Influence of nurse-patient relationship on hospital attendance. A qualitative study of patients in the Kwahu Government Hospital, Ghana.

BACKGROUND: The relationship of nurses and patients in healthcare settings has been central in ensuring good and efficient healthcare delivery. The total hospital attendance in the Kwahu Government Hospital have reduced in recent years. The study explored patients' perceptions of the nurse-patient relationship and its influence on hospital attendance at the Kwahu Government Hospital.
METHODS: A phenomenological qualitative study design, with a purposive sampling technique, was used to interview ten participants from the various wards in the hospital on their perceptions of the nurse patient relationship and its influence on hospital attendance. The data were transcribed and analysed using a thematic content analysis approach that embraces three interrelated stages, namely data reduction, data display, and data conclusion drawing.
RESULTS: Many of the participants had positive perceptions regarding the attitude of nurses, and that influenced hospital attendance while others opined that nurses' attitudes towards them made them attend a private facility. Almost all the participants suggested that patients should exhibit an equally good attitude and behaviour towards nurses, and better communication between patients and nurses as vital ways of improving the nurse-patient relationship. Nurses in the Kwahu Government Hospital are described as friendly, respectful and attend promptly to patient health care needs adequately. The range of perceived respect differed from patient to patient and include the nurse called patient by name, respond promptly to patient needs, helped "helpless patients" to feed and also assisted them change diapers, listen to patient concerns, linked patient to other professionals, work within the cultural context of hierarchy and that the nurse is sociable and interacted with patient positively.
CONCLUSION: Hospital management should conduct regular evaluations of patients' experiences as well as nurses' experiences to address deficiencies in communication and nurse-patient interactions.

Introduction

The nature of nurse-patients’ relationship in healthcare settings is pivotal in ensuring good and efficient healthcare delivery [1, 2, 3]. This relationship has been described by some to be influenced by the attitude of both parties [1, 2]. Nurses' attitudes towards patients in healthcare settings can either be positive or negative [1]. This attitude of nurses in some instances is limited to the knowledge level of nurses. When nurses are confronted with cases in which they are knowledgeable in and/or familiar, they exhibit a positive attitude towards patients while the opposite is also true [1]. Nurses that understand the disease process and the patients’ specific needs and attend to those needs are perceived to have a positive attitude. Positive perception of patients about nurses is identified as a key motivating factor that encourages hospital attendance and also influences how quickly patients recover from sickness or injury [1]. Nurses are often confronted with the issue of portraying negative attitudes towards patients [2]. The public is usually quick to associate all negative experiences in the hospital to the nurse. The situation is even worse for nurses in rural communities and in small towns where these nurses become an integral part of the community and the disease prevention system [2]. Although nurses are perceived to portray a negative attitude toward patients, some nurses are also often commended for portraying a good attitude; a culture that needs to be encouraged [3]. Patients' satisfaction and early recovery largely depend on emotional support, love, and care given to them by nurses. On the contrary, should nurses exhibit negative attitudes towards patients, this prevents patients from visiting health care facilities or affects their healing and recovery process [4]. On the African continent, specifically in Kenya, in a cross sectional study of patients in the Kenyatta hospital, patients' expectations and suggestions on how nurses should treat patients have been highlighted [5]. Patients expected nurses to be kind, cheerful, and responsive towards them [5]. In that study, children and the elderly (below 19 and over 60 year's old patients) were the categories of patients who expected nurses to be kind [5]. Honesty and friendliness were some of the virtues patients expect nurses to have to help improve relationships between nurses and patients [5]. On expectations of care based on gender in terms of how patients expected nurses to treat them, female patients were in dire need of responsive and tender care from nurses than their male counterparts [5]. Although in Ghana, few studies have focused on patients' perceptions and of nurses' attitudes and ways to improve the patient-nurse relationship, Peprah (2014) at the Sunyani Government Hospital showed the determinants of patients' satisfaction at the hospital that influence patient attendance [6]. Empathy towards patients was one of the key factors that could improve patients' perception of nurses in the hospitals [6]. Eliminating rudeness towards patients and the ability of nurses to provide individualized attention to the aged and physically challenged as well as understanding to patients' needs were also among the variables that were identified to aid in improving nurse-patient relationships [6]. Furthermore, keeping patients informed about when service will be performed, politeness of nurses, the willingness to answer patients' questions, patients being given enough time to tell a nurse their problem and the feeling of being secure at a hospital were key in erasing negative perceptions patients hold towards nurses and improved the nurse patient relationship [6].

