{"paper_id":"2ec292b2-a609-4929-8cc1-d4fa70617ee0","body_text":"Stakeholders' authentic experiences with unaccompanied care services:A grounded theory qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Stakeholders' authentic experiences with unaccompanied care services:A grounded theory qualitative study Bihui Chen, Haili Zhu, Juan Tang, Yulan Liang, Xing Li, Yan Liu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8735258/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Rapid aging in China has increased hospitalizations, straining the traditional family-based care model. The newly implemented national unaccompanied care service addresses this by transferring inpatient daily care to professional medical care assistants. The authentic experiences of stakeholders in this new model are underexplored. Methods A qualitative study guided by Straussian and Corbinian grounded theory. Semi-structured interviews were conducted with 42 stakeholders from a tertiary hospital in Hunan Province in September 2025. Results The authentic experiences of stakeholders in unaccompanied care services were established as a core category, which was influenced by three main categories: the reconstruction of a sense of security during the transfer of care responsibility, the dilemma of compatibility between professional care and humanistic needs, and the balance among authority, responsibility, and resources in service operation. Nine categories formed from 36 initial concepts were included under the three main categories. Conclusions The transition to unaccompanied care involves profound psychological, relational, and systemic shifts. Ensuring its sustainable and humanistic development requires a multi-faceted transformation: a cultural shift from familial filial piety to social care justice; policy recognition of medical care assistants' emotional labor; and human-centered technological application that empowers rather than replaces human care. This study provides a crucial theoretical foundation and empirical insights for optimizing care service policies and practices, offering valuable implications for global aging societies navigating similar transitions. unaccompanied care services qualitative research grounded theory aging society Figures Figure 1 Figure 2 Background China is accelerating toward becoming a super-aged society, a trend posing severe challenges to both the healthcare system and family caregiving models. Data from the Ministry of Civil Affairs of the People's Republic of China indicates that by the end of 2024, China's population aged 60 and above reached 310 million, accounting for 22% of the total population. The population aged 65 and above stood at 220 million, representing 15.6% of the total population[1]. The rising hospitalization rate is an inevitable consequence of this aging trend. The Statistical Bulletin on China's Health Development in 2023, released by the National Health Commission of the People's Republic of China, indicates that in 2023, the number of hospital admissions nationwide reached 301.873 million, with the annual hospitalization rate among residents hitting 21.4%[2]—significantly higher than the average hospitalization rate among Organisation for Economic Co-operation and Development(OECD) countries (13.05%)[3]. Against this backdrop, family caregivers of hospitalized patients face multiple pressures: high prevalence of chronic diseases, heavy time and financial burdens, lack of medical knowledge, role conflicts, and psychological strain. Furthermore, influenced by the one-child policy implemented from 1979 to 2016, data from the Seventh National Population Census (2020), conducted by the National Bureau of Statistics, indicate that China has approximately 200 million only children. It means a large number of families are caught in the predicament of \"one couple caring for four elderly parents,\" further exacerbating the fragility of family caregiving. Research shows that the heavier the burden on caregivers, the lower their willingness to provide care[4]. A qualitative systematic review[5]indicates that factors such as poor hospital environments, financial pressures, a lack of support systems, and ineffective collaboration with healthcare providers significantly diminish the capacity of family caregivers to provide care. International research further reveals this trend: Andrea Cattaneo et al.[6] used a demographic microsimulation model to project the burden of informal family caregiving across 31 European countries from 2000 to 2050. Their findings indicate that the overall burden of informal care in Europe is projected to increase by 49.7%. In low- and middle-income countries, informal caregivers face heightened marginalization and endure the dual pressures of cultural expectations and personal sacrifice[7]. Notably, excessive reliance on family caregiving may negatively impact patient recovery. For instance, a Turkish study[8]found hospitalized patients experience conflicting emotions toward informal caregivers: relying on their emotional support while simultaneously feeling guilty for imposing burdens. For a long time, inpatient care in China has primarily relied on family members providing care or patients hiring their own caregivers. This non-professional care model has led to issues such as inconsistent care quality, a high risk of hospital-acquired infections, and disorganized ward management. These problems not only compromise patient safety and experience but also increase the coordination burden on medical staff. To address this challenge, in October 2024, the National Healthcare Security Administration issued guidelines for nursing service projects, establishing a separate pricing category for unaccompanied care services under government-guided pricing. Starting in June 2025, China officially launched pilot programs for unaccompanied care services in tertiary hospitals across key provinces and cities with significant aging populations, as part of comprehensive healthcare reform [9]. Unaccompanied care services evolved from unaccompanied ward services. They primarily refer to daily living assistance provided by nurses or hospital-employed healthcare assistants to inpatients. This service is offered based on the patient's condition and level of self-care ability, with informed consent and voluntary choice from the patient or their family. Internationally, wards employ healthcare assistants (HCAs), certified nursing assistants (CNAs), or nurse aides to manage patients' daily care, effectively sharing the workload of registered nurses (RNs). This model has also spawned services like respite care[10]and day care services[11], better meeting the diverse needs of patients and families while enhancing the overall efficiency of healthcare systems. At present, China's unaccompanied care services are primarily provided by medical care assistants, marking a shift from family responsibilities to professional services. As these services remain in a pilot exploration phase, existing research has primarily focused on analyzing the burden on informal caregivers[12]or the practical difficulties in implementing unattended wards[13], with limited in-depth exploration of the actual experiences of patients and family caregivers. With China's rapidly aging population and the shift toward nuclear family structures, the traditional healthcare model, which relies on family accompaniment, faces severe challenges. Imbalanced nurse-to-patient ratios lead to declining care quality, while the phenomenon of \"one hospitalization burdening the entire family\" further exacerbates societal strain. During the initial pilot phase of unaccompanied care services, implementation effectiveness may be constrained by factors such as differing perceptions among patients and their families, insufficient attention to emotional needs, and variations in service quality. Internationally, Unaccompanied care services models have matured in countries such as Japan, Germany, the UK, Australia, and Singapore, where standardized management has significantly reduced family burdens and enhanced nursing quality[14, 15]. While these established practices demonstrate the feasibility of professionalized unattended care models, cultural differences necessitate localized exploration of the humanistic care dimension within such services. Therefore, systematically revealing the authentic experiences of patients and informal caregivers regarding unaccompanied care services through grounded theory not only provides empirical evidence for policy optimization but also serves as a critical pathway to bridge institutional design with real-world needs.This approach propels care models from reactive responses toward people-centered, sustainable development. Methods Design This study adopts grounded theory as a research framework and analytical methodology, a research methodology for qualitative research proposed by Anselm Strauss of Columbia University and Bar-ney Glaser of the University of Chicago in 1967, which seeks to explain and understand by generalizing concepts and theories from data to social phenomena. The grounded theory uses coding as its essential analytical tool, and we adopted Strauss and Corbin's programmed version, which consists of open coding, axial coding, and selective coding[ 16 ].Semi-structured in-depth interviews were conducted with patients, informal caregivers, medical care assistants, and managers of the care company who utilized the companion-free care service at a tertiary hospital in Hunan Province. The interviews took place in September 2025. Participants This study employed purposive sampling to recruit patients, informal caregivers, medical care assistants, and managers of the care company who met the inclusion and exclusion criteria from a tertiary hospital in Hunan Province. (1)Patients were required to be aged 18 years or older and to provide informed consent for voluntary participation. They were excluded if they were unable to express themselves or make autonomous decisions verbally or in writing, or if they had severe conditions such as critical heart, lung, or kidney failure that would prevent cooperation.Medical care assistants were included if they provided informed consent and voluntarily agreed to participate in the survey. They were excluded if they were unable to cooperate with the interview due to language barriers or mental health conditions.(2)Informal caregivers were eligible if they were aged 18 or older, had been the patient's primary caregiver since hospitalization, and provided informed consent for voluntary participation. Those unable to cooperate with the interview due to language barriers or mental disorders were excluded.(3)Medical care assistants were included if they provided informed consent and voluntarily agreed to participate in the survey. They were excluded if they were unable to cooperate with the interview due to language barriers or mental health conditions.(4)Managers of the care company were included if they were directly responsible for the operation and quality management of unaccompanied care services, had held the position for at least 3 months, and provided informed consent. Exclusion criteria were an inability to participate in the interview due to language barriers or mental health conditions. A total of 42 stakeholders were interviewed: 19 patients (P1–P19), comprising eight females and 11 males, aged 36–85 years (mean 59.7 years). They had received unaccompanied care services for 2–23 days (mean 9.5 days). 8 informal caregivers (C1–C8), including five females and three males. Their relationships to the patients were three daughters, one son, two wives, and two husbands. 13 medical care assistants (A1–A13), all female, aged 44–56 years (mean 46.8 years), with caregiving experience ranging from 6 months to 12 years (mean 4.7 years). 2 managers of the care company (M1, M2), one male and one female. Data collection Data were collected using semi-structured interviews. All interviews were conducted jointly by two researchers, with one primarily responsible for asking questions and the other observing, taking notes, and providing supplementary follow-up questions when appropriate. Prior to the interviews, both researchers engaged in in-depth theoretical studies, received guidance from experienced experts, and practised their interviewing skills through preliminary interviews to refine their technique. Before the formal interview began, the researchers clearly explained the purpose of the study to the participants. The interview commenced only after confirming their understanding. The interview guides are presented in Tables 1 , 2 , and 3 . Interviews were conducted face-to-face, each lasting approximately 20 to 40 minutes. Throughout the process, the researchers maintained an open, non-directive attitude, encouraging participants to express their genuine experiences and probing for deeper information through timely follow-up questions. After each interview, the audio recordings were immediately transcribed into text, followed by a process of progressive coding. Table 1 Interview guides for patients and informal caregivers Theme Questions for patients Questions for informal caregivers Perception and needs 1. What is your understanding of unaccompanied care services? 1. What is your understanding of unaccompanied care services? 2. What kind of help and support do you expect from the medical care assistants? 2. What are your most significant expectations of the medical care assistants? Decision and experience 3. What were your reasons for choosing unaccompanied care services? 3. What were your reasons for choosing unaccompanied care services? 4. What positive and negative experiences did you have during the service? Were there any difficulties, and if so, how did you cope? 4. Were there any particularly memorable incidents during the service? Emotion and life changes 5. During the service, did you feel the medical care assistants understood your emotions and needs? Could you give an example? 5. During the service, what positive or negative changes did you observe in the patient's condition? 6. How has your life changed after using unaccompanied care services? 6. How has your life changed after using unaccompanied care services? Intention for continued use 7. What factors might lead you to decline or continue using unaccompanied care services? 7. What factors might influence your decision to decline or continue choosing unaccompanied care services? Suggestions for improvement 8. What are your additional views or suggestions regarding the current unaccompanied care services? 8. What are your additional views or suggestions regarding the current unaccompanied care services? Table 2 Interview guide for medical care assistants Theme Questions for medical care assistants Role perception and responsibilities 1. How do you understand the professional role of a medical care assistant? 2. In the context of unaccompanied care services, what are your primary specific responsibilities? Work experience and challenges 3. During your actual service provision, what moments make you feel a sense of value or accomplishment? Could you provide an example? 