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J Korean Acad Fundam Nurs > Volume 28(2); 2021 > Article
Choi, Yoon, Kim, Kang, Park, Um, Kim, and Kim: Factors Affecting Interpersonal Competence of Nursing Students: Focused on Self-Assertiveness and Empathy

Abstract

Purpose

Interpersonal competence, a key competence for patient-centered care by nurses, should be understood. Therefore, factors influencing the interpersonal competence of nursing students should be identified to explore and enhance their interpersonal relationships during the undergraduate educational curriculum for nursing educators. In this study factors influencing interpersonal competence, especially on self-assertiveness and empathy in nursing students were identified and analysed.

Methods

A cross-sectional study design was used for the study in two Korean nursing colleges with similar baccalaureate nursing curricula. A total of 251 nursing students from freshman to senior year completed a questionnaire to measure related factors that were assumed to influence nursing students’ interpersonal competence. Data were collected from October 11~31, 2016. Study variables included self-assertiveness, empathy, interpersonal competence, and socio-demographic status. Multiple regression analysis was used for data analysis.

Results

Nursing students’ interpersonal competence was explained by personality (β=.22), self-assertiveness (β=.16) and empathy (β=.38). The explanatory power of these predictors was 26.8% (p<.001).

Conclusions

Nursing students’ interpersonal competence during the undergraduate nursing years can be enhanced by educational strategies that improve their interpersonal relationship as patient-centered care providers. Simultaneously, the attitude of the nurse educator is also important for nursing students who are to be treated as valuable learners and to improve students' empathy and self-assertiveness ability.

INTRODUCTION

Interpersonal relationships are a complex dynamic pro-cess and ongoing interaction between two or more people [1]. Building interpersonal relationships fosters oppor-tunities for high-quality person-centered care in nursing fields [2]. Nursing scholars focusing on human relation-ships promote mutual trusting relationships between nurses and patients, nurses and health workers, nurses and other involved multidisciplinary care team. If inter-personal relationship is not fundamentally achieved in the nursing environment, achieving the therapeutic effect through nursing care is difficult [3]. In particular, when patients are faced with physical and functional difficulties, are emotionally vulnerable, or require sustained and supportive care in the clinical nursing practice, a well-established therapeutic relationship plays an important role in the patient's recuperation from the disease and regaining their previous health status [2]. Therefore, nursing students' in-terpersonal competence is an important ability to form in-terpersonal relationships necessary as future nurses [4].
Peplau's Interpersonal Relations is a theory that ex-plains the importance of interpersonal relationships in nursing education [5]. This theory insisted that nursing students should participate in constructive learning for their growth and personal maturity during the learning process. Nursing students' interpersonal relationships should be developed in a more productive and innovative way, even if they experience frustration and conflict anxi-ety during the learning process. Nursing students not only learn the communication process in interpersonal relation-ships during the clinical practicum but also actual commu-nication as an important tool in forming interpersonal relationships [5]. Therefore, the ability to establish satisfactory interpersonal relationships during the nursing curriculum should be prepared by identifying factors influencing nursing students' interpersonal competence.
The twenty-first century is an era of self-assertion and self-expression. In the Korean society, the concept of ‘as-sertiveness’ tends to be understood differently from the concept in the West cultural society, that is, ‘self-assertion’ is regarded as insisting on one's position without consid-ering other party's feelings. Koreans especially tend to fo-cus on etiquette and consideration for their opponents; therefore, they hesitate to speak up undesired or conflicting events [6,7]. However, the social relationship is possi-bly developed by disclosing more personal information with each other. Avoiding self-assertiveness and lack of understanding about oneself are the great obstacles in building good interpersonal relationships [6,8]. Nurses' self-assertiveness is an important element of nursing ac-tivities, so that they can help patients efficiently. There-fore, before pursuing action-oriented nursing, a relation-ship should be established so that the patient can trust what the nurse presents and exposes regarding his/her problem [9]. Nurses needed to express their own similar experiences and feelings to their co-nurses and doctors, in order to help build intimacy and confidence. In addition, having adequate self-assertiveness can be one of the qual-ities required in providing quality nursing and performing effective nursing work [10]. Therefore, nurse educa-tors should identify self-assertiveness characteristics of Korean nursing students who are reluctant to assert them-selves due to cultural tendencies and describe how self-as-sertiveness affects the interpersonal skills important for nursing students or the nursing profession.
Empathy is the competency to understand and accept the opponent's position and perspective precisely in the same place as others and is an essential element that should be developed by nurses in order to establish ther-apeutic relationships with patients and during the clinical practice [11]. The empathic ability facilitates interaction be-tween nurses and patients to form a positive relationship. An effective communication with patients enables the patient and the caregiver to feel satisfied by recognizing patient's desire and solving the problem [12]. Therefore, em-pathy is an important characteristic that nursing students should have in order to grow as a nursing professional manpower. Moreover, nurse educators in the clinical nursing field must enhance the empathetic component of nursing students and maintain it at a high level from basic nursing education.
The importance of nursing students' interpersonal com-petence is insufficiently emphasized repeatedly; therefore, its influencing factors have been studied diversely [4,5]. However, majority of studies have identified the strong re-lationship between interpersonal competence and self-as-sertiveness [12,13] or between interpersonal competence and empathy [2,11,14]. No studies have attempted to in-vestigate the relationship among these three variables, in-terpersonal competence, self-assertiveness, and empathy, especially the effectiveness of self-assertiveness and em-pathy on the interpersonal competence of nursing students.
Therefore, this study aimed to verify the relationship among self-assertiveness, empathy, and interpersonal com-petence and the effects of self-assertiveness and empathy on the interpersonal competence of college nursing stu-dents. Exploring and enhancing students' interpersonal relationship during the undergraduate educational curric-ulum can significantly guide how nursing educators can teach their students to foster self-assertiveness and emotional empathy in nursing education.

