Quality in Primary Care Open Access

Keywords

first-contact care, general practitioner, nurse, nurse–doctor substitution, nurse practi-tioner

Introduction

Systematic reviews of nurse–general practitioner (GP) substitution in primary care have found that appro-priately trained nurses can produce as high-quality care as GPs, and achieve good health outcomes for patients.[1,2] Patient satisfaction assessed using stan-dard patient questionnaires has been found to be higher following nurse consultations for chronic dis-ease and minor illness conditions.[1,2] Nurses provide longer consultations and give more information to patients than GPs.[3] However, some patients seeing nurse practitioners for minor illness care report a preference to see a GP next time, despite being satis-fied with nurse consultations.[4,5]

Critics of patient satisfaction surveys suggest they consistently report high levels of satisfaction with healthcare services, but fail to examine what lies behind these results.[6] Patient satisfaction is a complex phe-nomenon, and may be influenced by a number of factors including expectations (which can in turn be determined by prior experience), patient character-istics, such as age and sex, presenting condition and psychosocial determinants.[7,8] A systematic review of the literature on the use of satisfaction measures for health care detailed a number of problems with this method of assessing patients’ views of healthcare services. These included the timing of surveys on reported satisfaction; the extent of bias introduced by the inquirers; cross-cultural issues and the role of consumer feedback in healthcare decision making.[9]

Crow et al concluded that despite the importance of expectations in the measurement of satisfaction, only 20% of studies considered this factor.[9] The nature of the relationship between patient expectations and satisfaction has not been clearly defined, yet evidence suggests there is a positive association between meet-ing expectations and satisfaction, and some evidence suggests unmet expectations are associated with dis-satisfaction.[10,11] However, there is also some evidence that satisfaction is unrelated to whether specific (spe-cific in this context refers to tests, referrals and new medications) expectations are met or unmet.[12] The relationship between patient expectations and satis-faction for nurse-led care is likely to be complex and might depend upon the type of consultation, i.e. first-contact or chronic disease management. Patient expectations might be determined by previous experi-ences with a particular individual and/or professional group. It is conceivable that patients may not expect nurses to be able to diagnose complex conditions, because historically they have not done so,[13] but they would expect GPs to do so. Conversely, patients may not expect their GP to make the time to listen to their concerns, but they might expect a nurse to do so.[14] The objective of this study was to explore patient expectations of GP and nurse consultations, and whether or not they are met, in an attempt to explain higher reported satisfaction rates with nurse consul-tations.

Methods

Design

Participants were interviewed prior to and up to two weeks after their consultation with either the nurse or GP. Semi-structured interview and constant comparative method were used in order to explore the issue from the perspective of the participants.[15]

Participants

All general practices in six primary care trusts (PCTs) were invited to participate in the study during 2004. Two practices, which employed nurses treating patients attending for first-contact care consultations in par-allel with GPs, agreed to participate. These two prac-tices were based in a major UK city. The populations attending both practices are predominantly white British; practice one was situated in a more deprived area than practice two. The inclusion criteria were adult patients aged 18 years and over, a patient-generated request for appointment, new presentation of the problem to the nurse/GP, or re-presentation of the problem at the patient’s request. Patients were recruited over several weeks, with the researcher being present in the practice for agreed sessions.

Results

Sample

The sample contained 28 patients, with a range of characteristics in terms of sex (male = 17, female = 11) and age (21–77 years). Participants presented with a variety of symptoms in the upper respiratory tract (4), back pain (7), ear problems (3), gastrointestinal symp-toms (2), injury/limb problems (4), mood change (2) and other (6).

Twenty-eight interviews were conducted with par-ticipants prior to their consultation with either the nurse (n = 11), GP (n = 16), or unknown professional (n = 1). One tape recording was unusable resulting in 27 usable interviews. Nineteen follow-up interviews were conducted, resulting in 18 paired interviews, of which eight nurse and ten GP consultations were usedfor this analysis.

