Cross-cultural Adaptation, Reliability, and Validity of the Turkish Version of the Health Professionals Communication Skills Scale

Purpose: The aim of this study is to evaluate the psychometric properties of the Turkish version of the Health Professionals Communication Skills Scale (HP-CSS).Methods: The HP-CSS was translated into Turkish following an international instrument translation guideline. A convenience sample of 394 health professionals participated in this study. Internal consistency reliability, content validity, test-retest reliability, and convergent validity were assessed. A confirmatory factor analysis was conducted to evaluate the construct validity.Results: The Turkish version of HP-CSS comprised four factors (empathy, informative communication, respect, and social skill). The HP-CSS-TR demonstrated adequate internal consistency (Cronbach's α values .72–.79). In terms of the content validity, the scale-level content validity index (CVI) was .94, and the item-level CVI ranged from .83 to 1.00. The HP-CSS-TR showed good test-retest reliability (intraclass correlation coefficients were above .82). No statistically significant difference was found between the applications. There was a good agreement between the HP-CSS-TR and communication skills inventory (CSI) scales. Confirmatory factor analysis results (χ2/df, GFI, AGFI, IFI, TLI, CFI, RMSEA, and SRMR) showed a good fit for the original four-factor model.Conclusion: Results showed that the Turkish version of the HP-CSS is a valid and reliable tool for the assessment of communication skills of health professionals in Turkey. The use of the HP-CSS-TR measure in clinical settings could be useful in enhancing the quality of care by identifying inadequacies and improving communication skills. Purpose: The aim of this study is to evaluate the psychometric properties of the Turkish version of the Health Professionals Communication Skills Scale (HP-CSS). Methods: The HP-CSS was translated into Turkish following an international instrument translation guideline. A convenience sample of 394 health professionals participated in this study. Internal consistency reliability, content validity, test-retest reliability, and convergent validity were assessed. A confirmatory factor analysis was conducted to evaluate the construct validity. Results: The Turkish version of HP-CSS comprised four factors (empathy, informative communication, respect, and social skill). The HP-CSS-TR demonstrated adequate internal consistency (Cronbach's α values .72–.79). In terms of the content validity, the scale-level content validity index (CVI) was .94, and the item-level CVI ranged from .83 to 1.00. The HP-CSS-TR showed good test-retest reliability (intraclass correlation coefficients were above .82). No statistically significant difference was found between the applications. There was a good agreement between the HP-CSS-TR and communication skills inventory (CSI) scales. Confirmatory factor analysis results (χ2/df, GFI, AGFI, IFI, TLI, CFI, RMSEA, and SRMR) showed a good fit for the original four-factor model. Conclusion: Results showed that the Turkish version of the HP-CSS is a valid and reliable tool for the assessment of communication skills of health professionals in Turkey. The use of the HP-CSS-TR measure in clinical settings could be useful in enhancing the quality of care by identifying inadequacies and improving communication skills. Communication is essential for healthcare professionals to share health information with the patients and their relatives. It plays a very significant role in defining patients' beliefs, emotions, needs, and expectations as well as their biomedical characteristics and in decision-making processes [1Rubinelli S. Silverman J. Aelbrecht K. Deveugele M. Finset A. 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These skills may indicate the ability to transmit information to patients and the ability to incorporate patients’ preferences in the decision-making process and to understand their messages [15Cubaka V.K. Schriver M. Vedsted P. Makoul G. Kallestrup P. Measuring patient-provider communication skills in Rwanda: selection, adaptation and assessment of psychometric properties of the communication assessment tool.Patient Educ Counsel. 2018; 101: 1601-1610https://doi.org/10.1016/j.pec.2018.04.010Crossref PubMed Scopus (7) Google Scholar,16Axboe M.K. Christensen K.S. Kofoed P.E. Ammentorp J. Development and validation of a self-efficacy questionnaire (SE-12) measuring the clinical communication skills of health care professionals.BMC Med Educ. 2016; 16: 272https://doi.org/10.1186/s12909-016-0798-7Crossref PubMed Scopus (39) Google Scholar]. 