Nursing students' experiences and perceptions of barriers to the implementation of person‐centred care in clinical settings: A qualitative study

Abstract

Aim

This study aimed to explore the barriers to implementing person‐centred care based on nursing students' experiences during clinical practice.

Design

This is a descriptive, qualitative study.

Methods

Seventeen nursing students were recruited through purposeful sampling from two universities in South Korea. The semi‐structured interviews consisting of open‐ended questions were conducted. The collected data were analysed using an inductive content analysis method.

Results

Five main categories were identified from nursing students' experiences: busyness, educational challenges, lack of awareness, lack of relationship building and lack of a policy approach.

1. INTRODUCTION

Person‐centred care involves identifying the values and preferences of each individual, guiding all aspects of healthcare and supporting realistic health and life goals (American Geriatrics Society Expert Panel on Person‐Centered Care, 2016). Currently, person‐centred care is often used interchangeably with patient‐centred care. Although there are many common aspects between the two, such as relationship, respect, decision‐making, communication and empathy, there is a difference in that the goal of person‐centred care is a meaningful life for patients, whereas that of patient‐centred care is a functional life through disease treatment (Eklund et al., 2019).

The World Health Organization (WHO) reported that people‐centred health service is essential for realizing integrated health services, with its urgency increasing with the increase in chronic and preventable diseases, requiring complex interventions (World Health Organization, 2015). In addition, the Institute of Medicine (2001) also recommended that patient‐centred care is crucial to achieve quality health care. Moreover, person‐centred care is probably to have a statistically significant impact on improving patient care by making patients feel more respected, consulted, supported and confident in continuing to improve their health (Price, 2019). In previous researches, for patients, there are many positive effects including reduced fall rates (Rossiter et al., 2020), improved estimated life expectancy, improved lifestyle, reduced chronic disease morbidity (Applegate et al., 2021) and improved health‐related quality of life (Pirhonen et al., 2017). In addition, the positive outcomes for nursing providers include improved job satisfaction and quality of care (McCormack et al., 2010; Surr et al., 2016).

Therefore, person‐centred care that recognizes the nurse–patient relationship as a form of care that promotes human dignity is essential (O'Connell, 2008). Person‐centred care in clinical practice should be continuously developed because it has positive outcomes not only for patients but also for nursing providers.

2. BACKGROUND

Person‐centred care has been developed in theory and in practice around the world (Lewandowski et al., 2021; McCormack et al., 2015; Stanhope et al., 2021). However, many studies in Korea have focused on nursing staff in long‐term care settings rather than nurses in clinical settings (Kong et al., 2021; Sagong & Lee, 2016). Previous studies on nursing students have explored students' understanding of the concept of person‐centred care (Ghane & Esmaeili, 2020), their experiences of person‐centred care for Alzheimer's patients (Skaalvik et al., 2010) and their perceived experience of learning person‐centred care during a one‐semester course (van Leeuwen & Jukema, 2018) or simulation (Oddvang et al., 2021). In addition, previous studies in Korea have mainly focused on factors affecting person‐centred care competency in nursing students (Ahn & Kim, 2021; Kim, 2020; Lim, 2020; Park & Choi, 2020).

In particular, domestically and internationally, studies exploring the barriers to implementing person‐centred care in clinical settings are limited. Also, research on the barriers to the implementation of person‐centred care in clinical settings based on nursing students' experiences has not yet been reported worldwide. Moreover, while research has been conducted on staff members' perceptions of barriers to implementing person‐centred care in nursing homes (Kong et al., 2021; Oppert et al., 2018), the barriers to implementing person‐centred care in clinical settings remain unexplored.

The depiction of nursing students' views can provide good information for identifying and solving problems in clinical settings because the nursing education for nursing students is closely related to the actual clinical environment (Allan et al., 2011; Papathanasiou et al., 2014). In addition, identifying barriers to implementing person‐centred care can provide solutions in the healthcare system (American Geriatrics Society Expert Panel on Person‐Centered Care, 2016), especially as regards the quality of life of patients. Therefore, a study on nursing students' experiences and perceptions during clinical training and barriers to the implementation of person‐centred care can provide important information to improve and establish person‐centred care in a clinical setting.

