Perception of Physicians about Advanced Nurse Practitioners in Saudi Arabia

This dissertation evaluates the perception of physicians in relation to the role of Advanced Nurse Practitioners within the healthcare system of Saudi Arabia. It covers the background, research aim, theory framework, educational need to be certified as ANP, perception of physicians about ANPs, significance, literature review, methodology, result and analysis, discussion, and conclusion.

Running head: Dissertation
LACK OF KNOWLEDGE, UNDERSTANDING AND AWANESS ABOUT THE
ROLE OF ADVANCED NURSE PRACTITIONERS AMONG PHYSICIANS IN SAUDI
ARABIA
Ahlam AL-Harbi
CAPSTONE PROJECT SUBMITTED FOR THE MASTER OF SINCE IN
NURSING: ADVANCED PRACTICE
DR.MARRY
DCU&PNU
18-6-2019

1DISSERTATION
Table of Contents
Chapter 1:.......................................................................................................................4
Introduction....................................................................................................................4
Background................................................................................................................4
Research aim:.............................................................................................................6
Theory Framework:....................................................................................................7
Educational Need to be certified as ANP:..................................................................8
Perception of physicians about ANPs........................................................................9
Significance..............................................................................................................10
CHAPTER 2:...............................................................................................................11
Literature review:.........................................................................................................11
Introduction..............................................................................................................11
Search strategy.........................................................................................................11
Inclusion and exclusion criteria...............................................................................11
Key words................................................................................................................12
Discussion................................................................................................................12
Chapter 3......................................................................................................................14
Methodology................................................................................................................14
3.1 Introduction........................................................................................................14
3.2 Research design..................................................................................................15
3.3 Research method................................................................................................16
3.4 Data collection...................................................................................................16

2DISSERTATION
3.5 Data analysis......................................................................................................16
3.6 Evaluation..........................................................................................................17
3.7 Method and materials (instruments)...................................................................17
3.8 Sample................................................................................................................18
3.9 Ethical considerations........................................................................................18
3.10 Preparation.......................................................................................................19
3.11 Protocol design.................................................................................................19
Chapter 4......................................................................................................................20
Result and analysis.......................................................................................................20
Demographic study (data collected prior to the conduction of survey).......................20
Profession of the participants.......................................................................................20
Experience of the participants......................................................................................20
Gender of the participants............................................................................................22
Training received in last one year................................................................................23
Nationality....................................................................................................................23
Highest degree of education.........................................................................................24
Current employment status..........................................................................................25
Demographic findings..................................................................................................26
Pre survey data analysis...............................................................................................26
Findings from the pre survey data................................................................................31
Conduction of post training survey and analysis of the data.......................................31

3DISSERTATION
Paired t-test for the repeated seven questions (Both in pre and post survey)..............32
Chapter 5......................................................................................................................38
Discussion....................................................................................................................38
Overview......................................................................................................................38
Interpretation and evaluation of the findings...............................................................39
Validating findings.......................................................................................................40
Chapter 6......................................................................................................................42
Conclusion....................................................................................................................42
References....................................................................................................................44
Appendix......................................................................................................................51

4DISSERTATION
List of Tables
Table 1.........................................................................................................................21
Table 2.........................................................................................................................21
Table 3.........................................................................................................................22
Table 4.........................................................................................................................23
Table 5.........................................................................................................................24
Table 6.........................................................................................................................24
Table 7.........................................................................................................................25
Table 8.........................................................................................................................26
Table 9.........................................................................................................................29
Table 10.......................................................................................................................29
Table 11.......................................................................................................................30
Table 12.......................................................................................................................32
Table 13.......................................................................................................................32
Table 14.......................................................................................................................34
Table 15.......................................................................................................................34
Table 16.......................................................................................................................36
Table 17.......................................................................................................................37
Table 18.......................................................................................................................37
Table 19.......................................................................................................................38
Table 20.......................................................................................................................39
Table 21.......................................................................................................................39
Table 22.......................................................................................................................40
Table 23.......................................................................................................................41

5DISSERTATION
Chapter 1:
Introduction
Background
Advanced Nurse Practitioners are specialized nursing professionals who possess years
of experience in the process of providing care services to the patient (Elliott et al. 2016). ANP
or Advanced Nurse Professionals possess the ability to assess, investigate, diagnose and
prescribe patient care independently (Aldossary 2013). However, research studies suggest
that the role of Advanced Nurse Practitioners in the field of health care system is not clearly
understood by the physicians and the allied health care professionals. Also, the concept of
ANP has not yet been absorbed within the healthcare system of Saudi Arabia (Begley et al.
2013). This paper therefore, intends to evaluate the perception of the physicians in relation to
the role of ANP within the healthcare system of Saudi Arabia.
An ANP (Advanced Nurse Practitioner) is classified as a mid-level practitioner. An
ANP is sufficiently trained to assess the needs of the patient, refer and interpret diagnostic lab
results, diagnose the disorder and accordingly prescribe medication or treatment routine
(Poghosyanet al. 2014). According to Begley et al. (2013), the ANP training critically covers
the aspects of prevention of health related risks, coordinated care planning and health
expertise. These training areas are substantially covered in the training process of Nurse
practitioners but in case of NPs, the training lacks expertise to identify complex cases that
indicate the prevalence of serious disease conditions with multiple symptoms (King, Tod and
Sanders 2017). As stated by the American Association of Nurse Practitioners, a nurse
practitioner who has acquired a master’s or doctoral degree is substantially equipped to
impart primary, acute, chronic as well as speciality care to the patients (Kleinpell, Cook and

