Developing the Ibn-e-Sina University Mirpurkhas Scale of Affective Domain (ISUMSAD): A Pilot Study

The Ibn-e-Sina University Mirpurkhas Scale of Affective Domain (ISUMSAD) is a newly developed instrument designed to measure the affective domain within health professions education and patient care. A pilot study was conducted to create a questionnaire with an optimal number of items, examining the measurement properties, underlying components, and latent variable structure of ISUMSAD. This initiative aimed to evaluate the feasibility and efficiency of a larger research project. The items encompass all five levels of the affective domain (Receiving, Responding, Valuing, Organizing, and Characterizing).

Fifty students from the Muhammad Institute of Physiotherapy & Rehabilitation Sciences (MIPRS), a constituent college of Ibn-e-Sina University Mirpurkhas (ISUM), completed ten initial scales comprising 217 affective domain items. These scales were selected by a five-member committee of medical education experts. We used low Corrected Item-Total Correlation, high Cronbach's Alpha if Item Deleted, low factor loadings and finally low communalities to identify items for removal, until the items were gradually reduced to 12, forming the finalized ISUMSAD scale. The same 50 students then rated these 12 items on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree), yielding total scores ranging from 12 to 84 per student.

The sample’s mean ISUMSAD score was 60.86/84 (SD = 12.7). Item-total correlations were positive, with Cronbach’s α = 0.92 and KMO = 0.855. Principal Component Analysis revealed two factors. Factor 1 was named “Empathy & Communication” and Factor 2 was named “Skills & Respect”.

Medical education has long prioritized cognitive knowledge and technical skills, often neglecting the affective domain-the dimension encompassing attitudes, emotions, values, and interpersonal skills [1]. While future physicians receive rigorous training in anatomy, pharmacology, and clinical procedures, far less emphasis is placed on affective competencies [2]. This oversight adversely impacts patient care, physician well-being, and healthcare systems, contributing to poor patient-provider relationships, burnout (affecting >50% of physicians) [3], ethical erosion, and dehumanized care [3].

Several factors explain this neglect: historical emphasis on cognitive/technical skills assessed via standardized exams (e.g., USMLE); difficulty quantifying affective traits; the hidden curriculum undermining formal training; time constraints; and concerns that affective education might "soften" physicians or compromise scientific rigor [4]. This persists despite evidence that empathy enhances diagnostic accuracy and treatment outcomes [5,6]. Consequently, empathy scales have been translated cross-culturally [7], and workshops improving emotional intelligence/communication skills developed [8].

Affective learning may be enhanced by developing practical assessment tools (e.g., ISUMSAD), creating dedicated affective domain curricula, integrating affective objectives into basic/clinical science courses, simulation-based training with standardized patients, reflective exercises (e.g., narrative medicine), and Mindfulness/resilience programs to mitigate burnout (Table 1).

Thus, we developed the 12-item ISUMSAD questionnaire to examine its measurement properties, components, and latent variable structure.

A group of 5 experts in Medical Education picked up 10 scales, related to the Affective Domain.

We decided to structure the response options (Outcome Space) in Likert scale, numbered from 1-7. While doing this, we seriously debated the inclusion or exclusion of a midpoint (number 4 bel). Ultimately, we decided to include the midpoint (option 4) into the options [9].

In order to select items of the scale, the expert team looked at the scales that measure some aspects of the affective domain. It was decided that the number of items that were found promising would be narrowed down to an acceptable number (Table 2).

Following 10 scales with 217 items were picked, including:

1. General components of the affective domain [10].
2. Groningen Reflection Ability Scale (GRAS) (containing 23 items) [11,12].
3. Jefferson scale of empathy (medical students’ version): (containing 20 items assessing empathy) [13].
4. Trait Emotional Intelligence Questionnaire (TEIQue) [14].
5. Modified professionalism mini evaluation exercise questionnaires (containing 21 items assessing Professionalism) [15].
6. Perceived choice and awareness of self-scale (assesses perceived choice and awareness of self. (The PCASS is a short, 10- item scale) [16].
7. Revised Asian Values Scale (AVS). (Examines the construct of Asian cultural values and its relationships to other psychological concepts. It has 25 items [17,18].
8. Observation method: The teacher observes students’ behavior and interactions during class/work to gauge their attitudes [19] (4 items).
9. Reflection activities: Students are asked to write their thoughts or feelings about the aspects of the affective domain or about an event in life (clinical or non-clinical) that is full of emotional involvement [20] (4 items).
10. Performance-based assessment: Students are asked to complete a task like taking a history or breaking bad news, and their performance is evaluated based on their attitude and effort [21] (30 items).