4. What are the main difficulties or pressures you encounter in your work, and how do you typically handle them? Interaction with patients/families 5. How do you understand and respond to the emotions and needs of patients? 6. In the process of communicating and collaborating with patients' families, have there been any particularly memorable incidents? Professional identity and development 7. What are your thoughts on how your income corresponds to your workload intensity? 8. Are you willing to continue in this profession in the future? What factors would influence your choice? Views and suggestions on the service system 9. What aspects of the current service model or management approach do you think could be improved? 10. What support would you hope to receive from the hospital, the care company, or at the policy level? Table 3 Interview guide for managers of the care company Theme Questions for managers Service operation and management model 1. What is the core operational and management model of the unaccompanied care services in your company? What are its main advantages and disadvantages compared to traditional accompanied care? Human resources and team development 2. What are the key challenges regarding personnel suitability within your team? How do you address issues of professional burnout and staff retention among care assistants? Service quality and risk control 3. How do you manage and control the service quality of unaccompanied care? What are the core risk points, and what measures are in place to address them? Cross-role collaboration and communication 4. What are the main challenges in collaboration and communication with medical staff, patients, and their families when providing unaccompanied care? How can these be optimised? Policy environment and industry development 5. How does the current policy environment impact the development of unaccompanied care services? 6. What are your expectations for the future development of the industry and for policy support? 7. Are there any other issues or experiences regarding unaccompanied care services that you would like to add? Data analysis This study analyzed 42 qualitative transcripts using a three-level coding approach based on the Strauss and Corbin version of grounded theory, employing NVivo 12.0 software for data management. The qualitative data underwent open coding, axial coding, and selective coding to construct a theoretical model. Open coding Open coding is a commonly used data analysis method in qualitative research. Its fundamental principle involves a detailed, line-by-line analysis of the textual data, where keywords, phrases, sentences, or paragraphs are annotated or coded to enable deeper analysis and understanding. Through continuous induction, organization, and the listing of items, along with the elimination of contradictory initial concepts, a total of 36 initial concepts were ultimately identified, forming nine categories. Axial coding Axial coding is a theme-based coding method designed to systematically classify and organize data, extracting central themes and key concepts. It is typically conducted following open coding and helps researchers gain a deeper understanding of the data, enabling more in-depth analysis and interpretation. By connecting the nine categories derived from open coding and clarifying their relational meanings, three main categories were developed: the reconstruction of a sense of security during the transfer of care responsibility, the dilemma of compatibility between professional care and humanistic needs, and the balance of authority, responsibility, and resources in service operation. Selective coding Selective coding employs the logic of \"plotting a storyline\" to synthesize all related conceptual categories into a theoretical model, clarifying the interactive relationships and structural connections between the main categories and the core code. We established the authentic experiences of stakeholders in unaccompanied care services as the core category. This core category is influenced by the three main categories derived from the axial coding stage. Theoretical saturation test Strauss posits that theory achieves good saturation when the additional data no longer generates new categories or insights[ 17 ]. The theoretical saturation test is a process of applying the three-level coding to reserved data to verify the accuracy of the previously obtained coding results. In this study, six reserved qualitative transcripts were used for the theoretical saturation test, repeating the three-level coding process for a new round of analysis. The results indicated that the initial concepts identified could be subsumed under the previously constructed 36 initial concepts, with no new concepts or categories emerging, and no new relational structures developing among the categories. Therefore, it can be concluded that the model has reached a state of theoretical saturation[ 18 ]. Ethical considerations The Medical Ethics Committee of the Changsha Hospital of Traditional Chinese Medicine(Changsha Eighth Hospital) approved the research project described here (Ref: 2025090228). All subjects provided verbal and written consent to participate, and only the researchers had access to the digital audio tapes and transcripts. Results Through the three-level coding process of grounded theory, this study distilled 36 initial concepts during the open coding phase. These were organized into nine categories for axial coding: fluctuation in sense of security and risk perception, mechanisms of trust building, conflict and adjustment of emotional bonds, capacity and limitations of service provision, diversity and conflict of service demands, gap in value recognition, systemic challenges in human resources, synergy and efficacy of operational management, and demands for policy and market support. Subsequently, three main categories were derived from selective coding. Specifically, the reconstruction of a sense of security during the transfer of care responsibility represents the most immediate psychological and relational experience for all parties following the service intervention. The dilemma of compatibility between professional care and humanistic needs constitutes the core conflict and efficacy challenge in matching supply with demand at the practical level of service delivery. The balance among authority, responsibility, and resources in service operation is the underlying systemic support and fundamental constraint for the first two categories. Together, these three elements form a dynamic explanatory framework: the clarity of authority/responsibility and the sufficiency of resources at the systemic level directly shape and constrain the ability to integrate professionalism and humanistic care in practice, ultimately determining whether patients, family caregivers, and medical care assistants can successfully establish stable trust and psychological safety during the transfer of care responsibility. This model suggests that optimizing service experience cannot be limited to improving interpersonal interactions but must also involve systemic governance encompassing human resources, management coordination, and policy safeguards. The overall model of factors shaping stakeholders' authentic experiences is presented in Fig. 1 . The dynamic relationships among the three core categories are further detailed in Fig. 2 . Representative original statements, integrated and summarized, are presented below. The reconstruction of a sense of security during the transfer of care responsibility Fluctuation in sense of security and risk perception Both patients and medical care assistants experience, across different dimensions, a fluctuation in their sense of security and the weight of risk perception. On one hand, medical care assistants bear significant psychological strain due to their direct caregiving responsibilities, which immerse them in persistent professional anxiety, subsequently affecting their work efficiency and emotional stability. Research indicates that this psychological pressure stems not only from demanding workloads but also from deep concern for patient health outcomes and the pressure of self-expectation[ 19 ]. On the other hand, while receiving professional care, patients also have to contend with the unfamiliarity of the medical environment, the fragmentation of their daily routines, and the heightened emotional sense of family absence, which intensifies their worries about treatment effectiveness. Consequently, their psychological state and sense of trust are also severely impacted during the medical process. \"One night, a grandma lowered her bed rail by herself to go to the bathroom and almost tripped over my caregiver's cot. It scared me so much my scalp went numb, and I still feel a shudder thinking about it.\" (Psychological burden behind safety vigilance, A8) \"Caring for a tracheostomy patient is overwhelmingly stressful because any oversight can be a matter of life and death. Especially when the patient's wife is present, that feeling of being scrutinized adds an invisible pressure, making me extra cautious.\" (Lack of confidence in managing complex conditions, A3) \"He has dementia. What worries me most now is that he keeps unconsciously trying to pull out his IV line.\" (Safety risks and behavioral management during hospitalization, P4) \"We have encountered cases where some patients become overly dependent on the medical care assistants. They frequently use the call button once the assistant is out of sight. When the assistant is slightly delayed due to handling the needs of multiple patients, this patient would then exaggerate complaints to the medical staff. This unnecessary frequent calling and biased complaining not only increases the workload for the assistants but also negatively impacts their professional dignity.\" (Power dynamics and moral hazard behind irrational calls, M2) \"Sometimes I look forward to the phone ringing, but I am also afraid of disturbing them (the children).\" (Sense of emptiness with family absent, P2) \"In the hospital, time feels fragmented. You are not even fully awake before the nurse comes to take your blood pressure and check your blood sugar.\" (Unfamiliarity and adaptation to the medical environment, P6) Mechanisms of trust building The construction of trust relationships in unaccompanied care services is a multidimensional and dynamic process. Its core mechanism is rooted in the bidirectional interaction between the output of professional competency from the care supply side and the feedback of emotional recognition from the demand side. From the perspective of care providers, a standardized pre-service training system lays the foundation for professional competence, while the application of caregiving skills in clinical settings transforms this professional ability into tangible care value, forming the material basis for trust establishment. From the perspective of care recipients, responsive care behaviors enabled by technological mediators (e.g., call buttons), along with caregivers' proactive explanations for service delays, reduce information asymmetry during the care process. Furthermore, care recipients' subjective understanding of the caregivers' professionalism and labor efforts elevates instrumental trust to emotional trust, ultimately facilitating the formation of stable trust relationships within unaccompanied care services. \"The company and the hospital provide theoretical and practical training, covering things like Cardiopulmonary Resuscitation ( CPR), the seven-step handwashing technique, patient turning and transfer, as well as prevention of constipation, thrombosis, and pressure injuries. You have to pass the exams before you can start working.\" (Professional competence and skill application, A5) \"The elderly patient is bedridden and completely dependent on care. I turn him and clean him every day. Over all this time, his skin has remained completely intact, with no pressure injuries at all.\" (Practical application of skills and sense of value, A12) \"The medical care assistant gave me a call button connected to her watch. Most of the time, she comes as soon as I press it. On the rare occasions she's late, she proactively explains the situation. We understand she might be busy with other patients at the same time.\" (Technological mediation and trust building in responsive care, P15) \"This assistant has been exceptionally kind to me and very meticulous in her work. I see it clearly and I also understand how hard they work.\" (Understanding of the assistant's professionalism and efforts, P15) Conflict and adjustment of emotional bonds Unaccompanied care services profoundly reconfigure traditional caregiving relationships rooted in kinship, triggering complex emotional tensions and adaptive adjustments among diverse stakeholders. This series of emotional and identity conflicts must be understood within specific cultural and social normative contexts. In Chinese society, the Confucian culture-rooted norm of filial piety and familialistic expectations shape a strong sense of moral responsibility among informal caregivers [ 20 ]. This study found that the process manifests as a dynamic interplay of multiple dimensions, including the generation of guilt, the expenditure of emotional labor, the mobilization of psychological resilience, and the transformation of identity. Patients and their families, due to the formalized transfer of care responsibility, may experience an \"outsider\" sense of alienation and an objectified position of being \"managed.\" Meanwhile, medical care assistants, while providing professional services, also bear emotional suppression and challenges to their professional dignity arising from perceived social status inequality. \"Every time I go to the hospital, it feels like I am a guest. Watching the medical care assistant busy all around, I feel like an outsider instead.\" \"Every time I come to the hospital to bring meals for my dad, and see the daughter in the next bed personally caring for her elderly parent, my heart really aches.\" (Guilt from not providing personal care, C4, C5) \"Some family members think that because they have paid over a hundred yuan, we are somehow inferior. When faced with unwarranted scolding, arguing doesn't solve the problem. My strategy is to avoid conflict and communicate after they've calmed down proactively. Of course, it feels stifling inside, but to keep doing this job, I have to slowly digest it myself.\" \"We've already done our absolute best, yet we still can't avoid complaints. Sometimes, the will to keep going feels almost drained. If your efforts aren't met with understanding, what's the point of persevering?\" (Emotional labor and psychological grievance, A1, A7) \"I just strive to do everything with full dedication, so my conscience is clear. Holding onto one's own integrity is more important than anything.\" \"The four of us medical care assistants get along like sisters, supporting and sharing the burden with each other.