It is important to improve patients' health and the quality of nursing care by performing high‐level, person‐centred care in clinical settings. For this, it is necessary to identify what actions hospitals and universities should take based on an in‐depth approach to explore the barriers to the implementation of person‐centred care in clinical settings. Therefore, exploring the barriers to implementing person‐centred care in clinical settings through the experiences of nursing students is necessary because improving person‐centred care is important for patients, nurses and nursing students.

2.1. Research question

This study's research question: What are the barriers to delivering person‐centred care in the current clinical setting?

3. METHODS

3.1. Study design

This study is a qualitative, descriptive design (Sandelowski, 2000, 2010) that limits the researcher's interpretation and conducts an analysis that is close to the data. Also, we used qualitative content analysis to analyse the data (Elo & Kyngäs, 2008). This design is suitable for exploring nursing students' experiences of and perceived barriers to implementing person‐centred care during clinical practice to understand their meaning and nature.

3.2. Setting and participants

In this study, convenience sampling was used to select participants among nursing students who attended nursing schools at universities in Kangwon and Chungbuk, South Korea. The selection criteria included students who (a) gave consent to participate in this study and (b) were enrolled in nursing school and had experienced clinical training for more than one semester at a general hospital. The exclusion criteria included (a) students under the age of 20 and (b) nursing students who had participated in qualitative research on person‐centred care before as such experience can influence their clinical training.

We recruited participants from each university to which the researcher belonged. The research assistant posted a recruitment notice in the students' chatroom, about the research purpose, method, period, inclusion and exclusion criteria, and confidentiality. Subsequently, we conducted the study on nursing students, who were contacted to voluntarily participate in the study.

3.3. Data collection

Data were collected from 1 February to 10 April 2021. According to the interview guidelines, interviews were conducted at the professor's laboratory to which the authors belonged at the participants' preferred times. Before the interviews commenced, the interviewers adjusted the room temperature and engaged in general conversation with participants to create a comfortable environment and, thus, enable a smooth interview process. Masks were worn to prevent the spread of COVID‐19. The interviewers were female nursing professors with PhD degrees, were majoring in gerontological nursing and had experience in conducting qualitative research.

We developed a semi‐structured interview guide containing open‐ended questions. The interview focused on exploring the barriers of implementing person‐centred care, and the requirements to promote this care in clinical settings through the experiences of nursing students. Before conducting an interview on this point, we first asked about their overall experience of clinical training, the meaning of person‐centred care and their experiences of providing this care, in order to give the participants time to think about person‐centred care. Additionally, we conducted a pilot test on two nursing students using the initially developed interview guide and corrected terms that were not clear, and changed the order of the questions. The final interview guide is shown in Table 1.

TABLE 1.

Interview questions

Interview questions

1. Tell me about your clinical practice at the hospital. 2. What do you think person‐centred care is? 3. Tell me about your experience of nurses who have conducted person‐centred care during clinical practice. 4. What is your experience of delivering person‐centred care during clinical practice? 5. What do you think are the barriers to delivering person‐centred care in the current clinical setting? 6. What do you think is needed to promote person‐centred care? 7. How do you feel about participating in the interview?

The data were collected and analysed until data saturation was achieved and until no new data or categories could be obtained. In this study, two interviews were conducted. The first interview posed questions about nursing students' experiences of and perceived barriers to implementing person‐centred care during clinical practice. The first interview lasted 44–61 min (average duration: 52 min and 33 s). The second interview is not only very useful but also provides context and greater meaning based on the content of the first interview and identifies parts that are unclear or require additional review (Knox & Burkard, 2014). Thus, the second interview consisted of receiving feedback on the results of the data analysis from the first interview data, and asking questions about unclear areas in the first interview. The second interview lasted approximately 14–36 min (average duration: 27 min and 12 s).

All interviews were recorded after obtaining the participants' consent. Field notes were written immediately after the interviews were completed. These notes included a description of the interview location and the participants' responses, as well as descriptions of the behaviours and emotions that they expressed.