50 undergraduate students from Muhammad Institute of Physiotherapy & Rehabilitation Sciences (MIPRS), a constituent college of ISUM were selected through simple random sampling. Students were informed that this was not an assessment of their abilities. They were encouraged to assign a score to each question with utmost honesty and integrity, avoiding excessive contemplation.

First step was to find the reliability (Cronbach alpha) and validity (Kaiser-Meyer-Olkin-KMO Bartlett Test of Sphericity). We decided to include the items of scales which had sufficient reliability ((Cronbach alpha above 0.7) and validity (KMO above 0.6). The following were the results:

Based upon this criteria, Modified Professionalism and Revised Asian Values Scale (having Cronbach alpha of 0.690 and 0.549 respectively) were not considered further. Similarly, Jefferson scale of empathy and Teique-SF Emotional Intelligence were found to have KMO values less than 0.6, while Observation method- professional behavior evaluation’s matrix was not positive definite, suggesting that the factors used in the analysis had low factorability and hence items of these 3 scales were removed (Table 3).

Finally, among these 10 scales, scale 1, 2, 6, 9 and 10 were found to have sufficient reliability and validity. In other words, out of 217 items, 140 items were removed and 77 were considered for developing new scale. These 77 items were as follows.

1. I feel welcomed in the classroom
2. I listen to my classmates when they share something to me
3. I give my ideas and suggestions regarding on the classroom rules
4. I obey classroom rules and guidelines.
5. I feel that the classroom environment helps me develop my interest in the subjects
6. I am motivated to participate actively in the class
7. I arrange the books in their desired place after we use them
8. I prepare my materials in advance for our group activity
9. I display kindness and respect to my classmates and teachers
10. I serve my classmates and teachers by offering help and support when needed
11. I review how I'm used to thinking
12. I want to know the reason for what I'm doing
13. I understand the importance of knowing the rules and the guidelines
14. I want to know my own characteristics (attitude, performance, perspective and personality).
15. I am aware of the mentalities that influence my thinking
16. I am aware of the emotions that influence my behaviour
17. I can examine my behaviour (as a neutral person) remotely
18. I evaluate my own judgement about others
19. I can examine an experience from different perspectives
20. I am aware of the cultural factors that influence my thinking.
21. I am aware of the mental effects that possibly different information has on people’s (views).
22. I can sympathize with someone in a different situation.
23. I know my own limitations.
24. I do not prefer different ways of thinking (negative scoring required).
25. Sometimes others say that I am exaggerating myself (negative scoring required).
26. I can understand people from different cultures and religions.
27. I do not like to discuss my views (negative scoring required).
28. Sometimes I find it difficult to explain an ethical point of view (negative scoring required).
29. I am accountable for what I say.
30. I take responsibility for what I say.
31. I am ready to discuss my views and opinions.
32. I sometimes find it difficult to think of alternative solutions to a problem (negative scoring required).
33. I don’t welcome explaining my personal performance (negative scoring required).
34. A. I always feel like I choose the things I do. B. I sometimes feel that it’s not really me choosing the things I do
35. A. My emotions sometimes seem alien to me. B. My emotions always seem to belong to me
36. A. I choose to do what I have to do. B. I do what I have to, but I don’t feel like it is really my choice
37. A. I feel that I am rarely myself. B. I feel like I am always completely myself
38. A. I do what I do because it interests me. B. I do what I do because I have to
39. A. When I accomplish something, I often feel it wasn't really me who did it. B. When I accomplish something, I always feel it's me who did it
40. A. I am free to do whatever I decide to do. B. What I do is often not what I'd choose to do
41. A. My body sometimes feels like a stranger to me. B. My body always feels like me
42. A. I feel pretty free to do whatever I choose to. B. I often do things that I don't choose to do.
43. A. Sometimes I look into the mirror and see a stranger. B. When I look into the mirror, I see myself
44. Self-Awareness and Reflection
45. Empathy and Perspective-Taking
46. Emotional Expression and Communication
47. Attitude and Values
48. Greets the patient properly.
49. Introduces him/herself to the patient including his/her name and role
50. Confirm the patient's name and date of birth
51. Explain the reason for the consultation
52. Gain consent to continue with the consultation
53. Undertake consultation in a comfortable, quiet and private space (if possible).
54. Set up room appropriately (e.g., avoid physical barriers between him or herself and the patient).
55. Offer to have another person present (healthcare professional or family member) with the patient’s consent.
56. Explore the sequence of events leading up to the consultation (e.g., previous consultations and investigations).
57. Establish what the patient already knows or is expecting to be told.
58. Identify any specific patient concerns.
59. Check the patient wishes to proceed with the consultation and be given the information.
60. Use a warning shot prior to breaking the bad news.
61. Deliver the information in sizeable ‘chunks’ using simple and clear language to explain medical concepts.
62. Use silence and allow the patient to process what you have told them after each ‘chunk.
63. Respond to any questions appropriately, without providing false hope or inaccurate information.
64. Avoid using medical jargon or euphemisms.
65. Recognize and respond to the patient’s emotions with empathy (verbal and non-verbal).
66. Provide a clear plan for next steps (e.g., specialist referral, follow up appointment).
67. Summarize and check the patient’s understanding.
68. Clarify any misunderstandings (if required).
69. Offer assistance to tell others.
70. Signpost to sources of further information (e.g., specialist nurses, support groups) including written materials (if appropriate).
71. Asks if there is anything more that can be done.
72. Thanks, and says goodbye.
73. Active listening.
74. Empathy (verbal and non-verbal).
75. Establishing rapport.
76. Summarising.be
77. Signposting.

