A quality indicator for the evaluation of nursing care

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A quality indicator for the evaluation of nursing care: determination of patient satisfaction and related factors at a university hospital in the Mediterranean Region in Turkey Emine Kol a,∗ , Fatma Arıkan b , Emine I˙ laslan c , Muhammed Ali Akıncı d , Mehmet Cuma Koçak d a

Department of Fundamentals Nursing, Akdeniz University Faculty of Nursing, Antalya, Turkey Internal Medicine Nursing Department, Akdeniz University Faculty of Nursing, Antalya, Turkey c Nurse Education Department, Akdeniz University Hospital, Antalya, Turkey d Nursing Department, Akdeniz University Hospital, Antalya, Turkey b

a r t i c l e

i n f o

Article history: Received 12 February 2016 Received in revised form 12 March 2017 Accepted 22 March 2017 Available online xxx Keywords: Patient satisfaction Nursing care Nursing care quality

a b s t r a c t Aim: The aim of this study was to determine the patient satisfaction levels as a quality indicator for the evaluation of nursing care in a university hospital in the Mediterranean Region in Turkey. Methods: This study was designed as a descriptive study and was conducted between February 2, 2015 and March 3, 2015. The study sample consisted of 400 patients. For data collection, the study used the Newcastle Satisfaction with Nursing Scale, which included two subscales: the Experience of Nursing Care Scale and Satisfaction with Nursing Care Scale. Results: The mean total ‘Satisfaction with Nursing Care Scale’ score was 62.08 ± 20.94, and the mean total ‘Experience of Nursing Care Scale’ was 71.97 ± 11.97. When the items were examined in both subscales, the highest satisfaction items were reported as ‘the skilfulness of nurses’ and ‘the nurses’ respect for the patients’ privacy’. However, the lowest scores were given to ‘the nurses’ efforts to make the patients feel at their home’ and ‘the way the nurse comforted your relatives and friends’. Conclusions: Considering the study results, patients require more individualised care from nurses regarding education, communication and comfort. © 2017 Australian College of Nursing Ltd. Published by Elsevier Ltd.

1. Introduction Rapid technological advances in specialisation, increasing costs, demographic changes and shifting patient expectations necessitate continuous updates to today’s healthcare systems. There is increasing interest in evaluation of patient healthcare perceptions to develop healthcare systems that are capable of meeting the needs and preferences of all patients (World Health Organization [WHO], 2007; Suhonen et al., 2012). National and international health organisations emphasise continuous monitoring of service and the evaluation of patient care to raise the quality of care (Türkiye Cumhuriyeti Sa˘glık Bakanlı˘gı-Republic of Turkey Ministry of Health [TCSB], 2003; WHO, 2003; Joint Commission

∗ Corresponding author at: Department of Fundamentals Nursing, Akdeniz University Faculty of Nursing, Antalya 07058, Turkey. Tel.: +90 2422272974; fax: +90 2422274490. E-mail address: [email protected] (E. Kol).

I˙ nternational [JCI], 2010). One of the most important tools for monitoring healthcare quality in hospitals is the assessment of patient satisfaction (Otani et al., 2009; JCI, 2010). Although patient satisfaction is closely related to expectations and perceptions, it is the most widely used metric of healthcare quality. Therefore, patient satisfaction is an important assessment tool for determining whether a system is capable of meeting patient values, expectations and requirements (Oyvind, Ingeborg, & Hilde, 2012; Sreenivas & Suresh Babu, 2012; Suhonen et al., 2012; Al-Abri & Al-Balushi, 2014). From the time of admission until discharge, patient satisfaction is correlated with perceptions of nursing care relative to ´ Simin, & Brkic, ´ 2012). The nurspatient expectations (Milutinovic, ing care provided by nurses is regarded as the most important factor in patient assessments of their satisfaction with health care (Johansson, Oleni, & Fridlund, 2002). Nurses spend more time with hospitalised patients compared to other healthcare professionals and nurses interact with patients more often than any other healthcare personnel in a hospital. Therefore, nurses have a significant impact upon patients’ perceptions about their hospital experience

http://dx.doi.org/10.1016/j.colegn.2017.03.006 1322-7696/© 2017 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Please cite this article in press as: Kol, E., et al. A quality indicator for the evaluation of nursing care: determination of patient satisfaction and related factors at a university hospital in the Mediterranean Region in Turkey. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.03.006


