Public perception of hospital-based nursing care: a study of the Tamale Metropolis in Ghana

INTRODUCTION

A key contributor for the improvement of patients’ health outcomes and their holistic well-being after hospital stay is the quality of nursing care received in hospitals of which may also be influenced by the perceptions the public precisely patients have about nursing care.¹ Public perception of nursing care refers to public view of services received and the results of the treatment provided by nurses which may be adopted to assess the delivery and quality of healthcare.² Consequently, patients and the public at large rate the performance of any health facility based on the degree of expertise exhibited by nurses in the performance of their duties.³

Nurses play an integral role in health care delivery through the exhibition of clinical skills as they interact often with patients than any other member in the multidisciplinary health care team.⁴ The services they undertake range from receiving patients to teaching and advocacy. Nurses are integral in health care provision and ensures the overall health outcomes and well-being of hospitalized patients. Considering the importance of nursing care to patient’s recovery, patients always demand a more efficient and standardised care from nurses based on their knowledge of what constitutes quality care, such as timely response to their needs, right diagnosis and treatment, correct information about their health condition and appropriate education on self-care management, in other to recover quickly from their ailments, have a timely discharge from the hospital.⁵

According to Ayyub et al, patients’ perceived nursing care as being qualitative when nurses respond promptly to their needs, provide care based on their expectations and concerning their human person.⁶ Patients are delighted when they have information on self-care and knowledge of how they can manage their conditions at home, as most of them dread hospital for reasons other than economics. Their expectation of nursing care does not lie only in physical components of care, but the inclusion of affective component which provides a sense of comfort and dignity for the patient and influences their perception of hospital care. Nurses must demonstrate adequate knowledge, positive attitude and a great level of skills in the discharge of the care they provide to patients.⁷

Patients’ satisfaction is an important element in assessing and improving healthcare systems.⁸ Considering the undesirable occurrences and attitudes demonstrated at healthcare facilities leading to mistrust and low confidence in healthcare systems [World Health Organization (WHO)], this study sought to assess the perception of the public on nursing care to better under the needs of the public so as to serve them better.⁹

METHODS

Study setting

The study was carried out from January, 2022 to March, 2022 at the Tamale Central Hospital. The Hospital provide a range of service such as general outpatient care, gynecological care, fistula services, diagnosis and management of common infections, pediatric services, pharmaceutical and diagnostic services. The hospital has a bed capacity of 180 and a staff capacity of 533.

Study design

The researchers employed a qualitative approach. This method was chosen because it enabled the researchers to collect data on both the independent and outcome variables simultaneously, and it was comparatively quicker and cheaper to carry out

Study population

The study population included all patients seeking out patient care at the Tamale Central Hospital at the time of the study.

Inclusion criteria

The study included patients who were 18 years and above and were not critically ill and parents/care takers of children.

Exclusion criteria

The study excluded patients who were mentally incapacitated or were in critical condition.

Sample and sampling techniques

In a qualitative study, the sample size is reached when there is information saturation.¹⁰ Vasileiou, et al further indicated that a sample size of 15 and above in a qualitative study is well grounded for theory and in-depth inductive analysis of the study units.¹⁰ Purposive sampling technique was employed in selecting 30 respondents for the study as data saturation was met. This technique was used to enable the researchers identify respondents who met in the inclusion criteria for the study.

Instrumentation

The main instrument for data collection was an in-depth interview guide. This was constructed based on the research questions formulated from the objectives of the study. The in-depth interviews allowed the researchers to seek answers to the research questions posed for the study. It also helped the researchers to grasp the perspectives and thoughts of patients regarding nursing care.

Data management and analysis

Data from the interviews were transcribed word for word. The transcribed data was read and re-read by all researchers over again. The transcribed data from the interviews were analyzed manually using thematic analysis. This helped the study identify the various re-occurring themes that best explained the patients’ perception and experiences on nursing care.