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Patient-provider communication: understanding diabetes management among adult females.Patient Educ Counsel. 2009; 76: 31-37https://doi.org/10.1016/j.pec.2008.11.022Crossref PubMed Scopus (51) Google Scholar], management of chronic diseases, and their motivation to adopt better lifestyles [19Claramita M. Arininta N. Fathonah Y. Kartika S. Prabandari Y.S. Pramantara I.D. A partnership-oriented and culturally-sensitive communication style of doctors can impact the health outcomes of patients with chronic illnesses in Indonesia.Patient Educ Counsel. 2019; 103: 292-300https://doi.org/10.1016/j.pec.2019.08.033Crossref PubMed Scopus (9) Google Scholar]. On the other hand, a minor mistake to be made by healthcare professionals due to the problems in communication leads to irrecoverable consequences and problems such as misdiagnosis, medication errors, and delayed treatment [20Foronda C. MacWilliams B. McArthur E. Interprofessional communication in healthcare: an integrative review.Nurse Educ Pract. 2016; 19: 36-40https://doi.org/10.1016/j.nepr.2016.04.005Crossref PubMed Scopus (211) Google Scholar]. The role given to communication studies in health services has increased over the years, and thus, Health Communication discipline has been established accordingly. United States Office of Disease Prevention and Health Promotion has indicated that health communication studies are essential for effective public health strategies and practices [21ODPHPHealth literacy. Office of Disease Prevention and Health Promotion, Washington2020https://health.gov/our-work/health-literacy/Google Scholar]. The USA has included the title of health communication within the context of “Healthy People 2010” targets and emphasized the increasing importance of it, and they also have included health communication under the title of “Health Communication and Health Information Technology” in the “Healthy People 2020” project aiming a healthier society in 2020 [22ODPHPHealthy people. Office of Disease Prevention and Health Promotion, Washington2020https://www.healthypeople.gov/2020/topics-objectives/Google Scholar]. There are different ways to evaluate the communication skills of healthcare professionals such as self-assessment questionnaires, patient-assessment questionnaires, and third-party observations. Various scales have been developed to assess communication skills. However, to the best of our knowledge, the number of studies that focus on the communication skills of health professionals is very limited. In a systematic review study conducted by Cömert et al., scales assessing the communication skills of medical students were investigated. In the study, the methodological quality of studies was reported mainly as poor [23Cömert M. Zill J. Christalle E. Dirmaier J. Härter M. Scholl I. Assessing communication skills of medical students in objective structured clinical examinations (OSCE) - a systematic review of rating scales.PloS One. 2016; 11e0152717https://doi.org/10.1371/journal.pone.0152717Crossref PubMed Scopus (83) Google Scholar]. The Health Professionals Communication Skills Scale (HP-CSS) shows good psychometric properties. Moreover, the HP-CSS is one of the rare instruments that show the entire process of scale development starting from the semantic and syntactic definition of the construct to the evaluation of psychometric properties [24Leal-Costa C. Tirado-González S. Román C.J.H. Rodríguez-Marín J. Creation of the communication skills scale in health professionals, CSS-HP.Anal Psicol. 2016; 32 (Spanish): 49-59https://doi.org/10.6018/analesps.32.1.184701Crossref Google Scholar]. In a very recent study conducted on 692 nurses, psychometric properties of the scale were analyzed and appropriate results were obtained. The study empirically revealed that nurses who have adequate communication skills feel themselves safer and more competent, and thus, their relationships with patients are improved [25Leal-Costa C. Tirado González S. Ramos-Morcillo A.J. Díaz Agea J.L. Ruzafa-Martínez M. Van-der Hofstadt Román C.J. Validación de la Escala sobre Habilidades de Comunicación [Validation of the Communication Skills Scale in nursing professionals].An del Sist Sanit Navar. 