|Year : 2020 | Volume
| Issue : 2 | Page : 84-90
Quality of nursing care assessment in the context of coronavirus disease (COVID-19) pandemic in the University of Benin teaching hospital, Benin-City, Nigeria: Patients' perspectives
Ngozi Rosemary Osunde1, Olaolorunpo Olorunfemi2, Lucy Chukwuka1, Oluwatosin Mary Oyewole3, Mojolaoluwa Omolade Olawale3
1 Department of Nursing, School of Clinical Medicine, Oba Okunade Sijuade College of Health Sciences, Igbinedion University, Okada, Edo State, Nigeria
2 Department of Medical Surgical Nursing, School of Nursing, University of Benin Teaching Hospital, Benin-City, Edo State, Nigeria
3 Department of Medical Surgical Nursing, School of Post Basic Nursing, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
|Date of Submission||09-Jul-2020|
|Date of Decision||30-Jul-2020|
|Date of Acceptance||17-Aug-2020|
|Date of Web Publication||9-Oct-2020|
Dr. Olaolorunpo Olorunfemi
Department of Medical Surgical Nursing, School of Nursing, University of Benin Teaching Hospital, Benin.City, Edo State
Source of Support: None, Conflict of Interest: None
Context: Quality of nursing care is the extent to which nursing health-care services provide an improved desired health outcome. Thus, using patients' perception as a proxy in measuring the quality of nursing care is highly recommended. Aims: The aim is to assess the quality of nursing care in the context of Coronavirus diseases (COVID-19) pandemic in the University of Benin Teaching Hospital (UBTH) from patients' perspectives. Materials and Methods: A cross-sectional descriptive study on the quality of nursing care: patients' perspective. Self-administered questionnaires were distributed to selected patients who had been on admission for not <2 weeks from the onset of the pandemic. A multistage sampling technique was used to select the sample size of 200 patients. Data collected were analysed using tables, percentages, means, standard deviation and Chi-square test; at 0.05 level of significance, through the Statistical Package for the Social Science software. Results: The findings revealed that patients had poor perception in some areas of nursing practice, and this is attributed to the shortage of nurses on the wards for patients' care. It also showed that nurse-patient relationship, and nurse-patient communication were significantly related to patients' perception of quality of nursing care (χ2 = 3.84, P ≤ 0.001) and (χ2 = 17.61, P = 0.003), respectively. Conclusion: The patient's perception of nursing care in UBTH was not perfect and this they attributed to the shortage of nurses on the wards for patients 'care, therefore the hospital management and the government should ensure more nurses are employed in the hospital so that the nurses can implement the standard ratio of nurse–patient relationship.
Keywords: pandemic, Coronavirus disease (COVID- 19), patients perspectives, quality of nursing care
|How to cite this article:|
Osunde NR, Olorunfemi O, Chukwuka L, Oyewole OM, Olawale MO. Quality of nursing care assessment in the context of coronavirus disease (COVID-19) pandemic in the University of Benin teaching hospital, Benin-City, Nigeria: Patients' perspectives. Niger J Basic Clin Sci 2020;17:84-90
|How to cite this URL:|
Osunde NR, Olorunfemi O, Chukwuka L, Oyewole OM, Olawale MO. Quality of nursing care assessment in the context of coronavirus disease (COVID-19) pandemic in the University of Benin teaching hospital, Benin-City, Nigeria: Patients' perspectives. Niger J Basic Clin Sci [serial online] 2020 [cited 2021 Jan 16];17:84-90. Available from: https://www.njbcs.net/text.asp?2020/17/2/84/297600
| Introduction|| |
The code of ethics for nurses said that the nurse's primary commitment is to the patient and they also owe the same duty to self as to others. These equal obligations can conflict during pandemics when nurses must continually care for critically ill infectious patients, often under extreme circumstances, including insufficient or inadequate resources and un-conducive working environment., In the early stages of the outbreak of coronavirus disease in 2019 (COVID-19) in Hubei, China, the local health-care system was overwhelmed, and nurses who had no infectious disease expertise were recruited to provide care to patients with COVID-19, therefore reducing the number of nurses available to attend to other patients suffering from other types of diseases, Today, many nurses find themselves on the frontline in the battle against COVID-19. These enormous challenges to nurses tend to pose threat to the quality of nursing care rendered., As care workers are vital in tackling the coronavirus outbreak, the World Health Organisation says there are nearly six million too few nurses globally., There is a global nursing shortage of 5.9 million, and this greatest gap is found in some of the poorest parts of the world, including countries in Africa, South East Asia and South America. In March 2020, it was published by Godsgift Onyedinefu in business day newspaper that there were 180,709, which translates 88. 