Factors Influencing Patient-Centered Care in the Primary Health Care Settings: The Impact of the Pandemic Crisis and Nurses’ Experience

Patient-centered care has over the past decades, been recognized worldwide as an important component of the health system giving a wider dimension to high-quality healthcare and service delivery. The impact on healthcare and services to the patient is the nurses’ ability to create a friendly rapport with the patients. Yet, the majority in the rural Primary Health Care facilities are still facing many challenges in demonstrating patient-centeredness services to the community. Thus, the objective of this study is to explore and describe the factors influencing patient-centered care provision and nurses’ experience in Primary Health Care facilities. An exploratory qualitative approach with purposive sampling was used to gather data. Individual interviews with 35 nurses were conducted using a semi-structure interview guide question in the Primary Health Care settings in Nigeria. Each of the interviews with the nurses lasted for 25 minutes to one hour. All interviews were audio-taped, and transcribed verbatim using Microsoft Word. The transcripts were read and re-read, coded using NVivo version 12 software to organize the relevant information and categorized them into themes and sub-themes. Thematic analysis guided this study. The findings revealed three themes and sub-themes. The impact of environmental factors with two subthemes—suitable working environment and coordinated care; resources—shortage of staff and inadequate resources as sub-themes, and lastly, cultural sensitivity and religious influence—commu-nication. Poor implementation of PCC strategies in most of the PHC facilities could lead to poor patient care and a lack of staff, provide a conducive working environment, and opportunities for further training programs for nurses to enable and empower them with the necessary knowledge and skills. This, in turn, will translate into a range of outcomes that are socially valued, such as health responsiveness, health coverage and fairness.


Introduction
Patient-Centered Care (PCC) has shifted from uniform procedures and has instead, turned the focus towards collaboration and customization within the nursing community's new working method as they play a pivotal role in the provision of highquality health care in Primary Health Care (PHC) settings [1]. In PCC, there are several factors that have been identified as the key to satisfaction [2]. They are preference of patients, coordination of care, the physical comfort of patients, emotional support, family and friends, continuity and transition, information and education, and access to health care [2]. This is to ensure quality, effective, and safe healthcare service delivery in the rural PHC health system. This is why the focus of this study is to explore and describe the factors influencing PCC integration and nurses' experience as a way to improve the quality of healthcare services in the PHC health system.
The mental wellbeing and job satisfaction among nurses especially during this COVID-19 pandemic crisis have attracted great attention to their workload and related work stress [3]. In the Netherlands, for example, a recent study showed clearly that 80% of the nurses experienced increased work-related stress pressure due to care needs assessment [1]. While also other researchers such as [4] have found a link to job satisfaction and work-related stress. Job satisfaction is important in view of the relationship to job change serving as a buffer against the negative influences that arise in the workplaces such as stress [5]. The freeze in the employment of new nurses among low-and middle-income countries through the International Monetary Fund (IMF) policies of controlling government ballooning wages has shifted the ground. It has made it essential and vital to pay attention to job satisfaction among the nurses and other health caregivers. This is due to the increase in stress levels occasioned by an increase in workload as shifts increase due to a shortage of adequate staff.
Improvements in the dimensions of PCC previously mentioned are expected to result in improved partnership and collaboration. This will lead to the co-creation of care between care providers and care recipients in PHC services. The co-creation of care's ultimate objective is shared goals, shared knowledge, mutual respect, frequent, timely, and accurate problem-solving communication [6] [7]. PCC is a part-Besides the professional support which is a social support aspect, job satisfaction leans more towards the practical aspects such as salary, work pressure and job training for skill development [5] [13]. However, Labrague and McEnroe-Petitte, [14], in their study found evidence of better work stress coping among experienced nurses as compared to newly recruited nurses. This difference in findings is linked directly to the changes in the nursing sector by the re-assignment of responsibility for the needs assessment of the nurses [15].

