Dimensionality and reliability of USM pre-clinical medical students' guidance and counselling needs questionnaire.

OBJECTIVE: There is no standard mechanism for empathy guidance and counselling for medical students. This study aimed to determine the dimensionality and reliability of a questionnaire developed for establishing guidance and counselling for pre-clinical medical students at Universiti Sains Malaysia (USM).
METHODS: A cross-sectional study was conducted among undergraduate medical students of the School of Medical Sciences of USM. The proposed USM Medical Students' Guidance and Counselling Needs (USM-MSGCN) questionnaire is a self-administered instrument that consists of 68 initial items developed from the recommendation of medical students, counsellors, and lecturers in the medical education department. To determine the dimensionality (construct validity) and reliability of the questionnaire, exploratory factor analysis and Cronbach's alpha internal consistency reliability analysis were conducted.
RESULTS: A total of 208 students participated in the study. Factor analysis revealed that the items were not unidimensional; four potential constructs could be extracted from the questionnaire, namely, self-leadership (7 items), communication (5 items), learning (5 items), and psychological coping skills (3 items), with factor loading ranges of 0.56-0.82, 0.56-0.88, 0.65-0.84, and 0.79-0.80, respectively. These domains had the following internal consistency reliability (Cronbach's alpha): 0.89, 0.90, 0.87, and 0.87, respectively; the overall alpha value was 0.93.
CONCLUSION: Four factors, with 20 items in the USM-MSGCN questionnaire had good validity and reliability values when administered among the pre-clinical medical students.

Introduction

Counselling, in its broadest sense, refers to a person helping another to clarify issues in his or her life and adopt further lines of action. Counselling service has become significant when people suffer from alarming levels of psychological problems, such as stress, depression, and anxiety.2, 3, 4, 5, 6, 7 Such psychological problems occur owing to the rapid development that impacts on the physical and mental well-being of people, including medical students. In the context of higher education, a counselling services centre offers consultation services to tackle not only students' psychological well-being but also their educational, career, and social development issues.10, 11 The United Nations Educational, Scientific and Cultural Organization (UNESC0) has specified three main roles of the student's affair section in higher education institutions: promoting personal, career, and education development.10, 11, 12 To promote these roles, counselling centre services are provided by professional counsellors who are responsible for developing a comprehensive counselling blueprint.8, 13 The positive impacts of counselling service have been recognised by students14, 15, 16 because they are consistent with their needs both nationally and internationally.18, 19, 20

The high rates of stress, depression, and anxiety among medical students21, 22, 23, 24, 25 confirm the importance of counselling services26, 27 for them to succeed in medical training. Therefore, it is important that clients are provided with counselling care of good quality. To design counselling care intervention strategies tailored to clients' need, it is crucial to identify clients using an accurate and validated assessment instrument. Despite the importance of counselling service, the credibility of its few assessment tools are not well studied. Therefore, the present study aimed to assess the dimensionality of the developed tool, the USM Pre-Clinical Medical Students' Guidance and Counselling Needs questionnaire (USM-MSGCN), and then report on its validation. Consistent with the study aim, a null hypothesis was developed. The suggested items of the USM-MSGCN were unidimensional; the research hypothesis was that these items would be multi-dimensional.

Studies on counselling needs beliefs in the context of education research have explored counselling needs through implementing the Mooney checklist29, 30, 31 and Depression, Anxiety and Stress Scales (DASS-21) instrument.31, 32 The Mooney checklist was developed by Gordon and Mooney (1950), whereas DASS-21 was developed by researchers at the University of New South Wales, Australia (1995). These instruments remain the most popular and widely used in counselling service. Despite their popularity, these instruments have limitations: they only focus on psychological components and exclude academic domains. Moreover, the targeted user is generalised; there is no instrument that gives specific focus on medical students.

