1. No category

INTERPERSONAL COMMUNICATION
ASSESSMENT SCALE:
PSYCHOMETRIC STUDY OF THE
PORTUGUESE VERSION
ROSA CRISTINA CORREIA LOPES, MS,⁎ ZAIDA DE AGUIAR SÁ AZEREDO, PHD,†
AND ROGÉRIO MANUEL CLEMENTE RODRIGUES, PHD‡
This article is a report of a study exploring the psychometric properties of the Portuguese version
of the Interpersonal Communication Assessment Scale (ICAS) related to nursing education.
Interpersonal communication in health care in general and in nursing care in particular is used to
transmit messages between the members involved so as to convey a meaning in their interaction.
The essence of nursing care is focused on the nurse–patient interpersonal communication. The
validation of ICAS developed in 4 steps: translation, back translation, comparison of both versions,
and evidence of the validity of Portuguese version. The psychometric study was carried out using
the Statistical Package for the Social Sciences. The nonprobabilistic convenience sample was
composed of 156 second-year students of the undergraduate nursing course (2008–2009). The
psychometric analysis showed high values in Cronbach's alpha (ICAS: .939; advocacy: .857;
therapeutic use of self: .890; and validation: .795), Pearson correlation (r = .740, P = .000), Bartlett's
test of sphericity (2190.278, P = .000), and Kaiser–Meyer–Olkin measure of sampling adequacy
(.910). In general, the psychometric properties of the ICAS–Portuguese version are comparable to
the original version. ICAS showed high internal consistency in reliability analysis and excellent
temporal stability, thus an appropriate tool for assessing interpersonal communication skills.
(Index words: Interpersonal communication; Nursing education; Psychometric study; Portuguese
version; Interpersonal communication assessment scale) J Prof Nurs 29:59–64, 2013. © 2013
Elsevier Inc. All rights reserved.
R
ENOWNED AUTHORS IN the science of nursing
(Chalifour, 1993; Colliére, 1989; Lazure, 1994;
Peplau, 1990; Phaneuf, 2005; Watson, 2006; among
others) unanimously agree that interpersonal relationships and relational skills are the basis of nursing care, a
skill that promotes excellence in nursing care.
⁎ Associate Professor, Nursing School of Coimbra, Portugal.
†Associate Professor, Biomedical Sciences Abel Salazar Institute,
University of Porto, Portugal.
‡Associate Professor, Nursing School of Coimbra, Portugal.
This study was funded by the Foundation for Science and Technology—
Ministry of Science, Technology, and Higher Education—Portugal,
SFRH/PROTEC/67586/2010.
Address correspondence to Prof. Lopes, MD: Nursing School of
Coimbra, Portugal. E-mail: rlopes@esenfc.pt
8755-7223/12/$ - see front matter
The importance of communication/relational skills
also includes the communication between different
team members, taking into account that the nurse is
part of a multidisciplinary health team. Communication
and development of communication skills have gained a
significant importance in the interpersonal relationships
between health team members with an impact on quality
of care.
Background
Interpersonal communication in nursing is used to
convey messages between the different parties so as to
provide a meaning to this exchange of messages. The
sender/nurse should convey the message to the receiver
in a clear and understandable way for the other person
to understand and make the necessary changes. Riley
(2004, p. 6) argues that interpersonal communication
in nursing should be “assertive, responsible and caring”
Journal of Professional Nursing, Vol 29, No. 1 (January/February), 2013: pp 59–64
© 2013 Elsevier Inc. All rights reserved.
59
http://dx.doi.org/10.1016/j.profnurs.2012.04.010
60
and that the acquisition of interpersonal communication skills is based on acquiring basic knowledge
(cognitive domain), becoming safer by believing in
the value and impact of positive communication
(affective domain), and measuring skill performance
(psychomotor domain).
In nurses' daily work, communication is used in
multiple activities of education, care delivery, and
liaison in the multiprofessional team; thus, it is
essential to consciously use communication by mastering communication skills (Silva, Brasil, Guimarães,
Savonitti, & Silva, 2008).