Perceived attitudinal issues of nurses towards patients in healthcare settings are not only a phenomenon peculiar to Africa but the world as a whole. Quality communication between nurses and patients is a major constraint of nursing service delivery in most hospitals [7]. In Africa, attitudinal conflicts between nurses and patients have been reported in Nigerian health care settings where nurses hardly receive a common ‘thank you’ from patients, an indication that their efforts are not appreciated by patients [8]. The perceived attitudinal problems between nurses and patients in some Ghanaian health care settings have been highlighted [9]. In a research that was titled “search for the modern-day Florence Nightingale” in Kumasi, Ghana, Adu-Gyamfi, and Brenya (2016) mentioned perceived negative attitudes of nurses towards patients as one of the forerunners that hinder good nursing care in the country [9]. There has been a paucity of information regarding nurse-patient relationships in recent years and especially in Ghana's eastern region particularly. This paucity of information highlights the need to explore the nurse patient relationship and its influence in hospital attendance.

Problem statement

The Kwahu Government Hospital (KGH) serves a bigger geographical area, with many communities. The hospital used to be very vibrant, serving over 80,000 people per annum. The 2014 and 2015 hospital attendance records in the outpatient department of the hospital were high, (78 754 and 79 489 respectively), these sharply reduced to 72 758 in 2016; and 67 092 in 2017. In Ghana, few studies have actually dealt with the patient's perception of the nurse-patient relationship and its influence on hospital attendance [6]. Furtherance to the paucity of information regarding the reasons for this reduction in hospital attendance, the study was motivated by the suggestions of Lawson et al., 2011. As has been suggested by Larsson, et al., 2011 on the role of nurses in enhancing patient attendance [1], the initiative was taken to explore the perceived nurses' attitudes towards patients and its impact on the general patients' attendance at the KGH. This study explored how patients perceive the nurse-patient relationship and its influence on hospital attendance in the KGH.

Aim

The study explored patients’ perceptions of the nurse-patient relationship and its influence on hospital attendance at the KGH.

Methodology

Study design

The phenomenological qualitative research design approach was used to explore patients’ perceptions of nurse-patient relationship and its influence on hospital attendance at the KGH as the study focuses on the commonality of lived experience of patients in the facility that is cardinal in extending health care access per the policy of the authorities in Ghana [10, 11]. The choice of phenomenological design afforded the researchers the opportunity to explore a phenomenon in the real-life context of patients' experiences of care received in the KGH [11].

Study area

The study was conducted at the KGH which is located in the Kwahu South District of the Eastern Region of Ghana. Data from the 2010 census indicated that the Kwahu South District has a population of 69, 757 constituting 2.6% of the population of the Eastern Region [11]. A total of 52.6% of the population is females [10]. The inhabitants are predominantly farmers with an average literacy rate [10]. The KGH was established in 1954 by the Seventh Day Adventist missionaries and handed over to the government of Ghana twenty years later in 1974. It has a bed capacity of 175 which is distributed among eight wards namely; Male, Female, Accident and Emergency, Children's, Gynaecology, Labour, Maternity, and Surgical wards. The hospital serves the population of both Kwahu South and Kwahu East Districts and serves as one of the referral health care facilities for some of the peripheral health care facilities.

Study population, sample and sampling

The population of this study was all patients who attended KGH at Atibie, and were at least 18 years, the legal age of consent in Ghana. In line with qualitative principles, the participants of this study were selected through purposive sampling technique [11] from the various wards of the hospital. Both male and female patients with varied disease diagnosis were recruited into the study as shown in Table 2. Participants were continually recruited until data saturation [11, 12] was reached on the 10th participants as no new and additional information was gotten [11]. The ten participants were none randomly selected and interviewed at the hospital, based on their availability and willingness to participate in the study [11, 12]. To qualify a participant should have accessed health care at the KGH, at least once, preceding the study. Patients that were critically ill to the extent that they could not respond favourably to the questions, were excluded.

Table 2

Demographic characteristics of participants.

Demographic characteristic	Frequency	Percentage
Sex
Male	2	20.0
Female	8	80.0
Age group
28–37	4	40.0
38–43	6	60.0
Marital status
Single	1	10.0
Married	8	80.0
Widowed	1	10.0
Educational level
Tertiary	2	20.0
Senior High School	1	10.0
Junior High School	2	20.0
Primary	5	50.0
Disease diagnosis received at the facility
Hypertension and diabetes	2	20
Malaria and suspected Typhoid fever	3	30
Fracture of lower limb	1	10
Multiple sclerosis	1	10
Burns of lower limbs and trunk	1	10
Liver disease	2	20

Data collection

A self developed semi-structured interview guide was used for data collection. The semi-structured interview guide provided the researchers with the opportunity to ask a set of predetermined questions that allowed for probing and clarification of answers from participants [11]. The researchers were able to get participants to share their experiences in detail through probing. Major themes of the study include, but are not limited to patients' perception of the nurse patient relationship, nature and satisfaction of care received from nurses, factors that influence the nurse patient relationship, means of improving nurse patient relationship as shown in Table 1. The interviews were conducted within the period of a week. Trained researchers (four people) with a minimum of a Bachelor's degree in nursing were recruited from the University of Health and Allied Sciences, Ho and used for data collection. The researchers received a day training in interview techniques, research ethics, the study tool and interpretation of qualitative research findings before the commencement of the study. Two males and eight females receiving health care at the facility were interviewed. Each interview session lasted approximately forty minutes and was conducted in a well-lit and ventilated environment devoid of noise and interference. The proceedings were then recorded on a voice recorder and subsequently transcribed verbatim into Microsoft word after each day's session.

