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NHS Lanarkshire - Patient satisfaction

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					     clinical




Patient satisfaction
 GIllIAN CoRbETT and TRICIA MCGUIGAN report the results of a survey of patients’ responses to
 the care they receive from minor/major injury/illness nurse treatment service (Mints) nurses
Gillian Corbett RGN,
DipN(Lond), HND,        N     HS Lanarkshire provides unscheduled care in
                              a wide variety of settings, including emergency
                        departments (EDs), acute receiving units, out-of-
                                                                                   also helped them to deliver the four-hour emergency
                                                                                   care operational standard (Scottish Executive 2005)
                                                                                   by how haS it done thiS?.
BA is a consultant
                        hours centres, community hospitals and GP minor
nurse
                        injury units.                                              SEE AND TREAT PATIENT SURVEY
Tricia McGuigan            As traditional clinical models have become              Pillot
RGN, BA is a MINTS      unsustainable over the past five years, following          The key outcome of the Unscheduled Care
research nurse          the introduction of the European Working                   Collaborative Programme (Scottish Executive 2005)
                        Time Directive, Modernising Medical Careers                is better, more satisfying experiences of health care
Both at                 (NHS Scotland 2007) and the Unscheduled Care               for patients and carers, achieved by improving
NHS Lanarkshire,        Collaborative Programme (Scottish Executive 2005),         patient access, and reducing waits and delays, in
Wishaw                  these services have grown rapidly.                         unscheduled care. For this outcome to be achieved,
                           New nursing roles have made a major contribution        emergency care staff must seek patients’ opinions
                        to service delivery in unscheduled care, with              about changes in service delivery.
                        advanced practitioners now managing the care of              In January 2007 therefore, the two authors
                        patients with either life-threatening, or major, and       conducted a pilot survey at Wishaw General Hospital
                        non-life-threatening, or minor, injuries and illnesses.    to discover whether patients are satisfied by see
                           To ensure that meeting the needs of patients and        and treat, out-of-hours services in NHS Lanarkshire’s
                        carers is paramount, the organisation and delivery         three EDs, and by the performance of MINTS nurses
                        of health care must be changed, and new working            compared with that of doctors.
                        methods must be adopted.                                     The sample analysed was of 1,000 patients who
                           Throughout the UK, the use of nurse practitioners       attended see and treat services and who were seen
                        has reduced waiting times while maintaining high           by different types of practitioner (Table 1).
                        standards of unscheduled care delivery (Cooper et al         Analysis of the returned questionnaires indicated
                        2002, Corbett 2006, Lamont 2005).                          high levels of patient satisfaction, and found that
                           Consequently, an innovative scheme known as             MINTS nurses performed better than doctors in
                        Minor/Major Injury/Illness Nurse Treatment Service         several areas. Because see and treat at Wishaw is
                        (MINTS), first described by Crouch et al (2001), has       mainly led by nurses, the two comparison group
                        been adopted in NHS Lanarkshire’s EDs.                     sizes were unequal, with 60 per cent of the patients
                           Can you give a very brief background to MintS here      in the sample being treated by MINTS nurses
                        ie how doeS it work? are they anPS? iS there a training    only and 40 per cent being treated by doctors.
                        PrograMMe? and can you Provide a webSite url for further   Consequently, the pilot’s findings have limited
                        info, which i’ll add to the end of the article.            application to other trusts iS thiS correct?.
                           Minor/Major Injury/Illness Nurse Treatment Service        One of the main findings of the pilot study is that
                        practitioners manage independently the care of             shorter waiting times do not ensure higher patient
                        patients who present with minor injuries or illnesses      satisfaction, in contrast with earlier research findings
                        to ED-based ‘see and treat’ out-of-hours services,         that come to the opposite conclusion (Jarvis 2007).
                        community hospitals or GP minor injury services.           Instead, the pilot found that patient satisfaction
                        They also ensure that patients with major injuries or      depends on several factors including whether they
                        illnesses in EDs or acute receiving units are advanced     have been listened to, treated with respect and
                        along their care pathways.                                 dignity, and involved in decisions about their care.
                           Around 3,000 patients with minor injuries or              The questionnaire was revised and re-tested
                        illnesses are managed each month by MINTS nurses           therefore in preparation for the see and treat
                        in various settings in NHS Lanarkshire.                    patient survey, which had the following aims:
                           A MINTS programme has been devised to ensure            n To measure patient satisfaction with the see and
This article has been   that nursing staff can acquire the additional                 treat, out-of-hours services in the EDs of Hairmyres
subject to double       knowledge and skills they need to influence and               Hospital, in East Kilbride, Monklands Hospital,
blind peer review       manage patient care directly. The programme has               in Airdrie, and Wishaw General Hospital



