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Year : 2011  |  Volume : 24  |  Issue : 1  |  Page : 499

Validation of the Catalan Version of the Communication Skills Attitude Scale (CSAS) in a Cohort of South European Medical and Nursing Students

Universitat Autònoma de Barcelona, Department Psiquiatria i Medicina Legal. Facultat de Medicina and Institut de Neurociències. Campus de Bellaterra, Bellaterra (Barcelona), Spain

Date of Submission12-Jun-2010
Date of Acceptance30-Dec-2010
Date of Web Publication29-Apr-2011

Correspondence Address:
B Molinuevo
Department Psiquiatria i Medicina Legal, Facultat de Medicina, Campus de Bellaterra, s/n, 08193 Bellaterra (Barcelona)
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Source of Support: None, Conflict of Interest: None

PMID: 21710418

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Context: The relevance of healthcare student training in communication skills has led to the development of instruments for measuring attitudes towards learning communication skills. One such instrument is the Communication Skills Attitude Scale (CSAS), developed in English speaking students and adapted to different languages and cultures. No data is available on the performance of CSAS with South European students. The aims of the present study were to translate the CSAS into the Catalan language and study its psychometric properties in South European healthcare students.
Methods: A total of 569 students from the School of Medicine of the Universitat Autònoma de Barcelona (UAB) participated. Students completed a Catalan version of the CSAS and provided demographic and education information.
Findings: Principal component analysis with oblimin rotation supported a two-factor original structure with some modifications. In general, internal consistency and test-retest reliability of the scales were satisfactory, especially for the factor measuring positive attitudes. Relationships of student responses on the two factors with demographic and education variables were consistent with previous work. Students with higher positive attitudes tended to be female, to be foreign students and to think that their communication skills needed improving. Students with higher negative attitudes tended to be male and to have parents that were doctors or nurses.
Conclusions: These data support the internal validity of a Catalan version of the CSAS and support its use in future research and educational studies related to attitudes towards learning communication skills for South European students who speak Catalan.

Keywords: Attitudes, communication skills, medical students, nursing students, undergraduate education

How to cite this article:
Molinuevo B, Torrubia R. Validation of the Catalan Version of the Communication Skills Attitude Scale (CSAS) in a Cohort of South European Medical and Nursing Students. Educ Health 2011;24:499

How to cite this URL:
Molinuevo B, Torrubia R. Validation of the Catalan Version of the Communication Skills Attitude Scale (CSAS) in a Cohort of South European Medical and Nursing Students. Educ Health [serial online] 2011 [cited 2022 Aug 15];24:499. Available from:


Communication skills (CS) are essential to relationships between healthcare professionals and patients. Good communication is associated with greater diagnostic accuracy, adherence to recommended treatment, effective use of health resources, professional wellbeing, patient satisfaction and fewer malpractice claims1. However, healthcare professionals often fail in performing key tasks when communicating with patients such as tailoring information to what the patients wants to know, verifying their understanding, and eliciting the patients’ perception of their main problem2. The domination of a biomedical model of disease3 can partly explain these deficiencies.

Presently, increased international recognition of the importance of teaching and assessing students’ CS during undergraduate medical training is reflected in curricular programs, international consensus statements and standards for professional practice4-6. Nevertheless, learning and practicing CS does not necessarily guarantee that students will perceive the usefulness of these skills for their future clinical practice. Therefore, guidelines for medical curriculums recommend not only developing knowledge and skills in CS in students but also fostering associated attitudes7 that can serve as a mediating link between students’ clinical competence and their clinical performance8.

Attitudes are a type of feelings, often based on our beliefs, which predispose us to respond in a particular way to objects, people and events9. Doctors' attitudes appear to influence a number of aspects of their clinical competence such as the quality of their collaboration with other professionals, their priorities in healthcare and medical decisions, and the quality of their communication with patients10,11. The availability of instruments that measure attitudes towards the learning of CS can be useful to assess the impact of undergraduate and postgraduate training programs, to allow for comparisons between different health sciences professionals and to provide a longitudinal perspective of the evolution of attitudes towards communication skills within particular groups. Recently, the impact of teaching courses on medical students’ attitudes toward specific domains has been measured before and after completing a training as a course in primary care12 and a course on aging13, and the students showed more positive attitudes after the training.

