Purpose
This study aims to determine nursing students’ orientation toward patient-centered care (PCC) and identify its influencing factors: their personality traits, empathy, and psychological capital (PsyCap). A mediating model was used to test the role of PsyCap in the association between empathy and PCC.
Methods: This cross-sectional study included 300 nursing students from seven universities in South Korea. Their orientation toward PCC was measured using the Patient-Practitioner Orientation Scale (PPOS). Moreover, we analyzed the data using independent t-tests, ANOVA, Pearson's r, and SPSS PROCESS macro.
Results: The overall mean score on the PPOS was 3.82±0.43, with the Caring and Sharing subscales accounting for 3.95±0.68 and 3.69±0.50, respectively. Nursing students’ satisfaction with their majors, practicums, and motivation for choosing this profession was significantly related to Caring-not Sharing. Nevertheless, PsyCap positively influenced both Caring (β=.24, p<.001) and Sharing (β=.18, p=.002). While empathy failed to significantly impact both Caring (β=.12, p=.087) and Sharing (β=.01, p=.931). PsyCap mediated the association of empathy with Caring (β=.20, p=.004); however, the same was not true for Sharing (β=.07, p=.366).
Conclusion: The findings indicate that the orientation of Korean nursing students toward PCC is not high. Therefore, to improve the PPOS Caring subscale, nurse educators should formulate better strategies to enhance nursing students’ satisfaction with their major and practicums, empathy, and PsyCap. The importance of sharing health-related information with patients and family caregivers should be emphasized in the nursing curriculum.
,1
Thi-Thanh-Tinh Giap,2
Eungyung Kim,3
Kyoungja Kim,4
Eunkyong Ahn,5
Namyoung Yang,6
Mi Hyang Lee,7
and Eunyoung Jeong8
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
This study aims to determine nursing students’ orientation toward patient-centered care (PCC) and identify its influencing factors: their personality traits, empathy, and psychological capital (PsyCap). A mediating model was used to test the role of PsyCap in the association between empathy and PCC.
This cross-sectional study included 300 nursing students from seven universities in South Korea. Their orientation toward PCC was measured using the Patient-Practitioner Orientation Scale (PPOS). Moreover, we analyzed the data using independent t-tests, ANOVA, Pearson's r, and SPSS PROCESS macro.
The overall mean score on the PPOS was 3.82±0.43, with the Caring and Sharing subscales accounting for 3.95±0.68 and 3.69±0.50, respectively. Nursing students’ satisfaction with their majors, practicums, and motivation for choosing this profession was significantly related to Caring-not Sharing. Nevertheless, PsyCap positively influenced both Caring (β=.24, p<.001) and Sharing (β=.18, p=.002). While empathy failed to significantly impact both Caring (β=.12, p=.087) and Sharing (β=.01, p=.931). PsyCap mediated the association of empathy with Caring (β=.20, p=.004); however, the same was not true for Sharing (β=.07, p=.366).
The findings indicate that the orientation of Korean nursing students toward PCC is not high. Therefore, to improve the PPOS Caring subscale, nurse educators should formulate better strategies to enhance nursing students’ satisfaction with their major and practicums, empathy, and PsyCap. The importance of sharing health-related information with patients and family caregivers should be emphasized in the nursing curriculum.
Patient-centered care (PCC) model has been emerging as a dominant paradigm that has been increasingly promoted for broadly being applied in healthcare facilities in recent years. It is a holistic (bio-psychosocial-spiritual) approach to delivering care that is respectful and individualized, allows negotiation of the care provided, and offers choice through a therapeutic relationship where patients are empowered to be involved in health decisions at whatever level they desire [1]. Numerous studies have indicated the benefits of implementing PCC for patients in terms of their self-care management, satisfaction with healthcare services, and (re)admissions; for their families in reducing stress, anxiety, and depression related to the health of their loved ones (patients); and for healthcare providers (HCPs) and healthcare facilities in improving job satisfaction, confidence at work, and the quality of care [2].
Despite the concept of patient-centered medicine being first presented in the medical literature six decades ago and then officially asserted as one of the important elements needed in the redesign of healthcare systems by the National Academy of Medicine - Health and Medicine Division of the USA in 2001 [3], the development of PCC educational programs for healthcare students has started receiving considerable attention only during the past decade. Most of these works have focused on medical students, with very few studies involving nursing students.
