Adaptation and Psychometric Properties of an Instrument to Assess Self-Efficacy in Client-Centeredness (SECCQ)

ABSTRACT This article assesses the reliability and validity of the Self-Efficacy in Client-Centredness questionnaire (SECCQ). SECCQ assesses social worker students’ subjective belief in their ability to provide client-centered care in their daily interaction with children or families. Self-efficacy is defined as an individual’s judgments concerning their capability to perform certain skills necessary to attain a desired outcome of behavior. Client-centeredness, on the other hand, relates to how social workers treat clients, not only from a clinical perspective, but also from an emotional, mental, and social perspective. Overall findings demonstrate that this questionnaire has satisfying psychometric properties and high reliability. Hence, the SECCQ may be a valuable tool for raising students’ awareness of their self-efficacy and the evaluation of student learning outcomes.

included in social work human behavior and practice courses, as one of many theoretical frameworks for social work practice and thought, his basic assumptions and guidelines for practitioners continue to permeate social work practice and education. The strength perspective and empowerment have been major themes in the recent social work literature, which also contain clear elements of the clientcentered approach. Particularly relevant is Rogers's emphasis on the client as an active participant who respects the client's subjective experiences, not presenting oneself as the expert (Green, 2017).
There is a need to develop good tools in Norwegian to measure the students' abilities to practice a client-centered approach and achieve learning outcomes, such as personal changes and self-efficacy. These would be used both to give students more orientation and feedback regarding this important teaching goal and a formative assessment for developing evidence-based education methods that positively stimulate the student's self-efficacy. Perceived self-efficacy forms the basis of any decision to act. It refers to a person's ability to implement situation-specific behaviors to attain established goals, expectations, or designated types of outcomes (Hoffman, 2013). There are multiple ways to define and measure learning outcomes within an educational context, and the most common one focuses on the student's behavioral performance. Our interest in self-efficacy relates to student learning outcomes, and by attending various lessons and different exercises, the main goal is to strengthen the student's self-efficacy in line with their progression within the study program, thereby facilitating good professional practice (Artino, 2012). Bandura (1977) defined self-efficacy as the conviction that one can successfully execute a behavior to produce a specified outcome. Perceived self-efficacy is concerned with a person's belief in their capability to exercise control over their own functioning and events that affect their life (Bandura, 1986). Self-efficacy is one of the central variables that distinguishes one individual from another. People can be characterized primarily based on their belief in the ability to control their own lives, because those beliefs powerfully determine the effort they make to adapt to their surroundings. Selfefficacy theory predicts that the more an individual feels capable of predicting and controlling threatening events, the less vulnerable they will be to anxiety or stress disorders in response to traumatic experiences (Fleming et al., 2003). It influences all forms of a person's motivation, cognition, emotions and actions. It operates mainly through the cognitive and affective channels and plays a crucial role in shaping our perception of life experiences as the belief in personal efficacy affects life choices, level of motivation, quality of functioning, resilience to adversity, and vulnerability to stress and depression (Bandura, 1986). People's belief in their efficacy is developed by four main sources of influence. These include our social skills, cognitive skills, observational learning, and social background. This self-system is the backbone of our personality, and self-efficacy is one its essential components (Bandura, 1977;Fleming et al., 2003). It has been found that increasing a person's perceived self-efficacy will optimize their developmental potential (Hoffman, 2013). Self-efficacy is a central construct of social cognitive theory (Bandura, 1977(Bandura, , 1986, formerly known as social learning theory. It states that behavior results from an individual's belief that the action will lead to a desired outcome. People who are confident in their abilities are thereby more likely to attempt difficult tasks, exert greater effort to master such tasks, and persist in their attempts despite difficulties (Williams & Bond, 2002). There is no guarantee that higher levels of self-efficacy will improve client outcomes. There is, however, reason to believe that a high level of self-efficacy within a social worker may improve client outcomes due to the social worker's confidence in their abilities, which is likely to influence their professional performance. Olesen and Jørgensen (2018) suggested the possibility of adapting the Self-Efficacy in Patient Centeredness Questionnaire (SEPCQ) developed by Zachariae et al. (2015) to be used as an instrument within social work. 1 SEPCQ is presented as a valid and practical questionnaire to assess competencies in patient-centeredness by focusing on student self-efficacy. Although this questionnaire is directed toward healthcare situations, focusing on physicians and medical students, we found most of the items within the questionnaire were also relevant to other professions, such as social work. The 1 Permission to use the SEPCQ was given by Dr. Martin Olesen (Aarhus University Collage). questionnaire provides several statements describing different aspects of how physicians and medical students can relate to and communicate with patients, with underlying teams focusing on the student's self-efficacy within the following skills: (a) exploring the patient perspective, (b) sharing information and power, and (c) dealing with communicative challenges (Zachariae et al., 2015). However, to be an instrument for social work students, it is necessary to adjust and adapt the questionnaire so that it assesses competencies in client-centeredness.

