Journal of Orthopaedic Nursing (2006) 10, 86–94

www.elsevierhealth.com/journals/joon

Journal ofOrthopaedic Nursing

An exploration of issues related to nurse led clinics

Sandra Flynn RGN, ONC, MSc (Clinical Nurse Specialist inOrthopaedics) a,*,Elizabeth Whitehead PhD, BA (Hons), PGDE, RGN, RM, RHV, ONC(Reader) b

a Countess of Chester NHS Foundation Trust, Orthopaedic Department, Liverpool Road, Chester, CH1 1UL,United Kingdomb School of Health and Social Care, University of Chester

Summary This review examines some topics that may have relevance toand impact upon the success of nurse led clinics in the United Kingdom (UK).The topics included are patient satisfaction, the role of the nurse practi-tioner, the concept of caring, nurse led clinics, nurse education and patienteducation.

�c 2006 Elsevier Ltd. All rights reserved.

KEYWORDSNurse led clinic;Patient satisfaction;Nurse practitioner;Caring;Nurse education;Patient education

1d

Editor’s commentThis exploration of nurse led clinics in the UK raises several important issues. Increasingly there is more evidence to demonstratethe effectiveness of nurses in these roles; perhaps we now need more evaluation of the cost effectiveness of such developments.

PD

Introduction

Within recent years nurse practitioner roles havesteadily increased and as a result the issues of qual-ity care and subsequent patient satisfaction havebecome the focus of many studies, (Jackson,2003; Studner and Hirsch, 1986; Hopkins et al.,1996). This review explores topics relevant to theconcept of nurse led clinics examining patient satis-

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* Tel.: +44 1244 365000x2700.E-mail address: Sandra.flynn@coch.nhs.uk (S. Flynn).

faction, the role of the nurse practitioner, the con-cept of caring, nurse led clinics, nurse educationand patient education. From an initial search, thesetopics have been chosen for inclusion due to theirrelevance to and impact upon nurse led clinics.

Patient satisfaction

Patient satisfaction is a difficult concept to defineas satisfaction means different things to differentindividuals and can be affected by factors whichare related to social constructs such as culture,

ved.

An exploration of issues related to nurse led clinics 87

gender, age or religion, (Locker and Dunt, 1978). Itwas Linder-Pelz (1982) who determined that pa-tient satisfaction relied upon an individual’s abilityto positively identify dimensions of health carewhich were dependent upon the attitudes and per-ceptions of the individual.

Eriksen (1995, p71), defined patient satisfactionwith nursing care as ‘‘the patient’s subjective eval-uation of the cognitive emotional response that re-sults from interaction of the patient’s expectationsof nursing care and their perceptions of actualnurse behaviours/characteristics’’.

When Carr-Hill et al. (1992) undertook to write apaper on the measurement of patient satisfactionhe stated that trying to define satisfaction in a un-ique sense was futile for the very reasons listed byLocker and Dunt (1978). Moreover, he continues toargue that the individual experiences with the ser-vice and treatment outcomes will also influencetheir perceived notion of satisfaction.

Patient satisfaction has by many authors beenviewed as not only a dependent variable of qualityof care but also an independent variable which canbe used to anticipate health related behaviours inthe future, (Ware et al., 1978; Linder-Pelz, 1982;Mahon, 1996).

The literature provides a varied insight intonurse led clinics in both primary and secondarycare settings and spans numerous health care spe-cialities, including medical, general surgical andpsychiatric care (Garvican et al., 1998; Wrightet al., 2001; Miles et al., 2002; Sharples et al.,2002). Within the orthopaedic speciality few stud-ies have been undertaken into patient satisfactionof nurse led clinics following joint replacement sur-gery. One such study undertaken by Jackson (2003)revealed that Orthopaedic Nurse Specialist led clin-ics could be successfully implemented and had apositive impact upon patient care. It was Bondand Thomas (1992) who first indicated the needfor nursing to establish how it affects patient out-comes of which patient satisfaction is the factormost frequently measured. Other areas of workon outcomes, although relatively underdevelopedinclude patient satisfaction with nursing care andnursing outcome classification (Thomas et al.,1996; Mass et al., 1996; Daly et al., 1997; Pierce,1997; Flanagan, 1998).