In the context of medical training, the scope of counselling and guidance needs is broad, including (i) mental health assessment,19, 24, 34, 35, 36 (ii) career development,37, 38 and (iii) personal and professional development.9, 20, 39, 40, 41, 42, 43 Evidence from literature review confirms that these domains represent the prominent problems of medical students.3, 4, 5, 7, 35, 44 Furthermore, studies have shown that these problems can be reduced through appropriate counselling intervention. For instance, studies on the effect of counselling intervention for physicians have showed that appropriate interventions can reduce job stress and burnout.35, 45

In other studies, career counselling and advising services are reported as important to medical students, including providing information on career options, elective guidance, residency applications, and social accountability.46, 47 For example, Canadian Medical school has enforced four areas covered by counselling: (i) career planning in medicine, (ii) providing a support system to enhance access to career information, (iii) collaborating with third parties to support medical students in career decision making, and (v) integrating career development theory and experiential learning practices in career consultation.37, 47, 48, 49 Meanwhile, medical students also need to be nurtured with respect to their ethical responsibility to self and others, reliability and dependability, service orientation, social skills, capacity for improvement, resilience and adaptability, cultural competence, oral communication, and teamwork.9, 50, 51, 52

Indeed, medical training has many issues that need urgent attention by the relevant parties. Despite the importance of counselling service to medical training, there is no specific instrument that assesses the counselling and guidance needs of those undertaking training. This situation has led to poor services in provided counselling. A credible instrument of the counselling and guidance needed for the targeted group, namely, medical students, is important. Thus, the present study aimed to assess the dimensionality of a developed relevant questionnaire and then validate the same.

Materials and Methods

Development of USM-MSGCN questionnaire

Development of the USM-MSGCN questionnaire began by collecting relevant information about counselling and guidance services offered to medical students in higher institution through literature reviews and focus group discussions with pre-clinical medical students and students' counsellors in the student affair department. Next, we categorised the data gathered based on similarities and differences to come up with a profile of counselling and guidance services. The last stage was to promote items related to the counselling and guidance issues.

In seeking the content and face validity of the USM-MSGCN questionnaire, five medical instructors and 20 medical students were recruited. Subsequently, necessary adjustments were made based on the comments given.

The questionnaire used a five-point rating scale to measure students' responses on counselling and guidance service needs: 1 = extremely not needed, 2 = not needed, 3 = less needed, 4 = needed, and 5 = extremely needed.

Assessment of dimensionality and reliability

A cross-sectional study was conducted in June 2017 among undergraduate students of the School of Medical Sciences, Universiti Sains Malaysia, to assess the dimensionality and reliability of the USM-MSGCN questionnaire. The inclusion criterion was enrolment as a medical undergraduate student in the pre-clinical year.

The sample size estimation was based on the sample-to-variable (N:p) ratio of 3:1. As there were 68 items in the initial questionnaire, the sample size required was 204. After accounting for 10% non-response rate, the required sample size was 227. Years one and two students were recruited as respondents via convenient sampling method. Prior to answering the questionnaire, the respondents were briefed on the background of the study and time given. Informed consent was requested from the potential respondents. Data were gathered by the guided self-administered questionnaire. Ethical approval for this study was obtained from the School of Medical Sciences and Human Ethical Committee of USM.

Statistical analysis

The item-level characteristics of each item were assessed by descriptive statistics to examine floor and ceiling effects. To determine the dimensionality of all items, exploratory factor analysis (EFA) was conducted. Keiser-Meyer-Olkin (KMO) and Bartlett's Test of Sphericity were calculated to test the partial correlation among items as suggestive of sample adequacy. The dimensionality of the USM-MSGCN questionnaire was evaluated by assessing the number of domains by Eigenvalues and scree plot. Based on the number of domains, item selection for each domain was made based on communalities, correlation, and factor loading values. Items with factor loading of <0.5 and communalities of <0.3 were removed. Cronbach's alpha internal consistency reliability analysis was used to determine the reliability of each domain of the USM-MSGCN questionnaire. Items within each domain were inspected; redundant items were removed made based on discussion among experts. All data entry and statistical analysis were conducted using IBM SPSS version 24.0.

Results

A total of 208 undergraduate medical students participated in the study (Table 1). Majority of the respondents were female (69.7%), Malays (72.1%), in year one (59.1%), and from the matriculation stream (47.1%). Moreover, 76% came from urban areas. Almost all (99%) stayed at the university hostel, and about half (56.7%) did not hold any scholarship.

