Exploring the Differences in Patients Satisfaction with Primary Care Provided by Nurses and Doctors - Research Proposal Example

Research Proposal Exploring the Differences in Patients’ Satisfaction with Primary Care Provided by Nurse Practitioners and General Practitioners Introduction Nowadays it is acknowledged that health systems of many countries experience a crisis caused by such challenges as population ageing, professional skills shortages, patients’ rising expectations, necessity of quality improvement concurrently with cost reduction. In order to meet these challenges new health sector programmes and reforms, as well as changes in the legislation, are carried out. One of the examples of recent innovations in health care systems is a substitution nurse practitioners (NPs) for general practitioners (GPs) (Dierick-van Daele, Spreeuwenberg, Derckx, Metsemakers & Vrijhoef, 2008). A nurse practitioner is a qualified nurse who has additional education and specialization in some particular area. In the USA, NPs must have a master’s degree minimum and 500 to 1,000 hours of training; the education of NPs is guided by the American Association of Colleges of Nursing (Rough, 2009). Traditionally, NPs work as doctor supplements providing services which extend services provided by GPs. Now more and more NPs start working as doctor substitutes, having rights to independently provide a wide range of services, usually provided by GPs. The aim of such shift of the NPs role mainly is to address current GPs shortage and to reduce cost of health care services (Dierick-van Daele et al., 2008). The doctor-nurse substitution is much debated in professional literature and in the press; a number of important problems related to permissibility, practicability and efficiency of this innovation have been studied during the last decade. This document presents a proposal for a piece of research which is aimed to explore the differences between patients’ satisfaction with services provided by NPs in comparison with patients’ satisfaction with services provided by GPs in primary care. In addition, we intend to explore factors influencing on the differences in patients’ satisfaction. We hope that our study will promote an effective process of NPs’ and GPs’ skill mix and substitution and make a contribution in positive changes in the US health system at a whole. Problem Statement The tendency to hire nurse practitioners as a substitute for doctors has intensified during last years. Rough (2009, para.4) cites the American Academy of Nurse Practitioners (AANP), which estimated that from 2004 to 2009 the number of NPs in the United States has increased by about 40 per cent, amounting to 125,000. Dierick-van Daele et al. (2008) consider four main reasons of the current demand for NPs: “(1) to overcome a shortage of doctors in particular settings; (2) to improve the quality of care; (3) to advance the career of nurses; and (4) to lower health care costs by employing the ‘lowest cost provider’” (p.481). Many experts agree that today’s nurses may work well not only as doctor supplements, but also as doctor substitutes, in particular in primary care. According to the recent research, from 25% to 70% of GP’s work might be successfully fulfilled by nurses (Laurant, Reeves, Hermens, Braspenning, Grol and Sibbald, 2007). This includes a wide range of activity from diagnosing, testing and prescribing medication to health promotion and routine management of chronic diseases. In several countries and the US states the shift in NPs’ status is supported by legislation, allowing NPs to work independently in various health care fields, including such specific ones as family practice, psychiatry, women health, pediatrics etc. However, there is a certain controversy in the medical community, as some experts argue about significant risks related to the independent work of NPs in primary care, such as misdiagnosis or inappropriate treatment. For example, the American Academy of Nurse Practitioners and the American Medical Association hold the opinion that NPs should work only in collaboration with GPs (Rough, 2009). Young (2010) agrees that while NPs are generally very good in fulfillment of standard treatment algorithms for single chronic diseases such as diabetes or asthma, in many other cases of primary care, for instance where a patient has multiple chronic diseases or unknown symptoms, they can be found incompetent and incapable of good help. Nevertheless, in spite of different, often contradictory, opinions concerning the role of NPs as substitutes for doctors, it is assumed that a nurse-led care practice is effective in terms of enhancing the quality of primary care services, reducing demand for doctors and lowering of costs. Laurant et al. (2007) prove this assumption by presenting a review of the number of researches carried out from 1998 to 2007, which found that while health outcomes for patients were similar in both doctor-led and nurse-led care, nurse-led care demonstrated “higher levels of patient compliance and satisfaction, longer consultations, and higher rates of laboratory testing” (p.2). We