BACKGROUND: Political developments have driven the need to use practitioners other than doctors to deliver services.
AIM: To assess patient satisfaction with the advanced nurse practitioner (ANP) role.
METHOD: A survey was carried out in one inner-city GP practice in the West Midlands, and the data analysed.
RESULTS AND DISCUSSION: In total, 55 questionnaires were completed. Patients expressed significant satisfaction with the ANP, in particular in the areas of communication, advanced assessment, partnership in consultation and preference to be seen by an ANP.
CONCLUSION: This study confirms that patients are satisfied with services provided by the ANP.
Haidar, E. (2008) Evaluating patient satisfaction with nurse practitioners. This is an extended version of the article published in Nursing Times; 104: 26, 32-33.
Elizabeth Haidar, MSc, BSc, CIDC, AHEA, RN, is lecturer in advanced practice, Florence Nightingale School of Nursing and Midwifery, King’s College, London.
The biggest challenges in terms of workforce include the limited supply of doctors and shorter working times due to the European Working Time Directive. Furthermore, GPs’ new GMS2 contract (introduced in 2004) means they can opt out of working out-of-hours, further reducing their working time. There is a need to have more staff working differently, with clearer leadership at all levels (given authority and autonomy). Although controversial, the substitution of doctors by nurses (Pruitt and Epping-Jordan, 2005) has proved to be an option by putting highly trained ‘knowledge and skills’ nurses as the first point of contact.
Developing primary care in this way is seen as an effective way to use an economical workforce by pooling resources, having Payment by Results (DH, 2003), and fostering competition between providers. The government is keen to maximise nursing contributions, reinforced in Liberating the Talents (DH, 2002), The NHS Plan (DH, 2000) and the national strategy for nursing (DH, 1999). It supports the local delivery plan and reflects the national modernisation agenda by funding contracts for advanced nurse practitioners (ANPs) (South Birmingham PCT, 2006).
There was a need for a service such as this in the West Midlands, where too few GPs served large populations of people with high deprivation who were unemployed. The GP practice involved in this study provided a service for young white families with social, alcohol, smoking and drug problems. The ANP role was seen as an additional clinical resource that could increase the number of quality consultations available to local residents by involving patients more proactively in their care.
The ANP role was to be the first contact for patients in this practice, providing a service tailored to their needs by using advanced skills in clinical examination, diagnosis and prescribing, as well as nursing skills in communication and listening. The ANP was to work in an area with inequalities and involve patients individually, to ensure they had input into their healthcare. This stemmed from reports such as Involving Patients and the Public in Healthcare (DH, 2001) and The Patients’ Charter (DH, 1991). The role would also help to bridge the gap between education and health by supporting patients in their health decisions. In order for it to succeed, it needed to be patient centred, clinically driven and locally led, as outlined by Lord Darzi (DH, 2008; DH, 2007).
Aim and method
This study aimed to assess patient satisfaction with the ANP role. A prospective survey was carried out in April 2005, inviting patients who attended the GP practice to complete a self-administered questionnaire in confidence. The questionnaires were placed in the practice’s reception area, but the surgery played a neutral role in inviting patients to complete them. The receptionist was the only person in the surgery who was to mention that patients could complete the questionnaire if they wanted to. No-one was coerced. Basic demographic data was obtained including gender and age. A postbox was constructed for patients to leave their completed questionnaire, and it was opened three weeks later to obtain the responses.
Before the survey was carried out, patients were asked what they perceived as the positive and negative aspects of their nursing care at the practice. The main themes that emerged were: the importance of communication skills; the need for thorough assessment of their condition; and longer consultations. Questions were subsequently developed and aimed to measure patients’ attitudes. These were later shown to a selection of people who attended the practice, to explore their responses to the way the questions were worded. The purpose of this was to ensure that patients understood the questions in the way they were intended.
The questionnaire included 15 Likert-scale and three open-ended questions. The 15 Likert-scale questions asked patients to respond to a series of statements using a four-point scale of ‘agree’, ‘sometimes agree’, ‘disagree’, and ‘can’t say’, with topics falling into four specific groups:
Effectiveness of the ANP’s communication skills;
Patient satisfaction with the ANP’s advanced assessment skills;
Partnership between the ANP and patients during consultation;
Patient view on whether they would have rather seen a doctor instead of the ANP.
The population studied and the eligibility criteria for sample selection included:
Patients registered with the practice;
Those willing to participate in the survey;
Patients who had appointments or attended opportunistically during the survey period.
For data analysis and drawings, Microsoft Excel was used.
In total, 55 questionnaires were completed. Of these, 44 respondents were female and 11 male. Age distribution is shown in Fig 1.
The ANP’s communication skills
Overall, 84% (n=46) of patients said the ANP made them feel at ease, with only 7% (n=4) agreeing it was difficult for them to discuss their problems with this practitioner.
