Quality describes a complex network of attitudes, values, and beliefs held by those who engage with healthcare systems. Care is seen as another crucial element of healthcare [1]. Two additional indicators of quality are the capacity of a service to satisfy stated needs [2] and the extent to which the recipients’ expectations are satisfied [3]. For healthcare services to be effective, efficient, affordable [4], and of adequate quality, they must produce the desired health outcomes [5].

Improvements in healthcare services are significantly influenced by patients’ perceptions of the quality of the care they receive [6]. Improving and maintaining the quality of nursing care is a primary issue for healthcare providers and consumers; accordingly, nursing professionals must meet this challenge by accurately evaluating the quality of the services they deliver [7].

According to earlier research, professional nursing is characterized by caring relationships, solicitude to human responses, the amalgamation of assessment data, application of scientific data, advancement of professional nursing knowledge, promotion of social justice, and assurance of safe and evidence-based practice [8]. Nursing is a profession where the patient should be at the center of practice; therefore, professional, personal, scientific, artistic, and ethical human transactions are crucial [9].

The environment in which people receive mental healthcare presents nurses with difficult and complicated tasks. They are expected to manage ward administrative tasks, admit mental healthcare users, attend meetings, dispense medication, and communicate with users, in addition to supporting and caring for individuals receiving treatment for mental illnesses in hospitals [10,11].

Risk factors for the onset and progression of mental diseases, such as psychosocial stress, poverty, loneliness, use of psychoactive substances, and violence, are on the rise globally [12]. To achieve and maintain optimal mental health in line with the UN’s Sustainable Development Goals, there is an increasing demand for treatment services [13]. In response, mental healthcare systems around the world have been designed to meet the emotional and psychosocial requirements of people with mental illness. In order to attract and retain the support of such users, they must therefore offer comprehensive mental health services encompassing prevention, treatment, and rehabilitation that are reasonable, readily available, and of high quality [14].

The need to deliver high-quality services has grown to be a significant problem for health systems in emerging nations, where providing economical access to healthcare while upholding the integrity of service quality is a challenging matter for healthcare organizations [15]. In the particular case of psychiatric services, their primary purpose is to promote mental health through interventions that aid in healing, enhance recovery, and prevent sickness. In this branch of healthcare, service quality is often assessed in terms of the patients’ opinions of the quality of care [16]. Patient satisfaction is considered an important and reliable indicator of quality of care and offers a feedback system that enables health administrators to ascertain the degree to which patients’ expectations have been met [17]. Patients in mental health facilities who are content with their care are more likely to follow medical advice, go back for follow-up appointments, and maximize their usage of the health services offered [18].

It is less common, however, for staff assessments of mental health service quality to be measured [19, 20], although gaining a better understanding of health professionals’ perceptions of service quality can aid in the identification of methods for enhancing the quality of mental health services [15], particularly when linked with patients’ perceptions of the care given on the same wards [21]. The value of examining nurses’ perceptions of care quality lies in the crucial role they play in offering emotional and psychological support to patients and their families in diverse settings, including assisting patients with diagnosis and ensuring they receive the best care possible. In addition to offering technical care, nurses must possess the necessary professional knowledge, attitudes, and abilities to offer informational, emotional, and practical assistance [22-24].

The study adopted a quantitative cross-sectional design and was set in El-Azazi Hospital for Mental Health in Abo Hamad City, Sharkia Governorate, Egypt.

Table 1 shows that half or more of participating patients were older than 35 years, with a mean age of 36±9.5, had a mental illness of more than 10 years duration (mean=8.9±5.6), had been admitted to a mental hospital at least three times (mean=3 ± 2.3), had currently been in hospital for two months or more (mean=2.9 ± 2.8), were urban dwellers, and had a sufficient income. About half also had a moderate level of education and three-fifths were single. The same table reveals that a large majority (over 90%) had had no previous surgery or chronic somatic disease that more than two-thirds reported no side effects of medication, which three quarters paid for themselves, and that more than a quarter received drug therapy.

