Abstract
Background
Most of the literature on factors influencing patient trust and loyalty has focused on measuring the quality of healthcare services, overlooking the role of nurses. To address this gap, the present study investigated the connection between nurses’ caring behaviors, patient trust in nurses, and patient loyalty. Also, the mediating role of trust towards nurses in relation between nurses’ caring behaviors with patient loyalty has been examined.
Methods
This study utilized a cross-sectional design and included a sample of 196 hospitalized patients from five universal hospitals in Iran. The participants were selected using stratified proportional random sampling based on the number of hospital beds and different departments. Data collection took place from October 2021 to April 2022. It involved gathering information on the patients’ demographic characteristics, as well as their responses to the Caring Behavior Inventory-24 (CBI-24), Trust in Nurses Scale (TNS), and a questionnaire on patient loyalty to the hospital. The collected data were analyzed using SPSS ver24 and AMOS ver24 software.
Results
The results indicate that patient perception of nurses’ caring behaviors has a significant and positive correlation with trust towards nurses and patient loyalty. Additionally, trust towards nurses also has a significant and positive correlation with patient loyalty. By controlling the demographic characteristics of the patients, there is an association between nurses’ caring behaviors with trust towards nurses (β = 0.756; R2 = 0.620; p < 0.001), nurses’ caring behaviors with patient loyalty (β = 0.565; R2 = 0.375; p < 0.001), and the trust toward nurse with patient loyalty (β = 0.602; R2 = 0.410; p < 0.001). The trust towards nurses was found to fully mediate the relationship between the nurses’ caring behaviors and patient loyalty (β = 0.503; p = 0.011; R2 = 0.48).
Conclusions
This study highlighted the crucial role of nursing care in fostering trust toward nurses, which in turn enhances patient loyalty. To promote a trusting relationship and increase patient loyalty, it is essential to improve nurses’ caring behaviors. Hospital administrators and nursing managers should focus on enhancing these behaviors in daily nursing practice.
Keywords: Caring behaviors, Patient loyalty, Trust towards nurses
Introduction
Over the past three decades, there has been a significant rise in competition within the healthcare industry, posing a challenge for healthcare centers across numerous countries [1]. Competition between hospitals enhances their services’ quality and encourages innovative interventions’ development [2]. In competitive conditions, organizations should focus on attracting and retaining customers. Patient loyalty is the willingness to choose the same institution for future healthcare needs or to recommend it to family and friends [1]. Encouraging patients to follow therapeutic and preventive regimens and accelerating treatment progress is achieved by maximizing their loyalty [3]. Patient loyalty, a key factor affecting the financial status of health care systems, is influenced by patients’ positive experiences of the quality of services received [4]. To enter the competitive market, hospitals have implemented the provision of high-quality services as a crucial strategy. This approach offers competitive advantages, including patient loyalty [5]. Some of the studies have shown a positive and significant correlation between patients’ perceptions of healthcare quality and patient loyalty [1, 6–8].
As the most significant percentage of hospital human resources, nurses are expected to guarantee patients’ quality of care, safety, and satisfaction. Nursing activities are confirmed through caring behaviors [9]. Caring behavior is defined as nurses’ actions for the patient’s well-being and comfort, including features such as sensitivity, calmness, empathetic listening, honesty, and acceptance without judgment [10]. Caring behaviors can be understood through two main components [9]. The first component includes instrumental behaviors, which refer to technical and physical actions. These involve task-oriented procedures and activities, as well as providing an appropriate physical environment, training, counseling, and problem-solving [11]. The second component encompasses expressive behaviors that address psychological, social, and emotional aspects. This includes qualities such as loyalty, trust, hope, kindness [9], emotional support, acceptance of feelings, sensitivity to patients’ needs, and respect for their privacy [11].
Few studies have examined the correlation between the quality of nursing care and patient loyalty [1]. Some studies have indicated a correlation between nurses’ caring behaviors and patients’ satisfaction [12–14]. A study found that patient trust is a crucial factor influencing patient loyalty. Interestingly, patient satisfaction does not have a direct relationship with patient loyalty. However, patient satisfaction can promote patient loyalty if patient trust acts as a mediating factor [15]. Another study found that patient trust had a partial mediating role in the relationship between patient experience and the willingness to see a doctor [16].
