Vietnamese nursing students` perception of person-centered care. : A Minor Field Study in Vietnam

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Vietnamese nursing students`

perception of person-centered care.

A Minor Field Study in Vietnam

SUBJECT AREA: Nursing science

AUTHORS: Karolina Löfgren, Linnea Neugebauer & Susanna Sjöberg

SUPERVISOR: Anna Abelsson

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Summary

Background: Person-centred care is a concept which aims to achieve quality in health care.

Person-centred care is about taking the patient's own story into account and creating a partnership between all involved parties. Aim: Exploring nursing students` perception of person-centred care in Vietnam. Method: This study is a qualitative study with a semi-structured interview guide. It has a deductive approach with a directed content analysis. Twelve nursing students were interviewed in this study. Result: The result showed that communication, nurses' knowledge, mutual respect, cooperation and family’s experienced knowledge about the patient were identified as important parts of the participants perceptions about person-centred care in Vietnam. Challenges such as time constraints and misunderstandings were shown to be a repeating problem. Conclusion: The nursing students' perception about implementing person-centred care in Vietnam is positive, but there are challenges in applying this in practice. The number of patients related to the number of nurses is uneven, which may lead to problems in Vietnam regarding person-centered care.

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Titel: Vietnamesiska sjuksköterskestudenters uppfattningar om

personcentrerad omvårdnad. En fältstudie i Vietnam.

Sammanfattning

Bakgrund: Personcentrerad omvårdnad är ett begrepp som används för att uppnå kvalitet i

hälso- och sjukvården. Person-centrerad omvårdnad handlar om att lyssna på patientens berättelse samt att skapa ett partnerskap mellan de olika individerna som är inblandande i vården. Syfte: Att undersöka sjuksköterskestudenters uppfattningar av personcentrerad omvårdnad i Vietnam. Metod: Studien är en kvalitativ intervjustudie där en semistrukturerad intervjuguide användes. Studien har en deduktiv ansats och en riktad innehållsanalys har genomförts. Sammanlagt intervjuades tolv sjuksköterskestudenter. Resultat:

Kommunikation och sjuksköterskans kunskap identifierades som viktiga delar, även respekt och samarbete mellan olika parter samt de anhörigas upplevda kunskap om patienten. Utmaningar som tidsbrist och missförstånd visade sig vara ett problem som påtalades.

Slutsats: Sjuksköterskestudenternas uppfattningar om att bedriva personcentrerad

omvårdnad är positiv, men det finns utmaningar i att tillämpa denna kunskap i praktiken. Antalet patienter relaterat till antalet sjuksköterskor i Vietnam är ojämnt, vilket kan leda till problem med att bedriva personcentrerad omvårdnad.

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Introduction

Health is a human right, which means that all humans should have the highest standard of health, no matter race or ethnicity. Implementation of the right to health is closely connected to other human rights as well. Such as education and non-discrimination, as well as access to information and participation in health care (World Health Organisation [WHO], 2019). Promoting patient participation is a worldwide priority in health care, and an important factor of person-centered care (Oxelmark, Ulin, Chaboyer, Bucknall & Ringdal, 2018). All have the right to good health and fair health care, and person-centered care could help implement this (WHO, 2019). Therefore, it is of great interest to explore in what way person-centered care is implemented in a country such as Vietnam.

Background

Vietnam

Vietnam is located in south-east Asia with an estimated population of 94,348,835 in 2015, all living on an area of 331,210 square kilometre. Vietnam is an elongated country with a long coast and a landscape mostly consisting of mountains and ridges. There is a long history of war in Vietnam. Among others, the Vietnam war that lasted between 1957-1975. It ended in favour to the socialist North Vietnam. The US and the anti-communist South Vietnam´s attempt to stop North Vietnam uniting the country under a communist rule failed (Globalis, 2019). Today, Vietnam is a communist one-party state, no other one-party or opposition organization is allowed. Human rights are limited, and those who criticize the government are often threatened with prison and in some cases arrested (Regeringskansliet, 2018).

The culture in Vietnam is described as influenced by China and is one of the oldest cultures in the world. In Vietnamese culture, family and clan are highly valued, and it is not unusual to see several generations of one family living together. There are three main religions that are practiced in Vietnam; Taoism, Buddhism and Confucianism. Ancestor worshiping is also practiced where altars are set up in both home environments and in office spaces (World Atlas, 2018).

Health care in Vietnam

Vietnam has a mixed public-private health care system, it aims to achieve affordable and universal coverage for all (Cheng, 2014). Health care in Vietnam is divided into different levels. Level one; central. Level two; provincial. Level three; district. Level four; commune (Das, 2018). Level one includes hospitals owned by the Ministry of health and municipalities like Hanoi. Levels two, three and four includes hospitals owned by local governments driven by profits (Takashima, Wada, Tra & Smith, 2017). In recent years, both economic development and health status in Vietnam has improved, this leading to increased life expectancy and decreased mortality rates among infants, according to Takashima et al. (2017). Despite this, there is still inequality in health care between rural residents and those living in bigger cities in Vietnam. Takashima et al. (2017) also describes the lack of employees in the health care sector, and how this leads to an inadequate distribution of human resources that cannot meet the needs of having enough trained health care professionals in hospitals.

