Second-
students' attitudes towards communication skills year medical students at Nottingham (n ˆ 197) were
learning. It is part of a larger study to look at commu- initially recruited by internal mail and E-mail in October
nication skills at the University of Nottingham. This 2000. However, this led to a poor response (n ˆ 43,
research began with a qualitative pilot study to explore 21á8%) within a 2-week period. Therefore, additional
the views and experiences of 5 ®rst-year medical stu- second-year students (n ˆ 87, 44á2%) were recruited
dents.9 This study showed that some medical students during a 50-minute lecture 2 weeks after being invited
had very positive attitudes towards communication by internal mail and E-mail. The study materials were
skills learning, e.g. they thought it was interesting, fun, distributed during the lecture and completed question-
useful and applicable to medicine. However, some naires were collected at the end of the lecture.
students had very negative attitudes towards commu- Although the study instruments were anonymous, 73
nication skills learning, e.g. they thought it was too easy second-year students from the University of Notting-
and not worth investing time in compared with other ham wrote their names on the ®rst set of questionnaires,
subjects that were assessed by written examinations. indicating that they were happy to receive a second copy
Some participants suggested that medical students' of the CSAS to complete. Of these students, 39 (53á4%)
attitudes towards communication skills learning were completed the second copy of the CSAS satisfactorily
related to other factors such as their previous educa- (with a 2-week interval between tests).

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Communication Skills Attitude Scale · C Rees et al. 143

Instruments Table 1 Total variance explained by the factors with eigenvalues

greater than 1
The Communication Skills Attitude Scale (CSAS) con-
sists of 26 items, 13 of which are written in the form of
Initial % of Cumulative %
positive statements and 13 negative statements about Factor eigenvalues variance of variance
communication skills learning. Each item is accom-
panied by a 5-point Likert scale, ranging from 1 1 8á205 31á56 31á56
(strongly disagree) to 5 (strongly agree). Brief instruc- 2 1á784 6á86 38á42
tions for the completion of this scale are included to 3 1á443 5á55 43á97
ensure that the scale can be self-administered (see 4 1á213 4á67 48á64
Appendix). 5 1á102 4á24 52á88
6 1á006 3á87 56á74
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 with loadings less than 0á01 were suppressed in the
determine their socioeconomic groups). rotated pattern matrix.
Of the 26 items, 12 (46á2%) items making positive
statements about communication skills learning loa-
Data analysis
ded positively on factor I (items 4, 5, 7, 9, 10, 12,
Data were analysed using the Statistical Package for the 14, 16, 18, 21, 23 and 25), with weightings ranging
Social Sciences (SPSS version 9á0). Exploratory data from 0á246 (item 18) to 0á883 (item 14). In addition,
analysis was conducted to establish the distribution of these 12 items either loaded negatively (n ˆ 8,
all continuous variables. Parametric statistics were 66á7%), failed to load (n ˆ 2, 16á7%) or loaded very
determined for normally distributed continuous varia- weakly on factor II (n ˆ 2, 16á7%). The remaining
bles and non-parametric statistics were established for positive statement about communication skills learn-
non-normally distributed continuous variables. In order ing (item 1) did not load on factor I but did load
to determine the structure underlying the CSAS, the highly and negatively (± 0á503) on factor II, suggest-
scale was factor analysed using maximum likelihood ing that its score should be reversed and added to
extraction with direct oblimin (oblique) rotation. Sub- subscale II.
scales were constructed on the basis of the factor Of the 26 items, 12 (46á2%) items making negative
loadings, with scores being reversed where necessary. statements about communication skills learning (items
The internal consistency of the subscales were identi- 2, 3, 6, 8, 11, 13, 15, 17, 19, 20, 24 and 26) and 2
®ed using Cronbach's alpha (a) coef®cients. The test- (7á7%) items making positive statements (items 5 and
retest reliability of the individual items on the CSAS 14) loaded positively on factor II, with weightings ran-
were measured by weighted kappa (j) coef®cients using ging from 0á128 (item 5) to 0á696 (item 26). In addition,
the statistical program SAS (Release 6á12). The test- the 12 negative attitude items either loaded negatively
retest reliability of the subscales was measured using (n ˆ 7, 58á3%) or failed to load (n ˆ 5, 41á7%) on
intraclass correlation coef®cients. 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-
Results
gesting that its score should be reversed and added to
subscale I. With the exception of items 5 and 14, none
Factor structure
of the variables could be considered complex variables,
Six factors possessed eigenvalues greater than 1, i.e. variables that loaded positively on both factors.11
accounting for 56á74% of the variance in the data (see The correlation between factors I and II was )0á552.
Table 1).
However, only two factors were extracted because
Internal consistency
the researchers wanted to use only demonstrably reli-
able factors11 and retain enough factors for an adequate After reversing the scores for items 1 and 22, the
®t but not extract so many that parsimony was lost11 internal consistency of the 13 items of subscale I (items
and because the scree plot suggested that two factors be 4, 5, 7, 9, 10, 12, 14, 16, 18, 21, 22, 23 and 25) was
extracted. After direct oblimin rotation, the pattern a ˆ 0á873 and subscale II (items 1, 2, 3, 6, 8, 11, 13,
matrix for each item was examined (see Table 2). Items 15, 17, 19, 20, 24 and 26) was a ˆ 0á805.