There were many repetitions in the items. Consequently, the team of five medical education experts reviewed each item, eliminating both verbal and literal redundancies, and rephrasing the items to ensure uniformity and clarity. Certain items were deemed irrelevant to the assessment of the affective domain and were subsequently excluded. 32 items were chosen and they were rewritten in simple, easy to understand form (Tables 4,5).

The expert committee did consider two important points at this stage. First about mitigating the confounding influence of a response pattern known as 'acquiescence response style, by turning half of the items phrased positively and scored directly (1 = very strongly disagree, 2 = less strongly disagree, 3 = mildly disagree, 4 = neither agree nor disagree, 5 = mildly agree, 6 = more strongly agree, and 7 = very strongly agree), While the other half phrased negatively, necessitating the researcher to reverse the scores assigned by the students as: 1 = very strongly agree, 2= less strongly agree, 3 = Mildly agree, 4 = Neither agree nor disagree, 5 = mildly disagree, 6 = more strongly disagree 7 = very strongly disagree). But this reverse is known to alter the way the responder answers the questions and hence the committee decided not to continue with developing the questionnaire in a 'acquiescence response style (Tables 6-10). Based upon the finding of the pilot study and recommendation of expert panel to simplify the items for easy understanding, a scale having 32 items was developed as follows.

1. I greet and introduce myself before starting any communication
2. I listen actively to others when they talk to me
3. I like to discuss my ideas and opinions, nor do I like to invite others’ views if they are different from mine.
4. I like to discuss my emotions, behaviours and judgements with others.
5. I understand and respect people from different cultures and religions.
6. I understand my own limitation
7. I feel enthusiasm for learning and improvement.
8. I consistently strive for excellence in learning new knowledge & skills.
9. I always strive to master and refresh skills.
10. I adjust my life according to the circumstances.
11. I review my thinking and actions, and admit and change where I find myself wrong.
12. I understand the importance of, and follow the procedures, protocols, rules and the guidelines.
13. I feel accountable for what I say or do.
14. I have interest in others.
15. I place the needs of the team and any member of the team above self-interest.
16. People consider me as a team leader and like to work under me.
17. I am motivated to participate actively in the class and in wards.
18. I display kindness and respect to others.
19. I like communicating with others to resolve problems.
20. I respect others right to self-determination and consent.
21. I respect others right to privacy and confidentiality.
22. I respond to any questions appropriately and positively, but without providing false hope or inaccurate information.
23. I serve others by offering help and support when needed.
24. I show verbal and non-verbal empathy with someone in a different situation.
25. People generally feel that I am trustworthy as an individual and professional.
26. I complete tasks and assignments on time.
27. I usually do not lose composure in difficult situations.
28. I complete and keep accurate documentation of patient care and learning activities.
29. I want to know the reason for what I'm doing.
30. I believe that understanding body language is as important as verbal communication.
31. I adjust my life according to the circumstances.
32. I adjust my views according to the circumstances.