26                                                                                                  emergency nurse   vol 16 no 3 june 2008
                                                                                                                        clinical



n To evaluate the performance, according to                practitioners, and to place completed questionnaires
  patients’ opinions, of MINTS nurses, and compare         in the clearly marked box in reception.
  this with that of doctors.                                 It was made clear to all patients that completion
                                                           was voluntary and would not affect their treatment.
Methodology                                                Verbal and written consent was sought, though
Ethical approval was not required for the patient          verbal consent was considered sufficient.
survey because the patient affairs committee agreed          Furthermore, patients were assured that their
that it was essentially a modification of previous         responses and comments would remain anonymous
surveys conducted in the organisation in 2005.             because the researches would remove the signed
  The committee recommended however that                   consent sheets from the questionnaires before
written and verbal consent be sought from all              analysis.
patients recruited for participation in the study.           A total of 1,368 patients (ie 1.76 Per cent of 77,557)
  The instrument used was the see and treat                accepted the see and treat questionnaire and made
questionnaire, which has been adapted in Table 2.          some attempt at completion. The remainder of the
This is a 40-item multiple choice questionnaire that       sample frame declined to take part, accepted but
aimed to measures patient satisfaction over a range        discarded the questionnaire at some point in their
of care components within the following subscales:         emergency care journeys, or left hospital with the
n Overall satisfaction                                     questionnaire.
n Waiting times                                              One thousand patients returned completed
n Patients’ perceptions of quality of care                 questionnaires, the definition of a ‘completed
n Patient information.                                     questionnaire’ being one in which at least 21 or
The questionnaire’s structure was based on the             More? questions had been answered. This allowed
Picker Institute’s model for ED surveys (Picker            patients to leave a few questions unanswered but
Institute 1998) and, after focus group work                still provide valuable data.
involving ED consultant doctors, senior nurses and           This gave a return rate of 73 per cent from the
managers, was modified for NHS Lanarkshire.                1,368 patients who accepted and attempted
  To test for content validity, the questionnaire was      completion, but a response rate of only 1.29 per cent
submitted to the divisional nurse director and the         from the entire sample of 77,557.
patient affairs manager so that each could rate              No differences in age, gender or ethnicity were
all of the 40 items according to their relevance           discerned between patients who decided to
and clarity.                                               participate and those who declined.
  An agreement score and content validity index
were calculated for each item. The content validity        Data analysis
indices for 34 items ranged from 0.8 to 1.0, and           The data were collated and analysed using Micro-
these items were retained. Those for six items             soft Excel, with correlations and partial correlations
ranged from 0.3 to 0.6, so their content was revised       performed on the Statistical Package for the Social
to ensure greater clarity.                                 Sciences (SPSS) for Windows, Version 15. Data from
  The sample frame was made up of patients who             the three sites were treated as a single sample and
presented at see and treat services with minor             no between-site comparison was undertaken.
injuries or illnesses between April 2 and November           Due to the number and variety of responses
15 2007. The total number of patients included             and missing values, and the unequal group sizes
was 77,557.                                                in this sample, the analysis focused on obtaining
  The use of a large sample taken from all
three EDs was considered necessary to avoid                 Table 1
the bias experienced in the pilot study because
                                                            Who in the see and treat services saw the patients
60 per cent of patients had been treated by MINTS
nurses only.                                                See and treat                   Number of patients        Percentage
  The authors handed the questionnaires to patients         practitioner
receiving see and treat services at either Hairmyres,       MINTS nurse                           545                   55
Monklands or Wishaw every weekday between 10am
and 4pm. They also answered patients’ questions             Doctor                                375                   38
about the survey. At other times, the questionnaires        Physician’s assistant                  23                    2
were left in the relevant departments at the three sites    (at Hairmyres only)
by ED receptionists or attending practitioners.
                                                            Don’t know or can’t                    57                    6
  Patients were asked to complete the questionnaires
                                                            remember
as they progressed through consultations with their



vol 16 no 3 june 2008 emergency nurse                                                                                              27
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 Table 2

 The see and treat questionnaire
 Section                Questions

 Arrival at the ED      1 How did you travel to the hospital?

                        2 How would you rate your reception in the ED?

 Waiting                3 How long in minutes did you wait before you first spoke to a nurse, doctor or physician’s assistant?

                        4 From the time you first arrived at the ED, how long in minutes did you wait before being examined by a doctor, nurse or physician’s assistant?