Trustworthiness

The study authors ensured member checks which allowed participants to cross check the information gathered which helped to correct and avoid errors and served as a basis of ensuring credibility.¹¹ The participants who were contacted for this process did not find any errors nor had any information to be included. Four members among the authors coded and independently analysed the data and had a general meeting of which the outcomes were compared and every differences were resolved. Credibility and confirmability was further ensured by supporting the interpretation of the data gathered with direct quotes from the study respondents.¹²

Ethical considerations

Before undertaking the research, ethical clearance was sought from the ethics committee of the hospital. The respondents were also assured of utmost confidentiality of the data to be provided and they gave their consent voluntarily.

RESULTS

Demographic characteristics

Thirty (30) respondents were interviewed comprising of 15 males and 15 females with a greater proportion of them 11 (36.7%) between the ages of 30 and 34 with only 3 (10%) above the age of 41. Also, majority of the respondents 14 (46.7%) had senior high school as their highest level of education, 9 (30.0%) had tertiary education and 7 (23.3%) had basic education. Details of all participants have been provided in Table 1.

Perception of patients on nursing care

Respondents were questioned on their perception towards nurses in public health facilities in the Tamale Metropolis. Most of the participants were of the view that nurses are very rude and disrespectful towards them and their significant others. Almost all respondents stressed the need for nurses to respect their clients as the narrations indicates:

“For me I think nurses are very disrespectful; how can you insult someone in pain? There are times people complain they are sick yet they do not feel like visiting the hospital because of the ill treatment you are most likely to experience. I expect them to respect patients entrusted in their care” (Respondent 11).

Again, some respondents indicated the need for nurses to communicate well with patients especially about their condition by clearly explaining to them in a language they could understand as well as to their level of understanding. Respondents however perceived nurses’ communication to be unsatisfactory.

“It would have been good if treatment procedures and medications were explained to the patient, but in most cases I hear they give you medication without telling you what the medication is meant for. You do not even know the sickness that is been treated” (Respondent 1). “For me I think nurses are impatient and do not know how to communicate, they mostly over react on the less provocation. Sometimes they behave as if the patient is an animal. That is my perception about them” (Respondent 18).

Other respondents indicated that nurses need to be time conscious when dealing with patients. Their expectations are however often not met as almost all respondents shared similar view that nurses in the Tamale Metropolis are not time abiding.

“Sometimes you come to the hospital because you are in pain and need immediate relieve, but some of the nurses will be on their phones, especially the young ones. When you meet an elderly nurse, its better. As for the young ones, majority of them see their phones more important than your health” (Respondent 29).

Experiences patients encountered while receiving nursing care

In exploring the experiences of respondents while receiving nursing care, a mixed experience of both negative and positive were recorded. While the positive experiences were related to the quality of care, the negative experiences on the other hand were on the attitude of nurses. Majority of the respondents were of the view that, even though nurses sometimes relate badly towards clients, the treatment outcomes were mostly positive.

Negative experiences

More specifically, some respondents perceived female young nurses to be rude and disrespectful while others also expressed a mixed experience as recounted below:

“If I have the opportunity to choose who should care for me, I will prefer a male nurse or an elderly female nurse. As for the young ones, they are very rude, disrespectful and careless. It is even worse when you are not educated, one day, one of these nurses looked at me as if I was a bush animal” (Respondent 12).

“My experience with nurses in the Tamale Metropolis has not been very bad and not much good too. Not too good in the sense that I once went to the hospital for treatment when I was suffering from malaria and accidently vomited in the ward and the nurses spoke harshly to me even though it was not intentional. The nurses told me that at my age I could not reason not to vomit in the ward” (Respondent 3).

Positive experiences

“For me, nurses in general are not bad, the problem is the workload on them. My experience with them was very cordial, once you understand them, you will like them” (Respondent 30).

“Every human being with too much workload may react in a way that people will think they are bad especially when some patients think that nurses can perform magic to alleviate their pain. To me they are not magicians and they do their best. I really appreciated how I was treated when I visited the hospital and was in pain” (Respondent 7).