Table 1

Profile of study participants (n = 208).

Variables	Frequency (%)
Sex (n = 208)
Male	63 (30.3)
Female	145 (69.7)
Ethnicity (n = 204)
Malay	150 (2.1)
Chinese	24 (2.5)
Indian	26 (1.5)
Others	4 (.9)
Year of study (n = 208)
Year 1	123 (9.1)
Year 2	85 (0.9)
Qualification (n = 206)
High School Certificate	5 (.4)
Matriculation	98 (7.1)
Science Foundation Programme	68 (2.7)
Other	35 (6.8)
Origin (n = 208)
Urban	158 (6.0)
Rural	20 (4.0)
Status of accommodation (n = 208)
Hostel	206 (9.0)
Non-hostel	2 (.0)
Scholarship (n = 208)
Yes	90 (3.3)
No	118 (6.7)

Item level descriptive statistics (Table 2) showed that the mean score for all 68 items ranged from 2.60 to 4.60. Based on the EFA, the initial solution showed a KMO value of 0.926 and Bartlett's Test of Sphericity was significant [χ2 (2278) = 12188, P < 0.001]. Eigenvalues and scree plot showed that the initial 68 items consisted of more than one factor. Thus, the null hypothesis was rejected, and we concluded that the items were not unidimensional. Varimax schedule rotated component matrix showed that the items formed four dimensions, which predicted 62.5% of the variants of dependent variables (44.3%, 7.1%, 7.0%, and 4.1% for factors 1, 2, 3, and 4, respectively). Sixteen items were removed sequentially for having a factor loading of <0.5; thus, 52 items remained, with factor loading ranges from 0.52 to 0.84.

Table 2

Item-level descriptive analysis for the USM Pre-Clinical Medical Students' Guidance and Counselling Needs questionnaire (n = 208).

