Kano Model-Based Analysis of Medical and Nursing Service Needs of Fracture Patients and Their Families

Introduction

With the accelerating global population aging, fractures resulting from conditions such as osteoporosis and traffic accidents have emerged as a major public health challenge.¹ It is estimated that by 2050, individuals aged 65 and above will comprise approximately one-sixth of the global population. Concurrently, the incidence of fractures, especially in elderly individuals, will rise substantially.^2,3 With the advancement of minimally invasive and precision-oriented approaches, clinical practice paradigms has shifted from single surgical interventions to integrated, full-cycle health management spanning acute care, rehabilitation, and long-term prevention.⁴ Meanwhile, patient expectations for healthcare services continue to rise, with higher demands for psychosocial support, pain management, and functional recovery.⁵

In this context, patient satisfaction not only serves as a core indicator for evaluating healthcare quality, but also constitutes a critical driver for continuous service improvement.⁶ However, the rehabilitation process of fracture patients involves physiological, psychological, and social dimensions, leading to complex and dynamic needs.⁷ Traditional satisfaction assessments are mostly based on one-dimensional linear models, which can only evaluate the performance of existing services, cannot identify patients’ unspoken potential needs, and cannot distinguish the asymmetric effects of different types of needs on satisfaction. Therefore, establishing a systematic method to identify, classify, and prioritize patient needs is essential for achieving patient-centered precision care.

The Kano model, proposed by Professor Noriaki Kano in 1984 based on the “Dual-Factor Theory”, is a “two-dimensional cognition theory”.⁸ Compared with traditional linear satisfaction models, the Kano model can better identify latent needs and reveal the nonlinear and asymmetric relationship between service provision and satisfaction changes.^9,10 In recent years, its application to healthcare quality management, nursing service optimization, patient experience improvement, and health policy design has gradually expanded.^11,12 It helps medical institutions accurately grasp patients’ internal expectations of nursing quality and provides a theoretical and practical basis for improving service precision and patient satisfaction.^11,13

However, the application of the Kano model in orthopedic care still has limitations. Most existing studies only focus on the needs of patients themselves, ignoring family members as important participants in the whole process of care.¹⁴ Additionally, most studies are limited to specific cultural or medical system backgrounds, and the universality of the conclusions needs to be further verified. At present, few studies have systematically analyzed the differences between patients and family members in the needs of medical and nursing services for fractures, and few have combined the Better–Worse coefficient to clarify the priority of service improvement.^15,16

To fill the above research gaps, this study adopted the Kano model to systematically explore the need structure of fracture patients and their families regarding medical and nursing services, identify key service attributes, and determine the priority of service improvement. The findings are expected to provide empirical evidence for establishing a needs-driven, resource-optimized orthopedic medical and nursing service system, so as to comprehensively improve patient satisfaction and clinical outcomes.

Materials and Methods

Study Design

A cross-sectional study was conducted and reported in accordance with the STROBE guidelines.¹⁷ All participants signed informed consent after fully understanding the purpose, process, and rights of the study. Participation was entirely voluntary, with the freedom to withdraw at any time. The study was approved by the Ethics Committee of The First Affiliated Hospital of Chengdu Medical College in October 2024, in line with the Declaration of Helsinki.

Subjects

A convenience sampling method was employed to recruit orthopedic inpatients and their family members from our hospital between January and October 2025. The inclusion criteria for patients were as follows: (1) met diagnostic criteria for orthopedic trauma with stable condition; (2) aged ≥18 years; (3) competent comprehension and communication; and (4) signed informed consent. Family members were required to meet criteria (2) to (4), with the additional requirement of having provided care for at least 3 consecutive days. Individuals not meeting the above criteria or those with diagnosed psychiatric disorders were excluded.

The sample size was estimated based on Kendall’s¹⁸ guideline for descriptive studies: N = n×(5~10) × (1 + 10%), where “N” represents the required sample size, and “n” represents the number of questionnaire items. This study involved 32 items. Consequently, the minimum sample size was calculated as N = (32 × 5) × (1 + 10%) = 176. Ultimately, a total of 300 participants were recruited.

