In South Korea, the integrated nursing care services initiative was launched as a government-backed pilot project in 2013. Its aim was to alleviate the burden on caregivers and provide high-quality nursing services. This was achieved by deploying specialized nursing personnel who could deliver comprehensive and professional care without the need for caregivers or family members to be present [1, 2]. The Ministry of Health and Welfare has set a goal to serve 2.5 million hospitalized patients and provide 100,000 beds by 2023. However, as of September 2022, the number of available beds stands at 63,408 [3]. The integrated nursing care services initiative has shown positive results, including a reduction in caregiver burden for families [4, 5], an improvement in the quality of nursing services [6, 7, 8], the creation of various nursing job opportunities [5, 9], and an improvement in patient safety indicators such as fall and pressure sore rates, as well as hospital infection rates [5]. However, despite these achievements, reports indicate that if patients do not receive nursing services commensurate with the additional nursing fees incurred during their stay in integrated nursing care service wards, over 88% of them would prefer to be transferred to general wards [6]. Therefore, ongoing quality management of integrated nursing care services is essential for the successful expansion and operation of these services [6].
Hospitals are tasked with meeting patient demands with a limited nursing staff. Enhancing the productivity, efficiency, and satisfaction of both nurses and patients can be achieved by providing nursing care that aligns with the patients' needs [10, 11, 12]. In wards that offer integrated nursing care services, it is crucial to accurately understand the patients' nursing needs and provide patient-centered care. This is because nursing personnel are responsible for providing nursing care, including caregiving, in lieu of caregivers. Patient-centered care involves identifying patients' nursing needs and executing nursing actions that address these needs [13, 14]. Nursing performance encompasses all the activities carried out by nurses to meet patients' nursing needs for health maintenance, promotion, and recovery [15]. Past research has indicated that patients often perceive nursing performance as falling short of their nursing needs, a discrepancy that can lead to decreased patient satisfaction [13, 16, 17]. Therefore, it is essential to scrutinize the gap between patients' nursing needs and their perception of nursing performance. This examination can serve as a benchmark for creating patient-centered nursing plans and assessing the quality of the nursing care provided.
The SERVQUAL model is a discrepancy model between expectation and performance, utilized to gauge service quality [18]. It posits that customer perceptions of the service provided are shaped by provider activities, beginning with the understanding of customer expectations. The quality of a service can be assessed by the gap between what customers expect and their perceptions of the service provided. This also includes the gap between the activities of the providers and their understanding of customer expectations [18]. The SERVQUAL model has been employed not only in business to measure service quality, but also in the nursing industry to evaluate the quality of nursing services [19, 20]. Given that the gap between patient expectations and the nursing care provided, as well as the disparity between the perceptions of patients and nurses, can influence the quality and satisfaction of nursing services [19, 20], it is crucial to undertake a thorough analysis of the patient-nurse perspective on gaps in nursing services.
Importance-Performance Analysis (IPA) is a technique that concurrently evaluates consumers' and providers' perceptions of the significance and effectiveness of key components of a product or service [21]. This method uses average attribute values plotted on the X and Y axes to distinguish four areas: "keep up the good work," "concentrate here," "low priority," and "possible overkill" [21]. IPA has found utility in nursing research for analyzing educational needs [22, 23] and nursing work analysis [24, 25], as it facilitates the easy identification of priorities and areas for enhancement. To implement the patient-nurse perspective of nursing needs-performance gaps in practice, it is crucial to ascertain directions of improvement for individual nursing activities and set priorities. As the term "importance" in IPA is defined as "consumers' expectations of the service" [21], the IPA methodology can be effectively utilized to analyze the gaps between nursing needs and performance.