Some authors consider communication in nursing as a
basic instrument of nurses, regardless of their area of
expertise (Castro & Silva, 2001; Matoso, 2006; Mok &
Chiu, 2004). Communication is a skill that should be
developed, practiced and, above all, trained and reflected
upon. However, the simple knowledge of communication
and relational theories is considered insufficient to health
care practice (Araújo, Silva, & Puggina, 2007; Batista,
2007; Cruz, Sá, Pereira, & Novais, 2002; Ferreira, 2001;
Matoso, 2006).
The client–nurse communication is not always therapeutic. In this relationship with the other, there are
poorly constructed messages that can hurt the patient
and cause hostility and exclusion from a therapeutic
commitment, jeopardizing the creation of the necessary
bond in the caring process and the development of a
relational hierarchical process instead of a collaborative
process. Thus, these messages can become iatrogenic
factors (Araújo et al., 2007).
Research studies with nurses in Belgium (Bowles,
Mackintosh, & Torn, 2001) and in Canada (Boscart,
2009) show that the practice of communication skills
through brief education-oriented interventions increases
nurses' awareness in their interactions, resulting in a
sustainable effect on the quality of the nurse–patient
communication. Interventions using coping strategies
have also proven to be very useful (de Lucio, Lopez,
Lopez, Hesse, & Caamano, 2000), whereas interprofessional education approaches develop a more comprehensive understanding of caring based on trust and
communication in the context of nursing care (Chan,
Mok, Po-Ying, & Man-Chun, 2009).
Therefore, nursing students/nurses should learn how
to communicate in an effective way because building a
relationship of concern and trust is to replace the habit
of communicating in a noneffective and nontherapeutic
way using actual helping relationships (Riley, 2004).
The learning of specific techniques of interaction
should be included in the curriculum of the degree
course in nursing or education organized by the service
(Apker, Propp, Zabava Ford, & Hofmeister, 2006).
Despite interpersonal communication being viewed as
the essence of nursing, there are few psychometric
instruments available to measure this skill in students/
nurses. The reviewed studies in the area of communication in nursing usually use qualitative tools specifically
developed for the respective study.
LOPES ET AL
In 2006, Klakovich and delaCruz developed the
Interpersonal Communication Assessment Scale (ICAS)
to measure the communication competencies of
undergraduate and graduate students. The authors
used retroductive triangulation, using both deductive
and inductive methods and the model of relational
competence in the conceptualization and development
of the scale.
The Study
Aims
This study aimed to validate and test the psychometric
properties of the Portuguese version of the ICAS
originally developed in English by Klakovich and
DelaCruz (2006).
Methodology
The research literature recommends using versions of
already tested measures in different cultures instead of
creating new ones for each country (Duarte & Bordin,
2000). These measures need to be validated in the new
cultural context and developed according to a strict
methodology so as to ensure the semantic and technical
equivalence and the construct, content, and criterion
validity (Duarte & Bordin, 2000; Polit, Beck, &
Hungler, 2004; Rocha et al., 2003). The ICAS–
Portuguese version was validated in four phases:
translation, back translation, comparison of both
versions (original and back translated), and evidence
of the scale's validity in the new context.
The ICAS was first translated into Portuguese by a
bilingual translator and, then, submitted to a panel of
four bilingual experts with renowned experience in the
scientific and academic community in the areas of
nursing science, education, and research.
It was then translated back into English by a
bilingual translator unfamiliar with the original version.
Both versions of the ICAS (original and back translated)
were compared by the experts that confirmed the
equivalence of both scales and the appropriateness of
the Portuguese version.
Sample/Participants
Ribeiro (2008) considers that the number of participants
to be included in a sample is usually related to the
number of variables in the study, with five being the
minimum number of participants required for each
variable. Thus, in the 23-item ICAS, the minimum
number required for our sample was 115 students.
In the first stage of this study, the (nonprobabilistic
convenience) sample was composed of 156 second-year
students enrolled in the second semester of the nursing
undergraduate program at the Nursing School of
Coimbra and undertook their clinical training in nursing
fundamentals (first clinical training) during the academic
year 2008–2009. The ICAS–Portuguese version was
administered in collaboration with these students'
supervising teachers who were asked to complete the
scale for each student in clinical training.
