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Original Article
Evaluation of the Quality of Nursing Care Received by Patients
Saadet Erzincanli
Aksaray University, Faculty of Health Sciences, Nursing Department, Aksaray, Turkey
Arzu Yuksel
Aksaray University, Faculty of Health Sciences, Nursing Department, Aksaray, Turkey
Corresponding author:
Saadet Erzincanli, Aksaray University, Faculty of Health Sciences, Nursing
Department, Aksaray, Turkey E-mail: saadeterzincanli@hotmail.com
Abstract
Aim: Nurses are responsible for the primary care of patients. This study was carried out to determine the
patients' perception of quality of nursing care and the factors affecting it.
Methods: 448 inpatients in a training and research hospital constituted the sample of the research carried out as
a descriptive study.
Results: It was determined that there was no relationship between the ages of the patients and the total point
averages of the nursing care quality perceptions of the patients and that the total point averages of the caring
behaviors inventory-24 of the patients who were informed by the nurse before the care were significantly higher
compared to other patients.
Conclusions: It can be said that the quality of care perceived by the patients is high and that being informed by
the nurses before the care positively affects the perception of quality of care.
Key words: Patient; Nurse; Nursing Care; Quality of Care
Introduction
The concept of care constitutes the basis of
nursing (Palese et al., 2011; Karlou et al., 2015).
Care, which is the independent function of nurse,
represents a basic human need (Elayan &
Ahmad, 2017).
Its main aim is to decrease the
pain and distress of the patient and it is one of the
most important determinants of quality in health
services (Kilic & Oztunc 2015; Edvardsson et al.,
2017). Therefore, it is indispensable for both
patients and nurses (He et al., 2013).
High quality care is a patient's right and the
responsibility of nurses (Elayan & Ahmad,
2017). Since nurses are the healthcare
professionals who spend the most time with the
patients during hospital stay (He et al., 2013), the
feeling that the patients perceive as a sense of
care originates from the care behaviors of nurses
(Papastavrou et al., 2012). The economic
constraints in health care systems, the demand
for improving the quality of care, and the
inclusion of patients' opinions in the care have
revealed the need for a clear understanding of
nursing behaviors (Papastavrou et al., 2012).
Therefore, it is necessary to investigate the
prevalence of the nurse's care behaviors for a
high-quality care (Edvardsson et al., 2015).
Quality care given by nurses is positively
reflected on the reduction in the duration of stay
in the hospital and costs, the improvement in
patient outcomes, and the patient's perception
and satisfaction about the quality of nursing care
(Palese et al., 2011; Kursun & Kanan 2012; He et
al., 2013; Edvardsson et al., 2017; Cerit &
Coskun 2018).
It has been indicated that patient experiences are
influential in the conceptualization of health and
nursing care practices and the quality of care and
can be used to evaluate and improve nursing
practices (Edvardsson et al., 2017). Furthermore,
it has been emphasized that patients' reviews
related to care are extremely important for the
development of a nursing service adapted
according to the needs, expectations and
individuality of patients (Papastavrou et al.,
2012). Moreover, it has been also stated that the
identification and accurate understanding of the
perceptions of the individuals receiving care may
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help to increase the quality of care and thus the
quality of service (Kilic & Oztunc 2015).
Therefore, in this study, it was thought that the
determination of the level of the quality of
nursing care perceived by patients and the
investigation of the factors affecting it would
contribute to give and improve a quality nursing
care, to meet patients' expectations for care and
to increase patient satisfaction.
Aim of the Research: The aim of this study was
to determine the patients' perceptions of the
quality of nursing care and the factors affecting
them.
Materials and Methods
It is a descriptive cross-sectional study. The
study was carried out in a training and research
hospital located in a province in the Central
Anatolia region of Turkey. The patients receiving
inpatient treatment in internal and surgical clinics
of the hospital where the study was carried out
between April-June 2018 constituted the
population of the study. 448 patients who agreed
to participate in the study, were staying in the
service for at least 3 days, were above the age of
18 years and conscious and had no mental
problem and communication difficulty
constituted the sample of the study.
