A nationwide survey of patient problem occurrence across different nursing healthcare sectors

Abstract Aim The aim of this study was to determine the patient problems that nurses encounter in different clinical settings and the extent to which they report being able to influence those patient problems. Design Exploratory online survey research. Method Data were collected through an online questionnaire. We prepared a 2 × 2 matrix to compare the rate of occurrence against the average level of reported influence. Descriptive statistics were used for the data analysis. Results A total of 440 nurses working in different settings completed the questionnaire. Nurses report having the most influence on patient problems related to self‐care, mobility and functions of the skin. Nurses experience less influence on problems with voice/speech and the tasks required for participation in work/employment.


| INTRODUCTION
Nurses provide care to people of all ages in various healthcare settings such as hospitals, residential care, general practices, primary care, psychiatric health care and care for the disabled. Nurses with various levels of education work together in collaboration with other healthcare professionals (Jacob, Mckenna, & D'Amore, 2015). The focus of nursing care can differ between clinical settings. For instance, psychiatric health nurses take care of patients with mental and emotional disorders (eg, depression, schizophrenia) and focus on coping and adjustment of anxiety or mood problems (MacNeela, Morris, Scott, Treacy, & Hyde, 2010). Hospital nursing care might be more concentrated on patients with physical diseases, such as heart failure or cancer and nursing care could be focused on the coping and adjustment of pain, dyspnoea or nausea (Griffiths, Richardson, & Blackwell, 2012). Although the focus of nursing care can differ between clinical settings, the problems or health issues that patients experience are not restricted to one specific setting. For instance, a patient with severe mobility problems has an increased risk of developing pressure ulcers, regardless of the healthcare setting where the patient resides.
From the patient's perspective, it is important that nursing care can be continued and that nursing information is up-to-date, accurate and not contradictory. From the perspective of nurses, it is important to have an actual record of the nursing care process that a patient has gone through and which can follow the patient after transfer to another setting.
The information nurses gather, share and exchange should therefore be used or reused when a patient is transferred from one setting to another. However, a retrospective patient record review showed variation in what nurses write in patient records in Dutch hospitals. Patient problem labels (N = 1635) with variances in descriptions were ascertained in 369 nursing records (Paans & Müller-Staub, 2015). Similarly, other studies on the transfer of information also found a wide variability of information in the nursing records (Griffiths, Morphet, Innes, Crawford, & Williams, 2014;Holly & Poletick, 2014). The variation and variability hampers the exchange and reuse of data within and across settings (Hughes, Lloyd, & Clark, 2008;Lavin, Harper, & Barr, 2015;Voyer, Cole, McCusker, St-Jacques, & Laplante, 2008). It is therefore essential to have a clear view of patient problems that commonly occur in clinical nursing practice across different healthcare settings.

| Background
Patient problems form the basis for a nursing care plan where nurses make clinical decisions in agreement with the patient and/or their close relatives, coordinate care, set goals and monitor care results (Johansen & O'Brien, 2016). Throughout this paper, the term "patient problem" will be used as a synonym for a nursing diagnosis, health or health-related issues, phenomena or problems. One essential aspect of identifying a patient problem is that nurses can plan interventions and actions to help the patient to achieve positive results (Lavin et al., 2004). For example, when an area of skin is placed under pressure, with appropriate interventions nurses can prevent that pressure ulcer emerges. In general, the scope of nursing care is focused on patient problems arising from an illness, disorder or disability and contributes to maintaining or restoring health, the ability to function and quality of life. The illness itself is not necessarily the focal point; rather, that is how the patient functions. This is viewed as an interaction between the illness or disorder on the one hand and, on the other, the ability to function and participate in a social context (Royal College of Nursing (RCN), 2014). Patient problems defined by nurses should therefore reflect and capture this scope.
On the other hand, there is a different perception about the inclusion of patient problems related to nursing practice. For instance, the classification of nursing diagnosis as developed by Nanda-International included a nursing diagnosis of "feeding self-care deficit" (Nursing Diagnoses 2015-2017: Definitions and Classification, 2014, which is not included as a problem by the Omaha System classification (Koster & Harmsen, 2015). Besides, nurses also describe patient problems in their own words (Paans & Müller-Staub, 2015), leading towards a diversity of patient problems and definitions. It could be argued that nurses do not have access to consistent and coherent nursing information, including patient problems. To determine which patient problems reflect and capture the scope of the nursing clinical practice, identifying the occurrence of relevant patient problems is a necessary first step (Coenen & Kim, 2010).
The aim of this research was to gain more insights into the occurrence of patient problems in the Dutch clinical nursing practice. In the Netherlands, running a query to identify which patient problems occur in nursing practice is difficult, because nursing care is mostly reported by hand in patient records (as narrative text). We therefore conducted a survey study among Dutch nurses across different healthcare settings to determine what patient problems they encounter. We also examined the extent to which they report being able to influence (prevent or minimise) patient problems. The extent of the influence that nurses experience in preventing or minimising patient problems may give an insight into which patient problems are relevant to nursing care (Heslop & Lu, 2014). This present study has been set up to gain more insight in the type of patient problems needs to be shared in the context of the clinical nursing practice across different healthcare setting and populations.

