2.1. Study design

This study employed an exploratory descriptive qualitative design underpinned by the interpretivist paradigm to explore perceptions of quality nursing care among adults living with end-stage kidney disease (ESKD) undergoing haemodialysis (HD). An exploratory qualitative approach is appropriate where limited evidence exists regarding a phenomenon and enables an in-depth understanding of participants’ experiences and perspectives [27]. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) to enhance methodological transparency and reporting quality.

2.2. Study setting

The study was conducted at the dialysis unit of Tamale Teaching Hospital (TTH), a tertiary referral hospital in the Northern Region of Ghana. TTH is the only public dialysis referral center serving the five northern regions of the country, making it an appropriate setting for the study. Established in 2010, the dialysis unit provides life-sustaining renal replacement therapy to approximately 50 adults each month

2.3. Study population and sample size determination

The study population comprised adults diagnosed with ESKD receiving maintenance HD at the dialysis unit of TTH. Participants were recruited using purposive sampling to ensure the inclusion of individuals with direct experience of HD and the ability to provide rich, relevant, and in-depth accounts of the quality of nursing care received.

The sample size was guided by the principle of data saturation. Initially, 25 eligible participants were approached for the study. However, three (3) participants withdrew their consent, and two (2) became clinically unwell before the interviews, leaving 20 eligible participants. Data collection and analysis were done concurrently. Data collection and analysis were conducted concurrently to monitor for the emergence of new concepts and themes. Following the thirteenth interview, no new insights, concepts, or themes emerged, indicating that saturation had been achieved. Two additional interviews were subsequently conducted to confirm saturation and ensure the completeness and robustness of the findings. Consequently, a total of 15 participants were interviewed, and all transcripts were included in the final analysis

2.4. Inclusion criteria

Adults who were eighteen years of age and above, living with ESKD, and had been undergoing HD treatment for at least six months at TTH were included in this study. The eighteen-year limit was decided on by the researchers because it is the legal age for adult consent in the context of Ghana.

2.5. Exclusion criteria

Adults with severe comorbidities, cognitive impairment, or an unwillingness to be part of the study were excluded.

2.6. Selection of study participants

Participant recruitment commenced after ethical approval had been obtained from the Tamale Teaching Hospital Institutional Review Board (TTH-IRB) and administrative permission granted by the dialysis unit management. Eligible participants were identified during their scheduled HD sessions and recruited by the first author using purposive sampling. The unit manager facilitated initial access to the dialysis unit but was not involved in participant selection or recruitment to minimise potential gatekeeper bias.

To further reduce selection bias, the first author approached potential participants directly in a private setting and emphasised that participation was entirely voluntary and would not affect the care they received. Purposive sampling was used to recruit participants with diverse demographic and clinical characteristics to capture a broad range of experiences and perspectives regarding the quality of nursing care. Although recruiting participants during HD sessions may have favoured individuals who were clinically stable and willing to participate, this potential bias was minimised through the consistent application of predefined inclusion and exclusion criteria. The researchers had no prior professional or personal relationship with any of the participants before the commencement of the study.

2.7. Data collection

Data were collected using a semi-structured interview guide and face-to-face interviews conducted in English, Dagbani, or Waali (Some Ghanaian languages spoken in Northern Ghana). All interviews were conducted by the first author, a male Senior Nursing Officer and nursing tutor with an MPhil in Nursing, qualitative research training, and no prior relationship with the participants. Interviews lasted between 45 and 60 minutes and were conducted once with each participant in a private office within the dialysis unit to ensure privacy and to minimise interruptions.

A semi-structured interview guide was developed and piloted prior to data collection to improve the clarity and relevance of the questions. The guide comprised two sections: Section A collected participants’ demographic information, while Section B contained open-ended questions with probing prompts designed to explore participants’ perceptions and experiences of the quality of nursing care during HD, including communication, respect for patient preferences, physical comfort, and overall care experiences. Example questions included: “Can you describe your overall experience with the nursing care you received during haemodialysis?”, “How would you like nurses to care for you during your dialysis sessions?”, “What do nurses do that makes you feel more comfortable?”, and “Have nurses ever asked for your opinions or preferences regarding your treatment?”