ARTICLE IN PRESS E. Kol et al. / Collegian xxx (2017) xxx–xxx

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(Samina, Quadri, Tabish, Samiya, & Riyaz, 2008; Koç, Sa˘glam, & S¸enol, 2011). When patient requirements and expectations are met through nursing care, the individual feels valued and strives for compliance with the treatment (Tu˘gut & Gölbas¸ı, 2013). As a result, patient satisfaction contributes to improving health and quality of life. Evaluation of patient satisfaction data can lead to continuous improvements to the quality of care (Wolf, 2012; Freitas, Silva, Minamisava, Bezerra, & Sousa, 2014). Therefore, it is important to evaluate patient satisfaction on a regular basis and to share the results of the satisfaction with health professionals. This research was designed as descriptively with the aim to determine the level of satisfaction of the patients with nursing care. 2. Study design and methods 2.1. Setting This study was designed as a descriptive evaluation and was conducted between February 2, 2015 and March 3, 2015 at a university hospital in the Mediterranean Region in Turkey. This hospital treats approximately 20,000–30,000 inpatients annually, with a bed capacity of 1080. Seven hundred nurses serve in the hospital. It is a regional hospital specialising in complex organ and tissue transplant cases. There are 11 intensive care units, 2 organ transplantation units and 2 stem cell transplantation units within the hospital. The number of patients per nurse in the surgical and medical clinics is 12.31 ± 2.10 between 8 am and 4 pm, 18.25 ± 3.24 from 4 pm to 12 pm and 18.25 ± 3.24 from 12 pm to 8 am. The quality management department of the hospital conducts patient satisfaction assessments annually. Assessments of nursing services are conducted by the nursing department.

NSNS includes two subscales: the Experience of Nursing Care Scale (ENCS) and the Satisfaction with Nursing Care Scale (SNCS). These two subscales can be applied either together or separately. In this study, the ENCS and SNCS were applied together. The SCNS consists of a total of 19 items using a 5-point Likert scale. The scoring for assessing the degree of satisfaction is as follows: 1: not at all satisfied, 2: barely satisfied, 3: quite satisfied, 4: very satisfied and 5: completely satisfied. Patient responses across all items are summed and transformed to yield an overall satisfaction score of 0–100, in which 100 denotes complete satisfaction with all aspects of nursing care. The ENCS was developed to evaluate patient experiences regarding nursing care services during their hospital stay. In this scale, a series of 26 statements on aspects of nursing are presented and respondents are asked to indicate how representative each was of their own experience using a 7-point Likert scale. The statements presented in scoring are as follows: 1: disagree completely, 2: disagree a lot, 3: disagree a little, 4: neither agree nor disagree, 5: agree a little, 6: agree a lot and 7: agree completely. To avoid affirmation bias, a mixture of 15 positively and 11 negatively worded statements are included. Scores of the negatively worded statements are recoded in an inverted way, so that 1 has a score of 0 and 7 has a score of 6. Responses across all items were summed and transformed to yield an overall experience score with a potential range of 0–100, where 100 represents the best possible experience. 2.3. Measures and analysis In this study the Cronbach’s alpha internal consistency coefficient was 0.92, which is consistent with the results reported previously (0.96) by Akın and Erdogan (2007). Mean and percentile values were calculated. The independent samples t-test, ANOVA and Cronbach’s alpha coefficient were applied.