Table 1

Thematic areas assessed during interview session.

Main theme	Sub theme
Perceptions of patients about the attitude of nurses.	1. Patients' perception of nurses. 2. Ways nurses treated patients 3. Some negative experiences with nurses. 4. Nonverbal mannerisms of nurses 5. Nurse patient confrontations. 6. Physical abuse by nurses.
Influence of patients' perceptions of nurses' attitude on hospital attendance	1. The influence of nurses attitude towards patients' hospital attendance 2. Reasons for switching point of service acquisition
Other factors that influence attendance to hospital either than the nurse attitude.	1. The impact of cost on service acquisition 2. The role of distance in seeking health care services
Ways to improve nurse patient relationship	1. Patients attitude towards nurses and nursing service 2. Nature of communication between nurses and patients 3. Nurses actions towards improved nurse patient relationship 4. Stakeholders' actions to promote good nurse patient relationships towards improved health care provision

Pretesting and rigor

The pretesting of the interview guide was done among three patients in the Kwahu Praso Health Centre, located in the eastern region of Ghana. Results and findings from the pilot study were not included in this manuscript. The setting of the pretesting facility has similar demographic characteristics as the study site and therefore allowed for appropriate adjustment (translation of the question to Akan language, reordering of sub thematic areas into main themes) of the interview guide. The main adjustments made were adjustment of the nature of questions, appropriateness of interpretations of questions into local dialects as well as modification of the sequence of questions. The aim of conducting the pilot study was mainly to establish the appropriateness of the interview guide questions, to test participant recruitment procedures, and to ascertain how participants were likely to react to questioning, taking into consideration the sensitivity of the research topic. It was also to test the overall research design of the study, including data analysis procedures that were to be employed in the main study. The trustworthiness of the study was ensured by a researcher checking with the participants through phone call during the data analysis that facilitated the full understanding of the responses. Furthermore, writing detailed field notes and discussing the findings among the investigators helped ensure trustworthiness of the study [12].

Data analysis

In data analysis, thematic analysis was engaged that embraces three interrelated stages, namely data reduction, data display, and data conclusion drawing/verifying [13]. Also, Guest, Macqueen, and Namey (2012) summarized the process of thematic analysis as construing through textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes [14]. In using this scheme, a codebook was first established, discussed, and accepted by the authors. The nodes were then created inside NVivo software (version 11) using the codebook. Line-by-line coding of the various transcripts was performed as either free or tree nodes. Double coding of each transcript was carried out by two of the authors. Coding comparison query was used to compare the coding and a kappa coefficient (the measurement of inter-coder reliability) was generated to compare the coding that was conducted by the two authors. Matrix coding query was performed to compare the coding against the nodes and attributes using NVivo software (version 11) that made it possible for the researchers to compare and contrast within-group and between-group responses. The responses made by respondent were then tallied under each node by the two researchers so as to group the responses under subthemes and subsequently the main themes (as shown in Table 1). Lived experiences and views expressed by the participants were then analysed and simple quotes used to support the presentation of the results.

Ethical considerations

Ethical clearance was obtained from the Research Ethics Committee of the of the Institute of Health research in the University of Health and Allied Sciences, Ho (UHAS-REC A.10 [21] 17-18). Permission was then sought from the Kwahu South District Health Directorate, which oversees the operations of the KGH. Consent (both written and verbal) was also sought from the participants at the facility. Participants were also granted the freedom to withdraw from the study whenever they felt uncomfortable to continue with the interview.

Results

Demographic characteristics of participants

The study involved ten (10) patients attending KGH in the Eastern region. The participants were females (80%) and aged 38–43 years (60%) as shown in Table 2. The disease diagnosis made when participants visited the hospital and subsequently confirmed the diagnosis in the patient's folder by the researchers, the findings showed hypertension and diabetes (20%) and malaria and queried typhoid (30%).

Perceptions of patients about the attitude of nurses

In order to understand the nature of the relationship that existed between nurses and patients in the hospital, the researcher sought to explore the perception of patients regarding the attitude of nurses. The thematic areas that were explored under this section included; patients' perception of behaviour, the ways nurses treated patients, some negative experience with nurses, nonverbal mannerisms of nurses, nurse patient confrontations and physical abuse by nurses.