1 nurses/100,000 members of population nurses to Nigeria's population, a ratio of 1:1135. On registered midwives, he said there are 120,870, which means 58.9 midwives per 100,000 members of the population, which is far lower than what it used to be before coronavirus pandemic in the country. There is no doubt that nursing is a profession with the essential ingredients of autonomy and accountability., Furthermore, the profession demands a great deal of responsibility to provide care and comfort for the patients. When the patient is on admission, how he/she thinks or feels about the nurse and the nursing care depends on nurse–patient interaction and this, in turn, forms their perception of nursing care. The public regards a nurse as someone who can give comfort and solace to someone in need; one who assists the doctor during and after treatment of the illness; one who assists the patient in keeping up his personal hygiene and taking the medications as prescribed; and dressing the wounds when there is a need to ensure the welfare of the patient However as in actual fact, nurses are pivotal to health care response to infectious disease pandemics and epidemics, and the systematic review showed that nurses' require Governments, policymakers and nursing groups to actively engage in supporting nurses, both during and following a pandemic or epidemic, without this, nurses are likely to experience substantial psychological issues that can lead to burnout and reduce the quality of nursing care rendering with an overall increase in morbidity and mortality rate of the patient. In line with these high expectations of nurses, it is a fact that hospital can not function effectively without a nurse because they take part in all aspect of patient care, and more specifically, the nurse–patient relationship, which is so central to quality patient care,, and with the shift from the health-care providers to the health-care consumers, patients' satisfaction is being increasingly used worldwide for the assessment of the quality of services provided by health-care institutions., To understand patients' satisfaction, 'patient's perception' of care must first be assessed. The nurse being in a unique position to influence and promote effective patients' relationships as they spend maximum time with the patients as compared with other health workers, this calls for a more patient-centered health-care system. The patients' perception of quality nursing care service refers to patients' view of services received, while patients' experiences are a reflection of what actually happened during the care process. Improving the quality of health-care delivery is an important global priority, and the purpose of health-care improvement initiatives is to ensure patients' safety, improve clinical effectiveness, and promote public accountability, especially now that the world is experiencing a public health emergency. Thus, the objective of the study was to determine the quality of nursing care in the context of coronavirus disease' pandemic from patients' perspective in the University of Benin Teaching Hospital (UBTH), Benin-City, Nigeria.
| Materials and Methods|| |
The study was a descriptive cross-sectional survey, conducted to find out the quality of nursing care in UBTH: patients' perspectives, with multistage sampling technique used to select the respondent; Stage one, UBTH was randomly selected from the three tertiary hospitals in Edo State; Stage two, three in-patient wards were also randomly selected: medical, surgical and obstetrics and gynaecological wards. Stage three, from the three selected in-patient' wards, the respondents were selected using accidental sampling techniques.
Sample size and sampling procedure
The sample size was determining using Taro Yamane method of sample size calculation according to the formula, n = sample size, e = margin of error = 0.05, with a confidence level of 95%. A sample size of 200 patients were selected from UBTH Benin-city. The inclusion criteria were: patient on admission in surgical wards, medical wards and obstetrics and gynecological wards for at least 2 weeks from the onset of COVID-19 pandemic and a regular consumer of health service in the hospital before the onset of the pandemic; to enable them compare their experience with previous experience and the patients must be well oriented to people, place, time and at least, must be an adolescent. The exclusion criterion was patients who do not consented to partake in the study.
Data collection tools and procedures
Data collection instruments were a structured questionnaire consisting of questions made up of six parts; Section A: sociodemographic data of respondent with 7 items, Section B: Patient's perception of nurse-patient relationship. The mean score of 3.5 and above rated as excellent, 2.6–3.4 rated as good, 2.5 rated as fair and <2.5 rated as poor perception. Section C: Patient's perception of nursing care activities. It contains 7 items and the mean is having same rating as section B. Section D: Patient's perception of nurse-patient communication. This section contained 10 items with same rating as above. Section E: Patient's perception about caring environment, with 7 items and same rating system. To ensure the reliability of the instrument, a pilot study was established by test-retest method by administering the instruments to 10% of the total respondents in Igbinedion teaching hospital, Okada, Edo State, and and analysed through Cronbach Alpha, the reliability of 0.72 was obtained, shows that the test item is highly reliable.