2.2. Data collection 2.4. Institutional Review Board approval The population of the study was calculated as approximately 20,000 inpatients over the prior year (using the formula n = N t2 ˛/d2 (N–1) + t2 ˛. In the formula, the symbols represent the following: (n) the sample size; (N) the size of the population; (t) the standard error rate at 95% confidence interval (1.96) and (˛) an estimated prevalence (70%) (Akın & Erdogan, 2007) and (d) a desired precision (0.05). The study sample consisted of 400 patients with a 95% confidence interval, 0.05% standard error and the proportion of patient satisfaction was 70% (Kumar et al., 2014; Akın & Erdogan, 2007). The sample group consisted of patients selected randomly from patients who met the inclusion criteria. The study inclusion criteria included admission to the hospital as inpatients staying in the hospital for >48 h, those who are older than 18 and willing to participate in the study. The exclusion criteria of the study were patients admitted to the intensive care unit, pediatrics or the psychiatry wards. Before gathering the study data, patients were informed about the purpose of the study and all study participants provided verbal consent to participate. Participating patients completed a questionnaire during their hospital stay. Patients without literacy completed the questionnaire via face-to-face interviews with the researcher. The Personal Information Form included patient age, sex, marital status, education, clinic where the patient was admitted, income status, presence of a chronic disease, whether he/she had been informed about the disease/treatment and if he/she had been informed, who provided this information (Johansson et al., 2002; Kelarijani, Jamshidi, Heidarian, & Khorshidi, 2014). In addition, the Newcastle Satisfaction with Nursing Scale (NSNS) was completed by all patients. The NSNS was developed by Thomas, McColl, Priest, Bond, and Boys (1996). The Turkish version of the scale was tested for its validity and reliability by Akın and Erdogan (2007). The

Written approval was obtained from the institution and verbal approval was obtained from the patients. This study was approved by Akdeniz University Research Ethics Committee. 3. Results 3.1. Patient characteristics Of the participant patients, 53.3% were male, 88% were married and 52% were primary school graduates; 50.7% of the participating patients were inpatients in medical clinics, 54% had a current chronic disease and 90. 5% of patients had family relatives. Family relatives are friends, relatives or neighbors, who provide assistance to the patient in the hospital but are unpaid for those services. About 75.2% were informed about their disease during their stay at the hospital and 33% received this information from the nurse. Participating patients had a mean age of 55.18 ± 17.08 and the duration of the hospital stay varied between 2 and 180 days, with a mean of 11.72 ± 17.46 days. The hospital length of stay of inpatients in medical clinics (an average of 17 days) was longer than that for surgical inpatients (an average of 9 days). SNCS–ENCS score and related factors: The mean total SNCS score of the participating patients was 62.08 ± 20.94, and mean total ENCS score was 71.97 ± 11.97. As shown in Fig. 1, regarding nursing care, patients reported the highest satisfaction for ‘the skilfulness of nurses’ and ‘their respect for privacy’. Patients were least satisfied with ‘the nurse’s efforts to make them feel at home’ and ‘the way nurses tried to comfort their relatives and friends’. There was a significant association between SNCS scores and the clinics where patients were admitted (P < 0.05). Patients admitted in




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Fig. 1. Satisfaction levels according to SNCS. *The lowest mean satisfaction score. **The highest mean satisfaction score. SNCS Nursing Care Parameters: 1. the amount of time the nurse allocated to you, 2. how skillful was the nurse at her work, 3. was there a nurse available at any time, 4. how was the nurse’s knowledge level, 5. whether they attended your every call, 6. whether they made you feel at home, 7. whether they gave sufficient information about your state and treatment, 8. frequency of the nurse to check your well-being, 9. whether they tried to help, 10. the way the nurse explained things, 11. the way the nurse comforted your relatives and friends, 12. their attitude towards their work 13. adequacy of the information given by the nurse, 14. whether they treated you as an important person, 15. the way they listened to your concerns and fears, 16. the extent of freedom provided to you in the ward, 17. whether they voluntarily responded to requests related with your care, 18. their respect for your privacy and 19. their awareness of your care and treatment requirements.

medical clinics had higher SNCS scores compared with patients admitted in surgical clinics (F = 8.934, P = 0.003) (Table 1). There was a statistically significant association between being informed about disease/treatment with SNCS and ENCS scores. Patients who were informed by their health professionals had higher scores according to both the SNCS (F = 21.777, P = 0.000) and ENCS (F = 51.593, P = 0.000) compared with the patients who were not informed (Table 1). The type of health professional who provided the information was determined to be important with regard to patient satisfaction (F = 21.084, P = 0.000) (Table 1). There was a significant association between patient satisfaction and the number of patients per nurse. In clinics where nurses were responsible for 12 or fewer patients, ENCS scores were higher than the other clinics (F = 14.305, P = 0.000) (Table 1). There were no significant differences in the NSNS depending on the presence of a chronic disease, sex, education level, marital status and having family caregivers (P > 0.05).