Patients' perception of nurses

Generally, many of the participants had positive perceptions regarding the attitude of nurses at the KGH. Regarding treatment by nurses, study participants showed that nurses attended promptly to their needs and were professional in dealing with the treatment processes. In total, the majority of the patients showed that nurses built a trusting relationship with them as patients and that promoted positively the treatment relationship that was established.

Some of the participants indicated that the nurses never shouted at them, were not maltreated, and did not disregard them while on admission and that influenced a positive relationship that was established. The following quotes summarize their views:

“The care we received from the nurses is based on the trust that has been established in the care relationship. I trust that the nurses have a positive mind-set, they are professionals and they seek for the good of the patients as they are trained to provide” (a 44 year old female patient).

“They (nurses) do not shout at me. As for this General Hospital, when they (nurses) see us, the older people, they give us some kind of special attention and care. The nurses are really good at how they treat patients” (A 54-year old female patient).

“I have never had an encounter where the nurses here shouted at me or any other patient. They treat every patient with dignity and respect. In fact, they are always calm and tolerant when out of pain some patients even act rude to them. So, for the nurses here, I can't say they have any bad attitude towards patients, they build good relationships with patients and their families.” (A 32-year old female patient).

“We are here because we are sick and the least we expect from the care provider is comfort and understanding. The nurses here generally care and understand how to support and engage patients towards a successful recovery” (A 29 year old female patient).

Ways nurses treated patients

Other participants said that the nurses attended to them with respect. The range of perceived respect differed from patient to patient yet core to this tenants included that the nurse called them by their name, the nurse responded promptly to their needs, the nurse helped “helpless patients” to change diapers and fed them, the nurse listened to their concerns, the nurse linked them to other professionals, the nurse worked within their cultural context of hierarchy and that the nurse was sociable and interacted with patient positively. The perception of nurses’ attitude was based on nurses attending to patients respectfully. For instance, some participant said;

“As for the nurses here, they attend to us respectfully, and sometimes, you feel as if they are your relatives……. Even the patients who cannot do anything for themselves, the nurse baths them, changes their diapers and feeds them. The nurses are very supportive to patient's needs” (A 29-year old female patient).

“….. They showed me respect. What makes them good is that they feed you when they have time or are not serving other people with medication. I saw them (referring to nurses) change diapers for some patients. Even though some of the relatives wanted to help but the nurses didn't allow them, so to me it is a good sign” (A 44-year old female patient).

“Anyway, compared to what we hear from other places, the nurses here are better in terms of respect to our rights. They understand that we are sick and seeking their services” (A 40 year old female patient).

Some negative experiences with nurses

However, some participants reported a negative experience with nurses. This negative attitude encountered related to the manner and time the nurse communicated with the patient. Some of the specific experiences were related to the nurse providing an instruction to a patient, especially when the person was in pain. One participant indicated that one nurse was rude to her, but she ignored the nurse.

“One nurse was trying to be rude to me, but I just ignored her. She wanted me to stand up from a chair to another chair meanwhile I was also in pain and didn't come to meet anyone sitting there, and I was not ready to stand up so she came and shouted at me but I ignored her” (A 40-year old female participant).

Nonverbal mannerisms of nurses

Patients indicated that since the nurse is a care provider for the ‘downtrodden’, it is expected that she will have a cheering facial expression and conduct herself with happy and positive emotion that can translate to positive patient outcomes. A participant noted;

“Some of them (the nurses) are not friendly at all, they always frown their face and hardly treat you well as a person” (A 39-year old female patient).

In fact, I must say that some nurses are really callous, they don't deserve the uniform they wear, and how can you be so disrespectful? (A 39-year old female patient retorted).

Nurse patient confrontations

Regarding patient-nurse confrontation, some of the participants reported that they have never had a verbal confrontation with any nurse in the hospital. Participants indicated that since the nurse is providing a service to them, they have not encountered a situation that will warrant a confrontation. They indicate the nurses are working within the professional remits of the law that governs their professional practice and as they do so patients have no reason to engage in a confrontation. Also, another reason espoused was because nurses hold themselves in good esteem and respect the tenants of their professional callings. The following quotes summarize their views:

“I have not been confronted by any of them (nurses) before. The nurse is doing her professional duty; I have no reason why we will be involved in a confrontation. I think the nurses here hold themselves with dignity and work with the professional tenants of their profession” (A 21-year old female participant).

“I think the nurses here really respect themselves. No matter how rude or untoward some patients may be, they will never have a confrontation with them. So, usually, we (the patients) ‘stand by them’ and reprimand such patients who try to disrespect them” (A 32-year old female patient).

Some reasons ascribed for some confrontations could be described as personal and had no bearing on the professional duty rendered by the nurse. 0ne participant was very outraged, she has had a confrontation with the nurses before. She stated that.

