A Survey on the Perceptions and Attitudes towards Patient-Reported Outcomes among 527 Nursing Staff in China

doi:10.21203/rs.3.rs-3622288/v1

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A Survey on the Perceptions and Attitudes towards Patient-Reported Outcomes among 527 Nursing Staff in China

https://doi.org/10.21203/rs.3.rs-3622288/v1

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Objective: This study aims to understand the current status of nursing staff’s knowledge and attitudes towards patient-reported outcomes in a tertiary hospital in China, to provide a reference related to the enthusiasm of nursing staff for its comprehensive implementation.

Methods: A survey was conducted on 527 nursing staff from a tertiary hospital in China using general information, self-designed knowledge understanding and demand questionnaires, and Liu Huan’s localized Outcome Measures Questionnaire (OMQ). Multiple linear regression analysis was employed to analyze the influencing factors of the nursing staff's attitudes towards it.

Results: The preferred methods of acquiring and wanting to understand were through reading literature (223 people, 42.36%) and academic conferences (186 people, 35.27%). The content of interest included the usage of measurement tools (382 people, 72.48%) and application (424 people, 80.51%). The total OMQ score was 64.12±0.92, with an average item score of 2.96±0.21. There were significant differences in attitudes scores among different genders, educational levels, departments, understanding, and nursing capabilities. Multiple linear regression analysis showed that gender and educational level were influencing factors for the total OMQ score and the practice barriers section of the questionnaire (P<0.05), while understanding, age, and title were influencing factors for the negative attitudes section of the OMQ (P<0.05).

Conclusion: Nursing staff in tertiary hospitals recognize the value of patient-reported outcomes, have a strong willingness to learn related content, but also harbor some negative attitudes. Measures can be taken against these influencing factors to enhance knowledge and attitudes, thus actively applying them in clinical practice.

Tertiary Hospital

Nursing Staff

Patient-Reported Outcomes

Knowledge

Attitude

Nursing Management

1.1 Background

Patient-reported outcomes (PROs) reflect the concept of a "patient-centered" approach, focusing on the subjective experiences and interests of the patient[1]. They encompass evaluations regarding diseases, treatments, and healthcare, derived directly from the patients' perspectives. They serve to assess symptoms and treatment effects based on self-reporting by the patients. Often, healthcare providers use patient-reported outcome measures (PROMs) to draw conclusions, rendering the data from the reported outcomes measurable, manageable, and conducive to clinical application[2]. However, the realization and efficacy of PROs and their measurement tools in domestic hospitals, especially in influencing medical decisions and nursing services, are inherently related to the understanding and attitude of the nursing personnel towards patient-reported outcomes. This study, through a questionnaire survey, explores the cognition and attitudes of clinical nursing staff in tertiary hospitals toward PROs, aiming to provide a reference for nursing managers to holistically apply and effectively implement patient-reported outcomes.

1.2 Subjects

This study, endorsed by the hospital ethics committee (Approval No: PJ-NBEY-KY-2020-109), involved 527 nursing staff from four tertiary hospitals in a city between December 1, 2022, to December 10, 2022, selected via convenient sampling.

Inclusion criteria comprised of voluntary participation; registered nurses involved in patient care and care decision-making in outpatient or inpatient settings. The exclusion criteria were training nurses, intern nurses, and those not currently in clinical nursing positions due to various reasons.

1.3 Methods

1.3.1 Research Tools

a) General Information Questionnaire included aspects such as gender, professional title, familiarity with patient-reported outcomes, educational qualification, age, years of experience, department, and nursing proficiency.

b) Knowledge and Acquisition Needs Questionnaire concerning Patient-reported Outcomes was developed by the researchers and was assessed for content validity (CVI) by six nursing experts, resulting in a CVI of 0.792. It includes various types of questions exploring the definition, acquisition, and interest in patient-reported outcomes[3].

3) The Outcome Measures Questionnaire (OMQ), translated and verified by Liu Huan[3], consisted of 22 items assessing the general and feedback attitudes toward patient outcomes, measured on a 6-point Likert scale. The questionnaire had a total Cronbach’s alpha coefficient of 0.906, ensuring reliability.

