Impact of a wellness charter on nursing practice for older adults in Tunisian healthcare centers: a cross-sectional quasi-experimental multicenter study

Abstract

Background

Wellness, a comprehensive approach to patient care, aims to promote freedom, respect and listening to the patient needs in order to prevent abuse. No previous study have assessed the impact of an intervention promoting wellness in older patients within hospital settings. Furthermore, the predictors of key wellness indicators remain unexplored. This gap hinders efforts to target both organizational and individual-level determinants of quality care for older patients. This cross-sectional quasi-experimental multicenter study aimed to assess the effects of introducing a wellness charter intervention on nursing care practices and health outcomes among older patients in Tunisia.

Methods

A before/after study was conducted with a sample of 500 Tunisian nurses. Initially, a self-assessment was carried out using a validated French questionnaire covering eight wellness-related domains (25 items total). This was followed by a communication and awareness campaign explaining the charter, after which the self-assessment was repeated. The domains assessed included: respect for privacy, dignity, and confidentiality (5 items), pain management (2 items), patient/resident comfort (2 items), end-of-life care (3 items), communication (2 items), promotion of patient autonomy (4 items), preservation of personal dignity (3 items), and changes in service organization practices (4 items). To determine factors independently linked to wellness outcomes—specifically, items 21 (discussion of wellness during annual evaluations) and 22 (presence of wellness-related materials in the department)—both univariate and multivariate analyses were performed.

Results

After the intervention, all eight domains showed statistically significant improvements: changes range from 8% to 46%. Factors significantly associated with the discussion of wellness during annual reviews included: maintaining confidentiality [odds-ratio (OR) = 2.28], avoiding professional discussions at the patient’s bedside [OR = 1.88], supporting end-of-life care and comfort [OR = 2.76], scheduling staff breaks in rotation [OR = 2.33], and monitoring patient call response times [OR = 2.43]. Factors significantly associated with the presence of wellness-related documents in the department included: consistent attention to pain management [OR = 6.73], collecting advance directives [OR = 2.28], encouraging patient mobility [OR = 0.14], rotating staff breaks [OR = 1.61], monitoring call response times [OR = 2.96], and offering flexible visiting hours [OR = 1.51].

Conclusion

Emphasizing staff training on patients’ rights and fostering an ethical nurse-patient relationship are crucial to improving wellness in care settings.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04185-4.

Introduction

Older people are frequently affected by frailty, a condition that results from the progressive decline in physiological reserves and leads to a heightened risk of disability and increased dependency in daily activities [1–3]. In many African and Arab countries, ageing populations are situated within a context of profound economic and socio-political transformations [4]. These changes disrupt the traditional balance between care providers and recipients, thereby exacerbating social and health inequities at both individual and societal levels [4]. Despite the rapid demographic shift, the implications of ageing and frailty are often under-recognized by policymakers in these regions. Although some recent attention has emerged, public policy responses and ethical frameworks remain insufficient to address the complex challenges of population ageing [5]. Studies have also highlighted that transitioning to institutionalized care, such as nursing homes, can significantly alter the lives of older adults, often exposing them to a greater risk of abuse [6, 7]. Elder abuse, which constitutes a serious violation of human rights, may include physical, sexual, psychological, emotional, and financial abuse, along with neglect, abandonment, and behaviors that compromise the dignity and respect owed to older patients [8–10]. In the majority of nations and medical facilities, elder abuse happens, although it is frequently ignored and untreated [11–13]. This important public health and socioeconomic issue is usually kept out of the public eye and regarded as a private concern [11–13]. In China, for instance, 36.2% of participants reported elder abuse, and the prevalence rates of financial, physical, caregiver neglect, and psychological abuse were 27.3, 15.8, and 2.0%, respectively [12]. In Italy, elder abuse is thought to affect between 10 and 12.7% of people [13]. In Tunisia, it appaears that 13.8% of people experienced elder abuse, with an average score of 8.35 on the abuse screening indicators [7]. According to subtypes, 10%, 2.5%, and 1.3%, reported psychological, physical, and financial abuses, respectively [7]. The latter abuses were frequent, and in every instance, the victims’ responses were passive [7].

In response to these issues, the concept of wellness has emerged as a guiding principle in healthcare practice [14], and has increasingly been integrated into healthcare quality certification processes, which require its implementation and documentation [7]. Wellness refers to an intentional, positive approach toward vulnerable individuals, with the goal of enhancing their well-being and quality of life (QoL) [15]. It embodies a holistic attitude towards care that centers on patient dignity, autonomy, and responsiveness to expressed needs, while also aiming to prevent abuse [16]. This involves attitudes and behaviors that respect cultural values, personal identity, lifestyle, and fundamental rights and freedoms of older adults [17, 18]. Such an approach emphasizes the importance of the interactions among all stakeholders, including healthcare professionals, institutions, patients, families, and service users. It calls for ongoing individual and collective reflection among these actors to ensure ethically sound and contextually appropriate care [19].

Previous studies have demonstrated that nursing education programs can enhance nurses’ self-perceived knowledge and competence in delivering wellness-oriented care for older adults [20, 21]. To date (i.e.; September 24, 2025), no studies from African or Arab countries have assessed the impact of an intervention aimed at promoting wellness in older adults within hospital settings. Furthermore, the predictors of key wellness indicators—such as whether wellness is addressed during annual evaluations or whether wellness-related materials are displayed within departments—remain unexplored. This gap hinders efforts to target both organizational and individual-level determinants of quality care for older patients.

The primary objective of this study was to evaluate the impact of an intervention based on the dissemination and promotion of a wellness charter [22] on nursing practices related to the care of older patients in healthcare facilities in central Tunisia. A wellness charter (e.g.; humanistic model of nursing care – Université de Montréal (HMNC-UdeM) [23]), which is a reflection of values, can be effective in bringing about positive changes in a target audience [24]. Evidence indicates that such a document can stimulate conversation and affirmation of the stated values [24]. It is also a mission statement that incorporates social, ethical, or societal goals can also positively influence organizational success [24]. A secondary objective was to identify predictors of two specific indicators of wellness: (i) whether wellness is discussed during annual staff evaluations, and (ii) the presence of wellness-related posters or documents within the departments.

In the present study, the following three theories (hypotheses) are advanced: (i) does the mobilization of nurses’ knowledge, interpersonal skills, and technical skills allow them to adopt a wellness approach toward older adults? (ii) if the wellness discussion is conducted during annual evaluations, will we maintain confidentiality, avoid professional conversations at the patient’s bedside, support end-of-life care and comfort, rotate staff breaks, and tracked response times to patient calls, and (iii) if the department has documents pertaining to best practices in wellness care, ongoing attention will be paid to pain management, gathering advance directives, promoting patient mobility, rotating staff breaks, tracking response times to calls, and providing flexible visiting hours.