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Das (2018) also mentions the negative effects caused by the lack of health care professionals. Meaning that the major challenges in Vietnam regarding the health care sector is overcrowding of patients and a lack of medical staff. To help with the inequality among the different levels, a system was developed to make sure that higher level hospitals will support the lower levels. This system is called Direction of Health Care Activities (DOHA) (Takashima et al., 2017). In Vietnam, too many patients are seeking care at higher level hospitals, especially central level, which causes overcrowding. By using DOHA, the heavy workload on these hospitals can be reduced. This is mainly done by technical skills training, leading to an improvement of quality care in all of Vietnam (Takashima et al., 2017).

Person-centered care

In today's society, a multitude of diseases can be treated with efficiency. But the patient´s knowledge and experiences can easily be overlooked, meaning that the individual being treated may be seen as a patient, rather than a person (Gothenburg University Centre for Person-centered Care [GPCC], 2017). Person-centred care (PCC) is a concept that connects to the importance of quality care for patients. This is done by including the patient and family to create a partnership between them and the health care professionals. To achieve an effective partnership, the patient's narrative must be included to best get a picture of the patient as a human being with their own needs, experiences and abilities. The health care professionals´ medical knowledge must be viewed as equal to the patient and family’s knowledge about the lived disease (GPCC, 2017).

According to Svensk sjuksköterskeförening (SSF) (2016) PCC is deemed to have its origin from Carl Rogers and humanistic psychology. Rogers said that the understanding of a person's situation is a prerequisite to help them (Rogers, 1956). Later, Tom Kitwood used the concept of PCC in the care for elderly people with dementia. Kitwood said that when using PCC, a prerequisite is that one must regard that the person is still the same person as they were before they became ill. Even though the disease may have hindered the ability to communicate their needs (Fazio, Pace, Flinner & Kallmyer, 2017). With the starting point in Kitwoods work, PCC has been developed with several theoretical models to best implement them into the health sector. PCC as a concept has also under the twenty first century grown internationally and is now included in international policy documents from WHO, as well as national guidelines in the US, Australia and New Zeeland among others (SSF, 2016).

In one study, medical staff were interviewed about their thoughts on caring for persons with dementia. In the result it became clear that in order to provide good care, a relationship had to be created between the person receiving care and the caregiver. The participants also mentioned the need for a relationship with the family. A good relationship is vital to be able to provide sufficient care (Berglund, Gillsjö & Svanström, 2018). The goal of PCC is that the patient feels involved in the health care team. Including the patient in their care is done by focusing on their needs and preferences and seeing them as a person rather than a disease (Olsson, Hansson & Ekman, 2016). Family can be a way of getting more information about the patient, therefore they can be a vital part of caring for patients. To involve the patient and family, it demands a dialogue between the nurse and the patient. This gives

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opportunity for the patient and family to be involved in the decision-making instead of just being informed (Olsson et al., 2016).

Schwind et al. (2014) describes the interpersonal relationship as basic prerequisite for PCC. A relationship based on respect, autonomy and empowerment that the patient possesses. An interpersonal relationship will help individualize the care by creating a safe and therapeutic environment. This is done best when the health care professional receives personal information from the patient, making the care more effective and giving the patient the best ability to heal (Schwind et al., 2014). This is also described by Alharbi, Ekman, Olsson, Dudas and Carlström (2012), who mean that PCC also considers the patient´s rights, capabilities and future plans. Also, that PCC will empower the patient and give them an active part in their care.

Three key concepts

Three key concepts are described by the Gothenburg University Centre for Person-centered Care (GPCC), Partnership, Patient narrative and Documentation (GPCC, 2017). Partnership is described as the most central aspect of PCC, it involves the patient, the family of the patient and health care professional, and the need for all involved parties to have respect for one another's knowledge. The patient and the family possess knowledge about the lived condition and the health care professional possess a more general knowledge about rehabilitation and treatment for the condition (GPCC, 2017).

The Patient narrative is about combining results from medical examinations and the narrative of the patient where their condition is described, this is the basis of PCC (GPCC, 2017). This means that a health plan, involving treatment, care and rehabilitation can be agreed upon in partnership with health care professionals. The family are often involved in this process. To achieve a narrative where needs, feelings and experiences are explained, the health care professional must create a safe environment and initiate the conversation. This will give the opportunity of understanding symptoms and the effect they have on the patient´s everyday life (GPCC, 2017).

Documentation is done on an everyday basis, new information is discovered frequently about the patient and it is the health care professionals' responsibility to document systematically to ensure that the care given is optimal for the patient (GPCC, 2017). The patient narrative is an important part of the documentation because it is the basis for working with PCC. The patient narrative includes creating a health care plan together with the patient and family in order to create a partnership. The documentation can be seen as the part that binds it all together and will work as a mutual agreement to further improve the patient´s health in a way that not will diminish the patient´s needs (GPCC, 2017).

Effects of person-centered care

According to SSF (2016), the ethical code of the International Council of Nurses (ICN) establishes that every nurse has an obligation to respect human rights. It states that every health care professionals' goal should be the patients' health. When caring for a patient there must be a balance between an objective aspect, where the nurse is supporting the patient with active help, and a relational aspect, which aims to give help in a way agreed upon with the patient (SSF, 2016). Being a nurse is about caring, and

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being responsible, for several patients at the same time. This means that prioritizing care is done on an everyday basis. To best prioritize care, the nurse must combine theoretical knowledge and the knowledge gathered from seeing the patients, and learning about their needs (Suhonen et al., 2018).