 Your Practitioner      5 When you were first examined in the ED, was this by a doctor, physician’s assistant or a nurse?

                        6 Did you have enough time to discuss your health or medical problem with your practitioner?

                        7 While you were in the ED did your practitioner explain everything about your condition and its treatment in a way you could understand?

                        8 Did your practitioner listen to what you had to say when you were speaking to him or her?

                        9 If you had any anxieties or fears, did you discuss them with your practitioner?

                        10 Did you have confidence and trust in the practitioner examining and treating you?

                        11 In your opinion, did the staff treating you know enough about your condition and its treatment?

 Your care and          12 While you were in the ED, how much information about your condition and its treatment was given to you?
 treatment
                        13 Were you involved as much as you wanted to be in decisions about your care and treatment?

                        14 Did the staff treating and assessing you introduce themselves?

 Tests such as X-rays   15 Did you have any tests such as x-rays, scans or blood tests in the ED?
 or scans
                        16 Did a member of staff explain to you what these tests would involve?

                        17 Did a member of staff explain the results of the tests in a way you could understand?


 Pain                   18 Were you in any pain while you were in the ED?

                        19 If yes, how much of the time were you in pain?

                        20 Did you request pain medicine, or was any offered to you?


                        21 How many minutes after your request, or after the offer of medicine did it take before you got any?


                        22 Do you think the hospital staff did everything they could to help control your pain?

 Leaving the ED         23 What happened at the end of your visit to the ED?




 Medications such as    24 Before you left the ED, were any new medications prescribed or ordered for you?
 medicines, tablets
                        25 Did a member of staff explain to you how to take the new medications?
 and creams
                        26 Did a member of staff explain the purpose of the medications you were to take at home, in a way you could understand?

                        27 Did a member of staff tell you about medication side effects to watch out for?

 Information            28 Did a member of staff tell you when you could resume your usual activities, such as when to go back to work or drive a car?

                        29 Did a member of staff tell you about the danger signals of your illness or treatment to watch for after you went home?

                        30 Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left the ED?

 Overall                31 Overall, how long in hours did your visit to the ED last?

                        32 Was the main reason you went to the ED dealt with to your satisfaction?

                        33 Overall, did you feel you were treated with respect and dignity while you were in the ED?

                        34 Overall, how would you rate the care you received in the ED?

 About you              35 Are you male or female?

                        36 What age are you?

                        37 In general, how would you rate your health during the past four weeks?

                        38 Do you have a long-standing physical or mental health problem or disability?

                        39 Was your disability given due consideration while you were in the ED?

                        40 To which of these ethnic groups would you say you belong?

 Other comments         Was there anything particularly good about your visit to the ED? Was there anything that could have been improved?
                        Did you find this questionnaire easy to complete? Any other comments?




28                                                                                                                          emergency nurse    vol 16 no 3 june 2008
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                                                                                         Answers (tick boxes)

    By ambulance ❏                         By car ❏                         By taxi ❏                   On foot ❏                   On public transport ❏                      Other ❏

 Excellent ❏             Very good ❏                         Good ❏                                Fair ❏                 Poor ❏               Very poor ❏           I did not see a receptionist ❏

                0-15 ❏                                16-30 ❏                                31-60 ❏                                More than 60 ❏                Don’t know or can’t remember ❏

  No wait ❏                  1-30 ❏                       31-60 ❏                       60-120 ❏                  121-240 ❏             More than 240 ❏                   Can’t remember ❏

                                Doctor ❏                                                                    Physician’s Assistant ❏                               Don’t know or can’t remember ❏

         Yes, definitely ❏                                      Yes, to some extent ❏                                                  No ❏

        Yes, completely ❏                                       Yes, to some extent ❏                                                  No ❏                                   No need ❏

         Yes, definitely ❏                                      Yes, to some extent ❏                                                  No ❏

        Yes, completely ❏                                       Yes, to some extent ❏                                                  No ❏                             No anxieties or fears ❏

         Yes, definitely ❏                                      Yes, to some extent ❏                                                  No ❏

All of them ❏                    Most of them ❏                                Some of them ❏                                   None of them ❏                    Don’t know or can’t remember ❏

Not enough ❏                  The right amount ❏                                Occasionally ❏                                        None ❏

         Yes, definitely ❏                                      Yes, to some extent ❏                                                  No ❏                       Not well enough to be involved ❏

        Yes, all of them ❏                                      Yes, some of them ❏                                       Very few or none of them ❏              Don’t know or can’t remember ❏

         Yes ❏ (go to 16)                                                                                                       No ❏ (go to 18)

