Parents' perception of satisfaction with pediatric nurse practitioners' care and parental intent to adhere to recommended health care regimen.
The PNP's communication skills, clinical competence, caring behavior, and decisional control are essential aspects of the PNP-client interaction during a well or sick visit. PNPs routinely teach parents about infant feeding, nutrition, immunizations, and the management of acute illness during health visits. Parents may benefit from the interaction with a PNP by making healthy choices for their child. Parent satisfaction with PNP care may predict the future health of children based on the interaction during the health visit and parental intent to adhere to the PNP plan of care.
Various settings in which satisfaction with nurse practitioners have been studied include nurse managed centers (Benkert, Barkaukas, Pohl, Tanner, & Nagelkirk, 2002), a school-based teen clinic (Benkert et ah, 2007), retail stores (Hunter, Weber, Morreale, & Wall, 2009), rural area clinics (Knudston, 2000), and an inpatient cystic fibrosis unit (Rideout, 2007). Samples consisted of a wide range of patient ages and diversity. The literature also reports nurse practitioner effectiveness as measured by the patient intention to adhere to the nurse practitioner plan of care. Researchers have also explored patient satisfaction and the quality of care given by nurse practitioners in comparison to other health providers. A synthesis of the findings of these studies suggests that clients are generally satisfied with nurse practitioners. However, there is a gap in the literature describing parent satisfaction with the care received from PNPs and parental intent to adhere to recommended health care regimen.
Research Questions And Hypothesis
This study addressed two research questions:
* What are parents' perceptions of overall satisfaction with PNP care and its components of communication skills, clinical competence, caring behavior, and decisional control?
* What are the relationships among parents' perception of PNP communication skills, clinical competence, caring behavior, decisional control, and intent to adhere to recommended care regimen?
The study hypothesis was as follows: The linear combination of parents' perceptions of pediatric nurse practitioners' communication skills, clinical competence, caring behavior, and decisional control will explain parents' intent to adhere to recommended care regimen better than any one variable alone.
This research study was guided by the Cox (1982) Interaction Model of Client Health Behavior (IMCHB) and the empirical instruments based on this model. The IMCHB was proposed in 1982 as a prescriptive nursing framework. According to Cox (1982), the goal of the model is to identify and suggest explanatory relationships between client singularity, client-provider relationships, and subsequent client health care behavior. The provider and client have unique characteristics and behaviors that are not static in their effects and as a result influence each client uniquely. The IMCHB is applicable to PNP practice and guides positive interaction with parents and children, therefore, framed this investigation.
[FIGURE 1 OMITTED]
Application of the IMCHB Model to this Study
The IMCHB model was adapted for use in this research study as shown in Figure 1. The model is organized by three major elements: client singularity, client-professional interaction, and health outcome. The demographic data questionnaire addressed the element client singularity in this study and described the parent/patient background variables. The element of client-professional interaction corresponded to the parent-PNP interaction. The interaction took place during a sick or well visit in the outpatient office setting. The parent's perception of satisfaction with PNP care was measured during this interaction. All four components of overall satisfaction with PNP care were measured during the parent/PNP interaction, by the Parents' Perception of Satisfaction with Care from Pediatric Nurse Practitioner instrument (PPSCPNP). The Visual Analog Scale recorded on the demographic questionnaire measured parental intent to adhere to recommended regimen by the PNP.
By applying the IMCHB model to the parent-PNP interaction, it was expected that the relationship among the PNPs' communication skills, clinical competence, caring behavior, decisional control, and parents' intent to adhere to recommended regimen would be revealed. The factors in the interaction are useful in nursing practice and education to help in understanding how to promote positive health choices by parents for their children and what influences can predict parental intent to adhere to a recommended regimen of care. Cox (1982) suggested that many nurse practitioners practice in a medical setting, and the IMCHB model offers nurse practitioners a holistic nursing approach to guide practice that is well suited for primary care and complementary to medical practices.
This study used a descriptive correlational research design. Descriptive statistics were computed to describe the parents' perception of overall satisfaction with PNP care and the four components of satisfaction. The relationships among the components of parent satisfaction (communication skill, clinical competence, caring behavior, and decisional control) were explored in relation to the parents' intent to adhere to the recommended care regimen. The relationships among the variables in the interaction of the PNP and the parent were analyzed with Pearson correlations and multiple regression. The outcome variable--parental intent to adhere with the PNP recommended health regimen--was studied, and any relationship with the explanatory variables was revealed through statistical analyses.