Questionnaire Design

The questionnaire was developed through literature analysis, open-ended interviews, expert consultation, and pre-investigation,^19,20 which consisted of two parts. The first part collected demographic information, including gender, age, education level, occupation, and income. The second part was a self-developed Kano model questionnaire for medical and nursing service quality. These identified needs were then translated into specific medical service measures, which were categorized into four dimensions: environmental facilities, humanistic care, professional medical skills, and health education. Finally, a structured questionnaire based on the Kano model was developed, and containing a total of 25 items.

Survey Method

Prior to the formal survey, a pilot test was conducted with 50 eligible hospitalized patients randomly. The questionnaire demonstrated acceptable reliability and validity, with a Cronbach’s α coefficient of 0.73 and a content validity index of 0.85. During the formal survey, trained nurses from our research team distributed the questionnaires. Participation was voluntary, following the provision of informed consent by patients and family members. For elderly or low-education participants, the questionnaire was administered orally by the research staff, who then recorded the responses. A total of 300 questionnaires were distributed, and all were effectively retrieved and deemed valid for analysis.

Data Processing

Attribute Definition

For each quality item, the questionnaire included positive and negative statements, with 5-level Likert responses (1=dissatisfied to 5=satisfied) (Table 1). Concurrently, the frequency of responses for each demand was calculated and the maximum frequency method was used to classify items into: Must-be attributes (M), One-dimensional attributes (O, Expectation attributes), Attractive attributes (A), Indifferent attributes (I), Reverse attributes (R), and Questionable results (Q)^13,21 (Table 2). According to Kano model theory, the priority order of these demand categories is M > R > O > A > I.

Table 1 Questionnaire Question Types of Kano Model

Table 2 Attribute Classification of Kano Model

Quality Attribute Evaluation

The impact of each quality attribute was assessed using Better-Worse coefficient analysis, which were calculated as follows: Better = (A + O)/(A + O + M + I), and Worse = (−1) × (O + M)/(A + O + M + I). A Better coefficient closer to 1, indicates that the item has a greater positive impact on patient satisfaction. The absolute value of the Worse coefficient closer to 1, indicates a greater negative impact on patient satisfaction upon non-fulfillment.^22,23 Furthermore, the nursing quality strategy quadrant diagram was constructed based on the Better-Worse coefficients (Figure 1).

Figure 1 The Kano model. (A) Correlation diagram of various attributes in the Kano model; (B) Kano model quadrant diagram.

Statistical Analysis

Two researchers independently entered and validated the questionnaire data using Epidata version 3.1.The data were then imported into Excel, where demographic characteristics were summarized using descriptive statistics. Intergroup comparisons were performed using the Chi-square test in R software. P<0.05 was considered statistically significant.

Results

Demographic Information

A total of 300 individuals were surveyed in this study, comprising 172 patients and 128 family members. The average age was (40.36 ± 24.07) years. Among the participants, 41.33% had bachelor’s degree or above, 28.67% were farmers, 74.00% were married, 59.67% had basic medical insurance. Further analysis revealed that, except for age, no significant differences were found in other attributes between patients and family members (Table 3).

Table 3 Demographic Characteristics of Patients and Their Families (n=300)

Overall Demand Attributes Analysis

The quality attributes for each demand item were determined using the “Maximum Frequency Method” to define their classifications. The patient demand analysis revealed 5 Must-be (M) attributes, 5 One-dimensional (O) attributes, 6 Attractive (A) attributes, and 3 Reverse (R) attributes. The combined proportion of (A+O+M) attributes accounted for 64.00% (Tables 4, 5).

Table 4 Quality Attribute and Better-Worse Coefficient of Each Project

The service indicator with the highest satisfaction rate was “Dietary guidance” (75.24%), while the lowest was “Privacy protection” (18.08%). The service indicator with the highest importance rating was “Health education materials provision” (76.07%), and the lowest was “Health knowledge platform provision” (2.56%) (Table 4).