In the first interview, 17 participants were interviewed face to face. In the second interview, 10 participants were interviewed using zoom video conferencing as seven participants dropped out due to hospital employment. The research assistants transcribed all 27 interviews in Korean according to the transcription guidelines to establish the consistency of transcription among research assistants. The authors reviewed the transcripts while listening to the recordings. The participants' quotations from the interviews were translated into English and then back‐translated into Korean by a bilingual expert. After verifying the translated quotations, the authors corrected all discrepancies in the translations.

3.4. Data analysis

Data analysis was performed simultaneously with the data collection. The data were analysed using an inductive content analysis method involving the processes of open coding, grouping, categorization and abstraction (Elo & Kyngäs, 2008). The data were coded using ATLAS.ti 8.2 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany), and the number and pattern of coding were identified. Two authors identified codes by reviewing data several times and creating coding sheets. The authors discussed the coding with each other and revised the codes and subcategories. Next, the authors grouped the subcategories into categories and similar categories into main categories. We reviewed the original data several times to ensure correct interpretation and discussed it together. Furthermore, the authors determined categories and main categories through a continued abstraction process.

For example, subcategories of high number of patients per nurse, insufficient number of nurses, insufficient personnel replenishment, unbalanced manpower allocation and high turnover rate of nurses are abstracted into the category of “labour power shortages.” In addition, other subcategories such as excessively repetitive work, ambiguous task classification, insufficient consideration of patient's severity and excessive administrative work are abstracted into the category of “excessive workload.” The two categories are again abstracted into the main category of “busyness.”

3.5. Trustworthiness

To enhance the rigour of the data analysis, this study observed the four aspects of trustworthiness suggested by Guba (1981). First, to enhance credibility, informants were asked to review the data analysis of the first interview through the second interview. Also, two authors then analysed all data independently several times. If there were any discrepancies, the authors held discussions until a consensus was reached. In addition, all authors corrected the English translation discrepancies, through the English translation and Korean back‐translation process by bilingual experts for quotations of participants, subcategory, category and main category. Second, to enhance transferability, the researchers provided a detailed description of data collection and analysis. Third, to enhance dependability, two authors used ATLAS.ti. The authors repeatedly analysed the data until the same main categories and categories were extracted, and peer checking was conducted by an expert who was conducting qualitative research. In addition, an accurate audit was conducted from the beginning of the study through data collection and analysis. Finally, to enhance confirmability, data collection and analysis were peer‐reviewed by an expert in qualitative research. Also, this study followed the guideline for COREQ (Consolidated Criteria for Reporting Qualitative Research guidelines) (Tong et al., 2007).

3.6. Ethical considerations

This study was approved by the institutional review board of the university (No. KWNUIRB‐2020‐03‐002‐001). Participants were provided with oral and written information about the study's purpose and procedure, benefits and risks, data confidentiality, withdrawal from the study and anonymity. Participants voluntarily participated after providing their oral and written consent. To ensure the anonymity of the participants, one of the authors assigned a number to all participants and described them with the number when reporting the results. All data were stored in a password‐protected computer file, and the questionnaires were stored in a locked drawer to ensure confidentiality. All authors considered potential ethical issues that can be expected in qualitative research and conducted this study according to the ethical principles (Orb et al., 2001).

4. RESULTS

Of the 17 nursing students, 76.5% were female, all in fourth grade, the average age was 24.41 ± 2.00 years, and 58.8% had a religion. All participants (100%) reported that education for person‐centred care was necessary or very necessary (Table 2).

TABLE 2.

