The Quantitative Analysis of Patients’ Dignity and Privacy Needs in Anesthesia Nursing Services Based on the Kano and SERVQUAL Models

Abstract

Background

Patients undergoing pulmonary anesthesia face dignity and privacy threats due to intraoperative positioning, unconsciousness, and postoperative discomfort. Existing studies focus mainly on technical safety, lacking systematic investigation from the patient’s perspective. This neglect may lead to patient dissatisfaction and ethical concerns.

Objective

To identify patients’ dignity and privacy needs, evaluate service quality gaps, and prioritize improvement targets in pulmonary anesthesia nursing using an integrated Kano–SERVQUAL framework.

Methods

A cross-sectional survey was conducted between March and September 2025 among patients undergoing pulmonary resection under general anesthesia in five tertiary hospitals in China. A 25-item questionnaire based on the Kano and SERVQUAL models was developed to assess dignity- and privacy-related service needs. Kano attribute classification, Better–Worse coefficient analysis, SERVQUAL gap analysis, and integrated quadrant analysis were performed.

Results

A total of 423 valid questionnaires were analyzed. Patients’ dignity- and privacy-related needs showed a clear hierarchical structure, with informed consent, confidentiality protection, professional competence, and body privacy identified as fundamental requirements. Significant gaps were observed between patients’ expectations and perceived service experiences, particularly in the domains of assurance and empathy. The integrated Kano–SERVQUAL analysis identified informed consent, privacy protection, responsiveness to patient concerns, professional competence, and respectful communication as the highest-priority areas for improvement.

Conclusion

Patients undergoing pulmonary anesthesia place substantial importance on dignity and privacy protection, yet important service gaps remain. This study is among the first to integrate Kano-based need hierarchy analysis with SERVQUAL service quality assessment in pulmonary anesthesia nursing, enabling simultaneous evaluation of patient priorities and service deficiencies. The proposed framework offers a practical and evidence-based strategy for prioritizing patient-centered quality improvement and resource allocation in perioperative anesthesia care.

Introduction

Pulmonary anesthesia is widely used in thoracic surgery and often involves one-lung ventilation, double-lumen endotracheal intubation, extensive body exposure, and temporary loss of patient autonomy.¹ During this period, patients become highly dependent on healthcare professionals for both physical safety and psychological security. Growing evidence suggests that dignity preservation, privacy protection, respectful communication, and patient involvement are increasingly recognized as essential components of high-quality perioperative care rather than merely ethical considerations.^2,3 Violations of dignity and privacy may adversely affect patient trust, satisfaction, emotional well-being, and overall healthcare experiences, particularly in vulnerable peri-anesthetic settings.^3–9

Despite increasing attention to patient-centered care, research in anesthesia nursing has predominantly focused on clinical outcomes such as safety, pain control, recovery quality, and complication prevention.^10–12 Studies addressing dignity and privacy have largely relied on qualitative investigations or general patient-satisfaction surveys, providing limited quantitative evidence regarding the relative importance of different patient needs and the extent to which current services meet these expectations.^13–16 Furthermore, existing evaluations typically assess either patient expectations or service performance alone, making it difficult to identify which deficiencies should be prioritized for quality improvement.¹⁷ Consequently, evidence-based strategies for optimizing dignity- and privacy-related anesthesia services remain insufficiently developed.¹⁸

To address these limitations, a more comprehensive evaluation framework is required. The Kano model enables classification of service attributes according to their influence on satisfaction, whereas the SERVQUAL model evaluates discrepancies between expected and perceived service quality.¹⁹ Integrating these complementary approaches allows simultaneous assessment of need hierarchy and service performance. Although both models have been widely applied in healthcare service evaluation, their combined use for assessing dignity and privacy needs in pulmonary anesthesia has rarely been reported. More importantly, such integration provides a practical method for distinguishing fundamental requirements from value-added services and for identifying improvement targets with the greatest potential impact on patient experience.^20–23

Therefore, this study aimed to quantitatively evaluate dignity- and privacy-related needs among patients undergoing pulmonary anesthesia using an integrated Kano–SERVQUAL framework. Specifically, we sought to identify the hierarchical structure of patient needs, examine gaps between expected and perceived service quality, and prioritize improvement targets according to their potential influence on patient satisfaction. We hypothesized that: (1) dignity- and privacy-related needs would exhibit distinct hierarchical characteristics; (2) significant service quality gaps would exist between patient expectations and actual experiences; and (3) the integrated Kano–SERVQUAL framework would provide a more effective approach for identifying priority areas for patient-centered quality improvement in pulmonary anesthesia nursing.