consider patients’ satisfaction is the key factor, as it is most of all associated with the quality of care, influencing on patients’ compliance with medical treatment, on patients’ willingness to follow prescribed medicine and advices, on the repetition of patients’ visits to the same doctor. All of this, in its turn, entails effectiveness of therapeutic procedures and the improved health status of patients. Meakin and Weinman (2002) say that “understanding what determines patient satisfaction with the consultation may have practical implications for improving patients’ health outcomes, the quality assessment of novel service provision and the doctor-patient interaction, and thus implications for clinical governance, training and revalidation” (p.258). Previous researches studied the differences in patients’ satisfaction with doctor-led and nurse-led primary care, but focusing mostly on the measuring of levels of satisfaction, rather than on the analysis of factors influencing on the differences. At the same time, Laurant et al. (2007) give notice that understanding of these factors is extremely important as they help to realize better how NPs’ and GPs’ skill mix and substitution can be provided more effectively. Our research is aimed to address this shortage by exploring differences in patients’ satisfaction with primary care provided by NPs and GPs. In addition we will explore major factors which have impact on these differences, in particular factors related to NPs and GPs skills and attitudes. Research objectives Aim The primary aim of the research is to explore the differences in patients’ satisfaction with primary care services provided by NPs and GPs and main factors influencing on these differences. Objectives To critically review and analyze state-of-the-art literature and previous researches with regard to the current understanding of differences in patients’ satisfaction with primary care services provided by NPs and GPs. To obtain primary care patients’ opinions regarding their satisfaction by primary care services provided by NPs and GPs. To identify differences between patients’ satisfaction by primary care services provided by NPs in comparison with those provided by GPs. To identify factors influencing on the differences (in particular in relation to NPs’ and GPs’ skills and attitudes). To conclude findings and identify theoretical and practical implications of the research. Hypothesis The study is intended to prove the hypothesis that primary care services provided by NPs differ from services provided by GPs in terms of patients’ satisfaction. The null and research hypotheses are stated as follows: Hypothesis H0. There are no significant differences in patients’ satisfaction with primary care services provided by NPs in comparing with those provided by GPs. Hypothesis H1. There are significant differences in patients’ satisfaction with primary care services provided by NPs in comparing with those provided by GPs. Literature Review The new role of NPs Doctors and nurses were always two partners working in teams in primary care to improve patients’ health. Traditionally their roles and statuses differed. Nurses were mainly seen as “caring for patients’ emotional and physical needs, having a more social perspective … [and] as advocates who speak for the patients’ needs within the multidisciplinary team” (Mardby, Akerlind & Hedenrud, 2009, para.3). At that GPs were mainly seen as “more clinical, emotionally neutral, setting the priorities and making the decisions …based more on scientific research” (Ibid.). Moreover, doctors were traditionally team leaders. Such roles assignment and power imbalance caused the current doctor-patient relationships, where patients commonly find nurses are more approachable for communication about their health, but in more extent prefer to consult with doctors and to comply with GPs’ prescription. However, the role of nurses is increasingly changing. The development of advanced nursing practice (APNs) became a major current trend within nurses. Sheer and Kam Yuet Wong (2008) define APNs as “registered nurses who have acquired the expert knowledge base, complex decision making skills, and clinical competencies for expanded practice” (p.204). Currently there are five roles of APNs: nurse practitioner, clinical nurse specialist, nurse anesthetist, nurse midwife, and case manager, where NPs are the largest group (Ibid.). In 2008 there were about 115,000 practicing NPs in the US (Kleinpell, Wesley and Grabenkort, 2008), in 2009 the total NPs number was over 125,000 (Gilmer & Smith, 2009) and their number tends to grow (see Fig.1). Researchers say that the role of today’s NPs is far more important for health care system than it was even several years ago. The major advantage is that they can practice at a higher level substituting GPs. Today’s NPs are able to fulfill up to 80% of the tasks that traditionally been viewed only within the role of GPs in primary care, Gilmer & Smith (2009, p.140) assert. Figure 1. Curent and projected workforce of nurse practitioners (NP) over time. Source: Kleinpell, Wesley & Grabenkort, 