Participants' general characteristics (N = 17)

Characteristics	Categories	n	%	Mean ± SD
Sex	Female	13	76.5
	Male	4	23.5
Grade	Third grade	0	0.0
	Fourth grade	17	100.0
Age (years)	≤24	12	70.6	24.41 ± 2.00
	>24	5	29.4
Religion	Yes	10	58.8
	No	7	41.2
Education for person‐ centred care	Very necessary	10	58.8
	Necessary	7	41.2
	Unnecessary	0	0.0

Through the data analysis, we extracted 459 codes from the material, grouped the codes into 36 subcategories, abstracted from subcategories to 10 categories and from categories to five main categories. In this study, the research question, “What are the barriers to delivering person‐centered care in the current clinical setting?” was explored through the experiences of nursing students. As a result, the barriers for nurses to perform person‐centred care in clinical settings were busyness, educational challenges, lack of awareness, lack of relationship building and lack of policy approaches (Table 3).

TABLE 3.

Main category, category and subcategory

Main category	Category	Subcategory
Busyness	Labour power shortages	High number of patients per nurse Insufficient number of nurses Insufficient personnel replenishment Unbalanced manpower allocation High turnover rate of nurses
	Excessive workload	Excessively repetitive work Ambiguous task classification Insufficient consideration of patient's severity Excessive administrative work
Educational challenges	Lack of education for nurses	Lack of systematic education Lack of specific case‐focused education Lack of periodic retraining
	Incomprehensive nursing curriculum	Lack of a regular curriculum Focus on a disease‐oriented curriculum Lack of theoretical education Lack of clinical training Lack of a practical and specific curriculum
Lack of awareness	Lack of nurses' awareness of person‐centred care	Task‐oriented care Obligatory care Disease‐oriented care Impersonal care Principled care
	Lack of patients' awareness of nurses' roles	Recognition of nurses as the doctor's assistants Recognition of nurses as the person administering medication
Lack of relationship building	Lack of respect for patients	Lack of interest in patients Lack of explanation about the process of care Lack of individual care Inappropriate attitude towards patients
	Lack of communication skills	Difficulty in interacting with patients Lack of training in communication skills Lack of empathy towards patients
Lack of policy approaches	Institutional issues	Absence of laws on the number of patients per nurse Absence of laws for adjusting the number of nurses according to patient's severity Insufficient hospital system for person‐centred care
	Inadequate working environment	Poor treatment of nurses Arduous working conditions of nurses

4.1. Busyness

Busyness barrier to implementing person‐centred care includes labour power shortages and excessive workloads.

4.1.1. Labour power shortages

Nursing students mentioned the labour power shortage as a barrier to the provision of person‐centred care in clinical settings. Due to this shortage, each nurse did not have enough time or patience to provide person‐centred care to many patients. Nursing students stated that one of the barriers to person‐centred care in the clinical setting was that they were busy with too many patients to care for per nurse. Nurses always had insufficient time to attend to care for patients. Additionally, the turnover rate of nurses is high because nurses were struggling.

I think the major reason for this is the lack of labor power. It takes more time to empathize and interact with patients. Because each nurse needs to provide nursing care to many patients in a short period, it would be difficult to provide person‐centered care. (Nursing student 14)

4.1.2. Excessive workload

Nursing students mentioned that nurses have excessive repetitive tasks and administrative works. In addition, task classification between jobs is ambiguous because there is no work manual, and there are too many tasks for nurses. Also, the workload is high because of severity of patients' disease, which is often not considered. Thus, nurses feel pressured on their tasks and spend less time focusing on patients because of the heavy workload, which altogether affects person‐centred care.

I think that problems are that the patients are in serious condition, there are too many patients to care for, and there are so many tasks that the nurses must do, such as administrative work and counting hospital supplies. (Nursing student 11)

4.2. Educational challenges

Nursing students said that there was a lack of education on person‐centred care for nurses in clinical settings and that the comprehensive curriculum on person‐centred care in nursing colleges was insufficient.

4.2.1. Lack of education for nurses

Nursing students pointed out that the lack of education on person‐centred care for nurses was a barrier. There is a lack of systematic education at the hospital level on person‐centred care for nurses in clinical settings. In addition, the nurses do not seem to know how to perform person‐centred care due to the lack of education that can be applied in practice. Therefore, specific case‐oriented education along with regular retraining education is necessary so that nurses can perform well person‐centred care in various clinical situations.