Data collection and analysis

The first interview was undertaken prior to the con-sultation in the general practice surgery, and the second post-consultation interview was undertaken in participants’ homes. The interviews were conduc-ted with the aid of prompt guides, which were used flexibly. The first interview was designed to obtain information about why the participant had attended and what they expected from the practitioner they were consulting with. The second interview was designed to explore participants’ views about the consultation. All interviews were conducted, audio-taped and tran-scribed verbatim by CJ. Open codes describing each unit of meaning within the transcripts were generated by CJ, and these were grouped into organising themes to form the coding frame. Data were assigned to the coding frame by CJ using QSR N5 software, and were modified where necessary to ensure an adequate ‘fit’ with data. AH, SR, and TS checked the assignment of data to categories in a sample of transcripts. The categories that emerged have been published in a paper entitled ‘Patients’ accounts of the differences in nurses’ and general practitioners’ roles in primary care’.[16] For this analysis, participants’ expectations of their consultation with either the nurse or GP were explored between the two interviews. A framework was developed matching participants’ prior expec-tations in terms of history taking, examination and outcome, with their accounts of whether or not their expectations were met within these three areas, from the post-consultation interviews.

Main findings

Expectations prior to the consultation

Participants consulting with both nurses and GPs found it diffcult to articulate all their expectations, and tended to focus on their desired outcome or an outcome based on previous experience. This might be a diagnosis of their problem with an accompanying prescription, answers to questions, examination or referral to another care provider, but it also included recognising whether they had a serious illness. Most participants based their expectations of the process of the consultation around their previous experiences consulting with GPs. Participants who had not ex-perienced a first-contact care consultation with a nurse before were generally cautious about what to expect.

‘There’ll be some tests of some sort no doubt and she’ll give me a vague idea of what she thinks is wrong.’ (participant 4 prior to nurse consultation)

‘I’m assuming that she’ll probably try and listen to my chest; ask me what my symptoms are.’ (participant 7 prior to nurse consultation)

Some participants approached the consultation with a belief that the nurse would be subordinate to the GP in terms of skills, knowledge and authority, and reflected that they may have to return to the practice to see the GP for treatment.

‘I believe that if she thinks there is something wrong they will actually make me a proper doctor’s appointment to come back at a later date.’ (participant 7 prior to nurse consultation)

‘I’ll get her to look at it and then see what she says. I may have to come back on Monday and see the doctor about it.’ (participant 27 prior to nurse consultation)

The difference between pre- and post-consultation expectations

It was not possible to explore whether prior expec-tations of the consultation differed between the nurse and the GP, since the patients had little prior experi-ence of nurse-led consultations. It was also diffcult to match participants’ prior expectations with the post-consultation interview data, because they changed over time and new/different expectations emerged. For a few participants the process of the consultation or subsequent events had resulted in their prior ex-pectations being almost forgotten. For example, par-ticipant 1 expected a ‘sick note’ and further treatment for a chest infection prior to her consultation with an unknown GP. Retrospectively she gave an account of the diffculties with the communication aspect of the consultation and her pre-consultation expectations around specific outcomes were only mentioned when prompted by the interviewer. Generally, participants with unexpressed expectations and/or those whose expectations went beyond the presenting condition expressed disappointment with the consultation (see Box 1).

Participant 2 presented with a lay diagnosis of ‘infection/blood poisoning’ in his arm based on previous experience, which he perceived as ‘serious’. Prior to the consultation he had specific expectations in terms of a prescription for anti-biotics for the infection and an examination: ‘I expect her to look at my arm and work from there’, and wider expectations concerning what else he would like to happen: ‘just a check up mainly that’s all’. The nurse diagnosed a muscle strain. During the post-consultation interview he expressed disappointment at unmet expectations: ‘not as expected, I don’t know what I expected really’.

In contrast, participants with specific expectations described how these were met during the consultation (see Box 2).

Expectations, outcome and satisfaction

Most of those who consulted with a GP they knew well reflected upon their satisfaction with the consultation. They described how their prior expectations had been

Box 2 Met expectations

Participant 16 presented with haemorrhoids. Prior to the consultation she articulated that she expected to explain her problem to the nurse and to be examined ‘I should expect that I will be examined and they will ask me how long I’ve had them’, and she talked about one possible treat-ment ‘well we’re not doctors ourselves so if they can help me, haemorrhoid cream or I don’t know’. Retrospectively she articulated her prior expectation of being examined: ‘I didn’t know what to expect. I knew I’d be examined, that was sort of obvious in my mind, but that was all’. She also expressed overall satisfaction with the con-sultation: ‘I feel that the cream that she gave me has done the trick. The doctor couldn’t have done any better in my opinion’.

shaped by an ongoing relationship which provided them with confidence in a successful outcome in terms of diagnosis or treatment.

‘I knew that when I left him I’d be a lot better than when I went to see him. We go back many years and he’s never let me down.’ (participant 5 following GP consultation)

However, participants who consulted with GPs they did not know were unsure about what to expect. A few participants reflected upon how the consultation failed to match their expectations, and this was pri-marily attributed to vagueness and misunderstanding during communication exchanges.

