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The SARS-CoV-2 pandemic impacted access to inpatient rehabilitation services. At the current state of research, it is unclear to what extent the adaptation of rehabilitation services to infection-protective standards affected patient-centered care in Germany.
The aim of this study was to determine the most relevant aspects of patient-centered care for patients in inpatient rehabilitation clinics under early phase pandemic conditions.
A deductive-inductive framework analysis of online patient reports posted on a leading German hospital rating website, Klinikbewertungen (Clinic Reviews), was performed. This website is a third-party, patient-centered commercial platform that operates independently of governmental entities. Following a theoretical sampling approach, online reports of rehabilitation stays in two federal states of Germany (Brandenburg and Saarland) uploaded between March 2020 and September 2021 were included. Independent of medical specialty groups, all reports were included. Keywords addressing framework domains were analyzed descriptively.
In total, 649 online reports reflecting inpatient rehabilitation services of 31 clinics (Brandenburg, n=23; Saarland, n=8) were analyzed. Keywords addressing the care environment were most frequently reported (59.9%), followed by staff prerequisites (33.0%), patient-centered processes (4.5%), and expected outcomes (2.6%). Qualitative in-depth analysis revealed SARS-CoV-2–related reports to be associated with domains of patient-centered processes and staff prerequisites. Discontinuous communication of infection protection standards was perceived to threaten patient autonomy. This was amplified by a tangible gratification crisis of medical staff. Established and emotional supportive relationships to clinicians and peer groups offered the potential to mitigate the adverse effects of infection protection standards.
Patients predominantly reported feedback associated with the care environment. SARS-CoV-2–related reports were strongly affected by increased staff workloads as well as patient-centered processes addressing discontinuous communication and organizationally demanding implementation of infection protection standards, which were perceived to threaten patient autonomy. Peer relationships formed during inpatient rehabilitation had the potential to mitigate these mechanisms.
In modern health systems, the relevance of patient-centered care (PCC) continues to progress as it is associated with improved patient satisfaction, self-management, and perceived quality of care [
In Germany, approximately 85% of medical rehabilitation services are provided in inpatient care settings [
Due to a historically grown separation of acute care and medical rehabilitation, the German system faces declining trends of rehabilitation claims as patients are self-responsible to initiate application processes to IRS and intersection communication among health care sectors is fragmented [
Looking at other inpatient care settings, Andersson et al [
Considering limited or delayed admission to IRS, changed process parameters, reduced availability of services, and nontransparent longitudinal leadership structures, it is unclear to what extent these adaptations affected PCC during rehabilitation in Germany. Moreover, an appropriate inclusion of patient perspectives is currently pending. Thus, the particular interest of this study was to evaluate which aspects of PCC were important for IRS recipients during the early phase of the SARS-CoV-2 pandemic in Germany. In that regard, the following research question motivated this study:
Which aspects of PCC are relevant for patients in inpatient rehabilitation clinics and how do they evaluate these aspects to be achieved under conditions of the SARS-CoV-2 pandemic?
By identifying SARS-CoV-2–related aspects affecting PCC in inpatient rehabilitation, the research team aimed at informing rehabilitation clinics to not only become resilient health care organizations but also to meet patient needs in highly demanding and exceptional circumstances of the future. Despite stating palpable organizational interests, this ambition also reflects a moral attitude being of central relevance to any health care organization.
In this qualitative analysis, a deductive-inductive framework approach was used. The applied framework was developed by Liu et al [
Theoretical framework introduced by Liu et al [
The sample of online posted patient reports was guided by a theoretical selection process. Reports on hospital stays posted on the most commonly used German hospital rating website Klinikbewertungen (Clinic Reviews) [
Given that this was an exploratory study, patient reports were included regardless of their medical indications. To contrast results, reports of IRS were included if referred rehabilitation clinics were located in the federal states of Brandenburg and Saarland, as these states demonstrated the highest and lowest decrease of applications for IRS provided by the Federal German Pension Fund, respectively (Saarland=58.3%, Brandenburg=23.9%) [
In this study, open-access online patient reports were used. Therefore, no ethical approval was required. However, we carefully anonymized all cited reports in the manuscript to avoid a linkage of patients’ user names of the hospital rating websites with referenced citations.