As previously discussed, it is essential to analyze the nursing needs and performance as perceived by both patients and nurses in integrated nursing care service wards for further institutional development. However, most studies on integrated nursing care services have primarily focused on either patients or nurses [8, 10, 16], which complicates understanding the differences. Additionally, most prior research has been conducted in tertiary hospitals [6, 10], making it challenging to find reports on integrated nursing care services in small and medium-sized hospitals. Nursing performance can fluctuate based on factors such as the severity of patients' conditions, job characteristics, hospital policies, nursing staff, ward facilities and environment, and the type of hospital [26, 27]. The staffing standards for integrated nursing care services vary depending on the type of hospital; the ratios are 1:6 for tertiary hospitals, 1:10 for general hospitals, and 1:12 for other hospitals. However, the staffing shortage in small and medium-sized hospitals has worsened due to the increasing number of experienced nurses transferring to tertiary hospitals to expand integrated nursing care services [28]. General hospitals differ from tertiary hospitals in several aspects, including the medical environment, nursing staff, and other factors, which may cause variations in the status of integrated nursing care services. Therefore, it is significant to examine the differences in service perceptions between patients and nurses in integrated nursing care service wards in small and medium-sized hospitals. The aim of this study is to identify the nursing needs and performance in integrated nursing care service wards in small and medium-sized hospitals from the perspective of both patients and nurses, and to use IPA to determine the priorities and directions for improving nursing activities. This information can serve as foundational data for establishing policies for integrated nursing care services in small and medium-sized hospitals and for developing strategies to enhance patient satisfaction and the quality of nursing services. The purpose of this study was to identify the differences in perceived nursing needs and performance between patients and nurses in integrated nursing care service wards within small to medium-sized hospitals, utilizing the SERVQUAL model as a basis. Furthermore, the study sought to establish priorities and strategies for enhancing nursing activities.
1. Study Design
This study is a descriptive survey designed to explore the perceived differences in nursing needs and performance from the perspectives of both patients and nurses in integrated nursing care service wards within small to medium-sized hospitals. The aim is to identify potential areas for improvement in nursing activities. The conceptual framework for this study is illustrated in Figure 1. In the context of this study, the term "consumers" refers to the patients in the integrated nursing care service wards, while "providers" denotes the nurses who deliver the integrated nursing care services. Gap 1 is defined as the discrepancy between the nursing needs as perceived by the patients and the nurses' understanding of these needs. Gap 2 signifies the difference between the nurses' understanding of the patients' nursing needs and the actual nursing performance delivered by the nurses. Gap 3 refers to the variance between the nursing performance as delivered by the nurses and the patients' perception of this performance. Gap 4 represents the difference between the patients' nursing needs and the actual nursing performance delivered by the nurses. Lastly, gap 5 denotes the discrepancy between the patients' nursing needs and their perception of the nursing performance.
2. Participants
This study involved participants from integrated nursing care service wards in small to medium-sized hospitals, each with a capacity of more than 100 but fewer than 300 beds. The patient participants were required to have been hospitalized in these wards for a minimum of 3 days and to be adults aged 19 or older without any communication issues. The nurse participants needed to have worked in these wards for at least six months. We excluded patients with cognitive impairments or diagnosed dementia, as well as nurses in managerial roles such as head nurses. The sample size was calculated using the G*Power 3.1.9 program. Based on a previous study [19], we used the two-tailed independent t-test with a significance level of .05, a medium effect size of 0.50, and a power of .95. This resulted in a minimum sample size of 105 patients and 105 nurses. To account for a potential 10% dropout rate, we distributed 116 questionnaires to both patients and nurses. The response rate was 100%, and all 232 collected questionnaires were utilized in our data analysis.
3. Study Tools
1) General characteristics
The general characteristics of patients encompass 15 factors: gender, age, educational background, marital status, religion, occupation, undergone surgery, treating department, length of hospital day, prior experience with Integrated Nursing Care Service Wards (INCSW), reasons for ward selection, intention to reuse the with INCSW, willingness to recommend, primary caregiver post-discharge, and satisfaction with the service. The general characteristics of nurses include 10 factors: gender, age, educational background, marital status, religion, total clinical experience, experience in the INCSW, type of INCSW, positon, and personal or familial experience with admission to INCSW.