Care, which is the essence of nursing, is based on mutual trust and relationship [17]. Gaining the patient’s trust is considered one of the patient’s rights and is on the agenda of healthcare system policymakers. Trust is the most crucial factor in forming relationships between nurses and patients, which has many positive effects on improving patients and increasing treatment effectiveness [4]. Establishing trust through genuine interactions is essential in reassuring patients about the quality of care they will receive. This confidence enables patients to express their pain and discomfort openly, which is significant in their successful recovery [18]. Nurses can create a sense of safety and worth for patients when trust exists between them. This trust is crucial as it allows nurses to effectively support patients in improving their overall health. Conversely, if patients do not trust their nurses, they may experience a sense of insecurity and vulnerability, ultimately leading to a decline in their health [19].
Several factors can enhance a patient’s trust in their nurse, the most important of which include allocating more time to the patient, giving them necessary information, actively listening to their concerns, ensuring confidentiality of their personal information, offering protection during distressing situations, and creating a safe and private environment for nursing care [20]. According to the findings of a study, improved hospital service quality increases customer trust, enhances service encounters, and strengthens doctor-patient loyalty [6]. The results of a study indicate that service quality and patient satisfaction significantly influence patient loyalty, with patient trust as a mediating variable [7]. In contrast, the findings of another study indicate that perceived service quality has a non-significant positive effect on patient loyalty, while the mediating role of patient satisfaction in this relationship was fully supported [21].
When examining the existing research gap, it is evident that most studies assessing the factors influencing patient loyalty and trust have focused on measuring the quality of healthcare services. This focus often overlooks the crucial role that nurses play in delivering holistic care. Additionally, there is a scarcity of research exploring the role of patient trust as a mediator between healthcare quality and patient loyalty. To address this gap, the present study investigated the association between nurses’ caring behaviors, patient trust in nurses, and patient loyalty. Also, the mediating role of trust towards nurses in relation between nurses’ caring behaviors with patient loyalty has been examined. Therefore, this study was conducted to more accurately evaluate the role of nurses in fostering patient loyalty and trust. To address these aims, we proposed the following four hypotheses:
Hypothesis 1
There is a positive association between nurses’ caring behaviors and trust towards nurses.
Hypothesis 2
There is a positive association between nurses’ caring behaviors and patient loyalty.
Hypothesis 3
There is a positive association between trust towards nurses and patient loyalty.
Hypothesis 4
The trust towards nurses has a mediating effect between nurses’ caring behaviors and patient loyalty.
Methods
Study design
A cross-sectional design was used for this study.
Participants and sampling
The research population includes all hospitalized patients in medical and surgical departments in five hospitals affiliated with Hamadan University of Medical Sciences from October 2021 to April 2022. These centers are the most important specialized and subspecialized public hospitals for adults in Hamadan city, recognized for their high patient volumes as they admit a significant number of patients from both Hamadan province and beyond. Inclusion criteria: (a) hospitalization in medical and surgical departments; (b) over 18 years of age; (c) hospitalization time of more than three days; (d) informed consent; (e) conscious; (f) ability to read and understand the questionnaire; (g) lack of communication problems (such as serious hearing or cognitive impairment). Failure to return or incomplete completion of questionnaires was considered as an exclusion criterion.
The sample size for this study was calculated based on a previous study [22] with a test power of 80%, α = 0.05 and a correlation coefficient of 0.55 by using the fallowing formula: 
. After a non-response rate of 20% was considered, the minimum sample size was 220 patients. The patients were selected using a stratified proportional random sampling method according to the number of hospital beds and departments. Initially, the number of samples for each hospital was determined based on the proportion of inpatient beds (medical and surgical departments) in each hospital to the total sample size. Subsequently, within each hospital, the number of samples for each department was calculated based on the ratio of beds in that department to the allocated sample size for each hospital. In conclusion, a simple random method was utilized for sampling.
Data collection tools
The study used several data collection tools, including a demographic information questionnaire which gathered data on age, gender, education level, and number of hospitalizations. The Caring Behavior Inventory-24 (CBI-24), Trust in Nurses Scale (TNS), and a questionnaire on patient loyalty to the hospital were also administered.