METHODS

1. Research Design

The authors used an exploratory cross-sectional de-scriptive study design to identify associated factors the in-terpersonal competence of nursing students focused on self-assertiveness and empathy.

2. Participants and Data Collection

The study participants were recruited in two nursing colleges with similar baccalaureate nursing curricula lo-cated in W urban city, Korea. Number of study partic-ipants were calculated using the G∗Power 3.1.2 package [15], under the condition of linear multiple regression with medium effect size .15[3], an ⍺ level of .05, power of .99 and number of predictors of 14. As a calculation result, at least 251 subjects were required. Therefore, a total of 260 questionnaires (approximately 65 students per grade from freshman to senior) were distributed from October 11 to October 31 2016. Data were collected by six trained re-search assistants in two nursing colleges. In this study, a total of 251 nursing students (115 participants from A uni-versity, 136 participants from B university) participated (96.5% response rate). Only participants who signed a con-sent form were allowed to participate in the data collection. The questionnaire response time was approx-imately 20 minutes. The completed questionnaire was col-lected in the unmarked envelopes.

3. Instruments

A self-administered questionnaire was used to identify the frequency of participant's sociodemographic charac-teristics (gender, school year, religion, sibling, personality, satisfaction on pocket money, residence with family, grade in college, attendance in communication class, participation in school club, and clinical practicum experience), self-assertiveness, empathy, and interpersonal competence.

1) Self-assertiveness

Self-assertiveness means an honest expression of one's ideas, such as his or her rights, desires, opinions, thoughts, and feelings, in a language or action, without compromising the rights or feelings of others during an interpersonal interaction [16]. Self-assertiveness was measured using a modified Beon and Kim [16]'s instrument, which was orig-inally developed by Rakos and Schroeder [17] as ‘Assertive Behaviour Assessment Scale,’ by adapting and evalu-ating self-assertiveness according to the Korean cultural background. This instrument consists of 20 questions with three subcategories: content (9 items), verbal (7 items), and non-verbal elements (4 items). Responses for each item are rated with a Likert 5-point scale (from ‘strongly disagree= 1’ to ‘strongly agree=5’). The authors then converted the total mean score to an item mean to facilitate comparisons with other study variables. Higher scores are more desir-able for self-assertive behaviour. In terms of instrument re-liability, Cronbach's ⍺ in an original study [17] was .80, .76 in a modified version study [16], and .88 in this study.