‘The first thing he should have done is examine my foot, not do my blood pressure, my weight and height. I think he should have tackled the problem I came in with and done them things after.’ (participant 10 following GP consultation)

Most participants expressed satisfaction following their consultation with the nurse.

‘She went into a lot more detail than I thought she was going to ... I expected to be in and out in sort of a minute rather than, I think it took about ten or 12 minutes. I didn’t expect her to listen to my chest properly.’ (partici-pant 7 following nurse consultation)

‘I was quite pleased [be]cause they done everything thoroughly so you know. I didn’t expect them to be saying what they did. But once they got the issues out of the way sort of thing, they just gave me the right information.’ (participant 28 following nurse consultation)

However, this was not always the case:

‘Well it was a bit different than what I actually expected because I didn’t expect her to go at the back of me to find out whether I can hear, because it made me feel as if I were lying.’ (participant 17 following nurse consultation)

Discussion

This study was undertaken to explore patient expec-tations of GP and nurse consultations and whether or not they are met, in an attempt to explain higher reported satisfaction rates with nurse consultations.[1,2] Participants consulting with nurses found it diffcult to articulate their expectations because they had no prior experience of nurse-led consultations. Although they wanted certainty with regard to the outcome of their consultation, most participants consulting with GPs also found it diffcult to articulate all their ex-pectations, and tended to focus on specific requests and outcomes based on previous experience. Partici-pants seeing either the nurse or GP did not always articulate desired expectations, which sometimes led to disappointment. This is consistent with the literature that leads some to conclude that patients are unwilling to present themselves with defined expectations be-cause of concerns about being ‘let down’ by healthcare services.[17] Mitchell Peck also found that patients ap-proached their consultation with vague expectations and that patients face barriers in expressing expec-tations because of the power difference in the patient– doctor relationship.[12] Some participants in this study either perceived or actually experienced the need to reduce their expectations to one presenting problem when consulting with nurses or GPs for first-contact care. Participants did not discriminate between nurses

and GPs in this respect, despite the fact that nurses are believed to have more time for patients.[3,14,16]

Participants whose expectations were based on previous experience with a known GP generally ex-pressed satisfaction following the consultation. Par-ticipants were cautious about what to expect from unknown GPs and nurses. They attached great value to interpersonal/relational continuity of care with a known GP.[18] However, at the time of data collection (2004) nurse-led consultations were a new service, and patients did not have much experience of the role. Retrospectively, participants were more able to articu-late what went wrong with their consultations with the unknown GP rather than nurse consultations. Partici-pants were unsure what to expect from a first-contact care nurse, which may explain why they tended to be more cautious about criticising them. Staniszewska and Henderson suggest that patients are often reluc-tant to judge care negatively and researchers may need special strategies to elicit negative evaluations.[19]

There was some evidence in this study that partici-pants’ expectations were at different levels. Some ex-pressed specific requests and outcomes, whereas others had wider expectations, some of which were only articulated retrospectively. A review of literature ex-amining visit-specific expectations suggested that the term ‘expectations’ is often used to indicate what patients hope will happen whether or not they ex-plicitly verbalise this as a request during their con-sultation.[10] Kravitz has observed that research in this area tends to focus on either what patients think will happen (probability expectations), or what patients would like to happen (value expectations).[20] Partici-pants in this study had very little experience of nurse-led consultations, and therefore found it diffcult to articulate what they thought might happen. Therefore we can conclude that probability expectations were lowered for participants approaching nurse compared to GP consultations. Retrospectively, some partici-pants were satisfied with their nurse consultation, which might explain the higher satisfaction rates previously reported in the literature.[1,2]

Study limitations

The study was restricted to two large general prac-tices and patients consulting with two nurses. Although this is unlikely to be relevant to prior expectations, patients’ descriptions of the thoroughness experienced during the nurse consultation in this study may not be generalisable. Nurses delivering first-contact care to patients come from a wide range of backgrounds, undertake different training and their role may differ between practices.

The number of paired interviews available for the analysis was small (n = 18). Recruiting participants for the first interviews was easier and there were some diffculties accessing people for the follow-up inter-view, which needed to be undertaken within two weeks. The recruitment of patients seeing the nurse at practice two was diffcult, and this resulted in a lower number of nurse consultations being available for analysis. Our findings should therefore be inter-preted cautiously.