Caring behavior Inventory-24 (CBI-24)
The Caring Behaviors Inventory (CBI) is a 42-item tool originally developed by Wolf et al. (1998) and modified after development. The Caring Behaviors Inventory-24 (CBI-24) is the short version of the 42-item CBI. CBI-24 consists of 4 sub-dimensions and 24 items: respectfulness, connectedness, knowledge and skill, and assurance. Scale items were designed with a Likert type consisting of six options (never = 1, rarely = 2, little times = 3, sometimes = 4, often = 5, and always = 6) [23, 24]. The average score of the questionnaire and its components was calculated by dividing the total score by the number of items and reported from 1 to 6. The validity and reliability study conducted in Iran revealed that the overall Cronbach’s alpha value of the inventory was 0.95, while the sub-dimensions exhibited a range of 0.84–0.95. Based on the findings of a study in Iran to determine the psychometric properties of the questionnaire, item 19 was removed because it caused the alpha value of the respectfulness dimension to drop to 0.32. The subscales identified through confirmatory factor analysis are categorized as follows: respectfulness (items 1, 3, 5, 6, 13, and 22); connectedness (items 2, 4, 7, 8, 14, and 17); knowledge and skill (items 9, 10, 11, 12, and 15); and assurance (items 16, 18, 20, 21, 23, and 24) [25]. The Cronbach alpha value in the current study was 0.96, with subscale values ranging between 0.88 and 0.89.
Trust in nurses scale (TNS)
In 2010, Radwin & Cabral developed a scale consisting of five items to evaluate patients’ trust toward nurses using a six-point Likert scale ranging from ‘always’ to ‘never’ (always = 6, usually = 5, often = 4, occasionally = 3, rarely = 2 and never = 1). The overall score can range between 5 and 30; with a higher score indicating a higher level of trust [26]. In the study conducted in Iran to assess the validity and reliability of the inventory, a Cronbach’s alpha value of 0.84 was obtained [27]. In the current study, Cronbach’s alpha was found to be 0.82.
Questionnaire of patient loyalty to the hospital
The loyalty dimension of Parasuraman, Zeithaml, and Berry’s questionnaire was utilized to assess loyalty. This dimension consists of five items that are rated on a 5-point Likert scale, ranging from strongly agree to strongly disagree (strongly agree = 5, agree = 4, no opinion = 3, disagree = 2, and strongly disagree = 1). The overall score can range between 5 and 25; a higher score indicates greater loyalty [28]. The questionnaire has been used in research studies. Evidence of its validity and reliability has been reported in numerous studies [29, 30]. In the present study, the Cronbach alpha was 0.92.
Ethics approval and consent to participate
The study design was approved by the Ethics Committee of the Hamadan University of Medical Sciences (IR.UMSHA.REC.1400.531). Informed consent was obtained from the participants. Patients were informed of the research goals, and they could stop their participation in the survey at any time without giving any reason or consequences.
Data collection
After receiving approval from the ethics committee at Hamadan University of Medical Sciences and coordinating with hospital officials, the investigator began assessing patients who met the criteria for participation in the study. A stratified proportional random sampling method was used for this purpose. The researcher coded the questionnaires and distributed them to the respondents in the hospital ward where the patients were being treated. The questionnaires were provided anonymously, in person, and in envelopes. Patients completed the questionnaires using a administered method. Written consent was obtained from each patient, and the questionnaires were filled out between 10:00 AM and 12:00 MD, following the doctor’s visit. They were distributed at times that ensured the treatment process and patient comfort were not disrupted. The completed questionnaires were then collected by the researcher. A total of 220 questionnaires were distributed across five hospitals. Out of the total, 196 questionnaires were analyzed, while 10 were excluded due to outliers and 14 due to incomplete responses, resulting in a response rate of 89.09%. The patient counts from each hospital were as follows: hospital A (n = 92), hospital B (n = 46), hospital C (n = 20), hospital D (n = 21), and hospital E (n = 17).
Data analysis
The data were analyzed by SPSS24. Descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential (Pearson’s correlation coefficient, and enter method of linear regression) statistics were used in this study. Skewness and kurtosis values for the study variables were between − 2 ~ 2 indicating that the data were normally distributed. The Pearson’s correlation coefficient was utilized to examine the relationship between variables. This study utilized linear regression equations to establish six distinct models in order to examine the impact of nurses’ caring behaviors on trust toward nurses and patient loyalty. Two distinct models were created using linear regression equations to examine the association between trust toward nurses and patient loyalty. In this study, background information of patients, including gender, education level, age, history of hospitalization, and number of days of hospitalization, were considered control variables. The mediating role of trust toward patients in this relationship was analyzed using AMOS-24 software. The following indices were used as model fit indicators to verify the Structural Equation Model (SEM): Comparative Fit Index (CFI), Incremental Fit Index (IFI), Normed Fit Index (NFI), Goodness-of-Fit Index (GFI), and Root Mean Square Error of Approximation (RMSEA). A value greater than 0.90 for NFI, CFI, GFI, and IFI indicates an acceptable model fit. For RMSEA, a value lower than 0.05 represents a good fit, while values around 0.08 indicate acceptable fit with reasonable error [6, 24, 25, 31]. Statistical significance was determined at a p-value of less than 0.05 (p < 0.05).