I think the person‐centered care topic should be included in refresher courses for nurses each year. This can help them retain what they have learned so it becomes part of them. I wish this form of basic education existed. (Nursing student 14)

4.2.2. Incomprehensive nursing curriculum

Nursing students stated that education on person‐centred care should be strengthened for nursing students. Currently, the curriculum of nursing colleges is focused on disease‐oriented care, and there is a lack of theoretical or clinical training on person‐centred care. Also, since there is a lack of practical and specific curriculum on person‐centred care, there is a need for education that will improve nursing students' awareness and utilization of person‐centred care in clinical training. Practical and specific education for nursing students is associated with specific methods such as rapport formation, identification of needs and preferences and collaboration with healthcare teams through actual patient cases encountered during clinical training. In addition, it was stated that adequate clinical training opportunity should be provided for nursing students because the experience of providing person‐centred care to patients is important.

I have heard a lot about the need for person‐centered care in theory but have not learned about what attitude to have when providing care and treating patients. I think it would be better if there was a specific curriculum for person‐centered care. (Nursing student 12)

4.3. Lack of awareness

Nursing students mentioned that the nurses' lack of awareness about person‐centred care and the patients' lack of awareness of nurses' roles were barriers to person‐centred care in the clinical setting, which suggests the need for improvement.

4.3.1. Lack of nurses' awareness of person‐centred care

Nursing students pointed out that nurses were performing task‐oriented care based on doctor's instructions rather than on person‐centred care in clinical practice. In addition, they carry out only tasks that must be performed and that are obligatory for the patient. Also, they perform disease‐oriented care rather than person‐centred care. In other words, they care for patients by labelling them as persons with diseases and focusing only on the treatment of the disease. Moreover, nurses only perform work frantically, like a machine that does routine work without emotions and only perform work based on principle.

It seems that nurses are not aware of person‐centered care. They do not seem to perceive patients as individuals, but only recognize them by their diseases. For example: “Is this person hypertensive or diabetic?” They seem to label them: “This person is a heart failure patient, and this person has a bit of a quirky personality.” (Nursing student 9)

4.3.2. Lack of patients' awareness of nurses' roles

Nursing students explained that interaction was important when providing person‐centred care. However, given that patients are not aware of the roles of nurses in clinical settings, their perceptions of nurses' roles need to be improved to promote the performance of person‐centred care. Nursing students explained that patients perceive nurses as assistants to doctors, which is likened to perceiving nurses as persons that carry out doctors' instructions, doctor‐dependent and under‐professionals rather than independent experts. They mentioned that for person‐centred care to develop, it involves changing the perception of patients about nurses towards trusting nurses as professional medical personnel whose roles are very important.

The perception of a nurse as a doctor's assistant is very prominent. Evidently, the status of nurses has risen compared to before, but there are still people who only think of them as medical staff who are responsible for giving medicine. It seems that many things need to be improved. (Nursing student 3)

4.4. Lack of relationship building

Nursing students mentioned that the lack of respect for patients and lack of communication skills were barriers to implementing person‐centred care.

4.4.1. Lack of respect for patients

Nurses are not interested in the patients but are only concerned about the treatment or medication that they provide to patients; they are not interested in patients' difficulties, inconveniences or preferences of the patients. In addition, patients are not provided with explanations during the care process, including explaining to them about the treatment, nursing, medication administered to them, or asking for patients' opinions on treatment or care. Therefore, patients do not often know exactly their health status, why they need some drugs or treatment, and cannot make decisions about their treatment methods. Lack of individual care included not performing care according to the patient's condition, preference, needs and situation, performing uniform care, and not considering patients' position. Inappropriate attitudes towards patients include speaking coercively and commandingly to the patient, not respecting their privacy, using negative words on them, and not listening to them.

