Patient outcomes affected by nurse practitioners in primary care

¶ … patient outcomes affected by using nurse practitioners instead of medical doctors?

In the next few years in the United States, the demand and need for primary health care services is expected to increase, due both to the increase in population and the Affordable Care Act (ACA) passage. Different researchers show that nurse practitioners have already been trained in order to provide different services of health care so they would help in fulfilling the demands. Because the demands would increase, and meeting the present growing needs of healthcare would become more important, there is need to ease the restrictions and policies so that nurse practitioners are encouraged, motivated, and incentivized to get more involved in this sector (NGA, n.d).

The relationship between healthcare providers and the satisfaction of patients/clients is a very multi-faceted and complex matter. The satisfaction of patients, utilized by different agencies as a benchmark and indicator of the care results, has showed acceptability regarding the nurse practitioners in different hospitals and clinics. However, studies related to the satisfaction of the patients in the primary care environment regarding the nurse practitioners are not available yet. This particular matter of interaction between the patient and the nurse practitioner is highly important and relevant in this sector as it creates new and easy ways of providing good health care to the patient. Data and information regarding different elements of the delivered primary care by the nurse practitioners is missing in literature, but its presence would benefit the NPs and the society, which is also the main purpose of this paper (Agosta, 2009).

Background

The growth and aging of the population of America, and the expansions of health care and other actions that come under the Affordable Care Act (ACA), are predicted to increase the importance and demand for primary care services. In 2010, a passage was included in the ACA that gave way to the enrollment of around 2 million people in health insurance. By 2016, this number is expected to rise as high as 30 million. However, in 2012, the states of America were given an option by the Supreme Court to decide whether they wanted to expand their programs. This has however, held ACA's decision and the full nature of the expansion of insurance under ACA is not yet clear. Despite that ruling, the 16 million people who can obtain the new subsidies regarding the private covering, given by health insurances under ACA and its mandate, would have high stemming coverage (NGA, n.d).

Some studies suggest that the need for primary care in America would reach between 15 and 25 million visits annually by 2019. This means that the requirement for physicians would reach to between 4 thousand and 7 thousand physicians needed. This increase would also impact the current shortage of physicians for primary care. According to the Health Resources and Services Administration (HRSA), more than 35.2 million living under 5870 Health Professional Shortage Areas (HPSAs) throughout the country are not able to receive the proper services of primary care (NGA, n.d.).

According to the Interactional Model of Client Health Behavior by Cox, the clients of healthcare are complex and unique. Their personal aspects consist of factors such as worldliness, emotions, motivation, personality characteristics, social influences, and demographic traits; all of these factors independently and collectively do their work in influencing the decisions, perceptions and health behavior of the client. The satisfaction of clients regarding the health care services is a relevant pointer towards the health care services and whether they are able to provide the individuals with influential outcomes and facilities (Alazri & Neal, 2003). The viewpoint of satisfaction with the services of health care is an important factor and part of the outcomes of health and (Agosta, 2009).

Theoretical framework or model

This study used the Nursing Role Effectiveness Model (NREM), developed by Irvine et al. (1998). This model provides the complete framework of an organization for discussion, analysis, data and methodology. The models expect that the routine effectiveness of nurses impacts the outcomes of patients and works as the base for improvements and evidence based-practice. The model uses the work of Donabedian (1988) and includes three factors to represent nursing. These three factors are patient and health outcomes, role of nurses, and structure (Irvine et al., 1998).

All these three factors are then divided further into categories of patient type, institution type, and type of care. The 'role of nurse' is divided into an interdependent role, a dependent role, and an independent role; 'structure' is divided into patient, organization, and nurse (Evangelista et al., 2012). The patient and health outcomes are divided into safety outcomes, quality and nursing outcomes, and patient outcomes.

Variables

The variables of structure include patient structure, clinic structure, organizational structure, and PNP structure. Further examples of PNP structure include appointment availability, patient-chief complaint, and testing and support staff of clinic, leadership, hospital nursing, practice scope, and PNP education.

The variables of 'process' include the interdependent, dependent and independent PNP practice functions because they are related to the clinics of PNP cardiology. The examples in this study are usage of practice guidelines, correct use of consulting with the colleagues, disease and diagnosis management and PNP assessment.

