Evaluating the quality of the relationship between health workers and patients/caregivers during the Covid-19 pandemic: a review

Introduction

In healthcare, quality in the care field was first discussed immediately after the end of the Second World War with W. E. Deming, an expert in business organization, who began to spread the criteria of organizational quality aimed at the continuous improvement of resources based on his experiences during the reconstruction of the American military and technological potential (Colucci A., F. Ferretti, R. Cioffi, 2009).

Avedis Donabedian, a founding physician of the study of healthcare quality, defines Quality as: “doing only what’s useful (theoretical effectiveness), in the best way (practical effectiveness) with the least cost (efficiency), to those (accessibility), and only to those, who really need it (appropriateness), having the care done by those who are competent to do it (competence), obtaining the results deemed best (satisfaction)” (Donabedian A., 1988).

In 1997, healthcare satisfaction was considered the most important predictor of the overall satisfaction in hospitals and is still one of the outcome indicators of the quality and efficiency in healthcare systems (Merkouris A, Papathanassoglou EDE, Lemonidou C., 2004).

In the study and evaluation of quality of care, it’s fundamental to include the relationship and bonding with the patients which is, according to the literature, the most perceived aspect in the care process.

However, the safety regulations imposed by the Covid-19 pandemic, especially with the use of the face masks, have taken away mimic elements of non-verbal communication from the relationship between health workers and patients/caregivers. These aforementioned elements are fundamental to establish a good doctor-patient alliance from the very beginning. Because of these changes, the relationship has inevitably changed, leading to the need of developing new skills regarding the quality of verbal and non-verbal communication in the care process: for instance, the ability to create patient trust, the ability to treat the patient with care, empathy and sensitivity (Egman S.,et al. 2011), which can guarantee an experience similar to that in the pre-pandemic condition.

Customer Satisfaction questionnaires, a tool used in almost all companies and not only the ones related to healthcare, allow one to have real feedback on the service offered, to identify problems and to show the quality of the services offered (Perucca R, 2001). Because of that, surveys on perceived quality are increasingly common in organizations that pay attention to the individual. (Tanese A., Negro G., Gramigna A, 2003).

Regarding the technical quality of care, the fundamental requirements are the appropriateness of the service provided and the skills with which the appropriate care is delivered, without neglecting the necessary balance between the risk/benefit assessment and ethical issues. While doctors and nurses would like to achieve technical excellence, patients seem to be more involved in accessibility and performance.

Then, Customer Satisfaction can represent a strategic lever to improve the service offered starting from the relationship between the health professional and the user, especially because healthcare personnel’s competence is expressed through the quality of the care. The focus must be on the patient as a whole, identifying their needs through a holistic approach (Egman S.,et al.,2011).

The SARS-Covid 19 pandemic has produced a change in the relationship between health professional and patient and between doctors and family members. Restrictions to avoid the spread of the virus encouraged the use of electronic communication in interactions and the use of face masks in hand-to-hand contact, reducing the possibility of communication.

Communication has changed, losing important non-verbal components and partly body language. This change risked impoverishing the relationship between doctor/nurse and patient/family, as the role of non-verbal communication is vital in healthcare (Diamare et al., 2021). Indeed, facial expressions, gestures, eye contact, posture and tone of voice ‘speak’ with great intensity, becoming an important tool for healthcare professionals in understanding symptoms.

To this end, it was decided to implement a health and business psychology survey to analyze any emerging needs and to improve the quality of the relationship in the healthcare facilities participating in the survey. Therefore, questionnaires were administered to healthcare professionals and patients/caregivers in order to investigate how they interact and their different points of view on similar issues.

Service objectives

In Public Local Health Service ‘A.S.L. Napoli 1 Centro’ a team of psychologists from the ‘U.O.C. Quality and Humanization’  (http://www.aslnapoli1centro.it/it/eventi/-/asset_publisher/LVl9/content/u-o-c-qualita-e-umanizzazione;jsessionid=D6A7778E6626841DFBE355BF817C5C6A?redirect=http%3A%2F%2Fwww.aslnapoli1centro.it%2Fit%2Feventi%3Bjsessionid%3DD6A7778E6626841DFBE355BF817C5C6A%3Fp_p_id%3D101_INSTANCE_LVl9%26p_p_lifecycle%3D0%26p_p_state%3Dnormal%26p_p_mode%3Dview%26p_p_col_id%3Dcolumn-2%26p_p_col_count%3D1), in partnership with the Primary Care Department, implemented a pathway to assess the quality of the relationship between health workers and patients/caregivers, and to research the services provided by the healthcare facilities during the period of the Covid-19 pandemic, in order to structure interventions aimed at reducing the discomforts expressed by internal/external users.

