International Journal of Nursing Practice 2009; 15: 213–218

RESEARCH PAPER

A survey of patient satisfaction in a metropolitan

Emergency Department: Comparing nurse
practitioners and emergency physicians
Natasha Jennings RN BN CCC(Emerg) GradDipAdvClinNurs MN(Melb)
Emergency Nurse Practitioner, The Alfred Emergency and Trauma Centre, Prahran, Victoria, Australia

Geraldine Lee MPhil RGN BSc PGDE

Masters of Nurse Practitioner Program Coordinator, Division of Nursing and Midwifery, Latrobe University, Bundoora, Melbourne, Victoria,
Australia

Kylie Chao RN PGD(Emerg) MN

Emergency Nurse Practitioner, The Alfred Emergency and Trauma Centre, Prahran, Victoria, Australia

Simon Keating RN BN PGD(Emerg) DipBusiness MN

Emergency Nurse Practitioner Candidate, The Alfred Emergency and Trauma Centre, Prahran, Victoria, Australia

Accepted for publication January 2009

Jennings N, Lee G, Chao K, Keating S. International Journal of Nursing Practice 2009; 15: 213–218
A survey of patient satisfaction in a metropolitan Emergency Department: Comparing nurse
practitioners and emergency physicians

The Emergency Nurse Practitioner role was introduced to an Emergency Department, Melbourne in 2004 as an
alternative health-care model to provide accessible and efficient patient care. The aim of the study was to explore patient
satisfaction using a questionnaire from their emergency department experience comparing Emergency Nurse Practitioners
and emergency department doctors. Patients who received care from either Emergency Nurse Practitioners or emergency
department doctors were given a self-administered questionnaire to complete. Descriptive statistics and non-parametric
tests were used for data analysis. A total of 202 patients completed the survey with 103 seen by the Emergency Nurse
Practitioners and 99 seen by emergency department doctors. Significant differences were reported in 12 of the 16
questions comparing patient satisfaction with either Emergency Nurse Practitioners or emergency department doctors
with greater patient satisfaction demonstrated with the Emergency Nurse Practitioners. The Emergency Nurse Practitio-
ner model demonstrates consistent levels of patient satisfaction with patients reporting more favourable satisfaction with
the Emergency Nurse Practitioners compared with emergency department doctors. ijn_1746 213..218

Key words: doctors, Emergency Department, nurse practitioner, patient satisfaction.

INTRODUCTION
The health-care system is experiencing unprecedented
Correspondence: Natasha Jennings, The Alfred Emergency and Trauma demands for service, which ultimately impacts on hospital
Centre, Commercial Road, Prahran, Vic. 3004, Australia. Email: resources and the quality of the care provided by both
n.jennings@alfred.org.au medical and nursing professionals. Patients are viewed as