Equipping PCC knowledge and skills for nursing students is essential because they are future nurses who account for the largest proportion of the health workforce, and to whom patients are most exposed during their hospitalization [4]. Thus, their ability to understand the importance of delivering PCC approaches in their future work could bring potential benefits to both their patients and healthcare facilities. Additionally, it will help them to become more effective in studying during their clinical practicums in healthcare facilities. Improving the PCC competency of nursing students is preparation for effectively working as registered nurses after they graduate. Consequently, Nurse educators have been making a lot of efforts to gradually deliver the PCC model into the Korean nursing curriculum.
One of the initial stages in the process of establishing appropriate PCC education programs is to assess the perception and attitude of nursing students toward PCC and the factors influencing their orientation. Empathy is considered a crucial attribute for developing a therapeutic relationship between patients and their HCPs; and it relates to the sensitivity to or understanding of the experiences, worries, and perspectives of others [5]. In terms of PCC, empathy is defined as the temporary condition that a health professional experiences in their effort to understand a patient's life without bonding with them [6]. Empathy is therefore a vital factor contributing to the PCC competency of HCPs and healthcare students [7, 8].
Psychological capital (PsyCap) refers to the positive psychological state of individuals and consists of four dimensions: self-efficacy, optimism, hope, and resilience [9]. Ji and Lee recently reported that the empathy of kindergarten teachers had a positive impact on their PsyCap [10]. Although PsyCap is not a new concept, it has only received attention from nursing scholars over the past decade as a mediating factor in many nurse-related issues, such as job stress and burnout, and the practice environment and work engagement [11, 12].
Based on the potential benefits of PsyCap in reducing stress and burnout [11, 12] as well as improving specialty satisfaction among HCPs and healthcare students [13], nursing professionals have suggested that PsyCap could be a significant predictor of PCC competency among nursing students [14]. A recent study has confirmed this hypothesis, with the available data indicating that PsyCap was a strong factor influencing the PCC competency of nursing students (β=.42, p<.001) [15]. Another study found that self-efficacy (one of the four PsyCap dimensions) significantly impacts the attitude of healthcare students toward PCC [16].
For this study, we assumed that PsyCap influences nursing students' orientation toward PCC, and hypothesized that it plays a mediating role in the association between empathy and orientation toward PCC. Besides the students' personalities (empathy and PsyCap), their sociodemographic and education-based characteristics should also be investigated as factors that potentially impact their orientation toward PCC.
The Quality and Safety Education for Nurses project has indicated that PCC is one of the six required competencies of nurses for improving the quality and safety of healthcare systems and that promoting PCC competency for nursing students should be a crucial part of the curriculum in nursing schools [17]. In South Korea, the PCC has been considered an important concept in the nursing field in recent years, and nurse educators are making efforts in developing appropriate PCC education for their students [18]. This study was therefore conducted to promote awareness of PCC for nursing students.
In particular, this study aimed to investigate the orientation of Korean nursing students toward PCC, identify the influences of the student characteristics on their PCC orientation, and test a model in which PsyCap mediates the association between empathy and PCC orientation.
This study had a cross-sectional design using a self-report questionnaire.
To improve the generalizability of the study findings, participants were recruited from multiple settings (seven nursing colleges/departments in Daejeon, South Korea) in 2018. Final-year nursing students were considered to have received the highest level of theory and practical nursing education, and so they were invited to participate in this study. Seven authors of this work each working as a faculty member in one study setting were responsible for data collection in their settings. The researchers explained the purposes of this investigation to the fourth-year nursing students and invited them to participate in this study. A structured survey questionnaire that included a section related to study consent was distributed to the students. The students who voluntarily agreed to participate in this study were asked to return the completed questionnaire with the consent part signed at their next class (1 week later).
To ensure an equal contribution between settings, all final-year students in one class from each of the seven nursing colleges/departments were invited to participate in this study. All of the 338 questionnaires distributed were completed and returned to the researchers.
The structured questionnaire measured three variables, as described below.
Nursing students' orientation toward PCC: The Patient Practitioner Orientation Scale (PPOS) was developed to measure attitudes toward the practitioner-patient relationship [19]. This scale has been modified and widely used in various countries to measure the PCC competency of nurses and nursing students, with good psychometrics being demonstrated [20, 21]. The tool used in this present study was the Korean version validated for use with health professionals and students (medical students, residents, and faculty members) [22, 23]. This scale comprises 18 items scored using a 6-point Likert scale, with higher scores indicating more positive responses. These items are classified into two subscales:(1) Sharing, comprising the first nine items that assess the extent to which students believe that patients desire information and should be part of the decision-making process; and (2) Caring, comprising the last nine items that assess the extent to which students see the expectations, feelings, and life circumstances of patients as critical elements in the caring process. Cronbach's α was 0.77 in a previous study conducted with Korean nursing students [23]. In this study, Cronbach's α was 0.70 for the total PPOS, 0.58 for Sharing, and 0.50 for Caring.