Table 2 reveals that over half of participating nurses were older than 28 years (mean age = 27.8±4.7), had more than five years’ experience in a psychiatric hospital (mean=6.23±5.01), and had received quality training. Three fifths of nurses were female, two thirds were married, and three quarters were educated to the Institute of Nursing level. The same table shows that more than four fifths had no experience in a general hospital, had been trained in psychiatric nursing, provided direct care for acute and chronic mentally ill patients, had chosen to work in psychiatric care, and intended to continue in their job.

As Table 3 shows in terms of the perception index, three-fifths of patients perceived the quality of nursing care provided for them to be high as regards patient satisfaction, with a mean score of 47.6±9.2 from a potential maximum of 65. The percentages perceiving a high quality of care provided in regard to the other subscales were 50.8 for influence, 80 for staff competence, 75.4 for caring/uncaring, and 72.3 for integrity. The only subscale on which a majority perceived quality to be low was organization, at 86.2%. The totals for the patient scale show that the overall perception of more than half of the participants (58.5%) was that a high quality of nursing care was provided for them.

Table 4 shows a majority of participating nurses similarly perceive quality of care as measured by the perception index to be high on five of the six subscales: psychosocial relations (55.0%), commitment (92.0%), work satisfaction (84.0%), openness/closeness (71.0%), and security/insecurity (71.0%). On competence development, however, 71% of nurses perceived the quality of care to be low. Overall, more than two thirds (70.0%) of participating psychiatric nurses recorded perceptions of high care quality as measured by the perception index of their total scores on the Karen-personnel instrument.

Table 5 reveals statistically highly significant relationships (p<0.001) of patients’ perceptions of nursing care quality with their age and with their place of residence. Patients aged over 35 years and those residing in rural areas perceived quality of nursing care as low overall, while younger ones and urban dwellers tended to perceive quality as high. Patients’ perceptions of care quality were also found to have statistically significant relationships (p<0.05) with educational level and with family income. Those with only primary education and those with low incomes tended to perceive the quality of care provided in the hospital as low, whereas a majority of patients with moderate education and an adequate income perceived care quality to be high.

Table 6 shows a number of statistically significant and highly significant relationships between patients’ perceptions of nursing care quality and their disease characteristics. These were highly significant (p<0.001) in the case of both diagnosis and number of hospital admissions: schizophrenic patients and those having had three or more hospital admissions were highly likely to perceive care as being of low quality, whereas those being treated for addiction and those with fewer than three admissions strongly tended to have perceptions of high care quality. Patients’ perceptions of quality of nursing care were also statistically significantly related (p<0.05) to their treatment modalities, side effects, and length of hospital stay, whereby perceptions of high quality were more likely among patients receiving psychotherapy, having no side effects, and having been in hospital for less than two months, whereas among patients reporting side effects, receiving drug therapy, and having been in hospital for two months or more, perceptions of low care quality were more frequent.

Table 7 shows that nurses’ perceptions of the quality of psychiatric nursing care provided in their hospital were related at a statistically significant level (p<0.05) to their education and their length of experience in psychiatric hospitals. Nurses educated to the institute of nursing level and those with five years or more of experience were significantly more likely to perceive the quality of care as high, in contrast to those with less experience, who more often reported perceptions of low care quality.

By comparing the mean ±SD scores of patients’ and nurses’ responses to items which were the same in both instruments, Table 8 reveals statistically highly significant differences between the two groups of participants on five of these variables. The patients reported more positive perceptions of care quality than the nurses in response to two items: “One receives individual and personal treatment” (p=0.001) and “There are so many staff categories” (p=0.0008). Conversely, nurses perceived the quality of care more positively than the patients when responding to three statements: “Here they are able to find out what’s wrong, to diagnose” (p=0.0004), “The staff shows consideration” (p=0.0001), and “The patient gets to know the staff” (p=0.0009). There was also a statistically significant difference (p=0.039) on “The staff shows commitment”, with nurses’ perceptions being more positive than those of the patients.

Table 9 shows significant predictors of patients’ perceptions of the quality of nursing care. Patients aged <35 years were 16.02 times more likely than those in the older group to perceive nursing care as of high quality, while patients being treated for addiction were 703 times more likely than those with depression to report perceptions of high-quality care.