2008, p.2889. Undoubtedly, the new NPs status requires more advanced knowledge and experience, so today many NPs are getting a doctorate degree, and according to the American Academy of Nurse Practitioners by 2015, all NPs programs will require a doctorate (Rough, 2009, Role of the NPs, para.6). The tendency is supported at the governmental level, special Doctor of nursing practice (DNP) programs are being developed to help NPs in preparation to the doctoral level (Sheer & Kam Yuet Wong, 2008). Differences in nurses-led and doctor-led primary care from patients’ perspective The doctor-nurse substitution started to be investigated in the early 1990s. The first meta-analysis of 38 American and Canadian studies was conducted by Brown and Grimes in 1995. Results of the analysis revealed that in most cases patients were happy with substitution NPs for GPs – health outcomes did not differ in both doctor-led and nurse-led care, while the latter was marked by higher level of patients’ satisfaction, as well as by longer consultations and by higher rates of laboratory testing (Laurant et al. 2007, p.2). In 2002 the findings were supported by another review of 34 studies that proved again the higher level of patients’ satisfaction with care by NPs and absence of differences in health status, prescriptions and return consultations (Horrocks, Anderson & Salisbury, 2002). The findings allowed researchers to conclude that, “increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care” (Horrocks et al., 2002, p.819). The conclusion was again supported in 2007 when Laurant et al. (2007) presented the results of review of 16 studies that were chosen from several large research databases according to the criteria that “nurses should be compared to doctors providing a similar primary health care service” (p.1). The findings of this research also revealed a dependence of patients’ satisfaction on certain factors. For example, it is shown that patients are more satisfied by NPs’ care because NPs provide longer consultations and give more information to patients concerning treatment and health state. In addition, the nature of a patient’s problem may have a significant impact on the patient’s preference – patients with ‘minor’ or ‘routine’ problems more likely prefer to consult with NPs, while patients with ‘serious’ or ‘difficult’ problems prefer GPs (Laurant et al., 2007, p.8). Quite the same conclusions were made by Redsell, Stokes, Jackson, Hastings and Baker (2007) who emphasize a profound effect of traditional role hierarchies in primary care on patients’ preferences. Their interviewers also preferred to consult with GPs for serious symptoms and with nurses for minor symptoms. In addition, the study revealed the importance such factors as interpersonal / relational continuity of care and trust for increasing of patients’ satisfaction and loyalty. Laurant, Hermens, Braspenning, Akkermans, Sibbald and Grol (2008) describe the result of a cross-sectional survey with 235 patients, which demonstrated that practically all patients prefer to consult with doctors for medical aspects of care. As for educational and routine aspects of care, a half of all patients prefer to consult with nurses, and another half of them have no particular preference. All patients were equally very satisfied with both nurses and doctors, although in relation to satisfaction with nurse-led care many patients emphasize aspects of care related to the patients’ and families’ support, as well as time spent with patients. Summarising the results of many researches, Gilmer and Smith (2009) conclude that today the nurse practitioner in the US can successfully provides an opportunity for doctors’ task substitution in primary care. They give a rich statistic data as proof of their conclusion: “approximately 6000 new NPs are prepared each year; 88% of NPs have graduate degree, 92% maintain national certification; 96.5% prescribe medications; 20% practice in rural or frontier settings, 66% in primary health care; 62% NPs see three to four patients per hour, 12% see over five per hour” (Gilmer & Smith, 2009, p.140). Differences in cost of nurses-led and doctor-led primary care As we mentioned above, one of the goals of doctor-nurse substitution is lowering costs of health services. The first researches addressed to this issue were conducted over 25 years ago, and during about four decades, “NPs have been proven to be cost-effective providers of high-quality care” (AANP, 2007, para.1). The findings of several recent researches in this area demonstrate either lower (Gilmer & Smith, 2009) or similar (Hollinghurst, Horrocks, Anderson & Salisbury, 2006) labour cost per visit in practices where NPs work as primary care providers. So, it makes good sense to use NPs as substitutes for more-expensive health professionals without reducing of health services quality. Research Methodology Methods In our study we intend to use a descriptive form of research, the objective of which is “to portray an accurate profile of persons, events or situations” (Saunders, Lewis & Thornhill, 2007, p.134). A descriptive form of research will help us to explore and present the true nature and status of existing practices, processes and relationships, as well as external environmental conditions (e.g. legislation) as they occur at the moment of the investigation. The descriptive approach will also allow us to obtain first hand data from the respondents, based on their current impressions, and thus to formulate rational and sound conclusions for the study (Creswell, 1994). Procedure The procedure of the research consists of the following main stages: 1. Initial preparation and gathering of materials. 2. State-of-the art literature review. 3. Design of research instruments (interview and survey questionnaires). 4. Agreements with primary care practices (5 NPs-led and 5 GPs-led practices). 5. Primary data collection. 6. Primary data analysis and interpretation. 7. Summarizing and final reporting. Design We will use a comparative study design, which will combine qualitative and quantitative research approaches. Such mixed research method will allow us to gather pertinent data and to achieve the objectives of the study more effectively. Qualitative research instrumentation and data collection Primary Sources of Data The qualitative research approach will be used to gain in-depth information (explanations, interpretations, opinions) on the situation from real patients of primary care practices. According to Maykut and Morehouse (1994), “the data of qualitative inquiry is most often people’s words and actions, and thus requires methods that allow the researcher to capture language and behaviour” (p. 46). As the main technique for gathering data we will use semi-structured face-to-face interview. Dawson (2002) asserts that “semi-structured interviewing is …the most common type of interview used in qualitative social research” (p.28). In this type of interview, the researcher obtains specific information which can be compared and contrasted with information gained in other interviews. In order to do this, we will ask the same questions in each interview, they will be open and precise enough to give the interviewee the place and the opportunity to speak and develop own ideas. We will try to remain the interview flexible so that other important information can still arise. We will also produce an interview schedule - a list of specific questions or a list of topics to be discussed; each interview will be conducting according this schedule to ensure continuity. We intend to use interview methods for investigation of the key factors influencing on patients’ satisfaction and preferences. Secondary Sources of Data In support of the primary data gathered, the exploring of state-of-the-art research reports and literature will be done with the help of such generally accessible data sources as academic and professional journal articles, magazines articles, books, as well as internet. This will help us to see how differences in patients’ satisfaction with primary care services provided by NPs and GPs are understood in the modern medical community. Quantitative research instrumentation and data collection The quantitative deductive approach will be used to draw measurable primary data to determine relationships between some variables and to prove or reject research hypothesis in regard to the given population. As the main technique for gathering data we will use structured questionnaire survey. Survey aims to draw information from a large sample; it allows us to derive and investigate precise and impartial data to support conclusions and generalizations. We intend to conduct the survey with using the 21-item “Medical Interview Satisfaction Scale” (MISS-21) (Meakin & Weinman, 2002). This questionnaire was developed purposely to assess patients’ satisfaction with individual doctor-patient consultations, and validity, reliability and applicability of the instrument has been proved in the number of previous studies (Ibid.). Questions in the survey are divided on four subscales – Distress Relief, Communication Comfort, Rapport and Compliance Intent, so the results of the survey will give us an opportunity not only to evaluate differences in patients’ satisfaction, but also to determine nature of factors influencing on their satisfaction. The survey is self-administered, questions are brief and understandable, and so it will be easy for patients to complete the survey quickly. Questionnaires will not be marked and patients will not be asked to identify them in any way, we hope the anonymity will help us to gain more honest and reliable answers from patients. The method of questioning is a five-point Likert scale indicating the agreement of a patient with statements about the nurse-led or doctor-led consultation. Population and Sample We intend to come to an agreement with 5 nurse-led primary care practices and 5 doctor-led primary care practices in order to they would take part in our survey. In each of the practices during 1-2 days we will randomly choose 7 patients. 2 of them we’ll ask to participate in the interview and 5 patients will be asked to participate in the survey. Thus, the population for our study will be composed as follows: Face-to-face interview population will include 10 patients of nurse-led practices and 10 patients of doctor-led practices. Questionnaire survey population will include 25 patients of nurse-led practices and 25 patients of doctor-led practices. Therefore to the end of the data collection stage we will have 20 completed interviews and 50 answered survey questionnaires. Total population of the study is 70 patients. Method of Analysis Qualitative data gathered during fact-to-face interviewing will be analyzed by reviewing, generalizing and interpreting appropriately, in order to determine interconnections and relationships between different elements, such as aspects of primary care, patients’ attitudes and perceptions, external factors, etc. Quantitative results of the survey will be analyzed using statistical methods (e.g. factor analysis, which determines the existence of relationships between the various dependent and independent variables). Time Schedule Stages of the research project are planned as it is shown in the Table 1. Table 1. The time schedule of the research. Activity Months 1 2 3 4 5 6 1 Initial preparation and gathering of materials 2 Conducting the state-of-the-art literature review 3 Design of questionnaire for face-to-face interview 4 Adaptation of MISS-21questionnaire for survey 5 Coming to agreements with 10 primary care practices for participation in the study 6 Printing interview schedules and survey forms for data collection 7 Primary data collection (70 participants) 8 Primary data analysis and interpretation 9 Summarizing and final reporting Resources needed The following resources are needed for our research: For gathering of materials, literature review, preparation to data collection, data analysis and final reporting: a computer with internet connection, a printer, stationary. For primary data collection: a phone, a dictaphone, printed interview schedules and survey forms, stationary. Personnel The additional personnel are not necessary. Budget The budget needed for the research to be satisfactorily completed is presented in Table 2. It is presumed that all necessary equipment (a computer with internet connection, a printer, a phone and a dictaphone) is already at our disposal, and it is not necessary to buy it within the research project. Table 2. The research budget. Item Cost 1 Stationery 25$ 2 Internet access 10$ x 6 months = 60$ 3 Access to online library resources 15$ 4 Phone speaking 10$ x 3 months = 30$ 5 Transport costs 100$ 6 Printing 15$ 10% contingency (in round figures) 25$ Total cost 270$ Needed assurances / clearances The specific assurances are not necessary in this type of research; however, in our study we will be strongly governed by ethical considerations. The general ethical principal, which we will adhere to, is that our research design will not subject people whom we will research (our research population) to embarrassment or any other material disadvantage (Saunders et al, 2007, p.153). Other principles are: Informed consent – we will conduct a research only among people who will give us a clear consent after receiving truthful information about the research. We will inform our participants of the purpose of the research, their role and procedures including those protected their anonymity. Participants will be assured that neither the patient nor his or her primary care professional will be subject to victimization, because it is not required to provide any names in the questionnaires. Moreover, we will explain how the patient’s participation will help in improving health care services. We understand that any participant has a right to withdraw their consent to participate in the research at any time without any explanation, and we will inform participants about that. If any participant wants to receive the final results of our study, we will provide that. Right to privacy – we appreciate the right of our participants to privacy and will not ask them to provide their names or other identity in the research. But for the purposes of the research we need some demographical characteristics, such as age, gender, education, nationality, family conditions, etc. So, we will ask participants provide the data but without identity. Protection from harm – we will not harm our participants neither physically, nor emotionally, nor by any other kind. We will be open, friendly and supportive. Limitations of the research The major limitation is connected to the ability to find and to come to agreements with primary care practices. There is a certain anxiety that they may refuse our offer. In order to involve them in participation in the study we intend to make a clear presentation of the research objectives and possible practical implications. Since the study intends to make use of both qualitative and quantitative data, problems regarding the data acquisition may be encountered. Face-to-face interview is able to provide significant information, but, giving the limitation of 20 persons, interview results would not possibly enable to make a broad generalization of the issue. Qualitative data is analyzed in the most part intuitively and they do not show cause-effect or correlation analysis of the relationship between variables. Besides, analysis and generalization of information will be done only by a researcher, so it will evidently have elements of subjectivity. As for questionnaire survey the main problem we may be faced with will be to diagnose the veracity of the comments by the respondents who fill in the questionnaire. Not all of them may want to tell the truth, so we can gather distorted information. Possible weaknesses of the qualitative data are also connected to departing from the original objectives of the research or excessive subjectivity of judgment (Cassell and Symon, 1994). We intend to compensate it by clearly stating and explaining the research problem to participants and by crosschecking with the results of statistical analyses. The time factor may become an important problem since we have to conduct interviews and surveys in limited period of time. In addition, the illness and some unpredictable problems may also affect the process of the research. To avoid these situations, we should try to work in advance. Besides, at the primary data collection stage we intend to travel a lot, so it may occur that the current budget is underestimated. So, it would be wise to consider the budget again after the agreement stage would be completed. References American Academy of Nurse Practitioners (AANP). (2007). Nurse practitioner cost-effectiveness. Austin, TX: American Academy of Nurse Practitioners. Retrieved from http://www.hospitalmedicine.org/AM/Template.cfm?Section=Reference_Material&Template=/CM/ContentDisplay.cfm&ContentID=16740 Cassell, C., & Symon, G. (1994). Qualitative research in work contexts. In C. Cassell, & G. Symon (Eds.), Qualitative methods in organizational research (pp. 1-13). Thousand Oaks, CA: Sage Publications. Creswell, J. W. (1994). Research design: Qualitative and quantitative approaches. Thousand Oaks, CA: Sage Publications. Dawson, C. (2002). Practical research methods: A user-friendly guide to mastering research. Oxford, UK: How To Books. Dierick-van Daele, A.T.M., Spreeuwenberg, C., Derckx, E.W.C.C., Metsemakers, J.F.M., & Vrijhoef, B.J.M. (2008). Critical appraisal of the literature on economic evaluations of substitution of skills between professionals: a systematic literature review. Journal of Evaluation in Clinical Practice, 14, 481–492. Gilmer, M.J., & Smith, M. (2009). The nurse practitioner provides a substantive opportunity for task substitution in primary care. Journal of Primary Health Care, 1(2), 140-143. Hollinghurst, S., Horrocks, S., Anderson, E., & Salisbury, C. (2006). Comparing the cost of nurse practitioners and GPs in primary care: Modelling economic data from randomised trials. British Journal of General Practice, 56, 530–535. Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ, 324, 819-823. Kleinpell, R. M., Wesley, E., & Grabenkort, R. (2008). Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review. Critical Care Medicine, 36(10), 2888-2897. Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2007). Substitution of doctors by nurses in primary care. The Cochrane Collaboration. Retrieved from http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001271/frame.html Laurant, M.G., Hermens, R.P., Braspenning, J.C., Akkermans, R.P., Sibbald, B., & Grol, R.P. (2008). An overview of patients' preference for, and satisfaction with, care provided by general practitioners and nurse practitioners. Journal of Clinical Nursing, 17(20), 2690-2698. Mardby, A.-S., Akerlind, I., & Hedenrud, T. (2009). General beliefs about medicines among doctors and nurses in out-patient care: A cross-sectional study. BMC Family Practice, 10(35). Retrieved from http://www.biomedcentral.com/1471-2296/10/35 Maykut, P. S., & Morehouse, R.E. (1994). Beginning qualitative research: A philosophic and practical guide. London, UK: The Falmer Press. Meakin, R., & Weinmann, J. (2002). The ‘Medical Interview Satisfaction Scale’ (MISS-21) adapted for British general practice. Family Practice, 19(3), 257-263. Redsell, S., Stokes, T., Jackson, C., Hastings, A., & Baker, R. (2007). Patients’ account of the differences in nurses' and general practitioners' roles in primary care. Journal of Advanced Nursing, 57(2), 172-180. Robinson, J.D., & Heritage, J. (2006). Physicians’ opening questions and patients’ satisfaction. Patient Education and Counselling, 60, 279–285. Rough, G. (2009). For many, a nurse practitioner is the doctor. The Arizona Republic. Retrieved from http://www.azcentral.com/news/articles/2009/02/21/20090221nursepractitioners0220.html#ixzz1E0tW0J7M Saunders, M., Lewis, P., & Thornhill, A. (2007). Research methods for business students. Harlow, UK: Pearson Education. Sheer, B., & Kam Yuet Wong, F. (2008). The Development of Advanced Nursing Practice Globally. Journal of Nursing Scholarship, 40(3), 204-211. Young, R. (2010). Nurse practitioners, Part 2 – Are they the answer for primary care? American Health Scare. Retrieved from http://www.healthscareonline.com/http:/www.healthscareonline.com/blog/nurse-practitioners-part-2-%E2%80%93-are-they-the-answer-for-primary-care/ Read More