The Nursing-Home Care Quality Perceived Levels from Patients and Caregivers: An Explanatory Study

Introduction

The care quality perceived both from patients and caregivers referred to their impressions assessed on the healthcare received and represented a helpful tool for health-care organizations to supervise the quality of health-related services provided, respectively.¹ By improving the healthcare quality delivered, health-care organizations also guaranteed patient security, increasing clinical efficiency, and encouraging public awareness.^2,3 Supplying elevated standards in quality care and assuring patients and caregivers achievements represented a novelty among health-care organizations all around the world. Nursing care quality perception, involving patient’s and also caregiver’s satisfaction, was considered a very important issue in the quality of healthcare assessment, both in hospital environmental management and accreditation requirements, too. However, the nursing care quality perception seemed to be very hard to assess.^4–6 Literature showed some validated instruments to measure the nursing care quality perceptions both from patients and their relating caregivers.^7–15

Additionally, the continuous increase in health-care efforts, the constant improvements in the quality of the nursing facilities became urgent with the quality assessment and its relating delivered services in order to emphasize patient satisfaction.¹⁶ Nantsupawat et al¹⁶ underlined how quality nursing care facilities improved, at the same time, physical, psychological, and social care spheres,¹⁷ by decreasing patients’ taking charge and arising home treatment.¹⁸

As nurses provided the largest ratio of the home-care treatments to patients, they played an important function in boosting the quality of services.¹⁹ However, evidence suggested how nursing quality perceptions were relatively inadequate in several countries.^20,21 In Italy, the quality of nursing-home care became the major focus for the public health-care facilities and the Italian government thanks to reforms aiming to improve the quality and the accountability of health-care facilities involved.²² The Italian National Health Service guaranteed home health-care plan to non-self-sufficient or fragile patients. This plan covered a multidimensional assessment of health-care needs, including functional and autonomy needs, and also socio-family-relational and economic requirements, too. Individual assistance project (PAI) or individual rehabilitation project (PRI) was therefore improved to recognize the required nursing-home care service and the execution and the duration of the treatment. These caring projects dealt with home care assistance and provision of medical, nursing, assistance or rehabilitation services with the frequency of home visits, according to the nature and the complexity of the clinical case.²² Because nursing care played an essential role in the increasing level of health-care services delivered to the community, the present study aimed to assess any differences existed in home-nursing care quality perceived levels both by patients and their caregivers.

Methods

Procedure

From November 2022 to January 2023 an ad-hoc-on-line and anonymous questionnaire was developed thanks to the Google Modules program and publicized through some social pages belonging to the Facebook and Instagram communities. The questionnaire was addressed both to patients and caregivers who benefited from home care nursing assistance both for a brief time, such as less than 12 months, and also from a longer time, such as more than 12 months. All potential interviewees were invited to fill the on-line questionnaire, by activating the created link. Only interviewees, who voluntarily agreed and gave their consent to processing data were included in the present study.

Measure

According to both current literature and to the aim of the present study, the questionnaire was elaborated “ad hoc”, containing 18 questions divided into three main dimensions. Specifically, the first part collected some sampling characteristics, such as:

• Gender, as female or male;
• Age divided into different groups, as: up to 30 years, up to 40 years, up to 50 years, up to 60 years, up to 70 years and over 71 years;
• Educational levels, such as: elementary, junior high, high school diploma, college degree;
• Home- care nursing service utilization, as less than 12 months or more than 12 months;
• Who suggested the nursing home-care service, as a health-care worker, a physician or another one.

The second part of the questionnaire contained six items which recognized a general level of the nursing-home care quality perceived. For each items, a Likert scale was associated which ranged from 1, as “very unsatisfied”, to 4, as “very satisfied”. The reference questionnaire was just published in the current literature²³ and only the general part and the part concerning the nursing staff was considered in this research. The items proposed were:

• Item no.1: How did you evaluate the waiting times for the request at the first contact with the home care service?
• Item no.2: Was it easy to get a reservation?
• Item no.3: How did you judge the information received before the first contact?
• Item no.4: How did you evaluate overall the welcome received at the first contact?
• Item no.5: How did you evaluate the completeness of the information received regarding the organization of the home care service?
• Item no.6: Overall, would you recommend the service to others?