How experiences of others affect perception of patients towards nursing care

Although respondents mostly recounted bad experiences with nurses, the results of the interview revealed that the negative experiences did not affect their perception towards receiving nursing care.

“As for me as a person, I have no bad feelings for nurses in general, some will definitely be good, others will be bad. That is how life is, so I think it is a normal phenomenon. For the fact that someone was treated badly does not mean that I will also be treated badly” (Respondent 5).

“You cannot treat someone based on what you heard from others, I have not personally experienced anything bad with nurses in the process of receiving nursing care. Until I experience it myself, am just neutral” (Respondent 19).

The level of satisfaction of patients on nursing care

Most respondents were dissatisfied with nursing care in the Tamale Metropolis. They were of the view that nurses can improve on their service if they want to. The most cited reasons for the dissatisfaction were, nurses not respecting, time wasting, no empathy, and spending more time on their mobile phones. Some respondents even compared the nursing care practices in the private health facilities to that of the public health facilities. They think there is a lot of difference between the two as some of them narrated below:

“For me comparing the public health facilities and the private health facilities in the metropolis, the nurses in the public health facilities are doing woefully bad, they do not care whether the patient is eating, whether he/she is comfortable or not. Honestly am not satisfied with nursing care in the metropolis, they can do better and they have to” (Respondent 21).

“For me, the problem I have with nurses here is their lack of compassion for patients, you will often see them making calls and laughing while the patient is in pain, they do not even respect the time for medication” (Respondent 26).

However, few respondents were satisfied with the nursing care in the Tamale Metropolis. The reason behind their satisfaction as cited by them was that, nursing care is generally seen as such everywhere and not just the Tamale Metropolis.

“I think the nursing care here is normal. I am very fine with the nursing care in Tamale. Mostly people just want to exaggerate things but I do not think it is that bad” (Respondent 28).

DISCUSSION

Perception of patients on nursing care

The study discovered that the public perceive most nurses to be rude, poor communicators and not time conscious. The perception of nurses being rude and disrespectful was cited by most of the respondents including those who had never been admitted in the hospital before. The findings revealed that, most respondents think nurses talk to clients disrespectfully regardless of the age of the patient. Most of the act of disrespect and crudity were directed to young female nurses. Similar to the findings of this study, Ahmed et al found that nurses often make unwholesome comments about patients.¹³ These derogatory remarks range from poor quality of care delivery to service delay, discontinuity of care, indifferent attitude of nursing staff and poor communication skills. The rudeness occurs when nurses feel patients are overstepping their boundaries by questioning them on the rationales for medications and other treatment procedures.

The negative perception of nursing care by patients may create problem in the health system by decreasing trust and less patronage of nursing care services as well as delayed health seeking with subsequent poor health outcome of the public. Similarly, Agani et al reported that negative attitudes have been found in a significant number of nursing populations since the 1960s and 1970s.¹⁴ They further concluded that though the proportion of nurses with pessimistic attitudes appears to have lessened throughout later decades, negative attitudes still exist today. As literacy increases in the population, health seeking behavior also increases with demand for more accountability from nurses. This is evidenced by the demand of effective communication between nurses and patients.

Experiences people encountered while receiving nursing care

While majority of the respondents had bad perception towards nursing care, the study found a mixture of both good and bad experiences from respondents on their encounter with nursing while receiving nursing care. The respondents believed that their experiences with nursing in the Tamale Metropolis was not an isolated case. They believe it is a global phenomenon and that some of them believed it is a normal human attitude. Other respondents attributed the unfriendly experiences they had with nurses to the overburdened workload on nurses.