Data Collection Tools: The “Personal
Information Form” and the "Caring Behaviours
Inventory-24" (CBI-24) were used in the
collection of research data. The research data
were collected by face-to-face interview method
after the aim of the study was explained to
patients and their voluntary participation was
ensured.
Personal Information Form: The Personal
Information Form developed by the researchers
consists of the questions aimed at determining
socio-demographic characteristics of patients
such as age, gender and marital status, and the
clinic stayed, the states of undergoing an
operation and keeping a hospital attendant
available.
Caring Behaviors Inventory-24 (CBI-24): CBI-
24 was developed by Wolf et al. (Wolf et al.,
1994). CBI-24, the short form of the 42-item
“Caring Behaviors Inventory” which is suitable
for bidirectional diagnosis by patients and nurses,
was structured by Wu et al. (Wu et al., 2006). Its
Turkish validity and reliability study was
conducted by Kursun and Kanan (Kursun &
Kanan 2012). For the sum of the scale, the
Cronbach's alpha value was found to be 0.97 in
patients and .96 in nurses. The scale consists of 4
sub-dimensions including assurance, knowledge-
skill, respectful and connectedness, and 24 items.
It is a 6-point likert (1=never, 6=always) scale.
The calculation of total scale score is obtained by
dividing the score obtained after adding the
points of 24 items by 24. As the total scale score
and sub-dimension scale score increase, the
quality of care perceived by the patients or
nurses increases.
10
In this study, the Cronbach's
alpha value was found to be 0.90 in patients.
Ethical Aspect of the Study
For the study, permissions were received from
the Human Research Ethics Committee (protocol
no: 2018/7) of a university, the institution where
the study was carried out, and the patients
participating in the study.
Analysis of Data: Data analysis was performed
using the SPSS 21.0 (Statistical Package for
Social Science) package program. The
Kolmogorov Smirnov and the Shapiro-Wilk tests
were used in the evaluation of the suitability of
research data for normal distribution. The
percentage distributions, the significance test of
the difference between two averages, correlation,
variance and Kruskal-Wallis analysis were used
in the evaluation of data. The level of
significance was considered to be p<0.05 in all
tests.
Limitations of the Study: The study is limited
to inpatients in the internal and surgical clinics of
the training and research hospital where the study
was carried out, so the results cannot be
generalized.
Results
The total CBI-24 point average of the patients
was 5.19±0.66. While the patients' total point
average of the "assurance" sub-dimension of the
CBI-24 was 5.32±0.67, total point average of the
"knowledge-skill" sub-dimension was 5.24±0.75,
total point average of the "respectful" sub-
dimension was 5.11±0.75 and total point average
of the "connectedness" sub-dimension was
5.03±0.85 (Table 1).
The average age of the patients participating in
the study was 59.14±17.97. In the correlation
analysis, it was found that there was no
relationship between the age of the patients and
the total CBI-24 point average (r: 0.01 p= 0.83)
(Table 2).
While the average age of the patients was
59.14±17.97, it was determined that 51.3% of
them were female, 72.5% of them were married,
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50.9% of them were primary school graduates,
81.7% of them were working, 49.6% of them
were living in the city, 59.8% of them found their
economic income sufficient, 65% of them stayed
in the internal clinic, 65.6% of them had a
chronic disease, 81.9% of them had previous
hospital experience, 76.1% of them had an
operation experience, 71.4% of them had a
hospital attendant, the hospital attendants of 54%
of them stayed continuously, and 88.4% of them
were informed by the nurse before the practices
to be conducted before care (Table 2).
No statistically significant difference was found
between total CBI-24 point averages of the
patients according to gender, marital status,
educational and working status, place of living,
economic situation, the clinic where treatment
was received, having a chronic disease, previous
hospitalization and surgery experience, keeping a
hospital attendant available and the type of the
stay of hospital attendant (p>0.05) (Table 2). It
was determined that total CBI-24 point averages
of the patients who were informed by the nurses
before the care were significantly higher
compared to other patients (p<0.05) (Table 2).
When CBI-24 item point averages of the patients
were examined, it was determined that the item
point averages were quite close to each other,
that the behaviors with the highest point average
were "Timely administration of the patient's
treatments and medications", "Keeping patient's
information secret" and "Treating the patient as
an individual", and that the behaviors with the
lowest point average were "Identification or
empathizing with the patient", "Training or
informing the patient" and "Ensuring the patient's
participation in the planning of care" (Table 3).