Materials and Methods

Study Design and Ethical Considerations

This study employed a cross-sectional survey design. The manuscript was prepared following the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines, and the study protocol was approved by the Ethics Committee of Shanghai Pulmonary Hospital (approval No. SPH-2025-048). All participants provided written informed consent, and the study was conducted in strict accordance with the ethical principles outlined in the Declaration of Helsinki. The questionnaire was administered anonymously, and all data were used solely for academic research purposes, with strict measures in place to protect participants’ privacy.

Study Population

A convenience sampling method was employed to recruit eligible patients from the thoracic surgery and anesthesiology departments of five tertiary hospitals across China between March and September 2025. To improve sample diversity and reduce potential selection bias, participants were recruited from multiple centers with varying patient demographics and clinical characteristics. Eligible participants were adult patients undergoing elective pulmonary resection (including lobectomy, segmentectomy, or pneumonectomy) under general anesthesia with double-lumen endotracheal intubation and one-lung ventilation.

Inclusion criteria were as follows: Age ≥18 years; Scheduled for elective pulmonary resection for pulmonary diseases (eg, lung cancer, pulmonary nodules, bronchiectasis) under general anesthesia, with intraoperative use of double-lumen intubation and one-lung ventilation; Postoperative consciousness intact, able to communicate effectively; Duration of stay in the post-anesthesia care unit (PACU) ≥30 minutes; Provided written informed consent and voluntarily participated.

Exclusion criteria included: Emergency surgery (eg, thoracic trauma); Preexisting cognitive impairment or psychiatric disorders; Postoperative complications requiring ICU admission or reoperation; Inability to complete the questionnaire due to language barriers; Conversion to thoracotomy or occurrence of major anesthesia-related adverse events during surgery.

Sample size estimation was based on methodological recommendations for questionnaire-based studies and Kano model applications, which suggest recruiting at least 5–10 participants per questionnaire item. Given the 25-item questionnaire used in this study, a minimum sample size of 250 participants was required. Assuming a 20% non-response rate, the target sample size was increased to 313 participants. To further enhance statistical stability and representativeness, 450 participants were ultimately recruited.

Survey Instrument

Questionnaire Development Process

The questionnaire was developed following these steps: First, A systematic literature search was conducted in the MEDLINE database via PubMed and the Wanfang database to identify studies related to thoracic anesthesia, lung anesthesia, patient dignity, privacy protection, and service quality, from which relevant items were extracted. Second, using the five dimensions of the SERVQUAL model (tangibility, reliability, responsiveness, assurance, and empathy) as the theoretical framework, and integrating the functional/dysfunctional question format of the Kano model, an initial item pool was constructed. Third, structured interviews were conducted with 10 patients who had recently undergone lung resection to explore their concerns regarding dignity and privacy during the anesthesia process, and to supplement or refine the items accordingly. Fourth, five experts (two thoracic anesthesia specialists, two anesthesia nursing experts, and one health services research methodologist) were invited to evaluate the content validity. After two rounds of expert consultation, a preliminary questionnaire was finalized. Fifth, a pilot survey was conducted with 30 patients to assess the reliability and comprehensibility of the questionnaire, and revisions to wording and format were made based on the feedback.

Questionnaire Structure

Kano Model Functional/Dysfunctional items: For each service item, both a functional (If this service is provided, how would you feel?) and a dysfunctional (If this service is not provided, how would you feel?) question were included. Responses were recorded on a 5-point Likert scale: 1 = like it very much, 2 = expected, 3 = indifferent, 4 = can tolerate, 5 = dislike it. According to the Kano evaluation table, each item was classified as: A = attractive attribute, O = one-dimensional attribute, M = must-be attribute, I = indifferent attribute, R = reverse attribute, Q = questionable result. The specific classification criteria are presented in Table 1.

Table 1.