The analysis of nurse practitioner roles in nurseled clinics were the subject of early descriptivestudies, evaluating safety, management compe-tence and patient satisfaction. The results of thesestudies were indeed promising (Ford and Silver,1967; Spitzer et al., 1974; Davidson and Lauver,1984; Salisbury and Tettersell, 1988; Wade andMoyer, 1989). Despite these early positive results

Mundinger (1994) discovered that on reflectionthese studies were flawed due to small samplesizes, lack of appropriate controls, lack of ran-domisation, failure to note differences in illnessseverity and failure to measure outcomes. As thecost of healthcare provision rises, healthcare pro-viders and consumers become understandably con-cerned with the quality and outcomes of care.

Recently health care providers have identifiedthat one such strategy for improving access to qual-ity care is through the use of nurse practitioners. Forexample Hamric et al. (1998) wrote that the role ofnurse practitioner is concerned with patient satis-faction and as a consequence of this, outcomes suchas compliance with treatment regimes are possible.

With the increasing introduction of the nursepractitioner role more studies are emerging intopatient satisfaction with nurse practitioner care.Green (2002) stresses the importance for substan-tive research to be performed so that the valueof nurse practitioner roles can be highlighted andthat distinction of the role from other health careprofessionals can be identified.

Patient satisfaction studies targeting the deliv-ery of nursing services have also been carriedout. Most have concerned themselves with nursingservices within hospital settings or have producedpatient satisfaction measurement tools (Jacoxet al., 1997; Ketefian et al., 1997; McCall et al.,1996; McDaniel and Nash, 1990).

Work by Mundinger et al. (2000), and Pinkertonand Bush (2000) indicated that patient satisfaction,and outcomes of care by nurse practitioners andphysicians were comparable. Pinkerton and Bush(2000), concluded that they found no significantdifference in perceived health and satisfactionwith care between physician client groups andnurse practitioner client groups in a managed caresetting. Mundinger et al. (2000) analysed compari-sons between nurse practitioner and physician carein the primary care setting. The authors studiedfactors including communication, time spent withthe patient and provider attributes. They foundno significant difference in the scores betweenthe two health professional groups after the firstvisit in regard to patient satisfaction. Patientsrated the physician group higher on the providerattribute skills in comparison to those demon-strated by the nurse practitioner. In conclusion nostatistical difference was demonstrated betweeneither group in the overall satisfaction and commu-nication rating.

The majority of these studies are American andtherefore results in many cases may not be perti-nent to the United Kingdom health care setting,Garvican et al. (1998) in a study into patient

88 S. Flynn, E. Whitehead

satisfaction in a breast clinic revealed thatalthough patients were satisfied with the care theyreceived when attending a nurse led clinic the pa-tients were not able to compare between the clinicrun by the nurse to that run by the doctor. Thisstudy was not a true comparison as the nurse onlyreviewed women with benign test results whereas the doctor reviewed women who had a diagnosisof cancer. Women reviewed by the nurse reportedhigher satisfaction scores in the survey.

Evaluation of patient satisfaction has been de-scribed by some authors as the ‘acid test’, whichany system of care delivery must pass, (Richardsand Lambert, 1987). Studies have revealed that pa-tient satisfaction with care is a difficult concept toassess, concluding that many satisfaction studieslack methodological validity, (Fitzpatrick, 1991;Bond and Thomas, 1992; Connor et al., 2002; Caineet al., 2002). In regard to satisfaction tools only ahandful have been rigorously tested. They weredeveloped to measure satisfaction given by eithermedical staff (Hulka et al., 1970; Ware and Davies,1983; Weiss and Senf, 1990; Meterko, 1990; Fitzpa-trick, 1991), nursing staff (Risser, 1975; Eriksen,1987; Blair et al., 1982; La Monica et al., 1986) orboth (Hill, 1997; Bond and Thomas, 1992; Connoret al., 2002; Caine et al., 2002).

Fitzpatrick (1991) cited that surveys of patients’views had become evident due to the NHS Manage-ment Inquiry (Department of Health and SocialSecurity, 1983) which ardently condemned the fail-ure of the NHS to research the views and experi-ences of health service users.

Fitzpatrick asserts that there are three mainreasons other than external pressures as to why pa-tient views should be genuinely sought. Firstly theyare an important outcome measure, secondly theyare useful in evaluating consultation and communi-cation patterns and thirdly, used systematically,the feedback can facilitate choice between alter-natives in organising or providing health care.

