English
中文1- Abstract
The objective of the study is to formulate a research proposal to ascertain the level of patient satisfaction following consultation with a nurse practitioner within the primary care setting in a general practice surgery. The design of this research proposal will incorporate a patient satisfaction questionnaire based survey of patients seeing the nurse practitioner on the same day as booking and having an appointment. The study will be taking place in on general practice with the United Kingdom and it will use 64 patients who will be required to do the questionnaire over a period of one month. Over the past sixteen years the role of nurse practitioner has developed as a response to the ever increasing demands upon the general practice within primary care, and has become a valuable commodity with which to enhance the service. In previous research studies, patient satisfaction has been high in regard to seeing nurse practitioners. The numbers of these studies are low however and patient satisfaction in many of these studies has not been the primary factor for the study. A larger scale study should be undertaken using multiple data collection methods toensure validity when looking at patient satisfaction in seeing nurse practitioners. Adequate patient population and multiple practice involvement with other nurse practitioners would also ensure validity and reliability of results.
2- Introduction
This study aims to systematically review five studies looking at the nurse practitioners working within the primary care setting. After reviewing current literature, a research proposal which the author developed after discussion with other colleagues within the GP practice will be discussed. Though the literature currently available tells of a nurse practitioners role, none specifically aims to look at patient satisfaction which led to the formulation of this hypothesis as there appears to be a gap in research. The research holds importance as patients opinion of healthcare standards is vital as Donabedian (1980) highlighted; one of the factors by which quality of care can be defined is how well it meets the public standards as to how care should be provided.
There have been few studies on the viability of nurse practitioners taking on the extra workload of GP’s in the United Kingdom, though as nurse practitioners have been well established within the United States, studies have been favorable when discussing nurse practitioners taking on some of the GP’s workload. (Rabin and Spector, 1980) It is known that specialised trained nurses can diagnose and treat a large proportion of those people who currently seek access to a GP. (Marsh and Dawes, 1995) However, Braspenning et al (2004) suggest that nurse practitioners could supplement or extend GP care rather than substitute it. It can be suggested that a study analysing patients’ satisfaction following a consultation with a nurse practitioner is important therefore.
3- Review of relevant literature articles (5)
Article 1
In a small study within a GP surgery of ten staff, fourteen patients and the nurse practitioner, Perry et al (2005) conducted semi structured interviews with the patients having consulted a nurse practitioner.
The Research Problem
The article gave the reader a clear view of the aims and objectives of the research which is of importance in any research article. (Bowling, 2002) The initial problem does bear immediate relevance to the author’s current practice as a nurse practitioner in primary care.
The Literature review.
The literature review is extremely relevant to the research proposal by being both comprehensive and up to date in its sources ranging from 1994 to 2001. It progresses in a logical manner with accurate referencing and at the end of this review the researcher explains its implications highlighting the rationale for proceeding investigational research.
Design of the study
The study design used a quantitative survey which was aimed to identify if having a nurse practitioner would alleviate problems in accessing primary care appointments within a GP surgery.
Data collection and analysis
Data collection is clearly described where it is stated that participants would be interviewed whilst being audio taped after permission was given. This system relied on patients’ ability to verbalise their thoughts which could potentially be influenced by the researcher for varying reasons such as the use of leading questions. (Abbott and Sapsford, 1998) However as all the interviews took place within the same environment for all participants, external validity was maintained. (Polit and Beck, 2006) Patients were asked open questions as open questions give respondents a greater freedom to answer the question because they answer in a way that suits their interpretation. (May, 2001:102) A pilot study did not take place in this study.
Conduct of the study
Prior to the start of the research ethical committee approval was sought as patients would be involved. (Abbott, and Sapsford, 1998) Participants who consented to the research signed a consent form.
Outcomes of the research
Both staff and patients interviewed felt that access had been improved by the addition of the nurse practitioner and expressed satisfaction about the consultation which compares favorably with Horrocks et al (2002).
Article 2
In a study of eleven randomised controlled trials Horrocks et al (2002) gave a systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.
The Research Problem
The research compared nurse practitioners and doctors providing care at first point of contact with undifferentiated problems in a primary care setting. The research aimed to find data on patient satisfaction, health status, costs and the process of care.
