International Journal of Nursing Practice 2009; 15: 213–218

RESEARCH PAPER

A survey of patient satisfaction in a metropolitan

Emergency Department: Comparing nurse
practitioners and emergency physicians
Natasha Jennings RN BN CCC(Emerg) GradDipAdvClinNurs MN(Melb)
Emergency Nurse Practitioner, The Alfred Emergency and Trauma Centre, Prahran, Victoria, Australia

Geraldine Lee MPhil RGN BSc PGDE

Masters of Nurse Practitioner Program Coordinator, Division of Nursing and Midwifery, Latrobe University, Bundoora, Melbourne, Victoria,
Australia

Kylie Chao RN PGD(Emerg) MN

Emergency Nurse Practitioner, The Alfred Emergency and Trauma Centre, Prahran, Victoria, Australia

Simon Keating RN BN PGD(Emerg) DipBusiness MN

Emergency Nurse Practitioner Candidate, The Alfred Emergency and Trauma Centre, Prahran, Victoria, Australia

Accepted for publication January 2009

Jennings N, Lee G, Chao K, Keating S. International Journal of Nursing Practice 2009; 15: 213–218
A survey of patient satisfaction in a metropolitan Emergency Department: Comparing nurse
practitioners and emergency physicians

The Emergency Nurse Practitioner role was introduced to an Emergency Department, Melbourne in 2004 as an
alternative health-care model to provide accessible and efficient patient care. The aim of the study was to explore patient
satisfaction using a questionnaire from their emergency department experience comparing Emergency Nurse Practitioners
and emergency department doctors. Patients who received care from either Emergency Nurse Practitioners or emergency
department doctors were given a self-administered questionnaire to complete. Descriptive statistics and non-parametric
tests were used for data analysis. A total of 202 patients completed the survey with 103 seen by the Emergency Nurse
Practitioners and 99 seen by emergency department doctors. Significant differences were reported in 12 of the 16
questions comparing patient satisfaction with either Emergency Nurse Practitioners or emergency department doctors
with greater patient satisfaction demonstrated with the Emergency Nurse Practitioners. The Emergency Nurse Practitio-
ner model demonstrates consistent levels of patient satisfaction with patients reporting more favourable satisfaction with
the Emergency Nurse Practitioners compared with emergency department doctors. ijn_1746 213..218

Key words: doctors, Emergency Department, nurse practitioner, patient satisfaction.

Correspondence: Natasha Jennings, The Alfred Emergency and Trauma
Centre, Commercial Road, Prahran, Vic. 3004, Australia. Email:
n.jennings@alfred.org.au
INTRODUCTION
The health-care system is experiencing unprecedented
demands for service, which ultimately impacts on hospital
resources and the quality of the care provided by both
medical and nursing professionals. Patients are viewed as