After developing this new scale, a pilot study was conducted where same 50 students (who had answered the 217 items of 10 scales) answered these 32 questions. The results of this newly developed 32 items were entered into SPSS® version. It was decided that we will reduce the number of items by removing those will low reliability (Cronbach’s alpha), validity (KMO, Bartlett’s test and Significance), dimension reduction, communalities and Corrected Item-Total Correlation. We decided to use the Principal Component Analysis as the Extraction Method, Promax with Kaiser Normalization as the Rotation Method and the Pattern Mixture model in longitudinal data analysis. The results were as follows in 4 steps of gradual reduction of items:

STEP 1: 32 items reliability, validity and dimension reduction.

STEP 2: 23 items reliability, validity, dimension reduction and communalities.

STEP 3: 20 items reliability, validity, dimension reduction and communalities.

STEP 4: Final scale with 12 items. Its reliability, validity, dimension reduction and communalities.

A lack of trust in physicians lowers the quality of care, discourages the use of preventive services, and adversely affects patients’ adherence to clinical advice. High levels of distrust can even lead to violence and destruction of medical equipment and property unless the legal system provides easy remedies for perceived harms caused by healthcare providers [22]. The World Medical Association, in its 2020 assembly, included an agenda item addressing the “surge of violence against health personnel worldwide [23]. Another study found that moral integrity, a patient-centered approach, effective communication skills, and trust lead to better management and improved patient satisfaction [24]. In a study investigating patient trust in doctors, more than half of participants rated doctors’ communication behavior as fair rather than good (53.6% vs 45.6%). Those over 50 years old (OR 1.96; p=0.007, 95% CI: 1.198-3.226) and those who perceived doctors’ communication as good (OR 8.48; p=0.0001, 95% CI: 5.257-13.709) were significantly more likely to have full trust in their doctors (Tables 11-13). Another study stressed that the moral integrity and personal qualities of the doctor are crucial for gaining patient trust [25].

According to patients, trust is built largely on a doctor's interpersonal competence. Behaviors associated with trust include thoroughly evaluating problems, understanding a patient's individual experience, showing compassion and empathy, advocacy, reliability, dependability, clear and complete communication, continuity of care, building partnerships, giving adequate time during consultations, providing appropriate and effective treatment, and being honest and respectful [26-32].

Therefore, it is important to include teaching and assessment of the affective domain in the medical curriculum. For this, we have developed the 12-item ISUMSAD described above.

When choosing the number of response options, we debated whether to allow respondents to choose from six options or to include a midpoint as a seventh option. Including or excluding a midpoint has both benefits and drawbacks. A midpoint allows respondents to express neutral feelings, but it may also serve as a “dumping ground” for those who lack knowledge, motivation, or wish to be socially acceptable. However, excluding the midpoint may deprive respondents of the opportunity to select an option that genuinely reflects their views, forcing them to choose inaccurately [33]. This has convinced some researchers, such as Hujat, et al, [34] to include the midpoint. On this occasion, we decided to include the midpoint.