Sample and Setting
A power analysis required a minimum sample size of 85 participants. A total of 91 participants were recruited in a two-month period. The demographic data for the sample of 91 participants are found in Table 1. The ages of the participants ranged from 18 to 62 years old. There were 79 mothers, 10 fathers, one grandmother, and one legal guardian. The ages of the children ranged from less than one month to 17 years old.
The convenience sample of parents was recruited from several primary pediatric practice settings. The settings were outpatient practices in suburban southeastern Pennsylvania area, and included four privately physician-owned practices and one hospital based clinic. The researcher contacted the practices and invited participation with a phone call to the PNP on site to explain the study. Parents or legal guardians were eligible to be participants. Clients who made an appointment with a PNP for either a well visit or sick visit were asked to participate.
Two instruments were used. The PPSC-PNP measured overall satisfaction of parents with PNP care. Components of overall satisfaction with PNP care (communication skills, clinical expertise, caring behavior, and decisional control) were measured by the newly developed instrument. A 100 mm VAS measured parents' intent to adhere to the PNP recommended care regimen. A 19-item demographic data questionnaire was included.
PPSC-PNP instrument. The PPSC-PNP instrument was developed and piloted for this study (DiAnna-Kinder & Allen, 2014). Initially, the PPSC-PNP consisted of 37-items. Nine were dropped based on item-to-total correlation computed with reliability statistics. The statistically strongest items were kept for each subscale. The final PPSC-PNP version consisted of a 28item questionnaire using a 5-point Likert scale with 1 (strongly disagree) through 5 (strongly agree).
The PPSC-PNP is based on Cox's (1982) Model of Client Health Behavior. Items were revised from Agosta's (2009) Nurse Practitioner Satisfaction Survey (NPSS), and Bear and Bowers' (1998) Client Satisfaction Tool. The third instrument, the Satisfaction with Decision Scale (Holmes-Rovner et al, 1996), was revised to reflect parental perception of decisional control. The authors of the instruments were contacted and consented to revision of their instruments. The majority of items on the PPSC-PNP were revised using Agosta's NPSS instrument. All items were revised to reflect parental perception of care from the PNP because the three instruments were originally developed for use by adults accessing care in adult health practices.
The subscales of the PPSC-PNP are communication skills, clinical competence, caring behavior, and decisional control. The subscales are components of overall satisfaction with care from PNP. Each subscale is measured by six items, and four additional items measure general satisfaction. Five content validity experts judged the placement of items on subscales. The four items for general satisfaction did not reflect any one particular component and were determined to reflect general satisfaction by the judges.
Validity. Content validity was established by five judges, all of whom were pediatric nurses. Two were doctorally prepared, three were master's prepared practicing PNPs, and one doctoral prepared judge was a family nurse practitioner. The judges rated the original 37 items on a 4-point Likert scale of relevancy for inclusion in the instrument. A content validity index of 0.81 for the 37 items resulted. Based on item-to-total correlations computed with the reliability statistics, the six strongest items for each subscale were kept in addition to four general items for overall satisfaction, producing a 28-item final version of the PPSC-PNP.
Reliability. SPSS version 18.0 was used to analyze the data from the pilot study (N = 25) and from the full study (N = 91) for the 28-item instrument. Cronbach's alpha internal consistency reliability for the PPSC-PNP instrument was 0.98 for both studies, indicating a highly reliable tool. The item-total statistics for all items on the instrument were greater than 0.20, with no negative or zero correlations. The item-total correlations ranged from 0.31 to 0.97 for the pilot study and from 0.40 to 0.95 for the full study. All four components of satisfaction computed high reliability indexes (see Table 2).
Scoring. The 28 items are measured by a 5-point Likert scale of 1 (strongly disagree) to 5 (strongly agree). Item # 9 was worded negatively so it was reverse coded prior to data analysis. The sum of all the 28 items yielded a range of 28 to 140. The sum of the subscales for each component ranged from 6 to 30. The higher the score, the higher the satisfaction with PNP care.
Intent to adhere to recommended care regimen by PNP. Parents' intent to adhere to recommended regimen by the PNP was measured by a single item on the demographic questionnaire. Item 10 was a 100 mm VAS that measured the magnitude of the parent's response. The scale consisted of a straight line (100 mm) with verbal descriptors at each end. At each end of the horizontal 100 mm line, the phrases, "I will definitely not follow the advice," and "I will definitely follow the advice of the PNP" were labeled. Parents were asked to place a mark through the line to indicate how they felt about following the PNP's advice. The VAS has been used successfully in clinical and research settings since the 1920s (Wewers & Lowe, 1990). One rigid ruler was consistently used to score the 100 mm horizontal line so the score was reliable. Scores could range from 0 to 100, with higher scores reflecting stronger intent to adhere to PNP recommended care regimen.
