1. Research Design

This study had a cross-sectional design using a self-report questionnaire.

2. Participants and Data Collection

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.

3. Measures

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.

4. Ethical Considerations

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.

5. Data Analysis

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.

1. Description of Participants

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)

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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%).

2. Orientation of Students toward PCC

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.

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3. Factors associated with Students' Orientation toward PCC

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)

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4. The Effects of Empathy and PsyCap on Students' Orientation toward PCC

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.

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1. Future Works

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.

2. Strengths and Limitations

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).