Results
Descriptive statistics
The study included patients with a mean age of 46.99 (16.70). Out of the total participants, 87 (44.4%) were female and 109 (55.6%) were male. Out of the participants, 100 (51.0%) had completed primary education, 75 (38.3%) held a diploma, and 21 (10.7%) were university graduates. A majority of participants, totaling 167 (85.2%), reported a history of hospitalization. On average, the patients had been hospitalized 1.63 (1.02) times. The average number of days that patients were hospitalized was 4.85, with a standard deviation of 4.88 days (Table 1).
Table 1.
Personal characteristics of the study participants (n = 196)
| Variable | Subscales | N (%) |
|---|---|---|
| Gender | Male | 109 (55.6) |
| Female | 87 (44.4) | |
| Education level | Primary education | 100 (51.0) |
| Diploma | 75 (38.3) | |
| University graduate | 21 (10.7) | |
| History of hospitalization | Yes | 167 (85.2) |
| No | 29 (14.8) | |
| Variable | Mean (SD) | |
| Age | 46.99 (16.70) | |
| Number of days of hospitalization | 4.59 (4.87) | |
| Number of previous hospitalizations | 1.63 (1.02) | |
The patients’ perceptions of nurse caring behaviors had a mean (SD) score of 5.16 (0.63). The subscales had mean (SD) scores ranging from 5.01 (0.74) for the connectedness subscale to 5.49 (0.55) for the knowledge and skills subscale. The total score for trust in nurses had a mean (SD) of 26.17 (2.82), while the total score for patient loyalty had a mean (SD) of 18.45 (3.85) (Table 2).
Table 2.
Correlations between nurses’ caring behaviors, trust towards nurses, and patient loyalty
| Variable | Subscales | Mean (SD) | Nurses’ caring behaviors | 6 | 7 | ||||
|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | |||||
| Nurses’ caring behaviors | 1. Respectfulness | 5.07 (0.76) | 1 | ||||||
| 2. Connectedness | 5.01 (0.74) | 0.909 * | 1 | ||||||
| 3. Knowledge and skill | 5.49 (0.55) | 0.734 * | 0.751 * | 1 | |||||
| 4. Assurance | 5.13 (0.65) | 0.824 * | 0.834 * | 0.791 * | 1 | ||||
| 5. Total of nurses’ caring behaviors | 5.16 (0.63) | 0.947 * | 0.952 * | 0.869 * | 0.929 * | 1 | |||
| 6. Trust towards nurses | 26.17 (2.82) | 0.711 * | 0.757 * | 0.651 * | 0.755 * | 0.778 * | 1 | ||
| 7. Patient loyalty | 18.45 (3.85) | 0.537 * | 0.596 * | 0.503 * | 0.562 * | 0.595 * | 0.617 * | 1 | |
*Refers to p < 0.001. The bold values indicated for significant effect
Correlation analysis
Results of Pearson correlation coefficient showed a positive and significant correlation between nurses’ caring behaviors with trust towards nurses (r = 0.778, P < 0.001) and patient loyalty (r = 0.595, P < 0.001). Study indicated that all five dimensions of nurses’ caring behaviors were significant in explaining trust towards nurses and patient loyalty. Additionally, there was a positive and significant correlation between trust towards nurses and patient loyalty (r = 0.617, P < 0.001) (Table 2).