2) Empathy

Empathy means understanding the other person's ob-served experience, as well as an emotional process and abil-ity to perceive it one's own situation from the person's point of view [18]. Empathy was measured using a modified Jeon [19]'s instrument, which was reconstructed from ‘Measure-ment of Emotional Empathy [20]', ‘Interpersonal Reactivity Index [18]', and ‘Index of Empathy [21]'. This instrument consists of 30 questions with two subcategories: cognitive (15 items) and emotional (15 items) empathy. A Likert 5-point (from ‘strongly disagree=1’ to ‘strongly agree=5)’ was used to rate each item. The authors then converted the total mean score to an item mean to facilitate comparisons with other study variables. Higher scores mean higher level of empathy. In terms of instrument reliability, Cronbach's ⍺ in Jeon [19] was .83 and .82 in this study was.

3) Interpersonal competence

Interpersonal relationships are psychological forms of how a person reacts to another person with a thought or feeling and how to perceive and act on that person. In this study, the authors used the ‘Interpersonal Competence Questionnaire’ developed by Buhrmester et al. [22] and translated by Kim and Kim [23]. This instrument consists of 40 questions with two subcategories, i.e., initiation (8 items), negative assertion (8 items), disclosure (8 items), emotional support (8 items), and conflict management (8 items). The response to each item is rated using a Likert 5-point scale (from ‘strongly disagree=1’ to ‘strongly agree=5’). The au-thors then converted the total mean score to an item mean to facilitate comparisons with other study variables. Higher scores indicate proper functioning in interpersonal relationships. In terms of instrument reliability, Cronbach's ⍺ in Buhrmester et al. [22] was .83, .82~91 in Kim and Kim [23], and .85 in this study.

4. Ethical Consideration

The study was approved by the institutional review board (IRB) at the authors’ institution (CR316041). Partici-pants were informed about the study objectivises, questionnaire contents, data confidentiality and anonymity, and their right to refuse from study participation at any time. Written informed consent was obtained from all par-ticipants prior to the start of the study.

5. Data Analysis

The collected data were analysed using IBM SPSS/WIN (version 25.0; IBM Corp., Armonk, NY, USA). Statistical significance was judged based on p<.05 on both sides. Study variables were analysed as frequency, percentage, mean, and standard deviation. Differences between study variables and interpersonal competence were analysed by independent t-test and one-way ANOVA. Correlations among self-assertiveness, empathy, and interpersonal com-petence were analysed by Pearson's correlation coefficients. After confirming the appropriateness of the regression model, multiple linear regression analysis was performed to identify influencing factors and explanatory power of interpersonal competence.

RESULTS

1. Sociodemographic Characteristics of Nursing Students

Among nursing students, 221 females (88.0%) and 30 male students (12.0%) participated, and 21.5~28.3% of stu-dents participated in each grade. A total of 116 (46.2%) stu-dents were religious, 213 (84.9%) had siblings, 139 (55.4 %) were introverts, and 112 (44.6%) were extrovert. Student who were satisfied with their pocket money were 128(51.0%), and those who reside with their family were 41(16.3%) only. Perceived own grade in college (GPA) was reported to be low in 33 (13.1%) patients, middle in 174(69.3%), and high in 44 (17.5%). Students who had been at-tending communication classes during college were 183(72.9%), and those participating in school club recently were 202 (80.5%). Lastly, half of the participants 123 (49.0%) had clinical practicum experiences (Table 1).
Table 1.
Sociodemographic Characteristics of Nursing Students (N=251)
Variables Categories n (%)
Gender Male 30 (12.0)
  Female 221 (88.0)
School year First 66 (26.3)
  Second 60 (23.9)
  Third 54 (21.5)
  Fourth 71 (28.3)
Religion No 135 (53.8)
  Yes 116 (46.2)
Siblings No 38 (15.1)
  Yes 213 (84.9)
Personality Introvert 139 (55.4)
  Extrovert 112 (44.6)
Satisfaction with pocket money No 123 (49.0)
  Yes 128 (51.0)
Residence with family No 210 (83.7)
  Yes 41 (16.3)
Grade in college (GPA) Low 33 (13.1)
  Middle 174 (69.3)
  High 44 (17.5)
Attended communication class No 68 (27.1)
  Yes 183 (72.9)
Participating school club No 49 (19.5)
  Yes 202 (80.5)
Have had clinical practicum experience No 128 (51.0)
  Yes 123 (49.0)