doi:10.1111/j.1440-172X.2009.01746.x © 2009 Blackwell Publishing Asia Pty Ltd

214 N Jennings et al.

‘consumers’ of health care and there is an emphasis house officers in the UK but higher levels of satisfaction
on surveying them and canvassing their opinions on the and clinical documentation quality were reported for the
quality of service provided. Emergency Departments NP group.10 In Australia, an aftercare questionnaire in ED
(EDs) are one such area under scrutiny. The introduction demonstrated patients were very satisfied with total care
of new health-care models such as the Nurse Practitioner received.16
(NP) in Australia requires a systematic evaluation process A common theme consistent in NP patient satisfaction
measuring the impacts both at an organizational level and surveys is that patients received more health education
at a patient level. Therefore, patient satisfaction with information from NPs, and were more likely to be given
the role is of importance as it directly correlates to the written instructions and information about obtaining
patients’ perceived quality of care provided. advice following discharge.1,12 The holistic centred care
The NP role was introduced into the Australian health- seems to be the major difference between NPs and phy-
care system to meet needs of an overstretched health-care sicians. Although one study (n = 41 029) from the USA
system. The model is both affordable and flexible and a demonstrated that care access or overall experience did
means to maintain quality in patient care.1 Various clinical not differ by practitioner type (ED doctor, physician assis-
settings employ NPs in primary health care and recently tant and NPs).3
the role has commenced within EDs. The literature evalu- In summary, patient satisfaction with care provided by
ating the implementation of the NP role has demonstrated the NP has been reported positively and would appear to
several positive themes including: decreased waiting lead to good health outcomes in patients while providing
times, cost-effectiveness and importantly increased a high quality of care.
patient satisfaction, all leading to improved health out-
comes for patients.2–4 NPs have been established as a METHODS
highly skilled and cost-effective model that demonstrates The role of the NP in Victoria, Australia, is relatively new
a high level of care.5,6 A systematic review reported that and to date only 42 nurses have been endorsed by the
nurses can provide a high quality of care and achieve good Nurses Board of Victoria (NBV).17 The title ‘Nurse Prac-
health outcomes for patients but their findings were titioner’ is protected by legislation in Victoria and pre-
limited to primary health care.7 vents the unauthorized use.18 Nurses who are practising
Patient satisfaction is defined as a quality outcome of within the role in a supervised training model prior to
care that underpins a patient’s health-care experience.8 endorsement by the NBV are referred to as nurse practi-
Measurement of patient satisfaction is influenced by many tioner candidates.
variables including communication between practitioner The Alfred Emergency Nurse Practitioner (ENP) team
and patient, length of stay, waiting times, demographics consists of both endorsed ENPs and ENP candidates. Gen-
and socioeconomic status specifically.9 These variables, erally, ENPs focus on Australasian Triage Scale (ATS)
many beyond the clinicians’ control, can impact the per- categories 3–5 emergency patient presentations. The ATS
ceived quality of care provided and therefore the subse- is the clinical tool that ensures patients are seen in a timely
quent assessment of patient satisfaction. Several papers manner that is commensurate with their clinical urgency
have reported patient and staff satisfaction with NP-led at time of presentation to ED.19 All patients presenting to
care.10–13 Some studies have reported patients perceiving EDs are triaged on arrival and an ATS code is allocated.
better-quality care from NPs compared with physicians.14 The ENP assumes responsibility for the completed
Others, however, have reported no differences between continuum of care for their patients from initial assess-
the two health professionals.13 ment, intervention, prescribing, diagnosis, treatment and
The majority of studies examining patient satisfaction disposition. The ED doctor-led care is considered the
are single centred and consist of self-administered ques- traditional medical model of care that includes patients
tionnaires that patients complete following a hospital receiving care by both a doctor and a nurse to complete
visit.1,3,10,12 One study outlined whether patients would be the continuum of care.
willing to be seen by NPs on a subsequent visit with 70% The Alfred Emergency and Trauma Centre is one of
(n = 213) willing to be treated by an NP for minor prob- two adult-level one-trauma centres in Victoria, Australia.
lems.15 In a randomized controlled trial, a high level of Annual attendances have been increasing by a rate of 19%
satisfaction was reported between the NPs and senior over the last 3 years, and in 2007, there were 47 000