1.3.2 Survey Methods

The survey was conducted online via Questionnaire Star. Research team liaisons sent out questionnaire links to the participants, explaining the purpose, content, and methodology of the survey. The survey was conducted based on the principle of voluntariness and anonymity, allowing one submission per IP address within a ten-day window.

1.3.3 Statistical Methods

Data analysis was performed using SPSS22.00, with quantitative data expressed as mean ± standard deviation and categorical data in frequency and percentage. Various statistical tests, such as the independent sample t-test and F-test, were employed for comparisons, and factors with P < 0.05 or P < 0.01 were considered statistically significant.

2.1 General Information

The survey was administered to 527 nursing staff, comprising 33 males (6.26%) and 494 females (93.74%). Educational qualifications were as follows: junior college 6 (1.45%), associate degree 51 (8.7%), bachelor's degree 452 (86.23%), and postgraduate or above 18 (3.62%). The participants belonged to various departments: Internal Medicine 163 (30.93%), Surgery 102 (19.35%), Intensive Care Unit 40 (7.59%), Emergency Department 121 (22.96%), Obstetrics and Pediatrics 78 (14.80%), etc. Additional details are provided in Table 2.

2.2 Knowledge and Acquisition Needs Regarding Patient-reported Outcomes

Regarding familiarity with patient-reported outcomes, some were partially familiar 128 (24.29%), familiar 389 (73.83%), and not familiar 10 (1.88%). 370 participants (70.15%) could correctly define patient-reported outcomes, and 323 (61.32%) knew what they encompass. Preferred modes of acquisition and learning were: reading literature 223 (42.36%), academic conferences 186 (35.27%), and peer discussions 165 (31.33%), with 106 (20.18%) being unsure about the learning routes. The areas of interest included the background and development of PROs 215 (40.78%), the use of measurement tools 382 (72.48%), interpretation and analysis of the results 378 (71.90%), and application and decision-making 424 (80.51%).

2.3 Attitudes Towards the Assessment of Patient-reported Outcomes

The overall score for assessment attitude was 64.12 ± 0.92, with an average item score of 2.96 ± 0.21. The total score for general attitude was 41.15 ± 0.82, and for feedback attitude, it was 26.22 ± 0.65. The three highest and lowest scoring items are presented in Table 1.

Table 1

Nursing Staff's Top and Bottom Three Scores on Attitudes Towards Patient-reported Outcome Assessments (N = 527, x ± s)
Item Score		Dimension
Top Three Scores
Providing feedback on patient outcome measurements will assist my treatment plan	3.84 ± 0.87	General Attitude
I see the value in altering clinical practices to support the use of patient self-assessment measurements	3.79 ± 0.78	General Attitude
Patient-reported outcomes cannot obtain immediate conditions of the patient	3.14 ± 1.18	Feedback Attitude
Bottom Three Scores
Providing feedback on patient outcome measurements will help doctors and patients cooperate more in treatment	1.91 ± 0.72	General Attitude
Cultivating my ability to provide feedback on disease progression to patients is valuable	1.95 ± 0.70	General Attitude
Using patient outcome measurements will assist me and my patients in making better treatment decisions	1.97 ± 0.84	General Attitude

2.4 Univariate Analysis of Nursing Staff’s Attitudes towards Patient-reported Outcomes

The attitudes held towards patient-reported outcomes by nursing staff of different genders, education levels, departments, those who have or have not come into contact with or have knowledge of patient-reported outcomes, and nursing competence levels were compared. The differences were statistically significant with P<0.05. See Table 2 for details.