                                                 Yes ❏                                                                                 No ❏

Yes and I definitely      Yes and I understood to some           Yes but I didn’t              I was never given                I was told that I would be        Don’t know or can’t remember ❏
  understood ❏                       extent ❏                 understand them ❏                     the results ❏                given the results later ❏

                                 Yes ❏ (go to 19)                                                                               No ❏ (go to 23)

    All, or most of the time ❏                                   Some of the time ❏                                                                    Occasionally ❏

 I requested medicine for pain ❏           Medicine was offered to me without my asking for it and I Medicine was offered to me without my                        I did not request any medicine for
                                                                       accepted it ❏                                   asking for it and I refused it ❏                    pain ❏ (go to 22)

Immediately ❏               1-5 ❏                             6-10 ❏                           11-15 ❏                    16-30 ❏          More than 30 ❏        I asked for pain medicine but wasn’t
                                                                                                                                                                             given any ❏

         Yes, definitely ❏                                      Yes, to some extent ❏                                                  No ❏                       Don’t know or can’t remember ❏

 I was admitted to the              I was transferred to a                 I went home ❏               I went to stay with a friend            I went back to work ❏        I went somewhere else ❏
  same hospital as an           different hospital or nursing                (go to 24)                         or relative ❏                       (go to 24)                      (go to 24)
 inpatient ❏ (go to 31)               home ❏ (go to 31)                                                           (go to 24)

                                 Yes ❏ (go to 25)                                                                               No ❏ (go to 28)

        Yes, completely ❏                                       Yes, to some extent ❏                                                  No ❏                                   No need ❏

        Yes, completely ❏                                       Yes, to some extent ❏                                                  No ❏                                   No need ❏

        Yes, completely ❏                                       Yes, to some extent ❏                                                  No ❏                                   No need ❏

         Yes, definitely ❏                                      Yes, to some extent ❏                                                  No ❏                                   No need ❏

        Yes, completely ❏                                       Yes, to some extent ❏                                                  No ❏                                   No need ❏

                                                    Yes                                                                                No ❏                       Don’t know or can’t remember ❏

              Up to 1 ❏                                       1-2 ❏                                    2-3 ❏                               3-4 ❏                            More than 4 ❏

        Yes, completely ❏                                       Yes, to some extent ❏                                                  No ❏

       Yes, all of the time ❏                                  Yes, some of the time ❏                                                 No ❏

      Excellent ❏                       Very good ❏                          Good ❏                              Fair ❏                              Poor ❏                       Very poor ❏

                                                Male ❏                                                                                                    Female ❏

         Enter age here:

      Excellent ❏                       Very good ❏                          Good ❏                              Fair ❏                              Poor ❏                       Very poor ❏

                                           Yes ❏ (go to 39)                                                                     N ❏ (go to 40)

         Yes, definitely ❏                                      Yes, to some extent ❏                                                  No ❏

          White ❏                                   Mixed ❏                     Asian or Asian British ❏                    Black or black British ❏                    Other ethnic group ❏




           vol 16 no 3 june 2008 emergency nurse                                                                                                                                                       29
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percentage data rather than means, standard
                                                           Figure 1
deviations and tests of significant differences.
  Comparison of the percentage data was restricted         Patient journey times by different types of practitioner
to patients seen by MINTS nurses and those seen by
doctors. This was because of the very small number                                                 1 6
in the ‘physician’s assistant’ and ‘don’t know or                                             37
can’t remember’ groups.                                                       2      58
                                                                             6                                          204
  Pearson’s correlation tests were performed to                           4 10
                                                                        1
identify significant relationships between patient
                                                                           19
satisfaction and the following variables:
                                                                   3     20
n Type of practitioner                                            2
n Waiting time until practitioner is first encountered
n Total journey time                                                   52
n A sense of involvement in their own care.
A test for partial correlation, which controls for
all other variables while testing for relationships                74                                                                  132
between each pair, was then performed on the
same variables. In this way for example, when
testing for a significant relationship between ‘patient                17
satisfaction’ and ‘total journey time’, analysis
                                                                 129
controlled for ‘type of practitioner’, ‘waiting time                                                                             25     12
until first encounter with practitioner’ and patients’
‘feelings of involvement in their own care’.                                   129

                                                                                                               179
RESUlTS
Demographics
The sample comprised:                                           Key. Journey times by practitioner role:
n Females: 440                                                   MINTS      Doctor    Physician’s Don’t       Total
n Males: 490                                                                         assistant (PA) know
n People who did not state their gender: 70
n Age range: from less than five years (3 per cent)                                                               373   Up to one hour
  to more than 60 years (9 per cent), with the                                                                    332   One to two hours
  largest group (22 per cent) being between
  31 and 45 years old                                                                                             131   Two to three hours
n Ninety per cent were ‘white British’.                                                                           44    Three to four hours

Journey times                                                                                                     18    More than four hours
Most patients in the total sample were first seen
                                                                                                                  102   Not stated
within 30 minutes of arrival and discharged
from the see and treat services within two hours
(Figure 1, Table 3).


