Nurse and Patient Assessments of COVID-19 Care Quality in China: A Comparative Survey Study

The COVID-19 pandemic posed an unprecedented burden on healthcare systems and generated high psychological stress among patients, increasing the need for high-quality nursing care. Nurses caring for COVID-19 patients in isolation wards used extensive PPE, which impeded visibility and communication and potentially affected care quality. Prior research often relies on nurses’ self-evaluations of caring behaviors, which tend to be high and may be influenced by social desirability. Patients’ perceptions are crucial because they affect outcomes and nurse–patient relationships, yet comparative evaluations between nurses and patients have been limited and inconsistent across countries. Given that caring is relational, congruence between nurse and patient perceptions is expected, and direct comparison provides critical insight into care quality. This study aimed to (a) describe caring behaviors evaluated by both nurses and patients, (b) compare consistency between nurse- and patient-evaluated caring behaviors, and (c) explore factors associated with these perceptions during the COVID-19 pandemic in Wuhan, China.

Existing studies indicate nurses often report high levels of caring behaviors via self-assessment tools, though social desirability may inflate scores. Patient perceptions of care quality are linked to outcomes and relationships, and factors such as family caregiver presence and person-centered care influence these perceptions. Comparative studies using the Caring Behaviors Inventory (CBI) across the US, Turkey, UK, Greece, China, and Indonesia show mixed results: many report nurses score higher than patients; some show parity or patients scoring higher. Few studies have examined such comparisons during public health emergencies (e.g., COVID-19), representing a gap this study addresses.

Design: Cross-sectional comparative survey conducted online from 17 March to 13 April 2020 in Wuhan, China. Setting: Five hospitals—three designated hospitals for severe COVID-19 cases and two mobile cabin hospitals for mild cases—selected by convenience. Participants: Convenience samples of nurses and patients from the same departments within the five hospitals. Inclusion (nurses): registered nurses; ≥1 week in designated hospitals; direct care for COVID-19 patients; consent; excluded if confirmed COVID-19 infection. Returned 247 questionnaires; 235 complete included. Inclusion (patients): confirmed COVID-19; hospitalized ≥1 week; age ≥18; Chinese-speaking/reading; consent; excluded suspected cases and severely ill on respiratory machines. Returned 131 questionnaires; 126 complete included. Instruments: Background information forms. Caring Behaviors Inventory (CBI-24, Chinese version): 24 items, four dimensions—assurance of human presence (8), professional knowledge and skills (5), patient respectfulness (6), positive connectedness (5). Items rated 1–6; higher scores indicate higher perceived caring. Subscale scores are mean of items per subscale; total is mean of all 24 items. Reliability: prior Cronbach’s alpha 0.96; in this study, α=0.97 (nurses), 0.96 (patients); subscales α=0.86–0.93. Data collection: Online platform (Sojump). Recruitment via contact persons: nurses approached through WeChat group flyers with QR codes; patients approached at bedside using flyers. Electronic informed consent obtained; one submission per device enforced by login ID; no personal identifiers collected; data stored by Sojump under confidentiality agreement. Ethics: Approved by IRB of Xiangya Nursing School, Central South University (E202023); conducted per Declaration of Helsinki. Analysis: SPSS 18.0. Categorical variables as frequencies/percentages; continuous as mean±SD. Univariate comparisons by t-test or one-way ANOVA with post hoc tests. Stepwise multiple linear regression (enter p=0.05, remove p=0.10) identified factors associated with CBI-24 total and subscale scores. Two-sided p<0.05 considered significant.