Recently, the Communication Skills Attitude Scale (CSAS) has been designed to assess attitudes towards learning CS14. It appears to be a promising measure and has generated extensive research in medical schools worldwide15-20. It is composed of two factors: the Positive Attitudes Scale (PAS) and the Negative Attitudes Scale (NAS). Items assess students’ perceptions about the way CS are taught, the importance of having good CS in order to pass exams and to be a good doctor, and the utility of CS in demonstrating respect in both patients and colleagues. However, its two-factor structure has not been replicated in all cultures and languages16,17 and, to our knowledge, no data is available with South European students or in Catalan.

To address these issues, the principal aim of the present study was to translate the CSAS into Catalan (language of Catalonia and other Spanish, French and Italian regions) and to study its psychometric properties (internal structure, internal consistency, test-retest reliability and external validity) in a sample of medical and nursing students. As the original version was tested with first- and second-year medical students, both groups are included in this study. In order to have an instrument adapted for students of other professions for which the quality of relationships with patients is relevant, the sample studied included nursing students.



First-year nursing students, first-year medicine students and second-year medicine students for the 2009-2010 academic year from the Basic Medical Sciences Teaching Unit at the School of Medicine of the Universitat Autònoma de Barcelona were invited to participate. This Unit offers basic pre-clinical or pre-hospital teaching. Medical students from third year onwards are taught in Hospital Units. The Nursing degree has been introduced for the first time at the School of Medicine the 2009-2010 academic year.

Of the total 606 students of these cohorts, 569 (93.9%) completed the CSAS: 85 nursing students, 251 first-year medical students and 233 second-year medical students. Participants represented 83.5% of the total number of students enrolled. Students were aged between 17 and 45 years old (M = 19.53; SD = 3.10). More demographic information is presented in Table 1.


Communication Skills: The Communications Skills Attitudes Scale (CSAS)14 is an instrument designed to measure attitudes towards CS learning. The original items were created considering the views and experiences of five first-year medical student towards CS learning in a previous qualitative study. The original version consists of a two-factor scale with 13 items on each subscale, the PAS (e.g., 'In order to be a good doctor I must have good communication skills') and the NAS (e.g., 'Nobody is going to fail their medical degree for having poor communication skills'). Items are scored from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate stronger attitudes. It has been found to show satisfactory internal consistency and test-retest reliability14.

As has been done in previous studies14, we added two questions to the original scale for this study: 1) Do you think that your CS for being a future doctor need to improve? (0 = no, 1 = yes), and 2) How would you rate your present CS to practice as a future doctor? They were answered on a 4-point scale from 1 (poor) to 4 (excellent). In the nursing students’ sample, the term ‘doctor’ was replaced with ‘nurse’.

Demographic Information: Additional items in the questionnaire queried students’ age, gender, country of origin, mother’s and father’s educational level and if one or both parents were doctors and/or nurses.


Firstly, the CSAS was translated and adapted to the Catalan language (CSAS-CAT) by the authors and was then translated back into English by the UAB’s Language Service. The back-translation was sent to the CSAS’s creator who suggested some revisions. Divergences were minor, and were studied and refined. Two parallel versions were elaborated, for medical and nursing students (see Appendix I and II). The only differences between the versions are found at the items 1, 3, 4, 18, 19, 21 and 23 for which the terms 'doctor', 'medical' and 'medicine' were changed to 'nurse' and 'nursing'.

The instruments were administered by the authors in students’ classrooms. First-year nursing students answered the questionnaire in a large group, the first day of the course Psychosocial Sciences. First-year medical students answered the questionnaire the first day of the course History of the Medicine, in three large groups of approximately 85 students each. Second-year medical students answered the questionnaire during the first seminar session of a course on CS within small groups of about 12 students each. 

To examine the test-retest reliability of the instrument, students participated in a retest session five weeks later. Only second-year medical students were invited to take part of the second evaluation in order to diminish other possible sources of error as students’ learning experiences vary depending on their program of study and courses. Two hundred and six students participated in the retest, 88.4% of second-year students who completed the original instrument.

Students were told that participation was anonymous and voluntary, and no compensation was offered. Along with the questionnaire, students were given an information sheet about the study. This study was approved by the Animal and Human Experimentation Ethics Committee of the UAB.

Data Analysis

Data were analyzed using SPSS version 13.0, and descriptive statistics were calculated. The internal structure of the CSAS-CAT was examined by a Principal Component Analysis (PCA), oblimin rotation. Decisions regarding factor retention were based on (a) eigenvalues of at least one, (b) loadings 0.30 or higher, (c) the difference of loadings in both scales 0.10 or higher, (d) adequate internal consistency of items for each factor, and (e) the interpretability of factors.