A significant number of the respondents however narrated bad experiences they had with nurses while receiving nursing care. Respondents cited verbal abuse, negligence, and disrespect as some of their experiences. The negative experiences were in relation to nurses’ interaction with patients. Majority of the respondents had at least junior high education and as such may have some understanding of their rights as patients and therefore expected nurses to interact with them professionally, if this is not met, they are most likely to regard it as negative experience. However, Yusefi et al revealed in their study that there was no statistically significant difference in the quality of nursing care with respect to education level.¹⁵ In their study, he discovered that patients opted out from care from health facilities due to poor interaction with nurses. Similarly, Rademakers, et al asserted that people with higher educational level place a higher degree of importance on their interaction with the clinician and are less likely to report positive experiences than less educated patients.¹⁶

Some respondents also reported nurses spending more time on their mobile phone to the neglect of patients. Negative experience of patients relating to time has been observed in previous studies. The Agency for Healthcare Research and Quality (AHRQ) found negative patient experience as not getting timely appointments, easy access to information, and good communication with health care providers.¹⁷ Likewise, Munyewende and Nunu noted that most patients had bad experiences regarding communication with nurses while receiving nursing care.¹⁸

Due to negative experiences, some respondents indicated their unwillingness to attend the health facilities in which they had such experiences. Agbele, et al made similar revelations in their study that bad experiences have led to poor public confidence in the health care delivery system.¹⁹ On the other hand, Okankwu et al noted that good patient experiences in turn builds the level of loyalty that makes patients keep the same hospital instead of searching for another and reduce the risk litigation.²⁰

The level of satisfaction of patients on nursing care

While some respondents were satisfied with nursing care in the Tamale metropolis, majority of them were dissatisfied. Respondents were of the view that nurses can improve on the performance of their duty if they are willing to do so.

Respondents were dissatisfied with time spent seeking treatment, attitude shown towards them and ineffective communication. This finding is inconsistent with that of an earlier study in Ghana. In that study, Ofei-Dodoo revealed high rates of patient satisfaction with health care based on factors such as: waiting time, respectfulness, clear communication, decision-making, privacy, choice and cleanliness.²¹ The finding of this study relating to communication is in line with Asare findings who found that some patients avoid the state-owned hospitals due to long queues, unavailability to access all the information that they desire and their healthcare expectations not being met.²² However, the finding of this study is in contrast with that of Olowe and Odeyemi, who indicated a high level of patient satisfaction with the services of nurses in their study.²³

In the current study, respondents mentioned the qualities of private health facilities that makes people patronize these health facilities including time consciousness, respect for patients, empathy. Other respondents however asserted that the attitude of nurses in the public health facilities are due to shortage of staff. Ndambuk made similar finding when he discovered that the cause of dissatisfaction by some patients was as a result of understaffing.²⁴

The study was conducted at the Tamale Central Hospital in Tamale (Ghana) with a sample size of 30 which makes it difficult to generalize the findings of the study to the larger population.

CONCLUSION

Based on the findings of the study, it was concluded that, people in the Tamale Metropolis have negative perception towards nursing care resulting from unmet expectations. These unmet expectations included ineffective communication between nurses and patients, lack of empathy and respect for patients. The causes of these inefficiencies according to some respondents is as a result of understaffing and increased workload of nurses. The findings therefore emphasize the need for Ghana health services to propagate the patients’ charter in synchronization with the standards of Ghana Health Services and WHO patients charter to ensure patient satisfaction with healthcare delivery.