In the future of health care, PCC is strongly recommended as it focuses on needs, values and resources from patients. PCC should not only be implemented to achieve an effective care, but also to increase patient safety (Jakobsson et al., 2019). They also describe the positive effects that is the shortened length of hospital stays and more participation from patients. This they mean, is linked to the understanding of patients´ experience of their health, having a more extensive knowledge about the patient can mean that changes occurring in patients´ behaviour are discovered quicker, thus improving patient safety. Hansson et al. (2015) discuss costs related to treatments for patients with chronic heart failure. By integrating PCC, length of hospital stays, and costs, has decreased. Also, an increase of health benefits and ability to perform daily activities can be seen. They also discuss the benefits of teamwork that is based on the partnership between patients and health care professionals.

By using PCC, it has been essential to both quality of care and quality of life for patients receiving care. However, health care staffs’ perceptions may play a big role in the provision of PCC (Caspar, Le, McGilton & Stone, 2019). This is also mentioned by Blake, Berry & Brown (2019). They mean that health care professionals can practice care in two different ways. Firstly, task-oriented care where it is based on effectiveness. Secondly, where the care is performed in accordance to the person preferences. For instance, when they like to get up in the mornings and if the person prefers a bath or a shower. The result shows that by implementing PCC, several factors can be improved. Some of these are communication, positiveness in the way information is given and supporting the persons strength and ability to do as much as they can themselves.

Problem formulation

Implementation of the right to health is linked to human rights. PCC as a framework can provide understanding of the individual’s needs. The nurse can respect people´s values and put the patient in the center of care. This implies taking into account the patient’s own preferences, principles and expressed needs (Tomaselli, Buttigieg, Rosano, Cassar & Grima, 2020). It also includes involving family and friends in the care according to the culture in Vietnam. The Vietnamese nursing students are educated to ensure and improve patient´s health. Also, to coordinate the execution of primary health care which include planning the care together with the patient and family. It is therefore of interest to describe the perceptions regarding PCC in a development country such as Vietnam and what the potential benefits could be for the future nurses and patients.

Aim

The aim of this study was to explore nursing students’ perceptions of person-centered care in Vietnam.

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Methods

Research design

A qualitative study design with a deductive approach was used with the aim of exploring nursing student’s perception of PCC in Vietnam. When implementing a deductive approach, a pre-existing theory, model or assumption is chosen in the planning stages of the study. This theory, model or assumption will then be used as a common ground throughout the study. It will be used to describe the problem in the background, create the interview guide and also to analyse the collected data (Henricsson & Billhult, 2017).

A qualitative design has its origin in the holistic tradition, which refers to getting a deeper understanding about the participant´s feelings, experiences, perceptions and own thoughts about a specific phenomenon. By using a qualitative design, the participants whole perspective and view of the concept is shown by using their own words (Polit & Beck, 2016). Reflection about, and understanding of, exploring nursing student's perception of PCC in Vietnam is of great importance. This may contribute to an increased understanding and awareness in both the University and in Vietnam as a country.

Participants

Inclusion criteria of this study were that the participants were students studying to become registered nurses in Vietnam, who had to be in their sixth semester at a specific University in Vietnam. They study for a total of four years, meaning that the nursing students participating in this study were in their next to last year. When they graduate they aim to have knowledge about communication, and health care education to be able to coordinate with doctors, patients, and the patient’s family.

The lecturer at the University asked twelve nursing students if they would like to participate in the study, all twelve agreed to participate. The respondents were females between the ages of 20-21 years old (mean 20,17 year).

Setting

This interview study took place at a specific University in Vietnam during January 2020. A strategic sampling was used during this study. Henricsson and Billhult (2017) mean that a strategic sampling is used to get participants with experience of a specific phenomenon.

Data collection

An information sheet about the study’s aim, method and approach was provided through e-mail to the lecturers at the University, two months before the study took place in 2020 (See attachment 1). The information was passed on by the lecturers to the students. A schedule of time and place for the interviews, as well as name of the nursing students who wanted to participate in the study was made by the lecturers at the University and sent to the researchers.

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One pilot interview was conducted. The same questions were used in the pilot interview that were to be used in the interviews with the nursing students. This was done to see if the questions were well formulated and corresponded to the aim of the study (Polit & Beck, 2016). In conjunction with the pilot interview situation, the recording equipment was tested to make sure everything worked. The pilot interview was not included in the result.

The interviews were conducted over two days on four different occasions. Each researcher conducted two interviews in the morning and two in the afternoon on two different days. A total of twelve nursing students were interviewed. The interviews with the students were made “one on one” to ensure that the participants felt comfortable and in accordance with literature it is a way to avoid any power structure (Polit & Beck, 2016). Because not all informants could speak English, a lecturer acted as an interpreter and was also in the room. The same room were used during all of the interviews and there was no risk of being disturbed. Before the interview started, a short presentation about the interviewer was made, which Polit & Beck (2016) mean is a way to make the interview situation more relaxed. Information about the aim of the study and information about how the interview should be conducted was presented. The researchers explained that the interview was voluntary and confidential and that the interview could be cancelled any time if the student so wishes. After that, the students were asked if the interviews could be recorded, and all students agreed to that. Lastly, a consent form was handed out for the participant to sign. A structured interview guide was used. According to Danielson (2017), a semi-structured interview is used in interviews with open questions, where the interviewer can adjust the order of the questions depending on the answers given. All interviews started with the same question; “Would you like to describe your thoughts about involving the patient in his or hers care?”. Follow-up questions were used depending on the answer that emerged (See attachment 2). The interview was finished by asking the participants if they had any further questions or if they had anything to add. The material was transcribed on a computer the same day the interview was conducted. By doing this, the chance of remembering the interviews in the most correct way increases according to Polit and Beck (2016). Pauses, including when the nursing student were telling their answer to the interpreter, sighs or laughs were not included in the transcribed data. The interviews took between 7-18 minutes (mean 10,54 minutes).