In response to the question asking whether the nurse should listen more, 62% (n=34) disagreed while 25% (n=14) agreed.
The ANP’s advanced assessment skills
The second area explored was patient satisfaction with the ANP’s advanced assessment skills. Three-quarters (75%, n=41) agreed the ANP examined them fully when necessary and 62% (n=34) felt confident the ANP knew about their history and condition.
Partnership between ANP and patients
Nearly three-quarters (71%, n=39) felt they were given the opportunity to have an active part when discussing their illness/condition, while 9% (n=5) disagreed with this.
Over half (53%, n=29) did not feel they came away from the consultation wishing they had asked more questions, while 18% (n=10) said they felt like this, and 25% (n=14) said they sometimes felt like this.
Nearly a quarter (24%, n=13) agreed there was not enough time to discuss their problems with the ANP, but 47% (n=26) disagreed with this.
Over half (58%, n=32) felt the ANP gave them more information about their illness/condition than any other healthcare professional, with 67% (n=37) agreeing the ANP explained the diagnosis clearly. Three-quarters (75%, n=41) of patients felt the ANP explained clearly any tests that may be required.
Only 5% (n=3) agreed there were frequent interruptions during the consultation, and 80% (n=44) disagreed.
Patient preferences on seeing a doctor or ANP
All patients were asked whether they left the practice feeling they wanted to see a doctor instead. Three-quarters (75%, n=41) disagreed, while 20% (n=11) agreed with this.
The prominence given to patient satisfaction surveys can be traced back to the Griffiths report (Department of Health and Social Security, 1983), which encouraged the use of market research to obtain consumers’ views. In fact, the most common method of data collection involves the use of pre-coded self-completion questionnaires (Batchelor et al, 1994).
One of the advantages of self-administered questionnaires is the absence of interviewer effect. However, the pilot study involved the ANP directly asking patients their views on the questions, and this could have biased the survey with a possible interviewer effect. This pilot study was performed because no valid, sensitive and reliable measure had yet been developed to measure patient satisfaction with nursing (Thomas, 1996).
In addition, there was a high rate of illiteracy and this could have had a substantial impact on the outcome. The survey received 67 responses, 12 of which were excluded because of incompletion. The ANP saw approximately 240 patients during the three-week survey period but played a neutral role in encouraging them to complete the questionnaire.
The study involved convenience sampling, whereby only those people available have a chance of being selected (Parahoo, 1997). However, this method had the advantage of preventing disruptions in the practice while carrying out the proposed research.
Another consideration is that all the questionnaires were completed in the surgery. The social and cultural factors of the environment in which research takes place must be taken into consideration - the setting of this ‘captive’ population of patients may not be the same as when they are interviewed in their own homes (Parahoo, 1997). It was hoped that staff playing a neutral role in the survey might help avoid any element of pressure to respond. A more appropriate scale to assess patient satisfaction would have benefited this survey to aid with validity and reliability.
The ANP’s communication skills
Good communication skills are fundamental in nursing and are an important aspect of nurse education (NMC, 2005). The DH (2006) emphasised the need for effective communication skills in its proposals for reform. As Lord Darzi (DH, 2007) suggested, practitioners need to listen to patients, the public and others to identify what is required over the next decade in order to commission and provide world-class care.
Regarding the effectiveness of the ANP’s communication skills, 84% of respondents said the ANP made them feel at ease, with only 7% agreeing it was difficult for them to discuss their problems. This was important in ensuring that patients felt comfortable enough to take an active role in their care.
While 25% agreed that the nurse should listen more, the question on this issue was felt to be ineffective as it could be misinterpreted by patients. The question could be viewed in two ways: either as stating that this was an attribute the ANP should have, or as suggesting this was an attribute they did not have and should have. Since it could be viewed in two ways, this made the answer invalid.
However, the feedback from questions 16 and 18, which asked about what patients like about their care and the differences between the ANP and doctors, supports the nurse’s listening skills. This was also highlighted as a difference between doctors and the ANP.
It was also interesting to note that patients in this practice were white British and yet it was owned and run by two Asian Indian doctors who had not been born in the UK. There could be various communication issues when comparing Asian and Western cultures. For example, many people of Asian origin avoid eye contact as it can be a sign of aggression or a disobedient gesture while a smile could be seen as a sign of discomfort or embarrassment (Selvaraj, 2002). Since the Asian culture is usually cautious about non-verbal forms of communication, this could account for patients’ negative feedback on doctors’ communication.
The ANP’s advanced assessment skills
The second area of interest was patient satisfaction with the nurse’s advanced assessment skills. Three-quarters (75%) agreed the ANP examined them fully when necessary and 62% felt confident the ANP knew about their history and condition. This supported Shum et al (2000) and Iliffe’s (2000) research suggesting nurses can do some of what doctors do with regard to the satisfaction of patients.
