Monique Mavronicolas_Research Project.pdf

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A Question of Quality:

What impact do Nurse Practitioners have on Primary Health Care in the UK?

Monique Mavronicolas

Date: March 2015

Word count: 6747


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Abstract

This study aims to access Nurse Practitioners’ perceptions of their impact on primary

health care and how their contribution to the health service industry influences the quality

of patient care. In order to gain insight into the health service industry in the United

Kingdom and the issues which have increasingly drawn media attention and concomitantly

put the spotlight directly on the medical fraternity, a cohort of seven qualified Nurse

Practitioners were invited to participate in this research study. Research findings in this

study strongly suggest that effective management of care standards requires careful

strategic planning between the boardroom and the bedside. Apart from health and social

care monitoring groups monitoring service standards, more proactive strategies need to be

set in place to prevent a mismatch in skills between supply and demand. Under sourcing of

community and social care services remains a concern and Government investment in the

current nursing workforce needs to be a priority.


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Table of Contents

Abstract …………………………………………………………………………………………………………………………….. 2

Table of Contents ……………………………………………………………………………………………………………… 3

Acknowledgements ………………………………………………………………………………………………………….. 4

1. Introduction ……………………………………………………………………………………………………. 5

1.1 Background …………………………………………………………………………………………………….. 5

1.2 Research Aims ………………………………………………………………………………………………… 5

1.3 Outline of Chapters …………………………………………………………………………………………. 6

2. Literature Review ……………………………………………………………………………………………. 7

2.1 Methodology …………………………………………………………………………………………………… 7

2.2

Nursing shortages and the impact on Patient Care …………………………………………. 9 2.3 The role of Nurse Practitioners compared to General Practitioners ……………….. 13

2.4 Improving service delivery in Primary Healthcare …………………………………………… 15

2.5 Discussion ………………………………………………………………………………………………………. 16

3. Research Methodology ………………………………………………………………………………….. 17

3.1 Introduction …………………………………………………………………………………………………… 18

3.2 Research Design …………………………………………………………………………………………….. 18

3.3 Research Methods …………………………………………………………………………………………. 19

3.3.1 Research Instrument ……………………………………………………………………………………… 19

3.3.2

Sampling ………………………………………………………………………………………………………… 21

3.3.3 Data Analysis ………………………………………………………………………………………………….. 22

3.4 Ethical Considerations …………………………………………………………………………………….. 22

3.5 Conclusion ………………………………………………………………………………………………………. 23

4. Research Findings …………………………………………………………………………………………… 25

4.1 Introduction …………………………………………………………………………………………………… 25

4.2 Quality of Frontline Patient Care ……………………………………………………………………. 25

4.3 Nurse Practitioner’s relation to General Practitioners ……………………………………. 28

4.4 Discussion ………………………………………………………………………………………………………. 29

5.

Conclusion and Recommendations …………………………………………………………………. 30

5.1 Research Limitations ………………………………………………………………………………………. 31

5.2 Summary of Research Findings ……………………………………………………………………….. 31

5.3 Implications of the Research Findings …………………………………………………………….. 32

5.4 Key Recommendations …………………………………………………………………………………… 33

5.5 Areas for Future Research ………………………………………………………………………………. 33

References …………………………………………………………………………………………………………………. 34

Appendix I & Appendix II ……………………………………………………………………………………….. 37-38

Consent Forms ………………………………………………………………………………………………………….. 40


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Acknowledgements

I would like to thank the study respondents who offered their time and invaluable insight

towards this research study.

A special thanks also to East Surrey College and to the teachers who offered advice and

feedback during the planning and research phase.

A final thanks goes to my husband for his continued support and for proofreading this study.


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Chapter 1 – Introduction

1.1 Background

Ever since the decrease in demand for the services of general practitioners (GP’s),

particularly in Western countries, the dynamic of patient care has had an interesting shift

and focused on nursing staff. For this reason, aspects of care usually provided by GP’s have

meant that nurses have had to undertake a more specialist role especially, for example, in

the routine management of chronic diseases. Depending on the complexity of patient care

needed, level of training of the nurse, as well as the degree of autonomy, care may be

provided by a nurse practitioner (Laurant et al . 2004).

However, with a very notable decline in nursing numbers in the United Kingdom

resulting from numerous factors such as poor strategic decisions and budget cuts, many of

the older and more experienced nurses have had to be recalled to lend their clinical

expertise and help train a young and inexperienced nursing workforce.

1.2 Research Aims

The study will take the form of empirical research. Due to the constraints of the size

of this small qualitative study, the sample group of interviewees will provide data which will

be limited to the perceptions of these interviewees.

The aim of this research study is to assess Nurse Practitioner’s perceptions of primary

health care in the United Kingdom with a view to their contribution to the health service

industry and whether in their view, this has any impact on the quality of service delivery in

patient care. These aims will be operationalised by means of the following specific objectives:


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I. to identify Nurse Practitioner’s perceptions of the quality of primary health care in

the UK

II. to identify the perceptions of what impact their role as health care providers has

on primary health care in the UK

III. to identify and examine the challenges which Nurse Practitioners face regarding

service delivery in primary health care

From examining the data generated by this research, it is hoped that the outcome of this

study will shed light on possible gaps in the public health services.