Data on patient reports were extracted using a web-scraping technique based on the computing package “Rvest” of the R Project for Statistical Computing [
The total and relative numbers of included rehabilitation clinics and their representing specialties were calculated. Keywords representing domains and categories of the applied framework were analyzed descriptively by reporting absolute and relative frequencies. Additionally, geographic differences in keyword distributions between the included federal states of Brandenburg and Saarland were tested by the
A deductive-inductive framework analysis was performed. Two researchers (LK and LL) independently pilot-coded patient reports of two rehabilitation clinics (n=72 online reports), which were randomly selected. After discussing discrepancies and achieving consensus, one researcher (LK) coded the pending data. The coding tree comprised 4 domains, 8 categories, and 25 subcategories of PCC reflecting the introduced framework of Liu et al [
Anchor quotes representing key findings of the qualitative analysis were preselected and translated into the English language by one researcher (LK). The selection and translation were cross-validated for representativeness and consistency by a second researcher (AC). Data management was provided by using MAXQDA. Data reporting was guided by the COREQ (consolidated criteria for reporting qualitative research) checklist [
In total, 43 rehabilitation clinics are located in the federal states of Brandenburg and Saarland, 31 of which are listed on the investigated hospital rating website. Within clinics, 11 medical specialty groups are settled with orthopedic (n=14, 23%), internal medicine (n=17, 28%), and psychiatric/psychosomatic (n=13, 22%) facilities, representing the most frequent specialty groups. During the targeted time period, a sample of 659 posted patient reports was identified. As 10 reports were recognizably related to rehabilitation stays prior to the SARS-CoV-2 pandemic, the final included sample size was 649 reports. State-specific sample characteristics are summarized in
Among the total of 15,125 keywords across federal states and medical specialty groups, keywords relating to food (n=3160, 20.89%) and room amenities (n=2721, 17.99%) were predominantly reported. This was followed by keywords associated with medical and administrative specialty groups, with therapeutic professions being the most commonly cited, including therapists (n=2513, 16.61%), staff (n=1915, 12.66%), physicians (n=1402, 9.27%), and nurses (n=820, 5.42%). Keywords relating to outcome expectancies and information provision were numerically the least represented categories (improvement: n=67, 0.44%; communication: n=66, 0.44%; information: n=30, 0.20%). The cumulative distribution of included keywords is additionally illustrated in
Comparing the average word count per online report, no significant differences across states were identified (Brandenburg, n=140.1 words; Saarland, n=148.3 words;
Sample characteristics of online patient reports.
Characteristics | Brandenburg | Saarland | Total |
Rehabilitation clinics, n (%) | 27 (64) | 15 (36) | 42 (100) |
Rehabilitation clinics listed online in the rating portal, n (%) | 23 (74) | 8 (26) | 31 (100) |
Represented specialty groups, n (%) | 11 (100) | 8 (73) | 11 (100) |
Patient reports, n (range) | 478 (2-85) | 181 (8-64) | 659 (2-85) |
Frequencies of keywords addressing PCC domains. PCC: patient-centered care.
Differences of keyword frequencies across two federal states in Germany.