Better-Worse Analysis

The threshold was determined based on 50% of the maximum values of Better% (37.62%) and Worse (%) (38.04%), and the quartile diagram for the quality of medical care services was established. Advantageous area (Quadrant I) has 14 items (56.00%), including item 1, 2, 5, 6, 8, 9, 12, 13, 16, 17, 18, 19, 21, and 23 (Figure 2, red). Improvement area (Quadrant II) has 7 items (28.00%), including item 4, 10, 11, 15, 20, 24, and 25 (Figure 2, orange). And 4 items (16.00%) falls into the reserved area (Quadrant IV), including item 3, 7, 14, and 22 (Figure 2, blue).

Figure 2 Better-Worse quartile diagram for all the Participants.

Comparison Between Patients and Family Members

Comparative analysis of the demands of patients and family members revealed that patient demands were primarily Attractive (A) attributes (48.00%), mainly manifested as the need for “Health education”. In contrast, family member demands were predominantly Indifferent (I) attributes (44.00%), reflected in a lack of concern for “Humanistic care”.

While, in the Better-Worse quadrant diagram, notable differences were observed between patients and family members regarding Expectation attributes (Quadrant I, Figure 3, red) and Must-be attributes (Quadrant IV, Figure 3, blue). Regarding Expectation attributes, both groups focused on areas such as professional support and health education. However, several attributes identified as Must-be for patients (items 1, 2, 12, 18, 22) were classified as Expectation attributes for family members. Furthermore, there was no significant difference in the demand for Attractive attributes (Quadrant II, Figure 3) between the two groups.

Figure 3 Better-Worse quartile diagram of patients and their families. (A) family Better-Worse quartile diagram of patient; (B) Better-Worse quartile diagram of family member.

Comparison Among Age Groups

Analysis of demands across different age groups of patients and family members indicated that, all age groups possessed relatively high levels of Expectation attributes, but their specific demands varied. Beyond the common need for professional support and health education, individuals under 45 years old expressed expectations regarding environmental facilities and humanistic care (Figure 4A). In contrast, those who aged 45–65 and over 65 showed relatively lower demand for environmental facilities (Figure 4B and C, red). Additionally, concerning Must-be attributes, individuals aged 45–65 had greater expectations for health education (Figure 4B, blue).

Figure 4 Better-Worse quartile diagram for each age group. (A) < 45 years old; (B) 45–65 years old; (C) ≥ 65 years old.

Discussion

Fracture patients often have limited mobility, severe pain, long hospital stays, and slow recovery. High-quality nursing services can relieve physical and psychological distress and promote functional recovery.^24,25 The Kano model provides a scientific tool for precise demand classification and service optimization.^7,26,27 In terms of service importance, promotional materials, privacy protection, and nursing respect ranked as the top three, suggesting a need to further strengthen humanistic care for patients and their families, as well as to improve the timeliness of medical and nursing services. In practice, our department used the WeChat Official Account to promote personalized health education, which significantly improved patient satisfaction with the aforementioned services, supporting the findings of this study.

Must-be attributes represent the fundamental medical and nursing services that patients consider essential for a department. For such items, patient satisfaction is relatively low, yet their perceived importance remains high.¹¹ Our results showed that, the Must-be attributes primarily include privacy protection, timely assistance, and essential health education. Meanwhile, we found that privacy protection had the lowest satisfaction rate (18.08%). The possible reason lies in the fact that patients perceive such basic services more intuitively and hold higher expectations for them. Therefore, improving Must-be attributes should be prioritized. By refining service details, we can enhance patient satisfaction while transforming these attributes into the department’s competitive advantages. Furthermore, as most orthopedic patients have limited self-care abilities and strongly desire assistance from doctors or nurses, evaluating satisfaction and importance indices can help determine the sequence for reforms. The results indicated that the satisfaction and importance indices for timely nursing assistance were 36.96% and 59.78%, respectively, which indicating that fulfilling this service need can substantially increase patient satisfaction.¹⁴

Attractive attributes reflect the distinctive characteristics of a department and are key indicators affecting patient satisfaction with medical services.¹⁴ A positive patient experience and perception of these nursing services can significantly enhance their trust and loyalty to the department.^28,29 Taking hip fracture patients as an example, the effective period for hospital rehabilitation intervention is about one year. Developing rehabilitation plans (such as exercise therapy, physical agents, and occupational therapy) can effectively promote functional recovery. This study revealed that the Worse indices for rehabilitation exercise guidance and knowledge platform provision were 20.65% and 2.56%, respectively, suggesting a particularly urgent demand from patients for these services. Addressing these needs can elevate the department’s attractive attributes. Surprisingly, “Quietness of wards” and “Medical staff patrol observation” were identified as reverse (R) attributes, a finding contrary to clinical reality. This discrepancy may be attributable to the selection of study participants.