6DISSERTATION
Padden 2018). Further, it should be noted that the scope of practice for the Nurse
Practitioners is regulated by territorial jurisdiction. On the basis of the Jurisdiction, it can be
mentioned that the ANP or Advanced Nurse Practitioners might be entitled to practice under
the supervision of a physician (King, Tod and Sanders 2017).
Research studies indicate that the role of ANP (Advanced Nurse Practitioners) came
into being during the mid-twentieth century in the United States of America (Lowe et al.
2013; Dalton 2013).In the year 1940 the individual role of the Nurse Anaesthetists and Nurse
Midwives were recognized. On the other hand, the year 1954 marks the recognition of
psychiatric nursing (Lowe et al. 2013). The recent concept of Advanced Nurse Practitioners
was developed recently in the 1960s when the world experienced a national shortage of
medical doctors. It should further be noted that the first certificate program for nurse
practitioners was developed by Henry Silver who was a physician in collaboration with
Loretta Ford who was a Nurse Practitioner (Hain and Fleck 2014). A formal recommendation
was made by the United States Secretary of Health, Education and Welfare who critically
explained the need to expand the scope of nursing practice so as to grant an equal status to the
Nurse Practitioners as that of Primary Care Providers (Sanders et al. 2016). The year between
1970s to early 1980s made it mandatory for Nurse Practitioners to complete a master’s degree
in order to be awarded with a practice certification (Begley et al. 2013). In the year 2012,
several discussions were held by different accreditation agencies and national certification
bodies as well as state boards that debated about the likelihood of making The Doctor of
Nursing Practice (DNP) as the minimum standard of education criteria for Nursing
Practitioner certification and licensure by the end of 2015 (King, Tod and Sanders 2017).
The quality of care provided by the Nurse Practitioners has often been questioned. It
should be mentioned in this context, that research studies have highlighted a number of issues
consistent with the lack of substantial training among the Nurse practitioners to impart

7DISSERTATION
quality in terms of care delivery (Harris et al. 2016). Issues such as wrong prescription of
antibiotics when not in need have been highlighted by the research studies (Donelan et al.
2013; Lowe et al. 2013). Also, it has been pointed out that there is a need to improve the skill
set of nursing abilities in order to ensure quality in terms of care delivery. Studies also
suggest that nurses are more likely to make unnecessary referrals when there is no need for
the same (Lucas et al. 2019). In addition to this, it has also been argued by researchers that
nurses are likely to order a set of unnecessary tests and procedures such as imaging studies or
skin biopsies for the detection of disease.
Advanced Nurse Practice is majorly dependent upon the contemporary as well as the
social health care needs of the people and identification of influencing factors such as public
health behaviours, population growth trend, life expectancies and community health
programs (Verma and Acharya 2018). The ANP make use of the advanced technology and
knowledge expertise to devise care according to the patient needs (AlYami and Watson
2014). While the healthcare systems of developed nations such as the United States and
Australia have absorbed the ANP care model to render care services to the patient, the same
seems a far-fetched reality for Saudi Arabia (Anderson 2017).
The Nursing profession in Saudi Arabia is laden with a number of challenges which
impedes the development and evolution of the profession. As stated by Lamadah and Sayed
(2014), the primary barriers in the form of lack of adequate staffing, confusion about job role
and lack of advanced education opportunities in Saudi Arabia has led to the decreased
acceptance of the ANP care model in Saudi Arabia (AlYami et al. 2014).
Research aim:
 This research aim of the study intends to assess the perception of Physicians in
relation to the role of Advanced Nurse Practitioners within Saudi Arabia.

8DISSERTATION
 The paper would critically analyse the scholarly literatures retrieved from the
electronic databases relevant to the research topic and develop an overview
about the research methodology that would be used to conduct the research.
Research Questions: The research questions that can be formulated on the basis of
the research title can be enlisted as follows;
RQ1: What are the perceptions of the physician as well as their beliefs about the role
of ANP in Saudi Arabia?
Theory Framework:
According to Field et al.(2014), while writing a dissertation, it is important to make
use of a relevant theoretical framework. As s stated by McDonnell et al. (2015), theoretical
frameworks can be defined as the procedure of applying theory to practice so as to maximise
the implementation efforts. In this context, it should be mentioned that the dissertation is
based upon the Knowledge to Action (KTA) framework (Spooner, Aitken and Chaboyer
2018). The KTA framework was propounded by Graham and his colleagues in Canada during
the early half of 2000s (Field et al. 2014). The framework was propounded after reviewing a
total of 31 planned action theories. The framework has two vital components that include
Knowledge creation and an action cycle. Both the mentioned components of the framework
comprise of multiple phases. The phases critically direct the steps of accumulation and
processing of information followed by implementing the acquired information into practice
(Lamadah and Sayed 2014).
This framework has been chosen for the conduction of this research as the aim of the
research was to understand the perception of the healthcare professionals about the roles and