2) Nursing needs and nursing performance
Nursing needs and nursing performance in this study were measured using an instrument initially created by Kim and Won [29], and later modified and validated by Yoon et al. [19]. We obtained prior permission to use this tool from both the original creator and the author of the revised and validated version via direct email correspondence. The tool measures nursing needs and performance by placing them on the left and right respectively, with a focus on the nursing items that hospitalized patients desire. It consists of five categories with a total of 35 items: the physical category (10 items), the therapeutic category (10 items), the emotional category (9 items), the educational category (5 items), and the economic category (1 item). The tool employs a 5-point Likert scale, with higher scores signifying greater nursing needs and performance. The original study [29] reported Cronbach's α reliability coefficients of .96 for patients and .94 for nurses, while the study by Yoon et al. [19] reported coefficients of .98 for patients and .95 for nurses. In our study, the reliability coefficient for both patients and nurses was .98.
4. Data Collection
After securing permission from the heads of nursing departments in five small to medium-sized hospitals, each with a capacity of over 100 but fewer than 300 beds, located in U City and Y City, we proceeded with data collection. This took place from July 18th to August 12th, 2022. We distributed questionnaires to patients in the integrated nursing care service wards, after explaining the purpose and nature of the study. Only those who voluntarily agreed to participate were included in the study. During the same period, nurses on duty also received questionnaires. To ensure the confidentiality of personal information, completed questionnaires and consent forms were stored in sealed envelopes and collected by the researchers during their visits. In total, we collected 232 data sets, comprising 116 patients and 116 nurses.
5. Ethical Considerations
This study was approved by the Institutional Review Board for Human Research at Y University (Approval No.: YSUIRB-202205-HR-110-02) to ensure the ethical rights of the research participants. The survey was carried out using structured, self-administered questionnaires, and participation was strictly voluntary. Participants were informed that they had the right to withdraw from the study at any point, even after giving their consent. Upon completion of the survey, participants were given incentives. The collected data were then recorded in a statistical program, ensuring no personal information of the participants was stored. The research data were kept on the researcher's computer, which will be permanently deleted three years after the conclusion of the study.
6. Data Analysis
Data analysis was conducted using the IBM SPSS Statistics 25.0 program. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to gain insight into the general characteristics of the participants. The independent t-test was used to analyze the differences between patients' perceived nursing needs and nurses' perceived nursing needs (gap 1), the differences between nurses' nursing performance and patients' perceived nursing performance (gap 3), and the differences between patients' nursing needs and nurses' nursing performance (gap 4). The paired t-test was used to analyze the differences between nurses' perceived nursing needs and nurses' nursing performance (gap 2), and the differences between patients' nursing needs and patients' perceived nursing performance (gap 5). IPA was carried out by plotting the mean values of nursing needs and performance for each gap on the X and Y axes, and then displaying the item values in the corresponding quadrants.
1. General Characteristics of the Subjects
1) Patient characteristics
Table 1 presents an analysis of the general characteristics of the patients who participated in this study. Of the 116 patients, 67 were women (57.8%), with an average age of 53.01±14.76 years. The most common educational background was high school graduation, represented by 49 individuals (42.2%). The majority of patients, 97 in total (81.0%), were married. There were 41 participants (35.4%) who were employed. In terms of surgical procedures, 84 patients (72.4%) had undergone surgery, and 95 patients (81.9%) were in the surgical department. The average length of hospital stay was 16.66±18.55 days. A significant number of patients, 92 in total (79.3%), had previous experience with admission to the integrated nursing care service wards. The most common reason for choosing this unit was to "to reduce the burden on family", a sentiment expressed by 77 individuals (66.4%). When asked about their intention to reuse the unit, the most common response was "strongly agree" given by 58 individuals (50.0%). After discharge, the majority of caregivers were family living with, accounting for 94 individuals (81.0%). Regarding service satisfaction, 49 patients (42.2%) responded with "strongly agree" and 45 patients (38.8%) responded with "agree."