The Better-Worse quartile categorizes service items into four quadrants: the Advantage Area (Quadrant I), the Improvement Area (Quadrant II), the Secondary Improvement Area (Quadrant III), and the Reserved Area (Quadrant IV), and different strategies should be applied to factors in different quadrants.²⁹ The survey results indicated that the Improvement and Advantage Area contains 7 and 14 items, respectively. First, priority attention should be given to items in the Improvement Area. These represent service elements that patients value highly but for which satisfaction was relatively low, representing major bottlenecks constraining the quality of care for fracture patients. For instance, patients expressed the need to understand doctors’ working dynamics and obtain timely illness information. While, elderly patients and those with lower education levels particularly desire detailed guidance on inpatient examinations and easily understandable rehabilitation exercise methods. These issues adequately indicated that the current level of attention paid by healthcare professionals to patient rights and interests remains insufficient. Hospitals should formulate targeted improvement measures to enhance medical service quality. Second, for service items located in the Advantage Area, such as nursing explanations, operational technology, assistance with examination, discharge procedures, and rehabilitation exercise guidance, their high levels of both satisfaction and importance represented a core competitive advantage for the hospital’s medical and nursing services. While maintaining current service standards, continuous exploration of optimization pathways should be pursued to achieve further enhancement.

The full implementation of the “family-centered” care model has extended the scope of healthcare services from individual patients to include their families, maximizing the positive role of family support throughout the disease management process. In previous satisfaction surveys, patients and family members were often treated as a unified whole.^30,31 However, due to their different roles, their expectations for medical and nursing services also vary. Our results revealed that certain Must-be attributes for patients were considered expectation attributes by family members. This discrepancy indicated that patients hold significantly higher expectations for medical and nursing services compared to their families and demonstrated a stronger emphasis on disease prognosis and outcomes. As a critical communication bridge between patients and medical staff, the role of family members in decision-making has shifted from partial participation to primary dominance.³² Therefore, clinical practice should adopt a family-centered model while prioritizing patients’ own needs.

Patients at different life stages exhibit distinct needs for medical and nursing services.³³ The findings of this study showed that respondents under 45 years old consider both environmental facilities and humanistic care as Must-be attributes, thus holding higher requirements for the quality of medical and nursing services. Though patients aged 45–65 and above 65 years shared similar expectation attributes, those aged 65 and above demonstrate a more pronounced need for humanistic care and health education. Evidently, demand attributes dynamically shift across different age groups. In response to this characteristic, hospitals should tailor treatment plans and develop personalized, precise medical and nursing services based on the specific needs of different age groups, thereby ensuring a precise match between service provision and patient needs.

This study has certain limitations. First, the convenience sampling and the single-center design, which may limit the generalizability of our findings. Future research should consider multi center collaboration with larger and more diverse samples, and use probability sampling methods to improve representativeness. Second, patient attitudes and demands towards medical services can change over time. The Kano model cannot reflect the dynamic nature of patient needs. Subsequent periodic communication and assessment are required to adjust nursing interventions timely, ensuring alignment with patients’ evolving demands. Third, this study did not differentiate among patients with different fracture types. Experiences such as pain levels and hospital stays vary significantly depending on the nature of the fracture, which may correspondingly influence their service requirements.

Conclusion

In conclusion, this study utilized the Kano model for demand management, taking the satisfaction of fracture patients and their families as the starting point. It innovatively identified the service demands of different population segments and clarified the quality attributes of various medical and nursing services. Clinical practice should prioritize Must-be attributes and Improvement Area services, fully consider the dual needs of patients and family members, and provide personalized precision care based on age differences. These strategies can effectively improve medical quality, patient satisfaction, and rehabilitation outcomes, and support the construction of high-quality orthopedic service systems.