In the latest section of the questionnaire specific items regarding quality perception in the home-nursing care assistance were proposed, which specifically concerned nursing staff and the interviewees’ quality perceptions of their nursing performances provided. Also, for each of the below items proposed, a Likert scale was associated which ranged from 1, as “very unsatisfied”, to 4, as “very satisfied”. Specifically, items concerned:

How did the interviewee rate nursing staff in:

• Item no.7: Personnel identification.
• Item no.8: Kindness and courtesy.
• Item no.9: Willingness to listen.
• Item no.10: Ability to calm and put at ease.
• Item no.11: Promptness in responding to patient inquiries.
• Item no.12: To consider the patient’s point of view, valuing responsibilities and skills.
• Item no.13: To apply health coping strategies.
• Item no.14: to apply therapeutic education, training in self-care.
• Item no.15: To promote empowerment processes.
• Item no.16: To create a therapeutic alliance.
• Item no.17: Availability and attention in analyzing the causes of failures, planning corrective actions, applying them without hesitation.
• Item no.18: To offer personalized assistance.

Ethical Considerations

The questionnaire administered first included a clear explanatory note of the research study, with its relative aim, and the option to freely participate or not in the study presented. All participants who did not give their consent were excluded from the study. The present study was compiled according to the Declaration of Helsinki. The study was presented and approved by the Ethics Committee of the General Hospital of Polyclinic of Bari, Italy, with id approval no. 0040/56/02/05/2022.

Data Analysis

All data were collected in an Excel data sheet and processed thanks to the Statistical Package for Social Sciences (SPSS) program, version 20. Internal consistency of the investigatory instrument was calculated through Cronbach Alpha test (α). Specifically, α for general level of the nursing home quality perceived was assessed as α = 0.909, α for the nursing staff issue was assessed as α = 0.633 and α for total items of the questionnaire was assessed as α = 0.918. Items proposed were also evaluated as distribution curves performing the Shapiro–Wilk and Kolmogorov–Smirnov tests. As the distributions of the variables analyzed did not conform to Gaussian distribution, intra-group comparisons were assessed using the chi square test. All p-values less than 0.05 were considered as statistically significant.

Results

A total of 677 patients and caregivers were enrolled in the present study. Table 1 explains all sampling characteristics collected according to the interviewees typology, as patient (43.4%) or caregiver (56.6%). More caregivers were female (29%) than patients (16.2%) (p < 0.001); while males were 27.2% patients and 27.6% caregivers, respectively. Additionally, more interviewers benefited from nursing-home care for a period less than 12 months (p = 0.014), both as patient (28.7) and caregiver, too (32.5%). More caregivers (17.1%) than patients (10.3%) were advised for the nursing-home care service by their health-care workers (p = 0.015).

Table 1 Sampling Characteristics (n = 677)

As explained in Table 2, quality perceptions did not significantly vary from patients and caregivers (p > 0.05) for all the items proposed (from item no.1 to item no.6).

Table 2 General Quality Perception Levels Both by Patients and Caregivers

A higher and significant satisfied perception level in the nursing listening skills was reported by caregivers (p = 0.034) than patients (Table 3).

Table 3 The Home-Nursing Care Quality Perception Levels Both from Patients and Caregivers