Aim
The aim of this study is to adapt the SEPCQ into the Self-Efficacy in Client-Centeredness Questionnaire (SECCQ) questionnaire by changing its target audience from medical to social science and evaluating its psychometric properties, providing preliminary evidence for its reliability and validity as a tool to measure perceived self-efficacy among social work students in client-centered communication.

Participants
A total of 156 out of approximately 200 second semester undergraduate students were present at four lectures in January and February 2019 where the SECCQ was distributed. The participants in the study were students from four different social science bachelor programs in Norway: social work, child welfare, work and welfare studies, and social education. Questionnaires that were less than 50% completed (n=10) were excluded from the statistical analysis (Meadows, 2012;Ware, 1995). A total of 146 completed questionnaires were returned. As the participants (n=146) constitute more than five times the size of the questionnaire (Q=27, ≥135), the sample size is in line with recommendations for validating an instrument derived from Willett (1998).

Measures
SECCQ is a Norwegian instrument developed to measure client-centered communication practice within social work. As in Zachariae et al.'s (2015) work with the SEPCQ, SECCQ uses a 5-point Likert scale with "1" (to a very low degree) and "5" (to a very high degree) as endpoints, and higher scores indicating higher level of self-efficacy. The general instruction from SEPCQ (Zachariae et al., 2015) was adapted, emphasizing that the questions cover neither actual behavior nor the desirability of the behavior. The questionnaire is developed as an instrument to measure how confident social worker students are in their ability to relate and communicate with the client. The students are asked how confident they are in their ability to make the client experience the particular behavior implicitly, as a necessary element of professional practice.

Procedure and data collection
SEPCQ contains 27 items with three underlying self-efficacy factors: (a) exploring a patients' perspective, (b) sharing information and power, and (c) dealing with communicative challenges (Zachariae et al., 2015). The adaption of the SEPCQ instrument to fit students from various studies within social work was conducted in six steps.

First step: Selection of existing items
The first step of the adaption was to identify and translate items in SEPCQ that are equally relevant for patient and client-centeredness communication. Items 9, 13, and 27 were identified and adapted from SEPCQ by translating the items from Danish to Norwegian. To achieve equality in the meaning of the content from the two versions, the chosen items were translated according to the "Guidelines of the Process of Cross-Cultural Adaption of Self-Reports" (Guillemin et al., 1993). Initially, a back translation was also conducted, where the difference between translated versions was evaluated and satisfactory compliance with the original scale achieved through the consensus of the translators. Three researchers from within the field evaluated the completed Norwegian item version cultural appropriateness. When deciding on the final items, the content of the original questionnaire was weighted more heavily than the direct meaning of the translated words, as recommended by Polit and Beck (2020).

Second step: Modification of existing items
The second step of the adaption concerned the modification of items. Of the 27 original SEPCQ items, 13 were modified to better suit the social work context by altering the formulations. For example, items 1, 4,5,8,10,11,14,15,16,17,20,22, and 23 were adapted by replacing "patient" with "client." The chosen items were then translated from Danish to Norwegian according to the "Guidelines of the Process of Cross-Cultural Adaption of Self-Reports" (Guillemin et al., 1993), as described under the first step.