Patients inevitably have questions about the medication. However, the nurses tend to only explain the possible adverse effects once and provide no explanation afterward when administering drugs. They simply say, “Starting now.” Giving patients a little more information about this would allow them to understand their conditions, have autonomy, and feel respected. (Nursing student 11)

4.4.2. Lack of communication skills

Nursing students stated that not only nurses but also nursing students lack the communication skills required for interacting with patients, and they think that communication skill is very important for person‐centred care. The difficulty in interacting with patients involved manner of approach to patients, rapport formation, asking appropriate questions, inability to talk comfortably and lack of experience in interacting with patients. Lack of training in communication skills was associated with the brief communication training in nursing college, lack of comprehensive communication education, lack of practical communication training according to specific situations and lack of regular communication education. Lack of empathy towards patients involved lack of emotional support for patients, lack of empathy experience, not knowing how to empathize and lack of time to empathize.

I think nurses need to have the ability to empathize and understand the situation and position of patients. I think it is necessary to have the skills to communicate with patients through such emotions and feelings to enable smoother interactions. (Nursing student 15)

4.5. Lack of a policy approach

Nursing students pointed out institutional issues and inadequate working environments for nurses as barriers to implementing person‐centred care.

4.5.1. Institutional issues

Institutional issues included the absence of laws on the number of patients per nurse and an insufficient hospital system for person‐centred care. Nursing students pointed out that fundamental changes are a priority to perform person‐centred care. It was mentioned that the absence of laws on the number of patients per nurse and laws on nurse input according to the patient's severity results in a shortage of nurses and an excessive workload for nurses. Insufficient hospital system for person‐centred care involved a lack of awareness of person‐centred care in hospitals, insufficient fundamental solutions, insufficient research for person‐centred care, insufficient hospital organization culture and insufficient manual for person‐centred care.

It is not easy to fundamentally change the provision of person‐centered care if there is no policy support in place. I hope that this substantial change is made. (Nursing student 3)

4.5.2. Inadequate work environment

An inadequate working environment included poor treatment of nurses and arduous working conditions for nurses. Poor treatment of nurses was associated with low remuneration relative to the workload, lack of resting time for nurses, decreased nurse satisfaction, treating nurses as an accessory, lack of improvement in nurses' difficulties and workplace bullying. Arduous working conditions for nurses included a three‐shift working system, lack of allocation of work and much responsibility for nurses.

There are many problems associated with the profession, such as the three‐shift working system, workplace bullying, hard work, low pay relative to the workload, and difficulty balancing work and life, which makes it difficult for the nurses to keep working. (Nursing student 8)

5. DISCUSSION

Developing person‐centred care in clinical practice is important not only for patients but also for nurses and nursing students. Therefore, exploring the barriers to implementing person‐centred care in clinical practice is necessary because it can improve person‐centred care. This study is the first qualitative study to explore the barriers that nurses encounter when practising person‐centred care based on nursing students' experiences during clinical practice. In addition, this study is statistically significant in that it showed the barriers related to the nurse–patient relationship, which are essential elements in person‐centred care, and how to overcome them. The results revealed five main categories: busyness, educational challenges, lack of awareness, lack of relationship building and lack of policy approaches.

Although previous studies have not reported on the barriers that nursing students experience in the provision of person‐centred care during clinical practice, the theme of having “insufficient time” was reported in a qualitative study on barriers to person‐centred care for aged care workers at long‐term care facilities (Oppert et al., 2018). This theme can be viewed in line with the current study's main category of “busyness.” In addition, a qualitative study on barriers to person‐centred care for nursing home staff (Kong et al., 2021) reported the themes of “insufficient resources,” “lack of education” and “poor relationships,” which are similar to the current study's main categories of “busyness,” “educational challenges” and “lack of relationship building.” However, other studies have not reported “lack of awareness” and “lack of a policy approach” as barriers to person‐centred care in clinical settings.

Previous studies (Kong et al., 2021; Oppert et al., 2018) have also reported “busyness” as a barrier to person‐centred care in long‐term care facilities, making it an important factor. Person‐centred care requires communication skills to enable interactions between patients and nurses and allow nurses to accurately understand patients' motivations, preferences and priorities (American Geriatrics Society Expert Panel on Person‐Centered Care, 2016). Sufficient time is required for such communication in person‐centred care, while busyness is a major barrier to it, especially in clinical settings. In this study, busyness was found to be one of the barriers to nurses' lack of person‐centred care in the clinical environment, and it includes too many patients being cared for per nurse and excessive workload due to repetitive and administrative work, which makes it difficult for nurses to perform person‐centred care in clinical practice. Therefore, it is necessary for hospitals to find ways to support nurses, adjust the number of patients being cared for per nurse and reduce excessive workload. Additionally, hospitals need to analyse the causes of high turnover rates of nurses, pay attention to difficulties encountered by nurses and have a will to improve person‐centred care.

