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.

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.