| Sample and recruitment process
For this study, 838 registered nurses were approached who had expressed willingness to complete online questionnaires. These nurses were participants in a pre-existing survey panel, the Nursing Staff Panel

| Developing the online questionnaire
As the aim of this study was to gain more insight into the occurrence of patient problems across different healthcare sectors, a questionnaire was set up (Fig. 1). The questionnaire was based on the theoretical framework of the International Classification of Functioning, Disability and Health (ICF), because of its conceptualization of health and health-related functioning (RIVM, 2007).
Nurses examine the relationships between disorders, limitations in activity and functioning and care for patients in different healthcare contexts (Heinen, van Achterberg, Roodbol, & Frederiks, 2005;Kearney & Pryor, 2004). The ICF approaches human functioning from three perspectives: the body, the individual and the social aspects (RIVM, 2007). The human organism is classified into organ systems, identified as the "body functions and structure" component. The second and third perspectives are addressed using the "activity and participation" component. Both components, "body functions and structure" and "activity and participation", are divided into 17 categories. These categories are in turn subdivided into subcategories with terms and descriptions. A category can include several subcategories. To address all aspects of patient problems from the different healthcare contexts, the patient problems were systematically organised by using the sorting of the ICF checklist (World Health Organization, 2003). The researcher checked if the categories could be connected to nursing practice and added a subcategory if necessary. Each category and subcategory was defined. The ICF definitions were literally incorporated into the online questionnaire (http://apps.who.int/classifications/icfbrowser/). The final categories and subcategories are shown in Appendix 1.

| The Questionnaire
For Question 1, the respondent was shown the 17 categories and asked to state the number of days during the preceding period of five F I G U R E 1 The online questionnaire Question 1: Please consider your last five working days and indicate on how many days you encountered patient problems within a category Question 2: Please indicate the category that you encounter most frequently in your daily nursing activities Question 3: Please indicate which specific problems you encounter every working day Each category was specified in subcategories of patient problems (based on the ICF checklist). Each patient problem was defined (the ICF definitions were literally used).
Question 4: Please indicate how much influence you experience on preventing or minimizing these problems: none, a bit, moderate, quite a lot, a great deal Each category was specified in subcategories of patient problems (based on the ICF checklist). Each patient problem was defined (the ICF definitions were literally used).
working days on which they encountered patient problems (see Fig. 1, Question 1). An explanation accompanying the question stated that it was irrelevant whether the problem occurred repeatedly with the same patient or with various patients.
Categories marked by respondents as "every working day" were counted automatically by the survey software. If a respondent gave this answer in more than seven categories, they were asked a supplementary question (Question 2). All respondents were subsequently shown the categories they had indicated (up to a maximum of seven) and asked to state which specific problems they encounter every working day (Question 3). An explanation accompanying the question, where each patient problem was defined in accordance with the definitions of the Dutch translation of the ICF (RIVM, 2007). The respondents were next asked to indicate how much influence they have in preventing or minimising problems ( Fig. 1, Question 4), with five possible answers: "none" (score 1), "a bit" (score 2), "moderate" (score 3), "quite a lot" (score 4) and "a great deal" (score 5).
To test the content validity of the draft questionnaire, a researcher

| Data collection
Subsequent to the test phase, an e-mail containing a hyperlink to the questionnaire was sent to 838 nurses. These nurses were participants in the Nursing Staff Panel (http://www.nivel.nl/panelvenv). The e-mail explained the objective and importance of the research. The respondents could complete the questionnaire anonymously. Nurses who had not yet done so were sent a maximum of three e-mail reminders at intervals of 2 weeks.

| Ethical considerations
All respondents received a letter explaining the objective of the study and stating that participation was voluntary. Further ethical approval of this study was not required under the legislation (www.ccmo.nl/en/) applicable in the Netherlands, as all respondents were competent individuals and this study did not involve any interventions or treatments.