Partnership between the ANP and patients
Nearly three-quarters (71%) felt they were given the chance to have an active part when discussing their illness or condition. This is important in allowing patients the opportunity to take responsibility for their healthcare to reduce the impact of long-term conditions and create a patient-led NHS (DH, 2005).
It was disappointing to discover that 18% of patients wanted to ask more questions, as the consultations were thought to be thorough. However, other findings supported the ANP’s thoroughness and ability to collaborate with patients - over half felt the ANP gave them more information about their illness or condition than any other healthcare professional, and over two-thirds felt the ANP clearly explained their diagnosis and any tests that may be required. This supports the findings of Laurant et al (2005), in which nurses provided more health advice and achieved higher levels of patient satisfaction compared with doctors. This will also help in the identification of key services to commission over the next decade.
The 18% (n=10) of patients who came away from the appointment feeling they wished they had asked more questions may have found their consultation too short, as suggested by the 24% who felt there was not enough time to discuss their problem with the ANP. Although the majority of patients appeared to be seen within 30 minutes of their appointment time, it could be argued the consultations were not as long as some researchers have suggested (Kinnersley et al, 2000; Shum et al, 2000; Venning et al, 2000).
Overall, few patients (5%) experienced interruptions in their consultations. Most felt involved in their care, asked questions and felt at ease with the assessment and communication within the consultation. For those patients who wished they had asked more questions, it was not clear whether these concerned the topic they came to discuss with the ANP or whether such questions concerned a separate issue that would require another appointment.
Patients deserve to be partners in their own healthcare. Furthermore, care can be delivered more effectively and efficiently if patients are fully involved in the process (Holman and Lorig, 2000). Individuals and communities need to accept greater responsibility for their health (Laurant et al, 2005), with a need to focus on prevention and early intervention. This can be incorporated into practice through forming partnerships between patients and the healthcare team. In addition, patients should be given more choice and control wherever possible (DH, 2005) in using modern information centres and self-care advice.
Patient preference on seeing a doctor rather than an ANP
Questions on this issue sought to identify whether the ANP’s role was complementary or a substitution. When asked if they had left the practice wishing they had seen a doctor instead, 75% disagreed while 20% agreed. This was an interesting question and answers to the three open-ended questions supported the responses to it (Box 1). Laurant et al (2005) reported that appropriately trained nurses can produce the same high-quality care as primary care doctors and achieve comparable health outcomes for patients. Systematic reviews in general suggested there were no appreciable differences between doctors and nurses for patients’ health outcomes, care processes, resource utilisation or cost (Horrocks et al, 2002). McGrath (1990) argued that ANPs are a cost-effective alternative to GPs but, almost two decades on, reports from the Commons’ public accounts committee on primary care prescription expenditure found nurse prescribing had a negligible impact on NHS finances (Tweddell, 2008).
For the fifth of patients who wished they had seen the doctor, this may have been because the ANP could only refer patients to other services if the doctor could support the nurse’s findings by also seeing them. The local acute care policy stipulates the ANP must have all referrals signed by a doctor, otherwise they are not recognised and are returned. This was a frustrating element in the ANP’s role but one which was being reviewed. However, it was not certain if patients preferred to see a doctor because of her/his medical abilities or because they knew they could not be referred to acute care for further treatment without seeing the doctor.
Patients made some interesting comments about feeling they were wasting the doctors’ time, although they felt staff at the surgery cared and were friendly, and they liked being able to just ‘drop in’ for an appointment. When asked what they least liked about the practice, they responded that they did not receive much time or support from the doctors - again, this could possibly relate to cultural differences.
The last question on the questionnaire asked patients if there was a difference between seeing the ANP and the doctor - two patients said there were probably no differences, and other comments tended to be in favour of the ANP role. Positive responses about the ANP were: ‘The nurse listens’, ‘is helpful’ and so on. Answers about doctors showed patients ‘did not want to waste doctors’ time’ and they had to ‘wait to see the doctor’. One patient thought the ‘doctor performed the examination’ and ‘prescribed everything’, suggesting the ANP could not but, overall, the responses were positive about the ANP’s role, with a marked focus on communication skills.
The ANP initiative in this GP practice sought to increase quality consultations and to develop a more proactive approach to health promotion by involving patients in care. This survey aimed to assess patient satisfaction with the ANP and confirmed patients were satisfied with the service. This was evident in the ANP’s communication skills, advanced assessment skills, partnerships in care and with the consultation overall.
However, the questionnaire developed was specific to general practice and the nursing profession could benefit by developing a questionnaire which enables comparable data and accuracy.
It was also interesting to note that some patients still wished they had seen a doctor. Future research needs to focus on this group to assess whether this was due to their individual preference or to their experience with the ANP.
This survey also highlighted other areas for future research, which include an exploration of cultural issues and consultations. This may be helpful in improving patient satisfaction.
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