Kano Evaluation Table for Attribute Classification

Functional\Dysfunctional	Like It	Must-Be	Neutral	Can Live with It	Dislike It
Like it	Q	A	A	A	O
Must-be	R	I	I	I	M
Neutral	R	I	I	I	M
Can live with it	R	I	I	I	M
Dislike it	R	R	R	R	Q

SERVQUAL Expectation-Perception Ratings: For each service item, patients rated their expectations (What is the ideal level of this service?) and perceptions (What was the actual level of service received?) using a 5-point Likert scale, ranging from 1 (very low/very dissatisfied) to 5 (very high/very satisfied). The service quality gap was calculated as: Perceived Score – Expected Score. Negative values indicated that service quality did not meet expectations, whereas positive values indicated that service exceeded expectations.

Draft Questionnaire Items

A total of 25 draft items were developed to assess pulmonary anesthesia nursing service needs from the perspective of patient dignity and privacy, structured according to the five dimensions of the SERVQUAL model:

Tangibility (4 Items)

1. The environment in the post-anesthesia care unit (PACU) ensures patient privacy (eg, partitions or curtains between beds to reduce mutual visibility). 2. Patients’ bodies, especially surgery-related areas such as the chest and axilla, are appropriately covered during emergence from anesthesia, preventing unnecessary exposure. 3. Clear signage is present outside the PACU (eg, “Family Waiting Area”, “Authorized Personnel Only”). 4. Anesthesia staff maintain a clean and professional appearance, conveying a sense of trustworthiness.

Reliability (5 Items)

5. The anesthesiologist clearly explains the specific procedures of pulmonary anesthesia (eg, one-lung ventilation, double-lumen intubation) and potential risks during preoperative visits. 6. Anesthesia staff properly safeguard patients’ medical records, including pulmonary imaging and function reports, and do not leave them unattended. 7. Only necessary medical personnel are present during anesthesia (particularly during patient positioning and sterile draping). 8. Anesthesia staff maintain the confidentiality of patients’ personal information (eg, smoking history, occupational exposures, preoperative sensitive data). 9. Preoperative visit times promised by the anesthesiologist are adhered to as scheduled.

Responsiveness (5 Items)

10. The anesthesiologist seeks consent before asking sensitive questions during preoperative visits (eg, smoking history, occupational exposures). 11. Nurses respond promptly to patients’ complaints of dyspnea, pain, or nausea during emergence from anesthesia. 12. The anesthesiologist addresses patients’ privacy concerns regarding pulmonary anesthesia (eg, safety of one-lung ventilation) in a timely manner. 13. During PACU interactions, staff avoid discussing sensitive patient information (eg, tumor characteristics, intraoperative details). 14. When patients request family presence during emergence, staff make reasonable arrangements (eg, allowing family members in designated areas).

Assurance (6 Items)

15. The anesthesiologist provides detailed explanations of the purpose and steps of procedures such as double-lumen intubation before performing them. 16. Explicit consent is obtained prior to invasive procedures (eg, arterial or central venous catheterization). 17. The professional competence of the anesthesiologist (eg, management of one-lung ventilation) instills confidence in patients. 18. Anesthesia staff conduct themselves respectfully, without showing impatience toward preoperative anxiety. 19. Staff appropriately address gender-sensitive issues (eg, explaining chest coverage for female patients). 20. Staff respect the special privacy needs of patients with diverse cultural or religious backgrounds (eg, attitudes toward blood transfusion).

Empathy (5 Items)

21. Anesthesia staff understand patients’ preoperative anxiety, particularly concerns about airway management. 22. The anesthesiologist explains complex pulmonary anesthesia concepts in plain language to reduce fear arising from misunderstanding. 23. Nurses monitor patients’ emotional changes (eg, agitation or crying) during emergence and provide appropriate comfort. 24. The anesthesiologist considers patients’ preferences when formulating anesthesia plans (eg, postoperative analgesia methods). 25. After anesthesia, staff inquire about patients’ experiences and any concerns regarding privacy (eg, whether they felt respected during surgery).