| Data analysis
The data collected were exported to SPSS (versions 18 and 21).
The frequencies of specific categories were arranged according to rate of occurrence and collated in a table. Next, the frequencies of the patient problems in each specific category were computed and sorted in descending order from most to least. Two groups were created by using the median to identify the 50% most frequently occurring and 50% least frequently occurring patient problems. The median frequency was 65.5 with a minimum of 4 and a maximum of 185. Similarly, we used the median to form two groups of level of influence: "high level" and a "low level" of perceived influence.
The median level was 2.96 with a minimum of 1.83 and a maximum of 3.68. A 2 × 2 table was then used to combine the frequency of occurrence with the level of reported influence. This created four quadrants: (i) frequently occurring/high level of influence experienced, (ii) frequently occurring/low level of influence experienced (iii) less frequently occurring/high level of influence experienced and (iv) less frequently occurring/low level of influence experienced. The four quadrants provide a framework by which patient problems and the level of reported influence can be explored and analysed further.

| RESULTS
In February and March 2014, 440 of the nurses approached completed the questionnaire (response rate of 52.5%). Of these, 377 (86%) were female (see Table 1). The average age of the respondents was 49 (standard deviation, or SD 10.2). The majority have a Bachelor's degree in nursing (53%), while 35% have an Associate degree and 2% a Master's degree. The largest group are those employed at hospitals (35%), followed by psychiatric healthcare (17%), general medical practice (16%), primary care (15%), health care for the disabled (11%) and residential care for the elderly (6%).  Working hours per week, mean (range) 28 (5-40) SD 6,9

| Most commonly occurring categories of patient problems
A total of 88% of respondents reported encountering one or more categories of patient problems "every working day". Figure 2 shows that 62% of respondents encounter patient problems in the category "mental functions" on a daily basis, followed by the categories "selfcare" (55%) and "functions of the cardiovascular, haematological, immunological and respiratory systems" (49%). The least reported categories were "voice and speech functions" (21%), "functions of the skin and related structures" (25%) and "major life areas" (28%). states the number, that is, how often a patient problem was encountered on a daily basis. The "Mean i" column gives the average level of influence that respondents reported.

| Specific patient problems and the level of influence reported
Quadrant 1 (frequently occurring/high level of influence experienced) and quadrant 3 (less frequently occurring/high level of influence experienced) contain patient problems that respondents said they had a high level of influence over in terms of prevention or minimization. Problems related to the "functions of the skin and related structures" (category 8), "general tasks and demands" (category 10), "mobility" (category 12) and "self-care"(category 13) are particularly striking. Nurses reported having a high level of influence over all the problems in these categories, irrespective of the rate of occurrence.
Quadrant 2 (frequently occurring/low level of influence experienced) and quadrant 4 (less frequently occurring/low level of influence experienced) contain patient problems that respondents said they had a low level of influence over. In this case, all the problems related to "voice and speech functions" (category 3), "neuromusculoskeletal and movement related functions" (category 7) and "major life areas" (category 16) are particularly striking. Irrespective of the rate of occurrence, respondents stated they had a low level of influence when it came to preventing or minimising problems in these categories. Nurses also experience a low level of influence over most of the problems in the category "mental functions" (category 1), except over problems with "emotional functions" and "sleep". The latter two are included in quadrant 1 (frequently occurring/high level of influence).