© 2009 Blackwell Publishing Asia Pty Ltd

Patient satisfaction in the Emergency Department 215

attendances. The ENPs focus on ATS categories 3–5 two-sided P-value < 0.05 was considered to be statisti-
patients with the majority of minor trauma and non- cally significant.
complex medical patient presentations. These patients
were usually geographically located in the Fast Track area RESULTS
of the ED, consisting of eight cubicles. A total of 202 patients were surveyed between February
The aims of the study were to explore patient satisfac- and May 2008 who attended the Alfred Emergency and
tion from their ED experience with care provided by the Trauma Centre. The mean age of the patients was 35.3
ENPs and the ED doctors. years (SD 14.9) in the ED doctor care group and 31.5
A patient survey was distributed to patients consisting years (SD 13.3) in the ENP care group, which was not
of 16 questions relating to their ED experience. The ques- significant (P = 0.156).
tions related to the thoroughness of the ENP- or ED Two hundred and two patients completed the survey
doctor-led care, whether they felt they had enough time with 103 patients in the ENP group and 99 in the ED
to ask questions, would they follow the advice given and doctor care group. Out of the 16 questions, 12 questions
would they see the doctor or nurse again with the same demonstrated a significant difference in comparing the ED
problem. The remaining questions related to health doctor care and ENP patient satisfaction in favour of the
education information, whom to contact regarding their ENP (P < 0.05). These 12 answers related to the doctor/
illness, written instructions about their injury, medication nurse being interested in the person, being thorough,
instructions, and how and when to contact their general patient being less worried about their health after seeing
practitioner, outpatients appointments and whether they the doctor/nurse and having enough time to discuss con-
would recommend the doctor/nurse to a friend. cerns in detail. In the remaining answers, there was a
The survey was distributed to patients by an ED team favourable trend for the ENPs patients’ level of satisfac-
member. Patients were not allocated to see the ENPs or tion with their care (relating to health education, written
ED doctors, but seen by whomever was available at that instructions on whom to contact once home, outpatients
time within the Fast Track area of ED. Patient care was appointments, prescribed medications and how and when
conducted in accordance with ATS category and depart- to contact their general practitioner.
mental policy in regards to time waiting priority. The In summary, in most cases except ‘There were other
patient satisfaction survey was distributed at the com- things I would have liked to discuss with nurse/doctor’,
mencement of treatment and patients were asked to there was a significant difference between the responses
complete the survey and place it in the locked collection for the two different groups with a more favourable res-
box at the conclusion of their treatment. ponse for the ENP care group (Table 1).
Data collection was undertaken from February to May
2008. Ethics approval was not required as it was deemed DISCUSSION
a quality assurance project but permission was sought A total of 202 patients completed the survey with 103
and gained from the Bayside Health Nursing Research and seen by the ENPs and 99 seen by ED physicians. Signifi-
Access Committee. All questionnaires were completed cant differences were reported in 12 of the 16 questions
anonymously and placed in the collection boxes at the staff (P < 0.05) comparing patient satisfaction with either ENP
station in the ED. The questionnaire was developed and or ED physicians with greater patient satisfaction demon-
adapted from a previously validated tool and used strated with the ENP.
throughout the literature to evaluate ENP patient satisfac- The results from our study have demonstrated a high
tion.12 The survey included a total of 16 questions using level of patient satisfaction with the ENPs care, which is
a Likert scale seeking responses from strongly disagree consistent with the literature.1,14,16,10,21
to strongly agree. Studies examining patient satisfaction with the ENP
Data were analysed using SPSS version 15.20 role in Australia have been limited to two studies.16,21 The
The patient satisfaction survey has ordinal properties (1 most recent ED-based study only surveyed 57 patients
(strongly disagree) to 4 (strongly agree)). Comparisons and showed that 70.2% of patients were very satisfied
between groups have been made using Wilcoxon rank with total care.16 The other ED-based study surveyed
sum tests with results reported as medians with an inter- 132 patients (71 physician-treated patients and 61 ENP-
quartile range (25th percentile to 75th percentile). A treated patients).21 The results concluded that patients

© 2009 Blackwell Publishing Asia Pty Ltd

 216

Table 1 Patient survey responses––median values, inter quartile range (IQR) and P-value (n = 202)

Question number ENP (n = 103) ED physician P-value

median (IQR) (n = 99)
median (IQR)