2. Self-Assertiveness, Empathy, and Interpersonal Competence of Nursing Students

Self-assertiveness value ranged from 1.85 to 4.80 out of 5, with a mean score of 3.74±0.53. As subcategories of self-assertiveness, the mean value of content expression was 3.52±0.48, verbal expression 3.82±0.74, and body ex-pression 4.08±0.75. Empathy value ranged from 2.00 to 4.43 out of 5, with a mean score of 3.49±0.35. As regards the subcategories of empathy, the mean value of cognitive empathy was 3.46±0.36 and emotional empathy was 3.51 ±0.41. Interpersonal competence value ranged from 1.18 to 4.30 out of 5, with a mean score of 3.51±0.32. As sub-categories of interpersonal competence, the mean value of initiation expression was 3.49±0.39, negative assertion 3.39±0.50, disclosure 3.41±0.46, emotional support 3.85± 0.51, and conflict management 3.40±0.37 (Table 2).
Table 2.
Self-Assertiveness, Empathy, and Interpersonal Competence of Nursing Students (N=251)
Variables Item M±SD Min. Max.
Self-assertiveness 3.74±0.53 1.85 4.80
 Content expression 3.52±0.48 2.11 4.67
 Verbal expression 3.82±0.74 1.57 5.00
 Body expression 4.08±0.75 1.25 5.00
Empathy 3.49±0.35 2.00 4.43
 Cognitive empathy 3.46±0.36 2.27 4.53
 Emotional empathy 3.51±0.41 1.73 4.40
Interpersonal competence 3.51±0.32 1.18 4.30
 Initiation 3.49±0.39 1.13 4.63
 Negative assertion 3.39±0.50 1.25 4.63
 Disclosure 3.41±0.46 1.50 4.75
 Emotional support 3.85±0.51 1.00 5.00
 Conflict management 3.40±0.37 1.00 4.63

Max.=Maximum; Min.=Minimum.

3. Interpersonal Competence according to Socio-demographic Characteristics of Nursing Stu-dents

Interpersonal competence was significantly different according to personality (t=-5.46, p <.001): 3.41±0.32 for introvert and 3.62±0.28 for extrovert personalities. However, other variables except personality were not significantly different (Table 3).
Table 3.
Interpersonal Competence according to Sociodemographic Characteristics of Nursing Students (N=251)
Variables Categories Interpersonal Competence
M±SD t or F(p)
Gender Male 3.54±0.26 0.58
  Female 3.50±0.33 (.560)
School year First 3.53±0.28 2.38
  Second 3.49±0.28 (.070)
  Third 3.42±0.41  
  Fourth 3.57±0.31  
Religion No 3.52±0.28 0.35
  Yes 3.50±0.36 (.729)
Sibling No 3.51±0.30 0.16
  Yes 3.51±0.33 (.876)
Personality Introvert 3.41±0.32 −5.46
  Extrovert 3.62±0.28 (<.001)
Satisfaction with pocket money No 3.48±0.29 −1.22
  Yes 3.53±0.35 (.223)
Residence with family No 3.50±0.33 −0.30
  Yes 3.52±0.27 (.765)
Grade in college Low 3.45±0.26 0.64
(GPA) Middle 3.51±0.34 (.526)
  High 3.53±0.30  
Attended communication class No 3.51±0.28 0.618
  Yes 3.51±0.36 (.537)
Participating in school club No 3.58±0.34 1.84
  Yes 3.49±0.32 (.066)
Have had clinical practicum experience No 3.53±0.27 0.06
  Yes 3.50±0.33 (.951)

4. Correlation among Self-Assertiveness, Empathy, and Interpersonal Competence of Nursing Stu-dents

Interpersonal competence was significantly positively correlated with self-assertiveness (r=.26, p<.001) and em-pathy (r=.42, p<.001). However, self-assertiveness was not significantly correlated with empathy (Table 4).
Table 4.
Correlation among Self-Assertiveness, Empathy, and Interpersonal Competence of Nursing Students (N=251)
Variables Empathy
Interpersonal competence
r (p) r (p)
Self-assertiveness .07 (.257) .26 (<.001)
Empathy   .42 (<.001)