Theoretical framework

The HMNC-UdeM provides a relevant theoretical framework to guide clinical practice, education, and research [23]. The HMNC-UdeM, which highlights the centrality of the human being in care delivery, is founded on five core principles [23]: (i) person-centeredness – recognizing the individual as an active participant in care, rather than merely a passive patient, and ensuring care respects personal dignity and autonomy; (ii) relational approach – emphasizing trust, empathy, communication, and presence in the therapeutic relationship between nurse and patient; (iii) holistic perspective – considering the biological, psychological, social, cultural, and spiritual dimensions of the person, with health viewed as a dynamic state; (iv) caring process – acknowledging that care goes beyond technical tasks and includes emotional and existential support; and (v) contextual understanding – recognizing that care is shaped by the broader environment, including family, society, and the healthcare system, and requiring nurses to be sensitive to ethical and socio-cultural factors. The HMNC-UdeM promotes excellence in care by fostering a partnership-based relationship in which the meaning patients attribute to their health and life goals is central [23]. It calls for nurses to develop professional competence grounded in both clinical knowledge and personal experience, while also embracing humanistic values that shape attitudes and, ultimately, guide behavior [25, 26].

Methods

Study design

This multicenter study adopted a cross-sectional quasi-experimental design using a before/after test approach. Data were collected from five university hospitals located in central Tunisia: Sahloul and Farhat Hached Hospitals (Sousse), Fattouma Bourguiba Hospital (Monastir), Taher Sfar Hospital (Mahdia), and Ibn Jazzar Hospital (Kairouan). Sixty-five hospital departments involved in the admission and care of older adults were included, enabling a comprehensive evaluation of nursing practices across a diverse range of clinical settings in the region. The study was conducted over a 9-month period (i.e.; from January to September 2019), following the guidelines established by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [27]. The study followed the principles of the Declaration of Helsinki. Prior to the initiation of participant recruitment, ethical approvals were obtained from the respective ethics committees of each participating hospital: Sahloul and Ibn Jazzar Hospitals (CEFMS 32/2019), Farhat Hached Hospital (IRB 00008931), Fattouma Bourguiba Hospital (IORG 0009738 / OMB 0990 − 0279), and Taher Sfar Hospital (P01 M.P.C-2020).

To ensure the protection of participants’ fundamental rights, voluntary participation was emphasized, and written informed consent was obtained from each nurse prior to data collection. The survey process was both anonymous and confidential. During the initial assessment of nursing practices (T₁), each nurse was assigned a unique code to maintain confidentiality. Nurses were also clearly informed of their right to withdraw from the study at any time without any negative consequences. These procedures adhered to established ethical standards and ensured the protection of participants throughout the research process. A clinical trial number is not applicable.

Protocol

A validated self-assessment questionnaire was distributed to nurses as part of an evaluative approach focused on daily nursing practices that promote wellness. The French questionnaire titled “Self-assessment of the wellness of older people living in care homes” [22], was developed and validated by the French National Health Authority. Since all participating Tunisian nurses are French-speaking and trained in French (paramedical studies in Tunisia are conducted in French), we considered it appropriate to use the validated French version directly. Therefore, we did not perform additional psychometric testing in our sample and no translation or cultural adaptation was required. The questionnaire comprised 25 closed-ended items assessing the implementation of key nursing practices across seven domains: respect for privacy, dignity, and confidentiality (5 items); pain management (2 items); patient/resident comfort (2 items); end-of-life care (3 items); communication (2 items); promotion of patient autonomy (4 items); and evolution of service organization practices (4 items). These practices were deemed essential, as neglecting any of them could lead to patient mistreatment. Designed to take approximately 15 min to complete, the questionnaire evaluated how consistently nurses incorporated wellness-promoting behaviors into their daily routines. The first round of data collection (T₁) took place over a seven-month period, from January to July 2019.

The aforementioned questionnaire, which was developed as part of a broader initiative to promote “respectful care” in healthcare and social institutions, is designed for professionals to evaluate their practices concerning the well-being of older residents in care settings [22]. Regarding its psychometric properties, the development process involved several key steps: (i) Conceptual framework: a multidisciplinary group modeled the concept of “respectful care” through brainstorming sessions and expert consensus, focusing on professional posture, institutional processes, and patient interactions; (ii) Item development: from these discussions, 44 items were generated to reflect various aspects of respectful care practices; (iii) Pilot testing: these items were pre-tested across 35 entities in 28 establishments to assess their relevance and clarity; (iv) Psychometric analysis: exploratory factor analysis with varimax rotation and confirmatory factor analysis were conducted to determine the underlying structure of the tool. Additionally, internal consistency was evaluated using Cronbach’s alpha coefficients; and (v) Fit indices: model fit was assessed using indices such as the root mean square error of approximation, normed fit index, and goodness of fit index, with acceptable thresholds indicating good model fit. These methodological steps suggest that the questionnaire underwent rigorous psychometric evaluation to ensure its reliability and validity in assessing the wellness of older individuals in care homes [22].

A group of specialists from the department of hygiene and quality (Farhat Hached university hospital, Sousse, Tunisia) authorized the French wellness charter [22] after it was modified for the Tunisian environment. Every department that took part in the study had a display of the wellness intervention charter. Nurses signatures attesting to their commitment to upholding the charter, mentions in internal communications, and awareness-raising and explanatory meetings with targeted training sessions based on active teaching techniques like role-playing and group discussions to familiarize participants with the concept of wellness and its challenges were used to supplement its dissemination. The intervention was distributed in person by one collaborator (FT in the authors’ list), with each department receiving the intervention for one hour. To ensure compliance and accurate responses, the distribution was structured and accompanied by guidance during the session. Following an institutional communication and awareness campaign introducing the wellness charter, the same group of nurses completed a second self-assessment (T₂) during August and September 2019. All interventions were administered and outcomes assessed by one collaborator (FT in the authors’ list), who was not blinded to study condition assignment.

This follow-up phase, covering a two-month period, aimed to assess changes in nursing practices since the initial implementation of the charter. A single researcher (FT in the authors’ list) conducted the study. Changes in responses between T₁ and T₂ were systematically analyzed. Composite indicators—such as respect for the privacy of older patients—were used to assess the extent of change and the practical impact of the wellness charter. This methodology provided a comprehensive evaluation of both the evolution of nursing practices and the effectiveness of the implemented intervention [22]. Files with missing data were initially planned for exclusion from final analysis.

Participants

A stratified random sampling method was used across the five participating hospitals. An exhaustive list of nurses from different professional categories was compiled from departments involved in the care of older adults (Fig. 1). Only nurses who had regular contact with older patients during the study period were considered eligible. Participation was limited to nurses who provided written informed consent, ensuring voluntary involvement. This sampling approach maintained both ethical integrity and the statistical robustness of the study (Fig. 2).

