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Role definition and effectiveness of nurse practitioners in an HIV ambulatory care setting

Peter Boswarva

• [Abstract]
• [Introduction]
• [Aims, objectives]
• [Definitions]
• [Methodology]
  • [Subjects]
  • [Instruments]
• [Data collection]
• [Method of analysis]
• [Results]
  • [The Nurse Practitioner Role]
  • [Client Satisfaction]
• [Discussion]
  • [Nurse Practitioner Role]
  • [Nurse Practitioner Effectiveness]
  • [Satisfaction with Health Care Practitioner]
• [Conclusion]
• [References]
• [Appendix 1]
• [Appendix 2]

Abstract

A four-year followup study of four nurse practitioners who completed the Pilot Course for Nurse Practitioners in HIV Disease conducted at St. Vincent's Hospital Sydney in 1990 is reported. The current role of the nurse practitioner is defined by work sampling methods as being comprised of three focuses of care (Direct Client Care: 21 %; Indirect Client Care: 39%; and Non Client Related Activities: 40%) and six broad categories (Clinical Trials Work: 30%; Primary Care: 14%; Ambulatory Nursing Care: 16%; Professional Matters: 7%; Meetings and Administration: 19%; and Other. 14%).

Clients were given a questionnaire to determine the reason for the visit, the health care practitioner seen and their perception of degree of 'wellness' and independence. Clients were also asked to determine their satisfaction with care on a 16 item data sheet. 69% of the questionnaires were returned. 96% of respondents had a positive reaction to the care given.

The sample of clients assessed was unrepresentative of usual nurse practitioner input. The very small number of clients seen by nurse practitioners makes significant, statistical inference of differences between the client's perception of effectiveness of nurse practitioners and of doctors unlikely. However, four items of satisfaction were found to be significantly different. Nurse practitioners better understood the client's needs, explained reasons for tests better, gave more information about possible side effects of treatment, and better informed clients about test results.

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Introduction

In 1989 four Clinical Nurse Specialists, with experience in the care of clients with HIV infection, were chosen to complete a one-year long Nurse Practitioner course specifically designed to prepare them as primary care givers in an ambulatory clinic for clients with the spectrum of HIV infection and disease. The course has been evaluated elsewhere (Boswarva, 1993). The present study seeks, some four years after the participants' graduation, to define the current role of the Nurse Practitioner at St. Vincent's Hospital and to determine the effectiveness of Nurse Practitioners as primary care givers.

Feldman, Ventura and Crosby's review of 56 studies (selected on the grounds of clarity, relevance and lack of methodological flaws) of Nurse Practitioner effectiveness reported in the literature, generally found that Nurse Practitioners compared favourably with medical officers in terms of safety, patient satisfaction and cost (1987). In particular, Nurse Practitioners were better at health promotion and the management of chronic disease (Sailsbury & Tettersell, 1988).

The only study of Nurse Practitioner effectiveness in managing clients with HIV infection and disease concluded that 'A Nurse Practitioner can provide health care to people with AIDS and ARC, equal in quality and safety, to that of a Physician in an outpatient setting.' (Wolbert, Rogers, Keyes et al., 1989).

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Aims, objectives

This study had two major aims:

1. To describe the current role of the Nurse Practitioner at St. Vincent's Hospital, and compare it to the intended role
2. To evaluate the effectiveness of the Nurse Practitioner as a primary care giver in terms of
   1. client satisfaction;
   2. client morbidity; and
   3. health promotion

   compared to medical officers.

• AIDS: Acquired Immunodeficiency Syndrome.
• HIV: Human Immunodeficiency Virus.
• Nurse Practitioner: A registered nurse who has undergone a program, of at least twelve months duration at either certificate or Masters level, that focuses on the provision of primary care.

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Methodology

1. Four Nurse Practitioners at St. Vincent's Hospital.
2. The entire HIV client population who presented at the HIV Ambulatory Care Clinic during a specified two-week period (approximately 100).

1. Nurse Practitioner Log (Appendix 1). The activities listed on the log were those most likely to encompass the range of duties of the Nurse Practitioner, as perceived by the practitioners themselves, and the investigator. The instrument has not been formally validated nor tested for reliability.
2. Client Satisfaction Questionnaire (Appendix 2). The 16 item, 5 point, Likert-type self-report tool was derived from the tool used in the National HIV/AIDS Strategy Evaluation: Client Satisfaction with HIV/AIDS Inpatient and Outpatient Services prepared by Ernst and Young (Burcham & Brandt, 1992). The adaptation replaced the term 'doctor' with the more generic term 'health care practitioner', and deleted some items not related to personal care. Demographics included type of health care practitioner seen, main reason for visit, and two, three-point scales to determine client morbidity: a generalised 'wellness' scale and a degree of independence scale.

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Data collection

• Log: Each Practitioner continued the log for two weeks, completing each section hourly as practicable.
• Questionnaire: Each client arriving for a clinic booking at the HIV clinic during the specified two-week period was invited to fill out the questionnaire. Clients were assured that refusal would in no way jeopardise their treatment.

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Method of analysis

Role Definition: The Log data was synthesised into a job description.

Satisfaction: Spearman Correlation Coefficient was used to compare measures of satisfaction with overall satisfaction. Mann-Whitney U tests were used to compare the satisfaction measures between health care practitioners.

Client Morbidity: Mann-whitney U tests were used to compare this measure between health care practitioners.

Nonparametric tests were deemed more appropriate than parametric tests due to the highly skewed nature of the data.