9DISSERTATION
responsibilities of the ANPs in the healthcare facilities. Hence, this would help to understand
the educational or knowledge gap which is present in the care process due to which majority
of the ANPs face discrimination or complication in their workplace (Field et al. 2014).
Hence, understanding the gaps in the process would develop knowledge creation scope and
with that they would be able to develop an educational and training session to modify their
perception about the ANPs and their roles and responsibilities in the healthcare facility
chosen for conduction of the process (Lamadah and Sayed 2014).
Educational Need to be certified as ANP:
The ANPs demonstrate an effective ability to integrate theory to practice. In addition
to this, ANPs acquire an increasing degree of control over the process of autonomous
decision making and implementation of interventions (Cepaluni, Mariano and Mariano 2019).
The intensive post-graduate program is based upon the learning principles of guiding a Nurse
Practitioner to effectively make use of decision making, engage in collaborative relationships,
creation of a supportive care environment and achieve positive patient outcomes (Yee et al.
2013; Kleinpell 2013). In addition to this, it is expected that Nurse practitioners must as well
possess the ability to build strong inter-professional relationships, practice according to the
legislation and laws, engage in culturally safe practice and advocate the rights of the patient
(Ferraris 2017). The ANP education program critically covers four important roles that
include, Clinical Nurse Specialists, nurse anaesthetists, nurse, midwives and Nurse
practitioners (Kleinpell 2013). In addition to this, it is important to note that the Nurse
Practitioners can also have several sub-specialties under the mentioned categories. Education,
accreditation as well as certification are the integral aspects of Advanced Nursing Practice
but these roles differ on the basis of different legislations (Field et al. 2014).

10DISSERTATION
Perception of physicians about ANPs
The concept of Advanced Nurse Practitioners has not yet assimilated completely
within Saudi Arabia. The most common perception about the role of ANP is equivalent to
that of an assistant to a physician (Manning et al. 2018). In addition to this, studies have also
indicated that in most health care organizations across Saudi Arabia the role of ANP is not
clear among the physician or other Registered Nurses (RNs) (Pedersen and Tariman 2018).
However, a number of research studies have also suggested that the inclusion of ANP in the
care practice has yielded positive patient outcomes (Iglehart 2013). The positive patient
outcomes have been studied in relation to reduction of hospitalization rate and provision of
quality care services (Yee et al. 2013). There is an increasing need to evaluate the current
perceptions and attitude of physicians in relation to ANP in order to effectively expand the
scope of practice and add value to their role within the healthcare setting (Manning et al.
2018).
The perception about the role of ANPs has been discussed in the research of
Halliday, Hunter and McMillan (2018) in which the primary aim of the researchers was
to examine the perception of the staff of the healthcare facility. This research identified
that the healthcare staff did not see the role of advanced practice clinically effective.
Further it was also seen that majority of the staff believe that they lack the skills that is
required for the management of the critical health conditions (Halliday, Hunter and
McMillan 2018). Hence, in this research conducted in the healthcare facilities of United
Kingdom, perception of the nursing practitioners, and healthcare staff about the ANPs
were not effective and they thought that such professionals require training and
education for their skill development (Halliday, Hunter and McMillan 2018).
However, it has been seen that ANPs are themselves not aware of their job roles
and Key Responsibility Area (KRAs) that they need to perform in their workplace.

11DISSERTATION
Hence, to understand that the research findings of Kerr (2016) should be mentioned as
they have conducted a research to understand the perceptions of the ANPs about their
own job roles and KRAs. It was found that majority of the ANPs are not aware of their
role fulfilments and KRAs and hence, their contribution in healthcare facilities
improved quality is minimum compared to other healthcare staff (Kerr 2016).
Therefore, to understand the perception of the healthcare professionals about
the role of ANPs in the chosen healthcare facility, this research has been conducted so
that their roles and responsibilities could be effectively understood.
Significance
The significance for conducting this research can be explained as evaluating the
perception and belief existing among the physicians about the role of Advanced Nurse
Practitioners. When the world is experiencing an acute shortage of care professionals to
deliver effective care delivery, there is an increasing need to include ANPs to ensure a
smooth care delivery process. According to a research conducted by Allen et al. (2014),
inclusion of ANP based care within a healthcare organization reduced the tenure of hospital
stay in patients suffering from cardiovascular disorder and also improved the quality of
patient care delivery. In addition to this, increasing the scope of practice for the advanced
nurse practitioners would improve the level of nurse and patient interaction and would
improve the quality of care. Further, on evaluating the Physician’s perception, it would help
in choosing a convenient framework that could be used an effective tool to disseminate
education and awareness about the role of Advanced Nurse Practitioners within a healthcare
environment (Halliday, Hunter and McMillan 2018).