Reliability and Validity Testing

The internal consistency and validity of the questionnaire were assessed before formal data collection. Cronbach’s alpha coefficient was used to evaluate reliability. The overall Cronbach’s alpha coefficient of the questionnaire was 0.91, with dimension-specific coefficients ranging from 0.82 to 0.88, indicating good internal consistency. Content validity was assessed by five experts using the content validity index (CVI), with item-level CVI (I-CVI) values ranging from 0.83 to 1.00 and a scale-level CVI (S-CVI) of 0.94. Construct validity was evaluated using exploratory factor analysis. The Kaiser–Meyer–Olkin (KMO) value was 0.89, and Bartlett’s test of sphericity was statistically significant (χ² = 2567.43, P < 0.001), supporting the structural validity of the questionnaire. These results indicate satisfactory reliability, content validity, and construct validity of the questionnaire.

Data Collection

Trained investigators administered face-to-face questionnaires to patients within 24–48 hours after transfer from the post-anesthesia care unit (PACU). This time window was selected to balance cognitive recovery and recall accuracy. At this stage, patients were generally fully conscious, clinically stable, and able to recall peri-anesthesia experiences with reasonable clarity, while minimizing recall decay associated with longer postoperative intervals. Prior to the survey, patients were informed of the study objectives, anonymity, and voluntary participation, and written informed consent was obtained. Given the complexity of the Kano model question format, investigators provided standardized instructions for questionnaire completion and answered participants’ questions using uniform explanations. The survey required approximately 20–25 minutes to complete. Questionnaires were reviewed for completeness immediately after collection, and any missing responses were verified and completed on site whenever possible. Questionnaires with substantial missing information were excluded from analysis. Consequently, the final analytical dataset contained no missing values.

Statistical Analysis

Data were double-entered using EpiData3.1 and analyzed with SPSS 26.0 and Excel 2019. Descriptive Analysis: Categorical variables were summarized as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation (SD). Kano Model Analysis: Each item’s functional/dysfunctional responses were classified into two-dimensional attributes according to the Kano evaluation table The frequency of each attribute category was counted, and the category with the highest frequency was assigned as the final attribute of the item. In cases of a tie between two categories, the priority order was: Must-be (M) > One-dimensional (O) > Attractive (A) > Indifferent (I). Better coefficient (satisfaction influence) and Worse coefficient (dissatisfaction influence) were calculated as follows:

A positive Better coefficient indicates the extent to which providing the service can enhance satisfaction, whereas a negative Worse coefficient indicates the extent to which not providing the service can reduce satisfaction.

SERVQUAL Gap Analysis

For each service item, expectation and perception scores were calculated, and the service quality gap was defined as Perception minus Expectation (P − E). Negative values indicated that perceived service quality did not meet patient expectations, whereas positive values indicated that service exceeded expectations. Paired t-tests were used to compare expectation and perception scores for each service item and SERVQUAL dimension, as these two measurements were obtained from the same participants and therefore constituted paired observations. Prior to analysis, the normality of score differences was assessed using the Shapiro–Wilk test. To reduce the risk of type I error arising from multiple comparisons across the 25 service items, Bonferroni correction was applied where appropriate, with an adjusted significance threshold of P < 0.002. Mean service quality gaps were calculated for each dimension and for the overall scale.

Integrated Analysis

A quadrant plot was created with the absolute value of the Worse coefficient on the x-axis and the SERVQUAL gap on the y-axis. The median values of absolute Worse coefficients and gaps were used as cutoff points to divide items into four quadrants:

Quadrant I (high Worse, large gap): Priority improvement zone

Quadrant II (low Worse, large gap): Secondary improvement zone

Quadrant III (low Worse, small gap): Maintenance zone

Quadrant IV (high Worse, small gap): Advantage retention zone

Improvement strategies were determined by integrating Kano attribute classifications.

Integrated Kano–SERVQUAL Analysis Procedure

To improve the reproducibility and practical applicability of the integrated framework, the Kano–SERVQUAL analysis was conducted in five sequential steps. First, Kano model analysis was performed to classify each service item into must-be, one-dimensional, attractive, indifferent, or reverse attributes based on patients’ functional and dysfunctional responses. Second, Better–Worse coefficient analysis was used to quantify the relative impact of each service attribute on patient satisfaction and dissatisfaction, providing additional sensitivity for priority assessment. Third, SERVQUAL gap analysis was conducted by calculating the difference between perception and expectation scores (P − E) for each item to identify service performance deficiencies. Fourth, the Kano attribute classifications were combined with SERVQUAL gap scores to construct an integrated priority matrix. Service items with both high patient importance and large negative service gaps were considered high-priority targets for improvement. Finally, the integrated results were interpreted to identify actionable intervention priorities in anesthesia nursing management, focusing on dignity and privacy protection.