When gathering information relating to patientsatisfaction the choice is whether to use a selfcompleted questionnaire or undertake interviews.Many researchers argue that an interview will al-ways surpass a questionnaire in obtaining accurateinformation which is relevant to the subject stud-ied, (Hall et al., 1988; Baker, 1990; Fitzpatrick,1991). However, Fitzpatrick (1991) points out thata carefully constructed and well piloted question-naire can be just as valuable in obtaining theappropriate information, which is important wherelarge numbers of patients are involved and inter-views would be considered too costly.

A study undertaken using a well-developed andpiloted questionnaire was undertaken in 1997 by

Hill in Leeds it involved 70 patients with rheuma-toid arthritis who were randomly selected to eithera nurse led clinic or consultant led clinic. Thisstudy ensured that the two groups were similar interms of age, duration of arthritis and gender. Allpatients were asked to complete a questionnaire,the Leeds Satisfaction Questionnaire (LSQ), whichwas designed to evaluate satisfaction with the pro-vision of health care given. Hill found patients indi-cated greater satisfaction with the nurse led clinicswhen compared to the consultant led ones. Per-haps the most significant findings of Hill’s studywas that patients reported significant satisfactionwith the nurses ability to provide information,empathy and in spending more time listening toproblems.

Hill’s study includes the use of a Likert scale (Lik-ert, 1932) and is acceptable for use as it is adapt-able and reliability and acceptability have alreadybeen established through published results. Satis-faction is now widely accepted as being an attitudeand therefore the use of attitude measurementscales is required, (Oppenheim, 1986). Researchersaccept the use of Likert Scales in the measurementof attitude; they tend to be used in more advancedquestionnaires. Respondents are asked to indicatetheir level of agreement or disagreement with givenstatements. To avoid bias the items are evenly bal-anced between positive and negative statements,(Bowling, 1992). The summed score of all the an-swers are taken to represent the person’s views.Psychometric analysis has in the past shown thatLikert scales are far more reliable than that of indi-vidual items (Oppenheim, 1986).

Satisfaction questionnaires tend to be designedin one of two ways, firstly they can relate to spe-cific episodes of care or can be more generalisedin terms of the questions being focused upon. Sec-ondly they can ask questions which are directlyrelated to patient satisfaction. The choice of de-sign relies partly on the type of research andthe health care setting (Hall et al., 1988; Fitzpa-trick, 1991).

Miles et al. (2002) performed a comparison andpatient satisfaction study between doctor andnurse led care in a sexual health clinic setting.The researchers chose to use a modified versionof the LSQ due to its adaptability and rigorous test-ing during its development. The questionnaire wastested for validity, stability, consistency and sub-scale homogeneity. The final version resulted in a34-item questionnaire using a five point Likertscale. This study was able to demonstrate thatthe LSQ was adaptable and gave valid and reliableresults. The authors concluded that patients weresatisfied with nurse led clinics.

An exploration of issues related to nurse led clinics 89

Nurse practitioner role

One of the most frequently asked questions in theliterature concerns the issue of whether or notnurse led clinics remove the nurse from the moretraditional role which patients expect and find valu-able (Studner and Hirsch, 1986; Haynes et al., 1992;Hill et al., 1994; Dowling et al., 1995; Hopkinset al., 1996). Hill et al. (1994) and Reynolds et al.(2000) argue that it is possible for nurses to effec-tively combine their traditional nursing role withthe medical approach. Rafferty and Elbom (2002)support the findings of Hill and Reynolds and sug-gests that nurses can and do focus on a more holisticstyle of care, thus facilitating continuity of care.The literature supports the concept that patientsrate highly continuity of care and in particular hav-ing their care delivered by the same health careprofessional, (Lucas, 2002; Moore et al., 2002;Laine et al., 1996 and Avis et al., 1995).

Several studies are provocative as they suggestthat patients do not necessarily need to see a doc-tor in order to be satisfied with the care given,(Garvican et al., 1998). Nurse practitioners areseen as a valuable resource by not only patientsbut other healthcare professionals. Aquilino(1997) measured perceptions of the nurse practi-tioner role by medical staff and found that doctorswith previous experience of working with nursepractitioners and general practitioners looked uponthe role more favourably than others. There areother areas in which the nurse practitioner role isvalued in particular a study by Moore et al. (2002)stated that improvements in communication andeasy access to nurse providers more than substitutefor the hurried consultation where important issuesfor the patient are inadequately addressed.

