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

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.

Table of Contents

Abstract .. 2
Table of Contents 3
Acknowledgements .. 4
1.
1.1
1.2
1.3
2.
2.1
2.2
2.3
2.4
2.5
3.
3.1
3.2
3.3
3.3.1
3.3.2
3.3.3
3.4
3.5
4.
4.1
4.2
4.3
4.4
5.
5.1
5.2
5.3
5.4
5.5

Introduction . 5
Background .. 5
Research Aims 5
Outline of Chapters . 6
Literature Review . 7
Methodology 7
Nursing shortages and the impact on Patient Care . 9
The role of Nurse Practitioners compared to General Practitioners .. 13
Improving service delivery in Primary Healthcare 15
Discussion . 16
Research Methodology .. 17
Introduction 18
Research Design .. 18
Research Methods . 19
Research Instrument 19
Sampling 21
Data Analysis .. 22
Ethical Considerations .. 22
Conclusion . 23
Research Findings 25
Introduction 25
Quality of Frontline Patient Care . 25
Nurse Practitioners relation to General Practitioners . 28
Discussion . 29
Conclusion and Recommendations . 30
Research Limitations . 31
Summary of Research Findings .. 31
Implications of the Research Findings .. 32
Key Recommendations 33
Areas for Future Research . 33

References . 34
Appendix I & Appendix II .. 37-38
Consent Forms .. 40
3

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.

Chapter 1 Introduction

1.1

Background
Ever since the decrease in demand for the services of general practitioners (GPs),

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 GPs 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 Practitioners 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:
5

I.

to identify Nurse Practitioners 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 NPs, 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.

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 NPs working in primary
health care, possibly providing equivalent care to GPs 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 NPs to improve on primary health care service delivery.
This strategy looks at workforce redesign in a climate where the nature of health care work
7

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,
8

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 (ANPs) 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 Englands 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
9

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 Boards 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 governments 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 NHSs
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

10

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 NHSs 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 nurses workload (Ball &
McElligot 2003).
11

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 burnoutsyndrome 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 professionals 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

12

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 NPs actions, they are professionally and personally accountable. For
example, should NPs 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 NPs vulnerabilities based on the fact that
they are managing clinical uncertainty. However in terms of vicarious liability, NPs 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 NPs are used as supplements rather
than substitutes when it comes to care given by GPs (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
13

general practitioner (GP). This means that they work with rather than for GPs 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 NPs 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 Masters 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.

14

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 GPs. 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 GPs 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

15

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 NPs are providing a supplementary service to GPs.

16

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 researchers professional network. Holt (2010) notes that interviews
17

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 respondents particular care roles. The last part of the
research interview schedule aimed to learn more about how significantly the respondents

18

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
Respondent
No.

Mode of
Communication
with the
Research
Interviewees

Qualification
of the
Research
Interviewee /
Job Title

Role & Responsibilities

Number of
Years in
Service

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
19

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

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

Face-to-Face
Interview

BSc (Hons)
Nursing/
Emergency
Nurse
Practitioner

Senior support and

autonomous practice
including medical,
surgical and A&E;
diagnostics, prescribing
treatments

Over 7
years with
just over 2
years as
ENP

Face-to-Face
Interview

MSc Primary
Health Care/
Lead Nurse
Practitioner

Patient assessment and

clinical examination,
extended and
supplementary
prescribing within
parameters of prescribing
authority, working with
medical and nursing
teams, managing patients
with chronic diseases

14 years

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,
womens health

2 years as
Community
Nurse/
7 years as
an ANP

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

20

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
21

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

22

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.

23

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 NPs relation to
General Practitioners. The reason for including this last section, was to gauge NPs
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 NPs 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.

24

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

25

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 GPs 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 Practitioners 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 GPs and NPs 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 NPs, brings them in line with GPs and
allows them to practice a full scope of medicine. For this reason, as respondent 5 explains,
NPs are receiving more job offers than ever before and it also means that their pay is
increasing. Respondent 2 explained that it was NPs who were boosting the demand for
medical services. While their roles in terms of primary health care, are supplementary
compared to GPs, respondent 2 still did not think that the pay difference was of sufficiently
high variances to warrant dissatisfaction on the part of NPs. 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 NPs are already at an advantage over their average registered nurse
counterparts. In fact, as they explained, with some NPs who hold a Masters degree, they
even have an advantage over some medical students as those NPs 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
27

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 NPs and GPs have a different commitment
despite NPs sharing many of the same duties as a GP. NPs study to diagnose and cure
patients, whereas GPs study to diagnose and cure diseases. Given the opportunity to study
further, respondent 4 would specialise as an Advanced Nurse Practitioner. Respondent 4s
response generally set the tone for all the respondents in that, given their current work
roles and qualifications, they were content with remaining NPs. 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 NPs in most health care settings in the UK, is reflective of
the comparatively small number of NPs 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
boards decision to close so many of the community hospitals, evidence points to an
29

explosive demand for GPs. 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 selfmanagement, 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
30

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

31

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Appendix I Participant Consent Form

Consent Form
East Surrey
College
Gatton
Point
London
Road
Redhill
Surrey
RH1 2JX
Tel: 01737 772611

35

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

36

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?

37

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.

38