\" (Positive psychological adjustment and professional resilience, A2, A11) \"Now, when my daughter visits, the first thing she always does is find the caregiver to check on me. Listening to them discuss my diet and daily routine, I feel like an object that needs to be managed.\" (The dilemma of identity shift from subject to object, P8) The dilemma of compatibility between professional care and humanistic needs Capacity and limitations of service provision The practical efficacy of unaccompanied care services relies on the caregiver's professional ability to meet the diverse care needs of patients. It is constrained by multiple practical factors within the caregiving context, such as time allocation, professional adaptation, and institutional regulations. This presents a coexistence of \"capacity compatibility\" and \"practical limitations.\" \"For this work-related injury hospitalization, the company arranged a care assistant for me. Her main responsibilities include my daily care, such as bathing, assisting with toileting, preparing meals, washing clothes, reminding me to take medication, and monitoring my IV drip. These tasks are both professional and mundane, but she performs them diligently and meticulously, ensuring my daily living needs are well-managed during recovery.\" (Support for life reconstruction within professional care, P13) \"Currently, taking care of two patients simultaneously is indeed overwhelming. This gentleman is accustomed to waking up early, around 7 a.m., whereas the younger patient typically sleeps until 1 or 2 a.m. and doesn't get up until 10 a.m. Their routines are opposite; even meal times don't align. It really requires attending to them separately.\" (Challenge of time coordination in cross-schedule care, A4) \"Transitioning from a domestic helper to a hospital care assistant is a new challenge for me. My husband looks after our grandson at home, and when needed, the supervisor can help arrange shift swaps, which allows me to balance work and family.\" (Skill challenge and adaptation in career transition, A3) \"Now, every care step needs to be logged, like feeding, administering medication, and turning the patient. I understand it's for standardized management, but it does affect the rhythm of care. I truly hope that while ensuring compliance, we could also be given more time to focus on the care itself.\" (Dilemma of balancing institutionalized recording with the human touch of care, A9) Diversity and conflict of service demands The demands of patients and their families for unaccompanied care services exhibit apparent diversity and often create tension with the actual service provision. On one hand, patients require not only basic life assistance but also, and more importantly, expect emotional support such as respect and patience, which they regard as core components of professional competence. On the other hand, family members, from the perspectives of care efficiency and their own peace of mind, propose specific suggestions for optimizing service processes and resource allocation. These diverse, specific, and often emotionally charged expectations directly clash and collide with the current standardized service provision operating within limited resources. \"When I needed to use the bathroom at night and called for the care assistant, she seemed very impatient. I later complained to the supervisor. I believe patience with patients is a fundamental professional requirement in this line of work.\" (Concern regarding assistant's quality and service consistency, P19) \"If the hospital could arrange for the several patients under one assistant's care to be in the same room, she could be readily available whenever needed. We would feel more at ease, and it would also save her effort. Wouldn't that be a win-win situation?\" (Suggestions for improving the service model and communication, C1) Gap in value recognition Within unaccompanied care services, a significant disparity exists in the understanding and expectations of care value among different stakeholders, creating a bidirectional gap in value recognition. Saiki M. found that a perceived expectation gap in role cognition is a key obstacle constraining the realization of value and team efficacy for medical care assistants[ 21 ]. Medical care assistants not only expect economic compensation commensurate with their labor but also yearn for their professional competence and emotional investment to be seen and accorded social respect. Conversely, some family members, unable to personally fulfill caregiving responsibilities, experience guilt over not doing enough and emotional alienation while enjoying the convenience of the service. \"What we give is not just physical effort, but also heart. Chatting with the elderly while bathing them, patiently soothing patients when they are restless... We hope these 'invisible' efforts can also be seen. We don't need sympathy, just the understanding and respect that should be accorded to medical care assistants.\" (Desire for labor value to be seen and respected, A7) \"The 'one-to-three' model (one caregiver for three patients) costs 154 yuan per patient per day, with the company taking a cut from that. There's a widespread hope that the company can establish a fairer compensation mechanism so our income better matches our current efforts.\" (Mismatch between income and effort, A1) \"Every time I go to the hospital, it feels like I'm a guest. Watching the medical care assistant busy all around, I feel like an outsider instead.\" (Guilt from not providing personal care, C4) The balance among authority, responsibility, and resources in service operation Systemic challenges in human resources The sustainable development of unaccompanied care services is highly dependent on human resource support. However, the industry currently faces systemic challenges across multiple dimensions, including talent supply, protection of physical and mental well-being, and career development. These issues not only hinder the stable development of the service workforce but also further limit the potential for improving service quality [ 22 ]. \"The team lacks younger members, creating bottlenecks in service philosophy, learning ability, and physical stamina. This makes it difficult to achieve a qualitative leap in overall service quality and management level.\" (The team dilemma of \"hard to recruit, hard to retain\", M1) \"I can't sleep soundly at night. The moment my patient makes a sound, I'm immediately awake. Sleep is fragmented; having deep sleep is a luxury.\" \"I'm responsible for three elderly patients at night and basically cannot sleep. Just as I settle one patient, I have to help the other two turn over or use the toilet. I dare not fall into deep sleep. Physical exhaustion is bearable, but this chronic sleep deprivation is truly agonizing.\" (Severe physical depletion and sleep deprivation, A1, A8) \"I'm 56. How long I can do this job depends entirely on my health. If I stay strong, I'll work another three to five years. If I feel I can't handle it anymore, I can't force myself. Ultimately, health is the foundation of everything.\" \"In our line of work, we don't dare think too far ahead. Where we'll be tomorrow is all uncertain.\" (Fragile occupational security and health risks, A6, A13) \"The career ladder in our field is indeed quite flat. Even if promoted to team leader, the pay increase is limited, but the trivial matters to worry about multiply.\" \"In our line of work, it seems there isn't much difference in professional identity between doing it for ten years and doing it for one.\" (Narrow career development path, A5, A11) \"I was a nurse for over a decade before switching to a management role in a care company. The main reason for the career change was my inability to withstand the impact of long-term night shifts on my physical and mental health.\" (Loss of nursing talent and career value reconstruction from the perspective of professional burnout, M2) \"I used to be in the catering industry. I switched to caregiving only because my child started school here. But the physical toll of this job is too great, and I deeply feel the income does not match the effort.\" (Occupational vulnerability and high turnover, A4) Synergy and efficacy of operational management The high-quality advancement of unaccompanied care services relies on the support of an operational management system characterized by multi-stakeholder synergy. Its efficacy is reflected in the multi-dimensional linkage of constructing cross-role collaboration mechanisms, fostering team cohesion, and stimulating caregiver professional identity. \"We have always hoped to regularly organize exchange sessions between medical care assistants and nurses, allowing both sides to address clinical collaboration issues openly and solve problems together. Simultaneously, we conduct bi-monthly satisfaction surveys. Once issues are identified, we immediately coordinate interventions and, if necessary, make personnel adjustments to ensure the stability and professionalism of the service team.\" (Building a management ecosystem of collaborative governance, M2) “As the group leader, I firmly believe patients come first. Sometimes when family members are upset and speak harshly, I can only patiently explain and communicate sincerely. After all, putting myself in their shoes, no family finds it easy when a loved one is ill. On our floor, we are like one big family. If someone calls for help, we all pitch in. Though I'm just a care group leader, I always believe putting others first is right. Our common goal is to take good care of the ward and provide good service.” (Professional conviction and view on team collaboration, A10) \"My mother-in-law had a stroke, and I cared for her at home for three years. After she passed last year, I became a medical care assistant. My husband wasn't keen on me working, but he respects my decision. I didn't have much schooling, but I'm willing to learn and work hard, and I'm satisfied with my current salary.\" (Professional identity and value realization, A8) Demands for policy and market support The rise of unaccompanied care services is a direct response to multiple challenges, including shortages in family caregiving resources, the intensification of societal ageing, and shifts in the workforce structure. To ensure its sustainable development, it is necessary to promote synergistic efforts between policy support and market mechanisms. Stakeholder appeals focus not only on practical needs such as alleviating payment burdens and expanding/optimizing service supply but also contain a deeper expectation for societal recognition of the value of caregiving labor [ 23 ]. \"Currently, these care services are entirely out-of-pocket for families. For ordinary households, it's indeed a significant expense. It would be great if the state could include some of it in medical insurance reimbursement.\" (Appeal for policy and financial support, M2) \"My children all have their own careers and families to attend to, which we understand. Hiring a caregiver means not disrupting their work while still ensuring I receive the care I need. It brings peace of mind for both sides.\" (Addressing the core pain point of absent family care, P17) \"This policy is truly a great thing for patients and families. At over a hundred yuan per day, it's much cheaper than before, tangibly easing the financial pressure on our family and making professional care more affordable.\" \"This policy has been a huge help. The only shortcoming is that the number of trained professional medical care assistants is still somewhat insufficient. It would be even better if more systematically trained assistants could be cultivated in the future.\" \"The state's introduction of this unaccompanied care policy has solved our biggest practical difficulty.\" (Perceived experience of policy beneficiaries, P9, P10, P12) \"My family wanted me to stay home and rest, but at home I'd just play cards and often lose money. Later, I thought, why not work as a caregiver? I could earn some money and help those in need. Though I'm not young, I can still work with my own hands, which actually makes me feel more settled.\" (Social value and self-actualization through midlife re-employment, A4) Conclusions This study, utilizing grounded theory, conducted an in-depth analysis of the authentic experiences of four core stakeholder groups in unaccompanied care services—patients, informal caregivers, medical care assistants, and managers—constructing a theoretical model centered on the axes of \"reconstruction of a sense of security,\" \"dilemma of compatibility,\" and \"balance among authority, responsibility, and resources.\" The analysis reveals that this emerging model precisely addresses the rigid demand for patient care in the absence of family companions, a demand arising from societal aging and changing family structures, demonstrating initial social value due to its accessibility and professionalism. However, its sustainability faces profound challenges: a sharp contradiction exists between the enormous market demand at the front end and a workforce of medical care assistants at the mid-tier, predominantly composed of middle-aged and older women, who are physically and mentally exhausted and whose labor value is not fairly compensated. The back end, meanwhile, is constrained by inefficient collaborative management and a lack of policy support. This imbalanced state of strong demand but fragile supply, significant value but insufficient support reflects China's transitional dilemma in its super-aging process, caught between traditional familial ethics and a modern professional care system. Reshaping the core concept: from familial filial piety to social care justice The fundamental contradiction of the service first stems from the cultural-cognitive level. In China, according to the Constitution of the People's Republic of China, the Civil Code of the People's Republic of China, and the Law on the Protection of the Rights and Interests of the Elderly, adult children bear comprehensive support obligations toward their parents, encompassing financial provision, daily care, and emotional comfort[ 24 – 26 ]. China's traditional filial piety culture embeds care responsibilities within the family, forming a kinship-based ethical obligation that influences choices regarding the type of care[ 27 ]. The emergence of unaccompanied care services signifies an institutional transfer of part of this responsibility from the private to the public sphere, and from ethical practice to professional service[ 28 ]. The widespread guilt felt by family members and the occasional objectification experienced by patients in this study are manifestations of the cultural-psychological conflict inherent in this transfer process. This suggests that the success of the service lies not only in technical substitution but, more importantly, in whether a discursive reconstruction of care justice can be achieved at the societal level—that is, establishing a new consensus: that professionalized, socialized care is also a legitimate and responsible form of fulfilling filial duty and love, not an abdication of familial responsibility. To realize this reconstruction, the core of the service must transcend task completion and return to a humanistic concern for the whole person. This requires integrating two care approaches validated by international research: First, valuing narrative care by encouraging medical care assistants to build emotional connections through listening to and respecting patients' life stories, which is a key pathway to acknowledging and responding to patients' emotional needs, thereby achieving personalized care[ 29 ]. Second, attending to spiritual health, which involves perceiving and responding to patients' needs for meaning, dignity, and inner peace within daily caregiving[ 30 ]. Such integration can help mitigate the risk of dehumanization potentially induced by institutionalized care, infusing the service with indispensable emotional warmth. Addressing the key dilemma: making emotional labor visible, measurable, and respected The experiences of medical care assistants profoundly expose the structural shortcomings of the service system. Their work is a classic example of emotional labor, involving not only physical exertion and skill but also the continuous regulation of emotions, psychological soothing, and preservation of dignity. However, within the current management and compensation systems, this emotional investment is invisible, and its value is systematically undervalued. Fanfan Lv et al.