In addition, the questionnaires were administered exclusively online, exploring the still-very-young area of healthcare digitalization.

Objectives

The aim of this study is to explore the different views of operators and patients/caregivers on the care provided and especially the operator/patient relationship during the period of the COVID-19 pandemic.

In particular, the aim was to develop a method for more in-depth future research into possible changes in non-verbal communication during pandemic emergencies following the use of personal protective equipment (PPE).

Target group

The questionnaires were addressed to operators in districts and hospital wards involved in the COVID-19 emergency, reaching a total of 62 operators in 30 days.

The mirror interview was previously addressed to caregivers and patients from the same catchment area.

Methods And Materials

The study was carried out through an online interview aimed at exploring, from the point of view of the healthcare operators, the perceived quality of healthcare and the relationship with patients/caregivers, especially regarding the degree of attention and participation in care, the quality of information and empathy.

In line with the current aims of healthcare digitization, the questionnaires administration was proposed exclusively online through a QR CODE, considering that questionnaires could not be handed on paper due to the ongoing pandemic.

This online protocol, illustrated by the posters displayed in the healthcare facilities, was supported by moments of unstructured sharing spaces, making the respondents participate in quality improvement processes through the evaluation of their degree of satisfaction. Despite the lack of digital literacy, there have been some responses and participation regardless.

The questionnaire was created and developed using the Microsoft Forms platform, which allows the creation and sharing of surveys. Thanks to this platform, it has been possible to create a QR code to fill in the questionnaire directly from smartphones. Health workers and users/caregivers accessed the questionnaire by framing the QR code inside the posters placed in the local healthcare facilities. This allowed the user to fill in the questionnaire faster and with certainty of data registration while respecting their privacy, since it was completely anonymous.

Results 

The qualitative analysis presented here is based on data emerged from a thematic comparison between the answers of the questionnaire addressed to users (reported in the previously published study “Humanisation of the health worker-user relationship and improvement of the quality of services” (Diamare et al. 2021)), with those of the questionnaire presented in this paper, adapted to be administered to health workers.

1. On the first item “How carefully and effectively do you think you participated in the care of your patients?” 57% of the respondents report that they participated very carefully and 15% “not at all”. Only 28% report having “moderately” participated. The majority is therefore satisfied with the job done with their patients, despite the difficulties and limitations due to the SARS-Covid 19 pandemic.

• In response to the question: “Do you believe that you provided clear and adequate information about the patient’s state of health and treatment during the period of hospitalization?” a large proportion of healthcare professionals claim to have provided the patient with clear and adequate information about the patient’s state of health and treatment in all facilities: 44% felt that they were very satisfied, 10% “not at all” satisfied with the clarity and 41% “moderately” satisfied.

• Concerning the question “Do you think that being “empathetic” is important for a doctor/health worker in relation to his patients?” all respondents considered empathy to be a pivotal factor in their profession. Specifically to the question “If yes, what level of empathy (from 1 “not at all” to 5 “plenty”) do you feel has been achieved in the relationship with your patients with whom you have had contact during the pandemic?” the practitioners find a good level of empathy with their patients. In fact, the majority of healthcare workers consider that a high level of empathy was achieved in their relationship with their patients, as can be seen from the graph in Tab. 3.

At the same time, patients/caregivers in the majority of cases perceive this relationship as positive, even though a small percentage (10% “extremely” and 3.3% “moderately”) report a low level of empathy with caregivers (Diamare S. et al., 2021)

• The question “Do you consider eye contact to be important in patient care during the pandemic period?” shows that almost all of the practitioners interviewed considered eye contact with patients to be important.

Only a small percentage does not attach the same importance (7% “moderately”, 3% “a little”) to eye contact.

Also for 86.6% of patients/caregivers the eyes are an important means of communication.

• Concerning the question “During the treatment period, how much were you able to emotionally support your patients/caregivers despite the limitations imposed by COVID-19?” more than half of the caregivers believe that they “moderately” (54%), “very much” (30%) or “extremely” (5%) offered their emotional closeness. However, there is a small percentage (11%) who feel that they have not been able to give their support, as can be seen from the percentages in the following graph (Tab. 5).