Fig. 1.

Distribution of nurses by hospitals

Fig. 2.

Study flowchart

The sample size was calculated using the following formula [28]: n =, where.

• “n” is the sample size,

• “N” is the size of the estimated target population,

• “P” is the expected proportion of population response (set to 0.50 by default),

• “tp” is the sampling confidence interval (95%, tp = 1.96), and

• “y” is the margin of sampling error (i.e.; 5%).

This approach ensured adequate representation of different nurse categories across various hospitals, potentially improving the study’s accuracy and representativeness by capturing key population characteristics and reducing estimation errors. After performing the calculations, we determined that the required sample size was 500 nurses. Assuming a 6% dropout rate for T₂, the corrected sample size was 530 nurses (530 = 500/(1-0.06)).

Data analysis

Data presentation

The Kolmogorov-Smirnov test was applied to assess the distribution of quantitative variables. Since variables such as age and professional experience followed a normal distribution, they were expressed as means ± standard deviation (SD), along with their range. Categorical variables were reported as frequencies and percentages. For each domain, a mean percentage score was calculated by summing the individual item percentages and dividing by the number of items within that domain.

Comparisons between T₁ and T₂

To compare responses between T₁ and T₂ assessments, the McNemar test was used to evaluate changes in the proportion of nurses who responded “yes” to each of the 25 questionnaire items. This statistical method enabled a detailed evaluation of changes in nursing practices following the implementation of the intervention [29]. The value change for each item was calculated as the simple difference in the percentage of “yes” responses between T₁ and T₂, which could be either positive or negative. The rate of change was computed using the formula: rate of change (%) = 100 × (T₂% - T1%) / T₁%. A significance level of p ≤ .05 was adopted for all statistical comparisons. This approach allowed for an objective, quantitative assessment of the impact of the intervention over time.

Univariate and multiple regression analyses (predictive factors)

To identify independent predictors of patient wellness—specifically regarding whether wellness was discussed during annual evaluations (item 21) and whether wellness-related posters or documents were present in the department (item 22)—a two-step statistical analysis was performed (i.e.; univariate and multivariate logistic regression model). First, univariate analyses were conducted to explore associations between each dependent variable (items 21 and 22) and the remaining questionnaire items (independent variables). Variables with a p-value ≤ 0.15 in the univariate analysis were then included in the multivariate logistic regression model, using the Hosmer and Lemeshow step-down procedure [30]. In the final model, only variables with a significance level of p ≤ .05 were retained, ensuring that only statistically robust predictors were identified. This analytical strategy minimized the influence of potential confounders and enhanced the reliability of findings concerning factors independently associated with wellness-related outcomes.

Statistical analyses were performed using IBM ‘Statistical Package for the Social Sciences’ Statistics for Windows, Version 22.0 (IBM Corp).

Results

Sociodemographic and professional characteristics of nurses

During the study period, 530 nurses were approached, and 500 (94%) completed the questionnaire (Fig. 2). No files contained missing data, and all collected data were included in the analysis. Table 1 presents the sociodemographic and professional characteristics of the participating nurses.

Table 1.

Socio-professional characteristics of nurses (n = 500)

Data	Unit/category	Number (%) or mean ± SD (range)
Sex	Male	139 (28)
Age range (Years)	< 30	108 (22)
	31–40	235 (47)
	41–50	88 (18)
	> 50	69 (14)
	All	38.3 ± 9.0 (26–59)
Experience (Years)	1 to 5	152 (30)
	6 to 10	129 (26)
	11 to 15	88 (18)
	> 15	131 (26)
	All	11.8 ± 9.5 (1–35)
Grade	Nurse	24 (5)
	Principal nurse	78 (16)
	Major nurse	355 (71)
	Principal major nurse	43 (9)
Hospital, Town	Fattouma Bourguiba University Hospital, Monastir	122 (24)
	Ibn Jazzar University Hospital, Kairouan	87 (17)
	Taher SfarUniversity Hospital, Mahdia	88 (18)
	Farhat Hached University Hospital, Sousse	98 (20)
	Sahloul University Hospital, Sousse	105 (21)
Department	Cardiology	47 (9)
	Intensive care unit	45 (9)
	Surgery	41 (8)
	Internal Medicine	35 (7)
	Orthopedics	33 (7)
	Urology	31 (6)
	Otorhinolaryngology	28 (6)
	Pneumology	26 (5)
	Ophthalmology	26 (5)
	Rheumatology	23 (5)
	Gastroenterology	19 (4)
	Nephrology	19 (4)
	Resuscitation	16 (3)
	Endocrinology	15 (3)
	Gynecology	15 (3)
	Neurosurgery	15 (3)
	Emergency	14 (3)
	Infectious diseases	14 (3)
	Neurology	11 (2)
	Hematology	10 (2)
	Dermatology	7 (1)
	General postoperative	6 (1)
	Medical oncology	4 (1)

SD: Standard deviation

Data collection instrument: self-evaluation questionnaire at T₁

Table 2 summarizes the nurses’ responses at T₁. Concerning “Respect for privacy, dignity, and confidentiality” 94% of nurses reported always respecting patient/resident privacy, 87% respected patient/resident dignity, and 86% ensured confidentiality of patient information. Furthermore, 85% preserved dignity and privacy during toileting or bathing, and 77% promoted patients or residents’ self-esteem through appropriate clothing and living conditions. Regarding “Pain management and patient/resident comfort” 82% of nurses consistently considered pain management, though 56% did not always explicitly mention the absence of pain. Additionally, 65% made efforts to reduce noise and light at night, while 49% avoided or discouraged clinical discussions at the bedside. About “End-of-life care” 75% of nurses reported ensuring that a medical treatment decision-maker was designated, and 73% supported and comforted patients/residents during end-of-life care. As to “Communication” 76% of nurses were attentive to both verbal and non-verbal communication, and 69% identified patients’ daily needs and abilities. Relating to “Promotion of patient autonomy” 74% of nurses encouraged patient autonomy, 71% recognized moments of distress, 62% promoted mobility and individual routines, and 53% took into account patients’ preferences and habits in meal planning. Vis-à-vis “Preservation of personal dignity” 67% of nurses viewed vulnerable individuals as full adults with unique life experiences, 66%included wellness as a topic in newcomer orientation, and 46% discussed wellness during annual evaluations. In relation to “Organizational aspects of care” 70% of nurses noted an absence of wellness-related posters or documents in their departments, 58% believed visiting hours were restrictive, and 69% indicated that doorbell response times were not flexible.

Table 2.