The university and one other data collection site required Institution Review Board (IRB) approval, which was obtained. All others required support letters, which were obtained from all private practice settings. The IRB for the hospital clinic granted expedited approval for this study. PNPs, physician's assistants, and pediatricians were employed at the sites. The PNP onsite or the researcher provided the parent with an explanation of the study form. If the parent agreed to participate, consent was implied, and the parent received a copy of the explanation of study form. The PPSC-PNP instrument was completed post-visit by parents. Confidentiality and compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) was assured. Completed surveys were placed in envelopes and sealed by participants after completion. Envelopes were placed in a box. Data were stored in the investigator's locked storage cabinet.
VAS. The scores ranged from 50 to 100. The mean score was 93.3 with a standard deviation of 8.8 for the sample of 91 participants. The distribution of scores was significantly skewed (skew = -2.1) and peaked (kurtosis = 6.1). The scores indicated that the majority of participants intended to adhere to recommended care by the PNP.
Research question 1. What are parents' perceptions of overall satisfaction with PNP care and its components of communication skills, clinical competence, caring behavior, and decisional control? The overall satisfaction scores ranged from 67 to 140. The mean was 132. The overall satisfaction and component scores are reported in Table 3. The distribution of scores was significantly skewed (skew = -2.34) and peaked (kurtosis = 6.97). The components of satisfaction scores were high, and there were relatively few low scores.
Research question 2. Research question 2 is connected to the hypothesis. Analyses revealed that clinical competence had the strongest positive relationship with parental intent to adhere to PNP recommended health regimen (r = 0.43, p = 0.001). The other three component correlations ranged from 0.37 to 0.41, indicating moderate relationships with the outcome variable. Correlations among the four variables ranged from 0.84 to 0.94, indicating they are highly inter-correlated. Clinical competence was the only variable to enter the stepwise multiple regression analysis (R = 0.43, [R.sup.2] = 0.185). Clinical competence was statistically significant (F[1,89] = 20.51, p = 0.001) and explained 18.5% of the variance in parental intent to adhere to recommended care regimen by the PNP scores. Other variables, not explored in this study, explain 81.5% of the residual variance. Communication, caring behavior, and decisional control were excluded from the model. Collinearity statistics revealed that the variables had high multicollinearity.
The combination of parents' perception of PNPs' communications skills, clinical competence, caring behavior, and decisional control did not explain parents' intent to adhere to recommended care regimen better than any one variable alone. The variables were highly intercorrelated with each other, which made it difficult to distinguish their individual influences on parental intent to adhere to recommended regimen. Although VAS scores were high (M = 93.3) for parental intent to adhere to the PNP recommended health regimen, only 18.5% of the variance was explained by the parental perception of clinical competence of the PNP.
Additional analyses. Descriptive statistics, Chi-square, cross tabs, independent f-test, Pearson correlation, and one-way ANOVA were computed, as appropriate, to explore relationships of selected demographic variables in relation to the research variables.
One-way ANOVAs were computed to explore differences in satisfaction scores based on various demographic data. Participants (n = 7) with no insurance (M = 25.71, SD = 2.98) scored significantly lower on the component decisional control than participants (n = 63) with private insurance (M = 28.57, SD = 2.50) (F[2,88] = 3.22, p = 0.045).
Participants' responses to questions about the influences of PNPs are reported in Table 4. The majority of participants indicated that the PNP influenced their decision regarding their child's health (63.7%) and increased their knowledge about a topic of discussion during their visit (61.5%). While 46.6% of the participants indicated that the PNP was the best health educator, 47.3% rated the PNP and physician as equally effective in providing the best health education. Many parents (49.5%) were most satisfied with the PNP as their health care provider.
Results from a one-way ANOVA revealed that participants with no insurance scored three points lower on the decisional control component of the PPSC-PNP scale than participants with private insurance. According to these findings, persons without insurance may feel they have no choices to make, and decisional control may not be an important factor for them. This interpretation may not have practicality and lack meaning because there were only seven participants with no insurance. One implication of this finding may be for the nurse practitioner to promote decisional control in all patients/parents regardless of insurance. Additionally, this finding supports Cox's Model and the literature that stresses the importance of interaction between patient background variables and decisions regarding health care (Green & Davis, 2005; Hallstrom & Elander, 2005; Knudston, 2000).