INTERPERSONAL COMMUNICATION ASSESSMENT SCALE: PORTUGESE
In the second phase of this study, 45 students who
had already been part of the sample in the first phase
were selected.
61
summative tool to assess the interpersonal communication skills of nursing students.
Data Collection
Instrument
Reliability analysis using Cronbach's alpha revealed an
extremely high reliability of .98 for the 54-item ICAS. The
aim of the authors was to develop a scale that would be
quick and easy for the supervising teachers in clinical
training to complete. Preserving the integrity of the
dimensions, the items with the highest item-total
correlations, were retained, resulting in a 32-item scale.
Exploratory factor analysis using principal components
extraction and varimax rotation showed a four-factor
solution. However, the fourth factor was not interpretable, and the scree plot indicated a three-factor solution.
Thus, a repeat exploratory factor analysis with a forced
free-factor solution allowed a logical interpretation of the
results. Items that factor loaded .60 or higher were
retained, resulting in a 23-item ICAS with three subscales
that explained 60% of the variance:
• F1—advocacy (clearly conveying diagnostic and
other relevant information in a way that supports
patient/family wishes and decisions);
• F2—therapeutic use of self (demonstrating interpersonal behaviors that assist clients in achieving
healthy emotional and behavioral outcomes by being
genuine, empathetic, and respectful to the client);
• F3—validation (listening carefully and verifying
that the intent of messages is accurately interpreted).
The ICAS is a Likert-type scale composed of 23 items
related to the interpersonal communication skills
expected from nursing students, and the level of
effectiveness ranged from 1 (seldom) to 4 (almost always).
The Cronbach's alpha for the 23-item ICAS (.96) and
its dimensions (F1 = .93, F2 = .93, F3 = .84) showed good
internal consistency.
The authors concluded that ICAS is a reliable
measure suitable for differentiating the interpersonal
communication competencies in beginning and graduating students in undergraduate and graduate nursing
programs, underscoring its potential as a formative and
In the first phase, so as to analyze the internal consistency
of the ICAS, 24 clinical faculty from a nursing college
supervising second-year students enrolled in the second
semester of the nursing undergraduate program and
undertaking their clinical training in nursing fundamentals (first clinical training) during the academic year
2008–2009 were asked to complete the ICAS–Portuguese
version. The teachers were informed about the purpose
and scope of the study, and their participation in the
study was voluntary and anonymous. Data were collected
from June 22nd to June 26th, 2009. There were 156
returned measures usable for analysis.
The second phase occurred after 2 weeks, so as to
assess the temporal stability of the ICAS, and seven
teachers were asked to apply the scale once again to the
students that they supervised. Thus, 45 measures were
duly completed and returned.
Data were analyzed using the Statistical Package for the
Social Sciences, Version 15, with a level of significance of
P b .001.
Ethical Considerations
This study was approved by the Ethical Committee of the
Research Unit in Health Science—Nursing of the Nursing
School of Coimbra.
Permission was obtained from the president of the
institution to conduct this study.
Participants were given a consent form explaining the
purpose and scope of the study, underlining the voluntary
nature of participation, and ensuring anonymity.
Results
In the first phase, the sample was composed of 156
students aged 19–33 years, with a mean age of 20.64 years
and a standard deviation of 2.20. Of the participants, 133
(85.26%) were female, and 23 (14.74%) were male.
In the second phase, 45 students were selected, aged
19–27 years, with a mean age of 20.31 years and a
standard deviation of 1.31. Of the participants, 34
(75.56%) were female, and 11 (24.44%) were male.
