88 VOLUME 14, ISSUE 2, FEBRUARY 2002

RESEARCH

INTRODUCTION

Quality of care is an issue that interests clients, third party payers, andproviders. Yet, there is little published research measuring or evaluating thequality of care provided by nurse practitioners (NP) or advanced practicenurses (APNs) as it relates to client satisfaction. Research on client satisfactionin nursing has primarily focused on nurse-managed centers’ accessibility,waiting time, facility, and cost of care (Attala, & Warmington, 1996; Bagwell,1987; Bear, & Bowers, 1998; Haq, 1993; Katzman, Holman, & Ashey, 1993;Larabee, Ferri, & Hartig, 1997; Pinkerton, & Bush, 2000; Pulliam, 1991;Ramsey, Edwards, Lenz, Odom, & Brown, 1993). Few studies have measuredsatisfaction of clients with APNs in relation to the interactional processbetween the client and APN. Interactional processes include therapeutic lis-tening, health education, and goal-setting between clients and health careproviders (Cox, 1982).

Client satisfaction is a primary goal of health care delivery. Policy makersand insurance companies need valid statistics to substantiate why personswould seek out APNs for health care (Buppert, 1995). Client satisfaction withAPNs is significant since consumer satisfaction level is seen as an importantoutcome of care.

LITERATURE REVIEW

Client satisfaction is one of the indicators of quality health care; however,there is limited information in the literature indicating clients’ satisfactionwith care provided by APNs. A meta-analysis by Brown and Grimes (1995)analyzed 33 outcomes of clients cared for by NPs and physicians. Client sat-isfaction was one of the outcomes studied. Nurse practitioners were found tohave greater client satisfaction when compared with physicians.

Rhee and Dermyer (1995) compared satisfaction with delivery of carebetween NPs and residents in an emergency room. Overall, satisfaction withthe NP care was similar to satisfaction with care by the resident. A study con-ducted in a managed care setting with 160 clients raging in age from 18-89years found no statistical difference in perceived health and satisfaction withcare between NP client groups and physician client groups (Pinkerton, &Bush, 2000).

A large randomized trial compared and analyzed primary care outcomes inclients treated by NPs and physicians. This study examined communicationfactors, willingness to refer the clinic to others and provider attributes, includ-ing provider’s technical skills, personal manner, and time

PurposeTo describe the satisfaction of clients with careprovided by advanced practice nurses (APNs)in the Wright State University (WSU) PilotProject. The Pilot Project was created throughstate legislation that recognized APNs associat-ed with three universities in Ohio for the pur-pose of granting the APNs title protection,prescriptive authority, and recognition leadingto reimbursement.

Data SourcesThe Interactional Model of Client HealthBehavior (Cox, 1982), which proposes thatclient characteristics and interactions withhealth professionals determine health out-comes, served as the framework for thisdescriptive study. The study measured client(n=506) satisfaction with care delivered by 36APNs at 26 different practice sites using anadapted Client Satisfaction Tool (CST). Theinternal consistency of the adapted CST was0.935.

ConclusionsClient (n=506) satisfaction scores ranged from28 to 50, with a mean score of 47.15(SD=4.00). Findings suggest that clients arevery satisfied with APNs in the WSU PilotProject.

Implications for Nursing PracticeClient satisfaction is one indicator used todetermine quality of care. Consumer satisfac-tion benefits the individual client and providesimportant information for the health carepayer. Measuring and reporting client satisfac-tion with care provided by APNs may increasethe visibility and marketability of APNs.

Advanced Practice Nurses: A Study of Client Satisfaction

Rebecca Bryant, MS, CRNP

Margaret Clark Graham, PhD, CRNP

JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 89

spent with the client. There was no significant difference, afterthe first visit, in scores between the physician and the NP on anyof the satisfaction factors. At the six-month interview, the physi-cian groups rated physician providers higher on provider attrib-utes than the NP groups rated the NPs. There was no differencebetween groups in the overall satisfaction and communications(Mundinger et al., 2000).

Client satisfaction with NPs has been reported positively inrelationship to services provided at nurse-managed clinics(Attala, & Warmington, 1996; Bagwell, 1987; Bear, & Bowers,1998; Haq, 1993; Katzman et al., 1993; Pulliam, 1991; Ramseyet al., 1993). The limited studies have reported the satisfactionof clients with APNs, in combination with services provided bythe health centers.