The educational challenges result is consistent with the “lack of education” theme identified as a barrier to person‐centred care in a previous study conducted on nursing home staff (Kong et al., 2021). As shown in the results of this study, hospitals need to systematically provide education for nurses and develop specific case‐oriented education that can be applied in practice. Also, hospitals need to strengthen cooperation with educational representatives to conduct systematic education for nurses. In previous studies, role modelling was suggested as an important strategy used to educate practitioners in person‐centred care by preceptors (Hinds, 2013); thus, it would be better to improve on it. Moreover, nursing students are required to take a professional and incremental approach to education on person‐centred care in the nursing curriculum (Currie et al., 2015). In addition, nursing education for nursing students in Korea focuses on caring for acute diseases (Kim, 2020) and care mainly aims to solve disease‐centred medical problems in the clinical setting, person‐centred care that provides individualized care to patients has inevitably been neglected (Yoo, 2020). In particular, there is a need for practical improvement in the nursing curriculum because the research results suggest that content related to information on person‐centred care should be increased in lectures for nursing students and understood through clinical practice (Steenbergen et al., 2013). Therefore, the college should develop a regular curriculum and strengthen not only theoretical education but also clinical practice education. In addition, the hospital should create a supervision system for nursing students so that they can apply person‐centred care in clinical practice. Additionally, in this study, some nursing students suggested educational methods through simulation, and it was a suitable method for nursing students in a previous study (Oppert et al., 2018); therefore, its reinforcement is also necessary.

Regarding the “lack of awareness,” while the nurses may lack awareness of person‐centred care, the patients may also lack awareness of nurses' roles, thus hindering the implementation of person‐centred care. As pointed out by some nursing students, the lack of awareness of person‐centred care by nurses is because they do not have good experiences with person‐centred care; therefore, it can be helpful to have a good experience through practical cases. In addition, hospitals should change the perception of nurses through continuous campaigns and education on person‐centred care. Given that person‐centred care is underpinned by the values of respect for others as well as mutual respect (McCormack et al., 2010), it is necessary to improve not only nurses' awareness of person‐centred care but also patients' awareness of the roles of nurses. A recent study reported that the behaviours of nurses affected the patients' perceptions of nursing (Zaghini et al., 2020); therefore, nurses need to make an effort to change this perception. Furthermore, according to the previous research, the lack of professionalism and the portrayal of nursing both online and in the media were factors that contributed to the image of nursing (Godsey et al., 2020). Therefore, it is necessary to strengthen the professionalism of nurses and enhance the way that the nursing profession is portrayed online and in the media.

The lack of relationship building manifested as a lack of respect for patients and a lack of communication skills. Respect and communication are the core elements of person‐centred care (Eklund et al., 2019; Morgan & Yoder, 2012), as nurses respect patients and provide individualized care through therapeutic relationships (Morgan & Yoder, 2012). Respect for the patient means approaching them in a respectful manner (Eklund et al., 2019) and respecting their choices (Sidani & Fox, 2014). Our study showed that a lack of respect for patients, which could manifest in denying their autonomy in decision‐making or giving them orders without explanations, could be a barrier to the practice of person‐centred care. Therefore, universities need to educate nursing students about relationship formation with patients in the curriculum, and hospitals need to strengthen education programmes so that nurses can have experiences in positive relationships with patients. Communication refers to the interaction between nurses and patients (Eklund et al., 2019), and nurses' communication skills are an important factor in establishing a therapeutic relationship with patients. Thus, the results of this study indicate that establishing a relationship with patients is an important factor in promoting person‐centred care. However, in this study, we found that nurses and nursing students found it difficult to communicate with patients in a clinical setting. Nursing students had only short communication education in the first grade and do not have regular education, so continuous communication education is required. Hospitals should develop and apply communication training programmes that would allow nurses to cope in different situations.