Consent form was given to the participants to seek written consent, verbal consent was also taken before data collection and the researcher ensured confidentiality of the participants' response to the questionnaire. Participants were not being exploited financially or physically.
Data obtained were coded and analysed using the Statistical Package for the Social Science (SPSS) version 21.00 statistical software (IBM corp. released 2012. IBM SPSS statistics for widows, version 21.0 Armonk, NY, USA: IBM Corp). Variables and research questions were analysed using frequencies, percentage, mean, standard deviation and Chi-square test for inferential statistics.
| Results|| |
The sociodemographic characteristics of the participants are reported in [Table 1]: It reveals that almost half of the respondents (47.0%) were admitted into the medical ward while a little above quarter (35.5%) were in the surgical ward and (17.5%) in obstetrics and gynaecological ward. Majority of the respondents (61.5%) were female while 38.5% were male. The highest age group of the respondents falls within the age bracket of 31–40 (55.0%), followed by ages 21–30 (33.0%). Most of the respondents were single (55.0%), while 35.0% were married. In addition, 65.0% were Christian and 35.0% were Muslim. In terms of education, majority of the respondents (49.5%) had a post secondary education. Furthermore, 75.0% had been in the ward for two to three weeks while 20.5% had stayed for one month, therefore qualify to narrate there perceived view on the nursing care they received.
|Table 1: Demographic characteristics of patients in University of Benin Teaching Hospital, Benin.City, Nigeria (n=200)|
Click here to view
The patients' perception of nurse-patient relationship is reported in [Table 2]: it shows that the patients have a poor perception about how nurses handle their emotional and psychological needs (2.45 ± 1.42). It also shows a poor perception about the listening skill of nurses as they carry out nursing duties (2.40 ± 1.39). This is found to be associated with the shortage of nurses available for patient care.
|Table 2: Patient's Perception of nurse . patient relationship among patients in University of Benin Teaching Hospital, Benin-City, Nigeria, 2020|
Click here to view
The patients' perception of nursing care activities is reported in [Table 3]: it shows that the patients have a poor perception about the number of nurses available for their care (1.65 ± 0.96). Majority of the participants subscribed to the fact that nurse-patients ratio is far below World health organisation recommendation. On the other hand, maintanance of privacy during examination, knowledge and skills of nursing care, shown by the hospital nurses were perceived to be excellence, as shown in [Table 3].
|Table 3: Patients' perception of nursing care activities in University of Benin Teaching Hospital, Benin-City, Nigeria, 2020|
Click here to view
The patients' perception of nurse-patient communication was reported in [Table 4]. Majority of the variables were rated 'good'; the nurses give opportunity to the patients to express their concern about illnes (3.04 ± 1.77); nurses give information regarding the illness (3.46 ± 2.01); the nurses give them information about investigation (3.10 ± 1.80); were rated good but on the contrary the nurses respond to their calls on time, and nurses spent adequate time with their patients were rated poor perception. This finding may be due to the fact that the number of nurses available for the patients' care were inadequate, which the participants believed is associated with the outbreak of the pandemic. The implication of this is that the few nurses available will not have an ample time to spend with the patients.
|Table 4: Patients' perception of nurse.patient communication in University of Benin Teaching Hospital, Benin-City, Nigeria, 2020|
Click here to view
The patients' perception about caring environment was reported in [Table 5]. It shows that the following variables were rated poor by majority of the respondents: the quality of the bed (0.78 ± 0.45); the quality and cleanliness of the bed linens (0.93 ± 0.54); number of bathrooms available (0.95 ± 0.55); cleanliness of the ward and toilets (1.98 ± 1.15); and the hospital environment (1.58 ± 0.91) while on the other hand the ventilation and lightening were rated good and excellence respectively. On the overall, the findings revealed that the patients' perception about the caring environment was not good or could be said not to be friendly enough for recovery purpose and nursing care.