1.3 Outline of Chapters

The literature review which proceeds this chapter, highlights the state of the health

services in the United Kingdom and the pressures facing the NHS. It also looks at the role of

the Nurse Practitioner in light of their working relationship with general practitioners and

lastly, a look at a few strategies for improving the delivery of health care services. Due to the

limitations of this study, it was not possible to explore detailed personal experiences or each

type of challenge facing Nurse Practitioners in detail. However, the interview process

detailed in Chapter 3, rendered results collected from interviews with NP’s, the findings of

which can be found in the research responses discussed in Chapter 4. The study concludes

with a summary of the research findings in Chapter 5, in addition to implications, key

recommendations and areas for future research.


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Chapter 2 – Literature Review

2.1 Methodology

This chapter aims to address the following research questions:

I. What are the perceived consequences of increased job demands on Nurse

Practitioners versus the quality of patient care they are able to provide?

II. Do NP in any way provide the equivalent care services to that of a GP? And lastly,

III. What are the best ways for enabling NP to improve on their primary care service

delivery and provide a forward looking strategy?

To address the first research question, the first part of the literature review will

purposely discuss the issue of nursing supply and demand issues, otherwise known as

workforce gaps, which presently affect NHS organisations and the consequential effect on

patient care. Specifically, reference will be made to studies which point towards nursing

workforce supply shortages, the related work-role demands placed on nurses and the

surveyed organizations having to recruit qualified nursing staff from outside of the UK.

To address the second research question, the second part of the literature review

purposely identifies and addresses the perceived elements of NP’s working in primary

health care, possibly providing equivalent care to GP’s with a view to ascertaining the

respective level of patient care outcomes such as patient satisfaction and quality of care.

Lastly, to address the third research question, the last part of the literature review

purposely discusses the need for strategic ways on how to effectively strategize a forward

looking framework for enabling NP’s to improve on primary health care service delivery.

This strategy looks at workforce redesign in a climate where the nature of health care work


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is changing and a necessity exists to address skills in order to match future health care

needs and related demands.

When selecting appropriate literature, keywords or search terms should be used

when locating useful information for the review of literature (Adler & Clark 2011). In search

for related literature relevant to this study, the following key search words/terms were

used in this study: ‘nurse practitioner’, ‘advanced nurse practitioner’, ‘primary health care’,

‘nurse practitioners working in primary care’, ‘national health services UK’, and ‘advanced

nursing in the UK’. The online databases of JSTOR and Highwire were used to locate related

peer-reviewed journals. In addition, Google Scholar was used to source relevant online

publications and news reports.

The use of inclusion and exclusion criteria is necessary in terms of allowing the

researcher to easily identify literature that is directly related to the research topic from those

that are unrelated (Aveyard 2010). Likewise, Aveyard (2010) notes that the use of inclusion

and exclusion criteria is useful in terms of finding articles that address the research questions

presented in this study.

Often times, the use of inclusion and exclusion criteria is useful in reducing the scope

of the preliminary search for related academic books, peer-reviewed journals and other

related online news reports (Fink 2010). Applicable to this study, inclusion criteria include

the following:

Critical appraisal is normally conducted to double check the reliability and validity of

each journal (LoBiondo-Wood & Haber 2014). Therefore, after the pre-screening of related

literature, each of the peer-reviewed journals was subjected to critical appraisal. Finally,


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information gathered from the academic publications and few selected peer-reviewed

journals, were subdivided and formally written under the following key themes:

2.2 Nursing shortages and the impact on Patient Care

In the United States, advanced nurse practitioners (ANP’s) make up 6 per cent of

nursing posts and outside of the US, figures reflect that they make up as little as 1 per cent

or less. Evidence suggests that a reason for shortages in the field of advanced nursing can

be attributed to the fact that it is still a relatively new and unknown discipline and the fact

that postgraduate studies are needed in order to qualify in the field when in some

countries, nursing is just a vocational training programme (Lipley 2014).

Primary health care can be described as the first point of contact in the health care system.

Forming the cornerstone of England’s National Health Services (NHS), the main source of

health care is in general practice (What is primary health care? n.d., para. 1). In terms of

global standards in health care and the availability of basic health care, the United Kingdom

affords a level of service which is ranked comparatively high according to international

standards. In fact, the Commonwealth Fund survey, found people in Britain to have the

best co-ordinated care, have among the fastest access to GPs and suffer among the fewest

medical errors. This was found to be the case of 11 high income countries surveyed, which

include France, Sweden and Germany (Adams 2011).