Regression analysis of general characteristics and nurses’ caring behaviors with trust towards nurses, and patient loyalty
Model 1 and Model 4 show that age significantly correlates with trust towards nurses and patient loyalty. The results from Model 2, Model 3, Model 5, and Model 6 demonstrate a significant positive impact of nurses’ caring behaviors on both trust towards nurses and patient loyalty. Model 2 shows that the subscales of nurses’ caring behaviors, including connectedness (β = 0.423, P < 0.001), and assurance (β = 0.341, P < 0.01), positively associate with trust towards nurses. The subscales of nurses’ caring behaviors predict 63.3% of the variance in the trust towards nurses while controlling demographic characteristics. Model 3 highlights a significant association between the overall nurses’ caring behaviors score and trust towards nurses (β = 0.756, P < 0.001, R2 = 0.620). Model 5 shows that the subscales of nurses’ caring behaviors, including connectedness (β = 0.492, P < 0.01), positively associate with patient loyalty. The subscales of nurses’ caring behaviors predict 39.6% of the variance in the patient loyalty while controlling demographic characteristics. Model 6 highlights a significant association between the overall nurses’ caring behaviors score and patient loyalty (β = 0.565, P < 0.001, R2 = 0.375). Therefore, Hypotheses H1 and H2 of this study are supported. The results are shown in Table 3.
Table 3.
Regression analysis of general characteristics and nurses’ caring behaviors with trust towards nurses, and patient loyalty
| Dependent variable | Trust towards nurses | Patient loyalty | |||||
|---|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 4 | Model 5 | Model 6 | ||
| β | β | β | β | β | β | ||
| Control variables | |||||||
| Gender | Male vs. Female | -0.048 | 0.005 | 0.004 | -0.019 | 0.011 | 0.019 |
| Education level | Primary education vs. University graduate | 0.004 | -0.007 | -0.049 | 0.132 | 0.146 | 0.092 |
| Diploma vs. University graduate | -0.125 | -0.056 | -0.106 | 0.046 | 0.116 | 0.060 | |
| History of hospitalization | Yes vs. No | -0.100 | -0.057 | -0.065 | 0.009 | 0.038 | 0.034 |
| Age | 0.232 ** | 0.050 | 0.062 | 0.215 * | 0.076 | 0.087 | |
| Number of days of hospitalization | 0.022 | 0.038 | 0.033 | -0.068 | -0.052 | -0.060 | |
| Independent variable | |||||||
| Nurses’ caring behaviors | Respectfulness | -0.020 | -0.183 | ||||
| Connectedness | 0.423 *** | 0.492 ** | |||||
| knowledge and skill | 0.067 | 0.069 | |||||
| Assurance | 0.341 ** | 0.226 | |||||
| Total | 0.756 *** | 0.565 *** | |||||
| R 2 | 0.096 | 0.633 | 0.620 | 0.082 | 0.396 | 0.375 | |
| AdjR 2 | 0.067 | 0.614 | 0.606 | 0.053 | 0.363 | 0.351 | |
| F | 3.350** | 31.975*** | 43.767*** | 2.831* | 12.129*** | 16.087*** | |
| Durbin-Watson | 1.739 | 1.868 | 1.852 | 1.582 | 1.736 | 1.724 | |
| Tolerance | 0.283–0.986 | 0.144–0.980 | 0.283–0.986 | 0.283–0.986 | 0.144–0.980 | 0.283–0.986 | |
| VIF | 1.014–3.531 | 1.020–6.946 | 1.015–3.537 | 1.014–3.531 | 1.020–6.946 | 1.015–3.537 | |
*Refers to p < 0.05; **refers to p < 0.01; ***refers to p < 0.001. The bold values indicated for significant effect
Regression analysis of general characteristics and trust towards nurses with patient loyalty
The results from Model 1 indicate that age has a significant positive impact on patient loyalty. Conversely, in Model 2, it was observed that increased trust toward nurses significantly positively affected patient loyalty (β = 0.602, p < 0.001, R2 = 0.410). Therefore, Hypotheses H3 of this study are supported. The results of the analysis are shown in Table 4.
Table 4.