Patient-centered care domain | Brandenburg (n=11,234), n (%) | Saarland (n=3891), n (%) | Total (n=15,125), n (%) | ||||||
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Competence | 121 (1.1) | 43 (1.1) | 164 (1.1) | .88 | ||||
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Therapists | 1757 (15.6) | 756 (19.4) | 2513 (16.6) | <.001 | ||||
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Nurses | 751 (6.7) | 69 (1.8) | 820 (5.4) | <.001 | ||||
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Physicians | 1074 (9.6) | 328 (8.4) | 1402 (9.3) | .03 | ||||
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Respect | 26 (0.2) | 10 (0.3) | 36 (0.2) | .78 | ||||
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Family | 78 (0.7) | 23 (0.6) | 101 (0.7) | .50 | ||||
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Feeling | 234 (2.1) | 98 (2.6) | 332 (2.2) | .11 | ||||
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Needs | 100 (0.9) | 39 (1.0) | 139 (0.9) | .53 | ||||
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Communication | 48 (0.4) | 18 (0.5) | 66 (0.4) | .77 | ||||
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Information | 18 (0.2) | 12 (0.3) | 30 (0.19) | .07 | ||||
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Food | 2292 (20.4) | 868 (22.3) | 3160 (20.9) | .01 | ||||
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Room | 1881 (16.7) | 840 (21.6) | 2721 (18.0) | <.001 | ||||
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Environment | 527 (4.7) | 101 (2.6) | 628 (4.2) | <.001 | ||||
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Leisure time | 188 (1.7) | 60 (1.5) | 248 (1.6) | .58 | ||||
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Staff | 1498 (13.3) | 417 (10.7) | 1915 (12.7) | .001 | ||||
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Clinic management | 101 (0.9) | 40 (1.0) | 141 (0.9) | .47 | ||||
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Atmosphere | 126 (1.1) | 37 (1.0) | 163 (1.1) | .37 | ||||
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Facility equipment | 126 (1.1) | 41 (1.1) | 167 (1.1) | .72 | ||||
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Success | 242 (2.2) | 67 (1.7) | 309 (2.0) | .10 | ||||
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Improvement | 45 (0.4) | 22 (0.6) | 67 (0.4) | .18 |
The following sections provide a qualitative in depth-analysis of online composed patient reports guided by the domains of the introduced PCC framework.
Within this domain, attributes of the patient-centered professional emerged to be of major significance for patients utilizing the referred hospital rating website. As a main result, patients felt a decreased sensitivity and a lack of empathy in interpersonal interactions between themselves and the medical staff. They perceived some physicians and therapists to exploit the naturally prevalent hierarchy among them and interpreted this patronizing human interaction as an expression of an imminent gratification crisis.
If you complain, they shoot back immediately and you have to shut up and pull yourself together […]. I have also noticed that some doctors and therapists think that patients are inferior and are here to be re-educated. In general, it seems to me that everyone has lost the desire to do their job. [...] Of course: there are exceptions
Among reports, a discontinuous communication of curfew legislation supported a perceived sense of disempowerment. This was further endorsed by hygiene rules, which were rated to be arbitrary as they noticeably differed across rehabilitation clinics and impacted the perceived autonomy of a relevant number of patients. Complaints addressing a decrease of autonomy were particularly prevalent in psychiatric facilities. However, a majority of patients rated existing hygiene rules to be appropriate.
In general, a prison character arises from the incapacitating, uncomprehending habitus of some therapists. Those to whom self-determination is an important value will not be happy here.
Referring to care continuity, intersectoral care was not always maintained. Patients criticized a lack of involvement of their family physician or their psychologist in charge. Apparently, this was reflected by the fact that diagnostic reports and treatment plans of ambulatory care were frequently not taken into account during IRS. Conversely, results of IRS were not transferred to the ambulatory health care practitioner. Moreover, patients reported to have limited access to structured ambulatory follow-up rehabilitation programs as responsible social workers were hard to reach. Despite stated constraints, established clinician-patient relationships had the potential to mitigate adverse effects of the pandemic on IRS as patients valued empathetic, personal contact.
I was in [rehabilitation clinic] for four weeks for rehab of my cervical spine and diabetes. Even the 12-hour quarantine (it was Corona time) flew by, as even during that time everyone from the kind staff and nurses cared about my well-being.
Availability of therapeutic and nursing care was mainly attributed to the care environment. Patients reported having limited access to therapeutic and nursing procedures. In some cases, this limited availability of care led to a termination of the inpatient rehabilitation stay.
In 3 months I was showered three times. When I asked for a shower as an incomplete paraplegic, I was told maybe tomorrow due to sparse staff availability. Sorry, but what? […] Even after talking to doctors, nothing has really changed. All in all, I have mixed feelings and it is very important not to blame everything on Corona.