|Table 5: Patients' perception about caring environment in University of Benin Teaching Hospital, Benin-City, Nigeria, 2020|
Click here to view
Finally, the relationship between nurse-patient relationship, nurse-patient communication and patients' perception of quality nursing care was reported in [Table 6]: it shows that there is significance relationship between the identified variables (χ2= 3.84, P ≤ 0.001) and (χ2= 17.61, P = 0.003) respectively as shown in [Table 6].
|Table 6: Chi-square test for relationship between nurse-patient relationships, nurse.patient communication and patients' perception of quality nursing care|
Click here to view
| Discussion|| |
Quality nursing care service delivery is necessary for optimal patient outcomes, and to achieve this focus has shifted from the healthcare providers to the healthcare consumers; patient satisfaction is being increasingly used worldwide as a tool for the assessment of quality nursing care services provided by healthcare institutions. Therefore, the nursing manager's core concern is the need to improve Patient's perception of quality nursing care or view of the nursing care they received from nursing staff during hospital stay. Using patient's perception as proxy in measuring quality of nursing care is highly recommended. This study shows that the patients have a poor perception about how nurses handle their emotional and psychological needs and also poor perception about their listening skills, which they believed that the situation is getting worst, since the onset of the pandemic. This is in agreement with a study on Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A focused ethnographic study in Hong Kong hospitals and found that many cancer patients do not receive enough psychosocial care in the form of emotional talks, listening ear or counselling from nurses because of their busy schedule, and therefore suggested that there is a need to improve the nurse-patient relationship by encouraging nurses to strengthen the practice of mindfulness and improve their communication skills. In addition, the patients' limited disclosure of their psychosocial concerns relates not only to their perception of their relationship with the nurses, but also to their perception of the roles played by nurses and of the nurses' competence in providing psychosocial care.
In the year 2020 another study on Communication in nurse-patient interaction in healthcare settings in sub-Saharan Africa: A scoping review; found that most nurses neglect patients' psychological and emotional needs but rather abuse and humiliate them, especially in maternal/antenatal and primary healthcare settings in public healthcare facilities. They opined that this attitude is as a result of shortages of nursing staff, poor communication skills, excessive workload, and lack of proper mentorship from nursing managers on junior nurses' ability to interact effectively with their clients.,
In addition this present study showed that the patient have a poor perception about the number of nurses available for their care since the onset of Coronavirus disease. Most of them believe that there is a gross shortage of nurse in the hospital which they believe is causing a major challenge or threat to holistic nursing care services. A study conducted among Jordanian inpatients, showed that shortage of nurses in the hospital increases the incidence of different type of errors in nursing care and result into higher mortality and morbidity rates, and they further explained that in any hospitals where there are high patient-to-nurse ratios; nurses will easily experience dissatisfaction, burnout, and on the other hand the patient's experienced higher mortality, financial burden, stay longer in hospital, and hospital acquired infection associated with improper management from nurses. This findings substantiate with a study carried out in England and they found that majority of all respondents indicated concern for the amount of time nurses have to spend with patients, as a result of the shortage of nurses, and this pose a major problem to health care delivery system because nurses play a key role in the early detection of patient complications and their ability to maintain patient safety Some studies have linked nurses to the timely identification of complications that, if acted upon quickly, might prevent deterioration in patients' condition and even avoid preventable deaths.,,
Moreover, this study also show that patients' have poor perception of nurse-patient communication because most of them believe that nurses do not always respond on time to their calls when they needed help and do not spend adequate time with the patients, when compared with their experience before the COVID- 19 pandemic. According to a study by Sibiya in South Africa, found that a nurse-patient communication is a core element of sound relationships, partnership and co-operation, which form an important aspect of professional nursing care practice and quality of nurse-patient communication in interactions between nurses and patients has a major influence on patient's treatment and outcomes. This study corroborate with a study carried out by Conroy et al. in Royal College of Nursing (Great Britain) and found that nurses do not always respond on time to Patients' Calls and early response by a nurse is a way of ensuring patients, or their family that the nurse is really concerned about the patient safety and wellbeing. On the contrary to this, in 2015 a study conducted on Inpatient Satisfaction among Patients Admitted in a Tertiary Care Hospital and found that patients were satisfied with nurse's services and good communication existed between the nurses and the patients. This difference in findings could be as a result of differences in developmental stages of these hospitals.