Results

Participant Demographics

A total of 450 questionnaires were distributed, and 423 valid responses were collected, yielding an effective response rate of 94.0%. The demographic and clinical characteristics of the participants are presented in Table 2. Among the respondents, 58.9% were male and 41.1% were female, with a mean age of 58.3 ± 10.7 years. Thoracoscopic surgery was the predominant surgical approach (72.8%), and 54.6% of participants had a prior history of surgery or anesthesia.

Table 2.

Demographic and Clinical Characteristics of Participants (N = 423)

Variable	Category	n	%
Gender	Male	249	58.9
	Female	174	41.1
Age (years)	18–40	45	10.6
	41–60	218	51.5
	≥61	160	37.9
Educational level	Junior high school or below	187	44.2
	Senior high school/Technical secondary school	135	31.9
	College or above	101	23.9
Surgical approach	Thoracoscopic	308	72.8
	Thoracotomy	115	27.2
Prior surgery/anesthesia history	Yes	231	54.6
	No	192	45.4
Type of pulmonary disease	Lung cancer	289	68.3
	Pulmonary nodules	89	21
	Bronchiectasis or others	45	10.7
Duration of anesthesia (minutes)	≤120	156	36.9
	121–180	198	46.8
	>180	69	16.3

Kano Model Analysis

Classification of Service Attributes

Kano analysis revealed a clear hierarchical structure of dignity- and privacy-related needs in pulmonary anesthesia nursing (Table 3), with detailed attribute distributions provided in Table S1. Among the 25 service attributes, six were classified as must-be attributes, six as one-dimensional attributes, four as attractive attributes, and nine as indifferent attributes, with no reverse or questionable attributes identified. Must-be attributes were primarily associated with informed consent, confidentiality protection, professional competence, explanation of anesthesia procedures, and intraoperative body privacy. These attributes represented fundamental expectations that patients considered essential components of anesthesia care. One-dimensional attributes mainly involved responsiveness to patient concerns, respectful communication, and management of gender- and culture-related privacy issues, indicating that improvements in these areas were directly associated with increased patient satisfaction. Attractive attributes were predominantly related to emotional support, understanding of preoperative anxiety, and postoperative feedback, suggesting that these services may further enhance patient experiences beyond basic expectations. Overall, the findings indicate that patients prioritize both technical professionalism and humanistic care, highlighting the multidimensional nature of dignity and privacy needs in pulmonary anesthesia settings.

Table 3.

Kano Attribute Classification and Better–Worse Coefficients of Dignity- and Privacy-Related Service Attributes in Pulmonary Anesthesia Nursing

Item	Kano Attribute	Better	Worse
1	I	0.39	−0.36
2	M	0.21	−0.74
3	I	0.35	−0.34
4	I	0.4	−0.31
5	M	0.31	−0.78
6	O	0.64	−0.71
7	I	0.44	−0.36
8	M	0.35	−0.75
9	I	0.38	−0.39
10	I	0.43	−0.33
11	O	0.61	−0.7
12	O	0.67	−0.68
13	A	0.69	−0.31
14	I	0.44	−0.38
15	M	0.3	−0.76
16	M	0.31	−0.75
17	M	0.32	−0.75
18	O	0.67	−0.68
19	O	0.66	−0.67
20	O	0.64	−0.66
21	A	0.69	−0.36
22	I	0.49	−0.43
23	A	0.7	−0.31
24	I	0.51	−0.42
25	A	0.69	−0.34

Better-Worse Coefficient Analysis

Better–Worse coefficient analysis was performed to quantify the potential influence of each service attribute on patient satisfaction and dissatisfaction (Table 3 and Figure 1). Overall, attributes related to emotional support, understanding preoperative anxiety, avoidance of sensitive conversations, and postoperative feedback demonstrated the highest Better coefficients, indicating substantial potential to enhance patient satisfaction when effectively delivered. In contrast, attributes associated with informed consent, explanation of anesthesia procedures, confidentiality protection, professional competence, and intraoperative body coverage exhibited the highest absolute Worse coefficients. These findings suggest that deficiencies in these areas are likely to generate considerable patient dissatisfaction and therefore represent fundamental expectations of pulmonary anesthesia care. The distribution of Better and Worse coefficients further supported the hierarchical structure identified by the Kano model. Specifically, attractive attributes tended to demonstrate greater satisfaction-enhancing effects, whereas must-be attributes were characterized by stronger dissatisfaction risks when absent. These results provided an important basis for the subsequent integration of Kano classifications with SERVQUAL gap analysis to establish evidence-based improvement priorities.