Table 1. Comparison of Mean, Standard Deviation, Ranges and Psychometric Properties (Reliability of Cronbach's Alpha Coefficient)
of ICAS and it's Dimensions in the Original and Portuguese Version
ICAS version
Original (n = 145)
Portuguese (n = 156)
M
SD
Range
Cronbach's α
M
SD
Range
Cronbach's α
F1Advocacy
(10 items)
F2Therapeutic
use of self (9 items)
F3Validation
(4 items)
Total ICAS
20.68
7.72
10–39
.93
26.25
5.52
13–37
.86
24.72
6.57
9–36
.93
26.80
5.43
12–26
.89
8.13
2.82
3–15
.84
11.03
2.70
4–16
.80
53.53
15.17
22–86
.96
64.08
12.83
30–88
.94
62
LOPES ET AL
Table 2. Reliability of Cronbach's Alpha Coefficient of the Items That Constitute the ICAS
Item
Corrected item-total
correlation
Cronbach's α if
item deleted
.737
.596
.935
.937
.651
.936
.666
.693
.936
.935
.645
.936
.595
.537
.937
.938
.677
.574
.624
.624
.936
.937
.936
.936
.640
.936
.663
.432
.703
.674
.483
.741
.936
.939
.935
.936
.938
.935
.356
.941
.684
.672
.935
.936
.596
.937
Dá instruções claras sobre a gestão das condições de cuidados.
Descreve os comportamentos em vez de fazer juízos de valor sobre o
doente/família para dar informações.
Incentiva o doente/membros da família a expressar sobre as reacções
aos cuidados e tratamentos.
Providencia o encaminhamento do doente. quando necessário.
Coloca perguntas específicas para obter pormenores sobre uma
potencial área-problema.
Revela comportamentos (como contacto visual. toque) quando comunica.
se for adequado à situação e aceitável para a cultura de origem
da outra pessoa.
Pede confirmação das suas próprias percepções.
Refere discrepâncias na informação fornecida pelo doente e família
durante a entrevista.
Pede clarificação.
Detecta contradições entre a comunicação verbal e a não-verbal.
Convida o doente e família a explorar as discrepâncias na informação.
Prepara o doente/família para os procedimentos. explicando o processo
e as suas razões antes de os efectuar.
Dá feedback indicando observações gerais do processo. do conteúdo
e dos sentimentos.
Reconhece como importantes as preocupações do doente e da família.
Requer consulta de outros profissionais de saúde quando necessário.
Identifica necessidades de apoio emocional para o doente/membro da família.
Ensina e promove cuidados preventivos de saúde.
Explica ao doente/família as diferentes opções de tratamento.
Dedica tempo com o doente e membros da família para ouvir as suas
preocupações e problemas.
Questiona a decisão do doente em não aderir ao tratamento ou
interrompê-lo.
As expressões faciais interligam-se com o contexto da conversa.
Mantém a distância e o espaço adequado à cultura de origem da outra
pessoa enquanto fala com o doente/membros da família.
Inicia uma conversa com o doente/membro da família que
habitualmente está em silêncio.
Internal Consistency
The internal consistency of ICAS was measured using
Cronbach's alpha in the total sample of Portuguese
nursing students (N = 156). The total ICAS revealed a
high reliability (Cronbach's alpha = .939). The Cronbach's alpha also indicated a good internal consistency in
the three dimensions (advocacy—.857; therapeutic use of
self—.890; and validation—.795; Table 1).
These values of internal consistency are slightly
higher than the ones found by the authors in the
original version (total ICAS—.96; advocacy—.93; therapeutic use of self—.93; and validation—.84; Table 1).
As for the validity of the items in the Portuguese
sample, interitem correlations, indicator of homogeneity
of the scale, show very high means. Item-total correlations (indicator of the higher the correlation, the better
the item discrimination) were high, with the exception of
Items 20, 15, and 18 with the lowest coefficients of
correlation (.356, .432, and .483, respectively). Cronbach's alpha if item deleted, which is the estimated value of
alpha if the given items were removed from the model,
was also high (alpha if item deleted was only higher than
total alpha value in Item 20; Table 2).