Table 1. CBI-24 Total and Subscale Mean Scores
Total and Sub-Dimension
X±SD Min-Max
Assurance 5.32±0.67 1-6
Knowledge and skill 5.24±0.75 1-6
Respectful 5.11±0.75 1-6
Connectedness 5.03±0.85 1-6
Total
5.19±0.66 1-6
Table 2. Distribution of CBI-24 Point Average according to Descriptive Characteristics of
Patients
Diagnostic features n % X±SD Test/p
Age
(mean±SD)
448
59.14±17.97
r:0.01 p=0.83
Gender
Female 230 51.3 5.24±0.61
t=1.52 p=0.12
Male 218 48.7 5.14
±
0.70
Marital status
Single 123 27.5 5.18
±
0.63
t=0.16 p=0.87
Married 325 72.5 5.20±0.67
Education status
Illiterate 142 31.7 5.21±0.68
χ
2
=3.79 p=0.43*
Literate 23 5.2 4.95
±
0.83
Primary School 228 50.9 5.20±0.61
High school 36 8.0 5.11
±
0.81
University 19 4.2 5.37±0.41
Working status
Employed 82 18.3 5.16±0.64
t=0.53 p=0.59
Unemployed 366 81.7 5.20
±
0.66
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*Kruskal Wallis test
Table 3. CBI-24 item point averages of the patients for CBI-24 items
Caring
Behaviors
Subscales Mean (SD)
Assurance Subscale
Q16 Going to the patient eagerly 5.20±1,09
Q17 Talking to the patient 5.24±1.03
Q18 Encourage the patient to call when he/she has a problem 5.14±1.14
Q20 Immediate response to the patient's call 5.34±0.92
Q21 Helping to reduce the patient's pain 5.37±0.86
Place of living
Province 222 49.6 5.21
±
0.69
F=0.22 p=0.79
District 59 13.2 5.15±0.61
Town-village-small town 167 37.2 5.19±0.64
Economic situation
Sufficient 268 59.8 5.19
±
0.69
t=0.05 p=0.95
Insufficient 180 40.2 5.19±0.61
Clinic where treatment is received
Internal 291 65.0 5.16
±
0.70
t=1.34 p=0.18
Surgical 157 35.0 5.58±0.57
State of having a chronic disease
Yes 294 65.6 5.18
±
0.70
t=0.59 p=0.55
No 154 34.4 5.22±0.57
Previous hospital experience
Yes 367 81.9 5.19
±
0.67
t=0.02 p=0.97
No 81 18.1 5.19±0.58
Surgery experience
Yes 341 76.1 5.18
±
0.68
t= 0.91 p= 0.36
No 107 23.9 5.24±0.59
State of keeping a hospital attendant available
Yes 320 71.4 5.21
±
0.64
t=0.70 p= 0.47
No 128 28.6 5.16±0.71
Type of the stay of hospital attendant
No hospital attendant 128 28.6 5.20
±
0.68
F=0.84 p=0.43
Stays continuously 242 54.0 5.22±0.62
Stays at certain hours 78 17.4 5.11±0.72
State of being informed by the nurse before the care
Those who receive
information
52 11.6 4.81
±
0.87
t=3.47
p=0.00
0
Those who do not receive
information
396 88.4 5.24±0.61
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Q22 Showing interest in the patient 5.27±0.94
Q23 Timely administration of the patient's treatments and medications 5.63±0.71
Q24 Relieving the patient's symptoms 5.24±0.82
Knowledge-skill Subscale
Q9 To know how to administer interventions such as injection and intravenous 5.05±1.26
Q10 Giving confidence to the patient 5.20±1.03
Q11 Showing professional/occupational knowledge and skills 5.18±1.06
Q12 Using tools and equipment skillfully 5.26±0.95
Q15 Keeping patient's information secret 5.51±0.93
Respectful Subscale
Q1 Listening to the patient carefully 5.30±0.95
Q3 Treating the patient as an individual 5.45±0.90
Q5 Supporting the patient 5.04±1.11
Q6 Identification or empathizing with the patient 4.86±1.19
Q13 To allow the patient to explain his/her feelings about the disease or treatment 5.08±1.13
Q19 Meeting the patient's needs that he/she has or has not mentioned 4.96±1.09
Connectedness Subscale
Q2 Training or informing the patient 4.90±1.26
Q4 To spare time for the patient 5.07±1.12
Q7 Helping/supporting the patient's development 5.02±1.16
Q8 Being patient and understanding towards the patient 5.20±1.09
Q14 Ensuring the patient's participation in the planning of care 4.96±1.21
Total Scale 5.19±0.66
Discussion
The perceptions of patients about the quality of
nursing care are important with respect to
reflecting the quality of the service provided. In
the present study, the quality of care perceived
by the patients was found to be high. This result
is in line with similar studies in the literature
(Palese et al., 2011; Zhao & Akkadechanunt
2011; Papastavrou et al., 2012; He et al., 2013;
Cevik & Eser 2014; Karlou et al., 2015; Kilic &
Oztunc 2015; Yılmaz et al., 2017; Findik &
Yesilyurt 2017; Cerit & Coskun 2018). This can
be interpreted that patients generally perceive the
quality of nursing care at the desired level.