An integral part of ensuring a high standard and availability of medical care in the

UK, is directly attributed to the National Health Service (NHS). The NHS was established on

5th July 1948, and its objective is to provide comprehensive medical services to all the UK

residents. Through the organization, the UK residents are able to access ambulatory, general


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practitioner and specialist care services through a cost-sharing arrangement. The NHS

accounts for the majority of the total health care expenditure and the organization is funded

by the UK government, national insurance contributions and user charges. The original

structure of the organization had three components: hospital services, primary care services

and community services. The three components form what is otherwise known as the

tripartite system, and under this arrangement regional hospital boards were formed to

administer services to the patients. The Board’s functions were complemented by the

independent contractors and the health workers under the county government. The

functions of the NHS were restructured in 1970s and 1980s with the introduction of modern

management processes.

Over time, the government’s expenditure on the NHS increased from £11.4billion in

1948 to almost £100 billion in 2010 (Graph 1). According to Pollock (2004) most of the NHS’s

funds are allocated to the primary care trusts. The general practitioners are paid by the

primary care for the services administered to the patients through a combination of the

following methods: salaries, capitation and fee-for-service. To improve the quality of the

services available to the patients of the NHS, a number of regulatory bodies have been

formed. The Nursing and Midwifery Council (NMC) for example, is responsible for practice

standards and guidance and is the largest body of its kind for healthcare professionals in the

UK. While ensuring patients receive quality care and services, the regulatory bodies, also

evaluated how funds are being used. The government has also borrowed a cue from the

private sector by introducing pay-per-performance programs. Under the new dispensation

the government has initiated a quality and outcome framework whose role is to monitor the

quality of care provided by the general practitioners. Under this arrangement, the general


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practitioners are awarded points with the aim of improving quality of care delivered to the

patients.

Graph 1: NHS expenditure

Despite the considerable year-on-year funding increase and most of the NHS’s funds

being allocated to the primary care trusts and notwithstanding the existence of regulatory

bodies ensuring quality care of services, the NHS has faced an increasing nurse shortage to

the point of chronic shortfalls. As a result, the NHS has had to recruit nurses from outside of

Britain with reportedly one in five nurses employed in UK hospitals coming from Spain, the

Philippines or from Portugal (Campbell 2014). More specifically, since 2010, the NHS has

reportedly lost 4,000 senior nursing posts (Nurse Practitioners and General Practice Nurses)

and the Royal College of Nursing (RCN) has indicated that this shortage has put patient care

at risk. However, these cuts to nursing have been put down to the NHS being under

pressure to save £20 billion by 2015 (News Health 2014).

Studies have suggested that nurses have a causal contribution towards the recovery

of patients with critical illnesses. The knowledge and experience of a nurse and the

respective quality of the care delivery which they are able to provide are either optimised

or compromised as based on the environmental work factors and nurse’s workload (Ball &

McElligot 2003).


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Nurses also experience ethical dilemmas and moral distress as a result of work

stresses directly associated with workload, hours worked and difficult care situations. As a

result, data accumulated over a 27 year study on nurses reveal that many of the nurse test

subjects experienced burnout and emotional exhaustion and depersonalization. This in turn

had a direct impact on their work performance and also in the way that they viewed their

professional performance. Consequently, their own depersonalization and burnout-

syndrome translated into a higher incidence of depersonalization towards patients (Oh &

Gastmans 2013).

Staff wellbeing has to do with care infrastructure and demands on staffing, where

healthcare staff report high demands on their time, which in turn has a negative causal

relationship between staff delivery and patient care and affects the perceived quality of

that service delivery (both from the medical professional’s perspective and from the

patient). The outcome of a 2012 study suggests that for a good patient experience, there

needs to be enhanced staff wellbeing. The higher the demand on the staff, the more stress

they experience which is coupled with exhaustion and a decrease in job satisfaction.

Contextually, to use one example from the study surrounding the area of elderly care; in

this specific setting, nursing staff members were found to have poor relational care and

failing to “connect” with individual elderly patients (National Institute for Health Research

2012).

2.3 The role of Nurse Practitioners compared to General Practitioners

An ambiguity exists regarding the use of the term ‘nurse practitioner’ as the lack of

role clarity presents an added barrier especially in terms of integrating the advanced

practice roles into regular nursing cohorts. In the UK, unlike the long tradition of advanced


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nursing training programmes established in the United States and Canada, the field of

advanced nursing is still relatively new. An added problem is that in the UK, there is no

separate registry or recordable qualification which recognises nurse practitioners on the

Nursing and Midwifery Council register (Morgan 2010).

Nurse Practitioners, by virtue of their work scope and responsibilities, are often

described as ‘autonomous’ and ‘independent’ practitioners. By implication this also means

that when it comes to NP’s actions, they are professionally and personally accountable. For

example, should NP’s decide not to undertake patient care in a certain way, they must be

given the autonomy and authority to make those decisions which are in the best interests

of their patient. Consequentially, this highlights NP’s vulnerabilities based on the fact that

they are managing clinical uncertainty. However in terms of vicarious liability, NP’s are no

more vulnerable to claims of liability than say, other nurses or even General Practitioners,

as it is usually the employer who is sued in the instance of things going wrong

(Competencies in nursing: Nurse practitioners 2005).