Regression analysis of general characteristics and trust towards nurses with patient loyalty
| Dependent variable | Patient loyalty | ||
|---|---|---|---|
| Model 1 | Model 2 | ||
| β | β | ||
| Control variables | |||
| Gender | Male vs. Female | -0.019 | 0.010 |
| Education level | Primary education vs. University graduate | 0.132 | 0.130 |
| Diploma vs. University graduate | 0.046 | 0.121 | |
| History of hospitalization | Yes vs. No | 0.009 | 0.068 |
| Age | 0.215 * | 0.075 | |
| Number of days of hospitalization | -0.068 | -0.082 | |
| Independent variable | |||
| Trust towards nurses | 0.602 *** | ||
| R 2 | 0.082 | 0.410 | |
| AdjR 2 | 0.053 | 0.388 | |
| F | 2.831* | 18.683*** | |
| Durbin-Watson | 1.582 | 1.832 | |
| Tolerance | 0.283–0.986 | 0.283–0.985 | |
| VIF | 1.014–3.531 | 1.015–3.531 | |
*Refers to p < 0.05; **refers to p < 0.01; ***refers to p < 0.001. The bold values indicated for significant effect
Structural equation model
The model fit indicators indicate an acceptable fitting model (CMIN/DF = 2.139, RMSEA = 0.076, IFI = 0.964, NFI = 0.935, GFI = 0.909, and CFI = 0.964) (Fig. 1). The fourth hypothesis states, “The trust towards nurses has a mediating effect between nurses’ caring behaviors and patient loyalty.” The results of the Table 5; Fig. 1 showed that the standard coefficient of nurses’ caring behaviors paths with trust towards nurses (β = 0.889), and trust towards nurses with patient loyalty (β = 0.566) according to the value of the critical ratio is higher than ± 1.96 and a significance level of less than 0.05 is significant. Also, the direct effect of nurses’ caring behaviors on patient loyalty was positive and non-significant (β = 0.142; p = 0.48). The results showed that the indirect path of nurses’ caring behaviors to patient loyalty with the mediation of trust towards nurses is positive and significant (β = 0.503; p = 0.011; R2 = 0.48). This indicates that trust fully mediates this relationship. As a result, Hypotheses H4 of this study are confirmed.
Fig. 1.
Structural Equation Modeling (SEM) of study
Table 5.
The direct effects of between study variables
| Direct path | β | S.E | C.R | P-value | R 2 |
|---|---|---|---|---|---|
| Nurses’ caring behaviors → Trust towards nurses | 0.889 | 0.069 | 8.904 | < 0.001 | 0.79 |
| Nurses’ caring behaviors → Patient loyalty | 0.142 | 0.185 | 0.749 | 0.454 | 0.48 |
| Trust towards nurses → Patient loyalty | 0.566 | 0.294 | 2.722 | 0.006 | 0.48 |
Note: C.R: The critical ratio; S.E: standard error; R2: regression coefficient
Discussion
This study’s first major finding is the importance of nurses’ caring behaviors in establishing patient trust. This aligns with existing literature that recognizes the crucial role of nurses in building trustful relationships with patients [32–34]. Trust is essential for patient satisfaction and active participation in healthcare [35], and our findings confirm that trust toward nurses is positively associated with patients’ perceptions of nursing care. This result is consistent with previous research emphasizing the positive impact of nursing care and hospital service quality on patient trust [14, 17, 36, 37]. Our study found that, by controlling demographic characteristics of patients, nurses’ caring behaviors, particularly in connectedness and assurance, significantly influenced patient trust toward nurses. Nurses can build patient trust by consistently assisting them and being readily available to meet their needs and ensure their safety. Involving patients in care plans and empowering them fosters trust in nurses. Patients experiencing anxiety, fear, and stress require nurses to dedicate time to address their concerns. Establishing a friendly and warm relationship with patients, actively listening to their concerns, and striving to meet their needs and expectations are key factors in building trust [36]. Being with someone who needs care defines the practice of professional nursing; without the presence of a nurse, health care disintegrates [38]. Nursing managers can enhance nursing presence by modifying management practices, standardizing work environments, and improving clinical competencies. Fallahnezhad et al. suggest using specific management techniques to increase motivation, recruiting based on expertise and preferences, and implementing a case management approach. Additionally, strengthening hospital infrastructure and aligning accreditation programs with the needs of patients and nurses can further improve nursing presence [39].
Another crucial aspect of our study examines the correlation between nurses’ caring behaviors and trust toward nurse with patient loyalty. Our study’s findings indicated that all aspects of nurses’ caring behaviors were significantly related to patient loyalty. However, in the regression model, after controlling for demographic characteristics, only the aspect of connectedness showed a significant association with patient loyalty. Connectedness, which includes patient empowerment, shared decision-making, and self-management, is the most significant predictor of patient loyalty. Care planning that emphasizes empowerment and participation can enhance patient loyalty and increase trust. This result is consistent with previous research emphasizing the positive impact of nursing care and hospital service quality on patient loyalty [1, 6–8]. Additionally, trust towards nurses also has a significant and positive correlation with patient loyalty. Patients who trust their healthcare providers are more likely to build long-term relationships and stay loyal to them. Previous research also supports these findings, emphasizing the importance of patient trust in nurturing patient loyalty [7, 35, 40]. Recognizing the substantial influence that nurses’ caring behaviors have on patients’ trust and loyalty, it is suggested that nursing managers identify factors that enhance the delivery of patient-centered and humanistic care. For example, one study findings highlight several important issues, including the need to enhance work-family support for nurses, promote a harmonious work environment among colleagues, stress the importance of self-care, increase job satisfaction and engagement, and encourage participation in educational programs aimed at fostering humanistic care [41]. These efforts can help develop the caring behaviors necessary to strengthen patients’ trust and loyalty.