2019; 42 (Spanish): 291-301https://doi.org/10.23938/ASSN.0745Crossref PubMed Scopus (8) Google Scholar]. In another study assessing the performance of fourth-year nursing students in the simulated clinical practices, a positive relationship between the students’ communication skills and their performance was reported. It was also revealed that higher levels of empathy, respect, informative communication, and assertiveness result in improved performance in the clinical environment [26Sánchez Expósito J. Leal Costa C. Díaz Agea J.L. Carrillo Izquierdo M.D. Jiménez Rodríguez D. Socio-emotional competencies as predictors of performance of nursing students in simulated clinical practice.Nurse Educ Pract. 2018; 32: 122-128https://doi.org/10.1016/j.nepr.2018.07.009Crossref PubMed Scopus (17) Google Scholar]. Reliable instruments can be used to assess nurses’ communication skills to contribute to the improvement of quality of care and the development of the studies on further improvement of their skills [15Cubaka V.K. Schriver M. Vedsted P. Makoul G. Kallestrup P. Measuring patient-provider communication skills in Rwanda: selection, adaptation and assessment of psychometric properties of the communication assessment tool.Patient Educ Counsel. 2018; 101: 1601-1610https://doi.org/10.1016/j.pec.2018.04.010Crossref PubMed Scopus (7) Google Scholar,27Korkut Owen F. Bugay A. Developing a communication skills scale: validity and reliability studies.Mersin Univ J Fac Educ. 2014; 10: 51-64Google Scholar]. Therefore, there is a need for valid and reliable measurement tools specially developed to evaluate the communication between healthcare professionals and patients [28Leal-Costa C. Tirado-González S. Rodríguez-Marín J. vander-Hofstadt-Román C.J. Psychometric properties of the health professionals communication skills scale (HP-CSS).Int J Clin Health Psychol. 2016; 16: 76-86https://doi.org/10.1016/j.ijchp.2015.04.001Crossref PubMed Scopus (17) Google Scholar]. As far as the literature review is concerned, no previous study was conducted to validate a communication skills scale specific to health professionals in Turkey. In general, studies assessing the communication skills of health professionals were carried out using scales developed not for health professionals, but for general use. The aims of the present study were to translate and adapt the HP-CSS developed by Leal-Costa et al. [28Leal-Costa C. Tirado-González S. Rodríguez-Marín J. vander-Hofstadt-Román C.J. Psychometric properties of the health professionals communication skills scale (HP-CSS).Int J Clin Health Psychol. 2016; 16: 76-86https://doi.org/10.1016/j.ijchp.2015.04.001Crossref PubMed Scopus (17) Google Scholar] into Turkish and to examine whether it is a valid and reliable tool for assessing the communication skills of health professionals. The study results will provide researchers and managers of health institutions with a useful tool for the new studies and assessments in Turkey. This methodological study consisted of two phases. In phase 1, the HP-CSS was translated and culturally adapted into Turkish following guidelines proposed by Sousa [29Sousa V. Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline.J Eval Clin Pract. 2010; 17: 268-274https://doi.org/10.1111/j.1365-2753.2010.01434.xCrossref PubMed Scopus (1226) Google Scholar] and World Health Organization (WHO) for cross-cultural adaptation process [30World Health Organization Process of translation and adaptation of instruments. World Health Organization, Geneva, Switzerland2015https://www.who.int/substance_abuse/research_tools/translation/en/Google Scholar]. In phase 2, the psychometric properties of the Turkish version of the HP-CSS were evaluated through a cross-sectional survey (Figure 1). The present study was conducted between September 2017 and February 2018. A convenience sampling method was used to recruit health professionals from three hospitals of a hospital group in Istanbul. A total of 394 health professionals including nurses and physicians participated in the study. In the adaptation of a scale to another language, it is recommended that the sample size should be 5–10 times greater than the number of items in the scale [31DeVellis R.F. Scale development: theory and applications.3rd ed. Sage Publications, London2012Google Scholar]. The HP-CSS consists of 18 items and our sampling size met this criterion with a ratio of 1 to 22. For adaptation of the HP-CSS to Turkish, written permission of César Leal-Costa, who developed the instrument, was taken. The ethics committee approval of the study was obtained from the Clinical Research Ethics Committee of Demiroglu Bilim University before conducting the study (Approval no. 