© 2009 Blackwell Publishing Asia Pty Ltd

1. The Doctor/Nurse understood why I had come to the Emergency Department. 4 (4–4) 3 (3–4) 0.007
2. The Doctor/Nurse was interested in me as a person. 4 (3–4) 4 (3–4) 0.019
3. The Doctor/Nurse seemed to be very thorough. 4 (3–4) 4 (3–4) 0.005
4. I was less worried about my health after seeing the Doctor/Nurse. 4 (3–4) 3 (3–4) 0.024
5. I will follow the advice of the Doctor/Nurse because I believe it was good advice. 4 (4–4) 4 (3–4) < 0.001
6. When I saw the Doctor/Nurse, I felt that I had enough time to discuss things fully. 4 (3–4) 3 (3–4) < 0.001
7. I would like to see the Doctor/Nurse again for a similar health problem. 4 (3–4) 3 (1–4) < 0.001
8. There were other things I would have liked to discuss with the Doctor/Nurse. 2 (0–2) 2 (0–2) 0.659
9. While I was in the Emergency Department, I was given health education or first aid advice from the Doctor/Nurse. 3 (0–4) 3 (0–4) 0.093
10. My friends/family were allowed to be with me during investigations/treatments. 3 (0–4) 3 (0–4) 0.849
11. I was told whom to contact if I needed more help or advice regarding my illness/injury once I was home. 4 (3–4) 3 (1–4) < 0.001
12. I was given written instructions about my illness/injury to take home. 3 (0–4) 2 (0–3) < 0.001
13. The Doctor/Nurse explained how to take the tablets/medicines prescribed. 3 (0–4) 3 (0–4) 0.223
14. I was informed of how and when to contact my GP (local doctor) about my illness/injury. 3 (2–4) 3 (0–4) 0.043
15. I was told verbally and given written information about my follow-up appointment. 3 (0–4) 2 (0–3) 0.044
16. If I was advising a friend, I would recommend the Doctor/Nurse. 4 (3–4) 3 (3–4) < 0.001

0, not applicable; 1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree. ED, Emergency Department; ENP, Emergency Nurse Practitioner; GP, general practitioner.
N Jennings et al.
Patient satisfaction in the Emergency Department 217

were very satisfied with NP care with no significant providing high-quality emergency care while maintaining
differences observed. Similar questions were used can- consistent levels of patient satisfaction.
vassing themes such as patient satisfaction with overall
care, explanations given before and after care, and were ACKNOWLEDGEMENTS
they willing to see the same health professional again. The researchers would like to thank the patients who
These results were consistent with earlier international completed the survey.
studies.1,10,12,13 These studies demonstrated that NPs had
a holistic approach to care in comparison with the ED REFERENCES
doctors. Our results are similar to those reported in the 1 McMullan M, Alexander MK, Bourgeois A, Goodman L.
literature10 with higher levels of satisfaction among the Evaluating a nurse practitioner service. Dimensions of Critical
ENP patients. The results imply that the ENP model can Care Nursing 2001; 20 (5): 30–34.
2 Jennings N, O’Reilly G, Lee G, Cameron P, Free B. Imple-
provide a high quality of care and provide patients with
menting the Emergency Nurse Practitioner into a major
adequate amounts of information in relation to their inner city trauma centre. A new model of care delivery for
presenting complaint. patients in the ED setting. Journal of Clinical Nursing 2008;
17: 1044–1050.
Limitations 3 Roblin DW, Becker ER, Adams EK, Howard DH, Roberts
Often there is criticism in the literature about patient MH. Patient satisfaction with primary care: Does type
satisfaction studies comparison of ENPs with midlevel of practitioner matter? Medical Care 2004; 42: 579–590.
practitioners (ED doctors), which might include physi- 4 Fry M. Triage nurses order x-rays for patients with isolated
distal limb injuries: A 12 month ED study. Journal of Emer-
cian’s assistants.3 As physician’s assistants are not parts of
gency Nursing 2002; 1: 17–22.
the current model at the Alfred Hospital ED, it is not a 5 Hylka SC, Beschle CJ. Nurse practitioners, cost savings,
major limitation. and improved patient care in the department of surgery.
There are many extraneous variables linked, which Nursing Economics 1995; 13: 349–366.
have an impact on patient satisfaction measurements. 6 Spisso J, O’Callaghan C, McKennan M, Holcroft JW.
Waiting times and length of stay were not measured in Improved quality of care and reduction of house staff work-
this study because of the nature of a very busy acute ED load using trauma nurse practitioners. Journal of Trauma
setting; this could in turn have impacted upon the survey 1990; 30: 660–664.
7 Laurent M, Reeves D, Hermens R, Braspenning J, Grol R,
responses and resultant correlation to a patient’s level of
Sibbald B. Substitution of doctors by nurses in primary care.
satisfaction and has previously been examined.2 Cochrane Database Systematic Review 2005; 5: CD001271.
It has been reported that client characteristics and 8 Muntlin A, Gunningberg L, Carlsson M. Patients’ percep-
interactions with the health professionals can determine tions of quality of care at an emergency department and
health outcomes in regards to patient satisfaction mea- identification of areas for quality improvement. Journal of
surements.22 These authors believe the patient satisfaction Clinical Nursing 2006; 15: 1045–1056.
results to be important in terms of costing and validating 9 Thrasher C, Purc-Stephenson R. Patient satisfaction with
the NP model. The results from our patient survey nurse practitioner care in emergency departments in
Canada. American Academy of Nurse Practitioners 2008; 20:
enhance steps to validate the ENP model of care.
231–237.
This study was conducted at a single centre that has 10 Cooper MA, Lindsay GM, Kinn S, Swann IJ. Evaluating
implemented the NP role within their ED. It is worth Emergency Nurse Practitioner services: A randomized con-
noting that the model has been adapted and replicated in trolled trial. Journal of Advanced Nursing 2002; 40: 721–730.
many other sites in both rural and urban emergency set- 11 Barr M, Johnston D, Mc Connell D. Patient satisfaction
tings. Greater validity of the results might be obtained by with a new nurse practitioner service. Accident and Emergency
combining results gained from such a multicentre study. Nursing 2002; 8: 144–147.
12 Byrne G, Richardson M, Brundson J, Patel A. Patient
satisfaction with emergency nurse practitioners in A and E.
Conclusion Journal of Clinical Nursing 2000; 9: 83–92.
The NP model has returned favourable results in this 13 Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrop J.
patient satisfaction survey. This study demonstrates the Care of minor injuries by emergency nurse practitioners or
acceptance of the ENPs within the emergency setting by junior doctors: A randomised controlled trial. The Lancet
patients. ENPs are able to address the needs of patients in 1999; 354: 1321–1326.