Client characteristics, client-professional interactions, andclient satisfaction with APNs are inter-related concepts (Cox,1982). Some studies that reported the relationship betweenclient characteristics and satisfaction with care primarily focusedon the demographics of the clients (Attala, & Warmington,1996; Bagwell, 1987; Haq, 1993). A limited number ofresearchers examined client-professional interactions’ effect onsatisfaction with care (Bear, & Bowers, 1998; Haq; Katzman etal., 1993). Cole, Mackey and Lindenberd (1999) concluded thatclients, when satisfied, are more likely to seek repeat services,comply with treatment and notice more favorable outcomes.

PURPOSE AND RESEARCH QUESTION

Research is needed to evaluate the health outcome measure ofclient satisfaction with care provided by APNs as a process ofcare. The purpose of this study was to collect and analyze datarelated to satisfaction with care by APNs in the Wright StateUniversity (WSU) College of Nursing and Health Pilot Projectas a health outcome measure of the interactional process betweenhealth care professionals and clients. The research questionaddressed in this study was: What is the client satisfaction levelwith APNs in the WSU Pilot Project?

THEORETICAL FRAMEWORK

The theoretical framework for this study on client satisfactionis based on Cox’s (1982) Interactional Model of Client HealthBehavior (IMCHB). According to Cox, the three major conceptsof client singularity, client-professional relationship, and healthcare outcomes are inter-related (Figure 1). Client singularitydescribes the client as a unique individual. Client-professionalinteractions contain the components of affective support, healthinformation, decisional control, and technical competencies. Eachof these components occurs during the interaction in varyingdegrees dependent upon the needs of the individual client. Lastly,health outcomes are the components of utilization of services,health status indicators, severity of the health care problems,adherence to a treatment regimen, and satisfaction with care.

METHOD AND SETTING

This descriptive study focused on measurement of the satis-faction of clients receiving care from 36 APNs in the WSU PilotProject between July 26, 1999 and August 14, 1999. The PilotProject was established in Ohio in 1992 by special state legisla-tion. The Pilot Project legislation recognized APNs associatedwith three universities in Ohio for the purpose of granting theAPNs title protection, prescriptive authority, and recognitionleading to reimbursement. Data from the Pilot Project, includ-ing this client satisfaction study, have been shared with legislatorsin an attempt to gain statewide prescriptive authority for APNs.Due to legislation passed into law in February 2000, it is antici-pated that all qualified APNs in Ohio will obtain prescriptiveauthority in February 2002.

At the time of this study, the WSU Pilot Project included 36APNs practicing at 26 different sites across Ohio. Specialties ofthe APNs in the study include: 24 family NPs, 4 adult NPs, 2pediatric NPs, 2 certified midwives, 1 women’s health NP, and 3APNs certified in other areas. Eighteen APNs in the WSU PilotProject practiced in a private or group practice; the remainderpracticed in community health or public clinic settings.

DATA COLLECTION PROCEDURE

Permission to conduct the study was obtained from the WSUInstitutional Review Board and the administrator of the WSUPilot Project. The anonymity of the sample population andAPNs providing the care was protected by the anonymous datacollection process. A cover letter was provided with each ques-tionnaire describing the purpose of the study, confidentiality,availability of results and voluntary participation; completion ofthe survey indicated a willingness of the client to participate.

Thirty-six APNs were instructed to collect data on all clientsseen on two typical days (not necessarily consecutive) betweenJuly 26, 1999 and August 14, 1999. The APNs were instructedto provide a cover letter and questionnaire to all potential sub-jects seen on two selected days. The APN was instructed that if

Key WordsClient Satisfaction; Quality of Care; Advanced PracticeNurse.

AuthorsRebecca Bryant, MS, CRNP, is a Family NursePractitioner in practice with T. R. Tigar, MD, Inc., inClarksville, Ohio, an internal medicine practice. MargaretClark Graham, PhD, CRNP, is the Director of FamilyNurse Practitioner Program at Wright State UniversityCollege of Nursing and Health, Dayton, Ohio, and aFamily and Pediatric Nurse Practitioner at the AdolescentWellness Center, an inner city primary care site inDayton, Ohio. Contact Dr. Graham by email at mar-garet.clark.graham@wright.edu.

90 VOLUME 14, ISSUE 2, FEBRUARY 2002

care was provided to a minor, the parent or adult accompanyingthe minor should be requested to complete the questionnaire. Ifcare was provided to an adolescent who was not accompanied tothe health center by an adult, the APN was instructed to ask theadolescent to complete the questionnaire.

The participants were directed to: 1) read the cover letter orhave someone read it for them, 2) complete the instrument, 3)place the completed instrument in an unmarked envelope, 4)seal the envelope, and 5) give the sealed envelope to the recep-tionist. The APNs instructed clients to place unanswered instru-ments in the envelopes for anonymous non-participation.Clerical personnel were requested to return all sealed envelopesto the administrator of the WSU Pilot Project.