Table 2

Univariate Analysis of General Information and Attitudes towards Patient-reported Outcomes by 527 Nursing Staff
	Item	Score(x ± s)	Number of Cases (cases, percentage, %)	t/F	P
Gender	Male	2.94 ± 0.17	33(6.26)	–2.740	0.006
Gender	Female	2.75 ± 0.39	494(93.74)
Nursing Level	N3-N4	3.07 ± 0.04	163(30.93%)	3.332	0.010
	N1-N2	2.78 ± 0.32	278(52.75%)
	N0	2.71 ± 0.47	13(2.47%)
	Specialized Nurse	2.58 ± 0.03	4(0.76%)
	Nursing Manager	2.77 ± 0.42	69(13.09%)
Years of Work	1~	2.83 ± 0.25	30(5.69%)	1.357	0.255
	4~	2.79 ± 0.35	94(17.84%)
	6~	2.81 ± 0.30	92(17.46%)
	>10	2.73 ± 0.42	311(59.01%)
Department	Internal Medicine	2.71 ± 0.42	163(30.93%)	3.707	0.003
	Surgery	2.84 ± 0.31	102(19.35%)
	Intensive Care	2.80 ± 0.35	40(7.59%)
	Emergency	2.82 ± 0.42	121(22.96%)
	Gynecology and Pediatrics	2.56 ± 0.45	78(14.80%)
	Others	2.71 ± 0.29	23(1.88%)
Awareness	Partial Awareness	2.74 ± 0.37	128(24.29%)	1.868	0.025
	Aware	2.77 ± 0.38	389(73.83%)
	Unaware	2.56 ± 0.64	10(1.90%)
Age Range (years)	18~	2.70 ± 0.32	51(9.68%)	2.16	0.072
	26~	2.81 ± 0.29	119(22.58%)
	31~	2.78 ± 0.41	296(56.17%)
	41~	2.71 ± 0.28	51(9.68%)
	>50	2.64 ± 0.45	10(1.90%)
Educational Level	Junior College	2.04 ± 0.31	6(1.45%)	7.983	< .001
	Associate Degree	2.87 ± 0.30	51(8.7%)
	Bachelor	2.76 ± 0.39	452(86.23%)
	Master and above	3.40 ± 0.30	18(3.42%)
Title	Nurse	2.80 ± 0.30	67(12.71%)	0.677	0.567
	Nursing Technician	2.78 ± 0.32	156(29.60%)
	Head Nurse	2.75 ± 0.44	268(50.85%)
	Associate Director and Above	2.72 ± 0.34	36(6.83%)

2.5 Multifactor Analysis of Nursing Staff's Attitude towards Patient-Reported Outcomes

Using the total score of OMQ as the dependent variable, and factors such as gender, professional title, and educational level from the unifactor analysis as independent variables, a multiple linear regression analysis is performed (α in = 0.05, α out = 0.10). The assignment method for the independent variables is shown in Table 3, and the analysis results are displayed in Table 4. Furthermore, the negative attitudes and practical obstacles involved in the feedback attitude in the OMQ scale are analyzed in more detail, as illustrated in Tables 5 and 6.

Table 3

Assignment Method for Independent Variables
Item	Assignment Method
Gender	Male = 0, Female = 1
Nursing Level	N3-N4 = 0, N1-N2 = 1, N0 = 2, Specialist Nurse = 3, Nursing Manager = 4
Years of Work Experience	1–3 = 0, 4–5 = 1, 6–10 = 2, >10 = 3
Department	Internal Medicine = 0, Surgery = 1, Intensive Care = 2, Emergency = 3, Obstetrics and Pediatrics = 4, Other = 5
Awareness	Partial Understanding = 0, Understanding = 1, No Understanding = 2
Age Group	18–25 = 0, 26–30 = 1, 31–40 = 2, 41–50 = 3, >50 = 4
Educational Level	Junior College = 0, Associate Degree = 1, Bachelor's Degree = 2, Master and Above = 3
Title	Nurse = 0, Nursing Technician = 1, Head Nurse = 2, Associate Director and Above = 3

Table 4

Multiple Linear Regression Analysis on the Attitude Towards Patient-Reported Outcomes of 527 Nursing Staff
	Regression Coefficient	Standard Error	Standardized Regression Coefficient	t	P
Constant	3.561	0.195	--	18.251	< 0.001
Gender	–0.174	0.072	–0.110	–2.418	0.016
Nursing Level	0.009	0.014	0.028	0.652	0.515
Years of Work	–0.046	0.035	–0.114	–1.324	0.186
Department	–0.012	0.009	–0.064	–1.376	0.170
Awareness	0.007	0.044	0.008	0.157	0.876
Age Group	0.026	0.039	0.058	0.672	0.502
Educational Level	–0.154	0.045	–0.165	–3.451	< 0.001
Title	0.029	0.037	0.060	0.775	0.439
Note: P < 0.001. R2 = 0.041;Adj. R2 = 0.026