Findings from analyses revealed no difference in intent to adhere to the recommended care regimen between parents who brought their child in for a well child or a sick child visit; however, the specific recommendations given by the PNP for sick child visits were not recorded. Topics discussed were recorded only for well visits. The majority of visits in this study were well visits. As indicated by the high scores on the PPSC-PNP, parents were satisfied with the visit, whether it was sick or well. Several studies suggest that the increased severity of illness of the patient, the higher the preference to be seen by physicians for sick visits and seek their recommendations. In a study by Gilbert and Hayes (2009), when the nurse practitioner suggested recommendations about medications, laboratory tests, or referrals to specialists, actual adherence was high. Patients were less likely to adhere to lifestyle changes, such as diet, exercise, or smoking cessation. It would be interesting to capture the specific recommendations suggested by the PNP for sick visits and if parents are likely to adhere to them in future studies.
Responses to the demographic questionnaire items concerning the PNP and other health care providers are significant for nursing and other health care providers. Although physician assistants (PAs) were employed at two of the data collection sites, none of the 91 participants chose PAs as the best health educator or as the provider with whom the participant was most satisfied. This result could indicate that participants were confused about the professional role of the PA and may have limited experience with various health providers. Another plausible explanation may be that in some medical offices, patients may not be offered the choice of which health provider they will actually see. In the nursing literature, patient satisfaction and clinical competence were compared among primary care providers, especially between nurse practitioners and physician assistants. The majority of studies confirm that patients were more satisfied with the nurse practitioner for their health care and report clinical competence to be high (Hunter et al., 2009).
[FIGURE 2 OMITTED]
The majority (63%) of parents responded to the questionnaire items that the PNP influenced their decision "a lot" and increased their knowledge on a topic of discussion during their visit (61.5%). Although 46.6% of participants indicated that the PNP was the best health educator, 47% rated the PNP and physician as equally good, but only 6% chose physician as the best health educator. These findings have implications for the role of the PNP and physician in the office setting. Parents preferred the health provider to answer questions and spend time with them, and the physician may have a limited schedule.
Proposed Model and Findings
Findings of this study provided partial support for Cox's model and the study's proposed model (see Figure 2). The scores of the PPSC-PNP were high for the four components of satisfaction, as well as overall satisfaction. As proposed in the model, findings revealed that parents in this study were satisfied with PNP care. The four components reflected the elements of client professional interaction of Cox's model. Communication skills, clinical competence, caring behavior, decisional control, and general satisfaction all yielded high scores. Of the four components of satisfaction, clinical competence was the only variable that entered multiple regression analysis and explained 18.5% of the variance of parental intent to adhere to recommended health regimen by the PNP, as shown in the model.
Based on the findings of this study, the proposed model for parent satisfaction with PNP care may be modified by adding additional variables, such as cognitive appraisal, motivation of the parent, severity of health problem, social resources, religion, values, and beliefs. In this study, VAS scores were high for intent to adhere to recommended health regimen. Measuring the actual adherence with a follow-up visit or phone call may promote understanding of the variables that predict intent to adhere. Actual adherence may reveal predictor variables in a clearer perspective by understanding the motivation that caused the behavior. A qualitative study to discover other variables that may influence intent to adhere to recommended health care regimen may provide additional knowledge. In addition, a longitudinal study may be needed to understand additional variables that influence and predict intent to adhere to the recommended care regimen.
Implications for Nursing
Despite the skewed scores, the PPSC-PNP scores revealed that parents are highly satisfied with PNPs, and the components of communication skills, clinical competence, caring behavior, and decisional control are all important to parent satisfaction. These findings have implications for nursing practice.
The new researcher-developed instrument, the PPSC-PNP, makes a contribution to nursing science and research. The PPSC-PNP can be adapted for use by other nursing professionals in a variety of settings to measure components of parent/client satisfaction and the extent to which adherence can be predicted. Family, adult, public, and geriatric nurse practitioners can adopt the instrument to explore satisfaction of their clients. Data from the PPSC-PNP can be used as a benchmark to ensure quality of care and practice guidelines. Nurse researchers should continue testing and refinement of the tool, including factor analysis to reduce the number of items and to validate the placement of items on subscales.
Vulnerable populations could be studied to better understand differing perspectives. In this study, most of the participants were college-educated, married, Caucasian, over 30 years old, and employed. Health disparities among subgroups of children, the effects of social economic status on children's health, and the effectiveness of PNP interaction with different populations may be a focus of future research. The information obtained from a study of vulnerable populations may enhance the interaction of PNPs and parents, and improve the health of children and adherence to recommended health care regimen. Feedback from parents and patients is an important quality indicator of care, especially when implementing new models of care as directed by the health care reform acts. The findings of this investigation align with the goals of the Institute of Medicine's (IOM) (2010) Future of Nursing report by enhancing patient care to promote healthy choices.