Quality of care is a growing global concern as a major aspect of the right to health and the path to equity and dignity for all healthcare service consumers [29, 30]. There is evidence that providing healthcare in accordance with quality standards tends to result in desired health outcomes, whereas inadequate healthcare quality worsens patient dissatisfaction, non-adherence, and mortality [31]. Finding ways to improve the quality of mental health services can be aided by having a better knowledge of health professionals’ viewpoints on service quality [15], especially by making comparisons with patients’ perceptions of the treatment given in the same ward [21]. The current study set out to determine the perceptions of the quality of psychiatric nursing care among nurses and mentally ill patients.

Patients participating in the study ranged in age from 20 to 60 years, with a mean age of 36±9.5, while single people, those with a moderate education, and urban dwellers were all in the majority. On these measures, the sample was similar to that in a study conducted in Nigeria, which reported that ages ranged from 18 to 60 years with a mean of 36.3±10.1 and that the majority of participants were single and had secondary education [32].

The current study found that the majority of participating patients perceived the overall quality of nursing care to be high, particularly in terms of staff competence, caring attitude, and integrity, whereas most perceived the organizational aspect of care as of low quality. This contrasting finding may be attributed to the majority of health service providers being nurses who would spend most of their time with their patients during their hospital stay, while also being expected to perform administrative activities, admit mentally ill patients, attend meetings, dispense medication, and communicate with mental healthcare users, in addition to supporting and caring for individuals receiving treatment for mental diseases. All of these factors may be responsible for the high quality of psychiatric nursing care perceived by patients. These findings are consistent with those of a number of studies conducted in Iran, Jamaica, and Singapore which found that nurses played a crucial role in providing emotional and psychological support to patients and their families in various settings, including assisting patients with diagnosis and ensuring that they received the best care possible. In addition to providing technical treatment, nurses need to possess the necessary professional knowledge, attitudes, and abilities to offer informational, emotional, and practical assistance [22-24]. Correspondingly, the openness, patience, empathy, communication, and sensitivity of nurses toward their patients are key components of caring nursing encounters that help patients to have positive care experiences [33].

The quality of nurses’ professional competence and care is one of the primary issues for health systems and healthcare practitioners throughout the world, since evidence suggests that it is crucial for this occupational group to achieve the mission of the healthcare system [34]. Meanwhile, as indicated in an Iranian study, patients are most frequently in contact with nurses, leading some experts to attribute to them alone the acceptability of the services provided, often allowing the major roles of other treatment groups to be overlooked [35]. According to a study conducted in London, a positive patient experience based on cooperation and reciprocated respect engenders gratitude and appreciation for the work of nurses [36]. Another qualitative study confirmed patient-centeredness as a crucial component of high-quality care in a psychiatric healthcare setting [37].

The finding that the lowest percentage of patients perceiving the quality of care as high was with regard to an organization may have resulted from nurses’ inability to provide more personalized nursing care, due to the large numbers of incoming patients being assigned to them. This result is congruent with earlier research indicating that the organization of nursing care, including the work atmosphere and nurse staffing levels, is associated with patient outcomes, including satisfaction with care as an increasingly significant outcome and performance measure [38-39].

The current study has identified significant predictors of patients’ perceptions of the quality of nursing care. Younger patients (<35 years) had more high perceptions of the quality of nursing care than older ones. Those receiving treatment for addiction reported more high perceptions of the quality of nursing care than patients with depression. The finding that patients’ age affected their perceptions of the quality of care rendered by psychiatric nurses is consistent with the conclusion of a London-based study that demographic variables including age may have an impact on patients’ assessments of the quality of care [40], but it is contradicted by a Jordanian study which found no association between patients’ ratings of the quality of psychiatric nursing care and their socio-demographic characteristics [41]. This discrepancy may be related to differences in sampling criteria.

As to the nurses participating in the current study, in the majority, they were female, above 28 years old, and married, had more than five years of experience working in a psychiatric hospital, and had attended psychiatric nursing training. These findings are consistent with nursing being a female-dominated profession and with the selection of mature nurses with significant experience to work in psychiatric care settings. They are also consistent with those of a prior study of psychiatric nurses at six in-patient mental clinics in KwaZulu-Natal, which reported that the majority of participants were female, between the ages of 30 and 39 [42]. Similarly, research from worldwide studies in Turkey found nursing to be an overwhelmingly female profession [43], while the above study in Jordan found that its participating nurses had a mean of 6.9 years of experience in psychiatric units [41].