ACKNOWLEDGEMENTS

We express our appreciation to all the respondents for their cooperation and accepting to participate in the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Sun JH, Twomey M, Tran J, Wallis LA. The need for a usable assessment tool to analyse the efficacy of emergency care systems in developing countries: proposal to use the TEWS methodology. Emerg Med J. 2012;29(11):882-6.
2. 2. Gishu T, Weldetsadik AY, Tekleab AM. Patients’ perception of quality of nursing care; a tertiary center experience from Ethiopia. BMC Nurs. 2019;18(1):1-6.
3. 3. Shawa E. Patients’ perceptions regarding nursing care in the general surgical wards at Kenyatta national hospital. 2017. Available from: http://hdl.handle.net/10755/621210. Accessed on 4 March 2023.
4. 4. Butler R, Monsalve M, Thomas GW, Herman T, Segre AM, Polgreen PM, et al. Estimating time physicians and other health care workers spend with patients in an intensive care unit using a sensor network. Am J Med. 2018;131(8):972-e9.
5. 5. Mohammad MA. Healthcare service quality: towards a broad definition. International journal of health care quality assurance. 2013;26(3):203-19.
6. 6. Ayyub R, Kanji Z, Dias J, Roshan R. Perceptions of patients regarding quality nursing care (QNC) at a tertiary care hospital, Karachi. Pakistan. J Clin Res Bioeth. 2015;6(254):2.
7. 7. Buchanan J, Dawkins P, Lindo JL. Satisfaction with nursing care in the emergency department of an urban hospital in the developing world: a pilot study. Int Emerg Nurs. 2015;23(3):218-24.
8. 8. Braaf S, Ameratunga S, Nunn A, Christie N, Teague W, Judson R, et al. Patient-identified information and communication needs in the context of major trauma. BMC Health Serv Res. 2018;18:1-3.
9. 9. World Health Organization. Strengthening the doctor-patient relationship. WHO Regional Office for South-East Asia; 2013.
10. 10. Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18:1-8.
11. 11. Connelly LM. Trustworthiness in qualitative research. Medsurg Nurs. 2016;25(6):435.
12. 12. Korstjens I, Moser A. Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing. Eur J Gen Pract. 2018;24(1):120-4.
13. 13. Ahmed T, Assefa N, Demisie A, Kenay A. Levels of adult patients’ satisfaction with nursing care in selected public hospitals in Ethiopia. Int J Health Sci. 2014;8(4):371.
14. 14. Afaya A, Hamza S, Gross J, Acquah NA, Aseku PA, Doeyela D. Assessing patient’s perception of nursing care in medical-surgical ward in Ghana. Int J Car Sci. 2017;10(3):1329-40.
15. 15. Yusefi AR, Sarvestani SR, Kavosi Z, Bahmaei J, Mehrizi MM, Mehralian G. Patients’ perceptions of the quality of nursing services. BMC Nurs. 2022;21(1):1-1.
16. 16. Rademakers J, Nijman J, van der Hoek L, Heijmans M, Rijken M. Measuring patient activation in The Netherlands: translation and validation of the American short form Patient Activation Measure (PAM13). BMC Public Health. 2012;12(1):1-7.
17. 17. Evensen CT, Yost KJ, Keller S, Arora NK, Frentzel E, Cowans T, et al. Development and testing of the CAHPS cancer care survey. J Oncol Pract. 2019;15(11):e969-78.
18. 18. Munyewende PO, Nunu WN. Patient satisfaction with nurse-delivery primary health care services in Free State and Gauteng provinces, South Africa: a comparative study. Afr J Prim Health Care Fam Med. 2017;9(1):1-8.
19. 19. Agbele TO, Nwambo JC, Nwankwo UC. Patients’ perception of quality nursing care in a Federal Medical Centre. SSRG Int J Nurs Health Sci. 2018;4(1):1-6.
20. 20. Okankwu EA, Emordi NA, Ezekiel R. Patients’ Characteristics and their perception of nursing care at Rivers State University Teaching Hospital, Port Harcourt. ARC J Public Health Community Med. 2020;5(2):13-22.
21. 21. Ofei-Dodoo S. Patients satisfaction and treatment outcomes of primary care practice in Ghana. Ghana Med J. 2019;53(1):63-70.
22. 22. Boadi EB, Wenxin W, Bentum-Micah G, Asare IK, Bosompem LS. Impact of service quality on customer satisfaction in Ghana hospitals: A PLS-SEM approach. Canad J Appl Sci Technol. 2019;7(3).
23. 23. Odeyemi O. SAssessment of Patient Satisfaction with Nursing Care in Selected Wards of the Lagos University Teaching Hospital (Luth). Biomed J Scient Tech Res. 2019;17(1):12489-97.
24. 24. Ndambuki J. The level of patients’ satisfaction and perception on quality of nursing services in the Renal unit, Kenyatta National Hospital Nairobi, Kenya. Open J Nurs. 2013;3(2):1-9.