doi:10.1111/j.1440-172X.2009.01746.x © 2009 Blackwell Publishing Asia Pty Ltd

214
‘consumers’ of health care and there is an emphasis
on surveying them and canvassing their opinions on the
quality of service provided. Emergency Departments
(EDs) are one such area under scrutiny. The introduction
of new health-care models such as the Nurse Practitioner
(NP) in Australia requires a systematic evaluation process
measuring the impacts both at an organizational level and
at a patient level. Therefore, patient satisfaction with
the role is of importance as it directly correlates to the
patients’ perceived quality of care provided.
The NP role was introduced into the Australian health-
care system to meet needs of an overstretched health-care
system. The model is both affordable and flexible and a
means to maintain quality in patient care.1 Various clinical
settings employ NPs in primary health care and recently
the role has commenced within EDs. The literature evalu-
ating the implementation of the NP role has demonstrated
several positive themes including: decreased waiting
times, cost-effectiveness and importantly increased
patient satisfaction, all leading to improved health out-
comes for patients.2–4 NPs have been established as a
highly skilled and cost-effective model that demonstrates
a high level of care.5,6 A systematic review reported that
nurses can provide a high quality of care and achieve good
health outcomes for patients but their findings were
limited to primary health care.7
Patient satisfaction is defined as a quality outcome of
care that underpins a patient’s health-care experience.8
Measurement of patient satisfaction is influenced by many
variables including communication between practitioner
and patient, length of stay, waiting times, demographics
and socioeconomic status specifically.9 These variables,
many beyond the clinicians’ control, can impact the per-
ceived quality of care provided and therefore the subse-
quent assessment of patient satisfaction. Several papers
have reported patient and staff satisfaction with NP-led
care.10–13 Some studies have reported patients perceiving
better-quality care from NPs compared with physicians.14
Others, however, have reported no differences between
the two health professionals.13
The majority of studies examining patient satisfaction
are single centred and consist of self-administered ques-
tionnaires that patients complete following a hospital
visit.1,3,10,12 One study outlined whether patients would be
willing to be seen by NPs on a subsequent visit with 70%
(n = 213) willing to be treated by an NP for minor prob-
lems.15 In a randomized controlled trial, a high level of
satisfaction was reported between the NPs and senior
© 2009 Blackwell Publishing Asia Pty Ltd
N Jennings et al.
house officers in the UK but higher levels of satisfaction
and clinical documentation quality were reported for the
NP group.10 In Australia, an aftercare questionnaire in ED
demonstrated patients were very satisfied with total care
received.16
A common theme consistent in NP patient satisfaction
surveys is that patients received more health education
information from NPs, and were more likely to be given
written instructions and information about obtaining
advice following discharge.1,12 The holistic centred care
seems to be the major difference between NPs and phy-
sicians. Although one study (n = 41 029) from the USA
demonstrated that care access or overall experience did
not differ by practitioner type (ED doctor, physician assis-
tant and NPs).3
In summary, patient satisfaction with care provided by
the NP has been reported positively and would appear to
lead to good health outcomes in patients while providing
a high quality of care.
METHODS
The role of the NP in Victoria, Australia, is relatively new
and to date only 42 nurses have been endorsed by the
Nurses Board of Victoria (NBV).17 The title ‘Nurse Prac-
titioner’ is protected by legislation in Victoria and pre-
vents the unauthorized use.18 Nurses who are practising
within the role in a supervised training model prior to
endorsement by the NBV are referred to as nurse practi-
tioner candidates.
The Alfred Emergency Nurse Practitioner (ENP) team
consists of both endorsed ENPs and ENP candidates. Gen-
erally, ENPs focus on Australasian Triage Scale (ATS)
categories 3–5 emergency patient presentations. The ATS
is the clinical tool that ensures patients are seen in a timely
manner that is commensurate with their clinical urgency
at time of presentation to ED.19 All patients presenting to
EDs are triaged on arrival and an ATS code is allocated.
The ENP assumes responsibility for the completed
continuum of care for their patients from initial assess-
ment, intervention, prescribing, diagnosis, treatment and
disposition. The ED doctor-led care is considered the
traditional medical model of care that includes patients
receiving care by both a doctor and a nurse to complete
the continuum of care.
The Alfred Emergency and Trauma Centre is one of
two adult-level one-trauma centres in Victoria, Australia.
Annual attendances have been increasing by a rate of 19%