Data analysis

The analysis was based on Hsieh and Shannon´s (2005) directed content analysis. A directed content analysis is used when a theory about a phenomenon, in this case the concept PCC, already exists, making the approach deductive. The existing theory can be used to focus the research question and predict the initial categories (Hsieh & Shannon, 2005). In this study, PCC, with the focus on Partnership and Patient narrative was the deductive frame used to sort through the text.

The first step in directed analysis is to find key concepts that will answer as the meaning units, this is done with the existing theory in mind (Hsieh & Shannon, 2005). The interviews were put into numerical order and meaning units that answered to the study´s aim was highlighted.

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oversight of all meaning units could easier be seen. Implementing the analysis scheme was done by first inserting the highlighted transcribed data that the researchers found relevant to the aim, in other words, meaning units. This was done in accordance to the interview order. Secondly, all meaning units were summarized to capture the message of the original text. These summaries made for the condensed meaning units. Thirdly, coding of the condensed meaning units was started (See table 1).

The second step also includes that the researchers will find definitions for the two categories, Partnership and Patient narrative, which are included in the chosen theory PCC (Hsieh & Shannon, 2005). Partnership is described by GPCC (2017) as mutual respect for the knowledge provided by both the patient and family and the knowledge provided by the nurse. Patient narrative is described as listening to the patients experience of living with the disease. To provide good and effective health care a health plan is made in partnership with the patient, the nurse and the family (GPCC, 2017).

The third step described by Hsieh and Shannon (2005) is coding, which was done by reading through the condensed meaning units and finding words or short sentences to summarize them. After coding all condensed meaning units, the codes were put into different clusters based on their similarity and connection to the two categories Partnership and Patient narrative. These clusters made for the sub-categories; Mutual respect and cooperation, family knowledge of the patient, communication and the health care professionals’ knowledge.

Table 1. Meaning units, condensed meaning units, codes, sub-categories and categories.

Meaning units Condensed

meaning units Codes Sub-category Category

Firstly,if the patient understands the situation, they can cooperate with the nurse and understand what they do... Secondly, they feel comfortable, and they understand what the nurse does, and they can follow what the nurse wants. And lastly, the recovery will be better If the patient understands the situation, they can cooperate with the nurse and understand what they do /.../ follow what the nurse wants. And lastly, the recovery will be better Cooperation leads to compliance Mutual respect

and cooperation Partnership

You know, family and friendsunderstand what the patient is, rather than the nurse, so the patients in the hospital have a relative taking care of them

Family and friends

understands what the patient is, rather than the nurse

Family have the best knowledge about the patient

Family knowledge

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Ethical considerations

It was essential that no participant felt ill at ease during this study. To ensure that, four ethical principles was implemented; the principles of respect for autonomy, beneficence, nonmaleficence and justice (Warren, 2011).

The researchers of this study have implemented these four principles by seeing all participants as equal and not being attached in what competence they had or who they were as a person. Also, to protect the participants personal sphere, because the student's perceptions and characteristics has been exposed, which may have been sensitive for the person in question. According to Kjellström (2017), this is of relevance to achieve an ethical correct study.

Furthermore, the participants’ integrity, right to self-determination, information requirement of the study and confidentiality of their private information was protected in accordance with the Declaration of Helsinki (World Medical Association [WMA], 2018). According to the information requirement, an information sheet about this study's aim, method and approach was sent out to the head of the nursing faculty at the University in Vietnam two months before the interviews took place. This letter contained information about the participants right to decline any question they did not feel comfortable answering, their right to end the interview or their participation in the study without further explanation and information regarding how the collected data would be dealt with. To ensure that all students had read the information letter,

It’s very important and necessary to let the patient get involved in the health care.

Because, as a nurse, we can know what they are thinking about and in that way, we will give an appropriate care to the patient.

We will let the patient talk about themselves, what they want, what is their problem, and by that way we can do good health education for them to help them taking care of

themselves. It is not only helpful for the patient, but also helpful for the nurse

It’s very important and necessary to letting the patient get involved in the health care /…/ We will let the patient talk about themselves, what they want, what is their problem, and by that way we can do good health education for them to help them taking care of themselves. It is not only helpful for the patient, but also helpful for the nurse Open communication leads to a favourable care

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the same information sheet was given to the participants in person on the interviewing day, together with a written consent form to sign, if they wanted to participate.

Before the interviews started, information about the study's aim, research procedure and how the interview would be conducted was given by the researchers. All students were asked permission if the interviews could be recorded. All of them said yes. The participants were granted confidentiality, meaning that the name of the participant, or the name of their school and in which city the school is located will not be shown or published. The answers given to the questions would not be attributed to them as persons when the study is presented. This is done to protect the participants (Vetenskapsrådet, 2017).