Thus, the expert committee decided to keep the midpoint, making it a 7-point questionnaire.

Although authors attempt to mitigate response bias by including negatively worded items in Likert scale, it is known to adversely affect reliability and validity. Hence, we decided not to include negatively worded items in our scale.

According to Cronbach [35], a reliability value greater than 0.6 is acceptable. Cronbach's alphas are claimed to mirror instructional grades, where A-0.9 or higher are considered excellent; B-0.8 to 0.9 are adequate; C-0.7 to 0.8 are marginal; D-0.6 to 0.07 are seriously suspect; F-less than 0.6 are totally unacceptable [36]. The higher the average correlation between items, the greater the internal consistency of a test. We saw the reliability increasing with Cronbach alpha moving from 0.720 to 0.858, 0.859 and finally to 0.920 for 32, 23, 20 and 12 items. Hence the internal consistency of 0.92 for 12 items ISUMSAD is excellent.

The most efficient method was to identify and remove items with low factor loadings (generally below 0.5) [37], as such items do not substantially contribute to the underlying factors and may adversely affect the KMO value. By discarding these items, we could improve overall inter-item correlations, potentially resulting in a higher KMO score37. We used Principal Component Analysis (PCA) for dimensionality reduction and data analysis. PCA focuses on finding principal components, which are orthogonal directions of maximum variance in the data. PCA reveals information about factor loadings or component loadings, which show how much each original variable contributes to the new principal components, analogous to factors in factor analysis [38]. PCA produced two distinct factors. Factor 1, consisting of 7 items has been named “Empathy-Communication’ and Factor 2, consisting of 5 items has been named “Skills-Respect”. Additionally, we have chosen to use the pattern matrix rather than the structure matrix, as the former demonstrates the distinct contribution of a variable to a factor and is simpler to interpret [37]. The structure matrix shows shared variance not accounted for by the pattern matrix and is more complicated to interpret [37]. The KMO test measures the sampling adequacy, while Bartlett's test checks for significant correlations between variables, indicating whether factor analysis is appropriate. A significant Bartlett's test (p < 0.05) and a KMO value above 0.6 (or 0.5, depending on the source) generally suggest that factor analysis is appropriate [39-42]. KMO value of 0.855 and Bartlett's test score with significance of 0.000 for the final 12 items reflect excellent validity.

While both inter-item correlation and Pearson’s correlation evaluate the relationships between variables, their uses are distinct. Inter-item correlation focuses on the connections between individual items within a single scale or test, and is a test of internal consistency. Inter-item correlation evaluates how closely the scores of one item of a scale is related to the scores of other items within that same scale [43]. This metric reflects the internal consistency of the scale, indicating how effectively the items collectively measure the same underlying concept. All our 12 items had inter-item correlation above 0.2 with each other, average being 0.492, indicating that items are related but not overly redundant. A Cronbach’s alpha of 9.2 and inter-item correlation of 0.492 suggest good internal consistency of ISUMSAF.

In contrast, Pearson’s correlation is a broader statistical tool that measures the linear association between any two continuous variables. The Pearson correlation (Tables 14,15) shows excellent linear relationships between different items and two factors of ISUMSAF.

Another interesting observation is that in our study, item means, Cronbach's alpha, KMO, Inter-Item Covariances and inter-item correlations keep increasing with reducing number of items (Table 16). Cronbach's alpha [44] & KMO are influenced by the number of items and the number of respondents. Reducing either can lead to lower values for both statistics, indicating potential issues with internal consistency and suitability for factor analysis. However, our values kept on going higher and higher with each reduction of the number of items, suggestion a great internal consistency and correlation between remaining items and little internal consistency and correlation with the items removed [45].

This pilot study has generated a 12 items ISUMSAD, which measures the affective domain with excellent reliability and validity. The correlation between items of the same factor, the associated factor and total scale score were found to be either excellent or moderate. This scale has all the qualities of being a good scale and may be used to assess the affective domain of students for various purposes. A larger follow up study is planned to further assess the scale.

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