Healthcare System Performance under PCC
There is a wide variation in health outcomes across the globe [16]. These variations are brought about by the health system performance. Health system performance differences are based on the design, content and management of the whole health system. This has translated to differences in a range of outcomes which are socially valued such as health responsiveness and fairness [17].
All levels of decision making in PHC should quantify variation in the healthcare system performance, thereby identifying the factors that influence it. This in return would be articulated in policy leading to the effective achievement of good results in a variety of PHC settings. There is a need for the performance of subcomponents of the health system such as regional divisions within a country or public health institutions to be strategically assessed. Comparable information on healthcare system performance can be explained using the scientific foundations of the health policy at the national level and the regional divisions of the entire health care system. [17] [18]. Healthcare system performance is often classified into two, namely: long inclusive lists of multiple layered approaches and secondly, overlapping lists of approaches.
The performance frameworks approach includes: health inequalities, equitable financing, quality, consumer satisfaction, allocative efficiency, technical efficiency, cost containment, political acceptability and financial sustainability among others [19]. Conversely, others would approach the performance of a health system from indicators available and construct or conduct a performance assessment and consistence and consistency as they fail to address the basic questions and purpose of a PHC system, for example what is a PHC system made for [19]?
In order to effectively measure the performance of a PHC health system effectively, the study of the factors that explain performance is very vital [20]. This can be done through the development of extensive lists of technical and institutional factors. Assessing performance and quality in healthcare delivery service is not a new concept, as it has been evidenced by the rapid growth of managed care today locally and globally [21]. Currently, there is a variety of definitions and perceptions on quality and performance. For instance, in the USA there is the National Committee on Quality Assurance (NCQA) that is tasked with monitoring the quality, safety, efficiency and effectiveness of PHC, and in Cambodia, the Organization Quality Assurance program (OQA) at the Angkor Hospital for Children (AHC) [22]. Such organizations define nationally derived measures and standards that are used to measure and assess the quality of health care [22].

Aim of the Study
The aim of the study was to explore and describe the factors influencing PCC provision in the PHC facilities and nurses' experience in Nigeria.

Methods
A qualitative exploratory research approach was employed to gain more understanding on the phenomenon of the study with a purposive sampling technique.
This study was conducted in the rural PHC setting in Osun State, Southwest, Nigeria. The PHC which is the grassroot of the healthcare system has registered nurses who run the clinic daily in the community and refer patients they cannot handle to general hospital which is the secondary level of the health system of the country.

Population and Sampling
The participants in this study were only registered nurses working in the rural PHC facilities, age ranges from 28 -59 years. The participants were randomly selected while PHC were purposively selected based on the availability of nurses and their ability to provide information regarding the phenomenon of interest in

Data Collection and Analysis
Data were collected using a semi-structured interview guide tool. A sample of registered nurses working in the rural PHC with a minimum of one year experience was recruited in the study using purposive sampling techniques. The researchers conducted one-on-one individual interviews with 35 participants to explore the experiences of professional nurses on PCC and factors that would mitigate or enable PCC provision at the PHC settings during the data collection phase.
Interviews were conducted in English languages since all the participants are English speaking individuals. Each interview lasted between 25minutes to-one hour and were audio-taped. Also, field notes were taken during data collection to capture non-verbal communication. Data saturation was reached with 35 professional nurses who participated in this study. All interviews were transcribed verbatim using Microsoft Word. The transcripts were read several times, and then the researcher began to code the relevant information. Coding was done by two individuals, which were later organized into similar codes to form themes and sub-themes. NVivo software application version 12 was used to organize the raw data into themes and sub-themes that emerged from the raw data. Thematic analysis of the data was performed in the study.

The Rigour of the Study
In qualitative studies, trustworthiness is the term used for validity and reliability [23]. The study was done by following all the ethical manner [24], the rigour of this study is achieved through credibility, dependability, confirmability and transferability.
Credibility: This is also known as internal validity of a study, aims at addressing the accuracy and the authenticity of the data collected and assesses the degree to which the researcher interpreted the data provided by the participants [23] [25]. It is achieved when there is confidence in the truth of the qualitative data collected and its interpretation [26]. This was ensured during analysis when the researcher compared codes that were extracted from the participants' raw data to form themes and sub-themes. Dependability: This focuses on the reliability of the process of the research data over time and over changing conditions [25] [26]. It is the extent to which data gathered in a study is dependable and consistent. This was achieved by ensuring that all the participants were all asked the same question using a semi structured interview guide tool. Confirmability: This refers to the transparency of the study [25]. The confirmability of this study was achieved by ensuring that the findings reported in this study emerged from the participants' information and not the author's imagination. Confirmability criterion was assessed through all data collected from the interviews being audiorecorded and transcribed verbatim. Transferability: Transferability according to Shenton [27], means that measures factored into the qualitative research ensure

Results
In this study, seven males and 28 females nurses participated with different age group which ranges between 28 -59 years. The findings of the study are presented in the form of themes and sub-themes that emerged from the raw data as influencing factors to PCC provision and nurses experience as outlined in Figure   1. The themes and sub-themes are briefly discussed with exemplifying extracts from the participants' narratives. Figure 2 shows the word clouds generated from the participants' reported data during analysis using NVivo 12 software application. Table 1 shows the characteristics of the participants.