Research on nurse led clinics support the use ofspecialist trained practitioners as an effective ad-junct to medically led care. New et al. (2003) statethat analysis of some nurse led clinics showed a sig-nificant reduction in mortality rates. Studner andHirsch (1986), whilst discussing the role of the nursepractitioner, make a valuable statement saying thatnurses may view the opportunity to take on dele-gated medical functions, not as a chance to becomequasi-doctors, but as a logical extension of thenurses’ traditional function of assisting patients inadjusting to their illness. Given sound knowledgeof their speciality and good educational trainingnurses can cross over into the medical domain with-out fear of being out of their depth, performing tasksthat would normally be undertaken by the doctor.(Hill et al., 1992; Campbell et al., 1998; Griffithset al., 2000; Kinley et al., 2001; Steiner et al., 2001).

Caring

To review studies that have relevance to this paperit was necessary to explore the components of car-ing and how caring behaviours amongst nurses im-pact upon patient satisfaction. There have beennumerous studies conducted into caring within thenursing profession. With the ever-increasing devel-opment of caring measurement tools, quantitativestudies are becoming more abundant (Brunton andBearnan, 2000). No studies were found for reviewwhich investigated perceptions of caring behavioursby nurse practitioners related to patient satisfac-tion, therefore studies were reviewed which mea-sured caring behaviours by nurses in general.

Wolf et al. (1994) undertook a study into dimen-sions of care in nursing. Using a 43 item CaringBehaviours Inventory (CBI), nurse and patient re-sponses were analysed. The CBI was grounded inWatson’s (1985) theory of transpersonal caring. Itincluded 43 questions and used a 4 point LikertScale to elicit caring responses and was adaptedfrom a 75 item CBI that was developed byWolf et al.

The study resulted in five dimensions:

(a) Respectful deference to the other;(b) Assurance of human presence;(c) Positive connectedness;(d) Professional knowledge and skill;(e) Attentiveness to the others’ experience.

Patients were encouraged to make comments oncare received and the author reported that most ofthe comments were positive. The negative re-sponses were mainly statements concerning lack ofemotional support, overworked nursing staff andlack of staff. The study concluded that there was asignificantly positive correlation between nurse car-ing andpatient satisfaction. Later studies into caringbehaviours, by the same authors, Wolf et al. (1998)expanded the 4 point Likert Scale to a 6-point scale.Wolf suggested that using a 6-point scale on anitem-by-item basis allowed for more variance.

In 1992 Duffy conducted a study into the rela-tionship between nurse caring behaviours and pa-tient satisfaction outcomes, which incorporatedhealth status perceptions. Like Wolf’s study Duffyreported that the relationship between patient sat-isfaction and nurse caring behaviours was signifi-cantly positive from a statistical stance.

Mullins (1996) undertook a study into nurse car-ing behaviours with patients suffering from HIV orAIDS. The caring behaviours assessment tool(CBA), (Cronin and Harrison, 1988) was used in con-junction with an open ended question which was

90 S. Flynn, E. Whitehead

aimed at identifying patient defined nursing behav-iour in addition to those contained within the CBA.The question asked: ‘‘Is there anything else thatnurses could do to make you feel cared for andcared about? If so what?’’

Several themes emerged from this study andthose with the highest mean scores included re-spect, acceptance, and non-judgemental attitudeof the nursing staff towards the patient and treat-ing the person as an individual. Mullins (1996) sug-gests that health care professionals could usethemes from the study by adopting these patientdefined caring behaviours.

The inter-professional boundaries and nature ofwork undertaken by different health care profes-sionals are continuously changing. As a conse-quence, work lying within the realm of any oneprofession is determined culturally rather than sci-entifically, (Hopkins et al., 1996). It is importantthat the definition of ’profession’ is considered,only then can assumptions be made as to whetherprofessional boundaries are changing.