 Table 3

 Total journey time by type of practitioner
 Waiting time                                       Percentage of patients seen by MINTS           Percentage of patients seen by doctors
                                                              nurses (n = 545)                                   (n = 375)

 Up to one hour                                            36                                               35

 Between one and two hours                                 33                                               34

 Between two and three hours                               14                                               14

 Between three and four hours                               4                                                 5

 More than four hours                                       2                                                 2

 Not stated                                                11                                               10




30                                                                                                         emergency nurse    vol 16 no 3 june 2008
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Patients’ perceptions of care
                                                               Table 4
Patients’ perceptions of the care they received
at the see and treat services were analysed, and               Patient perceptions of care by type of practitioner
responses from those seen by MINTS nurses and
                                                               Rating                Percentage of patients seen    Percentage of patients seen
those seen by doctors were compared. The results                                      by MINTS nurses (n = 545)         by doctors (n = 375)
of these comparisons can be seen in Figure 2 and
Table 4                                                        Excellent                       48                               50
  Patients also made a variety of different comments           Very Good                       28                               29
under the last section of the questionnaire. These
                                                               Good                            10                                9
comments included:
n ‘Staff extremely pleasant and cheerful’                      Fair                             5                                3
n ‘Most pleasant experience despite the                        Poor                             1                                1
   circumstances’
                                                               Very Poor                        1                                0
n ‘Staff were good with my child’
n ‘First class care’.                                          Not Stated                       7                                8


 Figure 2                                                                                    Correlations
                                                                                             Correlation tests performed on the data revealed
 Patient perceptions of care by type of practitioner                                         significant relationships between patient satisfaction
                              2              5                                               and total journey time (r = 0.376, p < 0.01), and
                    5 3 1                                                                    between patient satisfaction and feelings of
                        7               30                                                   involvement (r = 0.547, p < 0.01). This suggests
                   10 1           39
                                                                                             that patient satisfaction is higher when overall
               4                                                                             waiting time is lower and they are more involved in
          1         25                                         260
                                                                                             decisions about their care.
               34                                                                              However, partial correlations performed on each
                                                                                             pair of variables, while controlling for all other
                                                                                             variables, revealed no significant relationships
          57
                                                                                             between patient satisfaction and any of the other
                                                                                             variables considered.This suggests that factors
        19                                                                                   such as low waiting times alone are insufficient to
   6                                                                                         ensure high levels of patient satisfaction in see and
                                                                                             treat services, which is probably determined by a
                                                                                             combination of many variables.
              109
                                                                                             DISCUSSIoN
                                                                      188
                                                                                             The main aims of the see and treat survey were
                                                                                             to assess patient satisfaction and to evaluate the
                                                                                             performance of MINTS nurses compared with that
                                  152                                                        of doctors.
                                                 26
                                                          16                                   Overall, patient satisfaction was higher among
                                                                                             doctors’ patients than among MINTS nurses’
    Key. Satisfaction ratings by practitioner role:                                          patients, although the nurses were compared with
       MINTS         Doctor            PA    Don’t know   Total                              middle grade and consultant doctors what iS the
                                                                                             Significance of thiS?.
                                                           490           Excellent             Minor/Major Injury/Illness Nurse Treatment
                                                           286           Very good           Service nurses can see, treat and discharge patients
                                                                                             autonomously and this, combined with the
                                                               96        Good                elimination of triage, effectively reduced patient
                                                               36        Fair                waiting times.
                                                                                               When all other variables were considered, no
                                                               8         Poor                significant relationship between waiting time and
                                                                                             patient satisfaction was found, a finding that is in
                                                               10        Very poor
                                                                                             line with those of Palmer et al (2005), who found
                                                               74        Not stated          no correlation between patient satisfaction and
                                                                                             waiting time. Instead, these researchers found that



vol 16 no 3 june 2008 emergency nurse                                                                                                           31
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 Table 5

 Patients’ perceptions of care by type of practitioner
 Questions                                              Percentage seen by MINTS nurses (n = 545)        Percentage seen by doctors (n = 375)

                                                            Yes             No          Not stated          Yes              No           Not stated

 Did you think that you had been treated with               90               2              8               91                 1                  8
 respect and dignity?