At the same time, as shown in the previous Pilot Study, most of the patients/caregivers interviewed felt supported by the caregivers (“very much” 26.7% and “extremely” 53.3%).

• When asked “How much do you think that your state of mind influences your relationship with patients?” there is a certain heterogeneity in the thinking of the health workers (Tab. 6): 7% of the interviewed health workers state that their state of mind does not influence their relationship with the patient at all and 25% that it influences it “a little”; whereas 26% think that their state of mind is “moderately” influential on the patient, 31% that it influences them “very much” and 11% “extremely”.

• From the question “How well did you feel understood by your patients/caregivers with regard to the difficulties you faced in dealing with the Covid-19 pandemic?“

As the percentages below and the graph (Tab. 7) show, only 17% felt “very much” and 8% “extremely” understood by their patients/caregivers.

44% of the respondents felt “moderately” understood by their patients.

But the 31% who felt “a little” understood gives us an indication of an emerging critical issue, on which corrective actions need to be articulated.

Discussion

Analyzing the results relating to the Health Care Workers’ perception of the quality of their communication and relationship with their patients, it is possible to note that, despite the difficulties and restrictions imposed by the pandemic emergency, the workers believe that they managed to take care of their patients carefully and effectively, and that they provided clear and exhaustive information, both on their state of health and on the methods of care. Bearing in mind the impact of the pandemic and the difficult situation that many patients faced, emotional support from healthcare professionals is of paramount importance in dealing with this difficult time. In fact, one must not only consider the physical damage, but also the emotional impact that an illness has on the subject’s inner world; therefore, good communication between health workers and patients/caregivers offers a containment of suffering and emotional distress.

In line with what has been said so far, from the analysis of the answers it emerges that the healthcare personnel considers empathy as an essential tool of the work, strongly supported by the gaze that represents a vehicle of immediate understanding of the other. In this regard, an interesting point to be adequately investigated with further scientific studies is to understand whether the gaze assumes a greater weight in interpersonal relationships.

All health professions assume the role of ‘communicator and translator’ not only of information but also of feelings. But it is interesting to note that some practitioners believe that their state of mind does not have too much relevance on the relationship with the patient/caregiver.

An even minimal measure of the interviewed users would have wished for more empathy in the relationship. Therefore, what needs to be further investigated is the patient’s and caregiver’s view of the degree of understanding, closeness and empathy they feel they have received from the healthcare personnel, in order to have more elements available on the importance of the caregivers’ state of mind  in the relationship.

Not all workers, on the other hand, perceived understanding from patients and their caregivers with regard to the practical and emotional difficulties caused by the emergency, despite the fact that they, on the other hand, felt they had offered support and understanding to them. During the pandemic period, healthcare workers carried out their work in exceptionally difficult conditions, and understanding the emotional state of those working in healthcare facilities became a fundamental step in dealing with states of emergency while avoiding the risk of unwarranted aggression.

However, it is possible to infer from both of the assessments examined the strong spirit of adaptation that health workers and patients/caregivers demonstrated during the health emergency. There’s a certain congruence of the opinions of patients/caregivers and carers concerning the quality of the relationship, which represented perhaps one of the most important resources in the difficulties management.

These results were fundamental for the implementation of online communities of salutogenesis addressed both to practitioners and patients/caregivers such as the “Virtual Wellness Lounges” and of contents developed in the training courses “Health Advocacy and Psycho-body Empowerment” and in programmes aimed at conscious digitalisation such as “Enterprise 2.0 for Quality Improvement“.

In emergency situations, communicative exchange is essential because the feeling of participation increases resilience. Therefore, paths of humanisation and improved communication are also a priority in order to improve the quality of care in times of crisis in order to get closer to each other and to respond appropriately also to the submerged needs of the users.

The way of communicating with the patient/caregiver does not only depend on the scientific and technical level, but also on his/her ability to empathically ‘enter’ into contact with the patient and his/her body expressions. Mimicry is undoubtedly a useful tool, since it arouses in the interlocutor a feeling of “similarity”, and this opens up good communication channels.