In a study on primary care and the impact of nurse practitioners on the workload of

general practitioners, the randomized controlled trial revealed that by incorporating nurse

practitioners into general practice teams, did not initially reduce the workload of general

practitioners. Objective and subjective workloads were measured. This meant that, at least

in the short term, there was evidence to suggest that NP’s are used as supplements rather

than substitutes when it comes to care given by GP’s (Laurant et al. 2004).

Nurse Practitioners or Senior Practice Nurses have a focus working with patients

with long term conditions and provide an aspect of care known as preventative healthcare.

They typically also provide aspects of patient care which is often carried out previously by a


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general practitioner (GP). This means that they work with rather than for GP’s with the

emphasis being on collaboration rather than substitution. In terms of qualifications, they

will have had a minimum training of a degree level. Additionally, they will have been

trained and are able to demonstrate skills which include physical assessment, medical

consultations, diagnosis, health promotion and be able to support specific areas of long

term conditions which could include asthma and diabetes. The RCN makes the

recommendation for those wanting to become NP’s to undertake study and training to at

least an honours degree level while Advanced Nurse Practitioners (ANP), are typically able

to offer the same services of a nurse practitioner, but in addition will have a prescribing

qualification as well as a Master’s degree (NHS Careers).

In a systemic peer review of an international study on nurse practitioners, data

revealed that there was low to moderate evidence to suggest that despite patient health

outcomes being similar for nurse practitioners and doctors, the quality of care and patient

satisfaction was higher in relation to nurse practitioners compared with doctors. The study

also revealed that there was moderate quality evidence to suggest that nurse practitioners

undertook more investigations and had longer consultations compared with doctors. The

study was of nurse practitioners working in primary healthcare involving initial assessment

and autonomous management of patients (Shey & Chopra 2008).

2.4 Improving service delivery in Primary Healthcare

In terms of perspectives on workforce gaps, the RCN predicts that the fall in numbers

of nurses in the UK, could reach as much as 28 per cent (100,000) by 2022 (Buchan and

Seccombe 2011). This fall is driven by three factors: an aging nursing workforce, fewer

people training to be nurses and the international movement of healthcare workers.


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Another gap identified relates to a mismatch in skills between supply and demand. The

Centre of Workforce Intelligence in the UK forecasts an oversupply of hospital doctors and

an undersupply of GP’s. More specifically it points to issues of particular specialties where

the need is greatest and growing in areas of emergency, geriatric and psychiatric medicine,

the nature of healthcare is changing, there is a potentially dwindling workforce and the skills

of the current workforce are out of sync with the demands of future needs (Imison &

Bohmer 2013).

In the scope of improving patient care by more effectively co-ordinating community

and primary care services, initiatives have been taken in parts of the country to form larger

medical practices with specialist consultations and thus reducing the use of pressured

hospital services. Part of the initiatives have therefore also been to delegate more tasks to

nurses, particularly nurse practitioners and thus enabling GP’s to focus on urgent patient

conditions and diagnoses. These initiatives are the cost-effective shifting of public health

services, although evidence suggests that more resources, research and interest needs to be

invested in ways of making better use of skills especially in primary care teams (Ham et al.

2012).

2.5 Discussion

There are numerous incentives and monitoring bodies in place in the UK with the

purpose of improving the quality and availability of national health care services.

Additionally, funding has increased to try and accommodate demands in health care.

However, the cost-effective shifting of public health services has highlighted certain

vulnerabilities while leaving, especially the primary care sector, over stretched and under

nursed. This has had a negative impact, especially in an increasingly highlighted and


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assessed category of patient experience. The need to improving service delivery in primary

health care has therefore become equally important. The role of Nurse Practitioner in an

ever dwindling workforce thus becomes a focal point when assessing the quality of patient

care and how effectively NP’s are providing a supplementary service to GP’s.


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Chapter 3 – Research Methodology

3.1 Introduction

This chapter discusses the method used in the research study. Specifically, the first

section discusses the research study design, followed by detailing the importance of using key

search words or terms when selecting appropriate and related literature, the importance of

using the inclusion and exclusion criteria, as well as the design of the semi-structured research

interview schedule that will be used in the actual research interviews. In addition to discussing

the strengths and limitations of selecting the research strategy, the sample size, recruitment

and selection of highly qualified research interviewees are discussed in detail. After discussing

how the gathered primary and secondary data will be analyzed, the ethical considerations for

this study are also mentioned in this chapter. The last part of the chapter purposely discusses

the experience of the researcher during the entire process of completing this study.

3.2 Research Design

A qualitative research design was chosen, because it allows the researcher to gather

a more in-depth description concerning the professional experiences of each qualified

research interviewee. By using a semi-structured research interview schedule, the empirical

research study design, purposely made use of data obtained from interviews with senior

nurse practitioners.