Table 5

Multiple Linear Regression Analysis of Negative Attitudes towards Patient-Reported Outcomes among 527 Nursing Staff
	Regression Coefficient	Standard Error	Standardized Regression Coefficient	t	P
Constant	3.331	0.394	--	8.456	< 0.001
Gender	–0.157	0.145	–0.049	–1.084	0.279
Nursing Level	0.045	0.027	0.072	1.645	0.101
Years of Work	0.003	0.070	0.003	0.038	0.970
Department	0.011	0.017	0.030	0.645	0.519
Awareness	0.248	0.090	0.148	2.768	0.006
Age Group	–0.211	0.080	–0.230	–2.654	0.008
Educational Level	–0.169	0.090	–0.090	–1.869	0.062
Title	0.161	0.075	0.167	2.155	0.032
Note: P < 0.001. R2 = 0.041;Adj. R2 = 0.026

Table 6

Multiple Linear Regression Analysis of Practical Barriers to Patient-Reported Outcomes among 527 Nursing Staff
	Regression Coefficient	Standard Error	Standardized Regression Coefficient	t	P
Constant	4.577	0.333	--	13.757	< 0.001
Gender	–0.285	0.123	–0.106	–2.323	0.021
Nursing Level	–0.039	0.023	–0.073	–1.669	0.096
Years of Work	–0.009	0.059	–0.013	–0.148	0.882
Department	–0.024	0.015	–0.077	–1.646	0.100
Awareness	–0.111	0.076	–0.078	–1.458	0.145
Age Group	0.101	0.067	0.130	1.507	0.132
Educational Level	–0.263	0.076	–0.166	–3.454	< 0.001
Title	–0.003	0.063	–0.003	–0.040	0.968
Note: P < 0 .001. R² = 0.044;Adj. R² = 0.030

3.1 Current Status of Nursing Staff’s Awareness on Patient-Reported Outcomes

This study reveals that the majority of nursing staff have some understanding and exposure to patient-reported outcomes, with literature and academic conferences being the primary sources for acquiring and furthering their knowledge. The focus lies in how to utilize measurement tools and apply the results obtained in clinical settings. This could be associated with the growing application and attention to patient-reported outcomes in clinical practice in our country and a certain level of emphasis on nursing innovation, allowing more clinical nursing staff to participate in innovative research projects and academic exchanges [4–5]. The study indicates that the item "Patient-reported outcomes cannot capture the immediate condition of the patient" scored the highest, suggesting that nursing staff’s understanding of the meaning and specific content of patient-reported outcomes is not entirely accurate and is rather superficial; there is room for improvement. This suggests that nursing managers can help them acquire relevant knowledge through various means. Meanwhile, in this survey, while nursing staff expressed strong interest in the knowledge of patient-reported outcomes, 20.18% believe that the ways to acquire relevant knowledge are unclear, indicating a need for diverse acquisition methods. The use of patient-reported outcomes measurement tools (72.48%), interpretation of results (71.90%), and their application (80.51%) are considered the most interesting aspects [6]. This interest is slightly less than that of medical undergraduates. Some studies have confirmed that patient-reported outcomes are beneficial for comprehensively understanding the patient’s condition [7–8]. However, the introduction, standardized usage, types, and quality of domestic measurement tools are somewhat insufficient [9]. This study suggests that nursing managers or educators should transform this concept into systematic teaching, adding its teaching content in humanistic education in the standardized training courses for nursing staff, or guide and standardize the development, verification, and translation of measurement tools to scientifically and systematically enhance the cognitive level of nursing staff.