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Results

The role of the nurse practitioner was comprised of six broad categories and three focuses of care.

The categories were:

The focuses of care were:

Client Satisfaction

Seventy-five questionnaires were distributed and 52 were returned (69%).

The main reason given by the client for attending the clinic was:

Table 1 details the percentage of positive responses to overall satisfaction and 15 satisfaction items. Not all clients answered every question.

TABLE 1: CLIENT SATISFACTION WITH HEALTH CARE PRACTITIONER according to 16 satisfaction items, ranked in proportion of respondents who rated them favourably

Table 2 demonstrates the client's overall satisfaction and satisfaction with 15 aspects of care ranked by mean scores.

High correlation with overall satisfaction was seen when the client perceived that treatment questions were answered, needs were understood and information about community resources was available. Less strong correlation was seen when staff were willing to answer questions, confidentiality was maintained, and the client saw the health carer of choice (Table 3).

TABLE 2: CLIENT SATISFACTION WITH HEALTH CARE PRACTITIONER according to 16 satisfaction items, ranked from most positive (a low mean score) to least positive (a high mean score).

Nurse practitioners scored significantly better than medical officers in the items of understanding needs, explaining reasons for tests, information about possible side effects and giving information about test results (Table 4).

No significant difference was found between nurse practitioners and medical officers on measures of overall satisfaction, client morbidity or health promotion. Client Morbidity Sixty-seven per cent of clients considered themselves 'well'; 33% described themselves as 'unwell'. None considered himself or herself 'very ill'.

Fifty-seven per cent of clients considered themselves 'independent'; 41% required 'some help with activities of living'; 2% considered themselves 'dependent'.

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Discussion

The course was designed to:

1. equip registered nurses with advanced nursing skills in the areas of assessment and management of clients with HIV infection, enabling the nurse to provide primary care and clinical trial enrolment and followup; and
2. upgrade skills in teaching, research and communication.

TABLE 3: Spearman Rank Correlation Coefficient for satisfaction items compared to overall satisfaction ranked from highest to lowest correlation

TABLE 4: MANN-WHITNEY U TEST: Medical Officers Vs Nurse Practitioners (significant results only).

Advanced nursing practice accounted for 44% of the total hours the nurse practitioner was at work, and 90% of direct client care.

Teaching, research and networking accounted for 13% of non client-related activities (5% overall). These figures were based on the total times recorded on the logs of the four nurse practitioners. Each practitioner's role was slightly different: one worked part-time and had a high emphasis on trials work; one had taken on major administrative responsibilities; the third had a high direct client care component; the fourth had a high meeting commitment. Overall, the role has developed in a way that was generally expected from the structure of the Pilot Course for Nurse Practitioners, described elsewhere (Boswarva, 1993).

Nurse Practitioner Effectiveness

The sample of clients taken from the clinic was grossly unrepresentative of nurse practitioner input. The period selected for the data collection was unusually quiet, and collection over an extended period is warranted. The very small number of clients seen by a nurse practitioner makes significant, statistical inference unlikely. However four items of satisfaction were found to be significantly different between medical officers and nurse practitioners (Table 4). These items suggest that nurse practitioners were better communicators.

Satisfaction with Health Care Practitioner

Satisfaction with health care practitioners in general was positive, with 96% responding either positively or very positively for overall satisfaction.

Most clients (98%) saw the health practitioner of choice and found him or her to be willing to answer questions. The lowest proportion, over half the clients (53%), thought that they had received satisfactory information about test results, while 40% were dissatisfied with the wait to be seen. The most powerful predictors of an overall favourable outcome were when the client perceived that all questions about treatment were answered, needs were understood, information regarding community resources was available, questions were answered willingly and their diagnosis was kept confidential.

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Conclusion

The results of the study were encouraging, not only in terms of the intended role of the nurse practitioner, but also of his or her effectiveness in the role, and acceptance by the client. A longer study of client satisfaction should be undertaken to enable a more representative sample of nurse practitioner/client interaction to be examined.

The curriculum of the Pilot Program for Nurse Practitioners may be relevant in expanding the role of clinical trials nurses by enhancing skills of physical assessment and case management; thereby, enabling clinical trials nurses to take more responsibility in the followup of trials clients.

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References

• Boswarva, P. A. (1993), 'Pilot course for nurse practitioners in HIV disease at St. Vincent's Hospital Sydney', in D. McKenna, (Principal Ed.) (1993) St. Vincent's Nursing Monograph 1993: Selected Works, Nursing Division, St. Vincent's Hospital Sydney Limited: Sydney, pp. 20-33.
• Burcham, J. & Brandt, P. (1992) National HIV/AIDS Strategy Evaluation: Client Satisfaction with HIV/AIDS Inpatient and Outpatient Services (Draft Report), Ernst & Young for The Department of Health, Housing and Community Services, Canberra.
• Feldman, M.J., Ventura, M.R. & Crosby, F. (1987) 'Studies of nurse practitioner effectiveness.' Nursing Research, 36(5): 303-308.
• Salisbury, C.J. & Tettersell, M.J. (1988) 'Comparison of the work of a nurse practitioner with that of a general practitioner'. Journal of the Royal College of General Practitioners, 3 8 (312): 314-316.
• Wolbert, J., Rogers, P., Keyes, C., Marte, C. and Smothers, K. (1989) 'A comparison of health care delivered to people with AIDS and ARC by a nurse practitioner and a physician a case matched retrospective study.' Proceedings of the Fifth International Conference on AIDS, Montreal. (Abstract MBP 319): 275.

Appendix 1

Appendix 2

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