Typically, the use of semi-structured research interview methods, heavily rely on the

inter-personal skills of the research interviewer. Therefore, it is essential on the part of the

interviewer to first establish a rapport with his or her prospective research interviewees. In

this study, regardless of age, gender and nationality, qualified research interviewees were

identified through the researcher’s professional network. Holt (2010) notes that interviews


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can be done either face-to-face or via telephone. In line with this, the research interviews

were undertaken face-to-face with each of the research interviewees, by telephone or

through the use of Skype.

3.3 Research Methods

Semi-structured interviews were selected for this study as the best means for

gathering empirical data and additionally, there are a few reasons for selecting this method.

Firstly, it is common for semi-structured interviews to be conducted privately with the

appropriate research candidate. Therefore, the use of this particular primary research

technique, allows each of the research interviewees to disclose their own personal

thoughts and feelings regarding the research questions asked in the actual interviews (Holt,

2010). Aside from making ‘free flow’ research interviews possible, the researcher will be able

to gather pure subjective responses (Cohen, Manion & Morrison 2011) and valid information

concerning the personal experiences of each research interviewee (Taylor & Francis, 2013).

The semi-structured research interview schedule in this study, was designed under

four major classifications as follow: background, perspectives on quality and impact of care,

work-role challenges and lastly, career progression. Specifically, the first part of the

interview schedule was aimed at obtaining demographic profiling and job responsibility of

each interviewee. The second part of the interview schedule was aimed at identifying

individual perspectives on the quality of patient care and the impact this has on primary

health care. The third part of the interview schedule was purposely designed to know more

about work-related challenges in the respondent’s particular care roles. The last part of the

research interview schedule aimed to learn more about how significantly the respondents


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felt that their education and training could progress and whether they would consider

becoming a General Practitioner if they had the necessary support in achieving this goal.

3.3.1 Research Instrument

While in the design stage of developing the research instruments, it was decided

that in order to gauge the quality of the subjects in this study, data generation would only

be required from interviewing primary care Nurse Practitioners (NP) working at an advanced

level of practice – otherwise known as advanced nurse practitioners or ANP – and not

include Registered Nurses (RN) or Health Care Workers (HCW) or Health Care Assistants

(HCA). Additionally, the research respondents were required to be employed in the public

health care system.

The primary mode of communication used to generate data from the research

cohort, was the use of face-to-face interviews, although where this was not possible, Skype

video conferencing was used. Below, a profile summary of the research interviewees

tabularises the qualifications, role and responsibilities, as well as number of years in service

of each of the candidates.

Table 1.1 – Summary of Research Interviewees’ Demographic Profile

Research

RespondentNo.

Mode of

Communicationwith the

Research

Interviewees

Qualification

of theResearch

Interviewee /

Job Title

Role & Responsibilities Number of

Years inService

1 Face-to-Face

Interview

BSc Nursing,

Advanced

University

Diploma/

Permanent

Nurse

Practitioner

Cytology Immunisations,

Dressings and Wound

Management, Sexual

Health, Asthma,

Diabetes, ECG

Plembotomy

8 years

experience

of

traditional

PN duties,

with 5

years as


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2 Skype

Conference

MSc

postgraduate

diploma: Nurse

Practitioner in

Primary Care/

Emergency

Nurse

Practitioner

Work across acute and

community settings,

undertake clinical

assessments of patients

within the emergency

department, contribute

towards staff induction

programmes

12 years of

which 4

years in

primary

care

3 Face-to-Face

Interview

MSc, RNDipHE

/

Emergency

Nurse

Practitioner

Experience in X-Ray,

suture, plaster, minor

illness, minor injury,

prescribing, paediatrics

experience

16 years of

which over

5 years as

ENP

4 Face-to-FaceInterview

BSc (Hons)Nursing/

Emergency

Nurse

Practitioner

Senior support andautonomous practice

including medical,

surgical and A&E;

diagnostics, prescribing

treatments

Over 7years with

just over 2

years as

ENP

5 Face-to-Face

Interview

MSc Primary

Health Care/

Lead Nurse

Practitioner

Patient assessment and

clinical examination,

extended and

supplementary

prescribing withinparameters of prescribing

authority, working with

medical and nursing

teams, managing patients

with chronic diseases

14 years

6 Face-to-Face

Interview

BSc Hons Nurse

Practitioner/

Advanced

Nurse

Practitioner/

Independent

Prescriber

Home visits and

treatment room duties,

travel vaccinations and

diabetic checks,

dressings, health checks,

child immunisations,

women’s health

2 years as

Community

Nurse/

7 years asan ANP

7 Face-to-Face

Interview

Nurse

Practitioner/

Independent

Prescriber

Autonomous assessment,

examination, diagnosis

and management of

patients presenting with

acute and chronic

medical conditions in

both a walk-in and

9 years


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booked routine

appointments setting

3.3.2 Sampling

Once a list of potential candidates was located, all of whom were either currently

employed in public health services or at some stage in their career, their professional

expertise and overall profile was carefully reviewed by the researcher, before sending each

of the potential research candidates an introductory e-mail explaining the main purpose of

the study, the reasons for being invited to participate in the study, including other research

ethics required as a candidacy pre-requisite.