[ 31 ] further indicate that when caregivers perceive their contributions far exceed their rewards, it can easily trigger negative psychological responses, subsequently leading to reduced levels of emotional labor and increased professional burnout. This is the core mechanism underlying the widespread physical and mental exhaustion, income dissatisfaction, and high turnover rate among the current caregiver workforce, especially the group predominantly composed of middle-aged and older women. Addressing the emotional labor dilemma and stabilizing the caregiver workforce require implementing systematic, three-pronged interventions: First, drawing on tools like the Scale of Emotional Labor for Nurses developed by Jiyeon Hong et al.[ 32 ] in 2019, which was formulated based on the nursing cultural context, to transform abstract emotional care into observable, assessable professional behaviors, making its value visible. Second, by setting reasonable pay standards and designing clear career progression paths, ensuring the emotional efforts of medical care assistants are met with corresponding wages and professional respect. Finally, establishing a comprehensive psychological support system for medical care assistants, developing standardized emotional management training programs, enhancing guidance on emotional labor, and cultivating empathy and communication skills[ 33 ]. Only through collaborative efforts among policymakers, institutional managers, and service providers can emotional labor be transformed from an unpaid, hidden expenditure into a core care value that is formally recognized, measured, and respected, thereby improving care quality and professional attractiveness. Rebalancing relationships and technology: using digitalization to empower, not weaken, care warmth The introduction of technological tools (e.g., call buttons, electronic check-in systems) aims to enhance efficiency and safety. However, this study finds that if the design and management of technological systems fail to fully account for the relational nature of care work, unintended negative consequences can arise. The core issue lies in this: when technology solidifies a unilinear interaction mode of call-response and, in managerial terms, excessively reduces the work of medical care assistants to a series of task-based metrics, the time and space required for those unquantifiable yet crucial elements of care quality—such as proactive observation of a patient's condition, patient listening, and the provision of immediate emotional support based on the patient's mood—become systemically compressed. This dilemma reflects a deeper contradiction within the current care industry: the inherent tension between a nursing ethos of empathy and person-centeredness, and the procedural, impersonal nature inherent to digital technology itself[ 34 ]. Therefore, future technological applications should strive to shift from being \"task management tools\" to becoming relational support media, with their design core focused on how to assist, not replace, interpersonal care interactions. Consequently, the core principle of technological design should be empowerment,not substitution. Utilizing smart voice or wearable devices to automatically record routine data can free up medical care assistants' time spent on mechanical logging[ 35 ]. Developing mobile knowledge support systems can provide medical care assistants with instant guidance. Establishing secure information-sharing platforms can allow families to understand patients' non-medical daily status, alleviating their anxiety. The ultimate goal of technology should be to enhance, not diminish, the depth and warmth of human connection. In summary, unaccompanied care services represent a crucial institutional experiment for China in responding to a super-aging society. This study reveals that their long-term success depends on guiding a profound systemic transformation: reconstructing care justice at the cultural-cognitive level, recognizing the value of emotional labor in labor policies, adhering to a human-centered approach in technological application, and achieving integrated continuity within the service system. Through this multi-dimensional, systematic, and coordinated governance, this model can evolve from a temporary measure alleviating manpower shortages into an integral component of a just, sustainable, and humanistic modern healthcare system. Its experiences and lessons hold significant reference value for societies facing similar aging challenges. Abbreviations OECD Organisation for Economic Co-operation and Development HCAs Healthcare Assistants CNAs Certified Nursing Assistants RNs Registered Nurses CPR Cardiopulmonary Resuscitation Declarations Acknowledgements The authors wish to express their gratitude to all the participants who kindly shared their stories. Authors’ contributions All authors read and approved the final manuscript. BH Chen was responsible for the conceptualisation and design of the study, conducted the formal analysis, investigation, and data curation, and drafted the original manuscript. BH Chen, YY Wang and YL Liang were involved in acquiring funding for the study. HL Zhu, X Li, QN Han and Q Huang contributed to the validation of the study. J Tang assisted in investigation and data curation. YY Wang and X Li contributed to the formal analysis. Y Liu was responsible for software support. Q Huang and YY Wang provided resources and project administration. All authors participated in reviewing, and provided critical feedback for the development of the final analytic themes. Funding This research is supported by the Natural Science Foundation of Hunan Province (No: 2026JJ3415, 2026JJ2675, 2026JJ2734), the Science and Technology Project of Hunan Provincial Sports Bureau (No: 2025KT040), the Key Project of Changsha Traditional Chinese Medicine Research (No: SB2024-018), and the Key Project of University‑Hospital Joint Fund of Hunan University of Chinese Medicine (No: 2025XYLH115). Data availability The datasets used and/or analysed during this study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate This study was approved by The Medical Ethics Committee of the Changsha Hospital of Traditional Chinese Medicine(Changsha Eighth Hospital). 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Healthcare. 2021;9(1):72. 10.3390/healthcare9010072 . Pan WJ, Wang SF. Understanding patients' emotional needs to strengthen therapeutic relationships: A deep insight into narrative nursing. World J Psychiatry. 2025;15(3):103093. 10.5498/wjp.v15.i3.103093 . Wang Z, Zhao H, Zhang S, Wang Y, Zhang Y, Wang Z, et al. Correlations among spiritual care competence, spiritual care perceptions and spiritual health of Chinese nurses: A cross-sectional correlational study. Palliat Support Care. 2022;20(2):243–54. 10.1017/S1478951521001966 . Lv F, Li L, Wang N, Yu K, Nie X, Ke L et al. Impact of effort-reward imbalance, emotional labour, and nurse-patient relationship on physical and mental health of registered nurses in China: a structural equation modeling. BMC Nur,2025,24, 535. 10.1186/s12912-025-03147-0 Hong J, Kim O. Development and validation of an emotional labour scale for nurses[J]. J Nurs Adm Manag. 2019;27(3):509–16. 10.1111/jonm.12705 . Yang T, Zhao Z, Zhu J, Huang Q, Zhu Y, Zeng Z, et al. The relationship between emotional labor and job burnout among Chinese medical staff: The mediating role of organizational identification[J]. Medicine. 2025;104(22):e42598. 10.1097/MD.0000000000042598 . Wynn M. The digital dilemma in nursing: a critique of care in the digital age. Br J Nurs. 2024;33(11):496–9. 10.12968/bjon.2024.0023 . Pervez F, Shoukat M, Suresh V, Farooq MUB, Sandhu M, Qayyum A, et al. Medicine's New Rhythm: Harnessing Acoustic Sensing via the Internet of Audio Things for Healthcare[J]. IEEE Open J Comput Soc. 2024;5:491–510. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 09 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviewers invited by journal 24 Feb, 2026 Editor invited by journal 02 Feb, 2026 Editor assigned by journal 02 Feb, 2026 Submission checks completed at journal 02 Feb, 2026 First submitted to journal 29 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8735258\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":597011921,\"identity\":\"8bbf9eb5-af20-4337-8df6-01bc775280c7\",\"order_by\":0,\"name\":\"Bihui Chen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Changsha Hospital of Traditional Chinese Medicine(Changsha Eighth 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services\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig.1Aconceptualmodelofstakeholdersauthenticexperiencesinunaccompaniedcareservices.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8735258/v1/1d544bbaa1dfedd2609353bc.jpg\"},{\"id\":103495615,\"identity\":\"93993b7f-60ff-4385-a2fa-8025c0ae85f9\",\"added_by\":\"auto\",\"created_at\":\"2026-02-26 11:05:55\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":100076,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eDynamic interactions among core categories influencing stakeholders' experiences\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig.2Dynamicinteractionsamongcorecategoriesinfluencingstakeholdersexperiences.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8735258/v1/7a0889148d3bfe7cebd278bf.jpg\"},{\"id\":104397694,\"identity\":\"1cd98e27-58c4-48bb-ab51-2853d5a9bcca\",\"added_by\":\"auto\",\"created_at\":\"2026-03-11 11:54:41\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1508877,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8735258/v1/f07edf4d-efeb-49a1-88fd-788dd73f0e8a.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Stakeholders' authentic experiences with unaccompanied care services:A grounded theory qualitative study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eChina is accelerating toward becoming a super-aged society, a trend posing severe challenges to both the healthcare system and family caregiving models. Data from the Ministry of Civil Affairs of the People's Republic of China indicates that by the end of 2024, China's population aged 60 and above reached 310\\u0026nbsp;million, accounting for 22% of the total population. The population aged 65 and above stood at 220\\u0026nbsp;million, representing 15.6% of the total population[1]. The rising hospitalization rate is an inevitable consequence of this aging trend. The Statistical Bulletin on China's Health Development in 2023, released by the National Health Commission of the People's Republic of China, indicates that in 2023, the number of hospital admissions nationwide reached 301.873\\u0026nbsp;million, with the annual hospitalization rate among residents hitting 21.4%[2]\\u0026mdash;significantly higher than the average hospitalization rate among Organisation for Economic Co-operation and Development(OECD) countries (13.05%)[3].\\u003c/p\\u003e\\n\\u003cp\\u003eAgainst this backdrop, family caregivers of hospitalized patients face multiple pressures: high prevalence of chronic diseases, heavy time and financial burdens, lack of medical knowledge, role conflicts, and psychological strain. Furthermore, influenced by the one-child policy implemented from 1979 to 2016, data from the Seventh National Population Census (2020), conducted by the National Bureau of Statistics, indicate that China has approximately 200\\u0026nbsp;million only children. It means a large number of families are caught in the predicament of \\\"one couple caring for four elderly parents,\\\" further exacerbating the fragility of family caregiving. Research shows that the heavier the burden on caregivers, the lower their willingness to provide care[4]. A qualitative systematic review[5]indicates that factors such as poor hospital environments, financial pressures, a lack of support systems, and ineffective collaboration with healthcare providers significantly diminish the capacity of family caregivers to provide care. International research further reveals this trend: Andrea Cattaneo et al.[6] used a demographic microsimulation model to project the burden of informal family caregiving across 31 European countries from 2000 to 2050. Their findings indicate that the overall burden of informal care in Europe is projected to increase by 49.7%. In low- and middle-income countries, informal caregivers face heightened marginalization and endure the dual pressures of cultural expectations and personal sacrifice[7]. Notably, excessive reliance on family caregiving may negatively impact patient recovery. For instance, a Turkish study[8]found hospitalized patients experience conflicting emotions toward informal caregivers: relying on their emotional support while simultaneously feeling guilty for imposing burdens.