Items	n (%)					Mean	SD
	Extremely not needed	Not needed	Less needed	Needed	Extremely needed
A1	5 (.4)	20 (.6)	35 (6.8)	71 (4.1)	77 (7)	3.94	1.07
A2	21 (0.1)	52 (5)	69 (3.2)	44 (1.2)	22 (0.6)	2.97	1.14
A3	29 (3.9)	38 (8.3)	57 (7.4)	52 (5)	32 (5.4)	3.10	1.27
A4	31 (4.9)	49 (3.6)	51 (4.5)	40 (9.2)	37 (7.8)	3.01	1.32
A5	27 (3)	47 (2.6)	54 (6)	54 (6)	26 (2.5)	3.02	1.23
B6	14 (.7)	23 (1.1)	52 (5)	71 (4.1)	48 (3.1)	3.56	1.16
B7	14 (.7)	29 (3.9)	41 (9.7)	75 (6.1)	49 (3.6)	3.56	1.19
B8	11 (.3)	17 (.2)	49 (3.6)	66 (1.7)	65 (1.3)	3.75	1.14
B9	19 (.1)	38 (8.3)	58 (7.9)	56 (6.9)	37 (7.8)	3.26	1.21
B10	32 (5.4)	46 (2.1)	56 (6.9)	36 (7.3)	38 (8.3)	3.01	1.32
B11	19 (.1)	36 (7.3)	59 (8.4)	54 (6)	40 (9.2)	3.29	1.22
B12	26 (2.5)	37 (7.8)	54 (6)	55 (6.4)	36 (7.3)	3.18	1.27
C13	12 (.8)	18 (.7)	49 (3.6)	64 (0.8)	65 (1.3)	3.73	1.16
C14	12 (.8)	15 (.2)	57 (7.4)	72 (4.6)	52 (5)	3.66	1.11
C15	11 (.3)	17 (.2)	62 (9.8)	67 (2.2)	51 (4.5)	3.63	1.10
D16	35 (6.8)	45 (1.6)	69 (3.2)	37 (7.8)	22 (0.6)	2.84	1.21
D17	45 (1.6)	56 (6.9)	63 (0.3)	26 (2.5)	18 (.7)	2.60	1.20
D18	37 (7.8)	40 (9.2)	66 (1.7)	41 (9.7)	24 (1.5)	2.88	1.25
D19	18 (.7)	25 (2)	44 (1.2)	52 (5)	69 (3.2)	3.62	1.29
D20	28 (3.5)	44 (1.2)	65 (1.3)	49 (3.6)	22 (0.6)	2.97	1.19
D21	35 (6.8)	50 (4)	64 (0.8)	42 (0.2)	17 (.2)	2.79	1.19
D22	32 (5.4)	41 (9.7)	63 (0.3)	50 (4)	22 (0.6)	2.95	1.22
D23	20 (.6)	25 (2)	51 (4.5)	53 (5.5)	59 (8.4)	3.51	1.28
E24	16 (.7)	22 (0.6)	61 (9.3)	76 (6.5)	33 (5.9)	3.42	1.11
E25	14 (.7)	24 (1.5)	53 (5.5)	86 (1.3)	31 (4.9)	3.46	1.09
E26	19 (.1)	32 (5.4)	55 (6.4)	66 (1.7)	36 (7.3)	3.33	1.20
E27	25 (2)	39 (8.8)	62 (9.8)	50 (4)	32 (5.4)	3.12	1.23
E28	19 (.1)	30 (4.4)	54 (6)	73 (5.1)	32 (5.4)	3.33	1.17
E29	19 (.1)	24 (1.5)	49 (3.6)	61 (9.3)	55 (6.4)	3.52	1.25
E30	19 (.1)	31 (4.9)	57 (7.4)	65 (1.3)	36 (7.3)	3.33	1.19
E31	25 (2)	30 (4.4)	74 (5.6)	56 (6.9)	23 (1.1)	3.11	1.15
E32	23 (1.1)	29 (3.9)	56 (6.9)	65 (1.3)	35 (6.8)	3.29	1.22
E33	15 (.2)	30 (4.4)	49 (3.6)	58 (7.9)	56 (6.9)	3.53	1.23
E34	16 (.7)	31 (4.9)	47 (2.6)	56 (6.9)	58 (7.9)	3.52	1.25
E35	13 (.3)	29 (3.9)	29 (3.9)	60 (8.8)	77 (7)	3.76	1.26
E36	9 (.3)	16 (.7)	31 (4.9)	46 (2.1)	106 (1)	4.08	1.16
E37	4 (.9)	19 (.1)	32 (5.4)	48 (3.1)	105 (0.5)	4.11	1.09
E38	8 (.8)	12 (.8)	36 (7.3)	57 (7.4)	95 (5.7)	4.05	1.10
E39	2 ()	5 (.4)	25 (2)	44 (1.2)	132 (3.5)	4.44	0.87
E40	6 (.9)	9 (.3)	20 (.6)	61 (9.3)	111 (3.4)	4.27	1.00
E41	6 (.9)	7 (.4)	20 (.6)	48 (3.1)	127 (1.1)	4.36	0.99
E42	3 (.4)	4 (.9)	11 (.3)	56 (6.9)	134 (4.4)	4.51	0.80
E43	0 (.0)	5 (.4)	12 (.8)	49 (3.6)	142 (8.3)	4.58	0.71
E44	0 (.0)	4 (.9)	10 (.8)	51 (4.5)	143 (8.8)	4.60	0.67
E45	14 (.7)	16 (.7)	63 (0.3)	74 (5.6)	41 (9.7)	3.54	1.10
E46	15 (.2)	22 (0.6)	64 (0.8)	73 (5.1)	34 (6.3)	3.43	1.11
E47	22 (0.6)	30 (4.4)	58 (7.9)	62 (9.8)	36 (7.3)	3.29	1.22
E48	20 (.6)	24 (1.5)	61 (9.3)	54 (6)	49 (3.6)	3.42	1.24
E49	17 (.2)	21 (0.1)	53 (5.5)	67 (2.2)	50 (4)	3.54	1.20
F50	13 (.3)	21 (0.1)	56 (6.9)	62 (9.8)	56 (6.9)	3.61	1.17
F51	21 (0.1)	32 (5.4)	58 (7.9)	55 (6.4)	42 (0.2)	3.31	1.24
F52	14 (.7)	30 (4.4)	48 (3.1)	62 (9.8)	54 (6)	3.54	1.21
F53	14 (.7)	29 (3.9)	51 (4.5)	64 (0.8)	50 (4)	3.51	1.19
F54	15 (.2)	28 (3.5)	53 (5.5)	53 (5.5)	59 (8.4)	3.54	1.23
F55	15 (.2)	31 (4.9)	57 (7.4)	56 (6.9)	49 (3.6)	3.45	1.21
G56	15 (.2)	26 (2.5)	63 (0.3)	60 (8.8)	44 (1.2)	3.44	1.17
G57	14 (.7)	25 (2)	68 (2.7)	52 (5)	49 (3.6)	3.47	1.17
G58	13 (.3)	30 (4.4)	63 (0.3)	53 (5.5)	49 (3.6)	3.46	1.18
G59	15 (.2)	28 (3.5)	62 (9.8)	59 (8.4)	44 (1.2)	3.43	1.17
G60	15 (.2)	26 (2.5)	57 (7.4)	63 (0.3)	47 (2.6)	3.49	1.18
G61	15 (.2)	26 (2.5)	59 (8.4)	61 (9.3)	47 (2.6)	3.48	1.18
H62	15 (.2)	29 (3.9)	54 (6)	62 (9.8)	48 (3.1)	3.48	1.20
H63	17 (.2)	34 (6.3)	60 (8.8)	49 (3.6)	47 (2.6)	3.36	1.23
H64	18 (.7)	37 (7.8)	52 (5)	51 (4.5)	50 (4)	3.38	1.26
H65	17 (.2)	36 (7.3)	56 (6.9)	58 (7.9)	41 (9.7)	3.34	1.21
H66	15 (.2)	39 (8.8)	54 (6)	50 (4)	50 (4)	3.39	1.24
H67	20 (.6)	22 (0.6)	44 (1.2)	46 (2.1)	76 (6.5)	3.65	1.32
H68	22 (0.6)	23 (1.1)	42 (0.2)	50 (4)	71 (4.1)	3.60	1.34