12DISSERTATION
CHAPTER 2:
Literature review:
Introduction
The primary aim of inclusion of literature review in the paper is to develop an insight
of the available research articles that belongs to the research topic and research question
selected for the completion of the research project and then helps to provide a theoretical
guideline for the completion of the project.
Search strategy
Search strategy, according to Tsafnat et al. (2014), is the organised way of using
specific keywords in specific order so that the all the popular electronic databases such as
CINAHL, Medline, Google Scholar and PubMed could be searched and the obtained research
articles could be used to develop a strong literature review argument. In this aspect, specific
key terms are used in different permutation and combination so that all the available
literatures with similar research interests could be collected for the development of guidelines
to proceed with the research method.
Inclusion and exclusion criteria
As mentioned by Mosa, Yooand Sheets (2012), inclusion and exclusion criteria are set
of aspects depending on which the collected research articles from electronic databases are
used to develop the review of the research. The inclusion criteria includes characteristics such
as research article publish date within 2012 to 2019, research articles published in English
language and with full text articles.
On the other hand, the exclusion criteria are inclusive of research articles that does not
comprise of the criteria, including language of paper other than English and published before

13DISSERTATION
the provided year. Besides this, papers with abstract and lack of full text would be excluded
from the research study.
Key words
Key words are condensed terms or small and precise phrases that are used in research
process for the conduction of search study on the selected electronic databases. Further, as
mentioned by Fink (2019), application of precise keywords helps to identify and retrieve
relevant articles for the completion of an accurate literature review. The research articles that
are used for this research article are: ANP in Saudi Arabia, role of ANPs in Saudi Arabia,
perception of ANPs in Saudi Arabia, ANP’s role in improved care delivery,
characteristic ANP perceptions and beliefs, improved care process and ANP’s role in
Saudi Arabia, Knowledge of ANP’s about their role in Saudi Arabia.
This should be mentioned that the Boolean operators would also be used for the
refining the search process. Using AND/OR/NOT would help the search process to be
confined and compact so that effective results could be collected. After application of
Boolean Operator, the key term would be as follows: Role of ANPs in Saudi Arabia AND
ANP’s role in improved care delivery OR Knowledge of ANP’s about their role in Saudi
Arabia.
Discussion
Advanced Practice Nursing (ANP) is the nursing profession in which the
professionals have expanded roles and responsibilities of taking care of the patients. As per
the World Health Organisation (2019), to support the growing need of patients in global
healthcare needs. Hence, as per Hibbert et al. (2017), the Advanced Practice Nurses are
professionals with extended knowledge, ability to make effective decisions for patients, as
well as developing clinical competencies and these competencies are determined by the state

14DISSERTATION
or country for their credential practice. As per Alboliteeh, Magarey and Wiechula(2017), the
primary role of advanced practice nursing professionals in Saudi Arabia is associated with
contemporary healthcare demands and requirements of the patients by targeting the factors
associated with it such as the community group, increased life expectancy, lack of family
planning and other critical health related barriers. Hence, it is important for the ANPs to be
aware of their responsibilities and functions in the healthcare facility to provide an effective
and holistic care to the patients. Besides this, to conduct their processes, they should be aware
of the knowledge related to technologies, increased expectancy of patient and healthcare
process and hence, it is important to analyse the level of understanding of ANPs working in
KSA (Hibbert, Al-Sanea and Balens, 2012).
Reason for lack of awareness
In a paper developed by George (2016), it has been mentioned that nursing is still in
its primitive stage and constantly facing several complications related to application,
sustainability and improvement of the healthcare processes. As per the Ministry of Health
KSA (2019), the average age of nursing professionals working in KSA is 27 years and more
than 77% are having less than 5 years of experience. On the other hand, the average age of
nurses in Australia and Singapore is 45 years and 35 years respectively. Further, it was also
noted that the highest educational status of nurses in KSA is diploma (83%) in contrast to
Australian nursing professionals who have Bachelors in nursing as their highest educational
qualification (82%). Therefore, from these demographic data, it is easier to understand that
majority of the ANPs working in KSA are having less qualification and majority of them are
working in the healthcare facilities to gain experience and then are leaving the country for
better opportunities in other developed countries. Further, it was seen that cultural issues are
one of the critical aspects of advanced nursing professionals working in KSA as majority of
nursing professionals that are women, suffer from family obligations and social

15DISSERTATION
discriminations due to which they are unable to focus on their working abilities lack of
knowledge (Punch 2013). Hence, difficulty in their work-life balance has been observed.
Therefore, from these two research studies it is easier to mention that majority of the nursing
professionals in KSA are not clear about their clear pathway, lack of nursing advocacy and
due to their personal obligations are not aware of their professional roles and responsibilities
as an advanced nursing professional.
Besides these, another research mentioned about the upcoming shortage of nursing
professionals around the world, due to which, the number of nursing professionals working in
the healthcare facilities are not having proper education and training because of the increased
needs and requirements of the patients. Ramira et al. (2018) has mentioned in their research
project that the world would be facing a severe nursing professional shortage by the year
2020 and due to the increased population, the shortage of nursing professional would reach
up to 91,000 only in USA. Therefore, it has been seen, that nursing professionals that are
unaware of their roles and responsibilities due to shortage of training are travelling to KSA
and joining their task force for their growth and development.
Chapter 3
Methodology
3.1 Introduction
While developing a research process, methodology becomes the most important
section of the paper. As mentioned by Birley and Moreland (2014), in this section, effective
measures are taken to analyse the research problem and hence, with critical investigation, all
effective strategies to identify, select, process and analyse the specific problems are
determined. Further, with application of this methodological section, it becomes easier to