over the last 3 years, and in 2007, there were 47 000
Patient satisfaction in the Emergency Department
attendances. The ENPs focus on ATS categories 3–5
patients with the majority of minor trauma and non-
complex medical patient presentations. These patients
were usually geographically located in the Fast Track area
of the ED, consisting of eight cubicles.
The aims of the study were to explore patient satisfac-
tion from their ED experience with care provided by the
ENPs and the ED doctors.
A patient survey was distributed to patients consisting
of 16 questions relating to their ED experience. The ques-
tions related to the thoroughness of the ENP- or ED
doctor-led care, whether they felt they had enough time
to ask questions, would they follow the advice given and
would they see the doctor or nurse again with the same
problem. The remaining questions related to health
education information, whom to contact regarding their
illness, written instructions about their injury, medication
instructions, and how and when to contact their general
practitioner, outpatients appointments and whether they
would recommend the doctor/nurse to a friend.
The survey was distributed to patients by an ED team
member. Patients were not allocated to see the ENPs or
ED doctors, but seen by whomever was available at that
time within the Fast Track area of ED. Patient care was
conducted in accordance with ATS category and depart-
mental policy in regards to time waiting priority. The
patient satisfaction survey was distributed at the com-
mencement of treatment and patients were asked to
complete the survey and place it in the locked collection
box at the conclusion of their treatment.
Data collection was undertaken from February to May
2008. Ethics approval was not required as it was deemed
a quality assurance project but permission was sought
and gained from the Bayside Health Nursing Research and
Access Committee. All questionnaires were completed
anonymously and placed in the collection boxes at the staff
station in the ED. The questionnaire was developed and
adapted from a previously validated tool and used
throughout the literature to evaluate ENP patient satisfac-
tion.12 The survey included a total of 16 questions using
a Likert scale seeking responses from strongly disagree
to strongly agree.
Data were analysed using SPSS version 15.20
The patient satisfaction survey has ordinal properties (1
(strongly disagree) to 4 (strongly agree)). Comparisons
between groups have been made using Wilcoxon rank
sum tests with results reported as medians with an inter-
quartile range (25th percentile to 75th percentile). A
215
two-sided P-value < 0.05 was considered to be statisti-
cally significant.
RESULTS
A total of 202 patients were surveyed between February
and May 2008 who attended the Alfred Emergency and
Trauma Centre. The mean age of the patients was 35.3
years (SD 14.9) in the ED doctor care group and 31.5
years (SD 13.3) in the ENP care group, which was not
significant (P = 0.156).
Two hundred and two patients completed the survey
with 103 patients in the ENP group and 99 in the ED
doctor care group. Out of the 16 questions, 12 questions
demonstrated a significant difference in comparing the ED
doctor care and ENP patient satisfaction in favour of the
ENP (P < 0.05). These 12 answers related to the doctor/
nurse being interested in the person, being thorough,
patient being less worried about their health after seeing
the doctor/nurse and having enough time to discuss con-
cerns in detail. In the remaining answers, there was a
favourable trend for the ENPs patients’ level of satisfac-
tion with their care (relating to health education, written
instructions on whom to contact once home, outpatients
appointments, prescribed medications and how and when
to contact their general practitioner.
In summary, in most cases except ‘There were other
things I would have liked to discuss with nurse/doctor’,
there was a significant difference between the responses
for the two different groups with a more favourable res-
ponse for the ENP care group (Table 1).
DISCUSSION
A total of 202 patients completed the survey with 103
seen by the ENPs and 99 seen by ED physicians. Signifi-
cant differences were reported in 12 of the 16 questions
(P < 0.05) comparing patient satisfaction with either ENP
or ED physicians with greater patient satisfaction demon-
strated with the ENP.
The results from our study have demonstrated a high
level of patient satisfaction with the ENPs care, which is
consistent with the literature.1,14,16,10,21
Studies examining patient satisfaction with the ENP
role in Australia have been limited to two studies.16,21 The
most recent ED-based study only surveyed 57 patients
and showed that 70.2% of patients were very satisfied
with total care.16 The other ED-based study surveyed
132 patients (71 physician-treated patients and 61 ENP-
treated patients).21 The results concluded that patients
© 2009 Blackwell Publishing Asia Pty Ltd
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Table 1 Patient survey responses––median values, inter quartile range (IQR) and P-value (n = 202)