4. Discussion 4.1. The satisfaction level of patients related to nursing care The mean total score on the ‘satisfaction with nursing care scale’ among the patients included in this study was 62.08 ± 20.94, and the mean total score in the ‘experience of nursing care scale’ was 71.97 ± 11.97. Patients reported the highest satisfaction regarding

nursing care for the items of ‘the skilfulness of nurses’ and ‘their respect for privacy’. Other studies conducted using the same scale in Turkey have reported results similar to this study. These studies conducted in university hospitals showed that patients were satisfied with ‘nurses’ respect for privacy’ and ‘the skilfulness of nurses’ (Akın & Erdogan, 2007; Geçkil, Dündar, & S¸ahin, 2008; Hacıhasano˘glu & yıldırım, 2011; Kuzu & Ulus, 2014). Özlü and Uzun (2015) reported that as for the distribution of the patients’ opinions about the nursing care, 97% of the patients stated that there was not a specific nurse responsible for their care, and while 45.3% of them evaluated the nursing care to be good, 0.8% of them stated that the nursing care was very poor. Gürdo˘gan, Fındık, and Arslan (2015) reported that the patients’ perception of care has an effect on satisfaction with nursing care and that individualised care provided toward the patients’ needs increased satisfaction with nursing care and the NSNS point average was 71.41 ± 17.63. Koç et al. (2011) determined that the NSNS point average was 67.76 ± 16.07 and the highest items point average (3.80 ± 1.01) was for the item ‘respect for privacy’ and the lowest (3.32 ± 1.09) was for the item ‘nurses’ listening skills’ when the items of satisfaction score average was evaluated in the range of 1–5. In the original version of the NSNS and the Turkish version of the NSNS, the satisfaction score average was evaluated in the range of 0–100 (Akın & Erdogan, 2007; Thomas et al., 1996). Hence, the satisfaction level was evaluated as a higher score when the score was closer to 100 points. This study’s results and the results of the other studies in Turkey showed that


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4 Table 1 The patients’ satisfaction and related factors (n = 400). Variables

Number (%)

Mean ± SD (SNCS)

Sex Female

187 (46.8)

62.00 ± 20.69

Male Marital status Married

213 (53.3)

62.15 ± 21.20

352 (88.0)

62.30 ± 20.85

Single Education level Illiterate

48 (12.0)

60.47 ± 21.73

54 (13.5)

64.98 ± 18.48

Primary school High school University Presence of a chronic disease? Yes

208 (52.0) 82 (20.5) 56 (14.0)

62.87 ± 21.26 60.78 ± 21.15 58.24 ± 21.53

216 (54.0)

61.07 ± 20.01

No Admitted clinic in hospital Medical clinics

184 (46.0)

63.26 ± 21.98

203 (50.7)

64.98 ± 24.01

Surgical clinics Family caregiver Yes

197 (49.3)

58.77 ± 20.38

362 (90.5)

61.94 ± 21.01

No Were you informed about your disease? Yes

38 (09.5)

63.36 ± 20.52

302 (75.2)

64.81 ± 20.88

No Who provided the information Doctor

98 (24.8)

53.77 ± 18.92

153 (51)

71.76 ± 21.72

Nurse Both Number of patients per nurse in the clinic 12 or fewer

101 (33) 48 (16)

57.51 ± 18.84 57.78 ± 13.56

279

64.64 ± 21.52

121

56.16 ± 18.29

13 or more *

Mean ± SD (ENCS) F = 0.005 P = 0.944

71.95 ± 11.89

F = 0.002 P = 0.962

72.01 ± 11.41 F = 0.322 P = 0.571

71.11 ± 11.51

F = 0.345 P = 0.557

71.06 ± 12.49 F = 1.177 P = 0.318

71.81 ± 11.81

F = 0.147 P = 0.932

71.81 ± 11.67 72.74 ± 11.59 71.76 ± 1.55 F = 1.087 P = 0.288

72.91 ± 10.35

F = 3.045 P = 0.082

70.88 ± 12.90 F = 8.934 * P = 0.003

72.58 ± 10.48

F = 1.229 P = 0.268

71.29 ± 12.80 F = 0.157 P = 0.692

71.70 ± 11.86

F = 2.261 P = 0.133

74.67 ± 08.69 F = 21.777 * P = 0.000

74.24 ± 10.14

F = 51.593 * P = 0.000

65.12 ± 13.13 F = 21.084 * P = 0.000

74.83 ± 09.39

F = 17.928 * P = 0.000

74.83 ± 09.39 76.13 ± 10.31 F = 14.305 * P = 0.000

72.55 ± 11.23

F = 2.221 P = 0.137

70.67 ± 12.43

P < 0.05.