Practice evaluation during the first (T1) and second (T2) practice assessments (n = 500)

Domains and items	T1	T2	p-value	Value of change	Rate change
Adherence to privacy, dignity, and confidentiality standards	500 (86)	500 (92)	< 0.001	+ 6	8%
1. I respect patient/resident privacy in all situations	472 (94)	480 (96)	0.008	+ 2	2%
2. I respect the dignity of patients/residents in all situations	436 (87)	469 (94)	< 0.001	+ 7	8%
3. I promote the self-esteem of patients/residents through their clothing and lifestyle.	383 (77)	450 (90)	< 0.001	+ 13	18%
4. I respect the confidentiality of patient/resident information in all situations	429 (86)	453 (91)	< 0.001	+ 5	6%
5. While washing patients / residents I respect privacy and dignity	426 (85)	457 (91)	0.001	+ 6	7%
Pain management	500 (58)	500 (72)	< 0.001	+ 14	30%
6. I take pain into account in all situations	411 (82)	477 (95)	< 0.001	+ 13	16%
7. I always mention the absence of pain	173 (35)	247 (49)	< 0.001	+ 15	43%
Patient/resident comfort	500 (57)	500 (73)	< 0.001	+ 16	26%
8. I avoid noise/light at night	325 (65)	465 (93)	< 0.001	+ 28	43%
9. I avoid or discourage medical discussion at the patient bedside	247 (49)	269 (54)	< 0.001	+ 4	9%
End of life	500 (67)	500 (85)	< 0.001	+ 19	28%
10. I ensure the collection of advance directives	260 (52)	340 (68)	< 0.001	+ 16.0	31%
11. I ensure the collection of the trusted person	376 (75)	491 (98)	< 0.001	+ 23.0	31%
12. I accompany the patient/resident at the end of life and ensure his comfort	363 (73)	447 (89)	< 0.001	+ 16.8	23%
Communication	500 (73)	500 (90)	< 0.001	+ 17	24%
13. Every day I identify the needs and abilities of each one (to provide an adequate response).	345 (69)	443 (89)	< 0.001	+ 20	28%
14. I pay attention to verbal and non-verbal communication	382 (76)	457 (91)	< 0.001	+ 15	20%
Promoting patient autonomy	500 (65)	500 (95)	< 0.001	+ 30	49%
15. I promote movements, patient/resident rhythms	310 (62)	482 (96)	< 0.001	+ 34	55%
16. I consider the tastes, habits, and abilities of patients/residents for catering	264 (53)	483 (97)	< 0.001	+ 44	83%
17. I identify moments of distress for patients/residents	355 (71)	449 (90)	< 0.001	+ 19	26%
18. I support patient/resident autonomy (focus on “getting it done” rather than “doing it instead of”)	370 (74)	487 (97)	< 0.001	+ 24	32%
Upholding personal dignity	500 (60)	500 (76)	< 0.001	+ 17	28%
19. I recognize the weakened person as a full adult with his or her own life story	336 (67)	460 (92)	< 0.001	+ 25	37%
20. Wellness is the subject of recommendations from me to newcomers	332 (66)	404 (81)	< 0.001	+ 14	22%
21. During my annual evaluation interview, the wellness is the subject of an exchange	228 (46)	281 (56)	< 0.001	+ 11	23%
Evolution of service organization practices	500 (39)	500 (45)	< 0.001	+ 6	16%
22. There are posters, documents on wellness in my department	152 (30)	182 (36)	< 0.001	+ 6	20%
23. In my department, the staff break is organized in turn	261 (52)	308 (62)	< 0.001	+ 9	18%
24. In my department, doorbell wait times are assessed	154 (31)	163 (33)	0.004	+ 2	6%
25. In my department, visiting hours are free	212 (42)	250 (50)	< 0.001	+ 8	18%

Data were number (%)

p-value (McNemar test): T₁ vs. T₂

Mean percentage for each domain = sum of percentages of each item divided by the number of items

Rate change (%) = 100 x (T₂ (%) - T₁ (%)) / T₁ (%)

Value of change (%):T₂ (%) - T₁ (%)

Changes in nursing practices

Table 2 also highlights the changes in self-assessed nursing practices between T₁ and T₂. Statistically significant improvements were observed across all evaluated domains. The most notable increase was in the promotion of patient autonomy (+ 30%), whereas the smallest improvement was in organizational practices (+ 6%). The overall change rates ranged from 8% (for respect of privacy, dignity, and confidentiality) to 46% (for autonomy promotion), reflecting diverse progress across various aspects of practice.

Predictors of patient wellness

Association between annual wellness evaluations (i.e., item 21) and nursing practices

Table 3 outlines the factors associated with conducting annual wellness evaluations, based on univariate analysis. All factors except items 1, 2, and 11 showed a significant association with annual wellness evaluations. In multivariate analysis (Table 4), five variables (items 4, 9, 12, 23, and 24) emerged as independent predictors of whether wellness was addressed during annual evaluation interviews.

Table 3.

Factors determining the annual evaluation of wellness: univariate analysis (n = 500)