Figure 1.

Better–Worse coefficient scatter plot of 25 service items. The x-axis represents the absolute value of the Worse coefficient, and the y-axis represents the Better coefficient.

SERVQUAL Model Analysis

Comparison of Expected and Perceived Scores

Overall, patients’ expectations for the service items were 4.52, while the perceived scores were 3.95, resulting in an overall service quality gap of −0.57 (t = 18.42, P < 0.001). The expected, perceived, and gap scores for each SERVQUAL dimension are presented in Table 4. Among the five dimensions, the largest gap was observed in Assurance (−0.72), followed by Empathy (−0.68), whereas the smallest gap was found in Tangibility (−0.38). These results indicate that patients’ expectations regarding professional competence, communication, and emotional support were not fully met, highlighting areas for targeted service improvement. The differences among the five SERVQUAL dimensions are further illustrated in Figure 2.

Table 4.

SERVQUAL Dimension Scores: Expectation, Perception, and Gap (N = 423)

Dimension	No. of Items	Expectation	Perception	Gap (Perception Expectation)	T value	P value
Tangibility	4	4.38	4.00	−0.38	9.24	<0.001
Reliability	5	4.55	4.05	−0.5	12.56	<0.001
Responsiveness	5	4.48	3.98	−0.5	12.78	<0.001
Assurance	6	4.62	3.90	−0.72	18.96	<0.001
Empathy	5	4.51	3.83	−0.68	17.23	<0.001
Overall	25	4.52	3.95	−0.57	18.42	<0.001

Figure 2.

Service quality gaps across five SERVQUAL dimensions in pulmonary anesthesia nursing.

Service Quality Gap of Individual Items

The service quality gaps for each item are presented in Table 5. Items with relatively large negative gaps (Gap < −0.70) included: item 23: Emotional support during recovery period (−0.85); item 21: Understanding preoperative anxiety (−0.82); item 18: Feeling of being respected (−0.78); item 19: Handling of gender-sensitive issues (−0.75); item 12: Response to intraoperative concerns (−0.73). These items were predominantly within the Assurance and Empathy dimensions, indicating that patients’ expectations for professional competence, emotional support, and respectful communication were not fully met. Targeted improvement in these areas is therefore critical for enhancing patient satisfaction.

Table 5.

SERVQUAL Scores of Individual Items: Expectation, Perception, and Gap (N = 423)

Item No	Expectation	Perception	Gap (Perception Expectation)
1	4.42	4.05	−0.37
2	4.58	4.12	−0.46
3	4.28	3.95	−0.33
4	4.25	3.88	−0.37
5	4.68	4.10	−0.58
6	4.55	4.02	−0.53
7	4.48	4.08	−0.4
8	4.62	4.05	−0.57
9	4.42	4.00	−0.42
10	4.38	3.92	−0.46
11	4.58	4.02	−0.56
12	4.65	3.92	−0.73
13	4.35	3.88	−0.47
14	4.45	4.10	−0.35
15	4.70	4.05	−0.65
16	4.68	4.00	−0.68
17	4.72	4.15	−0.57
18	4.65	3.87	−0.78
19	4.58	3.83	−0.75
20	4.55	3.88	−0.67
21	4.62	3.80	−0.82
22	4.48	3.92	−0.56
23	4.55	3.70	−0.85
24	4.40	3.85	−0.55
25	4.50	3.88	−0.62

Integrated Kano–SERVQUAL Analysis

To identify improvement priorities, Kano attribute classifications were integrated with SERVQUAL gap scores using a quadrant analysis framework (Figure 3). Ten service attributes were located in the priority improvement zone, indicating both high dissatisfaction potential and substantial service quality deficiencies. These attributes mainly involved preoperative explanations of anesthesia procedures, informed consent, confidentiality protection, responsiveness to patient concerns, professional competence, respectful communication, and management of gender- and culture-related privacy issues. In contrast, several attributes related to environmental facilities and routine service processes exhibited relatively low dissatisfaction impact despite moderate service gaps, suggesting a lower priority for immediate intervention. Emotional support during recovery and intraoperative body coverage demonstrated comparatively good performance and should be maintained as strengths of current practice. Overall, the integrated analysis enabled simultaneous consideration of patient need hierarchy and service performance, providing a clear evidence-based framework for prioritizing dignity- and privacy-related quality improvement in pulmonary anesthesia nursing.