Considering the literature review and previous study of the topic, 17 items were grouped under the construct of Self-leadership Skills, seven items for Communication Skills, 12 items for Learning Skills, and 16 items for Psychological Coping Skills. The factor loading for each domain ranged from 0.52 to 0.82 for Self-leadership Skills, 0.53 to 0.8 for Communication Skills, 0.55 to 0.84 for Learning Skills, and 0.72 to 0.83 for Psychological Coping Skills.

The Cronbach's alpha internal consistency reliability of the questionnaire after the initial removal of items based on factor loading and communalities was 0.95 for Self-leadership Skills, 0.93 for both Communication and Learning Skills, and 0.98 for Psychological Coping Skills. As the Cronbach's alpha value for all domains exceeded 0.90, the items in each domain were inspected for redundancy.

In the Self-leadership Skills domain, five items addressed the issue of time management (A1–A5), eight items addressed group leadership skills (B6–B8, C13–C15, E30, and E32), and four items addressed skills of being a group member (B9–B12). All items pertaining to skills for time management were retained as each item tested different questions (A1, time for academic matters; A2, time for co-curriculum; A3, time for self-care; A4, time for family; and A5, time for social life). Regarding the eight items on group/organisation leadership skills, only item B7 (‘I need the skills for being a group leader’) was retained as this item alone could sufficiently reflect the need for skills in group/organisation management. Items B9–B12 addressed the issue of skills for being a group member. Of these four items, item B9 (‘I need the skills for being a group follower’) was retained as it echoed the other three items (B10, skills for respecting other group members; B11, skills for accepting other group members; and B12, skills for cooperating with group members). The final version of the Self-leadership Skills domain consisted of seven items with factor loading ranges from 0.56 to 0.82 and Cronbach's alpha internal consistency reliability of 0.89.

In the Communication Skills domain, three items were related to verbal communication skills (D16–D18) and four items to non-verbal communication skills (D20–D23). Items assessing skills related to top management language were removed (item D18, verbal communication skills; D22, non-verbal communication skills), as these items tested the same question as item D16 (verbal communication skills) and D20 (non-verbal communication skills) in a different guise. The final version of the Communication Skills domain consisted of five items with factor loading ranges from 0.56 to 0.88 and Cronbach's alpha internal consistency reliability of 0.90.