Items	Response	Item 21. During my annual evaluation interview, the wellness is the subject of an exchange		Univariate analysis
		No	Yes	OR [95% CI]	p-value
1. I respect patient/resident privacy in all situations	No	10 (5)	10 (4)	1.30 [0.53–3.17]	0.569
	Yes	209 (95)	271 (96)
2. I respect the dignity of patients/residents in all situations	No	16 (7)	15 (5)	1.40 [0.68–2.89]	0.367
	Yes	203 (93)	266 (95)
3. I promote the self-esteem of patients/residents through their clothing and lifestyle.	No	29 (13)	21 (7)	1.89 [1.05–3.42]	0.035
	Yes	190 (87)	260 (93)
4. I respect the confidentiality of patient/resident information in all situations	No	32 (15)	15 (5)	3.03 [1.59–5.76]	0.001
	Yes	187 (85)	266 (95)
5. While washing patients / residents I respect privacy and dignity	No	28 (13)	15 (5)	2.60 [1.35-5.00]	0.004
	Yes	191 (87)	266 (95)
6. I take pain into account in all situations	No	16 (7)	7 (2)	3.08 [1.24–7.63]	0.015
	Yes	203 (93)	274 (98)
7. I always mention the absence of pain	No	127 (58)	126 (45)	1.69 [1.18–2.42]	0.004
	Yes	92 (42)	155 (55)
8. I avoid noise/light at night	No	24 (11)	11 (4)	3.02 [1.44–6.31]	0.003
	Yes	195 (89)	270 (96)
9. I avoid or discourage medical discussion at the patient bedside	No	126 (58)	105 (37)	2.27 [1.58–3.25]	< 0.001
	Yes	93 (42)	176 (63)
10. I ensure the collection of advance directives	No	86 (39)	74 (26)	1.80 [1.23–2.64]	0.002
	Yes	133 (61)	207 (74)
11. I ensure the collection of the trusted person	No	6 (3)	3 (1)	2.61 [0.64–10.55]	0.178
	Yes	213 (97)	278 (99)
12. I accompany the patient/resident at the end of life and ensure his comfort	No	35 (16)	18 (6)	2.77 [1.52–5.05]	0.001
	Yes	184 (84)	263 (94)
13. Every day I identify the needs and abilities of each one (in order to provide an adequate response).	No	37 (17)	20 (7)	2.65 [1.49–4.71]	0.001
	Yes	182 (83)	261 (93)
14. I pay attention to verbal and non-verbal communication	No	29 (13)	14 (5)	2.91 [1.49–5.65]	0.002
	Yes	190 (87)	267 (95)
15. I promote movements, patient/resident rhythms	No	14 (6)	4 (1)	4.72 [1.53–14.57]	0.007
	Yes	205 (94)	277 (99)
16. I take into account the tastes, habits and abilities of patients/residents for catering	No	13 (6)	4 (1)	4.37 [1.40-13.59]	0.011
	Yes	206 (94)	277 (99)
17. I identify moments of distress for patients/residents.	No	35 (16)	16 (6)	3.15 [1.69–5.86]	< 0.001
	Yes	184 (84)	265 (94)
18. I support patient/resident autonomy (focus on “getting it done” rather than “doing it instead of”)	No	12 (6)	1 (0)	16.23 [2.09-125.82]	0.008
	Yes	207 (94)	280 (100)
19. I recognize the weakened person as a full adult with his or her own life story	No	25 (11)	15 (5)	2.28 [1.17–4.45]	0.015
	Yes	194 (89)	266 (95)
20. Wellness is the subject of recommendations from me to newcomers	No	60 (27)	36 (13)	2.56 [1.62–4.06]	< 0.001
	Yes	159 (73)	245 (87)
22. There are posters, documents on wellness in my department	No	158 (72)	160 (57)	1.95 [1.34–2.85]	< 0.001
	Yes	61 (28)	121 (43)
23. In my department, the staff break is organized in turn	No	114 (52)	78 (28)	2.82 [1.94–4.09]	< 0.001
	Yes	105 (48)	203 (72)
24. In my department, doorbell wait times are assessed	No	176 (80.4)	161 (57)	3.05 [2.02–4.59]	< 0.001
	Yes	43 (19.6)	120 (48)
25. In my department, visiting hours are free	No	126 (58)	124 (44)	1.71 [1.20–2.45]	0.003
	Yes	93 (42)	157 (56)

Data were number (%)

CI: Confidence interval. OR: Odds ratio

Table 4.

Factors determining the annual evaluation of wellness (item 21): multivariate analysis (n = 500)

Items	Odds-ratio [95% confidence interval]	p-value
4. I respect the confidentiality of patient/resident information in all situations	2.28 [1.12–4.62]	0.023
9. I avoid or discourage medical discussion at the patient bedside	1.88 [1.27–2.77]	0.001
12. I accompany the patient/resident at the end of life and ensure his comfort	2.76 [1.44–5.27]	0.002
23. In my department, the staff break is organized in turn	2.33 [1.57–3.46]	< 0.001
24. In my department, doorbell wait times are assessed	2.43 [1.57–3.75]	< 0.001

Association between wellness-related visual materials (i.e., item 22) and departmental practices/nursing practice

Table 5 presents the univariate analysis of factors associated with the presence of wellness-related posters or documents in departments. Fourteen factors (items 4, 5, 6, 7, 10, 14, 15, 17, 19, 20, 21, 23, 24, and 25) were significantly associated. In multivariate analysis (Table 6), six independent predictors were identified (items 6, 10, 15, 23, 24, and 25), indicating factors that significantly influenced the presence of wellness-related materials in clinical departments.

Table 5.

Factors determining the existence of posters, documents of wellness in the service: univariate analysis (n = 500)

Items	Response	Item 22. There are posters, documents on wellness in my department		Univariate analysis
		No	Yes	OR [95% CI]	p-value
1. I respect patient/resident privacy in all situations	No	11 (4)	9 (5)	0.69 [0.28–1.69]	0.417
	Yes	307 (96)	173 (95)
2. I respect the dignity of patients/residents in all situations	No	21 (6)	10 (5)	1.21 [0.56–2.64]	0.621
	Yes	297 (93)	172 (95)
3. I promote the self-esteem of patients/residents through their clothing and lifestyle.	No	28 (9)	22 (12)	0.70 [0.38–1.26]	0.241
	Yes	290 (91)	160 (88)
4. I respect the confidentiality of patient/resident information in all situations	No	36 (11)	11 (6)	1.98 [0.98-4.00]	0.055
	Yes	282 (89)	171 (94)
5. While washing patients / residents I respect privacy and dignity	No	32 (10)	11 (6)	1.73 [0.85–3.54]	0.127
	Yes	286 (89)	171 (94)
6. I take pain into account in all situations	No	19 (6)	4 (2)	2.82 [0.94–8.44]	0.063
	Yes	299 (94)	178 (98)
7. I always mention the absence of pain	No	176 (55)	77 (42)	1.69 [1.17–2.44]	0.005
	Yes	142 (45)	105 (58)
8. I avoid noise/light at night	No	25 (8)	10 (5)	1.46 [0.68–3.12]	0.321
	Yes	293 (92)	172 (95)
9. I avoid or discourage medical discussion at the patient bedside	No	150 (47)	81 (45)	1.11 [0.77–1.60]	0.565
	Yes	168 (53)	101 (55)
10. I ensure the collection of advance directives	No	122 (38)	38 (21)	2.35 [1.54–3.60]	< 0.001
	Yes	196 (62)	144 (79)
11. I ensure the collection of the trusted person	No	5 (2)	4 (2)	0.71 [0.18–2.68]	0.614
	Yes	313 (98)	178 (98)
12. I accompany the patient/resident at the end of life and ensure his comfort	No	35 (11)	18 (10)	1.12 [0.61–2.05]	0.697
	Yes	283 (89)	164 (90)
13. Every day I identify the needs and abilities of each one (in order to provide an adequate response).	No	40 (13)	17 (9)	1.39 [0.76–2.54]	0.275
	Yes	278 (87)	165 (91)
14. I pay attention to verbal and non-verbal communication	No	36 (11)	7 (4)	3.19 [1.39–7.32]	0.006
	Yes	282 (89)	175 (96)
15. I promote movements, patient/resident rhythms	No	9 (3)	9 (5)	0.56 [0.21–1.43]	0.028
	Yes	309 (97)	173 (95)
16. I take into account the tastes, habits and abilities of patients/residents for catering	No	11 (3)	6 (3)	1.05 [0.38–2.89]	0.923
	Yes	307 (97)	176 (97)
17. I identify moments of distress for patients/residents.	No	43 (13)	8 (4)	3.40 [1.56–7.40]	0.002
	Yes	275 (87)	174 (96)
18. I support patient/resident autonomy (focus on “getting it done” rather than “doing it instead of”)	No	8 (2)	5 (3)	0.91 [0.29–2.83]	0.876
	Yes	310 (98)	177 (97)
19. I recognize the weakened person as a full adult with his or her own life story	No	31 (10)	9 (5)	2.07 [0.96–4.46]	0.061
	Yes	287 (90)	173 (95)
20. Wellness is the subject of recommendations from me to newcomers	No	76 (24)	20 (11)	2.54 [1.49–4.32]	0.001
	Yes	242 (76)	162 (89)
21. During my annual evaluation interview, the wellness is the subject of an exchange	No	158 (50)	61 (33)	1.95 [1.34–2.85]	< 0.001
	Yes	160 (50)	121 (67)
23. In my department, the staff break is organized in turn	No	144 (45)	48 (26)	2.31 [1.55–3.43]	< 0.001
	Yes	174 (55)	134 (74)
24. In my department, doorbell wait times are assessed	No	245 (77)	92 (51)	3.28 [2.22–4.85]	< 0.001
	Yes	73 (23)	90 (49)
25. In my department, visiting hours are free	No	178 (56)	72 (40)	1.94 [1.34–2.81]	< 0.001
	Yes	140 (44)	110 (60)