Despite availability issues, it became apparent that hygiene legislations were more likely to be accepted if they were easily integrated into organizational routines. This was also seen as having the advantage to create a more familiar environment as, for instance, therapeutic care groups decreased in size. One factor not directly attributable to the pandemic was the available food, which was perceived to be inconsistent with nutrition education events offered during rehabilitation.
Due to the Corona pandemic, procedures were changed which wasn’t only bad: For instance, I perceived the cutting of the reference group actually very pleasant and more personal. I perceived the sessions to be more intense and individual. Perhaps, it should be considered whether this can be maintained after the pandemic.
In general, the domain of expected outcomes was of minor significance for patients in German rehabilitation clinics. However, it became apparent that a distinct communication of patient-relevant outcomes and their respective change after rehabilitation was positively associated with patient satisfaction. The communication of changes in outcomes seemed to be more straightforward to be implemented in somatic care facilities. Furthermore, available emotional support during IRS was perceived to facilitate the individual healing process by having a direct impact on activating self-efficacy and self-management potential.
I want to compliment the care provided by doctors and therapists. I arrived here with severe swelling and effusion in the knee and leave the rehab with great mobility and stability in my joint (70° on arrival 115° on departure).
I arrived as a diabetic with overweight, having taken medication for three years, including for high blood pressure. The holistic care of the staff has resulted in, me losing 12 kilograms in four weeks and I am now medication free. My long-term blood sugar now is 5.9 and I’m coming from over 8.
The domain of “peer relationship” inductively emerged during the process of analysis. Empowering peer-to-peer relationships was valued to have the potential to mitigate adverse effects of the pandemic on IRS. Thus, some patients reported that their stay remains unforgotten mainly due to their peers, who compensated for negative inconveniences. Patients also appealed to the personal responsibility of their peers. In their understanding, only active engagement allows expectations of rehabilitation success.
A rehab is not a vacation, your own participation is expected and necessary- success depends on you and your attitude toward rehab and your own illness; a rehab facility is not a hotel with many stars…
The first week was shaped by uncertainty of the unknown, but the great people I met supported me to deal with the problems that arose. Usually, we would meet for lunch to tell each other what had happened during the day. Many times, we were just listeners when a colleague of ours was feeling bad.
A comprehensive summary of online reported patient experiences addressing PCC domains and attributes is provided in
Key statements from patient reports related to inpatient rehabilitation service (IRS) during the SARS-CoV-2 pandemic.
Domain and attributes | Experiences | ||
Prerequisitesa: attributes of the patient-centered professional | Perceived gratification crisis of medical staff | ||
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Patient as a source of control | Discontinuous communication of curfew legislation creates a sense of disempowerment | |
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Patient autonomy | To maintain hygiene legislation, the patient decision-making autonomy is restricted, which is frequently perceived as arbitrariness | |
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Family and friends as supported caregivers | Lacking leisure time activities for companions | |
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Transition and continuity of care | Intersectoral care continuity is not always maintained | |
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Care based on a continuous healing relationship | Members of the nursing and therapy professions are perceived to be more trustworthy than physicians | |
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Clinician-patient relationship | Established clinician-patient relationships have the potential to mitigate adverse effects of the pandemic on IRS | |
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Availability | Availability of therapeutic and nursing services was in part severely limited | |
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Supportive organizational system | Acceptance of hygiene legislations increases if they can easily be integrated into organizational routines | |
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Therapeutic environment | Adapted routines create a personal, familiar environment; nutritional theory and lived practice are inconsistent | |
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Physical comfort | Distinct communication of therapeutic outcomes supports patient satisfaction | |
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Emotional support; alleviation of anxiety | Emotional support promotes the healing process and self-management | |
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Peer as a supported person of trust | Established peer-to-peer relationships have the potential to mitigate adverse effects of the pandemic on IRS | |
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A call for personal responsibility | IRS is to be appraised in addition to personal responsibility |
aDeductive domain.
bInductive domain.