In the Learning Skills domain, one item assessed time management skills for examinations (E37), one item assessed the need for guidance for being in an academic peer support group (E44), five items assessed skills related to lectures (E33–E36 and E38), and five items assessed skills for answering examination questions (E39–E43). Item E44 (‘I need a guide for being in an academic peer support group’) was removed as the content did not fit the domain of learning skills. From the five items assessing skills related to lectures, items E36 (‘I need guidance for understanding and remembering lecture notes’) and E38 (‘I need skills to understand the topic's learning outcome’) were retained, as these two items were able to represent the other three items concerning lectures (E33, guide for taking lecture notes; E34, guide for drawing mind maps; and E35, guide for summarising lecture notes). Two out of the five items related to skills for answering examinations were retained (E39, skills for tackling examination questions; and E40, skills for scoring good marks). The other three items were removed (E41, skills to answer scenario-based questions; E42, skills to answer multiple true–false/single best answer questions; and E43, skills to answer short essay questions), as these were closely related to item E39. The final version of the Learning Skills domain consisted of five items with factor loading ranges from 0.65 to 0.84 and Cronbach's alpha internal consistency reliability of 0.87.

In the Psychological Coping Skills domain, five items assessed psychological skills to cope with stress (F51–F55), six items assessed skills to cope with anxiety (G56–G61), and five items assessed skills to cope with depression (H62–H66). We retained one item each that best represented psychological coping skills for stress, anxiety, and depression (F52, skills for coping with stress; G59, skills for coping with anxiety; and H65, skills for coping with depression). The final version of the Psychological Coping Skills domain consisted of three items with factor loading ranges from 0.79 to 0.80 and Cronbach's alpha internal consistency reliability of 0.87.

The overall Cronbach's alpha for the final version of the 20-item USM-MSGCN questionnaire was 0.93. Table 3 shows the construct validity and reliability of the final questionnaire version.

Table 3

Construct validity and internal consistency reliability for the final version of the USM Pre-Clinical Medical Students' Guidance and Counselling Needs questionnaire (n = 208).

Dimension	Item	Question	Factor Loading	Cronbach's Alpha	Overall Cronbach's alpha
1: Self-leadership Skills	A1	I need skills in managing my time for academic matters.	0.61	0.89	0.93
	A2	I need skills in managing my time for co–curricular activities.	0.71
	A3	I need skills in managing my time for self-care.	0.82
	A4	I need skills in managing my time for family.	0.81
	A5	I need skills in managing my time for social life.	0.79
	B7	I need skills in leading group work.	0.57
	B9	I need skills in being a good group follower.	0.56
2: Communication Skills	D16	Verbal: I need guidance in understanding my lecturers' language.	0.83	0.90
	D17	Verbal: I need guidance in understanding my colleagues' language.	0.83
	D20	Non-verbal: I need guidance in understanding my lecturers' language.	0.88
	D21	Non-verbal: I need guidance in understanding my colleagues' language.	0.85
	D23	Non-verbal: I need guidance in understanding my patients' language.	0.56
3: Learning Skills	E36	I need guidance in understanding and remembering lecture notes.	0.65	0.87
	E37	I need the following skill: Time management in examinations.	0.79
	E38	I need the following skill: Understanding the topic's learning outcomes.	0.84
	E39	I need the following skill: Tackling questions.	0.84
	E40	I need the following skill: Technique for scoring good marks.	0.72
4: Psychological Coping Skills	F52	I need the following skill: Coping mechanism for stress.	0.79	0.87
	G59	I need the following skill: Coping mechanism for anxiety.	0.80
	H65	I need the following skill: Coping mechanism for depression.	0.79

Discussion

This study explored the dimensionality and reliability of the developed USM-MSGCN questionnaire. The background of the study respondents was aligned with the reality of the population of medical students in Malaysia, comprised of individuals of varied ethnicities, residential origin, entry qualifications, and sex. Thus, these features were considered as representative of Malaysian medical students' characteristics.