According to the statistical analysis, the trust towards nurses was found to fully mediate the relationship between the nurses’ caring behaviors and patient loyalty. Among the reasons for the relationship between nurses’ caring behaviors and patient loyalty is the role of mediating variables (patient trust and satisfaction) in establishing this association. For example, one study found that a better nursing care experience was associated with increased patient loyalty. Additionally, the impact of patient experience with nursing care on loyalty is partially mediated by patient satisfaction with nursing care and overall hospital services [1]. The results of other studies showed that service quality has no significant impact on patient loyalty, while patient satisfaction has a significant effect on patient loyalty. Additionally, it is found that service quality has an indirect effect on patient loyalty through patient satisfaction [21, 42]. The other studies’ findings showed a significant effect of service quality on patient loyalty, with patient trust as a mediating variable [6, 7]. The findings of another study also showed that both perceived service quality and patient satisfaction significantly influence patient loyalty [8]. The findings reveal a greater understanding of how nurses’ caring behaviors relate to patient loyalty. Specifically, providing high-quality nursing care is an effective strategy to enhance patient loyalty by fostering trust in nurses. This new insight can deepen our understanding of patient loyalty and enrich existing theories.
Limitations
The findings of this study have important implications for clinical practice and nursing management, although there are limitations to consider. These limitations include the study’s cross-sectional design, which does not prove causality, potential recall bias, social desirability bias in self-report data, and the limited timeframe that may have impacted the exploration of potential determinants. It is important to acknowledge these limitations as they may affect the generalizability and interpretation of the findings. Surveys were administered between 10:00 AM and 12:00 PM, following doctors’ visits. This may influence responses due to potential emotional or physical discomfort after a medical evaluation. However, the study provides valuable insights into the relationships between nurse’s caring behaviors, patient trust, and loyalty in the specific context of universal hospitals in Iran. Future research should address these limitations and explore this topic in different healthcare settings to deepen our understanding of these dynamics in healthcare.
Conclusion
This study firmly establishes the vital role of nursing care in building trust between patients and nurses, a relationship that is integral to fostering patient loyalty. Trust is cultivated through consistent, compassionate, and attentive nursing practices, which directly impact patients’ perceptions of care quality. To strengthen this trusting relationship and significantly boost patient loyalty, it is imperative to enhance nurses’ caring behaviors. This includes effective communication, active listening, empathy, and responsiveness to patient needs. Hospital administrators and nursing managers must prioritize targeted training and professional development programs to improve these behaviors in daily nursing practice, ensuring that all nursing staff are equipped to deliver exceptional, patient-centered care. By doing so, healthcare organizations can create an environment where patients feel valued and supported, ultimately leading to improved patient retention and satisfaction.
Acknowledgements
The authors would like to acknowledge all patients who participated in this research. The authors are grateful for the conduction and financial support of Hamadan University of Medical Sciences (project code 140007276049, ethical approval IR.UMSHA.REC.1400.531).
Author contributions
Study conception and design: Shima Sedighi, Amir Sadeghi, Ghodratollah Roshanaei, and Zahra Purfarzad; Data collection: Shima Sedighi; Data analysis and interpretation: Ghodratollah Roshanaei, Zahra Purfarzad; Drafting of the article: Shima Sedighi, Zahra Purfarzad. Critical review of the manuscript: Amir Sadeghi, Ghodratollah Roshanaei. All the authors have carefully reviewed the article and approved the final draft.
Funding
This research is part of the M.Sc. thesis of the first author at Hamadan University of Medical Sciences (NO.140007276049) in Iran.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The present study was conducted in terms of the principles of the revised Declaration of Helsinki. The study design was approved by the Ethics Committee of the Hamadan University of Medical Sciences (IR.UMSHA.REC.1400.531). Patients provided written and informed consent. Patients were informed of the research goals, and they could stop their participation in the survey at any time without giving any reason or consequences.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
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Associated Data
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.