04.07.2017/60-14). Additionally, verbal consent was obtained from each of the participants. The questionnaire was composed of three sections: (1) a demographic information form including age, gender, marital status, education level, major, working period, and attendance to any training related to communication skills before; (2) the HP-CSS developed by Leal-Costa et al. (2016), and (3) communication skills inventory (CSI) [32Ersanli K. Balci S. Developing a communication skills inventory: its validity and reliability.Turkish Psychol Counsel Guid J. 1998; 10 (Turkish): 7-12Google Scholar]. The HP-CSS is a self-report scale evaluating the communication skills of health professionals. The development of the original scale was completed in two phases. In the first phase, the authors analyzed the components of communication skills of health professionals, interrelationships between the components and relationships with other external constructs from a theoretical point of view. The adequacy of the definition of the construct was assessed by 29 experts using a Delphi-type methodology. Adequacy scores of each construct ranged between .83 and .93. The evidence of content validity was provided. In the second phase, the scale consisting of 46 items was developed. The items were evaluated by 27 experts specialized in health communication and they decided to remove four items. Consensus validity was based on expert agreement. The first preliminary test was carried out with a small group of health professionals consisting of two physicians, four nurses, and three nursing assistants [24Leal-Costa C. Tirado-González S. Román C.J.H. Rodríguez-Marín J. Creation of the communication skills scale in health professionals, CSS-HP.Anal Psicol. 2016; 32 (Spanish): 49-59https://doi.org/10.6018/analesps.32.1.184701Crossref Google Scholar]. Psychometric properties of the scale were investigated in another research, which is the continuation of the first study. Exploratory factor analysis and confirmatory factor analysis (CFA) were conducted to analyze the items and components they belong to. The resulting scale consisted of 18 items divided into four dimensions, including empathy (five items), informative communication (six items), respect (three items), and social skill (four items). The participants were assessed on how often each item applies to themselves by using a six-point Likert-type scale from 1 to 6 (1 = almost never, 2 = once in a while, 3 = sometimes, 4 = normally, 5 = very often, and 6 = many times). Empathy includes items 2, 4, 6, 11, and 12, and the score ranges between 5 and 30; informative communication includes items 5, 8, 9, 14, 17, and 18, and the score ranges between 6 and 36; respect includes items 1, 3, and 15, and the score ranges between 3 and 18; social skill includes items 7, 10, 13, and 16, and the score ranges between 4 and 24. Higher scores reflect better communication skills of health professionals. The Cronbach's α coefficients of the original scale were reported as .77, .78, .74, and .65 for empathy, informative communication, respect, and social skill dimensions, respectively [28Leal-Costa C. Tirado-González S. Rodríguez-Marín J. vander-Hofstadt-Román C.J. Psychometric properties of the health professionals communication skills scale (HP-CSS).Int J Clin Health Psychol. 2016; 16: 76-86https://doi.org/10.1016/j.ijchp.2015.04.001Crossref PubMed Scopus (17) Google Scholar]. The CSI consists of 45 items rated on a five-point Likert-type scale. The scale comprises three dimensions: behavioral (CSI-B), cognitive (CSI-C), and emotional (CSI-E). Scores range from 15 to 75 for each dimension; the higher the score, the better the communication skills [32Ersanli K. Balci S. Developing a communication skills inventory: its validity and reliability.Turkish Psychol Counsel Guid J. 1998; 10 (Turkish): 7-12Google Scholar]. The cross-cultural adaptation process was carried out in four steps: forward translation, expert panel back translation, pretesting and cognitive interviewing, and the final version [29Sousa V. Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline.J Eval Clin Pract. 