Data were number (%)

CI: Confidence interval. OR: Odds ratio

Table 6.

Factors determining the existence of posters, documents of wellness in the service (item 22): multivariate analysis (n = 500)

Items	Odds-ratio [95% confidence interval]	p-value
6. I take pain into account in all situations	6.73 [1.42–31.81]	0.016
10. I ensure the collection of advance directives	2.28 [1.42–3.63]	0.001
15. I promote movements, patient/resident rhythms	0.14 [0.03–0.50]	0.003
23. In my department, the staff break is organized in turn	1.61 [1,04 − 2,50]	0.032
24. In my department, doorbell wait times are assessed	2.96 [1.97–4.48]	< 0.001
25. In my department, visiting hours are free	1.51 [1.00-2.26]	0.046

Discussion

The main findings of this study, conducted among Tunisian nurses, can be summarized as follows: Among the 500 nurses, 85% reported respecting patients’/residents’ intimacy and dignity during bathroom use, 56% did not consistently mention the absence of pain, 53% took into account patients’ preferences, habits, and abilities when planning meals, 46% discussed wellness during annual evaluation interviews, and 58% considered visiting hours to be restrictive. Following the intervention, statistically significant improvements were observed across all evaluated domains, with change rates ranging from 8% (for adherence to privacy, dignity, and confidentiality) to 46% (for promotion of patient autonomy). Five independent variables were identified as predictors of wellness being discussed during annual evaluation interviews: respect for information confidentiality, avoidance of professional medical discussions at the patient’s bedside, accompaniment and comfort of patients during end-of-life care, organization of staff breaks on a rotating basis, and monitoring of doorbell waiting times. Six independent variables were identified as predictors of the presence of wellness-related posters and documents in the department: consistent consideration of pain, documentation of advance directives, encouragement of patient mobility, rotating staff break schedules, monitoring of doorbell waiting times, and implementation of flexible visiting hours. Therefore, our three hypotheses are retained.

To the best of the authors’ knowledge, it seems that our study is the first African and Arab study aiming to evaluate the impact of implementing a wellness charter intervention on nurses’ care practices and health outcomes for older people. In fact, only 12 publications were discovered when the following terms were combined in a PubMed search on September 23, 2025: wellness charter [Title/Abstract] AND (nursing practice [Title/Abstract]) [31–42]. Overall, research indicates that nurse practice and wellness charters have a strong conceptual congruence, but in order to fully achieve their potential, further training, assessment, and organizational transformation are required [31–42]. A number of recurring themes and findings about the use of wellness/health-promotion charters—most notably the Ottawa Charter [32, 33, 37, 42]—in nursing practice can be found in the aforementioned 12 papers. From acute care and curricula to community and school nursing, the Ottawa Charter offers a helpful and adaptable framework that is used in a variety of contexts. However, implementation varies and frequently calls for clear curriculum development, interprofessional collaboration, and real-world examples to put theory into practice [32, 33, 37, 42]. To support the entire range of health-promoting actions, a number of studies have found gaps in nurses’ readiness and learning needs, emphasizing the need for focused education (including web/hybrid approaches for advanced practice) [31, 36]. Nurse-led initiatives could effectively improve population health when backed by mechanisms for surveillance, assessment, and resources, according to empirical evaluations (e.g.; pediatric asthma monitoring, human papillomavirus-related health-promotion behaviors) [34, 35]. Organizational limitations and power disparities between nurses and patients are identified as barriers that can compromise autonomy and collaboration; on the other hand, encouraging patient autonomy and collaborative decision-making increases the adoption of wellness programs [39, 40]. Both structural support and educational change are necessary to integrate health promotion into practice, as demonstrated by case studies of innovation in community settings and the active role baccalaureate students are expected to play [38, 41].

Effects of the intervention

Caring

Adherence to privacy, dignity, and confidentiality standards

Privacy and dignity are foundational components of the human experience [43]. They encompass deeply personal and subjective dimensions—such as emotional, sexual, and domestic aspects—that are closely linked to an individual’s identity and sense of self [43]. These principles are especially critical in healthcare settings, where safeguarding patient privacy and dignity is essential to delivering ethical and respectful care [44]. This perspective highlights the intrinsic connection between intimacy, dignity, and personal identity, reinforcing their significance in the healthcare context [45]. Unlike earlier descriptions that may have ambiguously referred to “confusion” around these concepts, this interpretation underscores their interdependence and centrality to one’s self-worth [46]. This conceptual framework may partly explain our finding that the item related to respecting intimacy showed the smallest improvement following the intervention (+ 2%).

A comparable study, which evaluated adherence to the Patients’ Bill of Rights [48] in Iranian hospitals, reported that the highest levels of compliance were found in respecting patient privacy and maintaining confidentiality—areas rated by all participants as fully respected [47]. The findings from both studies [47, 48] support the close link between privacy and confidentiality in healthcare settings. However, the Iranian study also revealed that the lowest level of compliance was in respecting patient intimacy and providing clear, adequate information, with only 48% adherence in this domain [47]. In contrast, our study observed the greatest improvement in the promotion of patient self-esteem (+ 13%). Agrawal et al. [49] defined patients’ rights as a set of ethical and legal standards guiding interactions between patients and healthcare professionals. This definition emphasizes the role of these rights in shaping the quality of the patient-provider relationship [49]. Similarly, Aydin et al. [50] argued that implementing effective strategies to increase awareness and foster self-esteem among both patients and healthcare professionals is essential to improving overall care quality.