\\u003c/p\\u003e\\n\\u003cp\\u003eFor a long time, inpatient care in China has primarily relied on family members providing care or patients hiring their own caregivers. This non-professional care model has led to issues such as inconsistent care quality, a high risk of hospital-acquired infections, and disorganized ward management. These problems not only compromise patient safety and experience but also increase the coordination burden on medical staff. To address this challenge, in October 2024, the National Healthcare Security Administration issued guidelines for nursing service projects, establishing a separate pricing category for unaccompanied care services under government-guided pricing. Starting in June 2025, China officially launched pilot programs for unaccompanied care services in tertiary hospitals across key provinces and cities with significant aging populations, as part of comprehensive healthcare reform [9]. Unaccompanied care services evolved from unaccompanied ward services. They primarily refer to daily living assistance provided by nurses or hospital-employed healthcare assistants to inpatients. This service is offered based on the patient's condition and level of self-care ability, with informed consent and voluntary choice from the patient or their family. Internationally, wards employ healthcare assistants (HCAs), certified nursing assistants (CNAs), or nurse aides to manage patients' daily care, effectively sharing the workload of registered nurses (RNs). This model has also spawned services like respite care[10]and day care services[11], better meeting the diverse needs of patients and families while enhancing the overall efficiency of healthcare systems.\\u003c/p\\u003e\\n\\u003cp\\u003eAt present, China's unaccompanied care services are primarily provided by medical care assistants, marking a shift from family responsibilities to professional services. As these services remain in a pilot exploration phase, existing research has primarily focused on analyzing the burden on informal caregivers[12]or the practical difficulties in implementing unattended wards[13], with limited in-depth exploration of the actual experiences of patients and family caregivers. With China's rapidly aging population and the shift toward nuclear family structures, the traditional healthcare model, which relies on family accompaniment, faces severe challenges. Imbalanced nurse-to-patient ratios lead to declining care quality, while the phenomenon of \\\"one hospitalization burdening the entire family\\\" further exacerbates societal strain. During the initial pilot phase of unaccompanied care services, implementation effectiveness may be constrained by factors such as differing perceptions among patients and their families, insufficient attention to emotional needs, and variations in service quality. Internationally, Unaccompanied care services models have matured in countries such as Japan, Germany, the UK, Australia, and Singapore, where standardized management has significantly reduced family burdens and enhanced nursing quality[14, 15]. While these established practices demonstrate the feasibility of professionalized unattended care models, cultural differences necessitate localized exploration of the humanistic care dimension within such services. Therefore, systematically revealing the authentic experiences of patients and informal caregivers regarding unaccompanied care services through grounded theory not only provides empirical evidence for policy optimization but also serves as a critical pathway to bridge institutional design with real-world needs.This approach propels care models from reactive responses toward people-centered, sustainable development.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDesign\\u003c/h2\\u003e \\u003cp\\u003eThis study adopts grounded theory as a research framework and analytical methodology, a research methodology for qualitative research proposed by Anselm Strauss of Columbia University and Bar-ney Glaser of the University of Chicago in 1967, which seeks to explain and understand by generalizing concepts and theories from data to social phenomena. The grounded theory uses coding as its essential analytical tool, and we adopted Strauss and Corbin's programmed version, which consists of open coding, axial coding, and selective coding[\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e].Semi-structured in-depth interviews were conducted with patients, informal caregivers, medical care assistants, and managers of the care company who utilized the companion-free care service at a tertiary hospital in Hunan Province. The interviews took place in September 2025.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eParticipants\\u003c/h3\\u003e\\n\\u003cp\\u003eThis study employed purposive sampling to recruit patients, informal caregivers, medical care assistants, and managers of the care company who met the inclusion and exclusion criteria from a tertiary hospital in Hunan Province.\\u003c/p\\u003e \\u003cp\\u003e(1)Patients were required to be aged 18 years or older and to provide informed consent for voluntary participation. They were excluded if they were unable to express themselves or make autonomous decisions verbally or in writing, or if they had severe conditions such as critical heart, lung, or kidney failure that would prevent cooperation.Medical care assistants were included if they provided informed consent and voluntarily agreed to participate in the survey. They were excluded if they were unable to cooperate with the interview due to language barriers or mental health conditions.(2)Informal caregivers were eligible if they were aged 18 or older, had been the patient's primary caregiver since hospitalization, and provided informed consent for voluntary participation. Those unable to cooperate with the interview due to language barriers or mental disorders were excluded.(3)Medical care assistants were included if they provided informed consent and voluntarily agreed to participate in the survey. They were excluded if they were unable to cooperate with the interview due to language barriers or mental health conditions.(4)Managers of the care company were included if they were directly responsible for the operation and quality management of unaccompanied care services, had held the position for at least 3 months, and provided informed consent. Exclusion criteria were an inability to participate in the interview due to language barriers or mental health conditions.\\u003c/p\\u003e \\u003cp\\u003eA total of 42 stakeholders were interviewed:\\u003c/p\\u003e \\u003cp\\u003e19 patients (P1\\u0026ndash;P19), comprising eight females and 11 males, aged 36\\u0026ndash;85 years (mean 59.7 years). They had received unaccompanied care services for 2\\u0026ndash;23 days (mean 9.5 days).\\u003c/p\\u003e \\u003cp\\u003e8 informal caregivers (C1\\u0026ndash;C8), including five females and three males. Their relationships to the patients were three daughters, one son, two wives, and two husbands.\\u003c/p\\u003e \\u003cp\\u003e13 medical care assistants (A1\\u0026ndash;A13), all female, aged 44\\u0026ndash;56 years (mean 46.8 years), with caregiving experience ranging from 6 months to 12 years (mean 4.7 years).\\u003c/p\\u003e \\u003cp\\u003e2 managers of the care company (M1, M2), one male and one female.\\u003c/p\\u003e\\n\\u003ch3\\u003eData collection\\u003c/h3\\u003e\\n\\u003cp\\u003eData were collected using semi-structured interviews. All interviews were conducted jointly by two researchers, with one primarily responsible for asking questions and the other observing, taking notes, and providing supplementary follow-up questions when appropriate. Prior to the interviews, both researchers engaged in in-depth theoretical studies, received guidance from experienced experts, and practised their interviewing skills through preliminary interviews to refine their technique.\\u003c/p\\u003e \\u003cp\\u003e Before the formal interview began, the researchers clearly explained the purpose of the study to the participants. The interview commenced only after confirming their understanding. The interview guides are presented in Tables\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, and \\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e. Interviews were conducted face-to-face, each lasting approximately 20 to 40 minutes. Throughout the process, the researchers maintained an open, non-directive attitude, encouraging participants to express their genuine experiences and probing for deeper information through timely follow-up questions. After each interview, the audio recordings were immediately transcribed into text, followed by a process of progressive coding.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eInterview guides for patients and informal caregivers\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTheme\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eQuestions for patients\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eQuestions for informal caregivers\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003ePerception and needs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1. What is your understanding of unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1. What is your understanding of unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2. What kind of help and support do you expect from the medical care assistants?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2. What are your most significant expectations of the medical care assistants?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eDecision and experience\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3. What were your reasons for choosing unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3. What were your reasons for choosing unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4. What positive and negative experiences did you have during the service? Were there any difficulties, and if so, how did you cope?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4. Were there any particularly memorable incidents during the service?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eEmotion and life changes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5. During the service, did you feel the medical care assistants understood your emotions and needs? Could you give an example?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5. During the service, what positive or negative changes did you observe in the patient's condition?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6. How has your life changed after using unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6. How has your life changed after using unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIntention for continued use\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7. What factors might lead you to decline or continue using unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7. What factors might influence your decision to decline or continue choosing unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSuggestions for improvement\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8. What are your additional views or suggestions regarding the current unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8. What are your additional views or suggestions regarding the current unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eInterview guide for medical care assistants\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTheme\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eQuestions for medical care assistants\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eRole perception and responsibilities\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1. How do you understand the professional role of a medical care assistant?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2. In the context of unaccompanied care services, what are your primary specific responsibilities?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eWork experience and challenges\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3. During your actual service provision, what moments make you feel a sense of value or accomplishment? Could you provide an example?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4. What are the main difficulties or pressures you encounter in your work, and how do you typically handle them?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eInteraction with patients/families\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5. How do you understand and respond to the emotions and needs of patients?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6. In the process of communicating and collaborating with patients' families, have there been any particularly memorable incidents?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eProfessional identity and development\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7. What are your thoughts on how your income corresponds to your workload intensity?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8. Are you willing to continue in this profession in the future? What factors would influence your choice?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eViews and suggestions on the service system\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9. What aspects of the current service model or management approach do you think could be improved?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10. What support would you hope to receive from the hospital, the care company, or at the policy level?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eInterview guide for managers of the care company\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTheme\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eQuestions for managers\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eService operation and management model\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1. What is the core operational and management model of the unaccompanied care services in your company? What are its main advantages and disadvantages compared to traditional accompanied care?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHuman resources and team development\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2. What are the key challenges regarding personnel suitability within your team? How do you address issues of professional burnout and staff retention among care assistants?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eService quality and risk control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3. How do you manage and control the service quality of unaccompanied care? What are the core risk points, and what measures are in place to address them?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCross-role collaboration and communication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4. What are the main challenges in collaboration and communication with medical staff, patients, and their families when providing unaccompanied care? How can these be optimised?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003ePolicy environment and industry development\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5. How does the current policy environment impact the development of unaccompanied care services?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6. What are your expectations for the future development of the industry and for policy support?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7. Are there any other issues or experiences regarding unaccompanied care services that you would like to add?\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData analysis\\u003c/h2\\u003e \\u003cp\\u003eThis study analyzed 42 qualitative transcripts using a three-level coding approach based on the Strauss and Corbin version of grounded theory, employing NVivo 12.0 software for data management. The qualitative data underwent open coding, axial coding, and selective coding to construct a theoretical model.