Impact of Environmental Factors
These include the following two subthemes: suitable working environment and coordinated care.    1) Suitable working environment: Participants from this study reported dissatisfaction due to the working environment in the rural PHC. The nurses identified the poor working environment situation with the poor implementation of PCC. They revealed their discontentment with the way the government is handling the PHC healthcare system of the country especially the little attention given to it and the workers. It was, therefore, expressed that a suitable working environment will be a good influence on the nurses to effectively demonstrate PCC to patients. The extracts below are evidence: "The environment must be conducive to you before having the total attention of any patient. So the environment must be conducive to that kind of care [Participant 11]." "They should provide nurses a conducive working environment conducive to effective output. If you get to some health centres, even the chair the nurses sit on is bad, after leaving the work they will be having backache [Participant 3].

2) Co-ordinated care
It is imperative to understand that the co-ordination of care is a value in the healthcare delivery service as a positive factor. The nurses expressed that caring is a value in the profession and it should be well coordinated at every level of healthcare system and mentioned that coordinated care in the PHC setting is vital. It was stated that the appropriate healthcare needs of the community members are poorly coordinated due to poor organizational structure and policy. The followings were mentioned: lack of follow-up, inadequate qualified staff, role conflict among healthcare workers and poor welfare of the nurses. This makes it difficult for the nurses to deliver quality care services. This is reflected in the extracts below: "Somebody coming to work with too little pay, will have some frustration in her mind, the person may not approach the patient in the best way…Patient comes to you and you tell him. 'Go and sit down first, go and use the toilet.' Things like shouting at a patient who needed to be spoken to in a soft mannerbecause of what is happening to the nurse. So the service delivery has not been good, it has been very poor [Participant 1]." "The ages of the people who are working in PHC facilities is another challenge, in the bank you will see young people but in the nursing profession, especially here, you will see aged people in their fifties who are frustrated. They don't want to even work and will not want to be pushed into patient-oriented care [Participant 27]."

Resources
The theme resources have the following two subthemes: shortage of staff and inadequate resources 1) Shortage of staff Shortage of staff was reported by the nurses and was captured as a sub-theme. According to the participants, exhaustion resulting from the high workload does not allow them to provide PCC during healthcare and service delivery. The limited nurses in the PHC coupled with the unavailability of doctors with the increased flow of patients, affects the quality of service given to the community. The nurses expressed this as one of the barriers to the delivery high quality healthcare service. Therefore, it must be acknowledged that the recruitment of manpower could help to raise the standard of healthcare service in the PHC setting. The quotes below confirm this: "Manpower is another challenge…like in this health centre now we are used to seeing 100 clients per day. In such a case how can I give patient-centeredness if you really want to attend to everyone? [Participant 21]". "One of the major problems may be the staff shortage. Because of the shortage of the staff we cannot interact with them in their community [Participant 07]".
2) Inadequate resources Participants in this study reported inadequate resources such as intervention tools, medical equipment, transportation and poor maintenances of the few available ones. These resources were expressed as essential to effective nursing care, 228 Open Journal of Nursing patient diagnosis and treatment of disease in the rural PHC settings. All these were mentioned to have impacted negatively on effective PCC and healthcare service. The nurses further stated that for them to provide quality nursing care and utilize patient-centeredness, the government should provide adequately functioning equipment and put in place good structures that would strengthen utilization.
The following excerpts aptly support this: "There is a lot of constraint, a lot of compromises we have from the government, the right equipment to use in making sure that effective services are delivered to the right people who are in need of those services are not available…this is affecting a lot of our services that we can render [Participant 05]".
"If people's wellbeing is poorly attended to, we can't better it. So the government has to be more involved and do their part if we must really, really be effective, even though we accept the concept [Participant 01]." "…government that will provide all the instruments that we are going to use to make it effective. Let me give an example, like here now in this facility when we were including home visits into our practice here there are lots of constrain like lack of provision of vehicle to carry us to different destinations that we want to go and this lack of provision was a very big constraint because without a vehicle we cannot carry out home visiting effectively…so that is a big challenge [Participant 28]."

Cultural Sensitivity and Religious Influence
This theme has only one sub-theme of communication which emerged.