Empathy: Nursing students' empathy was measured using the Korean version [24] of the Interpersonal Reactivity Index [25]. This scale consists of 28 items scored using a 5-point Likert scale, with higher scores indicating more positive responses. The items are classified into four subscales (seven for each group): (1) Empathic Concern, referring to the feeling of emotional concern for others; (2) Perspective-Taking, referring to cognitively taking the perspective of another; (3) Fantasy, referring to emotional identification with characters in books, films, etc.; and (4) Personal distress, referring to negative feelings resulting from the distress of others. Cronbach's α was 0.78 in the original study [24] and 0.83 in this study.
PsyCap: Nursing students' PsyCap was measured using the Korean revised version [26] of the Positive Psychological Capital Questionnaire [27]. It consisted of 24 items scored using a 6-point Likert scale, with higher scores indicating more positive responses. These items are classified into four subscales (six for each group): (1) Self-efficacy, referring to having the confidence to take on and put in the necessary effort to succeed at challenging tasks; (2) Optimism, referring to having a positive attitude toward succeeding now and in the future; (3) Hope, referring to persevering toward goals and, when necessary, redirecting paths to goals to succeed; and (4) Resilience, referring to when beset by problems and adversity, sustaining and bouncing back and even beyond to attain success [9]. Cronbach's α was 0.89 in the original study of [27] and 0.89 in this study.
Sociodemographic and education-based characteristics of participants were also acquired.
This study was approved by the Institutional Review Board of Chungnam National University (IRB no. 201808-SB-126-01). To protect the rights of the study participants, the purpose and process of this study were presented in the written consent in detail. The students clearly understood that participation was entirely voluntary, they could withdraw at any point without any explanation required and disadvantages met, and their data would neither be used for any other purposes nor accessed by third parties. To avoid potential conflicts of interest, the study questionnaire did not require the participants to provide their student names and ID numbers.
Data were analyzed using SPSS version 26.0. Variables of the participants' characteristics and the scores for the students' PCC orientation, empathy, and PsyCap were described as M±SD values.
ANOVA tests and independent t-tests were performed to identify differences in measures between subgroups with differing participant characteristics. Pearson correlation coefficients were used to assess the relationships between measures.
Mediation effect models were analyzed using the SPSS PROCESS macro (version 3.5) [28]. The model was tested using model 4 (in this study, empathy played as the predictor, PsyCap as the mediator, and PPOS as the outcome) and 95% confidence intervals (CIs) were estimated using 5,000 bootstrapping resamples. The mediating effect was considered significant if the 95% CI of the indirect effect did not include '0' value.
Missing data were addressed using a multiple imputation method.
The characteristics of the participants are presented in Table 1. The students were aged 22.7 years, with most (87.7%) of them being female and nearly half (46.0%) having a religion.
Table 1
PPOS Scores of the Nursing Students' Characteristics (N=300)
In terms of their satisfaction, two-thirds (69.3%) were satisfied with their nursing major, more than half (52.7%) were satisfied with the clinical practicums, and nearly half (44.0%) were satisfied with their academic achievement. Most of the participants stated that they had awareness of PCC (80.7%), which had mainly been gained through school classes (90.3%). The largest proportion (41.3%) of the participants reported that they chose to become a nurse due to this being a major with a good job opportunity, followed by their interests (35.0%).
As shown in Figure 1, the mean overall PPOS score was 3.82±0.43 and the mean PPOS scores on the Sharing and Caring subscales were 3.69±0.50 and 3.95±0.48, respectively. Mean scores for the 18 PPOS items ranged from 2.57 to 5.08. The following two items achieved a score of greater than 5 points: item 7 "If nurses have truly good nursing skills, the way they relate to patients is not that important" - reversed (included in Sharing); and item 16 "It is not that important to know a patient's culture and background while caring for them" - reversed (included in Caring). Four items scored less than 3 points: three in Sharing and one in Caring. Those in Sharing were item 1 "It is the nurse who should decide what is discussed during the patient-nurse encounter" - reversed, item 2 "The difficulty associated with considering all of the unique situations of each patient is an inevitable part of the treatment" - reversed, and item 3 "The most important part of the patient assessment is the nurse's physical examination" - reversed. The item in Caring that scored less than 3 was item 15 "The patient must always be aware that the nurse is in charge" - reversed.