 Relationships among demographic and student factors were examined by Pearson's correlations. To assess their internal consistency, Cronbach’s alphas were calculated. Test-rest reliability was assessed through intra-class correlation coefficient (ICC) using a two-way mixed effects model. The relationships of the CSAS with external variables were analyzed with Pearson’s correlation, independent samples t-test and ANOVA depending on the variable. The Cohen’s d was computed to measure the effect size in significant t-tests, and Duncan post-hoc comparisons were calculated to determine the significant differences after ANOVA. 


Descriptive Data

Data related to self-rating about the present CS to practice as a future doctor (or nurse) showed that more than half of the respondent students considered their CS as ‘good’ and a third as ‘average’. Few students responded that their CS were ‘poor’ or ‘excellent’. Nearly all of the students rated their CS as needing improvement (90.3%) (Table 1).

Table 1: Demographic and education characteristics of the study sample

Internal Structure: Principal Component Analysis

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.88 and Barlett’s test of sphericity was significant (P<0.001), both confirming the appropriateness of factor analysis. The PCA with oblimin rotation revealed six factors with eigenvalues greater than 1, accounting for 49.91% of the variance prior to rotation; the first factor explained 23.99%. In a second step, two factors were explicitly extracted in order to see if the original structure was maintained; they accounted for 31.51% of the variance.

Item 13 (‘Learning CS is too easy’) was eliminated because it had loadings lower than 0.30 and items 19 (‘I don’t need CS to be a doctor’) and 26 (‘CS learning should be left to psychology students, not medical students’) were eliminated because their loadings on the two factors differed by less than 0.10 and the loading was slightly higher on the factor not expected. Difference of loading in item 8 (‘I can’t be bothered to turn up to sessions on CS’) was smaller than 0.10 but the loading was higher in the expected factor and it contributed to the internal consistency; therefore, this item was not eliminated. The total number of items of the CSAS-CAT was 23. The final two-factor solution and the loadings for each subscale are presented in Table 2.

Table 2:  Factor loadings from the rotated factor structure for the CSAS-CAT: Principal component analysis with oblimin (oblique) rotation

The first factor is composed of 13 items and it represents the PAS scale of the original version. Unlike the original version, item 1 (‘In order to be a good doctor I must have good communication skills’) loaded positively on this factor. The second factor is composed of 10 items and corresponds to the NAS scale with some variations; all the eliminated items belonged to this scale. Unlike the original version, item 22 (‘My ability to pass exams will get me through medical school rather than my ability to communicate’) loaded positively on this factor. The rest of the items loaded on the expected factor. Pearson correlation between the scales was -0.38 (p < 0.001).

Internal Consistency

The Cronbach’s alpha of scale I was 0.83 and of scale II was 0.64. Corrected item-total correlation and descriptive statistics for each item are presented in Table 3.

Table 3:  Test-retest reliability (ICC), Corrected Item-Total correlation (r), and Descriptive Statistics for each CSAS-CAT item

Test-retest Reliability

The intra-class correlation coefficient of factor 1 for a single measure (ICC1) was 0.63 (95% CI = 0.54 - 0.71) and for averaged measures (ICC2) it was 0.78 (95% CI = 0.70 - 0.83). For factor 2 for a single measure (ICC1) it was 0.65 (95% CI = 0.56 - 0.72) and for averaged measures (ICC2) it was 0.79 (95% CI = 0.72 - 0.84). ICC for each item is presented in Table 3.

External Validity

Significant relationships were identified between the CSAS-CAT scales and demographic and education characteristics (Table 4). Females demonstrated higher positive attitudes (d = 0.24) and lower negative attitudes scores than males (d = 0.49), and foreign students demonstrated higher positive attitudes scores than Spanish students (Duncan post-hoc analysis showed differences between groups). Students whose parents (one or both) were doctor or nurses showed higher negative attitudes scores than those whose parents had other professions (d = 0.20), and students who believed that they needed to improve their communication skills scored higher in positive attitudes than those who did not perceive the need to improve CS (d = 0.57). No significant differences in scale scores were found with the other variables.

Table 4:  Relationship between the CSAS and demographic and education variables


This study’s findings support a two-factor structure for the Catalan version of the CSAS. Results indicate that internal consistency of the positive attitudes scale was good but questionable for the negative attitudes scale21. Test-retest reliability was acceptable for both scales. Both scales were related to external variables reflecting students’ backgrounds and educations in accordance with the original version. Taken together, the data generally support the use of the CSAS for educational and research purposes in Catalan-speaking medical and nursing students.