Nurse led clinics

Recent years have seen a considerable change innursing roles in the United Kingdom (Jackson,2003). Sociologists have continually discussed theissue of what is meant by profession, Hopkinset al. (1996) wrote that sociologists such as Freid-son (1970) recognised there were fundamentalattributes of a profession. For instance, possessionof expert knowledge containing aspects such as along apprenticeship in order to acquire soundknowledge, control of entry into the professionby correct examination of knowledge acquiredfrom training which ultimately results in the con-trol of numbers. It is well recognised in the healthservice today that professional boundaries withinmedicine and nursing are blurring. This changehas been politically fuelled by the UK government’splans for modernising the National Health Serviceas outlined in the NHS Plan, (DOH, 2000) but moreimportantly the main drive is from the rise in con-sumerism, with users of the health service possess-ing greater knowledge. This knowledge has beengained through improvement of patient educationso that informed choices can be made, thusemerges a service more dedicated to patient fo-cused care. The quest for consumer opinion doesserve a public relations purpose but more impor-tantly such surveys can have a direct influence onservice planning, (Bond and Thomas, 1992).

Increasingly the emphasis is firmly placed uponbreaking down existing barriers between health

care professions thus paving the way for the devel-opment of new and innovative roles for nurses (Lu-cas, 2002). The nursing profession has the ability toadapt to change, responding positively to newhealth care needs (DOH, 1999). Benchley and Rob-inson (2001) suggest that nurse led outpatient clin-ics can provide examples of how nursing practicemay evolve with autonomy as a criteria forimplementation.

Cattini and Knowles (1999) acknowledge thatthere have been several changes within the UKdelivery of health care; this is attributed to healthservice reforms. Richley (2000) extends upon thisidea stating that there are nurses in specific areaswho are leaders in the field of service development,namely admitting and discharging patients andmaking complex clinical decisions. Breslin andDennison (2002) propose that nurses are now in aposition to offer a continuous and seamless servicewhich meets the needs of patients in a more holisticfashion. They exercise caution, warning that nursesmust be conscious of their limitations, as extendedroles can leave nurses feeling vulnerable. WhileSpilsbury and Meyer (2001) believe that profession-als are accountable for their delivery of patientcare regardless of the role they perform withinthe health service. Levenson and Vaughan (1999,p. 2), support this belief stating that all health careprofessionals no matter what their role have ‘‘a for-mal responsibility for exploring ways in which thequality of healthcare can be improved under theauspices of clinical governance.’’ It is importantthat responsibility for clinical governance is takenby individual hospital trusts thereby ensuring thatservice provision is quality driven and accountable,(A First Class Service: Quality in the NHS 1998).

Nurse education

The recent decrease in junior doctors’ hours, inline with the European Working Time Directive,and the Government’s drive to reduce consultant-waiting times for new patients signals an acknowl-edgement that the medical profession needs toplace value on interdependence with other healthprofessional roles rather than taking an individual-istic and independent stance. None the lessassumptions should not automatically be made thatnursing can establish itself in this new domain with-out appropriate training.

The literature recognises that in the early yearsof nurse led clinics there were no formal trainingcourses and the majority of training was undertakenin house with relatively little educational endorse-ment, (Sharples et al., 2002; Lucas, 2002). In 1999

An exploration of issues related to nurse led clinics 91

The United Kingdom Central Council for Nursing andMidwifery reported that nurse education was animportant concept in preparing nurses in order thatthey might provide care within changing contextsaffected by key factors such as an ageing popula-tion, changing health care delivery, changing pro-fessional roles and workforce expectations.Supporting this, the Making a Difference Report(DOH, 1999) set out the strategic intentions fornursing, midwifery and health visiting, thus signal-ling the governments recognition of the importantcontribution of nurses to health care delivery.

Nurse education has for some time addressedthe concept of health promotion, helping patientslearn to manage and cope with health care issues(Habel, 2002). Nurses are reliably informed onthe subject of health as an holistic concept andmore importantly to promote positive health aswell as prevention of disease, (UKCC, 1986; Toonet al., 1999). Pragmatically, the development andsuccess of such clinic initiatives must focus onthe level of education and training required tomeet patient and carer needs and expectations.Mundinger et al. (2000) and Rafferty and Elbom(2002), intensify this ideal stating that individualexperiences along with identified educationalrequirements are valuable factors.