The variables of 'outcome' include safety and quality outcomes, nursing outcomes and patient outcomes. The examples include management and diagnosis of congenital heart disease, correct assessment and satisfaction of nursing, satisfaction of the patient and access to appointments (Evangelista et al., 2012).

Literature Review

Clinical Outcomes Research

The outcomes of research addressing the role of the nurse practitioners has been satisfactory and complete as compared to the physicians; most of the patients are satisfied by the work of NPs. Horrocks, Anderson, and Salisbury (2002) in their study stated no difference in the cost and health status of the NPs and the physicians by reviewing and analyzing 23 studies of observation and eleven trials, based on the results of the patient's care process, health status and satisfaction. However, the five topics which showed the satisfaction of the patient as the data of outcome showed statistical and important variations between the satisfaction of the patient, and the satisfaction of the work between the NPs and the physicians. The investigation displayed that the longer the hours of consultation by the NPs, the higher the score of satisfaction went. The study by Mundinger et al. (2000) also stated that no statistical or important difference were found in the health status, satisfaction of the patient, or the results between the physician and NP- delivered services of health care. Different factors like high satisfaction among the patients, low rates of prescription, results and utilization of diagnostic tests, and safe outcomes of clinics has also been conducted (Agosta, 2009).

The study of the roles of NPs and satisfaction of the patients in diverse and varied systems of health care is an important challenge for the current advancements and evolution in the profession of nurse practitioners. As the comparable outcomes between the nurse practitioners and the physicians has been established, demand for more concentrated and focused areas of investigation related to the nurse practitioners' satisfaction has come forward as important and needed for the field. This research investigates and analyzes the model of nurse practitioners' delivered model of primary care in the professional setting (Agosta, 2009).

Different researchers that have measured the variations in outcomes of patient care have stated that the care provided by the NPs and the physicians is equal and not different to each other. In Canada in 1974, one of the first NP trials was conducted by Burlington. This explored and demonstrated the safety and effectiveness of the care that was being delivered by the NPs. The comparison of NPs and physicians was demonstrated based on the outcomes of safety and effectiveness of the services provided, clinic effectiveness, emotional, and physical function and motality. Some of the recommendations for further research suggested an exam to identify and delineate the unique and specific characteristics of the NPs (Sackett et al., 1974).

Around 248 papers were reviewed in a systematic manner. These discussed NPs and showed clinical outcomes and satisfaction to be either greater or equal to that found when compared to the physicians (Feldman, Ventura, & Crosby, 1987). Horrocks et al. (2002) stated that there was no difference between the costs and the health status when comparing the NPs and the physicians by reviewing 23 studies through observations and 11 trials based on the results of the care process, cost, health status, and satisfaction of the patient. The studies that were analyzed were the ones which compared the physicians and the nurse practitioners in the same settings of the clinic. In one of the 5 studies that showed the satisfaction of the patients, a significant amount of difference was seen between the NPs and the physicians. The other two researches which showed the results of patient satisfaction as dichotomous data showed no statistical importance and difference between the two providers. Other studies that were included showed the improvement in satisfaction level with the increased amount of consultation with the NPs (Agosta, 2005).

Another study analyzed the health care which was either received from the physicians of the nurse practitioners in general medical practice. The sample of the study included 1368 patients who were going for similar day visits of health care and were randomly sent to either the physicians of the NPs. The main variables that were examined were the satisfaction of the patient and the resolution of the symptom in the next visit after two weeks. The other outcomes were appointment reschedule as seen through the intention of the patient, consultation of follow-up, and the perception of the patient during the checkup. The patients gave their responses through a survey questionnaire right after their first visit and the following second visit after two weeks. The results of the questionnaire stated that the patients of NPs got long hours of consultations as compared to the physicians, but there was not difference in the outcome of the clinic (Agosta, 2005).

More conclusions that came forward was the complete satisfaction of the patients with the health care that they had received from the NPs. Mundinger et al. (2000) in a well publicized lay and medical article stated that there was no importance difference found in the outcome, satisfaction of the patient, or the health status of the patient between the health care provided by the physician or the NPs. This study included 1316 patients randomized to the group of NP or the physician based on four community clinics and one urban clinic. The satisfaction of the patients was calculated by a survey of fifteen questions which were conducted after the first visit and then after the second visit after six months. Additionally, the Medical Outcome Study Short Form 36 was used to analyze the physiological status throughout the two intervals of assessment. The researchers stated the outcome of satisfaction of patient and equality in care given by the physicians and the NPs that was supported strongly by the statistical analysis from the study's data (Agosta, 2005).

There was no important difference seen in the satisfaction of the patient of the health status either in the first visit or in the second visit after six months. An article by Sox (2000) in response to the study by Mundinger et al. (2000) said that the results of the research providing the same results between the physician and the NPs provided a doubt to the external validity of the research. The article also questioned the validity and the generalization of the study between NPs and the physicians, and also showed doubt in the indicators that were used in testing the six-month interval between the visits. It was stated by Sox (2000) that the sample of the research contained 76% females with 44 as an average age caused questions as to the validity of the work. However, he did not concede the fact that the study was done using sound methodology, which lists an outcome of a powerful interval validation. Sox (2000) accepted the study's outcome of generalization when it came to the short-term outcomes and service delivery; he also stated that generalizing them for long-term would require caution. Mundinger et al. (2000) also gave an outcome of the two-year follow up; that too validated no statistically important difference in the visits to the emergency room, referrals of the specialists, disease pathology, satisfaction and health status between the clients of NPs and the physicians' (Agosta, 2005)

A study by Kinnersley et al. (2000) examined the practicability of the NPs in an emphasized role by studying 286 patients for two years who were randomly assigned to either the physician or the NPs group for similar day appointments of the clinic. The research took into consideration different factors over the period of two years. The perception and satisfaction of the patients were analyzed right after the visit through the interviews. Thirty patients were additionally chosen for the interview after the follow-ups, regarding their satisfaction and perception of the NPs abilities over the time of two years. The outcome of the study included a significant and statistical difference between the time of consultation with the NPs in which the patients spent around 9.56 minutes with the nurse practitioners and 5.96 minutes with the physician. The awareness level regarding the diseases and their diagnosis of the physicians and the NPS is also seen (Agosta, 2005).

The benefits of having both the physicians and the nurse practitioners at the same clinic helps to shorten the waiting time of the patient and also helps to decrease the workload of the physician. A lot of patients prefer female NPs rather than the male physicians as they thought that talking to female NPs was much easier. A study by Myers, Lenci & Sheldon (1997) also stated that the nurse practitioners as compared to the physicians provide safe and healthy care in urgent issues. The NPs used advanced communication methods with the patients which showed higher levels of satisfaction in them. Another study by Cooper, Lindsay, Kinn & Swann (2002) analyzed 199 patients of the emergency room who were either treated by the physicians or the practitioners. All the patients were found to be satisfied by the care received by both the NPs and the physicians; however the nurse practitioners were still found to be easily communicated with, as they provided personalized information for the prevention of the disease and their wellness. Another study by Byrne, Richardson, Brundson and Paten (2000) regarding the NPs in emergency departments, showed patients were satisfied with both the physicians and the NPs. The patients were also found to be satisfied by the instructions and education of the NPs and their strengths showed good communication, explanations, and providing information (Agosta, 2005).

A study by Chang et al. (1999) provided answers from 232 patients who were present for the treatment in the emergency department and were being checked up either by the NPs or the physicians. There was no different seen between the physicians and the nurse practitioners when it came to patient satisfaction and clinical outcome. These findings in other systems of healthcare were also the same. Henderson et al. (2004) in a research of satisfaction and outcome with prostate biopsy method determined that test reliability and equal diagnostic results occurred in biopsies that were performed by the physicians and the NPS. Both the groups had same satisfaction levels (Agosta, 2005).

A study by Price & Clark (2004), in which there was a comparison of physicians' and NPs' management of the patients with urinary tract symptoms urine found high levels of satisfaction, same diagnostic lab test utilization, and low rates of prescription. Another study by Byrne et al. (1997) in a comparative analysis that included 70 patients suffering from rheumatoid arthritis, found out that there was high satisfaction from the patients who were getting their treatments from the NPs. The patients in this study were either being checked-up by the NPs or the physicians and were analyzed during a one year time with six visits. Some researchers also found that 97% of the patients who were getting their treatment from the NPs were satisfied (Cooper et al. 2001). Similarly, McKinley et al. (2000) also found out that there were equal levels of satisfaction from the patients for both the nurse practitioners and the physicians. The factors of professional, technical and educational perspectives were found out to be influential. Many researchers have studied the role of NPs in a patient's setting; however, Kinnersley et al. (2001) determined that physicians and NPs favorably compared to each other. Roblin et al., (2004) in their study conducted the study of effectiveness of the NPs in which they summarized thirty one research programs, and learned problems that were faced during the comparison of physicians and the NPs. The study stated that selection was not always done according to rigorous criteria and standards; they recommended that simple random sampling should be used in the future (Agosta, 2005).

According to the study of McKinley et al. (2000), the management of small illnesses by the nurse practitioners was considered to be both acceptable and safe by the patients. The results of the study stated that the patients were highly satisfied by the services that were delivered by the NPs. A study was conducted by Stables et al. (2004) in which 339 patients was being prepared for the procedure of cardiac catheterization. The study concluded that the patients were more satisfied by the services of the nurse practitioners as compared to the services provided by the physicians. Furthermore, in another study by Cooper et al. (2001), no important difference was found between the quality, skill and knowledge provided by either the NPs or the physicians. However, the patients who were getting their services from the nurse practitioners were more satisfied as compared to those who were taken care of by the physicians. The NPs' patients had higher levels of satisfaction regarding the healthcare worker's communication ability and the skills. In another comparative study, the management of diabetes and cholesterol levels in the patients was performed by either the physicians or the NPs. Important differences were seen in the time taken by the two groups with the patients; the collaborative team collectively spent 180 minutes, while the physicians took 85 minutes in total. Various differences were seen in the results and higher levels of satisfaction was seen from the patients who interacted with the nurse practitioners, mainly because they spent more time with the patients. Stables et al. (2004) also found out that the elements that were the result of higher satisfaction included quality time, communication, and advanced care for the patients (Agosta, 2005).

Preference

Layrant et al. (2008) examined the preferences of the patients and investigated who they preferred as their practitioners in relation to: [1] regular appointments; [2] follow up; [3] referral to other services of health providers; [4] advice and information of dealing with the illness; [5] education related to the medication prescribed; [5] education regarding the prognosis of disease; [6] discussion of emotional issues; [7] discussion of the physical complaints; and [8] medical treatment and care. The categories of responses include 'nurse practitioner,' 'general practitioner', and no preference. There was no fixed scale used for the questionnaire and the researcher used his own instrument. The different aspects chosen were made from the guidelines of general practitioners and nurse practitioners that both the groups provide to the people. The options were also confirmed by the NPs and the physicians. The reliability of the response was tested by Chronbachs' ? which showed the significance value of 0.784 showing that the preferences were measured. If any one of the aspect was removed, the reliability could not be improved further. The reliability and validity of the domain was also confirmed by different psychometric tests (Laurant et al., 2008).

The outcome of the questionnaire showed that in 7 out of 8 aspects, the patients preferred general practitioners. The majority of the patients preferred to be evaluated by the general practitioners in aspects like medical treatment, discussion of the physical complaints, and getting information regarding the prognosis and the diseases. For 6 out of 8 aspects, the patients did not prefer any group. 36.5% of the patients opted for nurse practitioners in the aspects of providing advice and information (Laurant et al., 2008).