With participants’ consent, all interviews were audio-recorded and supplemented with field notes to capture contextual observations and non-verbal cues that enriched data interpretation. Interviews conducted in Dagbani or Waali were translated into English before being transcribed verbatim for analysis. Participants were interviewed once, and all interview transcripts were included in the final analysis.

To enhance the credibility of the data, audio recordings were played back to participants immediately after each interview to verify the accuracy of their responses and to provide an opportunity for clarification or correction where necessary. This process ensured that participants’ accounts were accurately represented before data analysis commenced.

2.8. Data management

Data management is the storage and easy access or retrieval of data for easy analysis. Data management in research involves the organised handling of data from its creation or collection to its storage, preservation, and eventual sharing or disposal [28,29]. The researchers ensured strict adherence to the principles of the Ghana Data Protection Act, 2012 (Act 843). The Data Protection Act of Ghana is a comprehensive legal framework that governs the collection, processing, storage, and dissemination of personal data in Ghana. With this law, the participant’s privacy rights are protected with the highest standard of security and confidentiality that aligns with the international standard of data protection, crucial for global partnerships. Data were encrypted to enhance data security. Data encryption is when the participant’s information is converted into ciphertext to allow only authorised people who have the key to access the original plain text information. The soft copies of the data were stored on a laptop and double password-protected, and on the University of Ghana server.

Data management aims to ensure that data are accessible and secure and maintain their integrity, allowing for reliable analysis and reproducibility of research findings [30]. The researchers managed the hard data manually, such that it was easily accessible to them. Each participant was identified by a pseudonym (P1, P2, and P3), where P represents participant, and the number of interviews were identified by figures such as 1, 2, 3, and so on. The audio recorder, field notes, and transcribed data were added to the new file created and locked in a cabinet drawer for five years after the study, after which they will be destroyed.

2.9. Data analysis

Data was analysed using Braun and Clarke’s reflective thematic analysis [31] following their proposed six-step framework. All analyses were carried out manually. The analysis began with an immersion in the data, as a form of familiarisation by the first author, which involved initially translating the interviews in the Ghanaian languages (n = 4) into English, then transcribing interviews verbatim and repeatedly reading through, to fully engage with the participants’ stories. This was followed by the coding stage, by the first, second, and third authors, where significant sections of the text were highlighted and labelled to capture concepts related to nursing care. Codes were developed inductively, grouped into categories, and refined into themes. Within each theme, sub-themes were developed to capture more specific aspects of patients’ perspectives. To enhance analytical rigor and credibility, the coded transcript and emerging themes were independently reviewed by all the other researchers, who served as additional coders and critical reviewers of the analysis. Subsequently, themes and sub-themes were reviewed and refined to ensure they were clear, distinct, and consistent throughout the dataset. Differences in coding and interpretations were discussed through periodic meetings among the researchers until consensus was reached, and transcript data were revisited where necessary to ensure the final themes accurately reflected participant experiences and strengthened the trustworthiness of the findings.

2.10. Reflexive statement

The authors are nursing lecturers and trained nurses with teaching and clinical experience in adult health and renal care within the Ghanaian healthcare context. Therefore, their professional background provided a valuable understanding of HD practice and nurse–patient interactions, informing the design, data collection, and interpretation of the study. Nonetheless, it likewise brings into effect the threat of biases concerning what constitutes “quality nursing care” and how individuals may assess it. To lessen any potential prejudice, the authors engaged in constant reflexivity throughout the research process. This included bracketing prior assumptions, maintaining reflexive journaling, and significantly assessing how their professional positions and power dynamics might influence participant responses and data interpretation. The authors were therefore conscious of enabling a non-judgmental environment during interviews to encourage the participants’ open expression of their perspectives. Regular team discussions were also held to address any discrepancies in interpretations and ensure that findings remained grounded in participants’ accounts rather than the authors’ expectations. The researchers aimed to enhance the credibility and trustworthiness of the study by recognising their positionality and keenly reflecting on its influence.