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eOpen coding\\u003c/h3\\u003e\\n\\u003cp\\u003eOpen coding is a commonly used data analysis method in qualitative research. Its fundamental principle involves a detailed, line-by-line analysis of the textual data, where keywords, phrases, sentences, or paragraphs are annotated or coded to enable deeper analysis and understanding. Through continuous induction, organization, and the listing of items, along with the elimination of contradictory initial concepts, a total of 36 initial concepts were ultimately identified, forming nine categories.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAxial coding\\u003c/h2\\u003e \\u003cp\\u003eAxial coding is a theme-based coding method designed to systematically classify and organize data, extracting central themes and key concepts. It is typically conducted following open coding and helps researchers gain a deeper understanding of the data, enabling more in-depth analysis and interpretation. By connecting the nine categories derived from open coding and clarifying their relational meanings, three main categories were developed: the reconstruction of a sense of security during the transfer of care responsibility, the dilemma of compatibility between professional care and humanistic needs, and the balance of authority, responsibility, and resources in service operation.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eSelective coding\\u003c/h3\\u003e\\n\\u003cp\\u003eSelective coding employs the logic of \\\"plotting a storyline\\\" to synthesize all related conceptual categories into a theoretical model, clarifying the interactive relationships and structural connections between the main categories and the core code. We established the authentic experiences of stakeholders in unaccompanied care services as the core category. This core category is influenced by the three main categories derived from the axial coding stage.\\u003c/p\\u003e\\n\\u003ch3\\u003eTheoretical saturation test\\u003c/h3\\u003e\\n\\u003cp\\u003eStrauss posits that theory achieves good saturation when the additional data no longer generates new categories or insights[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. The theoretical saturation test is a process of applying the three-level coding to reserved data to verify the accuracy of the previously obtained coding results. In this study, six reserved qualitative transcripts were used for the theoretical saturation test, repeating the three-level coding process for a new round of analysis. The results indicated that the initial concepts identified could be subsumed under the previously constructed 36 initial concepts, with no new concepts or categories emerging, and no new relational structures developing among the categories. Therefore, it can be concluded that the model has reached a state of theoretical saturation[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEthical considerations\\u003c/h2\\u003e \\u003cp\\u003e The Medical Ethics Committee of the Changsha Hospital of Traditional Chinese Medicine(Changsha Eighth Hospital) approved the research project described here (Ref: 2025090228). All subjects provided verbal and written consent to participate, and only the researchers had access to the digital audio tapes and transcripts.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThrough the three-level coding process of grounded theory, this study distilled 36 initial concepts during the open coding phase. These were organized into nine categories for axial coding: fluctuation in sense of security and risk perception, mechanisms of trust building, conflict and adjustment of emotional bonds, capacity and limitations of service provision, diversity and conflict of service demands, gap in value recognition, systemic challenges in human resources, synergy and efficacy of operational management, and demands for policy and market support. Subsequently, three main categories were derived from selective coding. Specifically, the reconstruction of a sense of security during the transfer of care responsibility represents the most immediate psychological and relational experience for all parties following the service intervention. The dilemma of compatibility between professional care and humanistic needs constitutes the core conflict and efficacy challenge in matching supply with demand at the practical level of service delivery. The balance among authority, responsibility, and resources in service operation is the underlying systemic support and fundamental constraint for the first two categories. Together, these three elements form a dynamic explanatory framework: the clarity of authority/responsibility and the sufficiency of resources at the systemic level directly shape and constrain the ability to integrate professionalism and humanistic care in practice, ultimately determining whether patients, family caregivers, and medical care assistants can successfully establish stable trust and psychological safety during the transfer of care responsibility. This model suggests that optimizing service experience cannot be limited to improving interpersonal interactions but must also involve systemic governance encompassing human resources, management coordination, and policy safeguards. The overall model of factors shaping stakeholders' authentic experiences is presented in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. The dynamic relationships among the three core categories are further detailed in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. Representative original statements, integrated and summarized, are presented below.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThe reconstruction of a sense of security during the transfer of care responsibility\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eFluctuation in sense of security and risk perception\\u003c/h2\\u003e \\u003cp\\u003eBoth patients and medical care assistants experience, across different dimensions, a fluctuation in their sense of security and the weight of risk perception. On one hand, medical care assistants bear significant psychological strain due to their direct caregiving responsibilities, which immerse them in persistent professional anxiety, subsequently affecting their work efficiency and emotional stability. Research indicates that this psychological pressure stems not only from demanding workloads but also from deep concern for patient health outcomes and the pressure of self-expectation[\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. On the other hand, while receiving professional care, patients also have to contend with the unfamiliarity of the medical environment, the fragmentation of their daily routines, and the heightened emotional sense of family absence, which intensifies their worries about treatment effectiveness. Consequently, their psychological state and sense of trust are also severely impacted during the medical process.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"One night, a grandma lowered her bed rail by herself to go to the bathroom and almost tripped over my caregiver's cot. It scared me so much my scalp went numb, and I still feel a shudder thinking about it.\\\" (Psychological burden behind safety vigilance, A8)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Caring for a tracheostomy patient is overwhelmingly stressful because any oversight can be a matter of life and death. Especially when the patient's wife is present, that feeling of being scrutinized adds an invisible pressure, making me extra cautious.\\\" (Lack of confidence in managing complex conditions, A3)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"He has dementia. What worries me most now is that he keeps unconsciously trying to pull out his IV line.\\\" (Safety risks and behavioral management during hospitalization, P4)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"We have encountered cases where some patients become overly dependent on the medical care assistants. They frequently use the call button once the assistant is out of sight. When the assistant is slightly delayed due to handling the needs of multiple patients, this patient would then exaggerate complaints to the medical staff. This unnecessary frequent calling and biased complaining not only increases the workload for the assistants but also negatively impacts their professional dignity.\\\" (Power dynamics and moral hazard behind irrational calls, M2)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Sometimes I look forward to the phone ringing, but I am also afraid of disturbing them (the children).\\\" (Sense of emptiness with family absent, P2)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"In the hospital, time feels fragmented. You are not even fully awake before the nurse comes to take your blood pressure and check your blood sugar.\\\" (Unfamiliarity and adaptation to the medical environment, P6)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMechanisms of trust building\\u003c/h2\\u003e \\u003cp\\u003eThe construction of trust relationships in unaccompanied care services is a multidimensional and dynamic process. Its core mechanism is rooted in the bidirectional interaction between the output of professional competency from the care supply side and the feedback of emotional recognition from the demand side. From the perspective of care providers, a standardized pre-service training system lays the foundation for professional competence, while the application of caregiving skills in clinical settings transforms this professional ability into tangible care value, forming the material basis for trust establishment. From the perspective of care recipients, responsive care behaviors enabled by technological mediators (e.g., call buttons), along with caregivers' proactive explanations for service delays, reduce information asymmetry during the care process. Furthermore, care recipients' subjective understanding of the caregivers' professionalism and labor efforts elevates instrumental trust to emotional trust, ultimately facilitating the formation of stable trust relationships within unaccompanied care services.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The company and the hospital provide theoretical and practical training, covering things like Cardiopulmonary Resuscitation\\u003c/em\\u003e(\\u003cem\\u003eCPR), the seven-step handwashing technique, patient turning and transfer, as well as prevention of constipation, thrombosis, and pressure injuries. You have to pass the exams before you can start working.\\\" (Professional competence and skill application, A5)\\u003c/em\\u003e\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The elderly patient is bedridden and completely dependent on care. I turn him and clean him every day. Over all this time, his skin has remained completely intact, with no pressure injuries at all.\\\" (Practical application of skills and sense of value, A12)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The medical care assistant gave me a call button connected to her watch. Most of the time, she comes as soon as I press it. On the rare occasions she's late, she proactively explains the situation. We understand she might be busy with other patients at the same time.\\\" (Technological mediation and trust building in responsive care, P15)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"This assistant has been exceptionally kind to me and very meticulous in her work. I see it clearly and I also understand how hard they work.\\\" (Understanding of the assistant's professionalism and efforts, P15)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eConflict and adjustment of emotional bonds\\u003c/h2\\u003e \\u003cp\\u003eUnaccompanied care services profoundly reconfigure traditional caregiving relationships rooted in kinship, triggering complex emotional tensions and adaptive adjustments among diverse stakeholders. This series of emotional and identity conflicts must be understood within specific cultural and social normative contexts. In Chinese society, the Confucian culture-rooted norm of filial piety and familialistic expectations shape a strong sense of moral responsibility among informal caregivers [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]. This study found that the process manifests as a dynamic interplay of multiple dimensions, including the generation of guilt, the expenditure of emotional labor, the mobilization of psychological resilience, and the transformation of identity. Patients and their families, due to the formalized transfer of care responsibility, may experience an \\\"outsider\\\" sense of alienation and an objectified position of being \\\"managed.\\\" Meanwhile, medical care assistants, while providing professional services, also bear emotional suppression and challenges to their professional dignity arising from perceived social status inequality.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Every time I go to the hospital, it feels like I am a guest. Watching the medical care assistant busy all around, I feel like an outsider instead.\\\" \\\"Every time I come to the hospital to bring meals for my dad, and see the daughter in the next bed personally caring for her elderly parent, my heart really aches.\\\" (Guilt from not providing personal care, C4, C5)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Some family members think that because they have paid over a hundred yuan, we are somehow inferior. When faced with unwarranted scolding, arguing doesn't solve the problem. My strategy is to avoid conflict and communicate after they've calmed down proactively. Of course, it feels stifling inside, but to keep doing this job, I have to slowly digest it myself.\\\" \\\"We've already done our absolute best, yet we still can't avoid complaints. Sometimes, the will to keep going feels almost drained. If your efforts aren't met with understanding, what's the point of persevering?\\\" (Emotional labor and psychological grievance, A1, A7)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"I just strive to do everything with full dedication, so my conscience is clear. Holding onto one's own integrity is more important than anything.\\\" \\\"The four of us medical care assistants get along like sisters, supporting and sharing the burden with each other.\\\" (Positive psychological adjustment and professional resilience, A2, A11)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Now, when my daughter visits, the first thing she always does is find the caregiver to check on me. Listening to them discuss my diet and daily routine, I feel like an object that needs to be managed.