The level of education, clinical expertise andsupport available is the discussion of several re-search studies, for example Moon and Becker(2000), Showalter et al. (2000) Montin et al.(2002) argue that identification of suitable trainingand education in nurse led clinics has been acknowl-edged as being more complex than first thought. Itis possible that this is due to the belief that the re-quired education needs a more in-depth analysis.

In a study by Wright et al. (2001) patients feltthat nurses possessed adequate knowledge andskills to perform assessments, further analysis re-vealed that the same patient group were not happyfor nurses to undertake extended roles feeling thatmore complex issues should be referred to medicalstaff. Despite this a comparison study by Mooreet al. (2002) into nurse led follow up managementof patients with lung cancer discovered that pa-tients did not accept an offer to revert to conven-tional medical follow up when the study ended.

Patient education

One of the important goals for nurse practitionerled clinics is to achieve patient compliance withtreatment (Falvo, 1994; Goeppinger and Lorig,1996; Habel, 2002). Many patients undergo com-plex procedures, thus nurses must be well

equipped to undertake the daunting role of patientand carer education. This is not a straight forwardtask as there is a great deal of material to teach,often in an environment where time is limited, topatients who may not be willing, ready or able tolearn (Pestonjee, 2000). Outpatient clinics can pro-vide the perfect location in which the learningneeds of the patient can be met. Patient educationcan be defined as the process of influencing behav-iour and thereby producing changes in the individ-uals knowledge, attitudes and skills which arevital to maintain and improve health, (Rankin andStallings, 2001.)

Habel (2002) informs us that several studieshave shown that educated patients maintain betterhealth and have fewer complications Habel sum-marises that it is important for education to beongoing, interactive and consistent with the pa-tients’ care, educational level and needs for conti-nuity of care. To achieve this level of education themulti-professional team should be involved indeveloping educational plans. Engelke and Trim-born (1999) stress the significance of effectiveteaching plans, stating that they should designateresponsibility for teaching specific content andskills, including patient/family outcomes, teachingresources and a content outline of what should betaught and when.

The idea of allocating responsibility for particu-lar teaching allows for collaboration between themulti-professional teams, which is vital if effectivepatient and family education is to be achieved.Rankin and Stallings (2001) stress that this collabo-ration is imperative as all too often patients be-come confused by the number of healthprofessionals providing their care and regularly be-come frustrated by team members who repeatinstructions which have already been taught. Boydet al. (1998) recognised that nurses are the healthcare professionals who perhaps spend more timewith patients than any other member of the mul-ti-professional team. Thus creating the opportunityto forge a trusting relationship with patients, thisin turn provides an environment suitable for assess-ing the individual educational needs and providingcontinuity throughout the teaching–learning pro-cess. Rankin and Stallings (2001) remind us that pa-tient teaching is not a procedure but a process thatinvolves assessment, negotiation, critical thinkingand knowledge about what is being taught.

Conclusion

This review has presented studies that explore theelements associated with patient satisfaction,

92 S. Flynn, E. Whitehead

nurse led clinics, nurse and patient education andthe role of the nurse. Clearly there is much discus-sion regarding the movement of boundaries be-tween professions. It is important when definingwork as lying within the province of any one profes-sion, that this is acceptable to society, (Hopkinset al., 1996). What is evident from the literatureis the belief that patient satisfaction is the mostimportant and frequently measured outcome whenresearching health care delivery, of which nursingis but one part.

There are contraindications present especially inregards to the nature and proportion of care man-aged by the nurse. It is important to establish thatnurse led clinics offer a quality of care, which isacceptable to the individual patient regardless ofthe service speciality they are accessing. In addi-tion most studies do require replication at similarsites in other hospitals in order to confirm validity.The main limiting factor in studies into the effec-tiveness of nurse led clinics is that they have in-volved small numbers and the follow up periodhas been too short, (Murchie et al., 2003; Cupplesand McKnight, 1999).

Health care professionals tend to concentrate ontheir own clinical performance whereas patientsare concerned with their levels of satisfaction withservice provision. For example, there are gaps inthe literature between the measurement of satis-faction with care given by the healthcare profes-sional and what is perceived by the patient to bea satisfying and meaningful experience as a con-sumer of the National Health Service.

Acceptability with such clinics is as individual asthe patient and their health related problems. Mostimportantly patients’ perceptions and views ofquality and satisfaction are real and must be con-sidered if we are to achieve quality health careand ultimately patient satisfaction.

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