A goal of the IOM's (2010) Future of Nursing report suggests nurses should practice to the full extent of their education. Barriers to advanced nursing practice include licensing and practice regulations that vary from state to state. In some states, promulgation of scope of practice regulations may be controlled by medical boards and not nursing boards. Findings from this study indicate that parents scored high on overall satisfaction and the four components of satisfaction with the care given by the PNP. Findings from this study also suggest that clinical competence was the single variable to explain parental intent to adhere to recommended health regimen. These findings are significant for the role of nurse practitioners by confirming their value in practice.
Subsequent to health care reform, the PNP's role may expand to new primary care settings so clients have affordable access to primary health services. PNPs need to document data supporting quality care and parents' intent to adhere to recommended health care regimens in order to be recognized and reimbursed for their services. Patient-centered care, new community nursing models, and more complex holistic roles of nurse practitioners have implications toward the effectiveness of PNPs as health care providers. Home visitation programs, transition care from the hospital, medical homes, reducing medical errors, and expanded nurse-managed health centers all require that PNPs acquire and expand communication skills, clinical competence, caring behavior, and decisional control. Additional research to understand intent to adhere to health regimen by the PNP may promote positive health outcomes that may translate to reduced costs of care. Findings from this study support the satisfaction of parents with their interaction with PNPs during health visits, which have implications in practice, health policy, and economics.
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Bear, M., & Bowers, C. (1998). Using a nursing framework to measure client satisfaction at a nurse managed clinic. Public Health Nursing, 15, 50-59.
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DiAnna-Kinder, F., & Allen, L.R. (2014). Parents' perception of satisfaction with care from pediatric nurse practitioners instrument. Journal of Pediatric Health Care, 28(2), 128-135.
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Frances DiAnna Kinder, PhD, RN, CPNP PC, is an Assistant Professor of Nursing, La Salle University, Philadelphia, PA.
Table 1. Demographic Analysis of Sample (N = 91) Variable Categories N % Race Asian 6 7 Black/African American 13 14 Caucasian 63 69 Mixed 4 4 Age 18 to 29 23 25 30 to 39 41 45 40 to 49 22 24 50 to 62 5 6 Education Grammar 2 2 High school 22 24 Tech school 9 10 Community college 18 20 Bachelor degree 24 26 Master degree 16 18 Marital status Single 9 10 Married 66 72 Live with partner 6 7 Separated 5 5 Divorced 4 4 Widowed 1 1 Health insurance Private 63 69 Public 21 23 None 7 8 Employment Full-time 34 37 Part-time 19 21 Unemployed 17 19 Stay at home (FT) 21 23 Visit Well visit 57 63 Sick visit 34 37 Note: Some percentages less than 100% are due to missing data. Table 2. Reliability Coefficients PPSC-PNP for the Pilot Study (N = 25) and Full Study (N = 91) Pilot Study Scale Pilot Study Items Alpha Overall satisfaction 28 retained items of items 1-37 0.98 Communication 8, 14, 15, 25, 26, 30 0.84 Clinical competence 4, 5, 9, 20, 24, 32 0.92 Caring behavior 1,3, 11,21, 22, 29 0.95 Decisional control 10, 16, 17, 23, 33, 35 0.90 General satisfaction 13, 19, 36, 37 0.75 Full Study Scale Full Study Items Alpha Overall satisfaction 1 to 28 0.98 Communication 5, 10, 11, 20, 21,23 0.93 Clinical competence 3, 4, 6, 15, 19, 24 0.90 Caring behavior 1, 2, 8, 16, 17, 22 0.96 Decisional control 7, 12, 13, 18, 25, 26 0.93 General satisfaction 9, 14, 27, 28 0.82 Table 3 Scores of Overall Satisfaction and components on PPSC-PNP Variable Score Range Mean SD Overall satisfaction 67 to 140 132.47 12.99 Communication skills 19 to 30 28.56 2.49 Clinical competence 15 to 30 28.38 2.78 Caring behavior 6 to 30 28.42 3.37 Decisional control 15 to 30 28.21 2.95 General satisfaction 10 to 20 19.90 1.98 Table 4 Summary of Responses about the PNP Variables Categories N % Extent PNP A lot 58 63.7 influenced decision Some 27 29.7 A little 4 4.4 None 2 2.2 Extent PNP A lot 56 61.5 increased knowledge Some 32 35.2 A little 2 2.2 None 1 1.1 Best health educator PNP 42 46.6 Physician 6 6.6 All the same 43 47.3 Which provider PNP 45 49.5 most satisfied Physician 12 13.2 All the same 34 37.4
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|Author:||Kinder, Frances DiAnna|
|Date:||May 1, 2016|
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