It was observed that the patients had the highest
perception of quality of nursing care in the
"assurance" sub-dimension while they had the
lowest perception of quality of nursing care in
the “connectedness” sub-dimension. Although
these results are in parallel with the study of
Kilic and Oztunc (2015), it was stated in most
studies that the highest perception of quality of
nursing care was experienced in the "knowledge-
skill" sub-dimension while the lowest perception
of quality of nursing care was experienced in the
"connectedness" sub-dimension (Palese et al.,
2011; Papastavrou et al., 2012; He et al., 2013;
Hajinezhad & Azodi 2014; Karlou et al., 2015;
Findik & Yesilyurt 2017; Yılmaz et al., 2017;
Cerit & Coskun 2018). However, while Elayan
and Ahmad (2017) indicated that good
communication skills and meeting the needs of
patients, as well as having a high level of
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knowledge and skills and being competent in
clinical skills, were perceived as high-quality
care, Edvardson et al. (2017) indicated that the
aspects that are mostly related to the perceived
quality of nursing care were contactable staff,
timely assistance, environmental support, as well
as receiving the best possible care from
knowledgeable staff. These results can be
interpreted that not only knowledge and skill but
also the assurance including the behaviors such
as taking care of the patient and immediate
response to the patient's call are now further
appreciated by the patients and affect their
perceptions of the quality of care.
When the patients' perceptions of the quality of
nursing care were examined according to their
descriptive characteristics, it was determined that
there was no relationship between the age of the
patients and their perception of quality of nursing
care scores. The fact that age does not affect the
patients' perceptions of quality of care was
determined in the studies that were carried out
using the same scale is similar to our study
results (Cevik & Eser 2014; Findik & Yesilyurt
2017).
In this study, as well as in the literature, it was
found that gender (Yılmaz et al., 2017, Findik &
Yesilyurt 2017), marital status (Yılmaz et al.,
2017, Findik & Yesilyurt 2017, Cevik & Eser
2014) and educational status (Yılmaz et al.,
2017, Findik & Yesilyurt 2017, Cevik & Eser
2014), working status, place of living (Yılmaz et
al., 2017), economic situation (Yılmaz et al.,
2017), the clinic where treatment is received,
having a chronic disease, previous
hospitalization and surgery experiences did not
affect the perception of quality of care (Findik &
Yesilyurt 2017). Differently, in their study,
Cevik and Eser (2014) found that the patients
who were male and had no hospital experience
had higher perceptions of quality of care. These
results were supported by the relevant previous
studies. Karlou et al. (2015)
stated that there was
only a weak relationship between the patients'
educational status and perceptions of care.
It was indicated that most of the patient needs
were met since each patient is accompanied by a
hospital attendant and their expectations from
nursing care decreased, which may ensure that
patients perceive the quality of nursing care at
higher levels (Cevik & Eser 2014).