\\\" (The dilemma of identity shift from subject to object, P8)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThe dilemma of compatibility between professional care and humanistic needs\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eCapacity and limitations of service provision\\u003c/h2\\u003e \\u003cp\\u003eThe practical efficacy of unaccompanied care services relies on the caregiver's professional ability to meet the diverse care needs of patients. It is constrained by multiple practical factors within the caregiving context, such as time allocation, professional adaptation, and institutional regulations. This presents a coexistence of \\\"capacity compatibility\\\" and \\\"practical limitations.\\\"\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"For this work-related injury hospitalization, the company arranged a care assistant for me. Her main responsibilities include my daily care, such as bathing, assisting with toileting, preparing meals, washing clothes, reminding me to take medication, and monitoring my IV drip. These tasks are both professional and mundane, but she performs them diligently and meticulously, ensuring my daily living needs are well-managed during recovery.\\\" (Support for life reconstruction within professional care, P13)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Currently, taking care of two patients simultaneously is indeed overwhelming. This gentleman is accustomed to waking up early, around 7 a.m., whereas the younger patient typically sleeps until 1 or 2 a.m. and doesn't get up until 10 a.m. Their routines are opposite; even meal times don't align. It really requires attending to them separately.\\\" (Challenge of time coordination in cross-schedule care, A4)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Transitioning from a domestic helper to a hospital care assistant is a new challenge for me. My husband looks after our grandson at home, and when needed, the supervisor can help arrange shift swaps, which allows me to balance work and family.\\\" (Skill challenge and adaptation in career transition, A3)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Now, every care step needs to be logged, like feeding, administering medication, and turning the patient. I understand it's for standardized management, but it does affect the rhythm of care. I truly hope that while ensuring compliance, we could also be given more time to focus on the care itself.\\\" (Dilemma of balancing institutionalized recording with the human touch of care, A9)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDiversity and conflict of service demands\\u003c/h2\\u003e \\u003cp\\u003eThe demands of patients and their families for unaccompanied care services exhibit apparent diversity and often create tension with the actual service provision. On one hand, patients require not only basic life assistance but also, and more importantly, expect emotional support such as respect and patience, which they regard as core components of professional competence. On the other hand, family members, from the perspectives of care efficiency and their own peace of mind, propose specific suggestions for optimizing service processes and resource allocation. These diverse, specific, and often emotionally charged expectations directly clash and collide with the current standardized service provision operating within limited resources.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"When I needed to use the bathroom at night and called for the care assistant, she seemed very impatient. I later complained to the supervisor. I believe patience with patients is a fundamental professional requirement in this line of work.\\\" (Concern regarding assistant's quality and service consistency, P19)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"If the hospital could arrange for the several patients under one assistant's care to be in the same room, she could be readily available whenever needed. We would feel more at ease, and it would also save her effort. Wouldn't that be a win-win situation?\\\" (Suggestions for improving the service model and communication, C1)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eGap in value recognition\\u003c/h2\\u003e \\u003cp\\u003eWithin unaccompanied care services, a significant disparity exists in the understanding and expectations of care value among different stakeholders, creating a bidirectional gap in value recognition. Saiki M. found that a perceived expectation gap in role cognition is a key obstacle constraining the realization of value and team efficacy for medical care assistants[\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. Medical care assistants not only expect economic compensation commensurate with their labor but also yearn for their professional competence and emotional investment to be seen and accorded social respect. Conversely, some family members, unable to personally fulfill caregiving responsibilities, experience guilt over not doing enough and emotional alienation while enjoying the convenience of the service.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"What we give is not just physical effort, but also heart. Chatting with the elderly while bathing them, patiently soothing patients when they are restless... We hope these 'invisible' efforts can also be seen. We don't need sympathy, just the understanding and respect that should be accorded to medical care assistants.\\\" (Desire for labor value to be seen and respected, A7)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The 'one-to-three' model (one caregiver for three patients) costs 154 yuan per patient per day, with the company taking a cut from that. There's a widespread hope that the company can establish a fairer compensation mechanism so our income better matches our current efforts.\\\" (Mismatch between income and effort, A1)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Every time I go to the hospital, it feels like I'm a guest. Watching the medical care assistant busy all around, I feel like an outsider instead.\\\" (Guilt from not providing personal care, C4)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThe balance among authority, responsibility, and resources in service operation\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec22\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eSystemic challenges in human resources\\u003c/h2\\u003e \\u003cp\\u003eThe sustainable development of unaccompanied care services is highly dependent on human resource support. However, the industry currently faces systemic challenges across multiple dimensions, including talent supply, protection of physical and mental well-being, and career development. These issues not only hinder the stable development of the service workforce but also further limit the potential for improving service quality [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The team lacks younger members, creating bottlenecks in service philosophy, learning ability, and physical stamina. This makes it difficult to achieve a qualitative leap in overall service quality and management level.\\\" (The team dilemma of \\\"hard to recruit, hard to retain\\\", M1)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"I can't sleep soundly at night. The moment my patient makes a sound, I'm immediately awake. Sleep is fragmented; having deep sleep is a luxury.\\\" \\\"I'm responsible for three elderly patients at night and basically cannot sleep. Just as I settle one patient, I have to help the other two turn over or use the toilet. I dare not fall into deep sleep. Physical exhaustion is bearable, but this chronic sleep deprivation is truly agonizing.\\\" (Severe physical depletion and sleep deprivation, A1, A8)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"I'm 56. How long I can do this job depends entirely on my health. If I stay strong, I'll work another three to five years. If I feel I can't handle it anymore, I can't force myself. Ultimately, health is the foundation of everything.\\\" \\\"In our line of work, we don't dare think too far ahead. Where we'll be tomorrow is all uncertain.\\\" (Fragile occupational security and health risks, A6, A13)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003e \\\"The career ladder in our field is indeed quite flat. Even if promoted to team leader, the pay increase is limited, but the trivial matters to worry about multiply.\\\" \\\"In our line of work, it seems there isn't much difference in professional identity between doing it for ten years and doing it for one.\\\" (Narrow career development path, A5, A11)\\u003c/em\\u003e\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"I was a nurse for over a decade before switching to a management role in a care company. The main reason for the career change was my inability to withstand the impact of long-term night shifts on my physical and mental health.\\\" (Loss of nursing talent and career value reconstruction from the perspective of professional burnout, M2)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"I used to be in the catering industry. I switched to caregiving only because my child started school here. But the physical toll of this job is too great, and I deeply feel the income does not match the effort.\\\" (Occupational vulnerability and high turnover, A4)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec23\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eSynergy and efficacy of operational management\\u003c/h2\\u003e \\u003cp\\u003eThe high-quality advancement of unaccompanied care services relies on the support of an operational management system characterized by multi-stakeholder synergy. Its efficacy is reflected in the multi-dimensional linkage of constructing cross-role collaboration mechanisms, fostering team cohesion, and stimulating caregiver professional identity.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"We have always hoped to regularly organize exchange sessions between medical care assistants and nurses, allowing both sides to address clinical collaboration issues openly and solve problems together. Simultaneously, we conduct bi-monthly satisfaction surveys. Once issues are identified, we immediately coordinate interventions and, if necessary, make personnel adjustments to ensure the stability and professionalism of the service team.\\\" (Building a management ecosystem of collaborative governance, M2)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;As the group leader, I firmly believe patients come first. Sometimes when family members are upset and speak harshly, I can only patiently explain and communicate sincerely. After all, putting myself in their shoes, no family finds it easy when a loved one is ill. On our floor, we are like one big family. If someone calls for help, we all pitch in. Though I'm just a care group leader, I always believe putting others first is right. Our common goal is to take good care of the ward and provide good service.\\u0026rdquo; (Professional conviction and view on team collaboration, A10)\\u003c/em\\u003e\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"My mother-in-law had a stroke, and I cared for her at home for three years. After she passed last year, I became a medical care assistant. My husband wasn't keen on me working, but he respects my decision. I didn't have much schooling, but I'm willing to learn and work hard, and I'm satisfied with my current salary.\\\" (Professional identity and value realization, A8)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec24\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDemands for policy and market support\\u003c/h2\\u003e \\u003cp\\u003eThe rise of unaccompanied care services is a direct response to multiple challenges, including shortages in family caregiving resources, the intensification of societal ageing, and shifts in the workforce structure. To ensure its sustainable development, it is necessary to promote synergistic efforts between policy support and market mechanisms. Stakeholder appeals focus not only on practical needs such as alleviating payment burdens and expanding/optimizing service supply but also contain a deeper expectation for societal recognition of the value of caregiving labor [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Currently, these care services are entirely out-of-pocket for families. For ordinary households, it's indeed a significant expense. It would be great if the state could include some of it in medical insurance reimbursement.\\\" (Appeal for policy and financial support, M2)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"My children all have their own careers and families to attend to, which we understand. Hiring a caregiver means not disrupting their work while still ensuring I receive the care I need. It brings peace of mind for both sides.\\\" (Addressing the core pain point of absent family care, P17)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"This policy is truly a great thing for patients and families. At over a hundred yuan per day, it's much cheaper than before, tangibly easing the financial pressure on our family and making professional care more affordable.\\\" \\\"This policy has been a huge help. The only shortcoming is that the number of trained professional medical care assistants is still somewhat insufficient. It would be even better if more systematically trained assistants could be cultivated in the future.\\\" \\\"The state's introduction of this unaccompanied care policy has solved our biggest practical difficulty.\\\" (Perceived experience of policy beneficiaries, P9, P10, P12)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"My family wanted me to stay home and rest, but at home I'd just play cards and often lose money. Later, I thought, why not work as a caregiver? I could earn some money and help those in need. Though I'm not young, I can still work with my own hands, which actually makes me feel more settled.\\\" (Social value and self-actualization through midlife re-employment, A4)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003e This study, utilizing grounded theory, conducted an in-depth analysis of the authentic experiences of four core stakeholder groups in unaccompanied care services\\u0026mdash;patients, informal caregivers, medical care assistants, and managers\\u0026mdash;constructing a theoretical model centered on the axes of \\\"reconstruction of a sense of security,\\\" \\\"dilemma of compatibility,\\\" and \\\"balance among authority, responsibility, and resources.\\\" The analysis reveals that this emerging model precisely addresses the rigid demand for patient care in the absence of family companions, a demand arising from societal aging and changing family structures, demonstrating initial social value due to its accessibility and professionalism. However, its sustainability faces profound challenges: a sharp contradiction exists between the enormous market demand at the front end and a workforce of medical care assistants at the mid-tier, predominantly composed of middle-aged and older women, who are physically and mentally exhausted and whose labor value is not fairly compensated. The back end, meanwhile, is constrained by inefficient collaborative management and a lack of policy support. This imbalanced state of strong demand but fragile supply, significant value but insufficient support reflects China's transitional dilemma in its super-aging process, caught between traditional familial ethics and a modern professional care system.