Other studies also agreed with this findings in the area of spending quality time with patient as a means of enhancing nurse-patient communication and concluded that effective communication is essential in developing rapport with patients, and many nursing roles such as patient assessment, education, and counselling can only be effective if the nurse spend quality time with their patient.,,,
Furthermore, this present study also found that patient perception about the caring environment in the studied hospital is very poor because of the fact that the quality of hospital bed, bed linen, patients bathroom, toilet and hospital environment were not satisfactory and this actually influence their perception. This is in agreement with a study carried out in Ibadan, Nigeria on assessment of perinatal care satisfaction amongst mothers and found that the causes of poor perception of patient about the caring or hospital environment are dirty hospital environment, inadequate water supply, poor quality bed to sleep, other hospital facilities, time wasting, distance of hospital location, inadequate staffing, cost of materials, and physical and verbal abuse.
Finally this study showed that there is a significance relationship between nurse-patient relationship, nurse-patient communication and patients' perception of quality nursing care. This is agreement with a study that found that if nurse-patient relationship and communication is good, the nurse will gain more understanding on how the patient responds to their care and other concerns; this will produce a better perception from the patient.
Nevertheless, this study was faced with some limitation such as; the research only covered one hospital in the country. Probably; there is a peculiarity in the hospital that affected the outcome of the study.
| Conclusion|| |
The study has demonstrated that patients have poor perception in some areas of nursing practice, when compared with their previous experience in the hospital before the pandemic because all the participants were regular consumer of health service of the hospital. They were able to compare their experience with previous experience, which form the bases for their response and this they attributed to the shortage of nurses on the wards for patients' care, especially this period that most of the nurses were move to isolation unit to render help in the treatment of patient with coronavirus. This was reflected in poor perception of nurse-patient relationship and the nurse-patient communication. The hospital manager and the government should ensure more nurses are employed in the hospital so that the nurses can implement the standard ratio of nurse-patient relationship. This will avail the nurses the opportunity of establishing and maintaining good and therapeutic nursing relationship. The hospital managers should approve study leave with pay for nurses to take up refresher courses which will expose them to the importance of nurse-patient relationship and nurse-patient communication in emergency situation. Also the government should provide a good working conditions to enable them work with high morale and increase level of commitment. Finally, the standard of hospital environment: wards, beds linens, toilets and bathroom should be improved to help in maintaining healthy recovery environment for the patients.
The authors wish to sincerely thank all the patients and nurses of University of Benin Teaching Hospital, Benin-city, Nigeria.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Olson LL, Stokes F. The ANA code of ethics for nurses with interpretive statements: Resource for nursing regulation. J Nurs Regulat 2016;7:9-20.
Khan IU. Impact of Incongruous Jail Environment on the Juvenile Prisoners in Selected Jails of Khyber Pakhtunkhwa, Pakistan (Doctoral Dissertation, Gomal University, DI Khan.); 2018.
Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, et al
. The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. Lancet Glob Health 2020;8:e790-8.
Ibeh IN, Enitan SS, Akele RY, Isitua CC. A review of the COVID-19 pandemic and the role of medical laboratory scientists in containment. J Med Lab Sci 2020;30:68-89.
Golemi Minga I, Golemi L, Tafur A, Pursnani A. The Novel Coronavirus Disease (COVID-19) and Its Impact on Cardiovascular Disease. Cardiol Rev 2020;28:163-76.
Dubler O, Nagl F. Is vaginal breech delivery still justified? Arch Gynakol 1975;219:495-6.
World Health Organization. State of the World's Nursing: Investing in Education, Jobs and Leadership Geneva. World Health Organization; 2020.
Schwartz DA, Graham AL. Potential maternal and infant outcomes from (Wuhan) coronavirus 2019-nCoV infecting pregnant women: Lessons from SARS, MERS, and other human coronavirus infections. Viruses 2020;12:194.
World Health Organization. Global Strategy on Human Resources for Health: Geneva Workforce; 2030.
George V, Haag-Heitman B. Peer review in nursing: Essential components of a model supporting safety and quality. J Nurs Adm 2015;45:398-403.
Slatyer S, Coventry LL, Twigg D, Davis S. Professional practice models for nursing: A review of the literature and synthesis of key components. J Nurs Manag 2016;24:139-50.
Kisorio LC, Langley GC. Intensive care nurses' experiences of end-of-life care. Intensive Crit Care Nurs 2016;33:30-8.