1) Communication
Communication was reported by the participants as another hurdle to effective PCC utilization during healthcare service delivery to the people in the PHC setting. The nurses revealed that not understanding the language of patients, their beliefs and the culture of the community where they serve sometimes impacted negatively on patient care and healthcare service. It was further observed during the interviews that some of the nurses felt discouraged and demoralized about it. This is reflected by the following statement: "The beliefs and some taboos around assessing the health care service too can be a challenge… [Participant 11]." "Well, I can say language barrier it will be a challenge, so nurses that will want to give client centered during healthcare should be able to understand the languages, then their beliefs, their background too [Participant 09]."

Discussions
PCC has significant evidence-based benefits that are associated with quality health outcomes [28]. Yet our study shows that many factors influences this quality outcomes such as work environment, resources available for the healthcare providers impacts on the effective operations of the PCC concept that lead to quality health outcomes for the people. Another factor to the optimization of PCC is co- The issue of coordinated care is highlighted in this study due to poor communication, poor information sharing, the poor organization of service and long waiting times for service, the frustration of older nurses, cultural influence, inadequate patient involvement in decision making, and poor interaction with patients and healthcare providers as their focus has been moved from the patient to the diseases, thus affecting the quality of patient care and healthcare delivery service. Similar to our findings is revealed in other countries studies: Agoritsas et al. [29]; Mirzaei, Aspin, Essue, Jeon, Dugdale, Usherwood et al. [30]; and Dwamena, Holmes-Rovner, Gaulden, Jorgenson, Sadigh, Sikorskii et al. [31]. However, the challenges are more in low and middle-income countries as governments and policymakers struggle with limited or no budget in the maintenance of PHC.
This may be also due to the issue of competing priorities, budget constraints and rapidly changing political grounds. A healthcare service with poor information, poor communication, and poor resources, funds, human resources, and direction would not function effectively. Onwujekwe [32] research findings which revealed that the health system is the sum of all the organizations, institutions, and resources to function together in order to advance healthcare. This includes service delivery, health policy, and implementation. Thus, coordinated care is a requisite to effective PCC provision in healthcare service. Another significant factor identified in the management of PHC is resources. It was reported that in the PHC facilities there were not enough transportations, equipment and other intervention tools for healthcare workers to perform their tasks such as: immunization outreach services been inadequately conducted due to transportation challenges especially to the rural areas. The maintenance culture of the existing vehicles is poor and PHC vehicles were used for other purposes other than health related activities. All these are threats to effective and efficient healthcare delivery in the PHC facilities. This is identical to the World Health Organization's (WHO) report on the problem of inadequate functioning equipment in low and middle-income countries health systems being at 50% -80% [33]. Even though PCC is seen as a helpful drive in the healthcare delivery system, a significant number of these factors identified from this study have affected the nurses from effective use of PCC. Hence, it is recommended that enough resources be provided in the PHC centres for improved healthcare and services.
In addition, the shortage of staff leading to work overload was reported in the study. Nurses are faced with many hurdles in the care of patients across the nation. The heavy load of patient cares especially during the pandemic crisis is mostly borne by the nurses, with ever-increasing responsibilities despite their limited in number without a supportive system and in poor working conditions. This could be a big hindrance to effective PCC healthcare services especially in Nigerian PHC system where there is an insufficient number of medical personnel as well as uneven distribution. The Third Development Plan (1975Plan ( to 1980 for Nigeria focused on the inequity in the distribution of medical facilities and manpower or personnel [34]. Despite the desire of the government to ensure a more equitable distri-  [35]. There has been too much concentration of medical personnel in the urban areas to the neglect of the rural PHC settings [36]. Therefore, it is recommended that more focus and budget should be given to the grass root healthcare system, this will improve the rural PHC and the health personnels working in the rural communities. In addition, enhance health promotion and prevention of various diseases in the nation and improve job satisfaction.

Conclusion
Nurses play a significant role in the PHC health sector. Most of the time, nurses are often the first contact for patients at the point of healthcare services to them. Despite the nurses' noble contribution to the community, nurses in the communities are disadvantaged compared to their counterparts in urban hospitals. This is because little attention is paid to the working conditions of these nurses in the rural PHC, which affects their service delivery in regards to PCC provision. There is a need to improve the work environment, this will motivate and influence the attitudes and behaviors of the healthcare providers in ensuring patient-centeredness care to patients.

Author Contributions
AL conceptualized the paper, wrote the manuscript and EMM supervised the research study, read and critically reviewed the manuscript. Both authors agreed on the final versions of the manuscript.