Sample characteristics: Nurses (n=235): mean age 31.18±5.05 years; 81.7% female; 71.9% had ethical training; 46.8% had 6–10 years experience; 90.6% dispatched to Wuhan. Patients (n=126): mean age 52.63±14.18 years; 61.9% female; 94.4% communicated face to face; 18.3% had previous hospitalizations. Nurse vs patient caring behavior scores (CBI-24):

• Total: Nurses 5.32±0.72 vs Patients 5.14±0.70 (p=0.023); nurses rated higher overall.
• Technical caring behaviors: • Professional knowledge and skills: 5.39±0.74 vs 5.35±0.71 (p=0.614). • Assurance of human presence: 5.38±0.78 vs 5.27±0.73 (p=0.174).
• Expressive caring behaviors: • Patient respectfulness: 5.30±0.73 vs 5.01±0.79 (p=0.001). • Positive connectedness: 5.17±0.81 vs 4.87±0.86 (p=0.001).
• Lowest-rated item in both groups: “Spending time with the patient” (nurses 4.94±1.06; patients 4.29±1.37), with patients scoring notably lower. Several technical items had similar or slightly higher patient ratings (e.g., giving medications on time 5.60±0.66 vs nurses 5.47±0.95). Factors associated with nurse CBI-24 total (multiple regression):
• Female sex: β=0.266, p=0.015.
• Ethical training experience: β=0.286, p=0.003.
• Dispatched to Wuhan: β=0.384, p=0.008.
• Professional title (higher seniority): β=−0.256, p<0.001.
• Longer working experience (years): β=−0.115, p=0.031. Adjusted R²=0.220. Factors associated with patient CBI-24 total (multiple regression):
• Inpatient setting (designated hospital vs mobile cabin): β=0.516, p=0.001.
• Communication mode (face-to-face vs others): β=0.661, p=0.011. Adjusted R²=0.140. Subscale regressions were consistent: inpatient setting and face-to-face communication positively associated with patient subscale scores; for nurses, ethical training and sex positively associated, while higher title and longer experience negatively associated across several subscales; being dispatched to Wuhan associated with higher patient respectfulness and positive connectedness.

Both nurses and patients reported very high caring behavior scores despite challenges posed by the pandemic and PPE, contradicting assumptions that COVID-19 would markedly degrade perceived care quality. Possible contributors include robust humanistic policies during the outbreak (e.g., strong support for patients, adequate high-quality PPE, optimized staffing), fostering professional commitment and compassion among nurses and satisfaction among patients. Technical caring behaviors (professional knowledge/skills and assurance of presence) were rated higher than expressive behaviors by both groups, aligning with prior studies and reflecting emphasis on technical training in Chinese nursing education and performance evaluations, as well as time constraints and workload that limit emotional support. The lowest-scored item, spending time with patients, highlights restricted contact during early pandemic stages due to infection control and PPE burden, and heightened patient need for accompaniment amid isolation. Nurses consistently scored caring higher than patients, especially for expressive dimensions (patient respectfulness and positive connectedness), which may reflect nurses’ social desirability bias and patients’ increased emotional needs, impaired communication through PPE, and heightened sensitivity to stigma. Although differences were statistically significant, effect sizes were small; larger studies are needed to clarify clinical significance. Factors associated with higher nurse self-evaluations included female sex, ethical training, and being dispatched to Wuhan, while higher seniority and longer experience were linked to lower self-evaluations; reasons for the latter require qualitative exploration. Patients in designated hospitals and those communicating face to face rated care higher, underscoring the value of adequate staffing/attention and direct interpersonal interaction for expressive caring.

Nurses and patients perceived high-quality caring behaviors during the COVID-19 pandemic in Wuhan, China, but notable inconsistencies exist, particularly regarding time spent with patients and expressive caring, where patients rated lower than nurses. Enhancing effective nurse–patient communication in isolation settings and strengthening expressive caring are priorities. Given variability in nurse self-evaluations by sociodemographic and professional characteristics, qualitative research is warranted to understand underlying reasons and to inform targeted interventions. Future work should develop and test strategies to improve patient–nurse connectedness and optimize time with patients under infection-control constraints.

• Convenience sampling of registered nurses and patients from five Wuhan hospitals limits generalizability to all anti-pandemic settings and regions in China; non-registered nurses were not included.
• Online survey modality may affect data reliability, although instructions, bedside guidance where needed, and IP restrictions were used to enhance data quality.
• Reliance on quantitative measures may not capture the complexity of caring behaviors; mixed-methods approaches are needed.
• Potentially influential variables (e.g., patients’ fear levels, specific hospital identifiers) were not collected.