An important aspect, in the social context in which the questionnaire was administered, is to allow a reflection on perceived sadness and distress, as a “natural” reaction to an extraordinary event that has affected both patients/caregivers and operators and that, therefore, needs to be welcomed by specialized personnel trained in humanisation processes. That is to say, we are not only emphasizing the importance of ‘clinically treating’ people affected by overt reactive syndromes, but of taking care of a silent distress that runs through us, makes us unhappy and harms the wellbeing of the individual and of the community.

Conclusions

Analyzing the results it was found that, despite the important communication restrictions and the lack of contact, the quality of the caregiver-patient relationship is perceived positively in most cases. An interesting understanding was also established on the caregivers’ side regarding the difficulties encountered by healthcare workers during the COVID-19 pandemic in the management of patients and their families.

It can be said, in the end, that the health emergency, while amplifying negative emotions, generated deep trust in health personnel.

Regarding the aspects that could be further investigated by means of Customer Satisfaction surveys in healthcare, it’s interesting to introduce elements to assess the effectiveness of communication and relations: indicators of empathy, non-verbal communication, attention to the patients and caregivers’ state of mind, and to increase the resources allocated to such projects.

Acknowledgment

Bellocchio Olimpia (P.O. Ospedale del Mare), Scognamiglio Mariarca (P.O. Loreto Nuovo), Mario Sabatino (D.S. 25), Alberta Mariniello (P.O. Pellegrini) for the dissemination of questionnaires.

References

1. Al-Dogether AH.,2000. Inpatients satisfaction with nursing services at king kha-lid university hospital. Riyadh, Saudi arabia. J Fam Community Med.;7(3):37–45.
2. App, B., McIntosh, D. N., Reed, C. L., & Hertenstein, M. J. (2011). «Nonverbal channel use in communication of emotion: How may depend on why.» in Emotion, 11(3), 603-617
3. Bellavia M, Tomasello G, Damiani P, Damiani F, Geraci A, Accardo F, et al., 2012. Towards An Improvement of Hospital Services and Streamlining of Health Care Costs: The DRG Analysis in Italy. Iran J Public Health. 31;41(7):1–6.
4. Colucci A., F. Ferretti,R. Cioffi.,2009. Cenni teorici sul concetto di qualità percepita in sanità. Giornale Italiano di Medicina del Lavoro ed Ergonomia.Pavia:PI-ME;;31(3):34-41.
5. Crisp-Centro di ricerca intrauniversitario per i servizi di pubblica utilità, 2011. Manuale del Sistema di Valutazione della Performance degli Ospedali Lombardi. [online]. Università degli studi di Milano Bicocca.
6. Diamare S. (2017), «I “Salotti del Ben Essere”: spazio di promozione della salute per caregivers di pazienti con problemi di salute mentale» in La Salute Umana, Editore Perugia.
7. S. Diamare,  G. Cinquegrana, E. D’Anna, A. Glorioso, L. La Pignola,  A. Liuzzi, R. Valente, S. Verde, W. Longanella, M. Corvino (2021), Umanizzazione del rapporto operatore sanitario-utente e miglioramento della qualità dei servizi, La Salute Umana, n. 283
8. Diamare S. (2019), «Un metodo di Embodied Education in Riabilitazione: approcci di valutazione partecipata e di empowerment psicocorporeo», in Journal of Advanced Health Care.
9. Donabedian A., 1988. The Quality of Care: How Can It Be Assessed?. JAMA.260(12): 1743-8.
10. Egman S., Giammona S., Ziino Colanino M., Cappello G., Lombardo R., Marchese F.,2011. L’Infermiere Nel Processo Della Qualità. [online]. Nurse Science.;(19):1-10
11. Garista P., Pocetta C., (2005),  «Lavorare sui “casi” per lo sviluppo di conoscenze e il miglioramento di qualità in promozione della salute.», in Educazione sanitaria e promozione della salute.
12. Merkouris, A., Papathanassoglou, ED, & Lemonidou, C. (2004). Valutazione della soddisfazione del paziente per l’assistenza infermieristica: approccio quantitativo o qualitativo?. Rivista internazionale di studi infermieristici , 41 (4), 355-367.
13. Perucca R., 2001. Consumers with options. Service excellence models help to ensure that patients get the quality care they expect. Nursing Manage-ment.;32(9):20–24
14. Tanese A., Negro G., Gramigna A.,2003. La customer satisfaction nelle amministrazioni pubbliche. 2a Edizione. Roma: Rubbettino Editore.