Test–Retest Reliability
To assess the temporal stability of the ICAS, we applied
the scale again 15 days after it was first applied to 45
students, and similar results were found in the test–
retest measures (Cronbach's alpha = .932). Pearson
correlation coefficient was also measured between both
applications (Table 3), and a highly significant
correlation was found between ICAS total scale (r =
Table 3. Pearson Coefficient Correlation in Two Times (Test–
Retest)
Pearson correlation (n = 45)
Advocacy
Therapeutic use of self
Validation
Global ICAS
⁎P b .001.
.744 ⁎
.553 ⁎
.775 ⁎
.740 ⁎
INTERPERSONAL COMMUNICATION ASSESSMENT SCALE: PORTUGESE
Table 4. Tests KMO and Bartlett's Sphericity
KMO measure of sampling adequacy
Bartlett's test of sphericity
χ
df
Significance
2
.910
2190.278
253
.000
.740; P = .000) and subscales: advocacy (r = .744; P =
.000), therapeutic use of self (r = .553; P = .000), and
validation (r = .775; P = .000).
Factor Analysis
As this study aimed to validate and not to design a new
tool, it confirmed the factor analysis, the type of rotation,
and the factorial solution found by the authors, which
originally designed the instrument (Ribeiro 2008).
Therefore, given that the original scale's structure is
composed of three factors, the construct validity in the
Portuguese version, obtained through the study on
dimensionality, showed a forced three-factor solution in
the factor analysis. The analysis converged into a threefactor solution, which explained 58.872% of the total
variance, complemented by the principal component
analysis with varimax rotation. This analysis allowed us
to confirm the overall distribution of factors based on the
factor structure indicated by the scale's authors.
The degree of susceptibility or the suitability of the
data to factor analysis, that is, the factorability of the
scale, was assessed using Kaiser–Meyer–Olkin (KMO)
measure of sampling adequacy and Bartlett's test of
sphericity. The KMO index was .910, indicating a very
good adequacy of factor analysis to this study and
sampling adequacy. Bartlett's test of sphericity (χ 2 =
2190.278; P = .000), indicating item correlation, confirms
the adequacy of the factor analysis method to data
analysis and item correlation (Table 4).
Discussion
Despite the slightly lower levels of internal consistency
compared with the original version in the three dimensions (Cronbach's alpha: F1 = .96, F2 = .93, F3 = .93)
and in the total scale (Cronbach's alpha = .84), the
Portuguese version of the ICAS shows high levels of
internal consistency and a general correlation with the
scores of the original version (Pestana & Gageiro, 2005;
Polit et al., 2004).
As for the test–retest reliability, Pearson coefficients
(F1: r = .744, P = .000; F2: r = .553, P = .000; F3: r = .775,
P = .000; Total: r = .740, P = .000) showed a very good
temporal stability between the first and second application of the Portuguese version (Ribeiro, 2008).
The validity of the items in the Portuguese sample,
based on the content, construct, and criterion validity
proposed by the authors of the original version and
confirmed by the judges of the Portuguese version,
showed items with good discrimination and scale
homogeneity (Pestana & Gageiro, 2005).
Despite the highly satisfactory results in the sample of
students undertaking their first clinical training in
63
nursing, further research is recommended using the
ICAS–Portuguese version with final-year students of the
nursing undergraduate program and, also, students of the
master's in nursing.
Conclusion
This study aimed to validate the ICAS–Portuguese
version in a sample of 156 students in their first clinical
training of the nursing undergraduate program.
Based on the content, construct, and criterion validity
proposed by the authors of the ICAS original version and
confirmed by the judges of the translation into Portuguese, we conclude that, in general, the psychometric
properties of the Portuguese version are comparable to
those originally reported by Klakovich and DelaCruz
(2006). The reliability of the results is confirmed by the
high levels of internal consistency of the total ICAS and
its dimensions (advocacy, therapeutic use of self, and
validation) and a very good temporal stability between
the first and second application.
Based on these results, the ICAS–Portuguese version
was considered a suitable tool to assess the interpersonal
communication skills of nursing undergraduate students
in clinical training.
The expansion of the study using the ICAS will make it
possible to differentiate between the interpersonal
communication skills of nursing undergraduate and
graduate students and also provide a more in-depth
approach to the process of validation that started with
this study and that will never be truly finished.
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