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec26\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eReshaping the core concept: from familial filial piety to social care justice\\u003c/h2\\u003e \\u003cp\\u003eThe fundamental contradiction of the service first stems from the cultural-cognitive level. In China, according to the Constitution of the People's Republic of China, the Civil Code of the People's Republic of China, and the Law on the Protection of the Rights and Interests of the Elderly, adult children bear comprehensive support obligations toward their parents, encompassing financial provision, daily care, and emotional comfort[\\u003cspan additionalcitationids=\\\"CR25\\\" citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]. China's traditional filial piety culture embeds care responsibilities within the family, forming a kinship-based ethical obligation that influences choices regarding the type of care[\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e]. The emergence of unaccompanied care services signifies an institutional transfer of part of this responsibility from the private to the public sphere, and from ethical practice to professional service[\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e]. The widespread guilt felt by family members and the occasional objectification experienced by patients in this study are manifestations of the cultural-psychological conflict inherent in this transfer process. This suggests that the success of the service lies not only in technical substitution but, more importantly, in whether a discursive reconstruction of care justice can be achieved at the societal level\\u0026mdash;that is, establishing a new consensus: that professionalized, socialized care is also a legitimate and responsible form of fulfilling filial duty and love, not an abdication of familial responsibility.\\u003c/p\\u003e \\u003cp\\u003eTo realize this reconstruction, the core of the service must transcend task completion and return to a humanistic concern for the whole person. This requires integrating two care approaches validated by international research: First, valuing narrative care by encouraging medical care assistants to build emotional connections through listening to and respecting patients' life stories, which is a key pathway to acknowledging and responding to patients' emotional needs, thereby achieving personalized care[\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. Second, attending to spiritual health, which involves perceiving and responding to patients' needs for meaning, dignity, and inner peace within daily caregiving[\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. Such integration can help mitigate the risk of dehumanization potentially induced by institutionalized care, infusing the service with indispensable emotional warmth.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec27\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAddressing the key dilemma: making emotional labor visible, measurable, and respected\\u003c/h2\\u003e \\u003cp\\u003eThe experiences of medical care assistants profoundly expose the structural shortcomings of the service system. Their work is a classic example of emotional labor, involving not only physical exertion and skill but also the continuous regulation of emotions, psychological soothing, and preservation of dignity. However, within the current management and compensation systems, this emotional investment is invisible, and its value is systematically undervalued. Fanfan Lv et al.[\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e] further indicate that when caregivers perceive their contributions far exceed their rewards, it can easily trigger negative psychological responses, subsequently leading to reduced levels of emotional labor and increased professional burnout. This is the core mechanism underlying the widespread physical and mental exhaustion, income dissatisfaction, and high turnover rate among the current caregiver workforce, especially the group predominantly composed of middle-aged and older women.\\u003c/p\\u003e \\u003cp\\u003eAddressing the emotional labor dilemma and stabilizing the caregiver workforce require implementing systematic, three-pronged interventions: First, drawing on tools like the Scale of Emotional Labor for Nurses developed by Jiyeon Hong et al.[\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e] in 2019, which was formulated based on the nursing cultural context, to transform abstract emotional care into observable, assessable professional behaviors, making its value visible. Second, by setting reasonable pay standards and designing clear career progression paths, ensuring the emotional efforts of medical care assistants are met with corresponding wages and professional respect. Finally, establishing a comprehensive psychological support system for medical care assistants, developing standardized emotional management training programs, enhancing guidance on emotional labor, and cultivating empathy and communication skills[\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. Only through collaborative efforts among policymakers, institutional managers, and service providers can emotional labor be transformed from an unpaid, hidden expenditure into a core care value that is formally recognized, measured, and respected, thereby improving care quality and professional attractiveness.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec28\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eRebalancing relationships and technology: using digitalization to empower, not weaken, care warmth\\u003c/h2\\u003e \\u003cp\\u003eThe introduction of technological tools (e.g., call buttons, electronic check-in systems) aims to enhance efficiency and safety. However, this study finds that if the design and management of technological systems fail to fully account for the relational nature of care work, unintended negative consequences can arise. The core issue lies in this: when technology solidifies a unilinear interaction mode of call-response and, in managerial terms, excessively reduces the work of medical care assistants to a series of task-based metrics, the time and space required for those unquantifiable yet crucial elements of care quality\\u0026mdash;such as proactive observation of a patient's condition, patient listening, and the provision of immediate emotional support based on the patient's mood\\u0026mdash;become systemically compressed. This dilemma reflects a deeper contradiction within the current care industry: the inherent tension between a nursing ethos of empathy and person-centeredness, and the procedural, impersonal nature inherent to digital technology itself[\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e]. Therefore, future technological applications should strive to shift from being \\\"task management tools\\\" to becoming relational support media, with their design core focused on how to assist, not replace, interpersonal care interactions.\\u003c/p\\u003e \\u003cp\\u003eConsequently, the core principle of technological design should be empowerment,not substitution. Utilizing smart voice or wearable devices to automatically record routine data can free up medical care assistants' time spent on mechanical logging[\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. Developing mobile knowledge support systems can provide medical care assistants with instant guidance. Establishing secure information-sharing platforms can allow families to understand patients' non-medical daily status, alleviating their anxiety. The ultimate goal of technology should be to enhance, not diminish, the depth and warmth of human connection.\\u003c/p\\u003e \\u003cp\\u003eIn summary, unaccompanied care services represent a crucial institutional experiment for China in responding to a super-aging society. This study reveals that their long-term success depends on guiding a profound systemic transformation: reconstructing care justice at the cultural-cognitive level, recognizing the value of emotional labor in labor policies, adhering to a human-centered approach in technological application, and achieving integrated continuity within the service system. Through this multi-dimensional, systematic, and coordinated governance, this model can evolve from a temporary measure alleviating manpower shortages into an integral component of a just, sustainable, and humanistic modern healthcare system. Its experiences and lessons hold significant reference value for societies facing similar aging challenges.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eOECD Organisation for Economic Co-operation and Development\\u003c/p\\u003e\\n\\u003cp\\u003eHCAs Healthcare Assistants\\u003c/p\\u003e\\n\\u003cp\\u003eCNAs Certified Nursing Assistants\\u003c/p\\u003e\\n\\u003cp\\u003eRNs Registered Nurses\\u003c/p\\u003e\\n\\u003cp\\u003eCPR Cardiopulmonary Resuscitation\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors wish to express their gratitude to all the participants who kindly shared their stories.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors’ contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors read and approved the final manuscript. BH Chen was responsible for the conceptualisation and design of the study, conducted the formal analysis, investigation, and data curation, and drafted the original manuscript. BH Chen, YY Wang and YL Liang were involved in acquiring funding for the study. HL Zhu, X Li, QN Han and Q Huang contributed to the validation of the study. J Tang assisted in investigation and data curation. YY Wang and X Li contributed to the formal analysis. \\u0026nbsp; \\u0026nbsp; Y Liu was responsible for software support. Q Huang and YY Wang provided resources and project administration. All authors participated in reviewing, and provided critical feedback for the development of the final analytic themes.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research is supported by the Natural Science Foundation of Hunan Province (No: 2026JJ3415, 2026JJ2675, 2026JJ2734), the Science and Technology Project of Hunan Provincial Sports Bureau (No: 2025KT040), the Key Project of Changsha Traditional Chinese Medicine Research (No: SB2024-018), and the Key Project of University‑Hospital Joint Fund of Hunan University of Chinese Medicine (No: 2025XYLH115).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData availability\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during this study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDeclarations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was approved by The Medical Ethics Committee of the Changsha Hospital of Traditional Chinese Medicine(Changsha Eighth Hospital). All methods were carried out in accordance with relevant guidelines and regulations.Signed informed consent was obtained from all individual participants included in the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMinistry of Civil Affairs of the People's Republic of China.National Report on the Development of Aging Undertakings. 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IEEE Open J Comput Soc. 2024;5:491\\u0026ndash;510.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"unaccompanied care services, qualitative research, grounded theory, aging society\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8735258/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8735258/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e \\u003cb\\u003eBackground\\u003c/b\\u003e Rapid aging in China has increased hospitalizations, straining the traditional family-based care model. The newly implemented national unaccompanied care service addresses this by transferring inpatient daily care to professional medical care assistants. The authentic experiences of stakeholders in this new model are underexplored.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eMethods\\u003c/b\\u003e A qualitative study guided by Straussian and Corbinian grounded theory. Semi-structured interviews were conducted with 42 stakeholders from a tertiary hospital in Hunan Province in September 2025.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eResults\\u003c/b\\u003e The authentic experiences of stakeholders in unaccompanied care services were established as a core category, which was influenced by three main categories:\\u003c/p\\u003e \\u003cp\\u003ethe reconstruction of a sense of security during the transfer of care responsibility, the dilemma of compatibility between professional care and humanistic needs, and the balance among authority, responsibility, and resources in service operation. Nine categories formed from 36 initial concepts were included under the three main categories.\\u003c/p\\u003e \\u003cp\\u003e\\u003cb\\u003eConclusions\\u003c/b\\u003e The transition to unaccompanied care involves profound psychological, relational, and systemic shifts. Ensuring its sustainable and humanistic development requires a multi-faceted transformation: a cultural shift from familial filial piety to social care justice; policy recognition of medical care assistants' emotional labor; and human-centered technological application that empowers rather than replaces human care. This study provides a crucial theoretical foundation and empirical insights for optimizing care service policies and practices, offering valuable implications for global aging societies navigating similar transitions.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Stakeholders' authentic experiences with unaccompanied care services:A grounded theory qualitative study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-26 11:05:45\",\"doi\":\"10.21203/rs.3.rs-8735258/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-09T11:18:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"327640614094324844037133197490483068773\",\"date\":\"2026-03-06T01:12:40+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"150392229211820734330192015529265286400\",\"date\":\"2026-03-03T11:39:26+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-24T09:36:46+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-02-02T07:15:18+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-02T06:19:39+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-02T06:15:08+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Health Services Research\",\"date\":\"2026-01-29T21:29:12+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"8540045e-8d1e-4f89-98a1-8533dc22e1a4\",\"owner\":[],\"postedDate\":\"February 26th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-02-26T11:05:46+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-26 11:05:45\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8735258\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8735258\",\"identity\":\"rs-8735258\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}