Figure 3.

Kano–SERVQUAL quadrant analysis.

Subgroup Analysis

Subgroup analyses revealed significant differences in the Kano attribute classification for several items across patient characteristics. Gender: For item 19 (management of gender-sensitive issues), female patients were more likely to classify this item as an expected attribute compared with male patients (55.2% vs 42.6%). Surgical Approach: For item 2 (intraoperative body coverage), patients undergoing open thoracotomy were more likely to classify it as a must-be attribute than those undergoing video-assisted thoracoscopic surgery (VATS) (72.2% vs 57.8%). Age Groups: For item 21 (understanding preoperative anxiety), elderly patients (≥61 years) were more likely to classify it as a delighter (attractive) attribute compared with middle-aged patients (58.8% vs 44.5%). Previous Surgical/Anesthesia History: For item 5 (preoperative explanation of special anesthesia procedures), patients with prior surgical experience were more likely to classify it as a must-be attribute than those without previous surgery (62.3% vs 48.4%).

Discussion

Principal Findings and Interpretation

This study demonstrated that dignity- and privacy-related needs constitute important quality dimensions of pulmonary anesthesia care and exhibit a clear hierarchical structure. Attributes related to informed consent, confidentiality protection, professional competence, and intraoperative body privacy were identified as fundamental requirements, whereas emotional support and individualized communication functioned as value-enhancing services.^10,12,23 Notably, substantial service quality gaps were observed, particularly within the Assurance and Empathy dimensions, suggesting that patients’ expectations regarding communication, respect, and emotional support remain insufficiently fulfilled. An important finding is that the largest service deficiencies were not related to technical procedures but to interpersonal aspects of care. This observation indicates that patients evaluate anesthesia services through both clinical competence and perceived respect for dignity and autonomy.⁵ Given the highly vulnerable nature of pulmonary anesthesia, deficiencies in communication and privacy protection may be interpreted as breaches of trust rather than isolated service failures. These findings reinforce the growing recognition that humanistic care should be considered a core component of perioperative quality alongside traditional clinical outcomes.^13–15

Methodological Contribution of the Integrated Kano–SERVQUAL Framework

A key contribution of this study lies in the integration of Kano need hierarchy analysis with SERVQUAL service quality assessment. Previous studies have generally evaluated either the importance of patient needs or the magnitude of service deficiencies independently.^19,21,22 Such approaches provide limited guidance regarding which deficiencies should be prioritized when resources are constrained. By combining patient dissatisfaction potential with service performance gaps, the present framework enables a more strategic prioritization of quality-improvement initiatives. Rather than treating all service deficiencies equally, the integrated model identifies attributes that are both highly important to patients and inadequately delivered in practice.²³ This distinction is particularly valuable for healthcare managers because it supports evidence-based resource allocation and targeted intervention planning. Therefore, the methodological innovation of this study extends beyond service evaluation and offers a practical decision-support framework for patient-centered quality management in anesthesia nursing and potentially other clinical settings.

Cultural Context and International Applicability

The findings should be interpreted within the sociocultural context of Chinese healthcare. Traditional Chinese values place considerable emphasis on interpersonal respect, social harmony, and preservation of dignity during illness.^4,5 Consequently, patients may be particularly sensitive to issues such as respectful communication, confidentiality protection, informed consent, and avoidance of unnecessary exposure.¹¹ These cultural expectations may partly explain why dignity- and privacy-related attributes demonstrated strong effects on patient dissatisfaction. Nevertheless, several findings are likely to be applicable across healthcare systems. Respect for autonomy, privacy protection, effective communication, and emotional support are widely recognized principles of patient-centered care internationally. While the relative importance of specific attributes may differ according to cultural norms, healthcare organization, and legal frameworks, the need to preserve dignity during vulnerable perioperative experiences appears to be universal. Future multinational studies are warranted to determine whether the priority structure identified in this study can be replicated in different healthcare environments.

