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.

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

3.1

Introduction

18
3.2 Research Design

.. 18
3.3 Research Methods

. 19
3.3.1 Research Instrument

19
3.3.2 Sampling

21
3.3.3 Data Analysis

.. 22
3.4 Ethical Considerations
..
22
3.5 Conclusion

. 23
4.
Research Findings

25
4.1 Introduction

25
4.2 Quality of Frontline Patient Care
. 25
4.3 Nurse Practitioners relation to General Practitioners
. 28
4.4 Discussion

. 29
5.
Conclusion and Recommendations
. 30
5.1 Research Limitations

. 31
5.2 Summary of Research Findings
.. 31

5.3
5.4

5.5

Implications of the Research Findings

.. 32
Key Recommendations

33
Areas for Future Research
. 33

References

. 34 Appendix I & Appendix II

.. 3738
Consent Forms

.. 40
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:
I.

to identify Nurse Practitioners perceptions of the quality of

II.

primary health care in the UK

to identify the perceptions of what impact their role as health

III.

care providers has on primary health care in the UK

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

II.

able to provide?
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 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-

10

reviewed journals was subjected to critical appraisal. Finally, 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

11

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
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

12

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-perperformance 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 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
13

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).
Nurses also experience ethical dilemmas and moral distress as a
result of work stresses directly associated with workload, hours worked
and difficult care situations. As a result, data accumulated over a 27 year
study on nurses reveal that many of the nurse test subjects experienced
burnout and emotional exhaustion and depersonalization. This in turn had
a direct impact on their work performance and also in the way that they
viewed their professional performance. Consequently, their own
depersonalization and burnout- syndrome translated into a higher
incidence of depersonalization towards patients (Oh & Gastmans 2013).

14

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 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).

15

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 general practitioner

16

(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

17

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. 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 coordinating 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).

18

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 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.

19

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 semistructured 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

20

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 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
21

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 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
22

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
Respond
ent No.

Mode of
Communicat
ion with the
Research
Interviewee
s

Qualificati
on of the
Research
Interviewe
e / 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
experien
ce of
tradition
al PN
duties,
with 5
years as

Skype
Conference

MSc
postgraduat
e diploma:
Nurse
Practitioner
in Primary

Work across acute

and community
settings, undertake
clinical assessments
of patients within
the emergency

12 years
of which
4 years
in
primary
23

Care/
Emergency
Nurse
Practitioner
MSc,
RNDipHE
/
Emergency
Nurse
Practitioner

department,
contribute towards
staff induction
programmes

care

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

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
Commun
ity
Nurse/
7 years
as an
ANP

Face-to-Face
Interview

Nurse
Practitioner/
Independent
Prescriber

Autonomous
assessment,
examination,
diagnosis and
management of

9 years

24

patients presenting
with acute and
chronic medical
conditions in both a
walk-in and 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
25

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 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 - SemiStructured 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.

26

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 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.

27

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

28

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.
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
29

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 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
30

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.

4.3

Nurse Practitioners relation to General Practitioners

31

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.
32

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 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.

33

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
34

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 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

35

While there are numerous factors which attribute to the workpressures and demands on nurse practitioners, such as hospital
overcrowding and misuse of A&E centres, the stark reality is that where
there is an aging UK population, given the current pressures on the NHS,
the cost of bed-based care will only compound the problem of an already
dwindling nursing workforce. When it comes to primary care on supported
self-management, more help is needed from cross-agency, interprofessional 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 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

36

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.

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Appendix I Participant Consent Form

Consent
Form

East Surrey
College
Gatton
Point
London
Road
Redhill
Surrey
RH1 2JX

41

Tel: 01737
772611

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:
Signature:

Date:

Appendix II Semi-Structured Interview Schedule

42

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?

43

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

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.

44