2010; 17: 268-274https://doi.org/10.1111/j.1365-2753.2010.01434.xCrossref PubMed Scopus (1226) Google Scholar,30World Health Organization Process of translation and adaptation of instruments. World Health Organization, Geneva, Switzerland2015https://www.who.int/substance_abuse/research_tools/translation/en/Google Scholar]. The translation process was completed in 3 weeks with no significant difficulty.Step 1Forward translation: After the approval from the developer of the original HP-CSS, the scale was translated into Turkish. Two bilingual experts (a nurse professor and an English lecturer at the Faculty of Health Sciences), both fluent in English, independently translated the original scale into Turkish (TL1 and TL2). A panel including a third independent nurse professor, one communication professor, and the research team reviewed forward-translated versions to achieve the most accurate translation. After resolving ambiguities and disagreements, a preliminary initial translated version named as version 1 was created (PI-TL).Step 2Back translation: Version 1 of the scale was then independently translated back into English by two scholars in the English Language and Literature who have not seen the original HP-CSS (B-TL1 and B-TL2). One of the translators had experience in health terminology. The back-translated English versions were compared with the original version of the HP-CSS in English by an expert committee, comprising the researchers and all translators involved in the process. In this meeting, the committee discussed each item in more detail to ensure no major discrepancies existed and to achieve the best possible level of semantic and conceptual relevance. The expert committee decided to make minor changes to items 16 and 18. Item 16, “I find it difficult to make requests of patients” was changed to “It is difficult for me to make requests of patients.” Item 18, “I find it difficult to ask for information from patients” was modified to “It is difficult for me to ask questions to patients to collect information.” These changes were made considering the prevalence of use in Turkish to obtain appropriate items in terms of clarity and understandability. The comprehensibility and the cognitive equivalence of the translation were confirmed by the cognitive interviews. After a consensus was reached within the committee, the prefinal version named as version 2 was produced.Step 3Pretesting and cognitive interviewing: Next, version 2 of the scale was examined in a pilot study on 30 health professionals aged 20–42 from the same hospital. Of the participants, 23 were female. The health professionals were asked to read and answer all items of the prefinal version of the HP-CSS. Then, the participants were individually interviewed about their opinions regarding the clarity and understandability of the questions. All of the health professionals indicated that the items were easy to understand and did not have unnecessary words. At the end of the pilot study, no modification was required and version 3 was created.Step 4Final version: The last step is the proofreading of version 3. The final Turkish version of HP-CSS was completed by requesting a Turkish linguist for typo, spelling, or grammatical errors. The final version of the scale was named HP-CSS-TR. Regarding content validity, a panel of six independent experts (two teaching staff from the field of communication, two nurse academicians, one physician, and one registered nurse) reviewed and evaluated each item separately. The clarity and relevance of each item were assessed by using a four-point scale (1 = not clear/relevant, 2 = somewhat clear/relevant, 3 = quite clear/relevant, and 4 = highly clear/relevant). The content validity index (CVI) for each item was computed by dividing the total score of each item by the total number of experts. The overall CVI was computed by taking the average of the CVIs of all items. The CVI of the scale items (I-CVI) ranged from .83 to 1. The CVI for the overall scale (S-CVI) was .94, which supports that HP-CSS-TR has good content validity. Data were collected in three hospitals of a hospital group in Istanbul. The health professionals who voluntarily accepted to participate in the study were informed about the purpose of the study and the parts of the questionnaire. In the second part of the survey, they were asked to mark the most appropriate option for each item considering their experiences with the patients. A brief description of the purpose of the study was also included at the beginning of the survey form. It took 5–8 minutes to answer the HP-CSS-TR by the participants. The HP-CSS was re-administered to 30 health professionals 2 weeks later to evaluate the test-retest reliability of the scale. Data analyses were performed using the IBM SPSS Statistics 21 and IBM SPSS Amos 24 (IBM Corp., Armonk, NY, USA) software packages. Descriptive statistics (mean, standard deviation, and frequency distributions) were used to determin