Table 1
General Characteristics of Patients (N=116)
2) Nurse characteristics
Table 2 presents an analysis of the general characteristics of the nurses who participated in this study. Of the 116 nurses, 115 were women (99.1%), with an average age of 33.09±7.58 years. The most common educational background was a bachelor's degree, held by 70 nurses (60.3%). The majority of the nurses were single, also 70 individuals (60.3%). Most of the nurses had more than 10 years of clinical experience, with 47 individuals (40.5%), and the largest group of them (44 individuals, 37.9%) had between 3 to 10 years of experience working in INCSW. The surgical type was the most common area of work, with 87 individuals (75.0%), and the majority held the position of general nurse, accounting for 93 individuals (80.2 %). When asked about personal or family experience with admission to INCSW, 60 individuals (51.7%) responded affirmatively.
Table 2
General Characteristics of Nurses (N=116)
2. Discrepancies in Perceived Nursing Needs and Nursing Performance between Patients and Nurses
Table 3 presents an analysis of the discrepancies between patients' and nurses' perceptions of nursing needs and performance. The average score for patients' perceived nursing needs was 4.13±0.71, while their perceived nursing performance was 4.10±0.71. Nurses' perceived nursing needs scored 4.28±0.54, and their perceived nursing performance was 4.10±0.55. In gap 1, no statistically significant difference was found between patients' and nurses' perceptions of nursing needs (t=1.82, p=.070). However, a significant difference was observed in the physical category when examined by sub-category (t=3.07, p=.002). In gap 2, a statistically significant difference was noted between nurses' perceptions of nursing needs and performance (t=4.18, p<.001). This difference was also significant across all sub-categories. In gap 3, no statistically significant difference was found between nurses' perceived nursing performance and patients' perceived nursing performance (t=-0.02, p=.981). However, a significant difference was observed in the financial category (t=-2.08, p=.039). In gap 4, no statistically significant difference was found between patients' perceived nursing needs and nurses' nursing performance (t=-0.31, p=.760). Nonetheless, a significant difference was observed in the economic category (t=-3.79, p<.001). In gap 5, no statistically significant difference was found between patients' perceived nursing needs and their perceived nursing performance (t=0.34, p=.732). However, a significant difference was observed in the economic category (t=2.06, p=.042).
Table 3
Gaps between Perceptions of Nursing Needs and Performance (Patients N=116, Nurses N=116)
3. Importance-Performance Analysis of Nursing Needs and Nursing Performance
The IPA involved positioning the attributes of gaps on a two-dimensional matrix, with the gap attributes plotted along the X and Y axes. The matrix is divided into quadrants at the intersection points of the average scores of the variables on the X and Y axes, as depicted in Figure 2. The items corresponding to the second quadrant, which signifies the area requiring significant improvement (labeled as "concentrate here"), were as follows: For gap 1, these items include "Preventing me from contracting other infections in the hospital (P10)," "Respecting my rights when making decisions about treatment or tests (E6)," and "Providing instructions on managing meals, exercise, and medication after discharge (Edu4)." For gap 2, the items were "Performing injections or blood tests without causing pain (T5)," "Explaining my illness and the steps to overcome it (Edu3)," and "Guiding on how to manage meals, exercise, and medication after discharge (Edu5)."The items for gap 3 were "Maintaining cleanliness and regular change of the patient's gown and bedding (P2)," "Monitoring the patient's bowel and bladder function (P5)," and "Assisting the patient with changing positions, moving, or getting out of bed (P7)." For gap 4, the items include "Performing injections or blood tests without causing pain (T5)," "Respecting my rights when making decisions about treatment or tests (E6)," "Treating me with a caring attitude and a smile (E8)," "Explaining my illness and the steps to overcome it (Edu3)," and "Informing my family about my illness and guiding them on their role in my recovery (Edu4)." Lastly, for gap 5, the items were "Preventing me from contracting other infections in the hospital (P10)," "Being informed about the progression of my disease and preventing other health complications (T7)," "Informing my family about my illness and guiding them on their role in my recovery (Edu4)," and "Providing instructions on managing meals, exercise, and medication after discharge (Edu5)."