| DISCUSSION
Using an online survey, we collected information about patient problems in the clinical nursing practice across different healthcare settings and the level of influence nurses say they have in preventing or minimizing these problems. The first research question aimed to gain more insight into the occurrence of categories of patient problems.
Our study showed that mental functions, self-care and the functions involved in the cardiovascular system, haematological, immunological systems and the respiratory system were frequently occurring catego- ries. An interesting finding is that a category can have a high rate of occurrence, but nurses do not necessarily perceive any influence on all patient problems included in the specific category. For instance, the category "cardiovascular system, haematological, immunological systems and the respiratory system" was ranked as a frequently occurring. Looking at the specific patient problems included, nurses experienced a high level of influence on a less frequently occurring patient problem related to "sensations associated with cardiovascular and respiratory functions" (quadrant 3) in contrast to the patient F I G U R E 2 Categories of patient problems in the health care sector as a whole problem "heart functions, including heart rate, rhythm" (quadrant 2: frequently occurring/low level of influence).
When we consider the "high level of influence" more closely, we found that nurses feel they are in a position to influence a considerable number of patient problems (quadrants 1 and 3); related to washing, dressing, eating/drinking, pain, respiratory functions and handling stress. When reviewing the results, we found that our findings are broadly consistent with several studies. Doran's extended analysis of the evidence to include nursing outcomes in acute, community, home and long-term healthcare settings (Doran, 2011) confirmed that patient problems related to pain, symptom management (including fatigue, nausea and vomiting), dyspnoea and adverse patient outcomes (including pressure ulcers) can be affected by nursing care. Also, functional status (containing washing and drying yourself, dressing, toileting, eating, household activities and getting from bed to chair) as well as psychological distress are seen as nursing-sensitive, along with emotional functioning, handling stress and sleeping problems.
Escalada-Hernández et al. (Escalada-Hernández et al., 2015) performed a retrospective study that identified the nursing diagnoses of 690 patients with psychiatric illnesses. They found that common nursing diagnoses related to self-care deficits, including bathing, dressing, feeding, ineffective health management. The study by Paans & Müller-Staub (Paans & Müller-Staub, 2015) conducted in ten hospitals found the most prevalent patient problems to be acute pain, nausea, fatigue, feeding and risk of impaired skin integrity.
When we consider the "low level of influence" more closely, we found that nurses feel they have a low level of influence (quadrant 2 and 4) on several patient problems, eg, patient problems with attention, perception, memory, thought, orientation or problems associated with hearing, speaking, voice, urination, religion, work/economic life.
In reviewing the results, we found that both the study by MacNeela There are several possible explanations for the fact that nurses experience low influences on these patient problems. It may be that nurses simply have low influence on the prevention or minimisation of those types of problems. It could be argued that nurses collaborate with other professionals who are more influential due to their knowledge and competence. On the other hand it is conceivable that nurses are not choosing the correct interventions because they lack the experience or knowledge required to tackle those patient problems.
Another explanation is that the patient problems reported are sectorspecific and as such occur more often in a particular sector. Further research should be undertaken to explore why nurses feel this way.
The development of unambiguously defined nursing patient problems is an important issue for future research. To ensure that information will be transferred accurately from one healthcare context to another, nurses need to establish a standardised core set of patient problems (Matney et al., 2012), where each patient problem should have a unique term representing its meaning. Although nurses do not perceive a significant influence on the development of relevant nursing information (Gephart, Carrington, & Finley, 2015), they should explore whether a consensus can be reached regarding the various patient problems.

| Research strengths and limitations
One positive aspect of this research is that the respondents represent the entire nursing profession -all healthcare sectors are included. A response rate of 52% is acceptable compared with a mean response rate for online surveys of 36.83% (Sheehan, 2001 (Doran, 2011;Escalada-Hernández et al., 2015;MacNeela et al., 2010;Paans & Müller-Staub, 2015). We have therefore gained more understanding about patient problems that are common in nursing practice and the content underlying them.
Finally, we used medians to create the quadrants to ensure even distributions of the observations. The median for influence divided the problems into problems with less than a moderate level of influence and problems with at least a moderate level of influence. Despite the arbitrary nature of the dividing lines, we gained a better picture of which patient problems are relevant and useful to clinical nursing practice.

| CONCLUSION
The purpose of the current study was to determine which patient problems nurses encounter daily and the nurses' perceived degree of influence in preventing and minimizing these patient problems. This study found in general that patient problems related to self-care, such as washing yourself, dressing, toileting and pain occur frequently and that nurses perceive a high level of influence. On the other hand, nurses felt they had less influence on patient problems related to voice/speech or the tasks and actions required to participate in work/ employment. The findings of this study enhance our understanding of the patient problems that reflect clinical nursing practice and complement those of earlier studies investigating patient problems. Despite its exploratory nature, the patient problems identified could be used as the foundation for establishing a standardized core set of patient problems to exchange and reuse information within and across different healthcare settings. Overall, this research has increased our knowledge of and insight into patient problems that encapsulate the scope of nursing care.

| Implications for nursing practice
This research has revealed an overview of patient problems that encapsulate nursing practice. This finding has important implications for research to find a semantically consistent way of defining patient problems, as is required to exchange or reuse information within and across settings. Besides, nurses and nursing informatics should take the lead in exploring how various patient problems can be described and reported in a consistent manner (unambiguously). Only then will nurses be able to communicate, study the effectiveness of their actions and their contribution to the quality of care provided. Finally, nursing management and policymakers should address the findings of this study. It may provide support for developing and implementing policy to improve the consistency of nursing information capturing nursing practice in electronic health records.
A P P E N D I X 1 Overview of ICF categories and subcategories used in the questionnaire. The definitions are online available at: http://www. who.int/classifications/icf/icfchecklist.pdf?ua=1