Implications for future research

The results of our study suggest caution is needed when interpreting the results of patient satisfaction surveys in studies investigating nurse–doctor substitution. More research is needed on whether patients’ expectations of nurses increase as the role develops. Research also needs to examine the gap between what patients think will happen during a nurse consultation (probability expectations), and what they would like to happen (value expectations), in order to ensure that first-contact care consultations are fulfilling patient need.

Conclusion

The skills, knowledge and authority of nurses under-taking first-contact care was not fully understood by participants and they may have adjusted their expec-tations to take account of this. Patients consulting with nurses may report higher satisfaction rates with nurses because they have fewer expectations before-hand, and if these are exceeded in the resulting con-sultation, their satisfaction is accordingly greater.

Ackowledgements

The authors would like to thank the Division of General Practice (University of Leicester) for add-itional Funding; the practices involved for facilitating access to patients and the participants for their views.

References

1. Horrocks S, Anderson E and Salisbury C. Systematic review of whether nurse practitioners working in pri-mary care can provide equivalent care to doctors. BMJ 2002;324:819–23.
2. Laurant M, Reeves D, Hermens R et al. Substitution of doctors by nurses in primary care (Cochrane Review). Cochrane Database of Systematic Reviews 2005;CD001271.
3. Seale C, Anderson E and Kinnersley P. Comparison of GP and nurse practitioner consultations: an observational study. British Journal of General Practice 2005;55:938–43.
4. Kinnersley P, Anderson E, Parry K et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting same day con- sultations in primary care. BMJ 2000;320:1043–8.
5. Shum C, Humphreys A, Wheeler D et al. Nurse man-agement of patients with minor illness in general prac- tice multicentre randomised controlled trial. BMJ 2000; 320:1038–43.
6. Edwards C, Staniszweska S and Crichton C. Investigation of the ways in which patient reports of their satisfaction with healthcare are constructed. Sociology of Health and Illness 2004;6:159–83.
7. Baker R. A pragmatic model of patient satisfaction in general practice: progress towards a theory. Quality in Health Care 1997;6:201–4.
8. Sitzia J and Wood N. Patient satisfaction: A review of issues and concepts. Social Science and Medicine 1997; 45:1829–43.
9. Crow R, Gage H, Hampson S et al. The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature. Health Tech-nology Assessment 2002;6(32). www.hta.nhsweb.nhs.uk/ execsumm/summ632.htm (accessed 6 November 2006).
10. Rao J, Weinberger M and Kurt K. Visit-specific expec-tations and patient-centred outcomes: A literature re-view. Archives of Family Medicine 2000;9(10):1148–55.
11. McKinley RK, Stevenson K, Adams S and Manku-Scott TK. Meeting patient expectation of care: the major determinant of satisfaction with out-of-hours primary medical care. Family Practice 2002;19:333–8.
12. Mitchell Peck B, Ubel, P, Roter DL et al. Do unmet expectations for specific tests, referrals, and new medi-cations reduce patients’ satisfaction. Journal of General Internal Medicine 2004;19:1080–7.
13. Broadbent J. Practice nurses and the effects of the new general practitioner contract in the British NHS: The advent of a professional project. Social Science and Medicine 1998;47:497–506.
14. Williams A and Jones M. Patients’ assessments of consulting a nurse practitioner: the time factor. Journal of Advanced Nursing 2006;53:188–95.
15. Glaser BG and Strauss AL. The Discovery of Grounded Theory: strategies for qualitative research. Chicago: Aldine Publishing Co, 1967.
16. Redsell SA, Stokes T, Jackson C, Hastings AM and Baker R. Patients’ accounts of the differences in nurses’ and general practitioners’ roles in primary care. Journal of Advanced Nursing 2007;57(2):172–80.
17. Avis, M, Bond M and Arthur A. Questioning patient satisfaction: an empirical investigation in two outpatient clinics. Social Science and Medicine 1997;44:85–92.
18. Haggerty JL, Reid R, Freeman G et al. Continuity of care: a multidisciplinary review. BMJ 2003;327:1219–21.
19. Staniszewska S and Henderson L. Patients’ evaluations of their health care – the expression of negative evalu-ation and the role of adaptive strategies. Patient Edu-cation and Counselling 2004;55:185–92.
20. Kravitz R. Patients’ expectations for medical care: an expanded formulation based on review of the literature. Medical Care Research and Review 1996;53:3–27.

Funding

Scientific Foundation Board, Royal College of General Practitioners.

Ethical Approval

Ethical Approval was provided by the local Research Ethics Committee, and research governance approval was provided by the Primary Care Research Alliance.

Conflicts of Interest

None.