For patients receiving IRS, aspects of the care environment, staff prerequisites, and patient-centered processes were predominantly relevant to evaluate their inpatient stay. SARS-CoV-2–related adaptation mechanisms affecting these domains comprised discontinuous communication and elaborate implementation of infection protection standards, which were perceived to threaten the personal autonomy of action. These mechanisms were amplified by tangible gratification crises of medical staff. However, the prevalence of established and emotional supportive relationships to clinicians and peer groups provided the potential to mitigate the adverse effects of hygiene protection standards on IRS. Moreover, a distinct communication of therapeutic outcome variation seemed to support patient satisfaction. These insights provide the opportunity to develop informed strategies fostering resilient organizations that sustainably embody PCC within the setting of rehabilitative care.
Our findings are partly in line with those of Liu et al [
Considering the suitability of the applied PCC framework [
In this analysis, patients perceived a significant number of medical staff to present aspects of a developing gratification crisis reflecting generic psychological distress. This finding is supported by Dobson et al [
Despite illustrated challenges of IRS during the early phase of the SARS-CoV-2 pandemic, most patients felt safe and supported infection protection standards. This is underpinned by a survey of oncological patients treated in German rehabilitation clinics, 87% of whom reported to feel safe in facilities [
First, one limitation of our study is the limited representativeness of findings for other rehabilitation settings within Germany as hygiene regulations differed across states. Moreover, online reported patient complaints as a scientific data source produce concerns of representativeness and subjectivity as sample characteristics are uncontrolled and widely unknown. However, an analysis of Facebook reviews demonstrated that contents of reviews do not correlate with inpatient quality assessment indicators but instead correlate with a standardized national survey of patient experiences in German obstetrics [
Second, using online reported patient complaints is accompanied by unknown sample characteristics and thereby associated with hazards of selection bias. In this context, Han and colleagues [
Moreover, research activities of economic sciences identified online product ratings to be influenced by social dynamics. It is acknowledged that product ratings are not only affected by individual experiences but rather by prior ratings of one’s peer group [
Along with these stated limitations, this analysis faces unique restrictions. As the distribution of reports across included clinics varied strongly, a cluster bias of included rehabilitation clinics with disproportionately strong patient rating activities of some facilities cannot fully be ruled out. In this regard, it will be of interest to further investigate which clinic-related parameters affected ratings of clinics with above-average report numbers. Additionally, the current selection of keywords reflecting PCC domains was made inductively and potentially implies an incomplete list of keywords supporting a distortion of distributed domains.
Despite these limitations, patient rating portals became increasingly popular over the last 10 years [
Taking the present results into account, future research direction should investigate country-specific differences in the perceived significance of PCC domains. For instance, it remains to be answered why online reports of German inpatient care recipients are currently dominated by reports about the care environment, whereas health-relevant outcome expectations seem to have a subordinate role.
This analysis reflects previous research as German patients predominantly reported feedback associated with the care environment. SARS-CoV-2–related reports were strongly affected by aspects of patient-centered processes addressing discontinuous communication and an organizationally demanding implementation of infection protection standards, which was in some cases perceived to threaten patient autonomy. This perceived threat in reduced autonomy was amplified by a tangible increase in staff workload. Developed peer relationships during the rehabilitation stay had the potential to mitigate these mechanisms.
Data extraction code for web scraping.
COREQ (Consolidated criteria for Reporting Qualitative research) checklist.
Synopsis online reports (original German Version).
consolidated criteria for reporting qualitative research
inpatient rehabilitation service
patient-centered care
We would like to thank every patient who conducted online reports about their experiences on visiting inpatient rehabilitation clinics during the early phase of the SARS-CoV-2 pandemic. Without your willingness to share your experiences, this study would not have been possible.
The open-access data are available on Klinikbewertungen [
The research group is funded by the German Pension Fund (Deutsche Rentenversicherung Berlin-Brandenburg). One of the included rehabilitation clinics is operated by the German Pension Fund. However, the German Pension Fund had no influence on planning and execution of this study. Publication fees were funded by the Brandenburg Medical School publication fund supported by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG).