Two primary themes emerged regarding clients’ perceptions of nursing care services: (1) nurse–client communication, which highlighted disrespectful communication, lack of confidentiality, and lack of enthusiasm for serving clients; and (2) clients’ innovative suggestions to promote nursing care satisfaction, including customer care training and client involvement in decision-making (Table 2).
Theme 1: Nurse – client communication
Communication emerged as the primary theme from clients’ responses. This theme focused on clients’ satisfaction with the services provided by selected public health facilities in Namibia. Participants’ accounts suggest that communication is not merely an interpersonal skill, but a critical indicator of relational care, professional identity, and ethical practice. It stemmed from clients’ consistent expressions of disappointment regarding the conduct of nurses, characterised by disrespect, breaches of confidentiality, and apparent disengagement from caring responsibilities. These experiences point to a misalignment between the expected standards of professional nursing conduct and the realities encountered by clients in clinical settings. Within this theme, three key subthemes were identified: disrespectful communication, lack of client confidentiality, and lack of enthusiasm to serve.
Subtheme 1.1: Disrespectful communication: The care provided by the nurses did not meet the expectations of the clients, who reported negative behaviour. One issue that emerged from the clients’ responses was that nurses tended to shout. Participants recounted incidents where nurses belittled clients through verbal abuse and shouting, using derogatory terms such as ‘you’, ‘hey’, and ‘shut up’ during communication. From an interpretive perspective, such communication practices can be understood as forms of symbolic power that reinforce hierarchical relationships between nurses and clients. The use of authoritative or dismissive language positions the nurse as dominant and the client as subordinate, thereby undermining the principles of mutual respect and partnership central to contemporary nursing practice. This is particularly concerning in contexts where patients may already feel vulnerable due to illness or socio-economic circumstances:
‘mmmh, [angry tone], to say the least it is not what I expect from professional people. Using the word such as “hey you, shup up” and also referring to people as “you” instead of addressing me by my name is an insult.’ (PC7, 25-year-old, female)
‘I am not satisfied with nurses’ shouting and scolding of people in public. I was once addressed by my illness. Mostly the younger nurses are rude toward clients and they are ever on lunch …’ (PC1, 31-year-old, female)
‘Some nurses have persistent misbehaviour goes unpunished. This has potential to create an impression that those who joining nursing will follow those with bad behaviours. Nurses sometimes gossip about their clients’ sickness with unauthorised persons … leaking of this information often come from those closer or related to those nurses.’ (PC13, 35-year-old, female)
Subtheme 1.2: Lack of client confidentiality: Confidentiality of clients’ information was a recurring concern raised by participants. Confidentiality is a core ethical principle in nursing practice, essential for maintaining trust and safeguarding clients’ dignity. When this principle is violated, it not only harms individual clients but also erodes confidence in the healthcare system more broadly. Many clients expressed the belief that health complaints and diagnoses shared with a nurse should remain private between the nurse and the client. However, several participants reported instances where nurses disclosed confidential health information to other individuals. The reported disclosure of sensitive information to unauthorised individuals suggests gaps in ethical awareness, professional accountability, or both:
‘I don’t trust some nurses, especially those who are alcoholic [angry tone] once drunk they share clients’ illness with their friends.’ (PC5, 33-year-old, female)
‘Nurses sometimes gossip about their clients’ sickness [illnesses] with unauthorised persons … leaking of this information often comes from those closer or related to those nurses.’ (PC3, 35-year-old, male)
‘I was really shocked to hear that some nurses reveal client’s health information in public. As we were seated the nurse announced that patients [clients] who came for family planning injection must return into two days as there is no stock. Those who came for those particular services appeared embarrassed.’ (PC4, 51-year-old, female)
Subtheme 1.3: Lack of enthusiasm to serve: The study’s findings indicate that clients held a negative perception of the enthusiasm shown by nurses. Many participants noted that several nurses seemed uninterested and neglected their needs, while others felt they had to plead or beg for assistance. This perceived disinterest was not expressed as isolated incidents but rather as a recurring pattern across multiple accounts:
‘I believe some nurses pretend to be busy and purposefully ignore to entertain a client request. These are people who lack commitment to serve others.’ (PC2, 46-year-old, female)
In addition to perceived avoidance, participants highlighted the absence of warmth and approachability in nurse–client interactions. Descriptions such as ‘unapproachable’ and the absence of a ‘warm smile’ were used to convey emotional distance, making it difficult for clients to initiate communication or feel at ease in the care environment. For some, this lack of friendliness created a barrier to expressing concerns or seeking clarification:
‘Uuuh, [pausing] Many nurses, unfortunately, do not always provide a fulfilling service to their patients. Often, they come across as unapproachable and rarely offer a warm smile to those under their care. This lack of warmth and friendliness can make it challenging for patients to feel comfortable opening up to them.’ (PC1, 31-year-old, female)
Participants also described situations in which obtaining assistance required repeated requests, escalating to emotional distress. The need to ‘beg’, ‘ask over and over’, or even cry before receiving attention was reported as particularly distressing. These accounts reflect experiences where care was perceived as delayed until clients reached a point of visible desperation:
‘It is heartbreaking because you find yourself literally begging for basic help. You have to ask over and over, sometimes even crying, just to get a nurse to listen to you. It feels like you are a burden to them, and they only come to your bed when they see you have run out of options and are pleading for their mercy.’ (PC8, 36-year-old, female)
Ultimately, these findings suggest that the breakdown in communication is not merely a lack of information exchange but is deeply rooted in a perceived erosion of professional conduct and a lack of interpersonal empathy, which significantly diminishes the client’s sense of dignity within the clinical space.