This study examined the nursing needs and performance perceived by both patients and nurses within integrated nursing care services, using the SERVQUAL model as a basis. Furthermore, it employed IPA to pinpoint priority areas and potential improvements in nursing activities, corresponding to each identified gap.
The results revealed a statistically significant difference solely in gap2. Gap2 is defined as the scenario in which nurses comprehend patients' nursing needs well, yet fail to deliver nursing services that fulfill these needs. This indicates that nurses' perceived nursing needs significantly exceeded their actual nursing performance, aligning with findings from previous studies [19]. Nurses are pivotal healthcare providers, with the quality of healthcare being intimately tied to the availability of competent nurses [28, 30]. Recently, tertiary hospitals have shifted their focus towards managing nursing staff to broaden integrated nursing care services and uphold nursing standards. Consequently, numerous nursing professionals are departing from small and medium-sized hospitals, resulting in a nursing staff deficit in these establishments [28]. Therefore, it is crucial to implement policies that enhance the working conditions of nurses in small and medium-sized hospitals and improve ward facilities and environments to deliver high-quality, safe nursing services. Furthermore, it is necessary to propose standards for nursing staffing that take into account the circumstances of small and medium-sized hospitals.
In relation to the elements identified in gap 2 through the IPA, activities such as disease explanation, coping strategies, and discharge education were highlighted as areas needing improvement. This aligns with the findings from gap 4 and gap 5 in the IPA, which suggest that while nurses acknowledge the importance of patient education, they feel ill-equipped to deliver it effectively. Moreover, patients reported not receiving as much education as they would like. In this study, the majority of patients had undergone surgery, thereby increasing the demand for information and education about postoperative care, treatment procedures, and ongoing management due to concerns and anxiety about pain and potential complications [8]. Additionally, it has been found that educational factors significantly influence patient satisfaction in integrated nursing care units [6], underscoring the importance of providing patients with the necessary information and education to accurately understand their conditions and manage them proactively [14]. To enhance the provision of nursing information and education in small to medium-sized hospitals, the development and implementation of specialist nursing educators could be considered.
In gap 1, which denotes the discrepancy between patients' perceived nursing needs and the nurses' understanding of these needs, identified three key areas for improvement: infection control, respect for patient rights, and family education. The need for nursing care in relation to infection control has seen a significant rise, particularly in the wake of the COVID-19 pandemic [31]. Recently, infection control departments and dedicated staff have become a legal requirement in small and medium-sized hospitals. However, these hospitals average only 2.7 dedicated infection control staff members, a number significantly lower than the 8.2 staff members found in tertiary hospitals. Furthermore, the implementation of regular infection control programs in these smaller hospitals is at 86.1%, compared to a full 100% in tertiary hospitals [32]. Therefore, it is crucial for small and medium-sized hospitals to make organizational efforts to secure dedicated infection control personnel and ensure they actively perform their infection control duties. Research on patient satisfaction with integrated nursing care [6, 33, 34, 35] indicates that patients desire direct involvement in their treatment process and consider it important to be informed about their own illnesses. This aligns with the findings of this study. Patient-centered nursing [14], which upholds patients' rights, values individuality, and includes significant individuals in their care, can help deliver nursing care that meets these patient demands.