Discussion

The present study aimed to assess any differences in nursing-home care quality perceived both by patients and caregivers. Specifically, if interviewers were generally satisfied or not with the service received. Similarity among patients’ and caregivers’ perceptions in several dimensions of nursing assistance were essential to ensure the right individuals’ care requirements. Additionally, clarifying the elements which could be associated with patients’ and/or their caregivers’ perceptions of care a more personalizing care^24,25 could be improved. Nurses have a juridical and moral duty and obligation to the quality of nursing care provided, by recognizing their psychosocial skills and knowledge in arranging care which directly influenced the patient’s and, if there was one, the caregiver’s quality of care awareness. The nurse’s essential mission was to satisfy patients’ and caregivers’ essential demands, thanks to communication, interventional, assistance and helping skills through an appropriate approach which really satisfied both patients and their caregivers, too.²⁶ In the present study, a total of 677 patients and caregivers were enrolled, specifically 43.4% were patients and 56.6% were caregivers. Quality perceptions were assessed on average levels and were not significantly different from patients and caregivers (p > 0.05) for all the items proposed (from item no.1 to item no.6). In agreement with present results, numerous evidence assessed the average level of quality perception in nursing care received.^6,27,28 However, other studies highlighted low nursing quality perceptions both for patients and caregivers,^7,29,30 by identifying an unsuitable and disadvantageous level of quality of nursing delivery.^31,32 Discordances in quality perceptions’ results might also depend on several co-factors, such as: research circumstances, sample size and composition, sociocultural conditions.³³ In this aspect, a lot of research highlighted different standards of nursing care quality perception directly linked to the psychosocial sphere. For example, in the Dabirian et al study,³³ patients, who evaluated the quality of nursing care as poor, patients also reported a poor psychosocial dimension. The same trend was recognized in the Haghighi Khoshkho et al study:³⁴ patients, who assessed the quality of nursing care as acceptable also assessed an acceptable physical condition, too.³⁴ On the other hand, Neishabory et al³⁵ showed that the quality of nursing care was not directly correlated with the psychosocial dimension. Beyond the psychosocial status, Hosseinzadeh et al³⁶ also highlighted that nursing care quality perceptions were satisfactory when nurses paid attention to the physical sphere of care.³⁷ Though in this aspect literature was confused, as the study of Jamsahar et al²⁹ assessed 38.8% of patients recording an acceptable quality of nursing care in the physical dimension; while Gishu et al⁶ assessed that the quality of nursing care in the physical dimension as unsatisfactory.²⁸

In disagreement with the present findings, suggesting good levels both in patients’ and caregivers’ perceptions of nursing service received, a Swedish research reported discrepancies between patients and caregivers in their perceptions,³⁷ may be due to the assumption that caregivers might encourage achievements requiring more attention in their assistance.³⁸ Nevertheless, Charalambous et al³⁸ reported a similarity between their interviewed patients and relating caregivers on their quality of nursing care received. Particularly, caregivers recorded a poorer nursing quality perception in specific dimensions of: “Including the patient in the planning of his/her care” and “Talking with the patient”. These dimensions represented a more frightening sphere among patients who wished to be involved in the decision making particularly in nursing care provision.^36–38 An additional nursing quality aspect perceived by both patients and caregivers was the communication task. The present findings showed moderate perceived level in the nursing communication task. Also, in the present study, a significantly satisfied perception level in nursing listening skills was more reported in caregivers (p = 0.034) than patients. Both Neishabory et al³⁵ and Jamsahar et al²⁹ reported the quality of nursing care in the communication skill as satisfactory; while Haghighi Khoshkho et al³⁴ confirmed the opposite trend, respectively. However, Fallowfeld and Jenkins³⁸ highlighted the successful and helpful association between the nursing communication skills and patients’ and caregivers’ perceptions in several dimensions, such as: pain, recovery, compliance to treatment, mental and physical well-being.³⁹

However, a few limitations should be highlighted in the present study. First, the administration of the questionnaire, in on-line mode which might not reach patients with poorer internet-based knowledge. The questionnaire was also self-administered and it could represent a high chance of social desirability bias.

Conclusion

Patients and caregivers perceived average quality of nursing home care, with particular importance to some nursing skills, as listening skill. However, the general quality of nursing care was satisfactory. Findings suggested a more incisive action from the health-care nurses to improve quality of nursing care and both patient and caregiver satisfaction.

The present study highlighted differences in home-nursing care quality perceived both by patients and caregivers. Similarity among patients’ and caregivers’ perceptions on several dimensions of nursing assistance were essential to ensure the individual right care requirements in order to improve personalized care.