2.11. Methodological Rigor

To ensure the ethical soundness and trustworthiness of this qualitative study, the framework proposed by Guba & Lincoln 1985 was employed. This framework emphasises four essential criteria for ensuring rigor in qualitative research: credibility, transferability, dependability, and confirmability [32]. Each of these was addressed through procedures designed to uphold the highest ethical standards in research involving human participants.

Credibility relates to how accurately the study reflects the participants’ experiences [33]. Credibility was enhanced through purposive sampling based on clear inclusion and exclusion criteria to ensure that those with relevant experiences were ethically and appropriately recruited. Member checking was ensured by playing back the audio recording to participants after each interview to confirm the accuracy of their responses and allow for clarification and correction where necessary. Additionally, emerging interpretations were also discussed with some participants to verify that the findings accurately reflected their experiences and perceptions. For participants who could not understand English, the interview questions and consent form were explained in their preferred language to ensure clear understanding and accurate responses. To ensure transferability and enhance the relevance of the findings to other contexts, thick descriptions of the study context, participant demographics, recruitment strategies, and data collection procedures were documented in detail. This transparency allows other researchers and ethics boards to assess the relevance of the findings for similar populations or clinical environments. Dependability was achieved by using a standardised interview guide, consistent recording equipment, and a uniform data analysis method across all participants. Maintaining a well-documented protocol reviewed by some of the authors who are experts in qualitative research methods. Ensuring that every step taken in data collection and analysis is recorded and reproducible. Confirmability was ensured by maintaining an audit trail, documenting all stages of the research process, including transcripts, coding and theme development. Analytic decisions were recorded through reflective memos and notes outlining how codes and themes were developed and refined. These records were regularly reviewed through peer debriefing to ensure transparency and that findings were grounded in data. Reflexivity was also applied throughout the study, with the researchers critically reflecting on their assumptions and potential influence on data interpretation to ensure that findings were grounded in participants’ accounts rather than researcher bias.

2.12. Ethical considerations

Ethical clearance was sought from the TTH Institutional Review Board (TTH-IRB00013215) [28] after submitting copies of the introductory and support letter obtained from the University of Ghana, Legon. Upon approval, copies of the ethical clearance certificate, the proposal and the permission letter were submitted to the hospital administration for final approval before the commencement of data collection. To access participants, ward-in-charges at the dialysis unit assisted in identifying eligible individuals. Informed consent was obtained through a structured, ethical process to ensure participants fully understood the study and voluntarily agreed to participate. Initially, participants were approached and provided with a clear explanation of the study’s purpose, objectives, procedures, potential benefits, duration, and possible risks. A participant information sheet, outlining all relevant aspects of the study, was given to everyone. The researchers address any questions or concerns and provide clarification where necessary. For participants who cannot read or write, the consent form was verbally translated into their native language in the presence of an impartial witness. The participant and the witness signed or thumb-printed the consent form to affirm voluntary agreement.

Participation was entirely voluntary. No coercion or undue influence was exerted. Participants were informed that they have the right to withdraw from the study at any point without any consequences and may also decline to answer any questions they find uncomfortable. Privacy was respected by conducting interviews in private areas within the facility, away from interruptions and onlookers. Permission was obtained before audio-recording any interview. To maintain confidentiality, all data (audio recordings, field notes, and consent forms) were securely stored and accessible only to the researchers. Personal identifiers were removed from transcripts. Anonymity was assured by assigning pseudonyms (e.g., P1-P15) to participants. In anticipation of emotional distress that may arise as participants share their experiences, a referral arrangement was made with a clinical psychologist at the hospital to provide support where needed.