Third step: Construction of social work-specific items
Eleven items needed a more comprehensive content change, as the original items focused on healthcare-specific skills or themes that are not used within social work. Eleven new items were therefore developed to cover the social work-specific aspects of client-centered communication. To achieve equality of meaning between the content of the two versions, a linguistic analysis was used to determine new formulations adapted to social work. The new items included one item on "exploring the client perspective" (item 24), eight items on "sharing information and power" (items 2, 6, 7, 12, 18, 21, 25, and 26), and two items on "dealing with communicative challenges" (items 3 and 19). For example, "Accept when there is no longer curative treatment for the patient" was changed to "Accept when there is no intervention that will change the client's situation."

Fourth step: Adaption of instruction and response categories
To begin with, the general instruction from SEPCQ (Zachariae et al., 2015) was adapted by translating it from Danish to Norwegian, as were the response categories and 5-point Likert scale with "1" (to a very low degree) and "5" (to a very high degree) as endpoints. As described under the first step, equality of meaning was achieved in the content of the two versions by translating the introduction from Danish to Norwegian according to the "Guidelines of the Process of Cross-Cultural Adaption of Self-Reports" (Guillemin et al., 1993).

Fifth step: Pilot evaluation
A pilot evaluation of the content validity and comprehensibility of the 27-item social work questionnaire, along with clarity of instructions, was conducted by one of the researchers (TGA). This involved interviews with eight students and two social workers after their completion of the questionnaire. Students in the pilot study were third-year bachelor's students. Two students were attending programs in social work with the other six in child welfare. They gave their opinion on the relevance, acceptability, and understandability of the instructions and items.
The results from the pilot evaluation showed that the items comprised the quality of client-centered communication and that they, along with the instructions, were comprehensible. However, there was some reflection on the choice of words, which led to some minor adjustments. There was also a question regarding the suitability of item 3, as this could be interpreted differently depending on the students' professional understanding. Nevertheless, item 3 remained in the questionnaire for further assessment.

Sixth step: Data collection
The next step was to administer the SECCQ to students from four different social science bachelor's programs in Norway; namely, social work, child welfare, work and social welfare, and social education. All those who participated met the criteria of being second-year students attending their fourth semester of the bachelor's program within the social work area. Data collection was undertaken by researchers at the end of January and beginning of February 2019. Students were asked to participate during a lecture by one of the researchers. The students were provided written and oral information about the study; this information explained that participation was voluntary and that their answers would be treated confidentially. Students gave their consent by filling out the questionnaire and participating in the study. All participants filled out the questionnaire on paper and in person.

Ethical approval
All data were collected anonymously. In Norway, studies that use exclusively questionnaire-based data are not subject to ethical approval.

Statistical analysis
The students' responses were coded and entered into IBM SPSS version 25. To describe the sample characteristics, descriptive statistics were used, and data were checked for normality both graphically and by assessing skewness and kurtosis. As there is no previous exploration of the underlying components for the SECCQ, a principle component analysis (PCA) was performed to explore the links between the observed variables (items) and the latent variables (factors) and identify the factor structure. The data's suitability for PCA was assessed using Bartlett's test of sphericity, which evaluates the overall significant differences in the correlation matrix, and the Kaiser-Meyer-Olkin (KMO) test, which verifies if the sample adequacy was appropriate (Field, 2017;Hair et al., 2007). To guide the extraction of factors, Kaiser's criterion was used, and factors with eigenvalue ≥1.0 were obtained for further analysis (Field, 2017). To provide further support for the extraction of factors, oblique rotation, produced by the Oblimin with the Kaiser normalization method in SPSS, was used, as it allows for a degree of theoretical correlation among dimensions (Field, 2017;Tabachnick & Fidell, 2013). Items loading at ≥.4 were considered acceptable loadings for the factors (Hair et al., 2007).
Cronbach's alpha was used to establish internal consistency, with values above 0.70 indicating an acceptable level of reliability (Cronbach, 1951;Streiner & Norman, 2008). The number of missing values was less than 1%, and these were imputed as recommended at the series mean (Meadows, 2012;Ware, 1995).