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144 Communication Skills Attitude Scale · C Rees et al.

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 0á493 )0á196
of medicine
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 0á503
non-clinical lecturers
16. Learning communication skills has helped or will help me recognise patients' rights 0á641
regarding con®dentiality and informed consent
17. Communication skills teaching would have a better image if it sounded more like a 0á363
science subject
18. When applying for medicine, I thought it was a really good idea to learn 0á246 )0á334
communication skills
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 )0á394
ability to communicate
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 0á311 )0á497
is a lifelong skill
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 Levels of Subscale I Item Subscale II Item

Kappa (j) agreement* Frequency (%) number Frequency (%) 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.

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

Test-retest reliability
as measured by an intraclass correlation coef®cient was
The weighted kappa coef®cients between the items on 0á646 (P < 0á001). Test-retest analysis for the second
tests 1 and 2 ranged from 0á361 (item 25) to 0á611 subscale, as measured by an intraclass correlation
(item 18) on subscale I and 0á204 (item 1) to 0á526 coef®cient was 0á771 (P < 0á001).
(item 11) on subscale II. The index of agreement for
the 13 items on the ®rst and second subscale is
summarised in Table 3.

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Communication Skills Attitude Scale · C Rees et al. 145

This pilot study has a number of methodological

Discussion
weaknesses that must be taken into consideration when
All of the variables loading positively on factor I were interpreting the results. Kline14 suggested that a mini-
positive statements about communication skills learn- mum sample size of 100 participants was necessary
ing, suggesting that factor I re¯ected medical students' when assessing the test-retest reliability of a scale. This
positive attitudes towards communication skills. Inter- ®gure is greater than the 39 test-retest participants used
estingly, these items clustered together in three groups: in this study. Kline14 also recommended that there
(a) students' beliefs that communication skills learning should be at least a 3-month interval between tests to
would facilitate their interpersonal skills with both their establish a reliable estimate of test-retest reliability.
colleagues and with patients; (b) students' beliefs that However, due to time constraints, the interval between
communication skills learning was fun and interesting; tests was approximately 2 weeks. Thus, the test-retest
and (c) students' beliefs that communication skills reliability may have been in¯ated if participants were
learning was important within a medical context, atti- able to remember their answers from the ®rst test.
tudes consistent with those advocated by the GMC.1 In Therefore, the ®ndings associated with test-retest reli-
addition, these variables generally loaded negatively or ability must be treated with caution. In addition,
failed to load on factor II, suggesting that factor II may although the response rate for this study was high
represent negative attitudes towards communication (83á8%), nonresponders may have possessed different
skills learning. The remaining positive statement about (e.g. poorer) attitudes towards communication skills
communication skills learning (item 1) did not load on learning compared to responders, thus biasing the
factor I but did load highly and negatively with factor II, sample.
suggesting that its score should be reversed and added Despite some methodological limitations in the
to subscale II. study, this new scale does appear to be a consistent and
The hypothesis that factor II represented negative stable measure of medical students' attitudes towards
attitudes towards communication skills learning was communication skills learning. Further research is
given further weight by the ®nding that 12 of the 13 necessary with larger groups of students to con®rm
negative attitude statements loaded positively on these study ®ndings and to evaluate the validity of this
factor II. Interestingly, these items clustered together scale. We are currently using this scale to establish
in four groups: (a) medical students' negative atti- whether signi®cant associations exist between medical