Dimensionality relates to the homogeneity of items. It can be defined as the number of common factors needed to account for the correlation among items. The dimensionality of a measure can be assessed with exploratory or confirmatory factor analysis, or both. During the initial stage of scale development, EFA is commonly conducted, as the idea regarding a new measure's dimensionality tends to be limited. In the present study, EFA was used to determine the questionnaire's dimensionality. EFA was used instead of principal component analysis (PCA) because 1) PCA is often used for scale reduction instead of factor exploration, and 2) PCA has been shown to overestimate factor loading and possibly result in negatively biased component correlations.

EFA revealed that after the elimination of items based on factor loading and communalities, the preliminary final version of the questionnaire, which consisted of 52 items, had high coefficient alpha values for all the domains (ranges from 0.93 to 0.98). One of the possible reasons for this outcome is that the alpha was affected by the length of the test. Although coefficient alpha values from 0.70 to 0.95 are reported to be acceptable, a maximum value for coefficient alpha of 0.90 is recommended. An alpha that is too high may also suggest that some items within the domains are redundant and that further evaluations are required.56, 58 Thus, we removed the possible redundant items, and the total number of items was substantially reduced from 52 to 20.

The resulting 20-item questionnaire showed a good fit and relevance to medical students' needs for counselling and guidance service in the Malaysian context. The items were well loaded on four domains, namely, Communication, Self-leadership, Psychological, and Learning Skills, with all items having a factor loading exceeding 0.5. As such, all the constructs developed were independent of one another and aligned with the conceptualised students' issues in higher education. The results also revealed that these items could measure what should be measured; in this context, the pre-medical students' need for guidance and counselling needs. The domains created are aligned with those in previous studies on the areas of counselling service for medical students. Therefore, the developed questionnaire is a valid tool that can be applied to assess the counselling and guidance services needs among Malaysian medical students specifically.

The results of the reliability analyses showed that the model items of the USM-MSGCN questionnaire had high internal consistency, with an overall Cronbach's alpha of 0.93, which is considered as a good reliability value. Indeed, the developed USM-MSGCN questionnaire promises to be a reliable instrument in surveying medical students' needs for counselling and guidance service. The four validated dimensions in the USM-MSGCN questionnaire are extra domains for the Mooney checklist and DASS instruments. The inclusion of communication, self-leadership, and learning skills domains is important to tackle the issues faced by pre-medical students, helping them progress in their study smoothly. The results of the present study are consistent with evidence from previous studies on the importance of counselling and guidance service and better instruments to measure counselling and guidance needs.14, 15, 16

Although the factor and reliability analyses provided strong evidence of the validity and reliability of the USM-MSGCN questionnaire in assessing counselling and guidance service needs of pre-clinical medical students, a limitation of the present study is that it only involved one medical school in Malaysia. Moreover, the USM-MSGCN questionnaire is limited to undergraduate medical students. Similar studies applicable to other undergraduate medical students are needed so that the result can be compared, particularly the similarities and differences. The invitation of medical students as study population is also recommended to highlight their counselling and guidance needs. Through these efforts, the survey on the counselling and guidance service needs of medical students will be more comprehensive, valid, and credible.

Conclusion

We found that the developed USM-MSGCN questionnaire is a multidimensional instrument that consists of four related domains (self-leadership, communication, learning, and psychological coping skills). In addition, the instrument promised a good index of validation. Thus, it is a valid and reliable instrument for assessing the needs for counselling service among pre-clinical medical students. We expect that this instrument will benefit not only the students but also counsellors and students affair officials.

Source of funding

The authors received no specific funding or any kind of financial support for this work.

Conflict of interest

The authors have no conflict of interest to declare.

Ethical approval

The present study was conducted after approval by the USM ethics committee.

Authors' contributions

ZMMN significantly contributed to the research design, data collection, statistical analysis, interpretation of results, and manuscript writing. NMY significantly contributed to the research design, statistical analysis, interpretation of results, and manuscript writing. JAMM significantly contributed to the research design, data collection, interpretation, and manuscript writing. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.