3.1. Demographic characteristics

Fifteen adults with end-stage kidney disease (ESKD) receiving maintenance HD at the dialysis unit of Tamale Teaching Hospital participated in this study. The participants comprised of eight females and seven males, aged 28–68 years and represented diverse sociodemographic backgrounds. Most participants were married and identified as Muslims, whilst the remainder were Christians. Educational attainment ranged from no formal education to tertiary level, and occupations included trading, farming, professional employment, student status, and unemployment. The duration of the HD treatment ranged from one to nine years, capturing both relatively recent and long-term treatment experiences. Participants’ sociodemographic characteristics are presented in Table 1.

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Table 1. Demographic characteristics of participants involved in the study.

https://doi.org/10.1371/journal.pone.0356068.t001

3.2. Themes and sub-themes

Table 2 below is an account of the themes and sub-themes generated. Two major themes emerged: Respect for patient preference and Physical comfort, which underpin the perception of quality nursing care during dialysis. These themes reflect key relational and care delivery factors that shape patients’ experiences within the dialysis setting. Respect for patient preferences captures the extent to which patients felt involved, valued and supported in care decisions, while physical comfort reflects the effectiveness of nursing interventions in managing pain, meeting basic care needs and maintaining a therapeutic environment. Together, these themes highlight the central role of patient-centered nursing practices in influencing the perceived quality of care.

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Table 2. Themes and sub-themes.

https://doi.org/10.1371/journal.pone.0356068.t002

3.3. Respect for patient preferences

Participants described respect for their preferences as an important aspect of quality nursing care. Their accounts reflected experiences related to involvement in decision making, dignity, autonomy and consideration of cultural and personal preferences

3.4. Physical comfort

Participants described physical comfort as an important aspect of their HD care experiences. Their accounts reflected experiences related to pain management, assistance with daily needs and care environment

4.1. Implications for practice and policy

In terms of implications, the findings point to the need for multi-level interventions. At the practice level, simple and feasible strategies such as routine patient involvement in scheduling decisions, structured pain assessment, and use of local language communication can improve patient experiences without requiring significant additional resources. At the facility level, improvements in workflow organisation and maintenance of existing equipment can enhance both efficiency and patient comfort. At the health system level, addressing staffing shortages, ensuring a consistent supply of dialysis consumables, and improving infrastructure reliability are critical to reducing service disruptions. Additionally, policy efforts aimed at reducing the financial burden of HD would likely improve continuity of care and overall patient well-being.

4.2. Strengths and limitations

To the best of the authors’ knowledge, this is the first qualitative study in Northern Ghana, exploring the perceptions among adults undergoing HD treatment on quality nursing care, with a focus on respect for patients’ preferences and physical comfort. The use of a semi-structured interview tool allowed participants to share rich, in-depth experiences in their own languages. Also, inclusion of anonymised patient quotes enhances trustworthiness and gives voice to participants.

However, the study took place in a resource-constrained environment, and its outcomes are deeply tied to this context. Although this setting provides crucial insights into the practicalities of HD care under such conditions, the experiences and perspectives described here might not align with those found in healthcare systems that have more resources available. Interviews translated from local languages may have introduced interpretive bias. However, data saturation was achieved, and rigorous methods strengthened credibility.

4.3. Conclusion

This study demonstrates that adults undergoing HD at Tamale Teaching Hospital perceive quality nursing care primarily through respectful engagement, responsiveness to their preferences, culturally sensitive communication, and the provision of physical comfort. Although participants acknowledged the compassion and commitment of nurses, persistent health system constraints, including inadequate staffing, limited resources, and infrastructural challenges, adversely affected their care experiences. These findings underscore the need for person-centered HD care that addresses both interpersonal and structural dimensions of quality. Strengthening patient involvement, culturally responsive communication, and resource support may enhance patients’ care experiences and improve the quality of HD services in resource-constrained settings.