Results
Descriptive statistics at item level for the SECCQ are presented in Table 1. A total of 146 questionnaires with complete or almost complete data (>50) were returned. The number of missing values was less than 1%, and missing data were replaced at series mean.

Identifying factor structure
The suitability of data for factor analysis was assessed. An inspection of the correlation matrix revealed the presence of coefficients on 23 items of .4 and above. For three items this was between .35 and .4, and for one below .3. The KMO value was .89, exceeding the recommended value of .6, indicating that the sample should produce reliable and distinct factors (Field, 2017). Bartlett's test of sphericity (Bartlett, 1954) was of high statistical significance (p≤.001), supporting the factorability of the correlation matrix. To explore and ensure a stable factor solution for the 27 items of SECCQ, PCA was conducted using SPSS version 25. The PCA revealed the presence of six factors with eigenvalues exceeding 1, explaining 36.4%, 6.4%, 5.7%, 5.1%, 4.2%, and 3.7% of the variance, respectively. Parallel analysis using the free software Monte Carlo PCA (Watkins, 2000) showed, however, only two factors with eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size (27 variables × 146 respondents).
The two-dimensional solution explained 42.8% of the variance, with dimension 1 contributing 36.4% and dimension 2 contributing 6.4%. To aid in the interpretation of these two dimensions, oblique rotation was performed. The rotated solution revealed the presence of a simple structure (Thurstone, 1947), with both dimensions showing a number of strong loadings and variables loading substantially on only one dimension (Table 2). There was a negative correlation between the two dimensions (r=−.63).
A content analysis suggests the following two underlying dimensions of SECCQ; Factor 1, exploring and dealing with communicative challenges (16 items), and Factor 2, sharing information and power (11 items), as shown in Table 2.

Psychometric properties
Cronbach's alpha was used to measure the internal consistency and reliability of the construct. The Cronbach's alpha coefficient for the overall scale was high (α=.89), with high levels on both factor dimensions: Factor 1 (exploring end dealing with communicative challenges) α=.87, and Factor 2 (sharing information and power) α=.89.

Discussion
This article presents a SECCQ for use by Norwegian social work students. While the original questionnaire by Zachariae et al. (2015) was developed for medical students and physicians with the use of medical terms, the current study adapts and investigates the questionnaire's psychometric properties via an adapted version aimed at undergraduate social work students. The satisfying psychometric properties suggest high reliability in the context of social work students. Exploring the possible underlying factor structure of SECCQ, we identify two preliminary factors, consisting of 27 items: (a) exploring and dealing with communicative challenges and (b) sharing information and power. From both a statistical and a content-based perspective, the two factors appear to be valid subscales covering core aspects of client-centeredness self-efficacy. The construct validity was evaluated by performing an exploratory factor analysis using PCA, which shows a stable twofactor solution, with most items correlating strongly with the factors. Furthermore, the internal consistencies were generally high across different items.
Compared with the original SEPCQ (Zachariae et al., 2015), the items correlated differently, combining "exploring the clients' perspective" and "dealing with communicative challenges" into one dimension: exploring and dealing with communicative challenges. Additionally, two items (19 and 20) correlated with factors that differed from the SEPCQ. Item 19, "to stay focused on what is best for the client if there is a professional disagreement about the choice of intervention and the professional assessments," was previously described as an item belonging to the "dealing with communicative challenges" dimension. However, the content of the item, as it is in SECCQ, shows a good fit within the "sharing information and power" dimension. The change in item content may be due to cultural differences and different student academic professions. Linguistic differences may also lead to different contextual understandings. To "stay focused on what is best for the client (. . .)" is about actions that may lead to a feeling of empowerment for the client, as only the client would know what is best for itself. The item adds up to "sharing information" with the client, and thereby power. Within its social work context, both the item's content and correlation show that it belongs strongly in the "sharing information and power" dimension. Item 20, "make the client feel that he/she can talk with me about confidential, personal issues," was previously described as an item belonging to a different dimension. According to SEPCQ, item 20 correlated to the "exploring the patient perspective" dimension. Within the Norwegian language, item 20 contains elements of "dealing with communicative challenges" and "exploring the client perspectives," which is consistent with the first subscale of SECCQ. Item 20 loads almost equally on both subscales (.374 and −.380). The content of the item appears, however, much more conceptually related to the first subscale. By removing item 20 from one subscale and adding it to the other, the overall scale shows no change in the internal consistency and reliability of the construct (α=.89), albeit there was a slightly increased value of the first subscale, with a Cronbach's alpha coefficient increasing from .86 to .87. Equivalent reduction of value occurred in the second subscale, from .90 to .89. Overall, the assessment of item 20, as it is presented in SECCQ, therefore shows a good fit within the "Exploring and dealing with communicative challenges" dimension.
Four items have a correlation coefficient below .4. Items 2 (−.395), 13 (.352), and 20 (−.380) all have a correlation coefficient between .35 and .4. This indicates a moderate linear relationship to its dimensions. The content of items 2, 13, and 20 is, however, considered as a necessary skill for performing acceptable social work and therefore retained in the model based on content analysis. Item 2 addresses the students' reflections on what a "comprehensive mapping" consists of, while items 13 and 20 appeal to the students' emotional presence within social work.
The item about accepting when "there is no intervention that will change the client's situation" (item 3) has a correlation coefficient of .207, indicating a weak positive linear relation to its dimension. Exploratory analysis identified this item with strong correlations (.644) outside the two-factor solution, leading to a possible single item in the instrument. However, neither the Cronbach's alpha coefficient for the overall scale nor the factor dimension showed value of significance when deleting item 3 from the instrument. As this item addresses the skills necessary to perform acceptable social work, and excluding the item from the instrument did not show any value of interest, the item was retained in the model based on content analysis.