© 2009 Blackwell Publishing Asia Pty Ltd

218 N Jennings et al.

14 Horrocks S, Anderson E, Salisbury C. Review: Nurse 18 Department of Human Services. Nurse Practitioner Project.
practitioner primary care improves patient satisfaction and Available from URL: http://www.health.vic.gov.au/
quality of care with no difference in health outcomes. British nursing/furthering/practitioner.htm. Accessed 15 July
Medical Journal 2002; 324: 819–823. 2008.
15 Moser MS, Abu-Laban RB, Van Beek CA. Attitude of emer- 19 Australasian College for Emergency Medicine. Policy
gency department patients with minor problems to being Document: The Australasian Triage Scale. 2000. Available
treated by a nurse practitioner. Canadian Journal of Emergency from URL: http://www.acem.org.au/open/documents/
Medicine 2004; 6: 246–252. traigeguide.htm. Accessed 15 October 2008.
16 Wilson A, Shifaza F. An evaluation of the effectiveness and 20 SPSS Inc. Statistical Package for Social Scientists. SPSS Version
acceptability of nurse practitioners in an adult emergency 15. Chicago, IL, USA: SPSS Inc., 2008.
department. International Journal of Nursing Practice 2008; 21 Chang E, Daly J, Hawkins A et al. An evaluation of the
14: 149–156. nurse practitioner role in a major rural emergency depart-
17 Nurses Board of Victoria. Nurse Practitioner Endorse- ment. Journal of Advanced Nursing 1999; 1: 260–268.
ment. Available from URL: http://www.nbv.org.au/ 22 Bryant R, Graham MC. Advanced practice nurses: A study
registration/nurse-practitioner.aspx#process. Accessed 15 of client satisfaction. Journal of American Academic Nurse
July 2008. Practitioners 2002; 14: 88–92.

© 2009 Blackwell Publishing Asia Pty Ltd