End of life

Our results related to “End of life” are consistent with the findings of DeBroca et al. [51], who reported persistent challenges in addressing advance directives and in appointing a designated support person for residents and their families. Similarly, a French study examining palliative care practices in residential care facilities for dependent older adults revealed low rates of support person designation (28%), limited consideration of medical futility (36%), and limited documentation of advance directives (23%) [52]. Coffey et al. [53] identified that American nurses tend to have greater knowledge and experience regarding advance directives compared to their international counterparts. They also reported higher levels of confidence and comfort in managing end-of-life care.

Communication

Our results concerning communication are consistent with findings by Boudreault and Ntetua [54], who highlighted that age-related bias, along with a lack of communication, empathy, and compassion, can hinder older adults’ ability to feel at ease in social and care settings. Such challenges, particularly during hospitalization, may contribute to a decline in self-esteem among older people [54]. To help address these issues, Talbout [55] recommended reminiscence therapy as an effective strategy to enhance communication with older adults. This therapeutic approach—based on the intentional or spontaneous recall of personal memories from one’s autobiographical past, either individually or in groups—has been shown to reduce anxiety and promote calm behavior [55]. As a result, it contributes to increased satisfaction among caregivers, fellow patients, and families alike [55].

Promoting patient autonomy

Our findings about “Promoting patient autonomy” are comparable to these reported in literature [56, 57]. Alodhialah et al. [56] noted that the principle of respecting autonomy is frequently overlooked in the care of hospitalized or institutionalized older adults, both in medical and social contexts. Other authors have highlighted the importance of creating more opportunities to uphold this principle, thereby fostering greater respect for older individuals and supporting their decision-making capacity [57]. Additionally, a previous study found that stroke patients experiencing taste impairments are at increased risk of malnutrition and its associated complications, which can negatively influence recovery and overall QoL [57]. These sensory deficits are also linked to higher rates of depressive symptoms, which may further hinder the healing process [57].

Upholding personal dignity

Our results as to “Upholding personal dignity” likely reflect an evolution in participants’ self-perceived practices regarding respect for the individual between T₁ and T₂. The concepts of human rights and respect for the individual have long underpinned the ethical foundations of both care and research [58]. As such, healthcare institutions should prioritize the respect and dignity of hospitalized individuals and foster ethical reflection, particularly regarding how patients are welcomed and treated within the care environment [59]. Vernet et al. [59] noted that in healthcare units—often labeled with dissonant acronyms—integrating principles of care ethics and wellness is not optional but essential. This ethical commitment may help explain the improvements observed in our participants’ attitudes and practices.

Competence

Pain management

Our outcomes concerning “Pain management” reflect notable progress in the management of patient pain. Although advances in pain management have led to more sophisticated approaches, access to effective pain relief remains inconsistent [60]. Many patients suffering from severe and chronic pain still do not receive adequate assessment or treatment and are often not offered comprehensive, evidence-based interventions that are the standard in specialized pain care [61]. Therefore, involving all healthcare professionals in the management of both acute and chronic pain is essential [62]. Such an inclusive approach supports the implementation of evidence-based practices and contributes to standardizing pain management protocols, especially in the use of opioids [63]. Poor pain management not only compromises patient wellness but can also damage the reputation and financial sustainability of healthcare institutions [64]. Patient satisfaction is closely linked to their pain experience during hospitalization [65], and higher levels of pain and depression are strongly associated with lower satisfaction in institutional care settings [66].

Patient/resident comfort

Our findings in relation to “Patient/resident comfort” are comparable to these reported in literature [67–72]. It has long been recognized that seriously ill patients often experience disturbed, non-restorative sleep [67]. This issue has gained increasing attention due to its role as a potentially modifiable risk factor for delirium, which can lead to extended hospital stays and long-term cognitive and physical impairments [68]. Kamdar et al. [69] identified that most clinicians acknowledged poor sleep quality in hospitals and its negative impact on patient outcomes, yet few healthcare settings had implemented sleep improvement protocols. In response, various interventions have been introduced to promote rest, including strategies to minimize noise during nighttime hours [70]. Ulrich et al. [71] suggested that future healthcare facility design should incorporate features such as soundproof walls and redesigned room layouts. They also advocated for addressing common sources of noise pollution, including improving ventilation systems and alarm technologies [71]. Moreover, interventions should aim to align with patients’ circadian rhythms and promote quality sleep. A 2017 randomized controlled trial [72] demonstrated that lavender aromatherapy significantly improved sleep quality and reduced anxiety, reinforcing the benefits of non-pharmacological strategies for enhancing patient comfort.

Evolution of service organization practices

Our results linked to “Evolution of service organization practices” are comparable to these reported in literature [73, 74]. Beaulieu and Crevier [73] recommended that the integration of health and social services could help address, both implicitly and explicitly, the abuse of vulnerable populations. This type of service reorganization aims to improve access to care, enhance service quality and continuity, reduce delays in treatment, and ensure greater consistency in care delivery. Similarly, Thomassen et al. [74] emphasized that successful organizations often implement charters that support cultural and structural transformation. They noted that meaningful organizational change requires active engagement from all staff members, fostered through shared values, beliefs, attitudes, assumptions, and behaviors [74]. These insights highlight the importance of well-structured organizational practices in improving both patient outcomes and staff efficiency within healthcare settings [74].

Evolution of participants’ practices by domain

Our study demonstrated significant positive changes across all eight assessed domains. The greatest improvement was observed in the domain of respect for patient autonomy (+ 30%), while the smallest change was recorded in service organization practices (+ 6%). Healthcare professionals play a vital role in upholding and implementing patients’ rights [50]. Modern nursing carries an ethical obligation to defend and protect these rights, which serve as essential accountability mechanisms and contribute directly to healthcare quality [50]. The recognition and enforcement of patients’ rights not only enhance ethical standards but also act as a driving force for structural reform within healthcare systems [50]. States bear a responsibility to respect, protect, and promote these rights [50], with both governmental and non-governmental actors contributing to policy development and implementation across various levels [50]. However, knowledge about how multi-level institutional mechanisms support the enforcement of patient rights in healthcare facilities remains limited [75]. A Turkish study investigating patient rights practices in a developing country context found that many challenges encountered in healthcare delivery could be addressed through the enforcement of legislatively guaranteed patients’ rights [76]. The authors argued that the implementation of these rights should be seen as a manifestation of a socially responsible government health policy [76]. Sheikhtaheri et al. [48] reported that informing nurses about the patient rights charter led to increased awareness, although improving clinical performance still required additional interventions. In line with this, Abedian et al. [77] recommended enhancing nurses’ understanding of the charter through curriculum revisions in nursing education and the inclusion of relevant content in continuing professional development programs. Such strategies are essential for improving the quality of nursing care and promoting a culture of patient rights within healthcare systems.

