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PATIENT SATISFACTION WITH NURSE PRACTITIONER DELIVERED PRIMARY HEALTH CARE SERVICES A Dissertation Submitted to the Graduate Faculty of the Louisiana State University and Agricultural and Mechanical College in partial fulfillment of the requirements for the degree of Doctor of Philosophy in The Department of Human Resource Education and Workforce Development by Lucie J., Southeastern Louisiana University, 1983 M., University of Texas Health Science Center at Houston, 1987 August, 2005 ©Copyright 2005 Lucie Janelle Agosta All Rights Reserved ii Acknowledgements Special thanks to the staff of Employee Health at Woman’s Hospital for their assistance with this research study. Thanks also to the hospital employees and family members who participated as research subjects of the study. The assistance and expertise of Gay Middleton, librarian at the Woman’s Hospital Medical Library, Hilde Chenevert, Woman’s Hospital Biostatistician, Kathleen Bosch, Administrative Assistant, and Judy Nash, Printing Services is also appreciated. The input, guidance, and assistance of the members of my dissertation committee at Louisiana State University in Baton Rouge, Louisiana is sincerely appreciated, valued, and acknowledged.

Members include Krisanna Machtmes, PhD, Major Professor, Michael Burnett, PhD, Geraldine Holmes Johnson, PhD, Christine DiStefano, PhD, and Thomas Eugene Reagan, PhD. iii Table of Contents ACKNOWLEDGEMENTS…………………………….iii LIST OF TABLES…………………………………………………….vi LIST OF FIGURES…………………………………………………………….xi CHAPTER 1 INTRODUCTION……………………………………………………….1 Rationale and Justification…………………………………………………1 Problem Statement…………………………………………………………4 Research Objectives……………………………………………………….4 Significance of the Study………………………………………………….6 2 REVIEW OF LITERATURE…………………………………………….9 Advanced Practice Nursing.10 National Healthcare Challenges……………….13 Nurse Practitioner Role Evaluation………….14 Patient Satisfaction and Acceptance……….21 Patient Satisfaction Measurement and Instrumentation….32 Population and Sample…….34 Data Summary and Analysis…………………………………………….37 4 RESULTS AND DISCUSSION……………….91 5 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS….118 Purpose and Objectives………………………………………………….120 Summary of Findings……….………………121 Conclusions, Implications, and Recommendations…………….……………141 iv APPENDIX A LOUISIANA STATE UNIVERSITY INSTITUTIONAL REVIEW BOARD (IRB) FOR PROTECTION OF HUMAN SUBJECTS APPROVAL LETTER……………………………………………………150 B INFORMATION AND CONSENT SHEET……………………….……152 C NURSE PRACTITIONER SATISFACTION SURVEY INSTRUMENT……………………………………………….…159 v List of Tables 1. Age Distribution of Adult Clients Presenting for Nurse Practitioner Delivered Health Care Services…………………………………………………. Marital Status Reported by Adult Clients Presenting for Nurse Practitioner Delivered Primary Health Care Services……………………………….

Highest Level of Education Completed by Adult Clients Seeking Nurse Practitioner Delivered Primary Health Care Services………………………………. Health Insurance Type Indicated by Adult Clients Presenting for Nurse Practitioner Delivered Primary Health Care Services………………………………. Yearly Net Incomes as Reported by Adult Clients Presenting for Nurse Practitioner Delivered Primary Health Care Services……………………………. Employment Status Indicated by Adult Clients Presenting for Nurse Practitioner Provided Primary Health Care Services……………………………….

Medication Dependent Health Problems as Reported by Adult Clients Presenting for Nurse Practitioner Delivered Primary Health Care Services…………56 8. Number of Daily Prescription Medications Taken as Reported by Adult Clients Presenting for Nurse Practitioner Delivered Primary Health Care Services………. Frequency of Health Care Visits in the Past Year by Provider Type as Reported by Adult Clients Seeking Nurse Practitioner Delivered Primary Health Care Services………………………………………………………………………………58 10. Summed Squared Factor Loadings and Total Variance Explained for the Three Factor Extraction and Rotated Factor Solutions for Items Representing the Nurse Practitioner Satisfaction Survey………………………………………………64 11.

Variables and Factor Loadings for Items Representing the Nurse Practitioner Satisfaction Survey for the Rotated Three Factor Solution Using Principle Axis Factoring and Promax Rotation……………………………………………………. Factor One (Satisfaction Score) Variables, Means, and Standard Deviations for Items Representing General Satisfaction on the Nurse Practitioner Satisfaction Survey………………………………………………………………………………. Factor Two (Communication Score) Variables, Means, and Standard Deviations for Items Representing Communication Satisfaction on the Nurse Practitioner Satisfaction Survey…………………………………………………………………. Factor Three (Scheduling Score) Variables, Means, and Standard Deviations for Items Representing Scheduling Satisfaction on the Nurse Practitioner Satisfaction Survey………………………………………………………………….