The audiotaped material was recorded on a mobile phone with a lock-combination to minimize the risk that no one could get hold of the recorded material if the phone would be stolen. The transcript material was written down on a computer and was locked in a safety-cabinet with lock-combination when not used. An ethical review was carried out according to the School of Health and Welfare at Jönköping University(See attachment 3). The researchers have discussed and reflected about the ethical considerations this study might have. After that, the same ethical reviewwas filled out and sent to the supervisor in Jönköping to sign.

The trustworthiness of this study may have been affected by the language barriers during the interviews because all participants could not speak English and the lecturers acting as interpreters. The participants answer may also have been altered by their lecturer in some way, meaning that the answers may not reflect solely on the participants’ knowledge about PCC.

Results

The aim of this study was to explore nursing student´s perception of PCC in Vietnam. The deductive approach divided the information from the interviews into the two categories: Partnership and Patient narrative, each with sub-categories presented below (See table 2).

Table 2. Categories and sub-categories.

Partnership

Mutual respect and cooperation Family knowledge of the patient

Patient narrative

Communication

The health care professional´s knowledge

Partnership

The result of this study showed that the nursing students` perceptions of PCC in Vietnam were that partnership between the nurse and the patient, as well as the family of the patient, was the most central part. Further exploring the participants´ perceptions of partnership showed that an exchange of information, and mutual respect, between all parties in the health care process was needed to be able to create this partnership. This also had to be done with good cooperation. The nursing students also believed that the patient and the family knowledge about living with a disease was

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information of great importance for the medical staff. The participants mean that no one knows the patient better than the patient and the patient's family, and by including them in the care, favorable information will be shared that would not be known if they were not included in the health care process.

Mutual respect and cooperation

Cooperation was described by the participants to work only if the patient and the family could understand the situation they were in. The participants meant that cooperation was based on a genuine contact between the nurse and the patient. It was about mutual respect for one another, in order to provide the best care possible for the patient. The students expressed furthermore, that by letting the patient and family members be included in the health care process, showed that they have an important role in the care. The participants also mentioned that mutual respect and good cooperation may not only lead to a stronger partnership but may also make the patient feel safer and trust the nurse. The nursing students expressed that if the nurse shows respect in meetings with the patient, a deeper understanding about their time in the hospital may be achieved and give the patient a feeling of greater well-being.

“Firstly, if the patient can understand the situation, the patient can cooperate with the nurse and understand what the nurse does. Secondly, the patient understands what the nurse does, and they can follow what the nurse wants.”

“It is very important to let the patient and patient's family members and friends be involved in the health care in order to help the patient.”

“... if the patient can understand what the nurse does, they will feel comfortable and have trust in the nurse.”

To be able to create a strong partnership, the participants meant that a relationship between the nurse and the patient was also needed. Further perceptions about this was that a relationship was based on a good connection between all involved, and that the nurse must show a strong will of taking care of the patient. Which according to the nursing students were both positive and important. By implementing respect and cooperation, a more effective health care may be given because the nurse will understand the patient better. Without good cooperation and respecting each other in the health care process, the participants meant that the quality of care may not be as good.

“But the most important thing is the good relationship between the nurse and the patient, they should have a connection, a good connectionand a good commitment of taking care of the patient and I think that it is a good way to have effective health care.”

The nursing students experienced that there was a lack of nurses in Vietnam and that it affects the care given to the patients in the country. The participants perception about this was that they, in the future, want to give a good care, but the time and the number of patients related to the number of nurses in Vietnam makes it impossible to do so. This may lead to insufficient care and flaws in the cooperation between the

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the participants experienced that the nurse only has time for the medical procedures, and struggle with finding time to help with caring as well, therefore the family plays an important role in caring for the patients. Further perceptions about why it was important to invite family members was that they may be the ones that the patient feels secure with and wants to turn to, which may increase the patients´ sense of well-being.

“You know that in our country the number of the nurses is not quite enough for the number of patients, so it is very necessary that we have help from the family members. /.../ One nurse can have about 10-12 patient each at the hospital, that is a lot. The nurse does the medical stuff and the family members the rest.”

“In our country the number of nurses is weak and insufficient so the support from the relatives is important.”

Family knowledge of the patient

The participants believed that the family have a valuable role in the health care process. They meant that it was important that the nurse respect the family's opinions and how they look after the patient, even when the patient was in the hospital. The participants meant that the family always takes care of each other when someone becomes ill, this due to their culture. That means that the family members have knowledge about what their family member needs and therefore it was of great importance that the nurse respect the family and the way they care for the patient.

“The relatives understand what the patient needs and sometimes if the patient has a sensitive aspect, for example washing their bodies, the relatives can understand and do better than others.”

“It is very necessary to let the family and friends take care of the patient /.../ because they are very close.”

The nursing students explained that the family have extensive knowledge about the patient, and that it was important to take help from them in order to get a deeper understanding about the patient. The participants experienced that the family understand the patient´s needs and feelings in a way that the nurse cannot. The family’s knowledge about the patient was also of great importance when it comes to supporting the patient. The students meant that the nurse should always listen and learn from the family and friends because they may be a valuable source of understanding the patient in different situations. Therefore, the participants explained that it was important to utilize the families knowledge and take help from them. There may be a risk that valuable information was missed, if the nurse chooses not to include the family in the care, according to the nursing students.

“You know, family and friends understand the patient more than the nurse, so if the patient is in the hospital, they have a relative taking care of them.”