5. Effects of Self-Assertiveness and Empathy on the Interpersonal Competence of Nursing Stu-dents

To identify the effects of self-assertiveness and empathy on interpersonal competence, multiple linear regression was conducted. Personality, which was significantly dif-ferent based on sociodemographic variables, was input as control variable in this regression analysis. For evaluation of the assumptions, the tolerance limit of independent var-iables was .93, which was larger than 0.1, and the variance inflation factor (VIF) was 1.08, indicating no multi-colli-nearity. The Durbin-Watson statistic was 2.02, which was close to 2.0, suggesting no autocorrelation among inde-pendent variables. As a result of confirming the scatter plot of the dependent variable through the normal P-P plot, the shape of the residual was uniformly distributed, confirming the normality of the residual. It was also con-firmed that there were no outliers as the Cook distance was less than 1 from the minimum of .001 to the maximum of .947, and the standardized residual values were distri-buted between −2 and 2, confirming the equality of vari-ance.
The final regression model (Model 2) showed that per-sonality (β=.22, p<.001), self-assertiveness (β=.16, p=.004) and empathy (β=.38, p<.001) explained 26.8% of interper-sonal competence of nursing students (F=31.58, p<.001) (Table 5).
Table 5.
Effects of Self-Assertiveness and Empathy to Interpersonal Competence of Nursing Students (N=251)
Variables Model 1
Model 2
B SE β t p B SE β t p
(Constant) 3.41 0.26   132.05 <.001 1.84 0.21   8.66 <.001
Personality 0.21 0.04 .33 5.46 <.001 0.14 0.04 .22 3.89 <.001
Self-assertiveness           0.10 0.04 .16 2.87 .004
Empathy           0.35 0.05 .38 6.92 <.001
  Adjusted R2=.103, F=29.78, p<.001 Adjusted R2=.268, F=31.58, p<.001

Dummy variable: Personality (0=Introvert, 1=Extrovert).