Predictive of wellness

Evaluation of wellness practices

Our findings concerning the factors independently associated with the annual evaluation of wellness practices (i.e.; respecting information confidentiality, avoiding medical discussions between professionals at the patient’s bedside, accompanying patients at the end of life and ensuring their comfort, organizing staff breaks on a rotating basis, and assessing waiting times for doorbells) are consistent with existing literature [78–82]. Leader and Gillespie [78] highlighted that neglect by nurses is often rooted in organizational issues such as excessive workloads, burnout, and poor caregiver–patient relationships. Similarly, Wang et al. [79] identified that caregivers who worked fewer hours had lower education and social support, and experienced higher stress levels were more likely to engage in psychologically abusive behavior toward older adults. Braaten and Malmedal [80] emphasized the importance of strong communication skills, trustful relationships, and an organizational culture that encourages open discussions about ethical concerns. DeHart et al. [81] underlined the role of both verbal and nonverbal communication in reducing conflict and preventing abuse, noting that a lack of managerial oversight can contribute to higher abuse risk in care settings. Pillemer and Bachman-Prehn [82], in their analysis of nursing staff self-reports, identified burnout, resident aggression, negative attitudes toward residents, and younger staff age as predictors of psychological abuse. These findings collectively emphasize the complex interplay between organizational and individual-level factors that influence patient wellness and the potential for abuse in healthcare environments.

Presence of wellness-related posters and documents

Our findings regarding the factors independently associated with the presence of wellness-related visual materials in departments (i.e.; consideration of pain in all situations, ensuring collection of advance directives, encouraging patient movement, rotating staff breaks, assessing waiting times at doorbells, and flexible visiting schedules) align with previous research [83, 84]. A randomized controlled trial [83] demonstrated that nurses who received training on elder abuse showed significantly improved recognition of abuse, while the control group showed no significant change. The study concluded that in-service education enhances nurses’ ability to identify and appropriately respond to abuse. Additionally, earlier research [84] reported that the presence of standards addressing residents’ rights, effective staff management, and quality care systems led to better outcomes and reduced risk of abuse. Together, these findings reinforce the importance of implementing comprehensive strategies to promote wellness and protect older adults in healthcare settings.

Study limitations

This study has some limitations. First, access was restricted in some departments, some nurses declined to participate, and comparable studies within Tunisian healthcare institutions are lacking. As a result, the findings from the five university hospitals may not be generalizable to other older people care units nationally. Second, the sample is not nationally representative, and the survey relied on self-reported perceptions, which may be affected by mistrust, fear, reluctance, neglect, or lack of awareness. Third, the one to five months period from the before (T₁: May-July) to the after (T₂: August-September) data collection can slightly modify our results. In literature, the duration between the before-test and after-test varies depending on the type of interventional studies. For example, while one study concerning training were limited to one week [85], another one opted for one month [86]. Fourth, we did not conduct formal analyses to evaluate common method bias, early vs. late respondent bias, or non-response bias. Due to the lack of these assessments, we are unable to completely rule out the potential that our findings were impacted by systematic differences between respondents (n = 500) and nonrespondents (n = 10), or by artifacts resulting from evaluating predictors and outcomes in a single instrument. For instance, when nonrespondents differ significantly from respondents in important features, non-response bias is known to pose a danger to the validity of survey research [87]. Similarly, when the same method is used to measure both independent and dependent variables, shared method variance may cause observed associations to be inflated or deflated [88]. Therefore, care should be taken while interpreting our findings. Finally, the collaborator who both administered the interventions and assessed the outcomes was not blinded to the study condition assignment, which could represent a potential source of bias in outcome assessment. These five limitations underscore the need for further research, using larger and more diverse samples, to better understand and address the wellness of older adults in Tunisian healthcare contexts.

Implications and future research

The dissemination and increased awareness of the wellness charter resulted in a substantial improvement in nursing practice, demonstrating its practical value in enhancing the quality of care. These findings emphasize the critical importance of prioritizing patient rights education for caregivers and fostering an ethical, patient-centered approach in the nurse-patient relationship. Our research suggests that adopting a wellness-oriented approach, which promotes appropriate care and management strategies for older adults, can significantly enhance their QoL. Furthermore, the integration of interdisciplinary collaboration is essential to ensure comprehensive and effective care delivery. To strengthen the generalizability of these findings, we recommend that similar interventions and studies be conducted in diverse geriatric clinical settings, allowing for broader application and validation of the wellness charter approach.

Conclusion

This before/after intervention study conducted among Tunisian nurses demonstrated significant improvements in multiple dimensions of wellness-related nursing practices following the dissemination of the wellness charter. Change rates ranged from modest gains in respecting privacy, dignity, and confidentiality to substantial increases in the promotion of patient autonomy. Key predictors of wellness-related practices were also identified, offering valuable insights for targeting future interventions. These findings emphasize the central role of nurses in safeguarding the dignity, autonomy, and overall wellness of older adults, particularly in hospital settings where vulnerability is heightened. By fostering ethical and patient-centered practices, nurses can help mitigate the progressive loss of independence and functional capacity associated with aging and illness. Our study highlights the importance of implementing a multidisciplinary, wellness-oriented approach to care, supported by education on patient rights and organizational strategies that encourage adherence. Such initiatives not only improve day-to-day nursing practices but also contribute to enhancing the QoL of older adults. The observed improvements in wellness-oriented nursing care underscore the need for institutional policies that integrate the wellness charter principles into routine staff evaluation and continuing nursing education programs in geriatric care. Moreover, the feasibility and effectiveness of this intervention suggest that it could be replicated across other Maghreb countries, thereby reinforcing its potential contribution to the regional advancement of ethical and patient-centered geriatric care. Future research should extend this work to other geriatric care contexts to validate and generalize these results.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

FT HBS: Literature search, Manuscript preparation and Review of manuscript. NM SBA HL KK & KA & SC & NM & IB: Review of manuscript. All authors read and approved the final manuscript.

Funding

None.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information file: an Excel file including the data of the 500 nurses).

Declarations

Ethics approval and consent to participate

Ethical approvals were obtained from the respective ethics committees of each participating hospital: Sahloul and Ibn Jazzar Hospitals (CEFMS 32/2019), Farhat Hached Hospital (IRB 00008931), Fattouma Bourguiba Hospital (IORG 0009738 / OMB 0990 − 0279), and Taher Sfar Hospital (P01 M.P.C-2020). Written informed consent was obtained from each nurse prior to data collection. The study followed the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.