Introduction

Social skills, including communication, are necessary in the work of healthcare professionals, in addition to the hard-professional competences. These skills are of particular importance in human-focused professions such as nursing.1 Ineffective communication between the patient and members of the therapeutic team can negatively affect treatment outcomes.2 Alternatively, good communication can enable better diagnosis, increase patient compliance with treatment recommendations,2 reduce the number of medical errors committed by medical personnel3 and have a positive effect on the patient’s mood and satisfaction.4 Therefore, improving the quality of communication between participants of the healthcare system is a global priority.5

Because of the important role of nursing in the modern model of patient care, nurses must have high communication competencies,1 which takes into account shared decision-making in nursing practice. Shared decision-making is defined as a process taking place during a healthcare encounter with implications for the continuation of shared decisions over time offering patients an opportunity to return to the nurse for reconsiderations of past shared decisions. This approach prevent common communication errors.6 The most common communication errors made by nurses are in tailoring information to what the patients want to know, verifying their understanding and eliciting their perception of their main problem.7 Deficiencies in communication also lead to conflicts between members of the therapeutic team and increase aggressive behaviour of the staff towards patients; a tense atmosphere in the ward can contribute to increased aggression in patients inter alia towards nurses. Moreover, exposure to conflict and aggression promotes the development of avoidance, which leads to a deterioration of relationships between collaborators and patients in the long term, and is considered as one of the reasons for professional burnout.8

The increased interest in shaping communication competences in students and healthcare professionals is reflected in study programmes, international consensus statements and professional practice standards.5 It should be emphasised that the attitude is expressed in three important dimensions—cognitive (knowledge), emotional (emotions) and behavioural. Therefore, shaping an attitude is a comprehensive process.9 Focusing only on knowledge transfer and teaching of communication skills does not guarantee that a given person will recognise the usefulness of these skills in clinical practice. Therefore, it is important to shape positive attitudes among nurses, by stressing the importance of good communication for improving patient care.10

Data indicate that a well-planned process of learning communication skills can lead to positive attitudes of participants, but not in all cases.11 For example, there are some people who have a positive attitudes, but do not see the need to learn these skills. For this reason, in nursing education, it is necessary to learn much more about the mediating factors between a positive attitude and the need to shape communication skills. In this case, personal convictions could be important.12 Course planners should consider the individual attitudes of participants towards the studied subject.11 Thus, assessing the attitudes of nursing students and practitioners towards learning communication skills should form part of the design of education programmes.13 For this purpose, existing standardised measurement tools can be used, including the commonly used Communication Skills Attitude Scale (CSAS).14 It will be possible to take appropriate actions to enhance this positive attitude, and the factors determining the need to learn these skills.

Due to its good psychometric parameters and availability in many different language versions, CSAS is considered an international standard for assessing attitudes in this area. In addition to the original English language version of CSAS, validation has been done for Norwegian,15 Portuguese,16 17 Catalan,13 German18 and Finnish11 versions. CSAS was originally designed and used predominantly for evaluating medical students; the only CSAS version that has been developed and validated for assessment of attitudes in nursing students was one developed in the Catalan language.13 As there is currently no standardised tool in Poland that could be used to evaluate the attitudes of nursing students and practitioners towards learning communicative competence, a Polish language version of CSAS was developed.

The purpose of the study is twofold one. First, to translate and validate the multidimensional CSAS in Polish and second to validate the scale in a group of registered nurses. This is a major contribution to the relevant literature as the original study as well as the subsequent validations studies did not test the CSAS in population of registered nurses.

Methods

Results

Discussion

Overall, the validation results indicate a high degree of similarity of CSAS-P with the original scale developed by Rees et al 14 in terms of selected psychometric features. However, some differences were observed. In particular, when evaluating the factorial structure, the initial solution indicated a four-element structure for CSAS-P, while Rees et al 14 achieved a six-element solution. The results of others also indicate several components of CSAS: Laurence et al 24 (4 factors); Anvik et al 15 (5 factors); Harlak et al,21 Ahn et al,19 Molinuevo and Torrubia13 (6 factors) and Busch et al 18 (7 factors). Although the EFA results indicated a structure of more than two elements, the CSAS developers decided to impose a two-factor solution in line with the theoretical assumptions. A similar solution was adopted in this study when validating CSAS-P, as done by other authors.13 15 18 21 A CSAS-P structure other than the assumed one denotes the reduced theoretical accuracy of the scale. A validation of a good accuracy in this regard could be obtained in the construct validity analysis, however this was not possible due to the lack of an alternative Polish language tool for assessing attitudes towards communication skills.

According to the criterion proposed by Anvik et al,15 3 out of 26 items (1, 12 and 22) were removed from CSAS-P. The fit of the two models was compared using CFA (as done by Busch et al),18 and confirmed the reduced form was a better solution than the 26-item scale. Similar reductions in the number of items during validation was done by Ahn et al,19 Molinuevo and Torrubia13 (6 factors) and Busch et al 18 (7 factors). Although the Anvik et al,15 Busch et al,18 Laurence et al 24 and Molinuevo and Torrubia13 (ranging from 2 to 7 items). Finally, CSAS-P consisted of 23 items divided into two subscales: PAS-P (11 items) and NAS-P (12 items).

