Clinical Simulation in Nursing (2013) 9, e179-e180

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Making Sense of Methods and Measurement

Reliability: Measuring Internal Consistency Using Cronbachs a

Katie Anne Adamson, PhDa,*, Susan Prion, EdDb
a b

University of Washington Tacoma, Tacoma, WA 98402-3100, USA University of San Francisco, San Francisco, CA 94117-1080, USA

In previous articles we have explored the concepts of reliability, validity, and the importance of psychometrically sound measures for simulation research. This article will focus on how to measure the internal consistency among items on an instrument. A statistic commonly used to measure internal consistency is Cronbachs alpha (a). Cronbachs a can range from 0.0 to 1.0, and it quanties the degree to which items on an instrument are correlated with one another (Connelly, 2011). In order to discuss Cronbachs a in more detail, we will look at an example of a simulation evaluation instrument from the literature: the Lasater Clinical Judgment Rubric (LCJR; Lasater, 2007). The LCJR is frequently used in simulation research to measure students demonstration of clinical judgment. Although most would agree that clinical judgment is a necessary and observable trait, there is no graduated medicine cup or nomogram that can be used to accurately quantify it. Therefore, a scale was developed to measure the construct of clinical judgment and it is based on the Tanner Clinical Judgment Model (Tanner, 2006). The LCJR includes 11 items, and ratings (beginning, developing, accomplished, and exemplary) from these items are combined to reect a composite clinical judgment score. If each of the items on the LCJR measures the same construct (clinical judgment), the ratings on each should be correlated with one another. A perfect correlation would result in a 1.0 and the absence of any correlation would result in a 0.0. Similarly, if the items within the subscales on the LCJR each measure their respective construct, they should be correlated with the other items within that subscale. The

* Corresponding author: kadamson@u.washington.edu (K. A. Adamson).

subscales on the LCJR include noticing, interpreting, responding, and reecting. Each of the 11 items on the LCJR falls under one of these subscales. Recently, Mariani, Cantrell, Meakim, Prieto, and Dreifuerst (in press) estimated Cronbachs a for the items on the LCJR at two different time points to be 0.927 and 0.942, respectively, and the a for items under each of the various subscales to be between 0.800 and 0.909. Cronbachs a, like most statistical analyses, has several weaknesses and special cases. First, a high correlation among items reects good internal consistency but tells us little about the validity of the measure. All of the items could be consistently measuring the wrong thing. For this reason, we need to remember that validity and reliability go hand in hand. A measure may be reliable but invalid. Next, Cronbachs a reects the degree to which items on the scale are interrelated but does not necessarily tell us anything about the unidimensionality of the construct or measure (Schmitt, 1996). Said another way, high correlations between items on the LCJR may mean that they all measure highly related constructs, but not necessarily a single construct: clinical judgment (Segars, 1997). Finally, Cronbachs a is the appropriate choice for measuring internal consistency in scales where items have more than two response options. However, for scales with dichotomous items, the Kuder-Richardson formula 20 (KR-20) is the appropriate choice (Cronbach, 1951). The question remains: How internally consistent should a scale be? According to Bland and Altman (1997), scales used in the clinical setting should have a minimum a 0.90, however, scales such as the LCJR used to compare groups may be acceptable with an a as low as 0.70. That said, the ndings of Mariani et al. (in press) indicate

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Making Sense of Methods and Measurement a high reliability of the LCJR. Each of these measures of internal consistency is specic to the sample they used and should be recalculated with additional samples for future studies.

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Cronbach, L. J. (1951). Coefcient alpha and the internal structure of tests. Psychometrika, 16(3), 297-334. Mariani, B., Cantrell, M. A., Meakim, C., Prieto, P., & Dreifuerst, K. T. (In press). Structured debrieng and students clinical judgment abilities in simulation. Clinical Simulation in Nursing. Schmitt, N. (1996). Uses and abuses of coefcient alpha. Psychological Assessment, 8(4), 350-353. Segars, A. H. (1997). Assessing the unidimensionality of measurement: A paradigm and illustration within the context of information systems research. Omega, 25(1), 107-122. Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.

References
Bland, J. M., & Altman, D. G. (1997). Statistical notes: Cronbachs alpha. British Medical Journal, 314, 572. Connelly, L. M. (2011). Research roundtable. Cronbachs alpha. Medsurg Nursing, 20, 1.

pp e179-e180  Clinical Simulation in Nursing  Volume 9  Issue 5