16DISSERTATION
evaluate the variability and reliability of the study conducted. As mentioned by Fassinger and
Marrow (2014), methodological section of the research paper helps to analyse the process of
data collection, data analysis, as well as the process using which the understanding of the
ANPs about their roles and responsibilities in Saudi Arabia was determined.
3.2 Research design
As mentioned by the researcher Punch (2013), research design is the aspect using
which it becomes easier to answer the research questions. Basically, research design is the
tool that helps to analyse the research question and through the analysis of research
objectives, the type of research design accurate for conduction of the process is selected. As
per Punch (2013), there are generally two type of research design such as qualitative and
quantitative research design. While qualitative research data helps in the evaluation of the
qualitative responses collected from interviews and interactions, the quantitative research
design helps to analyse the numerical data and analyses it with the use of numeric data
analytical tools. In this aspect, it should be mentioned that the primary aim of this research
process was to analyse the lack of knowledge and awareness of the role of advanced practice
nurses working in the among the physicians working in a selected hospital in Saudi Arabia, as
well as after conducting the educational and training session, analyse the change in their
perceptions, the research aimed to evaluate the knowledge and understanding of the
physicians about the roles of ANPs in healthcare facilities. Hence, through the application of
pre and post survey the quantitative research analysis would be conducted. With a pre survey
among the physicians of a selected hospital, it would be easier to understand the perception of
physicians prior to attend the educational and training sessions and then evaluation of their
responses collected after the post survey conduction would help to analyse their difference in
the knowledge and attitude related to the role of ANPs in healthcare facilities. Therefore,

17DISSERTATION
application of quantitative study for the completion of the study would be an effective and
appropriate design.
3.3 Research method
Identification and application of an accurate methodology becomes one of the critical
aspects while conducting the research process as without the selection of an accurate research
method, it becomes critical to obtain accurate results. As per Lampard and Pole(2015), while
conducting primary quantitative study, the most accurate research method which should be
implemented is the survey or questionnaire as with collected data, it is easier to analyse the
set of collected data. As the primary aim of this research is to analyse and differentiate
between two sets of data such as pre and post survey data collected to understand the
perception of physicians about the role of ANPs working in a selected hospital, conduction of
surveys with pre-determined questionnaire set would be the accurate research method for this
process.
3.4 Data collection
As per Hartas (2018) data collection is the method, which helps the researchers to
gather and measure all the information collected from the research data and then measure all
the research variables included in the process. As this process is integral for both the
qualitative and quantitative process, research process and its integrity is maintained with data
collection method. The data collection method chosen for this paper and study would be
associated with conducting survey with the physicians twice, pre and post survey method and
in the process as the primary aim of the paper is to compare and contrast the level of
education among the professionals in KSA.

18DISSERTATION
3.5 Data analysis
The data collected from the pre and post survey from the 50 healthcare professionals
working in the selected hospital in the KSA were evaluated using statistical analysis process.
Tools such as SPSS that helps to provide a statistical analysis depending upon the two data
sets available were collected and then these data set ratios were used to conduct a
comparative t-test (Neuman and Robson, 2014). In this context, it should be mentioned that
the independent t-test is the statistical analysis that helps to analyse the two independent
groups of data collected from surveys conducted pre and post the educational or training
session about the role of ANPs in healthcare facilities. As the aim of the paper is to
understand the perception of physicians about the role of ANPs prior to the training or
education and then analyse their perception after the training, and do not aim to find out the
practice related aspect, hence only two sets of data and their comparison using t-test would be
conducted (Neuman and Robson, 2014).
3.6 Evaluation
Similar to the data analysis and data collection, evaluation is also an important part of
the methodological section and as per the aim of this research, evaluation is based upon the
training and educational sessions provided to the physicians, involved in study. Hence, in
such situation, the data evaluation would completely base on the findings collected after the
data analysis process. Hence, if the evaluation mentions loopholes and limitations in training
method, modifications would be conducted (Yilmaz, 2013).
3.7 Method and materials (instruments)
The methods and materials or the instruments that would be used in the research
process would depend on the training or educational session conducted to make the
physicians understand the role of ANPs working in the clinical situation (Berger, 2018).
Hence, in such situation, the materials that would be required to conduct the educational and