The lack of policy approach main category revealed that fundamental and practical changes were necessary for nurses to improve the implementation of person‐centred care in clinical settings. Person‐centred care cannot be improved by the individual motivation of a practitioner because it requires continuous effort to promote cultural change across teams and organizations (McCormack et al., 2011). In this study, we found that even if nurses know the importance of person‐centred care, it will be difficult for them to apply it unless there is a law that limits the number of patients per nurse and that changes the hospital system in a clinical setting. A recent study revealed that in tertiary general hospitals in South Korea, the ratio of nurses to patients was approximately 1:9 or 1:10 (Cho et al., 2020). This indicates that nurses have difficulty providing person‐centred care due to their workload, which suggests the need for fundamental changes through macro approaches and policies.

This study asked nursing students to describe barriers to the implementation of person‐centred care in clinical settings. With the aim to improve person‐centred care in the clinical setting, this study identified the barriers to and requirements for the implementation of person‐centred care based on the experiences of nursing students. In the future, efforts should be made to more efficiently allocate nurses' workload, improve education and awareness of person‐centred care, enhance relationship building between patients and nurses and develop policy approaches to fundamentally solve the identified problems.

5.1. Limitations and recommendations

This study has some limitations. First, the results should be generalized carefully because the study focused on nursing students from two universities in South Korea. Second, the findings were only based on the experiences of nursing students who had practised at secondary general hospitals. Lastly, since the interviewers were a professor who teaches nursing students at the same university, there must have been some nursing students who were not honest in their responses to the interviews. Based on the results, we suggest that a qualitative study is needed to identify the barriers to person‐centred care by recruiting nursing students from various universities who have undergone clinical training in tertiary general hospitals and small‐sized hospitals. In addition to the nursing students' experiences, it is also necessary to consider nurses' experiences when identifying the barriers that must be overcome in the implementation of person‐centred care in the clinical setting.

6. CONCLUSION

Person‐centred care has positive benefits for both patients and nurses; hence, it needs to be continuously developed in clinical settings. In addition, identifying barriers to implementing person‐centred care is essential, to find a solution that provides person‐centred care in clinical settings. The experiences of nursing students can provide substantial information to understand the clinical situation, since nursing education is closely related to the clinical environment. Therefore, this study explored the barriers that nurses face while delivering person‐centred care, through the nursing students' experiences during clinical practice. This study showed that the barriers to implement person‐centred care in clinical settings were busyness, educational challenges, lack of awareness, lack of relationship building and lack of policy approaches. These barriers can be overcome by, increasing the number of nurses, reducing their workload, providing specific education for nurses, developing an educational model for nursing students, strengthening supervision for supporting nursing students' approach to person‐centred care during clinical training, strengthening programmes for communication skills and improving the policies. The results should be generalized carefully, since we recruited from only two universities, and explored the experience of nursing students who practised in secondary general hospitals. However, this study is statistically significant in that it is the first qualitative study to explore the barriers and show how to overcome them in clinical settings through nursing students' experiences.

AUTHOR CONTRIBUTIONS

MK and SK: Conceptualization, design, methodology, investigation, data interpretation, and writing review and editing. MK: Writing and original draft preparation, visualization, project administration and funding acquisition. All authors have read and agreed to the published version of the manuscript.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

FUNDING INFORMATION

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. NRF‐2019R1G1A1009444).

ETHICS STATEMENT

The study received ethics approval from the Institutional Review Board of the Kangwon National University. We conducted according to the guidelines of the Declaration of Helsinki to ensure the confidentiality and anonymity of participants throughout the study.

Kim, S. , & Kim, M. (2023). Nursing students' experiences and perceptions of barriers to the implementation of person‐centred care in clinical settings: A qualitative study. Nursing Open, 10, 1889–1899. 10.1002/nop2.1514

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the authors.