In gap 3, which denotes the discrepancy between the nursing performance as perceived by nurses and patients, the activities that primarily require substantial improvement, according to the IPA results, are largely physical. These include changing patients' clothes, altering beds and linens, monitoring urine and stool, and repositioning, most of which pertain to basic personal hygiene. In the wards dedicated to integrated nursing care services, patients are solely dependent on the nursing staff due to restricted visitation and the absence of caregivers [8]. Given that patients anticipate services that match the care provided by their caregivers, strategies for patient guidance and education are essential to narrow the perception gap between patients and nursing staff concerning the extent of integrated nursing services. Furthermore, nurses and nursing assistants must strive harder to identify and cater to patients' physical needs with greater attention.
Statistically significant differences were noted in the financial category across gaps 2 to 5. The IPA results also identified the financial category as an area needing long-term improvement across all five gaps. The economic category pertains to "the provision of information on financial support and related professional counseling." While there is limited literature on the economic aspects of patient care, making comparisons and discussions challenging, these results may be due to the rising healthcare costs associated with an aging population and an increase in patients with chronic diseases. Other contributing factors could be the lack of fixed pricing for non-insured services such as physical therapy, vaccinations, and MRI, and the additional medical costs compared to general wards [4]. There is a clear need to establish a system that offers specialized counseling related to patients' financial issues. Additionally, it is crucial to raise awareness among nurses about the economic aspects of their nursing activities.
The IPA results from the nursing and caregiving service ward of a tertiary hospital revealed that areas related to the care of critically ill patients, such as emergency nursing, spiritual care, and end-of-life care, need significant improvement. This study categorized items related to patient rights, patient and family education, and counseling as long-term improvement areas, as they are closely associated with the focus of improvement [26]. This suggests that the type of nursing required can vary depending on the severity of the patients' conditions. This study not only provided a comprehensive assessment of the needs and performance of patients and nurses in the nursing and caregiving services of smaller hospitals with fewer than 300 beds, but also identified nursing activities that need focused improvement. This information offers specific guidance for enhancing the quality of nursing services. However, it is important to note that the nursing items developed for general wards may not align with the nursing activities in the integrated nursing service ward. Additionally, caution is needed when applying these results universally, as the study was conducted in specific regions only. In light of these findings, ongoing efforts are necessary to improve the quality of integrated nursing services through quality enhancement, activity improvement, and evaluations.
This study sought to provide foundational data to improve satisfaction levels in integrated nursing care services. This was achieved by examining the disparities between patients' and nurses' perceptions of nursing needs and performance in integrated nursing care service wards of small to medium-sized hospitals. The study also identified priority areas and potential improvements in nursing activities using the IPA. The findings revealed a statistically significant difference (gap 2) between the perceived nursing needs and the actual nursing performance as reported by nurses. In all categories, nurses' performance fell short of the perceived nursing needs. In terms of subcategories, patients' financial needs surpassed the nursing performance as perceived by both nurses and patients. The IPA results highlighted key areas for improvement, such as infection control, respect for patient rights, and patient and caregiver education regarding their conditions and treatments. The results also indicated that financial nursing is an area that requires long-term improvement. Based on the identified areas and specific items from this study, it is recommended that ongoing quality improvement activities and evaluations be conducted. Organizational cooperation is necessary to ensure the delivery of nursing services that meet patients' nursing needs. This can be achieved by aligning nursing staffing and the hospital environment with the circumstances of small and medium-sized hospitals. In light of the study's findings, several recommendations are proposed. First, as this study focused on patients and nurses in integrated nursing care service wards of small and medium-sized hospitals in specific regions, it is suggested that future studies include hospitals of various sizes and in broader regions. Second, the nursing item tool used in this study was designed for general wards. Therefore, it is recommended that future tools be developed to reflect the diverse situations encountered in integrated nursing care service wards. Lastly, it is recommended that research be conducted on interventions and program development to enhance the quality of integrated nursing care services in small and medium-sized hospitals, as well as to assess their effectiveness.
E-SUBMISSION