Instrument

Cole, Mackey, and Lindenberg (1999)'s created instrument was used to derive the two part Patient Satisfaction Survey. Similarly, it was also made use of in the Thrasher and Purc-Stephenson (2008)'s study that involved the satisfaction of the patient with Nurse Practitioners in Canada. Thrasher and Purc-Stephenson as part of the research arranged the instrumental factors by Cole et al. (1999) through principal components of factor analysis. Every factor of the questionnaire was analyzed for clarity and then was labeled with clarity of role, comprehensive care, and attentiveness. Validity and reliability showed the consistent range from 0.79 to 0.88. Permission for the adaption of the instrument was taken from Thrasher. The questionnaire survey included five sections that covered the demographics, including thirteen items in which the ten questions analyzed the perception of patients' satisfaction with nurse practitioners. Further three questions tested the clarity of the role of the NPs (Ryan & Rahman, 2012)

Flesh-Kincaid determined the readability scale in which the responses of the patients were determined by inserting the five-option Likert scale. The scale ranged in options from 'strongly agree' until 'strongly disagree'. The satisfaction of the patient can be checked by the level of expectations met of a patient. The survey of Thrasher & Purc-Stephenson (2008) captures the aspects by testing the response of the patients with statements including 'the nurse practitioner gave me a chance to say what was really on my mind' (p. 235).

Agosta (2009) in the study's literature review showed that no instrument that is existing as yet has showed any promise related to the object being studied. Therefore the 'Nurse Practitioner Satisfaction Survey', with a five point Likert scale, was made for the purpose, compiling different scales of satisfaction, reviewing literature related to the study, and professional opinions (Cole, Mackey & Lindenberg (1999). The Nurse Practitioner Satisfaction Survey is composed of 28 items of Likert scale (Agosta, 2005) and is combined with the intention of including aspects that are important in making perceptions of the patients. The survey items for the individual focused mainly on the dimensions and attributes that were occurring on the patient level, and the nurse practitioner interface that is hypothesized to serve as components in general satisfaction of the patient. These components included interpersonal communication, openness, receptivity, trust, knowledge, competence, accessibility, and convenience. The survey included the items that were linked to present and prior health status, demographics, previous interaction with the health providers, and the education and opinions that were received by the patients. The respondents were told to select the level of disagreement and agreement regarding the statement by choosing the options from Strongly Agree, Agree, Undecided, Disagree, Strongly Disagree (Agosta, 2009).

To analyze validity of the content, the instrument was examined and prepared by the nurse practitioners for applicability, relevancy, and completeness to the practice of nurse practitioner. The instrumental tool was also pilot tested in the same setting of clinic and the same population with the nurse practitioners before being finalized. Thirty nine surveys in the pilot study were returned and small modifications were done in order ensure appropriateness and clarity (Agosta, 2009).

The twenty survey items were tested by performing the Exploratory Factor Analysis (EFA) after which three constructs followed it (Agosta, 2009). The constructs represented the 3 sub-scales of satisfaction, convenience, accessibility, and communication. The scores of the satisfaction of the general patient were measured by responses from Likert scale that was loaded on one factor - satisfaction of the patient. The range of the sub-scales was from 18 to 90 points which showed the satisfaction. The alpha calculation of Cronbach for the satisfaction sub-scale was 0.98 (Agosta, 2009)

Discussion

The major objective of the study was to analyze if there were any factors that influence the patient satisfaction regarding the nurse practitioners. Seeing the review, the satisfaction level from the NPs was higher. In the literature review as well, the health care provided by the nurse practitioners meets the needs of the patients. It was also seen that the patients who were uninsured showed higher satisfaction scores than the people who were insured. This now challenges the outcomes of Thrasher & Purc-Stephenson (2008) and Agosta (2009) who stated that the people with higher levels of income and health insurance were more satisfied by the health care they were receiving. An assumption could be made that the people who were spending more money were getting better health care. Another explanation states that the patients who are not insured might not need health care so often as compared to the patients who were insured, so they are satisfied whenever they required check-ups. Educational level and age also were not proven as important factors that determine satisfaction (Cole et al., 1999; Thrasher & Purc-Stephenson, 2008; Ryan & Rahman, 2012).

Data of statistical importance that was gender based and linked with the friendliness of the nurse practitioners was also of interest. This could be because the patients might be familiar with a specific NP. Reviewing the literature in the study, it can be stated that the nurse practitioners provide comprehensive, conscientious, and proficient care. However, based on the responses of the patients in the survey, the evidence suggests that nurse practitioners are not6 yet publicly recognized. It is not clear whether this can be applied to both the rural and non-rural settings, because since the survey does not clarify that factor. It is also seen that gaining the health care services in the rural areas is very difficult because of the lack of resources there. So it can also be said that the patients seeking health care regarding their needs do not care about the training or the background of education of the nurse practitioner or the physician (Ryan & Rahman, 2012).