DISCUSSION

Establishing a successful interpersonal relationship is the most important challenge for nurses not only with patients who need quality nursing care but also with col-leagues who work with them. Nurses with successful in-terpersonal competence induce patient-centered care to maintain safety in providing effective nursing care [24]. Recognizing how interpersonal relationship can affect patient safety is an important first step in improving the quality of patient care [25]. Majority of nursing education curriculum focuses on the scientific basis of nursing and providing nursing skills, and only theoretical concepts are dealt inside the classroom about the interpersonal relationship, therapeutic communication, or concepts of em-pathy toward patients [26]. However, these concepts are usually learned and practiced through clinical practicum hours rather than in classes. Nursing educators should un-derstand key variables that affect nursing students to im-prove interpersonal competencies and how they can ap-proach to improve competencies required when nursing students deal with patients in clinical practice within the nursing major curriculum.
According to the final result of this study, nursing stu-dents’ interpersonal competence was explained by em-pathy, personality, and self-assertiveness. First of all, in-terpersonal competence in this study population was 3.51 out of 5 from freshman to senior. This value is slightly low-er than 3.65 in 231 Korean nursing and medical students from junior to senior [27]. However, it was similar to 3.58 in 1,209 college students from freshman to senior taking psychology courses at south western university in Ameri-ca [28], conducted in the same school year with this study population. In particular, senior students had the highest interpersonal competence scores, the same as in other com-parative studies [27,28]. This can be due to the increase in the interpersonal competence as the experience of forming relationships with various patients increases as seniors ac-cumulate clinical practice experience. However, the difference in interpersonal competency scores was not statisti-cally significant according to school years in this study. Therefore, further studies comparing the differences in competences after securing a sufficient number of partic-ipants from freshman to senior years should be conducted.
In addition, among the subcategories of interpersonal competence (initiation, negative assertion, disclosure, emotional support, and conflict management), the value of emotional support showed the highest score in this study and other two comparative studies [27,28]. ‘ Negative as-sertion’ had the lowest score in this and Je et al. [27]'s studies on Korean nursing and medical students, whereas ‘di-sclosure’ had the lowest score in Dunn [28]'s study in the USA. These results can be understood as a result of cul-tural characteristics of Koreans who do not express their opinions in front of others with different opinions [6]. However, based on the results found in this study, self-as-sertion is a major variable affecting the interpersonal com-petence of Korean nursing students. In a complex health-care environment, a cooperative relationship should be es-tablished through accurate communication, and self-ex-pression with colleagues from various disciplines sur-rounding the nurses will not only maintain patient's health who is the target of nursing but also bring the best practical outcomes [29]. Therefore, in the global era, nursing educators should become aware of their students’ dif-ferent characters according to their ethnic or culture in order to train and educate them accordingly so that they can express their opinions effectively.
As a variable affecting the interpersonal competence of college nursing students, the mean value of empathy in this study was similar to the scores in other studies [14]. Empathy is essential for clinical and educational practice and human resource management, combining scientific knowledge with interpersonal relationships in professio-nal-patient-focused nursing practice, health-disease proc-esses, technical skills development, and balance among all branches [11]. The results of this study demonstrated that empathy was positively correlated with interpersonal competency, and the important influence of empathy on the formation of successful interpersonal relationship was reconfirmed. The nursing educator's efforts to improve empathy can be proven by studies showing that it is im-proved through practicum class using simulation teaching methods [30]. These efforts are expected to have a signifi-cant impact on enabling nurse-patient interpersonal relationships, which Peplau [5] emphasized in nursing education, i.e., during the clinical practicum of nursing students.
As another affecting variable, the mean value of inter-personal competence in nursing students with an extrovert personality was significantly higher than those with an in-trovert personality in this study. This can be understood in the same manner as the result of correlation analysis be-tween variables in which students with high self-assertive-ness scores also had high interpersonal competence. These results are similar to those of researchers who insist that nurses’ self-assertive and interpersonal relationship abil-ities should be equally well established in order to form an emotional intelligence to become qualified clinical nurses and nurse leaders [8]. Therefore, nursing educators should recognize that the self-assertiveness of nursing students plays an important role in the formation of a successful in-terpersonal relationship between the nurse and patient or the nurse and other professionals in clinical practice and they should be able to identify students’ personality first to improve their self-assertiveness.
As the last affecting variable, self-assertion which was the ability to assert one's opinions and to empathize with others confirmed the important role of nursing students’ interpersonal relationships. Even if self-assertion is not culturally acceptable [6,7], nursing practice education can still produce the best nursing outcomes and maintain the best safety of patients by providing training to develop ef-fective self-assertive skills while improving empathy. This effort will be an important educational element for nursing educators to nurture prospective nurses who can form successful nurse-patient and nurse-other professionals’ relationships.
There are some limitatios of this study. This study was conducted only in two nursing colleges in Korea, therefore it is limited in explaining the interpersonal competence of nursing students of the Korean nursing students. When generalizing the current results to other cultural groups should be careful. In addition, this study focused only on self-assertiveness and empathy to interpersonal compe-tence although many diverse variables affect; therefore, it is limited in explaining general nursing students’ inter-personal competence. Further studies are needed to ex-plore nursing students’ interpersonal competence with more diverse factors.

CONCLUSION

Establishing a successful interpersonal relationship is the most important challenge for nurses. This study was conducted to identify factors influencing the interpersonal competence of Korean nursing students, especially on self- assertiveness and empathy. Based on the results, nursing students’ interpersonal competence was affected by per-sonality, self-assertiveness, and empathy in this study, and the explanatory power of personality, self-assertiveness and empathy on the interpersonal competence was 26.8%. Nursing educators should recognize that nursing stu-dents'self-assertiveness and empathy play an important role in enhancing their successful interpersonal compe-tence. Further, nursing students’ interpersonal compe-tence during the undergraduate nursing curriculum will be possibly enhanced by educational strategies that im-prove their self-assertiveness and empathy.

Acknowledgments

The authors express their deep appreciation to the stu-dents and nursing faculties who agreed to participate in data collection at nursing colleges for this study.

Declaration of Conflicting Interests

Conflicts of Interest
The authors declared no conflict of interest.

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