The Literature review
The article provided a comprehensive literature review where relevant primary sources from within the last five years were reviewed.
Design of the study
The study design is clear in its objective however the theoretical framework is not. The study itself is both quantitative and qualitative and a plan of action was clearly stated within the method section of the article.
Data collection and analysis
Methods of data collection and the rationale behind them were not clearly explained within the article. The sample selection and size was limited and this was discussed in the article. Observational studies were of poor quality and reliability and validity issues were not discussed within the article. Data collection tools were explained and then justified within the assessment of study quality section. Data analysis methods are described but extremely complicated and difficult to follow. Equally, the table findings were difficult to read and added little to the understanding of the findings, however, discussion of findings was very informative and clear.
Outcomes of the research
The study was problematic with difficulties in finding quality studies and trials to review; studies mainly concentrated on randomised trials. The significance of the findings and relevance to practice relates to the authors research proposal as patients were seen to be satisfied with point of contact care by nurse practitioners.
Article 3
In a study by Offredy and Townsend (2000), 36 semi structured interviews took place in four general practices; GP’s, Nurse Practitioners, receptionists, and patients were analysed in order to explore the role of the nurse practitioner in primary care.
The Research Problem
The purpose of the article is to explore the role of the nurse practitioner in primary care.
The Literature Review
Two articles from the United States were reviewed but neither dealt with nurse practitioners working in primary care in an integrated way. The literature review concluded by identifying the gaps in current research linking it in with implications for their study.
Design of the study
The study provides qualitative research taking the form of semi structured interviews which were highlighted in table form. A clear design is outlined, however the research does not provide a clear indication of the motivations that influenced it.
Data collection and analysis
The data collection method is clearly stated within the article which provides an explanation of the use of the structured audio-taped interview. Sample size was explained and rationalised within the method as was reliability in reducing sample bias. A pilot study was undertaken to formulate interview questions and the method of data analysis was appropriate in this study. The presentation of findings was clear within the broad categories of answers from transcripts of the interviews. The discussion was not satisfactory and did not answer the objective of the report.
Conduct of study
The study proceeded as planned and the findings were clearly stated. No ethical considerations were mentioned other than validation of transcripts by all the patients.
Outcomes of the research
The study produced significant findings which included workload reduction reported by GP’s after employing a nurse practitioner and variations in prescription policies between GP practices for nurse practitioners.
Article 4
In a randomised control trial of nurse practitioner versus general practitioner care for patients requesting ‘same day’ consultations in primary care, Kinnersley et al (2000) attempted to discover whether there were any marked differences between care within consultations.
The Research Problem
Within the title and abstract of the study both the purpose and aims were clear to the author and pertinent to the authors own research proposal.
The Literature review
The literature review in this study was both relevant and comprehensive using up to date primary sources laid out in a logical manner which lead to a rationale for the research that took place within the study.
Design of the study
The research design was clear and informed as identified by Robson (2002), showing clear purpose, method, theory, and sampling strategy together with the research question itself.
Data collection and analysis
The data collection method is clearly described within the study that states the use of a randomized patient satisfaction based survey within ten general practitioner practices with a total of 1368 patients participating. Reliability and validity were discussed in terms of using a randomised control trial and using block randomisation of patients in practices so as to achieve a balance of allocation between nurse practitioner and general practitioner. Homogeneity of subjects was ensured with patients all seeing same day consultations and with external validity ensured as all the patients in the study were being seen in general practice. (Polit and Beck, 2006) The general hypothesis of the study was tested by having the participants initially do a self completion satisfaction questionnaire immediately post consultations, then a postal questionnaire two weeks following consultation to discover whether all issues were resolved or further consultations were needed. The method of the analysis was complex and difficult to understand, however the findings were well laid out in table format which made them easy to interpret, as well as a full and concise discussion of them.
Conduct of the study
With the study being quantitative the statistical significance level of five percent was used throughout. Ethical considerations were not mentioned within the study apart from author gaining patient consent when they attended the surgery.
Outcomes of the research
The findings of the research suggest that nurse practitioners should be seen as a viable alternative to general practitioners. Identification of implications for further research were not as clear however but this article can be seen to support the extended role of the nurse within primary care
Article 5
In a small scale study by Williams and Jones (2006) patient’s perception if being seen by a nurse practitioner were analysed thematically within qualitative in depth interviews.