Limitations
Although the overall findings demonstrate that the SECCQ has satisfying psychometric properties and high reliability, and may be a valuable tool for raising students' awareness of their self-efficacy and the evaluation of student learning outcomes, the current study has some limitations. First, the validation and cross-cultural adaption process is based on a Norwegian context. Even though there is an English version of the instrument presented, the applicability of the instrument within other English-speaking countries is promising but unknown. There is therefore a need for further testing of the instrument within other cultural contexts, to be able to assess the validity of the instrument within other countries.
Second, the quality of measurements is important to all sciences. Exploratory factor analysis can be used to collect an important type of validity evidence, and increases the reliability of the scale by identifying inappropriate items that can be removed. However, validity is not a property of the measurement instrument but rather refers to its proposed interpretation and use. An instrument may be validated for a certain population and purpose, but that does not mean it will work across all populations and for all purposes (Knekta et al., 2019). Validity must be considered each time an instrument is used (Kane, 2016).
Third and last, it cannot be ruled out that differences in the structure and emphases of different educational systems across countries can result in differences regarding the conceptualization of the SECCQ construct. A cross-cultural assessment before use within other countries is therefore recommended.

Conclusion
The overall findings demonstrate that SECCQ has high psychometric properties and may be used as a valid and reliable instrument to measure the students' self-efficacy in client-centredness. The SECCQ could be a useful instrument for evaluating client-centeredness self-efficacy in various contexts (e.g., when evaluating outcomes of communication training courses or a student's development within professional practice). Nevertheless, it is important that further studies use SECCQ to measure its effectiveness. Further research is also needed on both the value of using this instrument within an educational context and what influence it may have on the students' self-development and learning outcomes.
As the instrument appears, it raises the question of whether it may be equally applicable to both students and practitioners. It is, however, developed for use within an educational context. The suitability of the instrument for practitioners is therefore as it appears in this study, hypothetical. There is thus a need for further research, where the instrument is introduced to various groups of practitioners, before concluding its validity or suitability outside the educational context.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Notes on contributors
Tina Gerdts-Andresen is an associate professor at Østfold University College. Anne Margrethe Glømmen is an assistant professor at Østfold University College. Inger Hjelmeland is an associate professor at Østfold University College. Erna Haug is an associate professor at Østfold University College. Heidi K. Grønlien is an associate professor at Østfold University College.

Ethics approval
The study was performed in accordance with the principles of the World Medical Association (Declaration of Helsinki).

Open access
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC-ND) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is noncommercial.