Question number ENP (n = 103) ED physician P-value

median (IQR) (n = 99)
median (IQR)

© 2009 Blackwell Publishing Asia Pty Ltd

1. The Doctor/Nurse understood why I had come to the Emergency Department. 4 (4–4) 3 (3–4) 0.007
2. The Doctor/Nurse was interested in me as a person. 4 (3–4) 4 (3–4) 0.019
3. The Doctor/Nurse seemed to be very thorough. 4 (3–4) 4 (3–4) 0.005
4. I was less worried about my health after seeing the Doctor/Nurse. 4 (3–4) 3 (3–4) 0.024
5. I will follow the advice of the Doctor/Nurse because I believe it was good advice. 4 (4–4) 4 (3–4) < 0.001
6. When I saw the Doctor/Nurse, I felt that I had enough time to discuss things fully. 4 (3–4) 3 (3–4) < 0.001
7. I would like to see the Doctor/Nurse again for a similar health problem. 4 (3–4) 3 (1–4) < 0.001
8. There were other things I would have liked to discuss with the Doctor/Nurse. 2 (0–2) 2 (0–2) 0.659
9. While I was in the Emergency Department, I was given health education or first aid advice from the Doctor/Nurse. 3 (0–4) 3 (0–4) 0.093
10. My friends/family were allowed to be with me during investigations/treatments. 3 (0–4) 3 (0–4) 0.849
11. I was told whom to contact if I needed more help or advice regarding my illness/injury once I was home. 4 (3–4) 3 (1–4) < 0.001
12. I was given written instructions about my illness/injury to take home. 3 (0–4) 2 (0–3) < 0.001
13. The Doctor/Nurse explained how to take the tablets/medicines prescribed. 3 (0–4) 3 (0–4) 0.223
14. I was informed of how and when to contact my GP (local doctor) about my illness/injury. 3 (2–4) 3 (0–4) 0.043
15. I was told verbally and given written information about my follow-up appointment. 3 (0–4) 2 (0–3) 0.044
16. If I was advising a friend, I would recommend the Doctor/Nurse. 4 (3–4) 3 (3–4) < 0.001

0, not applicable; 1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree. ED, Emergency Department; ENP, Emergency Nurse Practitioner; GP, general practitioner.
N Jennings et al.
Patient satisfaction in the Emergency Department
were very satisfied with NP care with no significant
differences observed. Similar questions were used can-
vassing themes such as patient satisfaction with overall
care, explanations given before and after care, and were
they willing to see the same health professional again.
These results were consistent with earlier international
studies.1,10,12,13 These studies demonstrated that NPs had
a holistic approach to care in comparison with the ED
doctors. Our results are similar to those reported in the
literature10 with higher levels of satisfaction among the
ENP patients. The results imply that the ENP model can
provide a high quality of care and provide patients with
adequate amounts of information in relation to their
presenting complaint.
Limitations
Often there is criticism in the literature about patient
satisfaction studies comparison of ENPs with midlevel
practitioners (ED doctors), which might include physi-
cian’s assistants.3 As physician’s assistants are not parts of
the current model at the Alfred Hospital ED, it is not a
major limitation.
There are many extraneous variables linked, which
have an impact on patient satisfaction measurements.
Waiting times and length of stay were not measured in
this study because of the nature of a very busy acute ED
setting; this could in turn have impacted upon the survey
responses and resultant correlation to a patient’s level of
satisfaction and has previously been examined.2
It has been reported that client characteristics and
interactions with the health professionals can determine
health outcomes in regards to patient satisfaction mea-
surements.22 These authors believe the patient satisfaction
results to be important in terms of costing and validating
the NP model. The results from our patient survey
enhance steps to validate the ENP model of care.
This study was conducted at a single centre that has
implemented the NP role within their ED. It is worth
noting that the model has been adapted and replicated in
many other sites in both rural and urban emergency set-
tings. Greater validity of the results might be obtained by
combining results gained from such a multicentre study.
Conclusion
The NP model has returned favourable results in this
patient satisfaction survey. This study demonstrates the
acceptance of the ENPs within the emergency setting by
patients. ENPs are able to address the needs of patients in
217
providing high-quality emergency care while maintaining
consistent levels of patient satisfaction.
ACKNOWLEDGEMENTS
The researchers would like to thank the patients who
completed the survey.
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