There was this nurse, even the way she walks, very disrespectful. I did not also spare her, I gave it to her, and I kept her in her right position (A 39-year old female patient).

Physical abuse by nurses

Regarding whether nurses in the hospital have in any way tried to physically abuse patients, all the participants indicated that they have never been physically abused by the nurse at the hospital. The respondent contends nurses have always maintained a cordial relationship with patients and they have not personally witnessed an untoward behaviour between a nurse and a patient especially during the care delivery process.

“None of the nurses have ever acted in any way towards me that suggested he/she wanted to physically abuse me. The nurses in this facility have always maintained a good relationship with the patient. I have not actually witnessed an unpleasant relationship between a nurse and a patient in this facility” (A 38-year old female participant).

“No nurse here has tried to hurt me physically. In fact, they treat you like their mother. They wouldn't even want to confront you, how much more physical struggle or abuse? I really appreciate them” (A 40-year old female patient).

“No, I have never been physically abused by any nurse. Possibly the female patients, but for me and all the men I know, no one has been physically abused by a nurse.” (A 29-year old male patient).

Influence of patients′ perceptions of nurses’ attitude on hospital attendance

The perception of nurses' attitude could potentially affect the patients' decision to revisit a health facility for care. This study sought to explore the influence of patients' perception of nurses' attitude on their attendance at the KGH. Some thematic views explored included; the influence of nurses' attitude towards patients’ hospital attendance and the reasons for switching point of service acquisition by patients.

The influence of nurses attitude towards patients’ hospital attendance

Some participants reported that the attitude of the nurses made them attend the hospital. Nurses in the KGH are described as friendly, respectful and attend promptly to patient health care needs adequately. In this light participants were happy they receive services from this cadre of professionals. These are some direct response from some participants:

“I used to attend a different facility. However, the way I was attended to when I came here for the first time, I decided to always come here instead. I realise the health care providers here were much friendly and professional. They gave me all the attention I needed and indeed the medications I received that day actually did help me a lot. I am happy to receive such professional care from this place that is actually shorter to my home compared to where I used to attend services.” (A 36-year female patient).

“The feeling that I am being respected and treated well by the nurses of this facility made me always want to come here for care. Sometimes, I know going to a drugstore will be okay. Yet, I always go to the hospital for care with even small ailments. I like the way I am treated at this facility.” (A 54-year female patient).

Also, a male participant averred;

“The way the nurses here cares for you while on admission makes me feel as if they are my sisters. So, I don't hesitate to rush here anytime I feel any symptoms. It's like being attended to by family members. It makes me feel good, so I always come.”

“I didn't like attending government health facilities for care because I didn't want any nurse to treat me badly. However, in this hospital, you're treated like how private hospitals treat their patients. Therefore, I make sure my wife and children also come here every time for care.” (A 29-year old male patient).

Reasons for switching point of service acquisition

Concerning the perception of nurses' attitude in the KGH making them switch point of care from the hospital to private facilities, participants opined that nurses' attitudes towards them made them attend a private clinic. The respondents contend in the private health facility the nurse is much friendly and understanding towards the patient compared to the government facility. Some reasons ascribed to this discrepancy include high workload in government facilities, lack of direct supervision by hospital management in government facilities and the perception that nurse salary or remuneration are not directly from the hospital's own internally generated resources. Nurses in private facilities understand that their remuneration is directly related to the income generated as a result of the care given to patients while in government facilities this does not matter, as salaries are paid by central government irrespective of the situation of patients who receive services in a particular facility. A participant noted;

“Some time ago in this hospital, there were some nurses here who were ‘shouting’ at patients. They will shout at you when they ask you to do something and you are not able to do it. They will shout at you when you pass here. Due to that, you are even afraid to go close to them to ask them a question because they will shout at you. God is so good, a private hospital was opened in my area, I decided to start going there before a friend told me now this place is better. I came here for the third time and I think it is better now. The nurses here at the moment don't shout at patients. That's why I am sure I will always be coming here” (A 36-year old female patient).

A neighbour of mine was the one who said due to the way a particular nurse treated her, she stopped coming to this hospital. She said the nurse was rude and hence, she wouldn't come here for care, but would go to a private clinic. But I haven't encountered such a thing before that's why I continue to use this place as a point of care.” (A 32-year old female patient).

Other factors that influence attendance to hospital

The researchers also sort to determine the factors that influence hospital attendance either than the attitude of the nurse. Under this section two sub thematic areas that emerged include cost and distance to the hospital.

The impact of cost on service acquisition

In describing the influence of cost on the place participants seek services, almost all of them indicated that service at the government health facility was much cheaper compared to those at the private facility. Participants indicated that in the government facility, they use health insurance to seek all services while in the private health facilities the national health insurance does not cover all services that are sought.