3.2 Current Attitude of Nursing Staff towards Patient-Reported Outcomes

This study indicates that the attitude of nursing staff towards patient-reported outcomes is between "somewhat agree" and "somewhat disagree." Female nursing staff, those with higher educational levels, nursing levels N3-N4, who are familiar with patient-reported outcomes, and those currently in surgical departments or intensive care units have higher and more positive scores. The three items with the lowest scores show that there are misconceptions and practical difficulties among nursing staff on how to apply patient-reported outcomes and their clinical value, with a mean value of < 2 points (falling into the "disagree" category), aligning with the study of Wohlfahrt et al. [10]. This may be related to its development still being in the initial stages in our country, concerns about whether integrating its measurement tools into clinical practice will increase the workload, leading to insufficient working time, and whether the complex evaluation content will affect the quality [11–12]. Thestrup Hansen et al.'s research [13] also supports that nursing staff will choose to complete their work first before considering using PROMs. Studies have found that there is a need to improve the understanding of patient-reported outcomes among doctors, nurses, and patients, and the introduced scales may have cultural differences and are not standardized in clinical use, causing medical staff to doubt the validity and authenticity of the measurement results, thus affecting their confidence in clinical promotion. This study suggests that besides training in relevant theoretical knowledge, it is necessary to demonstrate how to apply correctly, how to collect data from patients in actual clinical practice, and combine the characteristics of our country's medical environment and patient population to develop scientific and efficient measurement tools, thereby improving the attitudes of nursing staff, actively practicing positively, and making the data of patient-reported outcomes truly serve medical big data, benefiting doctors, nurses, and patients.

3.3 Multiple Factors Affect the Attitude of Nursing Staff towards Patient-Reported Outcomes

This research demonstrates that nursing staff who are female and possess a higher level of education manifest a more positive attitude towards patient-reported outcomes. Further analysis of the negative attitudes dimension in the OMQ scale reveals: those who are familiar with patient-reported outcomes, aged between 31–40 years, staff nurses, and head nurses score lower in negative attitudes. This could be related to the fact that individuals within this demographic are the backbone of their departments, experiencing a period of relative professional stability. This study contends that the more positive this group is, the more conducive it is to advance patient-reported outcomes clinically. This aligns with Zheng Xutong et al.'s analysis [15] showing that low seniority is a risk factor for expressive obstacles among domestic nurses, and Li Shuangshuang et al.’s research [16] indicating that young nurses experience high levels of depersonalization and professional burnout.

Further analysis of the practical barriers dimension in the OMQ scale indicates that female nursing staff and those with higher education levels are more willing to practice clinically. This may be attributed to women being better and more patient listeners compared to men and those with higher education levels having more opportunities to participate in clinical research, enjoying more learning and exchange opportunities, and maintaining better literature review habits, which align with the concept and primary acquisition pathways of patient-reported outcomes through literature review and learning exchanges. A meta-integration of one study [17] demonstrates that the clinical utilization rate of patient-reported outcomes and their measurement tools is relatively low [18], encountering numerous obstacles in promotion, and nursing staff do not have a sustained habit of collecting patient information [19]. The Theory of Reasoned Action model indicates that attitude is the driving force for behavioral change. The implementation of related training courses can improve attitudes towards patient-reported outcomes, effectively eliminating application barriers to facilitate smooth promotion [3].

3.4 Limitations

This study has some limitations. First, the questionnaire survey has inherent biases, which may affect the reliability of the findings. Second, the study is confined to the attitudes and understanding of nursing staff in a specific geographic location, which limits the generalization of the study's findings. Third, there is a limitation in accurately assessing the depth of understanding and application of PROs due to the quantitative nature of the survey.

3.5 Recommendations for Future Research and Practice

Considering the limitations of this study and the obtained results, it is recommended that future research should focus on exploring more diverse and in-depth qualitative studies to get a comprehensive understanding of the attitudes and understanding of nursing staff towards patient-reported outcomes. Furthermore, there is a need for a national or multi-center large-scale research study to generalize the findings to a wider population of nursing staff.

In practice, enhancing the level of understanding and positive attitude towards patient-reported outcomes among nursing staff is crucial. Nursing managers and educators should consider integrating relevant theoretical and practical knowledge into nursing curricula and continuing education programs. Besides, the development and implementation of standardized and culturally competent measurement tools are vital to enhance the reliability and validity of patient-reported outcomes in clinical practice, which will ultimately contribute to improving patient care and outcomes.

This study has shed light on the current understanding, attitudes, and factors affecting attitudes of nursing staff towards patient-reported outcomes. The findings suggest that there is a varying degree of understanding and a range of attitudes towards patient-reported outcomes among nursing staff, with several factors influencing these attitudes. There is a significant need to improve the knowledge and application of patient-reported outcomes in nursing practice through education, training, and the development of reliable and valid measurement tools. The enhancement of positive attitudes and understanding of patient-reported outcomes among nursing staff will not only benefit the nursing profession but will also contribute to better patient care and improved healthcare outcomes.

Disclosure of interest

The authors declare no conflict of interest.

