Clinical Simulation in Nursing (2013) 9, e179-e180
www.elsevier.com/locate/ecsn
Making Sense of Methods and Measurement
Reliability: Measuring Internal
Consistency Using Cronbach’s a
Katie Anne Adamson, PhDa,*, Susan Prion, EdDb
a
University of Washington Tacoma, Tacoma, WA 98402-3100, USA
b
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 Cronbach’s alpha (a).
Cronbach’s a can range from 0.0 to 1.0, and it quantifies
the degree to which items on an instrument are correlated
with one another (Connelly, 2011). In order to discuss
Cronbach’s 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 nec-
essary 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 reflect
a composite clinical judgment score. If each of the items
on the LCJR measures the same construct (clinical judg-
ment), the ratings on each should be correlated with one an-
other. A perfect correlation would result in a ¼ 1.0 and the
absence of any correlation would result in a ¼ 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).
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2012.12.001
subscales on the LCJR include noticing, interpreting,
responding, and reflecting. Each of the 11 items on the
LCJR falls under one of these subscales. Recently, Mariani,
Cantrell, Meakim, Prieto, and Dreifuerst (in press) esti-
mated Cronbach’s a for the items on the LCJR at two dif-
ferent time points to be 0.927 and 0.942, respectively, and
the a for items under each of the various subscales to be be-
tween 0.800 and 0.909.
Cronbach’s a, like most statistical analyses, has several
weaknesses and special cases. First, a high correlation
among items reflects 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,
Cronbach’s a reflects 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 be-
tween items on the LCJR may mean that they all measure
highly related constructs, but not necessarily a single con-
struct: clinical judgment (Segars, 1997). Finally, Cron-
bach’s a is the appropriate choice for measuring internal
consistency in scales where items have more than two re-
sponse options. However, for scales with dichotomous
items, the Kuder-Richardson formula 20 (KR-20) is the ap-
propriate 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 ¼ 0.90, however, scales such as the LCJR used to com-
pare groups may be acceptable with an a as low as 0.70.
That said, the findings of Mariani et al. (in press) indicate
 Making Sense of Methods and Measurement
a high reliability of the LCJR. Each of these measures of
internal consistency is specific to the sample they used
and should be recalculated with additional samples for fu-
ture studies.
References
Bland, J. M., & Altman, D. G. (1997). Statistical notes: Cronbach’s alpha.
British Medical Journal, 314, 572.
Connelly, L. M. (2011). Research roundtable. Cronbach’s alpha. Medsurg
Nursing, 20, 1.
pp e179-e180  Clinical Simulation in Nursing  Volume 9  Issue 5
e180
Cronbach, L. J. (1951). Coefficient 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 debriefing and students’ clinical judgment abilities in
simulation. Clinical Simulation in Nursing.
Schmitt, N. (1996). Uses and abuses of coefficient 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.