“The private facilities are costlier than the government health care facility. In the private hospital, it is not all the services that are covered by the national health insurance. So for some, services you have to pay. But in the government facility, the services are almost all covered and if they don't have a particular drug, they write a prescription for you that you are able to collect from a pharmacy in town. It is cheaper to attend government hospitals like this one” (A 29-year old male patient).

The role of distance in seeking health care services

Participants indicated that distance is not a major barrier to seeking services at the KGH. They contend that travelling a long distance to seek health remedy cannot be compared to the repercussions that are associated with ill health.

“What is the use of staying within one's environment if he or she can seek remedy elsewhere. For me this facility is not near my home, but I come here to seek services because I get cured. It is nice to have service near one's home, it saves time and money for transportation, but if one is not available, I do not mind travelling over several hours to seek service. The nurses here are kind and I do not regret travelling a long distance to this place to seek health care services” (A 32-year old female patient).

Ways to improve nurse patient relationship

The participants had different perceptions as to how to improve the nurse patient relationship that could lead to improved hospital attendance. The major thematic areas explored in this section included patients' attitude towards nurses and nursing service, the nature of communication between nurses and patients, nurses actions towards improved nurse patient relationship, stakeholders’ actions to promote good nurse patient relationship towards improved service provision.

Patients attitude towards nurses and nursing service

Almost all the participants suggested that patients should exhibit an equally good attitude and behaviour towards nurses, and there should be better communication between patients and nurses. On exhibiting equally good attitude and behaviour, some of the participants noted that some patients are sometimes responsible for how nurses behave towards them. They indicated that some patients disrespect nurses without any provocation and this could affect other patients and the mood of the nurses as she/he provides services during that day. To have an improved relationship, it is imperative nurses are accorded respect by patients. Their views are summarized in the following statements;

“Sometimes, we (the patients) are also equally responsible for how nurses behave towards us. Some patients disrespect the nurses without any provocation and the nurse's mood can change and this will affect her attitude toward subsequent patients. To have an improved relationship, it is imperative that patients respect the dignity and integrity of the nurse with a positive perception that the professional responsibility of the nurse is to help improve the health of the patients. While doing this we need to respect the professional judgement of the patient at all times” (A 40-year old female patient).

“Sometimes there are patients who already have the notion that nurses don't respect them so they bring their frustration just to attack. So in this instance, you will realise that even the best intentions of the nurse can end in bad interpretation by the patient. Patients need to have an ‘open mind’ regarding the care they receive from nurses as they are professionals and will take decisions that can only improve the health of the patient” (A 35-year old female patient).

“Patients should always have in their mind that not all nurses are rude. They should always have the mind-set that when they come to the hospital, the nurse is the only contact person for their healing to take place. So even when they are rude to you just follow the instructions and receive your treatment and go your way” (A 38-year old female patient).

Nature of communication between nurses and patients

Better communication between nurses and patients was also alluded to by some participants. The participants suggested that patients should tell the nurse what their problems are so that the nurse would know how to help and empathize with them. By so doing, there is an establishment of understanding and empathy that precedes the rendering of nursing care. Nurses on the other hand should be able to give explanations to patients for their inability to provide some services immediately. Their statements are summarized in the following quotes.

“We (patients) should tell them (nurses) our condition to get the immediate care that we need. The nurse will not be able to help the patient if she does not have the full complement of the health problem faced by the individual. It is imperative that during the care process, patients are able to divulge enough information to the nurse to make an informed judgement regarding the care process” (A 28-year old female patient).

Another participant also said;

“Telling the nurse exactly what our problem is will let them know how to help and show empathy too. Imagine being in pain and feeling that the nurse is delaying unnecessarily while she (the nurse) is not aware of your pain….. She may be attending to another patient whose condition may or may not be equally bad. So, we can even let them explain why the delay and this should be in a polite way. It is also important that when nurses are not able to attend to patients immediately when their services are sought they give an explanation for their inability. This will engender trust and mutual respect in the nurse patient relationship” (A 32-year old female patient).

Nurses actions towards improved nurse patient relationship

As to how the nurse would portray good behaviour in the face of the nurse-patient relationships, many of the participants suggested nurses being patient and professional. The nurse should be able to remain professional even in the face of extreme provocation, that is what nurses are trained for. A participant, for instance, noted;

“Professionally, what they should do is that they cannot bring problems from the home and vent it on the patient. Even though you may not be happy when you enter the hospital, your professionalism should come first, so, I think nurses should put their professionalism first before any other thing” (A 32-year old female participant).

Another participant said;

“Nurses should be respectful and put up smiling faces always because all a patient needs from the nurse is to pamper her and encourage her” (A 36-year old female participant).

Another female participant believed;

“Some patients may be in pain and therefore be rude to nurse, but she (the nurse) should understand. Some patients may be in pain so their attitude may be rude to the nurses, but the nurses should understand and must not respond to them rudely too” (A 44-year old female patient).