The differing results of previous individual validation studies regarding the factorial structure may in part be due to language translation. In addition, since the original version of CSAS was designed for medical students, validation of this tool in other groups requires appropriate corrections to the content of certain statements.18 24 Moreover, while most CSAS studies have imposed a two-factorial structure,11 13 18 21–23 some studies employed a different subscale structure.15 19 24 For example, in the Norwegian CSAS version, three subscales were applied: ‘learning’, ‘importance’ and ‘respecting’15; the American version added a fourth subscale—‘success’24, while the Korean version contained five dimensions—‘facilitating interpersonal skills’, ‘importance within a medical context’, ‘motivation’, ‘assessment’ and ‘overconfidence’.19 Therefore, when considering the cultural and linguistic differences, as well as the adaptation of CSAS to applications in different target groups, the different factorial models obtained can be accepted as correct.

Internal consistency of PAS-P and NAS-P was good, exceeding the recommended Cronbach’s α value of 0.70.32 The results correspond to those obtained by Rees et al 14 and Busch et al.18 However, the internal consistency of NAS-P was significantly better than that reported by Molinuevo and Torrubia13 and Harlak et al.21 Results by other authors also generally indicate that the NAS subscale is characterised by worse internal consistency than the PAS subscale.

Test–retest reliability of CSAS-P was slightly better than that obtained during validation of the original CSAS version: there were no cases where the weighted kappa would be <0.40, whereas Rees et al 14 reported eight such items. However, due to the lack of detailed data from the test–retest analysis carried out by Rees et al,14 it is difficult to assess which items results were worse, and which were better. In addition, better stability was found for the two subscales overall: ICC values were higher in PAS-P and NAS-P (0.895 and 0.789) than in the English version (0.646 and 0.771). Differences in test–retest reliability assessment may result from the number of participants, which was more than two times greater in CSAS-P than CSAS (91 vs 39). As it is recommended that a minimum of 100 people should participate in scale stability studies,35 the results of both validation studies should be cautiously compared. Another weakness of the test–retest analysis used in this study is the short time interval between repeated measurements (2 weeks), compared with the recommended period of at least 3 months.35 The test–retest analysis also has an error related to the need to repeat the test at a distant time.36 The questionnaire presented during the second session was not new to participants, unlike in the first measurement. Two key factors: memory/learning and experience may influence the results of the analysis. If the same tool is used twice, it cannot be ruled out that the attitude or knowledge and skills of a study participant change between the first and the second measurement. Nonetheless, the test–retest analysis showed CSAS-P has good absolute stability, indicating that measurements in the PAS-P and NAS-P subscales are resistant to random variability.

There was a fairly high degree of similarity in the attitudes of participants and homogeneity of the measured features, which ensures correct evaluation of the discriminant validity of this tool. The ability of CSAS-P and its subscales to differentiate participants was based on two assumptions. The first concerned the ability of CSAS-P to discriminate differences in the attitudes of people who declared they participated in prior communication skills courses. Indeed, participation in communication skills courses positively influences the attitudes of the respondents, as reflected by the results of this study. This observation is consistent with that of Koponen et al,11 who found positive attitudes to learning communication skills increased significantly after a pilot course in communication. However, the change of attitudes resulting from participation in communication skills courses is not always obvious, as evidenced by Rees and Sheard25 and Harlak et al.22 Discrepancies between the results of individual studies may be caused by differences in the way of conducting communication education, its duration and the organisation of the didactic process itself. In this study, participants only declared previous participation in communication courses, which could have different forms and cover a diverse range of content. Therefore, the results on discriminant validity should be treated with caution, and require further confirmation with well-designed studies such as those published by Koponen et al.11

The second assumption tested was the ability to differentiate the results of CSAS-P and its subscales depending on the level of self-assessment of communication skills of the respondents. Self-assessment only had a minor impact on the obtained score, which was similar to the results found by Molinuevo and Torrubia.13 It should be emphasised that self-assessment is a highly subjective measure and is influenced by multiple factors, and thus should not be the criterion for determining the discriminant validity of a tool used in psychometry. Indeed, Rees and Sheard25 found students rated their skills lower after completing a communication course than before.

The obtained results of psychometric analysis of CSAS-P allow us to assume that it can be used in practice as a tool for evaluating attitude towards learning communication competencies in professionally active nurses. The tool contains two complementary subscales with comparable psychometric properties. Assessment of attitudes can be used for testing newly admitted nurses in order to develop an individual plan of support for improving soft skills, particularly in the field of communication. Moreover, CSAS-P can be used by participants of courses improving professional qualifications either as an element of self-assessment or as an additional tool complementing measurement of learning outcomes.

Limitations

The study was conducted during an exam session, and thus, high stress among participants could have influenced the quality of the responses. The study was conducted on nurses who actively chose to improve their professional qualifications, so the group may be unrepresentative of the entire nursing community in Poland. The lack of assessment of criterion-related validity and convergent validity of CSAS-P constituted another limitation of the study.

Conclusion

This validation study confirms CSAS-P is comparable to the original English language version of the scale in terms of reliability and accuracy. The CSAS-P tool can be used both in educational activities, as well as to assess the attitudes of registered nurses working in different positions. However, it should be emphasised that CSAS-P measures attitude towards communication skills. Therefore, the results of CSAS-P should be interpreted with caution. A positive attitude towards communication skills does not always guarantee the need to learn these skills. Further research should look for factors which mediate between a positive attitude towards communication skills and the need to learn these skills.