“... if the patients go to the hospital with their relatives, apart from physical, the relatives understand about their feelings and their thinking and they can support the patient when they need.”

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Patient narrative

In addition to Partnership, the nursing students mentioned that listening to the patient´s stories and lived experience of their condition was important to be able to implement PCC. The participants explained that the care was planned with the patient and often together with family members, with the starting point from the Patient narrative. The participants experienced that the health care professional´s knowledge and the communication between the nurse, patient and the family played an important role of this part of PCC. The most effective care can be given when the patient´s narrative was included in the health care process, this due to the fact that the patient and their family possesses valuable information about the patient that will help to individualize the care given.

Communication

The nursing students believed that good and open communication was to be sought after. They expressed that it was favorable for the care given, because it creates an understanding of the care process and opens for agreement and conversations that may benefit everyone involved. An open communication may also increase the understanding of the patients experience of their health situation. To obtain the whole story of the patient, the nurse must listen and show an interest in the patient's story in order to get the whole narrative. The participants meant that if the communication was not working, the nurse cannot know how or in what way the patient wants the care to be given. This may cause the patient to feel unimportant or unseen, or just as a part of the health care process, instead of a person.

“We will let the patient talk about themselves, what they want, what their problem might be and by that way we can give good health education for them to help them taking care of themselves. It is not only helpful for the patient, but also helpful for the nurse.”

By allowing patients to talk about, and explain, their problems, the nurse gets a greater understanding of the patient, this according to the nursing students thoughts about communication. A relationship was created and through this, the patient can understand what the nurse wants and will do. It was important that the nurse explained what was going to happen and how the treatment was progressing. Although there must be time for the patients to ask questions. The participants also mentioned the importance of talking to and giving information in a way the patient understands, because the medical language may be difficult to understand in some cases. Therefore, the nursing students meant that the nurse have to talk without difficult medical terms when they give information to the patients.

"Before we do any nursing procedure, we should explain clearly for the patient and the relatives what we will do.”

“The patient can ask questions to the nurse and the nurse must explain what they do and how they do it for the patient, and then the recovery may be quicker. And if the patient agrees with the nurse, they feel very good and comfortable.”

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Knowledge about good and open communication exists among the nurses at the hospitals, but the participants experienced that sometimes there is no time, or not enough resources, to explain everything to the patients. This can cause conflicts when the patient does not understand the care given.

“In our Country, maybe we have some bad conflicts between the nurse and the relatives of the patient. Simply because the nurse has little time to explain the procedure for the patient and for the relatives.”

The health care professionals´ knowledge

To be able to execute PCC, the students mentioned their thoughts about the demand for knowledge among the nurses. The nursing students meant that a prerequisite for giving information about health education, was to have good knowledge about the subject.

“In order to help the patient’s family and friends take care of the patient, they have to have good knowledge about it. So, it means that the nurse has to give good education to the patient´s family and friends. And in order to give good health education, the nurse must have good knowledge.”

The nursing students believed that good knowledge among the nurses can encourage patients to perform good health care for themselves. They meant that by including the patient in the process of creating a health care plan the patient will get more information about how they can apply selfcare in their everyday life. The participants believed that this was very important and that it was crucial to help the patients with this.

“Getting the involvement of the patient, as the nurse we should talk to them how to take care of themselves and provide some health information. After that, if the patient has ability to do it, let them do it and encourage them.”

Although, the participants experienced that to further develop the health care in Vietnam, more knowledge is needed.

“/.../the nurse should learn more to broaden their horizon and get experience when they take care of the patient, and in the future I hope that we will get some support from other countries or maybe some universities to improve the nursing procedures and give good health care for the patient.”

Discussion

Method discussion

Trustworthiness of a study is, according to Polit & Beck (2016), based on three criteria. Credibility, dependability and transferability. Credibility in a study ensures its realness and that its validity is made clear for the reader (Henricson, 2017). The

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credibility is based on asking the right questions to ensure that they will measure what is meant to measure (Polit & Beck, 2016). In this study, a pilot interview was conducted to reassure that the questions were true to the aim.

A few days prior to the interviews, the researchers were contacted by lecturers from the University asking if they could be sent the interview guide. This was done with hesitation due to the fact the participants now would have the possibility of looking up facts to best answer the questions. During the transcriptions this was confirmed due to the many similar answers received, luckily the amount of follow-up questions made some differences in the answers given. This may have affected the credibility of the study. One outcome from this may have been that the participants beforehand could see if they didn’t know how to answer and look it up before the interview started. Meaning that the researchers may have gotten more extensive and longer answers compared to if the interview guide had not been shared with the lecturers and participants. This could have affected the credibility of this study because the answers given may not have reflected on the nursing student’s true perceptions before the interview guide was sent out.