Stakeholders’ actions to promote good nurse patient relationships towards improved health care provision

Some of the participants stated that the hospital management needs to provide in-service training for nurses to improve their interpersonal skills in handling patients as customers. A participant, for example, empathises with patients.

“Talking to the nurses and encouraging them to show empathy towards us (patients) and also being patient with us will make them treat us better” (A 36-year old female patient).

“The hospital management needs to talk with nurses about how to handle patients, it is because of the patients that is why they are there” (A 29-year old male patient).

“The management should educate them (nurses) about the importance of having good relations with us (patients) and how to demonstrate empathy in addition to the good care they provide. One thing we all need to realise is that they are nurses because we are patients, without patients there will be no need for nursing, I therefore think they need to have improved interpersonal relationships, and it's the role of their employers to ensure this” (A 33-year old female patient).

Many of the participants have similar views as to what they want the government to do to promote good attitudes between nurses and patients. Some of these participants were of the opinion that the government provides infrastructure, requisite logistics, increase the salary of nurses, recruit and post nurses to various facilities in proportionate numbers, and ensure prompt and adequate promotion of nurses to ensure that they are motivated in executing their duties. For instance, a female patient said;

“For the government, the only problem they have with nurses is the payment of salaries and increment of salaries. The salary of nurses should be increased as required on time” (A 32-year old female patient)

“Government should put in place good policies and their salaries should be looked at in ranks, should be faster and nurses should be given more. Their promotion should not be delayed. There should be continuing education and workshops for them….” “Also, I think the government should supply hospitals with basic items to work with. Sometimes the fault may not be from the nurse, but the system influencing her attitude” (A 32-year old female participant).

“The government should make sure there is an adequate number of nurses at the hospitals because sometimes you will see a large number of patients at the hospital with just a few nurses to attend to them. This makes them become tired, so with a little issue they become annoyed. If there are many nurses, then they can take good care of us. Their salaries should also be increased because if you have money in your pocket it makes you put on smiling faces” (A 34-year old female patient).

Discussion

The study explored patients' perceptions of the nurse-patient relationship and its influence on hospital attendance at the KGH. Participants perceive that nurses usually exhibit cordial relationships with patients. These relationships remain essential in the care process as success for the treatment is largely dependent on the trust that emanates from the patients perception of a positive nurse-patient relationship that is established. The Ghana Anti-Corruption Collation (GACC) found that patients complained that nurses often take them for granted and neglected patients' needs [15]. In KGH most patients' expectations of the nurse patient relationship and the way services should be provided to them are being met as patients indicated that nurses attended to their care needs promptly and adequately. The fundamental focus of nursing has always been the relentless determination to ensure and meet the needs of patients in all aspects of their development while ensuring nurses alleviate pain, give comfort, heal and/or ensure a peaceful death [9, 16]. This positive notion of patients enhances patients' satisfaction with overall health care provided at the facility and further deepens the nurse patient relationship. The implication of the positive influence of patients' perceptions about nurses’ attitude is that most patients seeking care at the hospital are satisfied with the way services are provided and promote essentially the nurse patient relationship [16]. The positive image of the hospital, resulting from a good nurse-patient relationship has an implication on the attainment of the sustainable development goal (SDG) three, ensuring access to quality health care for all [16]. Some studies have reported that, some nurses do indeed have a negative attitude in working with disabled children [2, 16], the study clarified that when nurses have sufficient training in dealing with a particular health condition, and they exhibit a positive attitude towards patients as they are confident enough to handle the situation [16]. The KGH had largely a positive relationship, especially between nurses and patients.

Patients in the KGH reported that nurse patient relationships have encouraged their continued attendance to the hospital. Patient and health care workers' relationship is paramount in encouraging patients to attend their scheduled appointments [17] as patients look forward to having a fulfilling interaction with healthcare service providers. However, some patients would not come to the KGH because they have not had a good relationship with the nurse as they contend that the nurses shout at them or the nurses were disrespectful or did not attend to them promptly when they needed their services. Patients' perceptions of the received care have been found to contribute to the quality of care [18]. Due to fear of being embarrassed by nurses, patients opt out to attend hospitals for health services [17, 19]. The general disregard to human dignity irrespective of the circumstance can adversely affect the resulting behaviour of the person even when sick. Exploring the quality of services provided by nurses is crucial and, therefore, nurses are challenged to maintain and improve the quality of care [20]. It is therefore instructive that at all time nurses ensure that they maintain a higher professional standard in dealing with patients' and patients' needs. A good patient-nurse relationship is paramount to patient care. Better communication between patients and nurses will improve the perception of nurses’ attitudes and help establish a good nurse patient relationship that promotes good care [5]. Poor or lack of communication breeds misunderstanding and raises tension that can explode as confrontation or abuse [5]. Patients expect humane and good interpersonal relationships from nurses when they attend hospitals. Unfortunately, this is not always the case in most hospitals in Ghana [15]. It was established that patients expected nurses to be kind, cheerful, and responsive towards them [5].