INSTRUMENT

The instrument used to measure client satisfaction in thisstudy was adapted from the Client Satisfaction Tool (CST; Bear,Covelli, & Brunell, 1996). The CST measures the variable ofclient satisfaction with nurse-managed clinic services based onCox’s (1982) IMCHB. Bear and Bowers (1998) reported theCronbach’s alpha of the 12-item Likert score to be 0.956 and atest-retest correlation was r=0.974 (p<0.001) for the 12-item

Figure 1. Interactional model of client health behavior

Elements of Client Singularity

Elements of Client-Professional Interaction

Elements of Health Outcome

Background Variables

4. Environmentalresources

1. Demographic characteristics

2. Social Influence

3. Previous health care experience

Intrinsic motivation

Cognitive appraisal

Affective response

Affective support

Healthinformation

Decisional control

Professional/technical

competencies

1. Utilization of health care services

2. Clinical health status indicators

3. Severity of health care problem

4. Adherence to recommendedcare regimen

5. Satisfaction with care

Nonrecursive block

Note. From Cox, C. L. (1982) An Interactional Model of Client Health Behavior. Advances in Nursing Science, 5(1), p. 47. Copyright 1982 by Aspen Publishers, Inc.

Reprinted with permission.

Table 1. Client Satisfaction Scores (n=506)

Score Frequency Percent Cumulative Percent*28 1 0.2 0.229 1 0.2 0.434 1 0.2 0.636 3 0.6 1.237 2 0.4 1.638 3 0.6 2.239 6 1.2 3.440 40 7.9 11.341 20 4.0 15.242 12 2.4 17.643 19 3.8 21.344 16 3.2 24.545 16 3.2 27.746 20 4.0 31.647 21 4.2 35.848 28 5.5 41.349 27 5.3 46.650 270 53.4 100.0

* some rounding of scores

JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 91

CST. Experts rated the CST as content valid with the conceptu-al elements of the IMCHB (Cox).

Adaptation of the CST to measure satisfaction of clients withAPNs based on the IMCHB included: (a) removal of items 1and 2 regarding clinic accessibility, and (b) insertion of the words“nurse practitioner” to items 3 through 12 to narrow the focusof measurement to care provided by APNs. Summing theresponses to all 10 items created an overall satisfaction score,which could range from 10 to 50 (higher scores indicating high-er levels of satisfaction).

FINDINGS

All 36 APNs were contacted and invited to participate in datacollection for two client care days. A total of 72 client care daysreturned for analysis would have indicated 100% participationby the APNs. Forty-nine client care days were actually returned(68% response rate). A total of 531 clients completed the sur-veys. Of the 531 individuals who participated, 506 (95%) pro-vided complete answers for analysis purposes. Only the com-pleted surveys were used for data analysis.

The possible range of scores on the client satisfaction ques-tionnaire completed by the clients was 10-50. The actual scoresranged form 28-50 (Table 1). Study participants indicated thattheir level of satisfaction was high. The mean satisfaction scorewas negatively skewed toward high satisfaction. The intra-quar-tile range was 45 to 50. A 95% confidence interval was calculat-ed and the average client satisfaction score was between 46.8 and47.5 points. Cronbach’s alpha was used to determine the inter-nal consistency of the adapted CST and the results were 0.935.

The adapted CST contained a section of two open-endedquestions. Many of the respondents used similar words in theirresponses to each question. A total of 278 comments were writ-ten to question number one describing the NP. The most fre-quently used words/phrases were “nice” (n=45), “caring” (n=41),“understanding” (n=34), “makes me feel comfortable” (n=25),“friendly” (n=20), “listens” (n=15), and “takes time” (n=12). Nonegative comments were stated following this question.

Comments (n=157) concerning the health care received atthe site were overwhelmingly positive, with four exceptions.Positive words listed in the comments included “good” (n=18)and “excellent” (n=16). Negative comments included staff (n=2),waiting time (n=1), and phone service (n=1).

DISCUSSION

The object of the IMCHB is to identify and suggest explana-tory relationships between the individual client characteristics,interactions with health professionals, and subsequent healthoutcomes. Satisfaction with care is a health outcome measure ofinteractions between clients and APNs (Cox, 1982). Satisfactionwith care by an APN may serve as a measure of the effectivenessof APN interactions with individual clients. The ability of thisWSU’s Pilot Project study to measure satisfaction of care with

APNs is one health outcome measure. The adapted CST onlymeasured satisfaction with care provided by APNs in the WSUPilot Project.