In their
study,
Karlou et al. (2015)
found only a weak
relationship between hospital attendant and the
perceptions of care. However, in this study, it
was found that the state of keeping a hospital
attendant available and the type of the stay of
hospital attendant did not affect the patients'
perceptions of quality of nursing care. This
suggests that nurses are able to perform their
roles and responsibilities related to care at a level
to meet patient expectations and to reflect it on
patient care.
The results of the study show that being
informed by the nurse before the care improves
the perception of the quality of nursing care
(Table 2). This result is similar to the results of
other studies (Elayan & Ahmad, 2017, Findik &
Yesilyurt 2017). To inform the patients before
the procedures to be performed is thought to be
effective in improving the quality of care
perceived by the patients since it will prevent the
patients' uncertainties about the procedures to be
administered to them and decrease the existing
anxiety by ensuring that the patients have
knowledge about the qualifications of the care
given.
It was determined that the behaviors in which the
patients perceived the quality of care at the
highest level were "Timely administration of the
patient's treatments and medications", "Keeping
patient's information secret" and "Treating the
patient as an individual". When the literature is
reviewed, similar to our study results, it is seen
that “timely administration of the patient's
treatments and medications” (He et al., 2013,
Cevik & Eser 2014; Karlou et al., 2015, Kilic &
Oztunc 2015), “keeping patient's information
secret” (Yılmaz et al., 2017) and “treating the
patient as an individual” (Elayan & Ahmad,
2017) are among the behaviors to which
importance is given. This situation suggests that
these behaviors were fulfilled by nurses at the
desired level, increased their satisfaction and
positively affected the patients' perceptions of
quality of nursing care. It can be also said that
timely treatment of patients by nurses, respecting
their privacy and to ensure that they feel that they
are valued have effects on the high level quality
of care perceived by them.
Patients have various expectations regarding
their care during their stay in the hospital, and to
meet the perceived needs as the goal of nursing
practices is important for a good care (Kilic &
Oztunc 2015). In this study, it was determined
that the behaviors in which the patients perceived
the quality of care at the lowest level were
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"Identification or empathizing with the patient",
"Training or informing the patient" and
"Ensuring the patient's participation in the
planning of care" (Table 3). In parallel with this
study, it is remarkable that “Identification or
empathizing with the patient” (Cevik & Eser
2014; Kilic & Oztunc 2015), “Training or
informing the patient” (Palese et al., 2011, Kilic
& Oztunc 2015, Yılmaz et al., 2017) and
“Ensuring the patient's participation in the
planning of care” (Palese et al., 2011; Karlou et
al., 2015,) are among the less scored behaviors in
other studies. In their study, Elayan and Ahmad
(2017) determined that the inclusion of patients
in the care process by the nurses was perceived
to be important by the participants. The results
of the study carried out show that the patients
themselves are not sufficiently understood,
cannot receive information at the desired level
and cannot have a part in taking the
responsibilities of their own care at the desired
level. Furthermore, it is stated that the difficulties
such as the insufficiency of the number of nurses,
medical supplies and equipment affect the time
spent with the patients and the quality of the
therapeutic relationship between the patient and
nurse (Elayan & Ahmad, 2017). Moreover, it has
been emphasized that the nurses spend most of
their time to perform the medical orders of the
doctor and have little time for the psychological
care of the patient (He et al., 2013). The results
of the study point out that all these difficulties
experienced may negatively affect identification
or empathizing with the patient, training or
informing the patient and ensuring the patient's
participation in the planning of care and that it is
necessary to determine the preventive factors and
to take necessary measures in order to increase
the application of these care behaviors.
Conclusion: As a result of the study, it was
found that the quality of nursing care given in
internal and surgical clinics was perceived to be
very positive by the patients and that being
informed before the procedures applied
positively affected the perception of quality of
care. Furthermore, it was determined that the
behaviors in which the patients perceived the
quality of care at the lowest level were
"identification or empathizing with the patient",
"training or informing the patient" and "ensuring
the patient's participation in the planning of
care".
In line with these results;
It is recommended to
provide trainings aimed at increasing
awareness on informing of the patients
before the procedures to be applied by the
nurses both before graduation and in the
clinical environment, to empathize with the
patients, to provide patients with trainings or
information, to determine the factors that
prevent or reduce the participation of
patients in the planning of care and to take
necessary measures.
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