 Did your practitioner listen to you?                       95               2              3               98                 1                  1

 Did you think you had had enough time to                   94               4              2               94                 5                  1
 discuss your treatment with the practitioner?

 Did you have confidence and trust in the                   94               3              3               97                 1                  2
 practitioner?

 Did you think that the practitioner was                    88               1             11               87                 1               12
 knowledgeable enough about your condition
 and treatment?

 Were you involved as much as you wanted to be              85               4             11               91                 2                  7
 in decisions about your care and treatment?


                            the most significant feature in determining patients’           Patients in the controlled trial (Cooper et al 2002)
                            dissatisfaction was practitioners’ lack of social skills.     reported however that ENPs were easier to talk to
                              Cooper et al (2002) conducted a randomised                  than SHOs and that overall patients were more
                            controlled trial to evaluate patient satisfaction with        satisfied with the care given by them (p= 0.001).
                            emergency nurse practitioners (ENPs) and senior                 The psychosocial skills of ENPs, like those of nurses
                            house officers (SHOs).                                        and doctors in general, are likely to be as important
                              The sample was much smaller (n=199) than in the             to patients as clinical ability really? why?.
                            authors’ study, but the findings were similar in that           According to the respondents in this survey,
                            patients reported high levels of satisfaction with            the clinical skills, timing and procedure an we have
                            both nursing and medical staff.                               PercentageS in bracketS after each here ? of MINTS


 Table 6

 Patients’ perceptions of the information they received by type of practitioner
 Questions                               Percentage seen by MINTS nurses (n = 545)                    Percentage seen by doctors (n = 375)

                                        Yes        No          Other         Not stated         Yes        No          Other             Not stated

 Did you receive a clear explanation     86         3             4               7             93           2           1                    4
 of your condition and treatment?

 Did you receive a clear                 76        16             0               8             80          12           0                    8
 explanation of test procedures?

 Did you receive a clear                 76         4             1              19             73           4           1                   22
 explanation of test results?

 Were you advised about taking           57         2             6              35             59           2           9                   30
 prescribed medication?

 Were you advised about the              39        17             16             28             39          11          19                   31
 potential side effects of your
 medication?

 Were you advised about                  54        11             20             15             51          11          23                   15
 returning to normal activities?

 Were you advised about making           56        22             5              17             56          24           4                   16
 appropriate contact if you are
 concerned following discharge?




32                                                                                                           emergency nurse       vol 16 no 3 june 2008
                                                                                                                              clinical



nurses were well regarded, but some of the                able to balance the psychosocial with the technical
psychosocial aspects of their work were not ...           elements of their work, while continuing to develop
and here?. The differences are small however and,         a patient-centred communication style.
as Table 5 shows, patients generally rated MINTS
nurses highly.                                            Information
  Research shows that patients’ and nurses’               Of the sample, 85 per cent of patients thought they
perceptions of caring differ (Hegedus 1999),              had been given the right amount of information
and nurses’ perceptions of caring behaviours are          about their condition and treatment (Table 6).
affected by their age, gender, culture, nursing             The see and treat survey results indicate an
experience and area of specialty (Greenhalgh et al        improvement in patient satisfaction over several
1998, Watson et al 1999).                                 components of care, including patient information,
  By using filmed episodes of nurse-patient               since the Picker Institute surveys were conducted
interactions in an ED, Wiman and Wikblad                  in 2005.
(2004) identify what they call ‘instrumental                When asked about receiving information on
behaviour’, which they describe as ‘a high degree         condition and treatment in 2005, 46 per cent of

 Table 6

 Patients’ experiences of pain management by type of practitioner
 Questions                  Percentage of patients seen by MINTS nurses (n = 545)     Percentage of patients seen by doctors (n = 375)

                              Offered     Requested        Not        Not stated     Offered      Requested          Not        Not stated
                                                        requested                                                 requested

 Was analgesia offered         26            6              63             5          29             3               63             5
 to you or did you
 request analgesia?

                                 Yes          No          Other       Not stated       Yes            No           Other        Not stated

 Was analgesia given           67                            8            25          65                              6            29
 within 15 minutes of
 the offer or request?

 Were you given all            68           10              12            10          69            10               12            14
 forms of available
 pain relief?