Mako T, Svanäng P, Bjerså K. Patients' perceptions of the meaning of good care in surgical care: A grounded theory study. BMC Nurs 2016;15:47.
Arreciado Marañón A, Isla Pera MP. Contradictory views of nursing care among students at the end of their nursing education. J Adv Nurs 2017;73:410-20.
Fernandez R, Lord H, Halcomb E, Moxham L, Middleton R, Alananzeh I, Ellwood L. Implications for COVID-19: A systematic review of nurses' experiences of working in acute care hospital settings during a respiratory pandemic. Int J Nurs Stud 2020;8:103637.
Uhrenfeldt L, Sørensen EE, Bahnsen IB, Pedersen PU. The centrality of the nurse-patient relationship: A Scandinavian perspective. J Clin Nurs 2018;27:3197-204.
Iannuzzi JC, Kahn SA, Zhang L, Gestring ML, Noyes K, Monson JR. Getting satisfaction: Drivers of surgical hospital consumer assessment of health care providers and systems survey scores. J Surg Res 2015;197:155-61.
Vogus TJ, McClelland LE. When the customer is the patient: Lessons from healthcare research on patient satisfaction and service quality ratings. Hum Resource Manag Rev 2016;26:37-49.
Salmond SW, Echevarria M. Healthcare transformation and changing roles for nursing. Orthop Nurs 2017;36:12-25.
Chan EA, Wong F, Cheung MY, Lam W. Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A focused ethnographic study. PLoS One 2018;13:e0199183.
Kwame A, Petrucka PM. Communication in nurse-patient interaction in healthcare settings in sub-Saharan Africa: A scoping review. Int J Afr Nurs Sci 2020;12:100198.
Olorunfemi Olaolorunpo RN, BNSC P. Mentoring in nursing: A concept analysis. International Journal Caring Sciences 2019;12:142-8.
Al-Hussami M, Al-Momani M, Hammad S, Maharmeh M, Darawad M. Patients' perception of the quality of nursing care and related hospital services. Health Primary Care 2017;1:1-6.
Griffiths P, Ball J, Drennan J, Dall'Ora C, Jones J, Maruotti A, et al
. Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development. Int J Nurs Stud 2016;63:213-25.
Ozekcin LR, Tuite P, Willner K, Hravnak M. Simulation education: Early identification of patient physiologic deterioration by acute care nurses. Clin Nurse Spec 2015;29:166-73.
Mohammmed Iddrisu S, Hutchinson AF, Sungkar Y, Considine J. Nurses' role in recognising and responding to clinical deterioration in surgical patients. J Clin Nurs 2018;27:1920-30.
Petit C, Bezemer R, Atallah L. A review of recent advances in data analytics for post-operative patient deterioration detection. J Clin Monit Comput 2018;32:391-402.
Sibiya MN. Effective communication in nursing. Nursing 2018;119: 19-36.
Conroy T, Feo R, Boucaut R, Alderman J, Kitson A. Role of effective nurse-patient relationships in enhancing patient safety. Nurs Stand 2017;31:53-63.
Philoreshmi S. Inpatient satisfaction among patients admitted in a tertiary care hospital. Int J Adv Nurs Manag 2015;3:124-6.
Staples S. Examining the linguistic needs of internationally educated nurses: A corpus-based study of lexico-grammatical features in nurse–patient interactions. English for Specific Purposes 2015;37:122-36.
De Simone S, Planta A, Cicotto G. The role of job satisfaction, work engagement, self-efficacy and agentic capacities on nurses' turnover intention and patient satisfaction. Appl Nurs Res 2018;39:130-40.
Walczak A, Butow PN, Bu S, Clayton JM. A systematic review of evidence for end-of-life communication interventions: Who do they target, how are they structured and do they work? Patient Educ Couns 2016;99:3-16.
Nouri SS, Rudd RE. Health literacy in the “oral exchange”: An important element of patient–provider communication. Patient Educ Couns 2015;98:565-71.
Odetola TD, Fakorede EO. Assessment of perinatal care satisfaction amongst mothers attending postnatal care in Ibadan, Nigeria. Ann Glob Health 2018;84:36-46.
Tyrrell EF, Pryor J. Nurses as agents of change in the rehabilitation process. J Australas Rehabil Nurs' Associ 2016;19:13-20.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]