title: A grounded theory of patient satisfaction with nurse-led chronic disease management in general practice
Creators: name: Mahomed, Rosemary
Publisher: name: Griffith University
Year: 2010
Subjects: subject: Chronic disease management
subject: Practice Nurse Project
subject: Navigating Care Theory

description: This study was an investigation into the process of patient satisfaction with nurse-led management of chronic conditions in general practice. It adds to the theoretical understanding of patient satisfaction by providing an explanation of the processes patients go through to determine their level of satisfaction with chronic disease management provided by a practice nurse (PN) in collaboration with a general medical practitioner (GP). This study was nested within the Practice Nurse Project funded by the Australian Research Council (ARC), which trialled a new model of nurse-led care in three general practices, one in Western Victoria and two in South East Queensland. Three chronic conditions were managed by the PNs in the project; diabetes type 2, Ischaemic heart disease (IHD) and hypertension. A grounded theory approach, underpinned by constructivist ontology and an interpretive epistemology, was used for this study. Participants for the study were drawn from those patients who had consented to be part of the PN Project and who had been randomised to the PN arm of the project. Initially purposive sampling was employed to access men and women with a range of ages and chronic conditions at each of the study locations. As data were analysed, theoretical sampling was used to develop and integrate emerging categories. In-depth interviews were held with 38 participants, some of whom were interviewed more than once. The interview guides were continually revised to reflect developing concepts. Data collection continued until theoretical saturation occurred, that is, all categories were fully developed and integrated into a theory. Constant comparative analysis of the data was undertaken concurrently with sampling and data collection consistent with grounded theory methods. The basic social process to emerge from the data was Navigating Care, which is comprised of three separate but interrelated processes; Determining Care Needs, Forming a Relationship and Having Confidence. Navigating care is an on-going and cyclical process and issues with any part of the process can reduce patients’ satisfaction or may lead to them opting out of PN-led management. Patients determine their care needs through a process of monitoring and selfassessment. If they consider that the PN is the appropriate person to provide for their care needs, they then proceed to Forming a Relationship with and Having Confidence in the PN. These two processes are concurrent and interdependent. The patient’s experience during these processes also provides a feedback loop to further determination of their care needs. The two stages involved in Forming a Relationship are Building Rapport and Working Together. Time, Communication and Continuity are important properties of Forming a Relationship. The confidence that patients have in PN-led chronic disease management is built on Trusting the Model of Care, Trusting the Role of Nurse, Trusting their Doctor and Evaluating the PN. The extent to which each of these processes influence the level of confidence depends on the individual patient. Communication is also an important property of Having Confidence, especially in Evaluating the PN. The theory of Navigating Care provides an explanation of the processes undertaken by patients in determining their satisfaction with PN-led management of chronic conditions, which adds to the existing theoretical understanding of patient satisfaction. This understanding can be used to facilitate acceptance of new models of nurse-led care in general practice and assist in identifying patients for whom nurse-led care would be suitable. The findings can also be used to inform nursing practice and inform the development of more sensitive instruments measuring patient satisfaction. Finally, if patients feel more comfortable with PNs than doctors, they may be more willing to engage with nurses in systematic management of their chronic conditions.