The present study found that nurses had high perceptions of the quality of all aspects of psychiatric nursing care except competence development, which may reflect their perceived need for in-service training to enhance their competence. These results are in agreement with those of Alsyouf and colleagues, who found that the highest subscale index was for openness/closeness, while the lowest was for competence development [41]. If nurses are not well prepared for the modern practice environment, their behaviors and attitudes have the potential to shape their judgments of future neutral or favorable nursing experiences [44].

When comparing the perceptions of patients with those of staff nurses, the current study found that on the whole, participating patients perceived the quality of nursing care higher than the nurses did in respect of two variables, namely receiving individual and personal treatment and there being many staff categories. Conversely, nurses tended to have higher perceptions of care quality than the patients did in relation to diagnosis, to the consideration shown by staff, and to patients getting to know the staff. In addition to these five differences between the two participating groups, which were all statistically highly significant, there was one other statistically significant difference: nurses perceived the quality of nursing care more positively than the patients in terms of staff commitment. These findings are consistent with the idea that patients and nurses vary in their viewpoints on the quality of psychiatric nursing care; they also suggest that there are differences between providers of healthcare services and those who receive them in how they assess the standard of psychiatric nursing care. One explanation is that patients may lack the knowledge or experience necessary to reliably assess the quality of psychiatric nursing care, perhaps partly because they are likely never to have had the chance to discuss care plans with their nurses. Additionally, the nature of mental illness means that inpatients may also be cognitively impaired, which may affect their perception. These results are consistent with a study conducted in Jordan which found significant differences between patients’ and nurses’ perceptions in several areas that reflect the quality of psychiatric nursing care. The same study found that patients and nurses were equally satisfied with the quality of psychiatric nursing care, but patients scored lower than nurses [41]. According to Zhao et al. [7], because nurses and patients use distinct criteria and methods to describe and assess the nursing care given, they have diverse perspectives on the quality of nursing care.

The study has a number of limitations, including the inability to generalize its findings to a larger population due to the use of only one psychiatric hospital in Egypt. Additionally, because all study participants were male, it was difficult to study the impact of gender differences on patients' perceptions of the quality of care provided by psychiatric nurses.

It can be concluded that the majority of patients participating in this study had an overall higher perception of the quality of nursing care in terms of staff competence, caring attitude, and integrity, while most had a low perception of the quality of the organization. There were two significant predictors of high perceptions among patients: being aged under 35 years and being treated for addiction rather than depression. Perceptions of the quality of psychiatric nursing care were also high among nurses in respect of all variables except competence development. The perceptions of the two groups differed significantly in six areas: patients perceived the quality of nursing care higher than nurses on receiving individual and personal treatment and on the number of staff categories, while nurses’ perceptions were higher on diagnosis, on the staff showing consideration, on patients getting to know the staff, and on staff commitment.

To enhance and maintain the quality of psychiatric nursing care, further research is needed into valid clinical indicators of quality. It is important to address the issues that patients’ perceptions and understanding of the treatment plans offered to pose as an impediment to the quality of mental nursing care. Both undergraduate and graduate nursing programs should incorporate an emphasis on the elements of high-quality mental nursing care. Future research should build on the present study by recruiting a larger number of mentally ill patients in more than one psychiatric hospital.

The Scientific Research Ethics Committee at the Faculty of Nursing at Zagazig University provided the researchers with an official letter approving the study. The committee's reference number is (ID/Zu.Nur.REC#:0003). Official authorization to conduct the study was acquired through the submission of an official letter from the Dean of the Faculty of Nursing at Zagazig University to the director of El-Azazi Hospital for Mental Health. A written informed consent form was signed by the nurses and patients. It has been shown that the nurses and patients voluntarily participated in the study and have the right to do so at any moment for any reason. Nurses and patients were told that the data would only be used for research, and confidentiality of the collected information was guaranteed.

No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.

Informed consent was obtained from all participants.

STROBE guidelines were followed.

The data and supportive information are available within the article.

None.