Funded by

Ningbo Medical Key Discipline - Neurology Project (2022-B12)

Zhejiang Provincial Medical and Health Science and Technology Plan (2023KY276)

Huamei Research Fund Project (2020HMKY64)

Author contribution

The contributions of each author to the manuscript are as follows: Zhang Lumin designed the project, conducted the research, and wrote the manuscript. Fan Weinv and Nie Liangqin contributed to data collection and data processing. Fan Weinv performed the data analysis. Gui Zongying reviewed and provided critical feedback on the manuscript. All authors actively participated in the revision of the manuscript, contributing to its finalization.

Data Availability Statement

Data available on request from the authors.

Consent for Publication

We affirm that consent to publish was obtained from all the study participants. This includes their agreement to the publication of their identifiable data in an online, open-access journal. The purpose, nature, potential risks, and benefits of the study were thoroughly explained to the participants prior to obtaining their consent.

Ethics Approval and Consent to Participate

This study was conducted in strict accordance with the principles outlined in the Declaration of Helsinki. Ethical approval was granted by the Ethics Committee of Ningbo Second Hospital, China (Approval No.: PJ-NBEY-KY-2018-038-01). Informed consent was obtained from all individual participants involved in the study, ensuring their awareness and understanding of the study's objectives and procedures. This includes their consent to participate in the research and the utilization of their medical data, maintaining the highest standards of ethical conduct and patient confidentiality.

Notes on contributors

Lumin Zhang holds a Master's degree and serves as the head nurse with a distinguished role as a nurse in charge. With nearly two decades dedicated to clinical nursing, Lumin has cultivated expertise in attending to patients in respiratory medicine and neurology. Lumin's commitment and proficiency in these specialties make them a recognized figure in clinical nursing.

Weinv Fan, a protomedicus, is the deputy director of neurology with a profound specialization in diagnosing and treating a spectrum of neurological conditions. He excels particularly in managing Parkinson's disease, dystonia, cerebrovascular disease, and other neurological disorders. With a deep understanding of both common and intricate diseases, Weinv is renowned for his adeptness in handling critical cases.

Liangqin Nie is an esteemed attending physician at Ningbo N0.2 Hospital's department of radiotherapy and chemotherapy. Holding a Master's in oncology, Liangqin has a notable emphasis on chest tumors, and a proven record in the treatment of head and neck tumors. With a solid foundation in release, chemical, and targeted treatments, she's accomplished in providing standardized cancer pain treatments. A revered scholar, she has helmed significant medical research projects, authored numerous papers, and is an active youth committee member of notable associations.

Zongying Gui, the head nurse at Ningbo N0.2 Hospital's Department of radiotherapy and chemotherapy, is imbued with comprehensive knowledge in radiotherapy, chemotherapy, and clinical nursing management. Her adeptness encompasses a wide range of care practices for tumor patients, ranging from catheter care to disease complication treatments. With numerous academic papers to her credit, Zongying has contributed extensively to the development of clinical nursing instruments, boasting 15 patents. Furthermore, her role as a part-time instructor in health vocational colleges and her involvement in crafting nursing books underscore her commitment to the discipline.

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A Survey on the Perceptions and Attitudes towards Patient-Reported Outcomes among 527 Nursing Staff in China

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Abstract

1 Introduction

1.1 Background

1.2 Subjects

1.3 Methods

1.3.1 Research Tools

1.3.2 Survey Methods

1.3.3 Statistical Methods

2 Results

2.1 General Information

2.2 Knowledge and Acquisition Needs Regarding Patient-reported Outcomes

2.3 Attitudes Towards the Assessment of Patient-reported Outcomes

2.4 Univariate Analysis of Nursing Staff’s Attitudes towards Patient-reported Outcomes

2.5 Multifactor Analysis of Nursing Staff's Attitude towards Patient-Reported Outcomes

3 Discussion

3.1 Current Status of Nursing Staff’s Awareness on Patient-Reported Outcomes

3.2 Current Attitude of Nursing Staff towards Patient-Reported Outcomes

3.3 Multiple Factors Affect the Attitude of Nursing Staff towards Patient-Reported Outcomes

3.4 Limitations

3.5 Recommendations for Future Research and Practice

4 Conclusion

Declarations

References

Additional Declarations

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