tudes towards communication skills learning as a so- students' attitudes and their demographic and educa-
cial science subject, a ®nding consistent with previous tion-related characteristics. These ®ndings will help us
research;8 (b) students' apathy towards learning establish the construct validity of this scale.
communication skills, a ®nding inconsistent with the
attitudes recommended in Tomorrow's Doctors;1
Contributors
(c) students' negative beliefs that communication
skills learning was dif®cult to take seriously; and (d) All the authors contributed to the writing of the
students' negative attitudes towards communication preliminary version of this paper. The ®rst and second
skills assessment. In addition, these variables generally author wrote the ®nal version of the paper. The ®rst
loaded negatively or failed to load on factor I, sug- author designed the Communication Skills Attitude
gesting that factor I did indeed represent positive Scale and the ®rst and third author designed the study.
attitudes towards communication skills learning. The All authors participated in the data collection, data
remaining negative statement (item 22) did not load entry and data analysis for this study.
on factor II but did load negatively with factor I,
suggesting that its score should be reversed and added
Acknowledgements
to subscale I.
The a value for the positive and negative attitude We would like to thank the students who participated in
subscales were both above 0á8, indicating that the this study and our colleagues at the Universities of
subscales possessed satisfactory internal consistency.12 Nottingham and Leicester who helped us collect data
In addition, the majority (n ˆ 18, 69á2%) of items for this study. From the University of Nottingham
possessed substantial or moderate kappa coef®cients, Division of Psychiatry we would like to thank (in
indicating satisfactory test-retest reliability.13 Finally, alphabetical order) Drs Kim Cornish and Paul Garrud
test-retest analysis for both subscales, as measured by and Ms Amy McPherson. From the University of
intraclass correlations, indicated that the subscales Leicester Department of General Practice and Primary
possessed satisfactory test-retest reliability. Health Care we would like to thank (in alphabetical

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146 Communication Skills Attitude Scale · C Rees et al.

order) Drs Aram, Cole, Coleman, de Caestecker, 5 Harrison A, Glasgow N, Townsend T. Communication skills
Hastings, Hay, Heap, Lazarus, Professor Lindsey, Dr training early in the medical curriculum: the UAE experience.
McKinley, Professor Petersen, Drs Preston-Whyte, Med Teacher 1996;18:35±41.
6 Hajek P, Najberg E, Cushing A. Medical students' concerns
Robinsen, Scarborough, Stokes, Sutton and Turner.
about communicating with patients. Med Educ 2000;34:656±8.
We would also like to thank Dr Paul Garrud for peer-
7 Batenburg V, Smal JA. Does a communication skills course
reviewing the revised manuscript.
in¯uence medical students' attitudes? Med Teacher
1997;19:263±9.
Funding 8 Benbassat J. Teaching the social sciences to undergraduate
medical students. Israel J Med Sci 1996;32:217±21.
The Division of Psychiatry at the University of Not- 9 Rees CE, Garrud P. Identifying undergraduate medical stu-
tingham funded this study. dents' attitudes towards communication skills learning: a pilot
study. Med Teacher 2001;23:400±6.
10 Of®ce of Population Censuses and Surveys. Standard Occu-
References pational Classi®cation, Vol. 3. London: HMSO; 1991.
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mendations on Undergraduate Medical Education. London: edn. New York: HarperCollins College Publishers; 1996.
General Medical Council; 1993. 12 Bland JM, Altman DG. Cronbach's alpha. BMJ
2 Kurtz SM, Laidlaw T, Makoul G, Schnabl G. Medical 1997;314:572.
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3 Hargie O, Dickson D, Boohan M, Hughes K. A survey of 14 Kline P. The Handbook of Psychological Testing. London:
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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 ˆ strongly disagree
2 ˆ disagree
3 ˆ neutral
4 ˆ agree
5 ˆ 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 1 2 3 4 5
con®dentiality and informed consent

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Communication Skills Attitude Scale · C Rees et al. 147

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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