Figure 1
Modified PPOS: mean scores (N=338).
*Reversed item; PPOS=Patient–Practitioner Orientation Scale.
Regarding characteristics of the students, the overall PPOS and Caring scores were affected by the same characteristic variables such as their satisfaction with the nursing major, satisfaction with practicums, and motivation for choosing nursing. In particular, the students who were satisfied with their nursing major and/or practicums obtained significantly higher PPOS and Caring scores. Additionally, students who entered the nursing college because of job opportunities showed the lowest PPOS and Caring scores and were significantly lower than the student group who entered the nursing college for other reasons. The Sharing score did not differ significantly between groups across all characteristic variables (Table 1).
Table 2 presents the correlations among subscales of PPOS, empathy, and PsyCap. The data show that the Caring subscale was significantly positively correlated with two out of the four components of empathy: Perspective taking, and Empathic concern, and with all dimensions of PsyCap; and negatively correlated with one component of empathy: Personal distress. Whereas Sharing was significantly positively related to one dimension of empathy: Perspective-taking, and all four subscales of PsyCap; and negatively correlated with Personal distress. All the correlations were at small levels (-0.16≤r≤0.26).
Table 2
Correlations between All the Subscale of the Three Variables (N=338)
As indicated in Figure 2, the effect of PsyCap on PPOS scores was statistically significant (β=.21, p<.001). Although there was a nonsignificant direct effect of empathy on PPOS scores, its total effect on PPOS scores through PsyCap was statistically significant (β=.13, p=.035). Regarding the subscales of PPOS, PsyCap had significant effects on Sharing (β=.18, p=.002) and Caring (β=.24, p<.001). While the total effect of empathy on Sharing was not statistically significant (β=.07, p>.05), there was a significant impact of empathy on Caring (β=.20, p<.01) through PsyCap.
Figure 2
Mediation models testing the effect of empathy on nursing students’ orientation toward PCC through PsyCap.
Standardized coefficients (Beta) are used to report effect sizes. Of which, D is direct effect sizes, T is total effect sizes; PPOS=Patient–Practitioner Orientation Scale; PsyCap: Psychological capital.
This study had two main purposes: (1) determining the orientation of Korean nursing students toward PCC and (2) identifying the influences of empathy, PsyCap, and characteristics of the students on their orientation toward PCC. In terms of the first purpose, the PPOS score was 3.82±0.43 (out of a maximum potential score of 6). Compared with the score of nursing students from other countries (using the same measuring tool), this score is lower than those found in Western countries such as Finland (4.30) [21], and Portugal (4.57) [29]. Compared with medical students, this score is mostly consistent with the findings of a previous study performed in South Korea (3.76) [22], while it is lower than those found in Finland (4.30) [21], and the USA (4.57) [30]. These differences can be explained by the PCC provided in nursing education systems varying between countries. In numerous Western countries, PCC has been educated in curriculums with a long history and has become a common concept among healthcare students [31]. It has been included in the General Medical Council standards for promoting excellence in medical education in the UK [32]. Meanwhile, the PCC concept has been introduced to Korean nursing students in recent years, and the developing PCC education programs are still at the beginning stage.
In terms of general characteristics, students' satisfaction with their nursing major and with practicums have positive correlations with scores on the PPOS Caring subscale. Students demonstrating such satisfaction will tend to understand that the patient's expectations, feelings, and individual life circumstances are critical elements in the care process. However, a similar result was not obtained for the Sharing score. In particular, the perception of the importance of sharing information with patients in the decision-making process did not differ significantly between those who were satisfied and not satisfied. A previous study that also investigated the PCC competency of Korean nursing students found that neither the Sharing nor Caring scores were related to students' satisfaction with their major or practicums [23]. This discrepancy between the previous study [30] and this present study may be because the present study only enrolled fourth-year nursing students, while the previous study recruited first-, second-, third-, and fourth-year nursing students. We, therefore, assume that the correlations between nursing students' satisfaction with Caring scores vary with the grade. This relationship should be investigated in future studies in order to facilitate the development of appropriate strategies for improving Caring scores for particular student grades.