3.3.3 Data Analysis

As far as data and analysis of research findings is concerned, it is deemed ethical not

to fabricate, falsify or commit any signs of plagiarism during the course of the research study

(Marsden & Wright, 2010). To avoid the likelihood of any such perils, the gathering of primary

data from the research interviews, was analyzed together with the gathered secondary data.

3.4 Ethical Considerations

A number of ethical considerations governing the study, were highlighted in the

research design. Prior to commencing research, all the ethical considerations were fully

adhered to. The rule of conduct associated with informed consent, pertains to providing

each of the potential research interviewees, with the choice of voluntary participation in the

research interview (de Vaus, 2002). As such, it was ethical to provide each of the potential

research interviewees, with the option of choosing whether or not to participate in this

study. In respect to the principles of informed consent, each of the research interviewees

were informed about the main purpose of the study, the option of research interview


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participation, including their right to withdraw (up to the point where the data is analysed)

without the need to provide a reason for withdrawal. Additionally, each of the research

respondents were informed that any questions they may have at any stage of the research

study, would be answered in full by the researcher (See appendix II - Semi-Structured

Interview Schedule). During the study, the principle of anonymity and confidentiality was

also observed. This involves keeping the personal information of each of the research

participants anonymous at all times (i.e. name of the research participants, the organization

they belong to, contact number and addresses, etc.) (Marsden & Wright, 2010). In the

process of keeping the identity of each research interviewees anonymous, Marsden and

Wright (2010) explained that there is a higher chance wherein the research interviewees

would freely provide more sincere and honest responses to each of the research questions

asked during interviews. Therefore, to improve the chance of obtaining improved and more

forthright answers during interviews, participants were assured their anonymity in the

study.

It is sometimes the case that third parties are interested in using the gathered data

presented in an academic study. This would understandably present data usage

considerations in accordance with regulation, in the case of this particular study, in

accordance with the Data Protection Act (1998). As such, participants were informed about

the likelihood of the recorded data provided in this study, being archived or made available

for future research studies. Except for the subjective response from each of the research

interviewees, the research topic of this study was not deemed sensitive in nature. To avoid

plagiarism in any form, all information found in peer-reviewed journals, academic books or


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relevant organizational websites, were paraphrased. Likewise, appropriate referencing was

observed throughout this study.

3.5 Conclusion

The research respondents were found to be very helpful and forthcoming during the

interview process. The atmosphere during the interviews was relaxed and the interviewees

often added more information to the questions than was needed by the researcher.

Additionally, where there were technical elements that the researcher was not familiar with

or unsure of, such as certain terminology, the respondents always took time to elaborate

further.


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Chapter 4 – Research Findings

4.1 Introduction

The semi-structured interview schedule can be viewed under Appendix II of this

study. Question 1 – 3 of the interview schedule are summarised in table 1.1 listed above in

the previous chapter. The research findings based on the remaining interview questions,

which are detailed in the proceeding subsections of this chapter, are grouped into two main

sections, namely quality of frontline patient care, followed by a section on NP’s relation to

General Practitioners. The reason for including this last section, was to gauge NP’s

perceptions of how they felt about their ‘supplementary’ roles in a healthcare environment

where often times, despite their assistance to general practitioners, in practice they perform

many of the same functions.

4.2 Quality of Frontline Patient Care

In response to question number 4, relating to the NP’s perceptions on the quality of

primary health care in the UK, the majority of the research respondents felt that while

primary health care was comparatively better than in most other high income countries,

there were very clear challenges to providing a consistent standard of health care. Interview

respondent number 3 felt that the Nursing and Midwifery Council set out clear enough

guidelines and was proactive enough with their hearings and outcomes processes for

dealing with restrictions, sanctions and suspension orders in investigating complaints

regarding nurses. Respondent number 5 and 6 felt that the education and training of UK

nurses was of a sufficiently high enough standard and that this factored into the quality of

care which nurse practitioners were able to provide to their patients.


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Question number 5 of the interview schedule asked the interview respondents about

how they perceived their impact on the public health system in terms of providing patient

care. The responses were understandably more diverse and individually subjective than the

answers to question number 4. Participant 2 and 7 felt that they had a sense of personal

pride in providing a high level of patient care and that because they were surrounded by a

supportive team of colleagues, this made it a pleasure to do their jobs and it meant that

their patients acknowledged their level of care. Respondent number 1 mentioned that

frontline public health, although often challenging and emotionally demanding, was a

rewarding profession to be in although her concern was that with the budget cuts made,

patients who are in pain for example and requiring medication to relieve their pain, have to

be refused that medication based on the fact that it is too expensive. The respondent

therefore felt that it is issues like this that make it difficult as a nurse practitioner, to feel like

one is having a positive impact on frontline health care. Participants 3, 4 and 5 all shared a

similar viewpoint in that they felt that they were overextended in their practices and

therefore could not take on more duties. This therefore had a negative impact on their

contribution in terms of providing patient care as they had to keep their consultations to a

bare minimum.