This study showed that participants have asked nurses to demonstrate patience and show empathy and professionalism when working or attending to their needs. It is imperative that nurses are able to deal with personal problems and biases without allowing that to influence their patient relationships as good nurse patient interactions improve the success of the care relationship that is established. Personal factors have been noted as being significant in predicting professional learning activities and behaviour [21]. Patients opined that lack of professionalism and courteous treatment from nurses makes patients develop negative perceptions [22]. Cautious and reclusive characters may deleteriously affect professional climate, especially in the field of good communication, and conversely, people with a positive, impressive character will improve the professional climate [23].

It is important that nurses increase their knowledge of patients' health problems and that they will intend to improve their relationship with patients. Ignorance about a health condition/situation often leads to an exhibition of unacceptable/bad attitudes, fear and stigmatization of certain categories of patients and fuels the exhibition of bad attitudes towards patients during service delivery [24, 25]. Education in human relations, increments of salaries, incentives by the government, as well as the adequate distribution of nurses, adequate infrastructure, and requisite logistics will improve patients’ perception of nurses, encourage nurses to be professional, diligent, and hence improve nurse-patient relationships. The remuneration of nurses remains central in total job satisfaction and can improve the relationship they exhibit towards patients. Some of the ways to address this include government, making sure that the remunerations of nursing are well catered for so that they can have a decent life in order to provide efficient services to the patient [9, 18]. Service incentives could make nurses bring out their best while caring for patients [18]. In an assessment of the quality of health care services, part of the strategy includes (1) meeting the basic standards such as performance, infrastructure, service delivery, and operational process; (2) consulting consumers; and (3) driving the quality of care by consumers where they are heard, listened to and involved in the actual decision making [26]. The role of hospital logistics, infrastructure, and adequate useable logistics cannot be overemphasised in the nurse-patient relationship. These views were strongly expressed by patients as one of the central components in ensuring a good relationship between patients and nurses.

The quality of bedside nursing care is constantly affected by the related hospital services such as the quality of the beds, the quality and cleanliness of bed linens, the number of bathrooms available, and the quality of the bathrooms available, cleanliness of the toilets, and ventilation and lighting in the wards [18]. The availability of required basic services, equipment, and logistics with increased nursing staff numbers will have a significant impact on a patient's satisfaction with nursing care. Satisfied patients are likely to exhibit positive attitudes that improve patient nurse relationships [5]. This could be because the related hospital services allow nurses to spend more time on direct patients [18]. As government and other stakeholders put in efforts to ensure that these essential basic amenities are provided within the hospital settings, nurses must make a conscious effort at all times to provide professional interpersonal relationships when caring for patients.

This research was conducted in a secondary level health care facility in Ghana. The participants were purposely selected and therefore raise limitations as to the ability to generalize this research findings to non similar settings as cultural variations could have an influence. The views expressed even though may represent the general views of the patients in that setting, as there was conscious effort to have a mix of different characteristics that are associated with the participants. The use of qualitative methods enhanced the depth of this study as it allowed for the study participants to express in detail the views they associate with nurse patient relationship and hospital attendance.

Conclusion

It was found that patients had a positive perception of nurses' attitudes at the hospital that translated to a positive nurse patient relationship. The study also showed that the perception of nurses' attitudes positively influenced patients' hospital attendance as patients indicated that they were satisfied with the services provided by the nurses. Many patients preferred seeking care at the KGH because they perceived that nurses gave them professional attention and a positive attitude which eventually improved their relationship. Good attitude of patients, as well as better communication between patients and nurses, will improve the perception of nurses' attitudes. Noteworthy, education on good human relations by management and adequate staff recruitment will positively influence the nurse-patient relationship in the facility. Hospital management should conduct regular evaluations of patients' experiences as well as nurses' experiences to address deficiencies in communication. There is also the need to implement better management policies such as motivation for staff and behaviour remodelling for staff to ensure efficient service delivery by improving communication and interpersonal relationships. The aforementioned recommendations will ensure that staff undergoing any emotional or psychological stress that may affect their relationship with the patient or performance are supported appropriately. Hospital management should develop routine attitudinal change workshops to enhance nurses’ human relations.

Declarations

Author contribution statement

Kennedy Diema Konlan, Joel Afram Saah, Abdul-Razak Doat, Roberta Mensima Amoah, Juliana Asibi Abdulai, Iddrisu Mohammed and Kennedy Dodam Konlan: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

Data included in article/supplementary material/referenced in article.

Declaration of interests statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.