The Research Problem
The study looked at patients’ experience of the consultation with the nurse practitioner and also aimed to identify the value added to the delivery of care by primary care nurse practitioners for stakeholder evaluation which is relevant within the author’s area of practice.
The Literature Review
The literature review gave a rationale as to why the authors felt there was a need to undertake the research citing Horrocks et al (2002) in recognising the need for further research and clarification of nurse practitioners operational value within the primary care setting.
Design of the study
The design and theoretical framework are extremely clear and easy to understand within the article.
Data Collection and analysis
Data collection is discussed adequately within the article with a clear rationale for the data collection method within the text. In depth interviews were undertaken to gain results. Williams and Jones (2006) cited Burgess (1984) in justifying their small judgment sample of patients enabling them to fully utilize the time available in conducting an in depth analysis. Discussion regarding the validity and reliability of the study structure was identified giving clear rationale behind the thematic themes of the in depth interviews. The method of data analysis used was appropriate as the author had fully justified these methods within the scale of the study.
Conduct of the study
The study proceeded as planned with a clear explanation and discussion of the findings. Ethical considerations were fully identified and structured within the study and followed through.
Outcomes of the research
The main finding of the research was that time played a major factor in patients’ satisfaction in seeing a nurse practitioner. As the nurse practitioners consultations were longer than general practitioners, the patients within the study highlighted that greater time was used to consider their emotional needs and support. Increased time and increased support in seeing a nurse practitioner has been demonstrated in previous research by Kendall (2001).
4- Methodology
The proposed study aimed to be simple in design and easily undertaken by the author within their area of practice. Practicalities, as stated by Lobiondo-Wood and Haber (2002), of the availability of subjects for study, time required for them to participate, any potential cost involved, and timing of the research have to be considered with developing a research proposal. When these issues were taken into account, it was concluded that a small scale study would be most appropriately used by the author. The study would be conducted at the workplace practice as to maximise the control of variables which influence the study. (Polit and Beck, 2006) Generalisation of the results of any proposed study would not be representative of the practice population as a whole due to the scale and numbers involved, however it may point to possible larger scale study for the primary care trust.
After reviewing the research in the literature review and having basic practicalities in mind, the author formulated a research proposal with the aim to investigate how patients perceive being consulted by the nurse practitioner as measured by their level of patient satisfaction. This has been shown to be both a feasible and measurable within other research studies. (Kinnersley et al, 2000)
Patients requesting a same day appointment would be recruited, as this has been seen to be acceptable within previous studies which have taken place by nurse practitioners for minor illnesses (Poulton, 1996). Within the proposed study by the author no boundaries would be set (i.e.) age, as the patients were not screened for these variances during normal practice and therefore represent a valid reflection of the patient population. However the validity of this would depend on the size of the study. As previously stated; generalisations cannot be made regarding the greater population if sample size is too small. (Bowling, 2002) There would be a control aspect to the study that only patients seeking a same day consultation would be asked to take part within the study. The study would be randomly sampled in that patients phoning for a same day consultation should be given the choice of seeing the author as nurse practitioner or seeing a general practitioner. At this stage if the patients wanted to see the nurse practitioner then consent to take part in the research study would be obtained when they saw the receptionist on arrival at the surgery. They would then be given the appropriate amount of information regarding the research which can be seen in appendix 1. (Polit and Beck, 2006) It has to be stated that ethical approval would have been sought from the local health authority ethics committee as patients would be involved within the study should it occur. (Bowling, 2002)
The research would be taken over the course of one month, as the author who would have had the role of nurse practitioner held two surgeries a week seeing 8 patients per surgery which would give optimum sample size of 64 patients. Data collection would be achieved through a self filling questionnaire based approach to collect the information from the patients immediately post consultation. The questionnaire would be given to the patient by the receptionist, who would also receive the completed one.