The research respondents were observably interested in answering question 6, which

asked about providing feedback on challenges which they encountered in their work roles.

There was a unanimous agreement among respondents concerning the challenging aspect

of their work roles as nurse practitioners. The interesting outcome of the responses in

relation to question 6, was that the respondents all agreed that their advanced education

and training enabled them to effectively cope with the clinical complexities of their work


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roles. However, the number of challenges present in their work environments, were often

either directly or indirectly a result of factors outside the scope of their roles as primary

health care practitioners. For example, participant 2 expressed that what was sometimes

challenging about their role as a nurse practitioner and which bore an indirect impact on the

level of service they were able to provide to patients, was the obsession with meeting

targets set by management and that this consequently contributed towards overall staff

stress levels. Participant 5 explained that what they found challenging was sometimes

seeing clear evidence of cases involving hospital patients who had been neglected, not by

their own family or carers, but by other general nursing staff. It was further explained that

in their view, a present and future challenge, is the demand for nurses and that the growing

elderly population has a direct bearing on this need. Participant 6 had a fairly similar

response to participant 5. They explained that what they found challenging was the

disconcertment of seeing patients who sometimes get lost and confused in the system and

then having to return for appointments. This is seen particularly where there is more than

one specialist treating the patient or lack of coordination of other services provided.

Participants 1, 3 and 7 commented on overcrowding in A&E wards. Participant 3 added that

they see the prevalence of patients willing to wait for hours in A&E simply because they

cannot get a quick enough appointment with their own GP’s or they would rather wait in

A&E to see someone face to face than to speak to a nurse practitioner over the phone. The

consensus among the interview participants was that this inclination seen in certain

patients, while understandable to a degree, only created more complications both for

emergency staff teams as well as those A&E patients who legitimately needed emergency

medical treatment. However, participant 7 concluded that the alternative advice to patients

to stay away from A&E unless their lives are at risk, is simply ludicrous advice.


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4.3 Nurse Practitioner’s relation to General Practitioners

When the respondents were asked question 7, whether they felt that the pay gap

between advanced nurses and general practitioners was too big, the answers provided by

the respondents also revealed an insight into the subtle nuances of their working

relationships with GP staff. For example respondent number 5, who holds the position of

Lead Nurse Practitioner in their particular work setting, explained that GP’s and NP’s are

similar in that they both diagnose and treat patients with acute and chronic diseases. The

level of clinical autonomy which is also afforded to NP’s, brings them in line with GP’s and

allows them to practice a full scope of medicine. For this reason, as respondent 5 explains,

NP’s are receiving more job offers than ever before and it also means that their pay is

increasing. Respondent 2 explained that it was NP’s who were boosting the demand for

medical services. While their roles in terms of primary health care, are supplementary

compared to GP’s, respondent 2 still did not think that the pay difference was of sufficiently

high variances to warrant dissatisfaction on the part of NP’s. The remainder of the

respondents held similar viewpoints to question 7.

When question 8 was posed to the research respondents, the majority expressed

their satisfaction with the qualifications they had attained in advanced nursing. Respondent

5 explained that NP’s are already at an advantage over their average registered nurse

counterparts. In fact, as they explained, with some NP’s who hold a Master’s degree, they

even have an advantage over some medical students as those NP’s with advanced degrees

have already studied and passed many of the courses required by students studying towards

becoming a doctor. Respondent 3 explained that becoming a NP holds a slight advantage in

that, especially in terms of primary health care, one is able to start practicing sooner which


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also increases your earning potential and paying off any student loans sooner. Given the

choice to start over again, they would definitely not hesitate to follow the NP study route

over the GP route. Respondent 4 felt that NP’s and GP’s have a different commitment

despite NP’s sharing many of the same duties as a GP. NP’s study to diagnose and cure

patients, whereas GP’s study to diagnose and cure diseases. Given the opportunity to study

further, respondent 4 would specialise as an Advanced Nurse Practitioner. Respondent 4’s

response generally set the tone for all the respondents in that, given their current work

roles and qualifications, they were content with remaining NP’s. The contentment factor

stems from their work advantages, such as ease of employability, work autonomy and

frontline commitment to patient care and work satisfaction.

4.4 Discussion

While it is challenging to ascertain whether the perceptions of a small cross-section

of Nurse Practitioners represented in this study, accurately embody the perceptions of the

wider profession of primary care practitioners, what the data has revealed, are two points:

Firstly, that the respondents are generally in agreement with regards to views on the status

of primary health care in the UK. Secondly, that their views and opinions, particularly with

regards to primary health care, closely mirror issues highlighted by the media and research

reports.


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Chapter 5 – Conclusion and Recommendations

5.1 Research Limitations

The small cross-section of Nurse Practitioners composing the study cohort in this

paper, despite the prevalence of NP’s in most health care settings in the UK, is reflective of

the comparatively small number of NP’s not only presently employed in the United

Kingdom, but also worldwide. This provided an increased challenge in accumulating the

total number of respondents available to take part in this study and a larger test sample

would therefore provide important validating data in much needed future research on the

same topic. Additionally, the existence of a marked ambiguity in defining what a Nurse

Practitioner is in terms of their role and function, added to the limited existing data

available for purposes of and use in this study.