19DISSERTATION
training session effectively would be a community room in their healthcare facility where the
educational and training session would be conducted. Besides this, a projector, a detailed
power point presentation, the fully developed questionnaires for pre and post educational
survey and refreshments for the participants. The instrument that were used to develop the
reliable and validated questionnaire was related to The Jefferson Scale of Attitudes Toward
Physician-Nurse Collaboration (JSATPNC) that has been used in this research article for the
measure the perception of the healthcare professionals about the role of ANPs in care facility
(Elsous et al. 2017). Besides this, the community hall, proper lighting, interactive sessions,
note books and the proper seating arrangement for the participant healthcare professionals
would be determined.
3.8 Sample
The subjects or participants of this quantitative research process would be 50 nursing
and healthcare professionals working in the selected hospitals in Saudi Arabia. There would
be very general criteria for the selection of nursing and healthcare professionals selected for
the study as from each shift, and each department one professionals an nursing professionals
would be collected or included in the study. All the subjects that are taking part in the study
would be provided with survey form for pre analysis and then after the training and
educational sessions related to the role of ANPs working in the process so that with
knowledge of their roles and responsibilities, positive work culture could be developed.
3.9 Ethical considerations
As mentioned in the paper of Leung (2015), while analysing and conducting the
primary research, application of ethical consideration becomes the most important aspect.
Ethical consideration makes every process fair and allows the research professionals
conducting the process with the ability to perform their tests without asking any question or
answering anyone anything, as they have the consent for every aspect of the study. As there

20DISSERTATION
were 50 healthcare professionals that were involved in the process and involved in both pre
and post survey for the analysis of their understanding of the role of ANPs in healthcare
facilities, it was important to seek their permission to perform this experiment with them
(Hirschi and Selvin, 2017). Hence, they were asked for consent, or the written permission that
provides the professionals with the ability to take part in the process. Further, ethical approval
also taken from the hospital as all the staffs were provided with flyer and their notice section
were occupied with posters related to this paper. However, most importantly, all the nursing
professional or physicians that were involved in the paper had showed their interest to take
part in the process and hence upon receiving their consent, all the actions of the research
process were conducted (Yilmaz, 2013).
3.10 Preparation
Prior to conduct the educational and training session, all the participants were invited
to take part in this introductory session, so that each professional could prepare themselves.
In this aspect, the participants would be provided with education regarding the aim and
objective of the process, the outcome this research is aiming to achieve (Leung, 2015).
Therefore, this would help the research with an accurate flow so that no hurdle could affect
the conduction of the research process and research could be completed with an effective
manner (Berger 2018).
3.11 Protocol design
This section included a section in which educational sessions were provided with
education for their increased awareness of the role of ANPs in the care process and hence, it
increased the efficiency of the research to expertise. Further, in between pre and post survey,
each of the participants was educated about the research and these are the processes that
helped in the outcome promotion. Starting from sample selection to conduction of pre survey,

21DISSERTATION
then educational session and then post survey would be the total protocol of the research
conducted in this study.

22DISSERTATION
Chapter 4
Result and analysis
Demographic study (data collected prior to the conduction of survey)
Profession of the participants
Table 1
Clinical Nurses Physicians ANPs
Number out of 50 16 15 19
Percentage (%) 32% 30% 38%
Graphical representation:
percentage
No. of clinical nurses
No. of physicians
No. of ANPs

23DISSERTATION
Experience of the participants
Table 2
Experience Number out of 50 Percentages
juniors healthcare
professionals
12 24
Experience less than a year 14 28
Experience 1 to 5 years 8 16
Experience 5 to 10 years 9 18
More than 10 years 7 14
Graphical representation:
percentage
Interns
Experience less than a year
Experience 1 to 5 years
Experience 5 to 10 years
More than 10 years
Department they worked in
Table 3
Number out of 50 Percentage
Surgical department 11 22
medical department 8 16
ICCU 6 12
Maternity wards 12 24
Emergency department 13 26

24DISSERTATION
Graphical representation:
Percentage
Surgical department
medical department
ICCU
Maternity wards
Emergency department
Gender of the participants
Table 4
Male (out of 50) Female (out of 50)
Number 45 5
percentage 90 10
Graphical representation:

25DISSERTATION
percentage
males
females
Training received in last one year
Table 5
Training Number Percentage
Never 11 22
Once in a year 25 50
Received multiple times 14 28
Graphical representation:

26DISSERTATION
percentage
never
Once in a year
Received multiple times
Nationality
Table 6
Saudi-Arabian Origin Non Saudi origin
Percentage 27 23
Graphical representation:

27DISSERTATION
percentage
Saudi-Arabian origin
Non Saudi-Arabian origin
Highest degree of education
Table 7
Number Percentage
Certificate level 9 18
Diploma 24 48
Bachelor’s level 6 12
Masters level 11 22
Graphical representation:

28DISSERTATION
percentage
Certificate level
Diploma
Bachelor’s level
Masters level
Current employment status
Table 8
Employment time Number Percentage
Full time 28 56
Part time 15 30
Flexible timing 7 14
Graphical representation:

29DISSERTATION
percentage
part time
full time
flexible timing

30DISSERTATION
Demographic findings
These data were collected from the participants prior to their involvement in the pre
survey that is a part of the research process conducted to understand the understanding of the
participants about the role of ANPs in the healthcare facility.
 Majority of the participants (38%) were ANPs and after that clinical nurses were
involved in the study.
 The majority of the participants were involved in the emergency department, then
maternity ward
 Majority of the participants had less than a year of experience in the healthcare
facility
 Majority of the participants were females and only 10% males were involved in the
process
 It was also found that majority of the participants received only one education and
training in the year
 57% of the respondents belonged to Saudi Arabian origin and 48% within that had
only diploma as their highest level of education
 56% of the participants that were involved in the study had fulltime job in the
selected hospital
Therefore, from the study it was seen that majority of the participants of the research
has no education or training about each other’s role and responsibilities.
Pre survey data analysis
1. Participant’s perception about role of ANPs as collaborator and colleague rather than
his or her assistant

31DISSERTATION
Yes No Can’t say
Percentage 13.3% 36.7% 50%
Table 9
Graphical representation
percentage
yes
No
Cant Say
2. Do you think ANPs are qualified to respond to the psychological aspects of patient’s
needs?
Table 10
Yes No Can’t Say
Perception 30 26.7 43.3
Graphical representation

32DISSERTATION
percentage
yes
No
Cant say
3. During their education, do you think medical and ANPs should be involved in teamwork
in order to understand their respective roles?
Table 11
Yes No Can’t say
Percentage 46.7 16.7 36.7
Graphical representation
percentage
yes
no
cant say

33DISSERTATION
4. Do you think ANPs should be involved in the policy development and decision making
regarding their working conditions?

34DISSERTATION
yes No can’t say
Percentage 34.5 31 34.5
Table 12
Graphical representation
percentage
yes
No
Can't say
5. Do you think ANPs are accountable for their patients care process?
Table 13
Yes No Can’t say
Percentage 23.3 40 36.7
Graphical representation

35DISSERTATION
percentage
yes
no
cant say

36DISSERTATION
6. Are you aware of the overlapping areas that lie between the responsibilities of doctors and
ANPs?
Table 14
yes no can’t say
percentage 24.1 37.9 37.9
Graphical representation
percentage
yes
No
can't say
7. Do you agree with the fact that ANPs expertise in patient education and psychological
counselling?
Table 15
yes no can’t say
Percentage 24.1 34.5 41.4
Graphical representation

37DISSERTATION
percentage
yes
no
cant say
Findings from the pre survey data
Total seven questions were asked to the participants in the pre survey conduction so
that people that are associated with the process could be analysed for their knowledge about
the role of ANPs in the facilities. Majority of the responses collected indicated to the fact that
the nursing or healthcare professionals working in the care facilities are unaware of ANP’s
roles and responsibilities in the healthcare facility due to which their effectiveness decreased.
Hence, the educational and training session was conducted after which the post survey was
commenced so that the increase in the level of understanding of the participants could be
easily understood.
Conduction of post training survey and analysis of the data
In this survey, all the seven questions asked in the pre survey were repeated and then
to further analyse the understanding of the participants, eight more question related to the
roles and responsibilities of the ANPs were asked to understand the improved understanding
of the participants. In this aspect, it should be mentioned that all the seven questions, that

38DISSERTATION
were asked, were framed differently so that the bias or repetition could be removed.
Statistical analysis using paired t-test was conducted for the seven questions and then using
the t values, the level of understanding and improved knowledge of participants would be
compared and analysed.
Paired t-test for the repeated seven questions (Both in pre and post survey)
Table 16
paired differences t value
mean St.
deviation
95% confidence interval
lower upper
Pair 1 -.037 .192 -.079 .006 -1.755
Pair 2 -.829 1.267 -1.108 -.544 -5.854
Pair 3 -.589 1.301 -.893 -.321 -4.048
Pair 4 -.511 1.182 -.678 -.128 -3.898
Pair 5 -.789 1.308 -1.080 -.499 -5.380
Pair 6 -.038 .023 -.080 .003 -1.759
Pair 7 -.512 1.178 -.512 -.302 -3.891
The finding from the above-mentioned test indicated to the fact that there is a
significant difference between the pre and post survey conducted for the analysis of
knowledge of the physicians about the role of ANPs in healthcare facilities. The negative
values of the t test mentioned that the knowledge of physicians about the ANPs role and
responsibilities prior to the education was lower than after providing the training. Hence, a
significant increase in the knowledge of the physicians was observed.

39DISSERTATION
8. Do you agree with the fact that doctors should be provided with all the dominant authority
in healthcare matters?
Table 17
yes no can’t say
percentages 50.7 25.9 23.3
Graphical representations
percentage s
yes
no
cant say
9. Do you support the fact that doctors and ANPs should equally contribute to the decisions
regarding the discharge of patients from the acute care service?
Table 18
yes no can’t say
percentages 50 16.7 33.3
Graphical representations

40DISSERTATION
percentages
yes
no
cant say
10. Do you think the primary role of ANP is to carry out the physicians order?
Table 19
Yes no can’t say
percentages 50 17.9 32.1
Graphical representations
percentages
yes
no
cant say