Theme 2: Clients’ innovative suggestions to promote client satisfaction
The second theme that emerged from client interviews focused on their recommendations for improving their experiences in public health facilities. Participants not only recounted negative experiences but also articulated specific, and at times detailed, proposals for enhancing nursing care. These suggestions were often framed in direct relation to their prior encounters with nurses, highlighting areas where participants felt improvements were necessary to foster more satisfactory interactions.
Across the interviews, clients demonstrated an awareness of both interpersonal and procedural aspects of care. Their recommendations focused on strengthening relational engagement, improving communication practices, and creating opportunities for more inclusive participation in care processes. Two subthemes that were identified include providing customer care training and involving clients in the decision-making process.
Subtheme 2.1: Customer care training: While maintaining emotional control is considered essential for effective customer care, participants expressed concerns about the quality of customer care provided by nurses. Their accounts indicate that client satisfaction was closely associated with how nurses managed interpersonal interactions, particularly in emotionally charged or vulnerable situations. Concerns were raised about nurses’ ability to regulate their emotions, communicate respectfully, and maintain a professional demeanour during client encounters.
Some participants described experiences in which perceived deficiencies in customer care resulted in interactions that felt dismissive or belittling. These experiences were linked to difficulties in establishing open communication, as clients reported feeling discouraged from sharing information or engaging fully in their care:
‘I am not impressed at all. I expect nurses to be the most understanding people but [a] lack of customer service [skills allow] some nurses to belittle people and inhibits clients from opening up with nurses during their care … I recommend customer care training.’ (PC4, 51-year-old, male)
To address these issues, they recommended that nurses attend courses on customer care to enhance client satisfaction with nursing care services. Some participants suggested that nurses be capacitated to control their emotions, an attribute important in dealing with difficult clients.
‘I think some nurses need anger management courses and or customer care training. Many times nurses lose their temper too easily.’ (PC11, 32-year-old, female)
Participants also referred to a perceived inconsistency between expected professional conduct and observed behaviours. References to the ‘professional oath’ suggest that clients hold clear expectations regarding the ethical and interpersonal standards of nursing practice. Within this context, customer care training was described as a way to reinforce respectful and compassionate engagement:
‘Unfortunately, many nurses exhibit behaviours that conflict with their professional oath. There is a clear need for intensive customer care training to ensure patients are treated with consistent respect and compassion …’ (PC1, 31-year-old, female)
Subtheme 2.2: Clients’ involvement in decision-making: Participants also expressed a desire for greater involvement in decisions related to their care. Their accounts suggest that current interactions may not consistently provide opportunities for clients to ask questions, share their perspectives, or seek clarification before decisions are made. This was described as limiting their understanding of care processes and reducing their sense of participation.
Several participants highlighted the importance of being invited into conversations about their care, particularly through open dialogue and the opportunity to ask questions. Encouraging such engagement was viewed as a way to enhance clarity and mutual understanding:
‘Nurses should encourage clients to share their views or even ask questions regarding their care. This will mean clients can get issues clarified before a decision is made regarding their care.’ (PC5, 33-year-old, female)
Participants emphasised the importance of being listened to. Being heard and having one’s views considered were described as key elements of meaningful involvement in care processes:
‘I suggest it is important for nurses to be good listeners and consider clients’ views in their care.’ (PC9, 28-year-old, male)
Across these accounts, participation in decision-making was described in terms of dialogue, listening, and mutual exchange. These suggestions reveal a shift in client expectations, in which individuals no longer view themselves as passive recipients of care but as active stakeholders seeking a collaborative and ‘customer-centric’ healthcare experience that prioritises respect and shared agency.