The objectives of the questionnaire were that it should be simple to understand, should not take too long to complete and should be made easy for the patients to make a valid response to questions being asked. The questionnaire was designed to be anonymous and demographic data would be omitted. The questionnaire would adopt a five point Likert-type scale which consisted of six questions based on the patient satisfaction questionnaire (Baker, 1990) to obtain the numerical grading of the patients view of how they thought the consultation went. After the patients completed the questionnaire they would hand it into the reception staff. The questionnaire can be seen in appendix 2. Data would be analysed by means of using Microsoft word, and Microsoft office xp for windows.
The study did not look at the content of consultations in detail especially regarding specific management issues of prescribing, investigations requested and referral to GP’s. Although specific aspects of consultations would be explored which formed the basis of the patient questionnaire and overall patient satisfaction; clinical indicators were omitted in order to focus upon patient satisfaction. Unlike many studies conducted previously this study would focus upon patient satisfaction following consultation with the nurse practitioner as opposed to comparing the satisfaction of patients with nurse practitioners and GP’s. (Horrocks et aI, 2002) Within the proposed study the professional experience of the nurse practitioner in question may not be typical of other nurse practitioners within the same locality or area due to a variety of differing nursing backgrounds prior to embarking on the nurse practitioner course. Generalisation of these specific results, if the study was undertaken, to other nurse practitioners, could not be made. Larger studies would have to be undertaken to include other nurse practitioners in other practices. Patient long term behaviour was not included within the study unlike Kinnersley et al (2000) so future studies could include extra questionnaires to examine views from weeks following consultation. The study was designed to be carried out over a relatively short period which may not be large enough to capture a fair representation of patient population for that practice. Also because the proposed study was localised, larger study would be needed to capture bigger patient numbers and other practices with other nurse practitioners as in Kinnersley et al (2000). Demographic detail and social class were also omitted from the questionnaire. The questionnaire was also designed to be relatively short to aid patient compliance as well as for collection convenience for both reception staff and patients. A longer more detailed questionnaire may yield a deeper insight into level of patient satisfaction; however this may also increase patient anxiety together with patient compliance. (Bowling, 2002)
5- Discussion and Conclusion
The role of the nurse practitioner is a relatively new addition to primary care and has already been seen to be a valuable asset to the future of primary care in meeting the increased demands upon it and to enable the service to become ever more enhanced.
Nurse practitioners have been able to provide a quality of care which is as good as, and in some way, better than doctors. (Horrocks et aI, 2002) However, it has also been observed in recent studies that they are no substitute, but a supplementation for GP care. (Braspenning, 2004) Previous studies have outlined that patient satisfaction with the nurse practitioner role is high; however more detailed larger studies regarding this are required to examine and reinforce this view. As nurse practitioners are still relatively new to the United Kingdom this study could provide valuable research in the area of primary care. As discussed in the study, many studies have focused on the United States but one may suggest that it is important to produce a study that will mirror a true meaning for practices in the United Kingdom. This study will provide research that will be original for the United Kingdom as it will focus on the patients’ satisfaction after seeing a nurse practitioner. The patients’ views and satisfaction should be at the forefront of any healthcare service and a study such as this will enable the service to develop and meet the needs of the patient.
The author of this research is situated in an ideal position as stated earlier in the methodology; research would be taken over the course of one month, as the author who would have had the role of nurse practitioner held two surgeries a week seeing 8 patients per surgery which would give optimum sample size of 64 patients. This enables easy access to gaining sufficient participants and ultimately results. Also the use of questionnaires will provide a quick way of gaining results as they are very easy to produce on a large scale. The methodology states that data collection would be achieved through a self filling questionnaire based approach to collect the information from the patients immediately post consultation. The questionnaire would be given to the patient by the receptionist, who would also receive the completed one. This represents an easy method of discovering if patients are satisfied with the service provided. The results will be collected over a period of one month which should give adequate time to finding 64 patients who are willing to complete the questionnaire. This study has taken influence from the research by Kinnersley et al (2002), described in the literature review, in terms of its framework and use of questionnaire. Although their research used a vast amount of patients in its study (1368) one can still take influence from this even though this study is only small in scale. It can be suggested that the more participants an investigation contains, the more reliable and valid it will become as it will represent more of the population. Although this study is similar to Kinnersley et al’s in the use of same day as the consultation questionnaires, this study upholds its originality as its focus remains with the patients’ satisfaction rather than a comparison between nurse practitioners and general practitioners.