Exploratory factor analysis supported a two-factor structure similar to that reported by Rees et al14.: positive (13 items) and negative attitudes (10 items, three were eliminated). Two items (1 and 22) loaded on a scale other than the original version but they were not omitted because they loaded on the scale that had been expected in the initial constitution of the CSAS for theoretical considerations14. In this study, item 1 loads on the PAS and item 22 on the NAS. After eliminations, all items loaded on the factors they were intended to measure with loadings higher than 0.33. We also found the two factors to be negatively and moderately related, as in the original version. Differences in the number of items in the scales compared to the original version may partly be due to cultural differences between the student groups assessed, the translation of the CSAS and/or because we used more criteria for item selection than employed in the original work.

The internal consistency of the PAS was above 0.70, as recommended, and for the NAS was only 0.64. Values between 0.60 and 0.69 are viewed as acceptable for group assessment22. The different length of scales may explain the difference in alphas for the two scales, since more items generally increase alphas. It is also possible that the negative formulation of the items can affect the reliability because of social desirability. Previous studies have also found the internal consistency of the NAS to be lower than the PAS18-20. In sum, the evidence from this study and the findings from the others suggest that the NAS should be revised in the original version to provide a more replicable scale and enhance CSAS validity.

Although there is no consensus on the significance of the ICC23, we believe that this study’s data show adequate stability of the CSAS over time. Test-retest differences in students’ responses on the PAS were similar to those found for the original version, but differences were slightly greater for the NAS. The findings for the NAS may be because the test-retest time interval used for this study was greater than the three weeks used in the original scale development work. Sources of measurement as the time interval between tests and learning experiences of the students may diminish test-retest reliability. In our case, second-year students took a course related to CS which might have influenced the consistency of the two scales.

Findings concerning the external validity of the CSAS are similar to those found for the original version. Compared to male students, female students in our study tended to demonstrate higher positive attitudes and lower negative attitudes towards learning CS18,24 and having parents who are doctors or nurses was associated with higher negative attitudes24. Non-Spanish students scored higher than Spanish students on the PAS. Rees and Sheard24 found that students whose ethnicity was non-white had higher scores on the NAS. As the categories of this variable are different, we cannot compare this result. Differences could be explained by an effect of different cultural attitudes and by students’ understanding of the Catalan language. Students’ age and parents’ level of education was not statistically related to scale scores. Rees et al14. found that younger students had more positive attitudes than older students but just in one of the two samples considered in their study and found no significant associations with socio-economic status24. According to previous studies15,24, students who considered that they must improve their CS presented higher positive attitudes.

The size of group differences was medium for differences between boys and girls and between students who consider that they must improve their CS and those who do not25. It was small for the other differences noted.


Some methodological limitations should be mentioned. The method of collecting data did not consider the students not attending on the day of the study and was not the same for first-year nursing and medical students (large groups) compared to second-year medical students (small groups). The cross-sectional study design limits our ability to make causal inferences. These data are based largely on medical students with a small sample of nursing students. Generalization of findings to other nursing student groups will require further testing in larger, more broadly representative nursing student samples. Finally, the test-retest interval established might not have been long enough. Nevertheless, we consider that a period of five weeks could be acceptable for a behavioral characteristic that can fluctuate over time26.

Future research is required to improve the reliability of the NAS, to confirm the internal structure of the CSAS with confirmatory factorial analyses, to study its psychometric properties in other populations and settings (e.g. medical students in clinical years of training, residents), with other communication attitudes questionnaires and with methods of assessment of CS (e.g. through OSCE).

These findings have important implications for education research in health sciences and educational practice. They provide further evidence of the validity of the CSAS in students culturally different to previously studied samples. The results support its use as a quick, useful and economical method for assessing attitudes towards learning CS in undergraduate medical students and for evaluating the impact of training courses on communication attitudes. The systematically significant relationship between these attitudes and demographic and education variables contributes to a better understanding of the characteristics of students related to attitudes about CS. This knowledge will allow educators design more successful courses.


We would like to thank the students who participated in this study; Toni Cañete for his help in entering study data onto SPSS; Dr Charlotte Rees for granting permission to use the CSAS and her help in translation, and our colleagues (in alphabetical order) Rosa-Maria Escorihuela PhD, Albert Fernández-Teruel PhD, Miquel-Angel Fullana PhD and Jorge Molero PhD who helped us collect data for this study.


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Appendix I: Catalan translation of the CSAS for medical students

Appendix II: Catalan translation of the CSAS for nursing students


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