 Was the main reason           88            3               0             9          88             2                0            10
 you went to the ED
 dealt with to your
 satisfaction?


of concentration on the ongoing procedures                patients indicated that they had been given enough
surrounding the patient’. This behaviour implies that     information. When asked the same question for the
nurses lack emotional involvement with patients           see and treat survey in 2007, 85 per cent of patients
without implying that they are insensitive.               expressed this opinion.
  Instrumental behaviour may be relevant to the’             Whether patients have long-term or acute injuries
study in that, due to the nature of minor injuries        or illnesses, they can be be empowered and given
and professional accountability, the development of       a sense of control over their health and wellbeing if
knowledge and clinical skills is emphasised.              they are given the correct information.
  The positive outcome of this is reflected here, in         This view is confirmed by Steptoe and Wardle
that patient perceptions of MINTS nurses compare          2001, who associate a high internal locus of control
favourably with those of middle grade medical staff,      with healthier behaviours and better adaptation to
consultant doctors and consultant nurses.                 illness.
  The MINTS programme is only how Many in June               Meanwhile, Ryan et al (2003) find that patient
2008? years old, and MINTS practitioners are still        information, along with empathy and involvement
developing their professional confidence.                 with patients, are major factors in improving
  As this grows however, MINTS practitioners will         perceived control among people with rheumatoid
develop a professional identity, and will be more         arthritis.



vol 16 no 3 june 2008 emergency nurse                                                                                                    33
     clinical



                                  Pain                                                                 ioners play in helping to shape patients’ expectations
                                  Of the total sample, 70 per cent of patients stated                  and beliefs about pain management.
                                  that they were in pain when they attended see and                      Patients may expect to be offered analgesia
                                  treat services (Table 7).                                            without having to ask for it; as Corbally and
                                    A large proportion of patients who responded                       Gallacher (2006) find, most patients take no
                                  to the see and treat survey were in pain did not                     analgesia before they arrive at EDs, which implies
                                  request analgesia. But, when it was requested,                       that they are willing to let healthcare professionals
                                  67 per cent of nurses and 65 per cent from doctors                   take responsibility for their pain relief.
                                  provided it within 15 minutes.                                         The MINTS nurses in the survey adopted a ‘wait
                                    There are individual differences in patients’ abilities            and see’ approach, yet one patient who was in pain
                                  to cope with pain, and these are often related to                    ‘most of the time’ requested that no analgesia was
                                  gender, age and ethnicity (Evans 2004, Frantsve                      given, but then wrote of the nurse: ‘She didn’t even
                                  and Kerns 2007, Hogan 2005, Weiss et al 2003).                       give me something for pain’.
                                    Todd et al (2007) found that 42 per cent of                          Nurses working in NHS Lanarkshire see and treat
                                  patients who received no analgesia had wanted it,                    services can administer paracetamol and ibuprofen
                                  while Tanabe and Bushchmann (1999) find however                      using patient group directions what about indePendent
                                  that 19 per cent of patients in pain refuse analgesia,               PreScriberS?
                                  even if it were offered, for the following reasons:                    what’S the difference between PreScribing and uSing
                                  n Fear of addiction                                                  Patient grouP directionS?.
                                  n Avoidance of medications generally
                                  n Concern that pain medication slows healing                           One of the most common drug errors involves
                                     processes                                                         paracetamol (Morrow-Frost 2006) and perhaps fears
                                  n Preganancy concerns                                                about liability make nurses reluctant to offer it.
                                  n Concern that analgesia will impair mental                            There is a strong focus on drug education in the
                                     processes.                                                        MINTS programme however and, as the clinical
                                  The extent to which patients refuse analgesia                        confidence of MINTs grow, the list of drugs available
                                  highlights the important role emergency practit-                     for them to administer is likely to expand.




References
Corbally M, Gallagher P (2006) Accessible yet          Evans C (2004) Improving assessment of pain in older    Hogan SL (2005) Patient satisfaction with pain
not accessed? A literature review exploring factors    people. Emergency Nurse. 12, 5, 18-21.                  management in the emergency department. Topics in
which may prevent patients taking over the counter                                                             Emergency Medicine. 27, 4, 284-294.
analgesia prior to attending. Accident and Emergency   Frantsve, LM, Kerns RD (2007) Patient-Provider
Nursing. 14, 92, 78-82.                                Interactions in the management of chronic pain:         Jarvis M (2007) Satisfaction guaranteed? Emergency
Corbett G (2006) See and Treat Option Appraisal.       current findings within the context of shared medical   Nurse. 14, 9, 34-37.
NHS Lanarkshire Health Board.                          decision making. Pain Medicine. 8, 1, 25-35.
                                                                                                               Lamont SS (2005) See and Treat: Spreading like
Cooper MA, Lindsay GM, Kinn S, Swann IJ (2002)         Greenhalgh J, Vanhaned L, Kyngas H (1998)               wildfire? A qualitative study into factors affecting its
Evaluating Emergency Nurse Practitioner services:      Nurse caring behaviors. Journal of Advanced Nursing.    introduction and spread. Emergency Medical Journal.
a randomized controlled trial. Journal of Advanced
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Nursing. 40, 6, 721-730.
Crouch R, Brook S, Armstrong B, Rush H,                Hegedus KS (1999) Providers’ and consumers’             Morrow-Frost C (2006) Nurses’ knowledge of
Robinson N (2001) Minor Injuries/Illness Nurse         perspective of nurses’ caring behaviours. Journal of    commonly used drugs: a clinical audit. Emergency
Treatment Service. Emergency Nurse. 9, 7, 18-22.       Advanced Nursing. 30, 5, 1090-1096.                     Nurse. 13, 10, 32-37.