the satisfaction was above moderate (0–100). When the research findings were compared with studies conducted using the same scale internationally, average satisfaction scores were close to 100. In the literature, international studies have reported similar average satisfaction scores to the results of this study (Gutysz-Wojnicka, Dyk, Cudak, & Ozga, 2013; Legesse, Salgedo, & Walle, 2016; Shinde & Kapurkar, 2014; Tang, Soong, & Lim, 2013). Alhusban and Abualrub (2009a,b) reported that patients were mostly satisfied with aspects such as ‘the nurses capability of their job’ while the most negative experiences with aspects such as ‘nurses had time to sit and talk to me’. Another study showed that the majority of patients were highly satisfied with the affective support shown by nurses, which comprised ‘respect’, ‘smile’ and ‘caring’ (Tang et al., 2013). Ozga, Gutysz-Wojnicka, Wojtaszek, and Lewandowski (2014) showed that the average value for the assessment of satisfaction amounted to 68.05 ± 8.31. Belayneh (2016) stated that patients were very satisfied with nursing care and the nurses’ willingness and helpfulness to patients; however, they were least satisfied with the given information by nurses. As seen in this research and other studies, the technical and professional capabilities of nurses were the satisfaction of most patients and information plays an important part in their satisfaction. As seen in this research and other studies, the technical and professional capabilities of nurses play an important for the satisfaction of patients, at the same time patients need to information related to illness, treatment and interventions. Establishing clear communication and providing information about nursing care are a prerequisite for patient satisfaction. Increasing the technical and

professional capabilities of nurses promotes awareness in terms of patient–nurse mutual rights increased patients’ trust on medical staff, and improved satisfaction with health care (Motaghed, Mahboobi-Ardakan, & Meskarpour-Amiri, 2016). This study’s result of the highest satisfaction with nursing skills can be explained by the wide availability of patient confidentiality and clinical skills within the scope of the nursing education curriculum and in-service training in Turkey and the hospital in which this study was conducted (Hems¸irelik Ulusal Çekirdek Programı Nursing National Core Program [HUÇEP], 2014; TCSB, 2009, 2011). 4.2. Patient satisfaction level and related factors Studies from Turkey and other countries evaluating patient satisfaction with nursing care have reported that patient satisfaction is influenced by many individual factors (age, gender, education), institutional factors (medical and nursing services of the hospital) and environmental factors (cleanliness, food, sound level, the comfort and aesthetics of the premises) (Agosta, 2009; Atallah, Hamdan-Mansour, Al-Sayed, & Aboshaiqah, 2013; Johansson et al., 2002; Özsoy, Özgür, & Durmaz Akyol, 2007). In this study, ENCS scores in clinics where nurses are responsible for the care of 12 or fewer patients were higher than those who have 13 or more patients. The nurse to patient ratio, which is known to directly affect patient satisfaction, also appears to be reflected in this study’s results (Wolf, 2012). In a cross-sectional study in 12 European countries and the USA, the authors reported that reduced ratios of patients to nurses were associated with increased