Limitations in the ability to generalize the informationobtained from this study to describe client satisfaction of careprovided by APNs in the WSU Pilot Project include influencesof APNs, such as different practice methods on the days of datacollection and failure of APNs to participate. Errors in data col-lecting/coding and the use of a non-random sampling methodare other limitations in the ability to generalize. The study didnot determine other variables of client satisfaction not measuredby the adapted CST.

Recommendations for future research include: (a) studyingCox’s (1982) framework elements, including client characteris-tics (demographics, social influences, previous health care expe-riences, and environmental resources) and client-APN interac-tions on health outcomes, (b) replication of this study with arandom-sampling method, (c) qualitative research to determineconcepts specific to APN interactions, and (d) comparing CSTscores as an outcome measure between APNs and physicians.

CONCLUSIONS

Client-APN interactions during a health care visit influenceclients’ satisfaction with care (Cox, 1982). Affective support,health information, decisional control, and technical competen-cies occur during the interaction in varying degrees dependentupon the needs of the individual client. Advanced practice nurs-es can evaluate and improve their delivery of health care by mea-suring practice level outcomes (Buppert, 2000). The WSU PilotProject study to assess satisfaction of care with APNs is one mea-sure of the quality of care delivered.

Advanced practice nurses must take a proactive role in theevaluation of the care they provide to their clients. Satisfiedclients can be advocates of the APN model of health care deliv-ery. Consumer satisfaction benefits the individual client and pro-vides important information for the health care payer.Measuring and reporting client satisfaction with care providedby APNs may increase the visibility and marketability of APNs.

REFERENCESAttala, J., & Warmington, M. (1996). Client’s evaluation of health care services

in a battered women’s shelter. Public Health Nursing, 13(4), 269-275.Bagwell, M. (1987). Client satisfaction with nursing center services. Journal of

Community Health Nursing, 4(1), 29-42.Bear, M., & Bowers, C. (1998). Using a nursing framework to measure client sat-

isfaction at a nurse-managed clinic. Public Health Nursing, 15(1), 50-59.Bear, M., Covelli, M., & Brunell, M. (1996). Client Satisfaction Tool: Questionnaire

received from authors and implemented with authors’ permission.Brown, S., & Grimes, D. (1995). A meta-analysis of nurse practitioners and

nurse midwives in primary care. Nursing Research, 44(6), 332-339.Buppert, C. (1995). Justifying nurse practitioner existence: Hard facts to hard

figures. Nurse Practitioner, 20(8), 43-48.Buppert, C. (2000). Measuring outcomes in primary care practice. The Nurse

Practitioner, 25(1), 88-98.

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Cole, F., Mackey, T., & Lindenberd, J. (1999). Quality improvement:Psychometric evaluation of patient satisfaction with nurse practitioner careinstrument. Journal of the American Academy of Nurse Practitioners,11(11), 471-475.

Cox, C. (1982). An interaction model of client health behavior: Theoretical pre-scription for nursing. Advances in Nursing Science, 5(1), 41-56.

Haq, M. (1993). Understanding older adult satisfaction with primary health careservices at a nursing center. Applied Nursing Research, 6(3), 125-131.

Katzman, E., Holman, E., & Ashey, J. (1993). A nurse managed client satisfac-tion survey. Nursing and Health Care, 14(8), 420-425.

Larrabee, J., Ferri, J., & Hartig, M. (1997). Patient satisfaction with nurse prac-titioner care in primary care. Journal of Care Quality, 11(5), 9-14.

Mundinger, M., Kane, R., Lenz, E., Totten, A., Tsai, W., Cleary, P., Friedewald, W.,Siu, A., & Shelanski, M. (2000). Primary care outcomes in patients treated

by nurse practitioners or physicians: A randomized trial. Journal of theAmerican Medical Association, 283(1), 59-68.

Pinkerton, J., & Bush, H. (2000). Nurse practitioners and physicians: Patients’perceived health and satisfaction with care. Journal of the AmericanAcademy of Nurse Practitioners, 12 (6), 211-217.

Pulliam, L. (1991). Client satisfaction with a nurse-managed clinic. Journal ofCommunity Health Nursing, 8(2), 97-112.

Ramsey, P., Edwards, J., Lenz, C., Odom, J., & Brown. J. (1993). Types of healthproblems and satisfaction with services in a rural nurse-managed clinic.Journal of Community Health Nursing, 10(3), 161-170.

Rhee, K., & Dermyer, A. (1995). Patient satisfaction with a nurse practitioner ina university emergency service. Annals of Emergency Medicine, 26(2), 130-132.