Factor Correlations between the Constructs “Satisfaction,” “Communication,” and “Scheduling”………………………………………………. Names, Number of Items, Reliability, Means, Standard Deviations, Skewness, and Kurtosis of Factors Derived from the Three-Factor Solution……………. Group Sizes, Mean Patient Satisfaction Subscale Scores, and Standard Deviations by Gender for Respondents of the Nurse Practitioner Satisfaction Survey………………………………………………………………………………. Sample Sizes, Mean Patient Satisfaction Subscale Scores, and Standard Deviations by Recoded Racial Group Distributions for Nurse Practitioner Satisfaction Survey Respondents…………………………………………………….

Sample Sizes, Mean Patient Satisfaction Subscale Scores, and Standard Deviations by Recoded Age Group Distribution for Nurse Practitioner Satisfaction Survey Respondents……………………………………………………. Sample Sizes, Mean Patient Satisfaction Subscale Scores, and Standard Deviations by Marital Status Distributions for Nurse Practitioner Satisfaction Survey Respondents…………………………………………………………………. Mean Satisfaction Subscale Scores, Standard Deviations, and Sample Sizes for Highest Education Levels Reported by Nurse Practitioner Satisfaction Survey Respondents…………………………………………………………………. Mean Satisfaction Subscale Scores, Standard Deviations, and Sample Sizes for Insurance Groupings Reported by Nurse Practitioner Satisfaction Survey Respondents………………………………………………………………….

Mean Satisfaction Subscale Scores, Standard Deviations, and Group Sizes by Reported Annual Net Income Level for Respondents of the Nurse Practitioner Satisfaction Survey…………………………………………………………………. Group Sizes, Satisfaction Subscale Scores, and Standard Deviations for Reported Patient Types of Respondents of the Nurse Practitioner Satisfaction Survey………………………………………………………………………………. Analysis of Variance Illustrating Differences in Patient Satisfaction Subscale Scores between Patient Type Groups for Respondents of the Nurse Practitioner Satisfaction Survey……………………………………………………. Group Sizes, Mean Satisfaction Subscale Scores, and Standard Deviations by Employment Status for Respondents of the Nurse Practitioner Satisfaction Survey……………………………………………………………………………….

Analysis of Variance of Overall Means of General Patient Satisfaction Scores between Patient Employment Status Groups for Respondents of the Nurse Practitioner Satisfaction Survey……………………………………………………. Group Sizes, Mean Satisfaction Subscale Scores, and Standard Deviations by Subjective Report of Degree of Illness Currently Experienced for Respondents of the Nurse Practitioner Satisfaction Survey………………………………………. Analysis of Variance of Overall Means of General Patient Satisfaction Subscale Scores between Degrees of Reported Illness by Respondents of the Nurse Practitioner Satisfaction Survey……………………………………………………. Group Sizes, Mean Satisfaction Subscale Scores, and Standard Deviations by Subjective Report of Degree of Injury Currently Experienced by Nurse Practitioner Satisfaction Survey Respondents……………………………………….

Analysis of Variance of Overall Means of General Patient Satisfaction Subscale Scores between Degrees of Reported Illness by Respondents of the Nurse Practitioner Satisfaction Survey……………………………………………………. Sample Size, Pearson’s Product Moment Bivariate Correlations and Significance Levels Representing the Relationship between Each Dummy Coded Level of the Independent Variables Age, Income, Educational Level, and Gender and the Dependent Variable Patient Satisfaction Subscale Scores…………………………. Significance of the Regression Equation Employing Educational Level “Some College” in Predicting Patient Satisfaction with Nurse Practitioner Delivered Health Care…………………………………………………………………………. Coefficient Tables, Standard Errors, Standardized Coefficient Values, T Values And Significance Levels for Dummy Coded Independent Variables Retained in the Regression Equation Predicting Patient Satisfaction Subscale Scores……….

DFBETA and Standardized DFBETA Values for the Satisfaction Subscale Score Regression Equation Intercept and Educational Level Predictor Variable “Some College”……………………………………………………………. Excluded Variables, Standardized Coefficients, T Values, Significance Levels, Partial Correlations, and Tolerance Levels for the Regression Equation Predicting Patient Satisfaction Subscale Scores……………………………. Sample Size, Pearson’s Product Moment Correlations, and Significance Levels Representing the Relationship between all Dummy Coded Independent Variables with the Dependent Variable Communication Subscale Score…………. Significance of Age Group 18-25 and Masters Educational Level in Predicting Satisfaction with Communication Aspects of the Patient and Nurse Practitioner Interaction………………………………………………………105 39.

Coefficient Values, Standard Errors, Standardized Coefficient Values, T Values and Associated Significance Levels, R2 Change and Corresponding F Value Changes, and Significance Levels for Independent Variables Determined to be Statistically Significant in Predicting Satisfaction with Nurse Practitioner Communication…………………………………………………106 40. DFBETA and Standardized DFBETA Values for the Communication Subscale Score Regression Equation Intercept and Predictor Variables Age 18-25 and Masters Level Education……………………………………………………………107 41. Excluded Variables, Standardized Coefficients, T Values, Significance Levels, Partial Correlations, Tolerance Levels and Variance Inflation Factors for the Final Regression Equation Predicting Satisfaction with Communication with the Nurse Practitioner………………………………………………………………108 42. Sample Size, Pearson’s Product Moment Correlations and Significance Levels Demonstrating the Relationship between Each Dummy Coded Level of the Independent Variables Age, Income, Educational Level, and Gender with the Dependent Variable Patient Satisfaction with Scheduling…………………………112 43.