Regarding mediation models, the present findings demonstrated that all factors in the hypothesized model were associated with the PPOS Caring score but not with that for Sharing. If only considering the orientation of the students toward PCC based on the overall PPOS score, the findings are consistent with previous studies in indicating that empathy is a significant predictor of PCC [7, 8]. However, the present study has provided additional knowledge for clarifying the association between empathy and PCC components. In particular, empathy had no direct impact on either Sharing or Caring, whereas its total effect was significant on Caring but not on Sharing. These findings demonstrate that PsyCap exerts significant direct effects on Sharing and Caring, and also acts as a mediating factor in the association between empathy and Caring. Since Sharing was influenced by PsyCap only, we suppose that recognizing the importance of sharing information is a cumulative process. It requires the students need to be educated about the roles and impacts of sharing information with their patients and families, as well as learned and practiced proper methods to share information effectively.
From the available evidence, we suggest that PCC competency should be considered with separated components and that the contribution of factors influencing the components varies. Thus, potential approaches for improving the PCC competency of nursing students should be applied to particular components. We assume that strategies to enhance the students' satisfaction with their major and practicums, empathy, and PsyCap will be meaningful in promoting students' perception of the importance of patients' preferences, and their expectations while providing care (and hence the PPOS Caring score). Additionally, interventions are needed to change the motivation to pursue the nursing major, since this should not only be due to job opportunities but also due to an appreciation of the value of and passion for nursing. Moreover, the inherent personality of students and their characteristics play relatively minor roles in influencing their attitude toward Sharing. Therefore, helping students to realize the importance of sharing information with patients and their family in the decision-making process is crucial, and they should be provided with opportunities to share health-related information with patients and their families in simulation and clinical practicums.
Based on the present findings, the following aspects should be addressed in future studies. First, along with assessing the orientation of nursing students toward PCC, measuring their behaviors will be highly valuable for reflecting on the actual situation, although this will take time and involve a complex procedure. Second, it is necessary to design appropriate approaches for effectively improving the attitude and behaviors of nursing students. In the current context, holistic care to satisfy the tailored needs of individual patients is a goal that all healthcare facilities should pursue, while recognizing the importance of paying attention to the emotions and lifestyle of patients (Caring score) as well as empowering patients (Sharing score). Therefore, the education system should provide PCC education programs for both undergraduate and graduate nursing students. Nurse educators and researchers should actively study and develop innovative teaching strategies that can effectively improve the PCC competency of nursing students such as the design-thinking method [18], digital storytelling [33], and faculty-led role-plays simulations [34]. Also, managers and educators should determine the most appropriate time for delivering such a course, such as before or during the clinical practicums. Furthermore, PCC competence should be considered a qualification requirement to become a nurse. Third, the attitude and satisfaction of patients and their families toward PCC need to be investigated, since the obtained information will be valuable for evaluating the effects of implementing PCC.
The findings of this study should be widely generalizable because it included a relatively large sample of 300 nursing students from seven nursing colleges/departments, and therefore should accurately reflect the orientation of nursing students toward PCC in South Korea. Strategies for establishing appropriate PCC training programs for nursing students should consider the study results as a crucial foundation for determining the factors influencing the attitude toward PCC among nursing students in South Korea.
A few limitations of this study should be mentioned. The findings for the attitude of students toward PCC might not be consistent with their patient-centered behaviors, and hence the findings might not perfectly reflect how they would behave in a clinical environment. Secondly, most of the students self-reported that they knew about PCC in this study, but the extent of their PCC knowledge was not quantitatively measured. This restricted the ability to assess the relationship between their perception of PCC and their attitude toward PCC. Finally, instead of using a mathematical method to calculate the sample size, this study recruited approximately equal numbers of participants from multiple study settings (one class in each study college/department) and got a relatively large sample size (N=300). With this sample size to detect a small effect size (f2=0.05), the statistic power was computed at a high level (0.97).
This study found that the score for the orientation of nursing students toward PCC was not high, which might indicate that they lack systematic PCC knowledge. Based on factors influencing their attitude toward PCC discovered in this study, approaches for enhancing the satisfaction of nursing students with their major and practicums, empathy, and PsyCap have the potential to improve Caring. In contrast, PsyCap is the only significant influencing factor of Sharing. Therefore, developing strategies for improving the PsyCap of nursing students is necessary for further studies. Additionally, the importance of sharing health-related information with patients and their family caregivers should be emphasized, and opportunities to practice sharing should be provided.
This work was supported by the Korean Academy of Nursing Administration.