Dependability is about how the data is collected, if enough information has been gathered from the interviews and if the chosen method is right. It is also about bias from the researchers (Polit & Beck, 2016). Interviewing the participants one on one was decided early on to diminish the risk for power structures, since there are three researchers in this study. Since the participants could not speak English, an interpreter was necessary. Lecturers from the University was set on using themselves as interpreters, that has been discussed and questioned among the researchers. If the researchers had the option, an interpreter with no connection to the University would have been chosen. Unfortunately, that was not possible. Having the lecturers as interpreters may have affected the data collection; the participants may have held back on their answers to make sure that nothing “wrong” was said in front of their teacher. One other factor that may have affected the dependability is that the teachers may have altered the answers given to what they believed the researchers wanted to hear. Two different interpreters were used, this may also have affected the collected data since differences were found in the interpretations in the transcribed data. The differences occurring was that Interpreter 1 had better pronunciation and enunciation of words, which made the transcription easier. The entirety of the interview could be transcribed compared to the interviews with Interpreter 2, where several words or meanings could not be heard, meaning that some answers could not be included in the transcription. The trustworthiness of the study may have been affected by the interviews with Interpreter 2 since important answers may have been missed. In contrast, Interpreter 2 made the participants talk more by explaining the questions more extensively in Vietnamese. When Interpreter 2 was used, more elaborate information came from the participants.

To be able to start from a deductive approach, a preunderstanding of the subject to be investigated is needed. It is important to be briefed on the subject, which is also a requirement to work in this way (Hsieh & Shannon, 2005). The researchers therefore had to study further about PCC to gain a deeper understanding and get more knowledge to carry with them to do the best work possible in the deductive analyze. One important factor to be aware of is that by using a preexisting theory in the directed content analysis, the researcher would have extensive knowledge about the phenomenon, which means that the approach would be biased (Hsieh & Shannon,

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2005). The analysis was done with all three researchers together, this to open up for discussion and to achieve a deeper understanding about the collected data. Also, to ensure that a discussion was conducted consistently on how existing knowledge is interpreted.

Transferability is about how the result of the study can be transferred to other situations or groups. To be able to determine if the result can be transferred it has to be clear (Mårtensson & Fridlund, 2017). Polit & Beck (2016), says that transferability also is based on how the chosen method and the data analysis is described. The researchers have therefore described the method in depth and the analysis step by step, and at the same time consistently kept a dialogue with the supervisor in Sweden to make sure that it was described in a way easily understood by future readers. The result from this study may only be able to transfer to similar studies in Vietnam. The researchers believe that if the interviews had been conducted on Swedish nursing students, the result would have been different. Due to both differences in culture and structure of health care in Vietnam in comparison to Sweden or countries like Sweden. To sample the participants, the researchers contacted lecturers from the University in Vietnam and sent out an information sheet to be handed out to the students. After three weeks, a schedule with names and contact information was sent back to the researchers. In what way these participants were chosen has not been shared to the researchers. To be able to conduct the interviews the students on the schedule were therefore used. The ethical nature of that was discussed before the interviews took place since they may not have been fully voluntary this in accordance to WMA (2018), who states that the participants should participate at their own free will. Information about the fact that participation in the study was voluntary and that it could be ended at any time without any explanation therefore felt important to be clear on before the interview started, and that they were given the opportunity of signing the consent form. A consent form gives participants the opportunity to end their participation at any time during the study (Polit & Beck, 2016).

Result discussion

The result of this study showed that the nursing students’ perceptions about PCC was overall positive, and that it is a concept frequently implemented by nurses in Vietnam. Partnership and Patient narrative were shown to be important parts in how they treat their patients at the hospitals. Top findings were that cooperation and communication between the nurse and the patient was something the participants deemed important in their meetings with patients.

According to GPCC (2017), partnership is the most central part in PCC and is described as when two experts meet, which refers to the nurse and the patient. The partnership entails a shared responsibility between the health care professional and the patient, and the care for the patient should always adapt the patient's preferences and needs into the health care process. Rajamohan, Porock & Chang (2019) also meant that one of the most important factors regarding PCC is the partnership between the patient and the nurse, this to ensure quality of care. In this current study, the participants mentioned that creating a partnership with the patients is important to ensure that the patients feel safe and comfortable in their time spent at the hospital. This study also shows that to be able to create this partnership, good cooperation and mutual respect against each other's knowledge is needed, in order to make the patient feel involved in the care. This can be reinforced by an article by Thojampa & Gunda

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(2019), who describes the importance of using PCC to give the patient and family the feeling of respect knowing that they are engaged in the care that is given.

In an article by Pham and Ziegert (2016), involving the patient is seen as something positive and health promoting, although the result described some difficulties to implement this relationship due to the cultural aspects in Vietnam. According to Pham and Ziegert (2016), family members have a big role in the health care process in Vietnam because they provide many treatments at home, and in the hospitals. The family is important as they take care of the patient's hygiene, clothing, and feeding. The result of this current study showed that there are many similarities to what the participants said, and to Pham and Ziegert´s (2016) study. The result of this study showed that because of the culture in Vietnam, family automatically becomes a big part in the care. The nurse must respect their way of how the family takes care of each other, even in the hospitals. This means that the nurses must be aware of the differences that may occur in treating patients and take regard to the family. Otherwise, there is a risk that conflicts may arise between the family and the nurse which may affect the partnership in a negative way.

Described by the participants in this study, is the lack of nurses in Vietnam, and the uneven number of nurses related to the number of patients. This has been described as a factor that may lead to conflicts between patients and nurses, because the nurses don´t always have time to explain what will happen. This may lead to difficulties within the cooperation and flaws in the partnership between the nurse and the patient. This is also mentioned in one study conducted by Upvall et al. (2017), who writes that the partnership among the nurse and the patient in Vietnam is an important part, but it is something that needs to be improved in relation to the nursing situation in the country. Because of this, the family serves as an even more important factor in the health care process.