Significance of the Regression Equation Employing Age Group 18-25 in Predicting Satisfaction with Scheduling Appointments for Nurse Practitioner Health Care Visits…………………………………………………………………. Coefficient Values, Standard Errors, Standardized Coefficient Values, T Values and Significance Levels for the Dummy Coded Independent Variable Retained in the Regression Equation Predicting Scheduling Satisfaction Scores……………114 45. DFBETA and Standardized DFBETA Values for the Scheduling Score Regression Equation Intercept and Predictor Variable Age 18-25…………………115 46. Excluded Variables, Standardized Coefficients, T Values with Corresponding Significance Levels, Partial Correlations, Tolerance Levels, and Variance Inflation Factors for the Regression Equation Predicting Satisfaction with Scheduling………………………………………………………………………….115 ix List of Figures 1.

Boxplot Examination of Patient Satisfaction Scores among Nurse Practitioner Clients………………………………………………………………………………. Histogram Depicting Standardized Residuals for the Dependent Variable Satisfaction Subscale Scores…………………………………………………………93 3. Histogram Depicting Standardized Residuals for the Dependent Variable Communication Subscale Scores…………………………………………………. Histogram Depicting Standardized Residuals for the Dependent Variable Scheduling Subscale Score…………………………………………………………110 x Abstract The purpose of this study was to explore and determine the degree of client satisfaction with utilization of primary healthcare services delivered by a nurse practitioner in the Employee Health Services department of a not for profit hospital in the Southern United States.

The Nurse Practitioner Satisfaction Survey (NPSS), a 28-item Likert-type survey instrument was specifically developed for this study and administered to a sample of 300 clients. Overall high levels of patient satisfaction with nurse practitioner delivered health care services were demonstrated. The mean general satisfaction score was determined to be 86.86 / 90, with mean communication and scheduling subscale scores of 28. Factor analysis of the dataset resulted in a three-factor model that explained 70.77% of the variance.

Eighteen variables with loadings ranging from .391 loaded on factor one, general satisfaction. Six variables with loadings ranging from .435 loaded on the second factor, communication satisfaction, and four variables with loadings ranging from .748 loaded on the third factor, scheduling satisfaction. No statistically significant differences in scores on the general satisfaction subscale were noted between subjects based on gender, race, age, highest educational level completed, type of health care coverage, yearly net income levels, patient type, employment status, or degree of illness or injury. Married or cohabitating subjects, however, reported general satisfaction subscale scores that were statistically higher than those who were single and never married.

xi Multiple regression analysis of the dummy coded variables gender, age, income, and highest educational level as possible predictors of general satisfaction subscale scores revealed that subjects reporting some college attendance demonstrated scores which were –2.243 points lower than those of the other educational levels. Additionally, being a member of the 18-25 year old age group resulted in a decrease in communication subscale scores of –1.194 points, while being a member of the masters level educational group resulted in increases of 1. Further analysis revealed that scheduling satisfaction scores for subjects in the 18-25 year old age group were -.954 points lower than those reporting ages above 18-25 years. xii Chapter 1 Introduction Rationale/Justification Healthcare costs have increased exponentially in recent years for both individual healthcare consumers and employers providing health care benefits for employees.

Companies with self-insured/self funded health plans are particularly cognizant of the high cost of insurance and healthcare. Healthcare comprises approximately 1.4 trillion or 15% of the Gross Domestic Product (Center for Medicare and Medicaid Services, 2005). In 2002 businesses paid an average of $6300 per employee, over 42.3% of payroll expenses for medical benefits (United States Chamber of Commerce, 2004). Employee illness is very expensive for employers, in terms of both cost of healthcare services as well as time and lost workplace productivity resulting from employee job absences for infirmity and healthcare provider visits.

Both employers and employees benefit from the provision of accessible, on site, comprehensive healthcare in the most cost effective and efficient methods possible. Extensive documentation indicates that for most healthcare situations, prevention and early access to care is more cost effective. Therefore, there has been rapid growth in programs placing emphasis on wellness, prevention, and early access to care (United States Preventive Services Task Force, 2003). The establishment of on-site health care services is an issue that has been of increased interest in the health and wellness arena, especially among self-insured organizations.

The expansion of employer provided healthcare services to family 1 members of employees extends the promotion of employee wellness and health care participation beyond the workplace and into the family arena, thus enhancing provided employment benefits for both employees and employers. Unfortunately, the cost of maintaining a full time physician is prohibitive for most organizations (Lugo, 1997). An alternative is the use of a nurse practitioner to provide on site health care services within an organization.