Clinical, Policy, and Managerial Implications

The findings of this study have direct implications for clinical practice, institutional policy, and anesthesia nursing management. At the clinical level, dignity and privacy protection should be incorporated into routine perioperative anesthesia care rather than treated as optional aspects of humanistic service. Standardized preoperative informed consent procedures should be strengthened to ensure that patients receive clear explanations of pulmonary anesthesia procedures, such as double-lumen intubation, one-lung ventilation, invasive catheterization, and potential privacy-related concerns. In addition, perioperative privacy-protection checklists may be introduced to reduce unnecessary body exposure, limit the presence of non-essential personnel, and strengthen confidentiality practices during patient transfer, positioning, emergence from anesthesia, and PACU care.

At the managerial level, the integrated Kano–SERVQUAL framework provides a practical decision-support tool for prioritizing quality-improvement activities under resource constraints. Rather than improving all service items equally, anesthesia nursing managers can use the quadrant analysis to identify service attributes with both high dissatisfaction potential and large service-quality gaps. In the present study, these priority areas included informed consent, confidentiality protection, responsiveness to patient concerns, professional competence, respectful communication, and gender- or culture-sensitive privacy management. These findings suggest that hospitals should allocate training, staffing, supervision, and audit resources preferentially to service processes that are most likely to affect patient trust and dissatisfaction.

At the policy level, dignity- and privacy-related indicators may be incorporated into institutional quality assessment systems for perioperative anesthesia nursing. Hospitals may consider developing formal protocols for privacy protection, sensitive-information communication, gender-sensitive care, and postoperative emotional support. Regular staff training and performance feedback should be implemented to improve respectful communication, shared decision-making, and patient-centered responses to anxiety or discomfort. These measures can help translate patient-reported needs into actionable standards for anesthesia nursing management.

This study also contributes to the broader literature on patient-centered perioperative care. Previous studies have often examined technical safety, recovery outcomes, patient satisfaction, or service quality separately. By integrating the Kano model with SERVQUAL analysis, the present study extends existing research by linking the hierarchy of patient needs with actual service-performance gaps. This approach challenges the traditional emphasis on technical and procedural quality alone and demonstrates that dignity, privacy, communication, and emotional support are measurable and manageable components of anesthesia service quality. Therefore, the proposed framework may be adapted by other perioperative departments seeking to improve patient-centered quality management.

Study Limitations

Several limitations should be acknowledged when interpreting the findings of this study. First, the use of convenience sampling may have introduced selection bias, and the findings should therefore be interpreted within the context of tertiary-care settings in China. Second, data were collected within 24–48 hours after surgery; although this timeframe was selected to capture patients’ experiences promptly, some degree of recall bias may have occurred. Third, evaluations were based solely on patients’ postoperative perceptions, as actual intraoperative exposure and privacy-related practices were not directly observed. Finally, the cross-sectional design precludes causal inference. Future multicenter prospective studies incorporating direct observational measures are needed to validate and extend these findings.

Conclusions

This study integrated the Kano and SERVQUAL models to systematically analyze patients’ dignity and privacy needs in pulmonary anesthesia nursing. The findings indicate a hierarchical structure of patient needs: must-be attributes are primarily related to intraoperative privacy protection and informed consent, one-dimensional attributes involve sensitive information management and the sense of being respected, and attractive attributes include emotional support during the postoperative recovery period. Significant gaps were identified in service quality, particularly in the assurance and empathy dimensions.

The integrated Kano–SERVQUAL analysis highlighted ten priority improvement areas, mainly covering preoperative informed consent, sensitive information management, responses to patient concerns, respectful communication, and management of discomfort during recovery. These findings have practical implications for anesthesia nursing policy and management. Hospitals should consider implementing standardized informed-consent checklists, perioperative privacy-protection protocols, gender- and culture-sensitive communication procedures, and post-anesthesia emotional support pathways.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Patient and Public Involvement

No patients or members of the public were involved in the design, conduct, analysis, or interpretation of this study, nor in the preparation of the manuscript.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request, subject to ethical and privacy considerations.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.