In accordance to GPCC (2017), patient narrative can be a source of more extensive information about the patients experienced symptoms and needs. This is also mentioned in an article by Mould (2015), who describes that by letting the patient share their narrative with the nurse, the patient can put into words their inner thoughts and their emotions. By listening to the patient, it also means that the imbalanced relationship between the nurse and the patient can be decreased by acknowledging the patient as an important and skilled source for information. Other research shows that there are different strategies to secure that the patient gets involved in the care by utilizing the patient narrative, such as listening to, and engaging, the patient in their care (Oxelmark et al., 2018). By listening to the patient, the health care professional can more easily treat the patient by using the information received. The patient's strengths will be brought to life and can be used as a resource in caring for the patient (Mould, 2015). This has also been mentioned by the participants in this current study, where they mean that when the patient is included in the care, they also will get a better understanding of their situation. And when a patient has the means to care for themselves, the nurse must encourage the patient furthermore and play to their strengths.

According to the Health Innovation Network (2016), there are several important factors that are included in PCC to create this involvement. One of the most central factors is “taking into account people’s preferences and expressed needs” in order to get the whole patient narrative. In this study, the result showed that the nurse must be

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health care process, only then will the patient narrative have an opportunity to come forward. Although, it is important to mention that the result of this study also showed that the nurses in Vietnam do not always have the time to sit down and get the whole patient narrative because of the time restraints. If the nurse does not have time to explain the situation in a way that the patient can understand, then how could PCC be achieved?

However, the patient narrative can also be seen as an aspect of PCC that will help achieve a relationship, this built by the shared experience from the patient which gives the nurse a bigger picture of his or her patient. This can in other words be described as a therapeutic relationship (Mould, 2015). This is also mentioned by Schwind et al. (2014), who describes the interpersonal relationship that serves as a foundation of PCC. They mean that by creating a safe and therapeutic environment, an individualized care will be achieved with the help of the patient narrative. GPCC (2017), also mentions the demand for knowledge among the nurses in order to both create a safe relationship and to best initiate a conversation where the patient and the family can share concerns or worries. This will lead to a care where the person receiving care will be seen as a person, and not just a patient.

The nurses in Vietnam are doing the best they can to provide good health care and meet their patients in a person-centred way. But what really came through during this result was that most of the time that is not possible related to overcrowding, time restrains and few nurses at the hospitals. So, a question for discussion is if the nurses really can provide a care that is person-centered with the current health care system in Vietnam. This result demonstrates that there is a risk that patient safety is affected because of this, and that is why new research about PCC really is needed to both create a better health care system, highlight negative outcomes and of course, increase patient-safety.

Conclusion

Overall, PCC is deemed important in caring for patients in Vietnam. Getting the involvement from patients and families is important, both for creating a relationship between the caretakers and the caregivers, but also for the health care professionals to give the best care possible.

The result showed that the lack of nurses in Vietnam is a big problem. The nurses possess knowledge about how to create a partnership and give good health care to the patients by listening and respecting the patient and the family's needs, but they do not always have the resources or work force to do so. This may affect the cooperation between the nurse and the patient in a negatively way which can lead to conflicts or misunderstanding.

Clinical implications

The aim of this study was to explore nursing students' perceptions of PCC in Vietnam. The clinical implications of this study were not to see if the students worked from a PCC perspective or invite them to do it. The clinical implications were to highlight in which way the nurses include the patient and the family members in the patientcare in Vietnam. With this study, a reflection and discussion about PCC as a concept is to be created, which may increase positivity's, curiosity and awareness about working from a perspective like this. Hopefully, our result will bring further knowledge about

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PCC, both to the nursing students on a professional level, but to Vietnam health care and to other development countries as well.

Funding

The Swedish International Developing Cooperation Agency (SIDA) has been a part of the financing of this study, due to the Minor Field Scholarship (MFS) received in 2019.

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Attachment 1

Information sheet

Information sheet

Dear students at xxx University,

During the Spring of 2020, nursing students Karolina Löfgren, Linnea

Neugebauer and Susanna Sjöberg from the School of Health and Welfare at

Jönköping University, will travel to xxx to conduct a study with the aim explore

nursing students’ perceptions of person-centered care in Vietnam.

Person-centered care is a concept that aims to integrate patients and family’s needs and preferences in the care that is given.

We are now asking students that are in their sixth semester to participate in this project. This means that you will be interviewed by one of us. The interview will take approximately 30 minutes and you may decide a time and place for the interviews. We

will interview a total of 12 nursing students. Our result that is based on your

answers during the interviews will be confidential and only dealt with by the research group, meaning that no one can trace the answers back to you. Your participation in this study is voluntary and you can choose to end your participation at any time during the study without any explanation. We will not collect any personal information about you. This is based on the Declaration of Helsinki. The result will be presented in a study on a bachelor level.

Do you want to participate? Please sign here:

Sign... Date ...

Should you require further information, please do not hesitate to contact us.

Susanna Sjöberg E-mail: XXX / phonenumber: XXX Karolina Löfgren E-mail: XXX / phonenumber: XXX Linnea Neugebauer E-mail: XXX / phonenumber: XXX

Supervisors at Jönköping University, Sweden: Anna Abelsson

PhD, Senior Lecturer Nursing Science

Department of Nursing School of Health and Welfare Jönköping University Email: XXX

Vietnamese nursing students` perception of person-centered care. : A Minor Field Study in Vietnam