5.2 Summary of Research Findings

The majority of Nurse Practitioners interviewed, were confident in the fact that their

education and training, enabled them with a certain proficiency to provide a good level of

primary health care. There was a consensus among the respondents that the problem with

primary health care in the UK, was with managing to provide a consistent standard of health

care across the board. Additionally, the consensus among respondents was that their work

roles presented a number of varying challenges. These challenges ranged from the reported

obsession with meeting targets set by management, being overextended in their practices

which reduced the consultation times with patients, to dealing with the overcrowding of

A&E wards. The data supplied by the respondents therefore mirrors a number of the points

raised in the literature review in chapter two of this study. Specifically, with the health

board’s decision to close so many of the community hospitals, evidence points to an


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explosive demand for GP’s. Concomitantly with difficulties in seeing or access to a GP,

patients are being attended to by Nurse Practitioners. Likewise, there is evidence that

hospitals are struggling to cope with the sheer number of patients and this points to

understaffing issues in primary health care. Decreased moral of nurses and failing to

“connect” with individual elderly patients documented by the National Institute for Health

Research, was reflected by the data response offered by respondent number 5 – that there

was clear evidence of cases involving hospital patients who had been neglected.

Regarding the career progression of the respondents, the overall consensus was that

they were content with their specific occupations as advanced nurses and that should there

be the likelihood of career progression, it would invariably be in a more specialised role as

opposed to following the General Practitioner route.

5.3 Implications of the Research Findings

While there are numerous factors which attribute to the work-pressures and

demands on nurse practitioners, such as hospital overcrowding and misuse of A&E centres,

the stark reality is that where there is an aging UK population, given the current pressures

on the NHS, the cost of bed-based care will only compound the problem of an already

dwindling nursing workforce. When it comes to primary care on supported self-

management, more help is needed from cross-agency, inter-professional groups in order to

alleviate the dependence on nurse practitioners.

5.4 Key Recommendations

More research is needed in terms of developing and testing the data regarding

studies involving Nurse Practitioners and their role in primary health care, as much of the

data in existing studies, is already out of date and fewer still reflect data specific to the


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United Kingdom. Moreover, as the data in support of this study revealed, when it comes to

clinical diagnoses and patient consultation, telephone consultations are a temporary

solution. Evidence strongly suggests the need for human contact, which telephone

consultations are not effectively able to provide. Provision standards need to be improved

in order to alleviate overcrowding of A&E waiting rooms.

5.5 Areas for Future Research

As the data reviewed in this study revealed, including the personal insight offered by

the study respondents, the services of emergency nurse practitioners are increasingly in

demand. Based on the overburdening of hospitals and public resources in the UK which

includes the shortage of General Practitioners, continued studies into ENP’s and outcomes

related to safety and quality of patient care, is needed.


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What is primary health care?, n.d. University of Bristol: Centre for Academic Primary Care,

para. 1. Available from: http://www.bristol.ac.uk/primaryhealthcare/whatisphc.html [02

March 2015].

Appendix I – Participant Consent Form

East Surrey

College

Gatton

Point

London

Road

Redhill

Surrey

RH1 2JX

Tel: 01737 772611

Consent Form

http://www.bristol.ac.uk/primaryhealthcare/whatisphc.htmlhttp://www.bristol.ac.uk/primaryhealthcare/whatisphc.htmlhttp://www.bristol.ac.uk/primaryhealthcare/whatisphc.html


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Project Title: A Question of Quality: What impact do Nurse Practitioners have in Primary

Health Care in the UK?

Name of Researcher: Monique Mavronicolas

Please initial box

1. I confirm that I understand the purpose of the study. Through explanation,

I have had the opportunity to consider the information, ask questions and

have had these answered satisfactorily.

2. I understand that my participation is voluntary and that I am free to

withdraw at any time without giving any reason, up to the point when the

data is analysed.

3. I understand that data collected during the study, may be looked at by

individuals from the East Surrey College as well as study participants.

I give permission for these individuals to have access to my anonymous data.

4. I agree to being quoted verbatim.

5. I agree to take part in the above study.

Name of Participant: Date: Signature:

Appendix II – Semi-Structured Interview Schedule


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Question 1: What is your job role?

Question 2: What are your major responsibilities?

Question 3: How many years have you been in service?

Question 4: What are your views on the quality of care in the UK?

Question 5: What do you perceive to be your impact on the public health system in terms

of providing patient care?

Question 6: What are the challenges which you face in your work role?


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Question 7: Do you think the monetary gap between advance nurses and doctors is too

big?

Question 8: Would you consider continuing your studies and becoming a doctor if there

was a follow on study path to achieving this?

Thank you for your time.

Monique Mavronicolas_Research Project.pdf

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