The Australian Capital Territory Patient Enablement and Satisfaction Study (ACTPESS): A mixed methods study examining the impact of nursing care on the quality of care in Australian general practice

BACKGROUND: In response to demographic changes, increasing rates of chronic disease and demand for primary health care services, since the early 2000’s Australia has increased the number and roles of general practice nurses (GPNs). There is a scarcity of evidence establishing whether the increased availability and use of nursing care in general practice has resulted in improved patient outcomes. Two key quality outcomes – patient satisfaction and enablement – have been examined extensively as outcomes of general practitioner care; however an evidence gap exists regarding these outcomes in relation to GPN care. The aim of this study was to examine the relationship between general practice and GPN consultation characteristics, and patient satisfaction and enablement. METHODS: A concurrent mixed methods study was conducted. The quantitative component consisted of a cross-sectional study of 678 patients (response rate = 41%) receiving GPN care in 21 general practices in the Australian Capital Territory. Patient Enablement and Satisfaction Surveys were distributed to these patients between September 2013 and March 2014. Multilevel mixed effect models were used to analyse these data. The qualitative component took a grounded theory approach to in-depth interviews with GPNs (n=16), patients (n=23) and practice managers (n=9) from these same general practices. Data generation and analysis were conducted concurrently using constant comparative analysis and theoretical sampling. After the separate quantitative and qualitative analyses, findings were integrated. This involved quantification of selected qualitative variables for inclusion in multilevel analyses and a secondary integration of findings. FINDINGS: The results of this study provided evidence of: ● a significant association between patient satisfaction and Nursing scope of practice and autonomy, Continuity of GPN care, Patients making appointments to see a particular GPN, Consultation type and Duration of consultation; ● a significant association between patient enablement and Nursing scope of practice and autonomy, Consultation type and Duration of consultation;● behaviours that characterise ‘the just right nurse’; ● an interconnection between patient satisfaction and enablement. This evidence is presented in the form of a theoretical model called, developing a positive patient experience with nurses in general practice: an integrated model of patient satisfaction and enablement. This process-based model includes general practice and GPN consultation characteristics underpinning actions and interactions that support the triggering of health care partnerships between patients and GPNs, and tailoring care to meet each patient’s unique needs. The effectiveness of this model is contingent on the general practice context in which it operates. Examination of characteristics that support broad scopes of nursing practice coupled with high levels of autonomy facilitated an understanding of ‘enabling’ and ‘less-enabling’ general practices. CONCLUSION: This integrated model of patient satisfaction and enablement is a practical tool to inform education and training for GPNs and other clinicians, particularly in relation to the management of patients with chronic and long-term conditions. This evidence provides impetus to deepen our insight into general practice models of care that facilitate enhanced nursing scope of practice and autonomy, continuity of care and adequate time for nursing consultations. Integral to patient-centred care, these interprofessional models are the key to optimising GPN roles and the associated quality patient outcomes