The literature review also noted the importance of understanding the role of the nurse practitioners regarding the education of the patient. The survey conducted reported that 67.9% of the respondents had a college degree and the patients who had higher levels of education were reported to be more aware of the role of the nurse practitioners. Some of the patients responded that they were not aware of the fact that the treatment was being provided to them by the nurse practitioners. According to Gunter et al. (2009), the patients should be aware regarding who they are getting their treatment from and also know the role of the nurse practitioners and the type of care that can be provided to them by the NPs (Ryan & Rahman, 2012).

The limitations in methodology also need to be addressed. Firstly, the identification of survey disadvantages was made in this research. According to Roblin et al. (2004), the surveys do not calculate the experiences of healthcare in an objective manner because every family and patient has their own expectations from their visit; the researchers state that the surveys are more subjective. The development of APSS was done to calculate the patient satisfaction on the pediatric ambulatory in only one hospital, so it does not fulfill the generalizability that other hospitals are also satisfied. Secondly, the methodology could not randomize the patients to the type of visit; this created a population sample that could not be compared. The PNP managed model of care delivery that assessed the cardiology clinics scored high levels of satisfaction which improved the access of appointment. The literature review also stated that the nurse practitioners provided more quality care and the patients were highly satisfied with them (Mundinger et al. 2000; Evangelista et al., 2012).

The literature review states that the clinics managed by the PNP resulted in more satisfaction for the patients and the research also increased care access and compared them to the clinics managed by the nurse practitioners. The implementation of clinics managed by PNP were also examined. The literature review also adds that the new material for the healthcare clinicians and executives was working to make sure that the quality care and access was made well and improved (Evangelista et al. 2012).

Summary

The demand of health services is soaring high these days and more than sixteen million people are predicted to go for health insurance by the year 2016. Due to this, many states are also thinking about increasing the number of health care providers. One of the options for the states is to examine their laws regarding the governing of the nurse practitioners. The Advanced Nurse Practitioners are another group who serve the patients under the supervision of several physicians (NGA, n.d). A lot of studies that were reviewed showed high levels of satisfaction of the patients regarding the nurse practitioners; however, as yet there were not many studies that tested the nurse practitioners in the outpatient primary health care. The satisfaction levels of the married people were higher than the single individuals. Other than that, there were no differences (Agosta, 2009).

The scholars who were addressing the evaluation and implementation of the role of the nurse practitioners advocate for beginning studies to talk about the results linking to the efficacy and safety, transfer or role and costs, satisfaction and acceptance (Sox, 2000; Branson et al., 2003; Alazri & Neal, 2003). The works of Donohue (2003) talk about the efficacy, and safety of the role of the nurse practitioners in practice of gerontology; The works of Price & Clark (2004) address the transfer of role and safety as addressed in the setting of mental health; the works of McKinley et a. (2002) talk about the role of acceptance in the setting of primary care. No study regarding the satisfaction and acceptance of the role of nurse practitioner in New Zealand has yet been published.

Satisfaction is the main result of the health care facility and a lot of researchers have linked the results of improved health care, and lower use of resources to be the main focus. In order to calculate the outcomes, different instruments are required which measure to score easily and accurately and also capture the whole concepts. Calculating the satisfaction of the patients is very difficult because there are a lot of factors that affect those components. An instrument was developed by Thrasher & Purc-Stephenson (2008) which measured the levels of satisfaction of the people regarding the nurse practitioners. The same instrument is also made use of in this study and is also discussed in different sections of the study (Jo Gagan & Maybee, 2011).

The main implication by the study states that a lot of patients who were getting their health care from the nurse practitioners had the ability to make informed and intelligent decisions regarding the type and choice of health care provider they need. The subjects that were studied also previewed another option which was to get their health care from the physicians as an alternative. A lot of patients voluntarily selected the physician for their emergent and acute health care needs. The findings of the study can be used to maintain and adopt a professional and active approach for the well-being and care for the people with higher educational levels (Agosta, 2005).