34                                                                                                                       emergency nurse        vol 16 no 3 june 2008
                                                                                                                                                 clinical



lIMITATIoNS                                                        can encourage response bias. For example, in the
The main limitation of the see and treat study                     demographic section, 90 per cent of respondents
was the unequal size of the comparison groups.                     said that they were ‘white British’ but some may
Furthermore, the number and diversity of non-                      have done so because they misunderstood the term
responses mean that results focused mainly                         ‘white British’. Some questions must be redrafted
on overall percentage data rather than means,                      for the next see and treat questionnaire therefore
standard deviations and significant differences                    and copies may be reproduced in languages other
between groups. Further studies may have to be                     than English.
undertaken in which other types of sampling and                      The next questionnaire will also undergo further
methodology are considered.                                        tests for reliability and validity, including tests to
  There was also a specific methodological                         establish Cronbach’s alpha and Cohen’s kappa
weakness is in the way that the questionnaires were                coefficients.
distributed. Patients were recruited by the people
responsible for treating them, namely the authors,                 CoNClUSIoN
and this may have made some of them reluctant                      The survey revealed that patients’ satisfaction with
to participate even after being assured that their                 the see and treat services was high and independent
treatment would be unaffected. The use of several                  of waiting times alone.
dedicated see and treat researchers on each site                     When compared to middle grade and consultant
would be more suitable.                                            doctors, MINTS nurses performed well and,
  The questions that remained unanswered                           according to patients, were knowledgeable and
by participants most commonly concerned                            competent, and had good communication skills.
demographic information (questions 39 and 40).                       While MINTS nurses achieved high scores on all
The last questions on each page of the published                   subscales of the questionnaire, results suggest that
questionnaire were commonly left unanswered too,                   lack of professional confidence is an issue worth
which is something worth remembering for future                    addressing in the future. Pain management and
questionnaire design. More generally, self-report                  patient-centred communication are also relevant
instruments such as the one used in this study                     topics for further study.




NHS Scotland (2007) Modernising Medical Careers.      Scottish Executive (2005) An Introduction to             and emergency medicine initiative (PEMI) multicenter
www.mmc.scot.nhs.uk/ (Last accessed May 29 2008).     The Unscheduled Care Collaborative Programme:            study. Journal of Pain. 8, 6, 46-466.
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                                                      local change and innovation and raising national
Evans GWL (2005) Urban legend versus rural reality:                                                            study into the perceptions of caring and nursing
                                                      standards. SE, Edinburgh.
patients’ experience of attendance at accident and                                                             among student nurses. Journal of Advanced Nursing.
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Medicine Journal. 22, 165-170.                        health behaviour revisited: a multivariate analysis of
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Picker Institute (1998) NHS Patient Surveys. www.
                                                      Psychology. 92, 659-672.                                 The influence of gender and race on physicians’
pickereurope.org/page.php?id=45 (Last accessed:
May 30 2008.)                                         Tanabe P, Buschmann MB (2000) Emergency nurses’          pain management decisions. Journal of Pain.
                                                      knowledge of pain management principles. Journal of      4, 9, 505-510.
Ryan S, Hassell A, Dawes P, Kendall S (2003)
                                                      Emergency Nursing. 26, 4, 299-305.                       Wiman E, Wikblad K (2004) Caring and uncaring
Control perceptions in patients with rheumatoid
arthritis: the impact of the medical consultation.    Todd KH, Ducharme J, Choiniere M et al (2007)            encounters in nursing in an emergency department.
Rheumatology. 42, 1, 135-140.                         Pain in the emergency department: results of the pain    Journal of Clinical Nursing. 13, 4, 422-429.




vol 16 no 3 june 2008 emergency nurse                                                                                                                            35

				
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