care quality and patient satisfaction, and patients in hospitals with higher ratios of patients to nurses (that is, increased nurse workload) were less likely to rate their hospital highly and to recommend their hospital (Aiken et al., 2012). In a study conducted to examine the relationship between nurse staffing and patient outcomes in hospitals, 5430 patient surveys from 600 medical and surgical units were analysed. The effects of nurse staffing on patient outcomes showed that more nursing staff per patient had statistically significant positive effects on patients’ reports of satisfaction (Zhu et al., 2012). Seago, Williamson, and Atwood (2006) reported that as total hours of care per patient day increase and as the skill-mix becomes richer, patient satisfaction levels increase. Han, Connolly, and Canham (2003) stated that nurses’ unit working experience had a positive effect on patient satisfaction with nursing care. TervoHeikkinen, Kvist, Partanen, Vehviläinen-Julkunen, and Aalto (2008) reported that the nurse staffing indicators (patient-to-nurse ratio in the day shift and in all shifts, nurse hours per patient load and working years in the same ward) were significantly associated with some parts of the patient satisfaction scores. Although number and quality of nurses in hospitals are important for patient satisfaction, the rate of nurse turnover is increasing. In Turkey, contracted nurses have left the institution after achieving a permanent position in the state service. For the nurses work in state service, all personal rights such as salary, health insurance and job guarantee are in the security of government, nevertheless, contracted nurses have not yet these rights (Demirkaya & Ince, 2013). For this reason, nurses working under the government security do not feel the fear of being removed from the job. In Turkey, nurses work in hospitals either by contracting through a subcontractor company or by being settled in the state staff where all personal rights are secured by the government (Bas¸ara, Güler, & Yentur, 2015). Kocaman, Seren, Kurt, and Erer (2010) reported that turnover of regular staff nurses from 2003 to 2007 at the three universities studied was found to range between 2.0 and 5.3% and that of contracted staff nurses from 2.2 to 17.5%. The resignation rate of contracted nurses who left the hospitals during the period in question due to their passing centralised state employee examinations for state employment was at a range of 30.9–82%. Studies on the turnover rates of nurses in Turkey have shown that nurses working in temporary contract positions have a much higher turnover rate than those in permanent positions (Türkmen, Badır, Balcı, & Akkus¸Topçu, 2011; U˘gur Gök & Kocaman, 2011). On this basis, a total of 25% nurses left the hospital in which the study was conducted, during the last year. We think that this staff problem affects patient satisfaction. In this study, patients who were treated as inpatients in medical clinics had significantly higher satisfaction levels compared to patients at the surgery clinic. The first and the most important reason is that inpatients in medical clinics frequently suffer from chronic diseases and have longer staying periods in hospital than surgical inpatients. The hospital length of stay of inpatients in medical clinics (an average of 17 days) was longer than that for surgical inpatients (an average of 9 days). Diseases with internal diagnosis are characterised by the complexity of care and indicated by a long hospital stay. The patients with internal diagnosis are more familiar with other aspects of nursing services (such as education, consulting, home visits and individualised care) than those with a surgical diagnosis. Tokunaga and Imanaka (2002) examined specific patient satisfaction items related to overall satisfaction by different length of stay (LOS); group 1, LOS ≤1 week; group 2, LOS ≤1 month and group 3, LOS >1 month. Some unique satisfaction items for each group (e.g. ‘skill of nursing care’ in group 1, ‘Recovery of physical health’, ‘skill of nursing care’ and ‘respect for patients opinions and feelings’ in group 2, and ‘relief from pain’ and ‘respect for patients’ opinions and feelings’ in group 3) were significantly associated with over-

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all satisfaction (Tokunaga & Imanaka, 2002). The nursing care can be assessed in detail as long as the patient’s stay in the hospital is prolonged. In Turkey, Gürdo˘gan et al. (2015) found a positive correlation between satisfaction with nursing care and perception of individualised care. Another study by Findik, Unsar, and Sut (2010) assessed patient satisfaction with nursing care and the relationship between patient satisfaction and patient characteristics using NSNS. They found the length of stay of the patients as follows: 0–10 days (69%), 11–21 days (19%) and 22–28 (12%) and reported that patients who were hospitalised for long periods (22–28 days) were most satisfied. Özer, Köçkar, and Yurttas¸ (2009) stated that patients staying in clinic for 8–14 days were more satisfied than those staying in clinic for at least 1 month and longer. Patients’ number of night spent in the ward affect patients’ satisfaction. So, the duration of hospital stay is an important parameter in the evaluation of patient satisfaction with nursing care.

5. Conclusion The findings of this study provide nurses with information about aspects that enhance or hinder patient satisfaction. In this study, patients reported the highest satisfaction regarding nursing care for the items of ‘the skilfulness of nurses’ and ‘their respect for privacy’. There was no significant relationship between individual characteristics of patients and satisfaction levels. Low patient–nurse rate and longer length of stay in hospital have affected patient satisfaction positively. In line with the findings of the research, the possible suggestions for better healthcare are: institutions to determine the number of nurses in clinics according to the ideal nurse/patient ratio, to periodically conduct studies assessing patients’ satisfaction levels with nursing care. Also, nurse administrators and managers should capitalise on the importance of continuity of nursing care, and nurse competences and skills by providing regular workshops and continuing education and training classes.

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