41DISSERTATION
11. Do you agree that one of the primary role of ANP is to involve in making policy
decisions about the hospital support services upon which their work depends?
Table 20
Yes No Can’t say
percentage 49.9 7.3 42.9
Graphical representations
percentages
yes
no
cant say
12. Do you think it is the responsibility of the ANPs to monitor the effect of medical treatment
for the patients?
Table 21
Yes No Can’t say
Percentages 43.3 23.3 33.3
Graphical representations

42DISSERTATION
percentations
yes
no
cant say
13. Do you think ANPs should clarify the doctor’s order when they feel it might have the
potential of detrimental effect on the patients?
Table 22
Yes No Cant say
percentages 33.3 33.3 33.3
Graphical representations
percentages
yes
no
cant say

43DISSERTATION
14. Do you think the ANP education should be inclusive of strategies for inter-professional
relationship between ANPs and doctors?
Table 23
yes no can’t say
Percentages 60 20 20
Graphical representations
percentages
yes
no
cant say

44DISSERTATION
Chapter 5
Discussion
Overview
Discussion is one of the critical aspects of any dissertation or thesis in which the
findings and results are analysed and then with the help of literatures all the aspects are
compared to validate the findings of the research (Neuman and Robson, 2014). In this
research paper, the discussion included all the relevant research articles and hence, through
this aspect, authenticity and validity of the findings were analysed (Choy, 2014). In this
aspect, it should be mentioned that the primary aim of this particular research was to conduct
an educational and workshop session so that the roles and responsibilities of the ANPs could
be understood and then their improve compliance to their own and roles and responsibilities
would be assessed (Kutzleb et al. 2015). In this research, majority of the aspects that were
observed from the survey mentioned that the health system of KSA lacked proper training
and education so that people could enhance their knowledge of each other’s roles and
responsibilities to develop and enhance the quality of the healthcare process. Further, it was
also assessed that majority of the participants were not being able to receive proper training
and education, due to which they were unable to understand their key roles and job
responsibilities (PinoJones et al. 2019). Hence, conduction of this research and the
obtained findings completely answered the research question that has been developed to
understand the perception of the healthcare professionals about ANPs and then
understanding the reason of such perception that eventually discussed the lack of
knowledge among healthcare professionals. Hence, these findings provide wide array of

45DISSERTATION
future implication for practice related to healthcare professionals education and
learning.
Interpretation and evaluation of the findings
Upon analysing the data and conducting the survey, it was clearly seen that majority
of the participants in the study were female and a considerable amount of participants were
from non-Saudi Arabian origin due to which, they were unaware of the healthcare structure
and responsibilities of each professional. These conducted descriptive study helped to
understand the reason of the found responses and hence, the conduction and analysis of this
data was important for the complete and effective analysis of the process. In the conduction
of the process, majority of the participants, nearly 38% of the participants were ANPs. With
that more than 32% of the participants were clinical nursing professionals associated with the
study. Within these, majority of the participants were involved in the emergency department,
as well as in the maternity ward and after receiving the consent from these participants, they
were included in the study. It was also seen that majority of the participants had less than a
year of experience in the healthcare facility and hence they themselves mentioned that they
received only one education and training in the year. Finally, as per the survey conducted,
57% of the respondents belonged to Saudi Arabian origin and 48% within that had only
diploma as their highest level of education, as well as 56% of the participants that were
involved in the study had fulltime job in selected hospital. Hence, from the study conducted,
it was seen that majority of the participants that were involved in the study, did not had any
formal knowledge about the roles and responsibility of ANPs in the healthcare facility and
hence, it was important to make them aware of this responsibilities. Hence, the educational
and training session was conducted in the process so that after this education, they can
become aware of their own roles and responsibilities. After that, again they were involved in

46DISSERTATION
the survey so that their educational knowledge could be effectively analysed. Then, a
statistical analysis was conducted with t-test as the primary data analysis.
It should be mentioned that the relationship between the difference in perception
among the participants involved in the study was analysed through the conduction of before
and after training and workshop and the analysis was conducted through paired sample t-test.
The paired t-test was conducted for all the seven question pairs that was repeated in both the
surveys. Finally, after the conduction of the study, it was seen that majority of the paired
variables involved in the study indicated to the fact that a significant difference exists
between the before and after analysis of applied training as well as the workshop. Further, it
was seen that all the t-test was included in the paper was included in the paper found negative
t values. All these negative values of the t-test suggested thatall the professionals were
included in the study were associated with negative t-test and it was seen that all the care
professionals included in the test were unaware of the roles and responsibilities of ANPs and
after conduction of the educational sessions, their awareness increased. Overall it can be
mentioned that after the completion of the training, the care professionals were able to
understand the responsibilities of the ANP professionals and hence, it was an effective mean
for making professionals aware of the study. Further, it was also seen that the care
professionals acquired maximum of the confidence while performing their practice the
professionals were able to understand the responsibilities of ANPs.
Validating findings
From the conduction of the research process, it was seen that with effective training
and education, training as well as workshop about the roles and responsibilities of the ANPs
professionals in the healthcare facilities of KSA, the level of perception of the ANPs among
the care professionals changed significantly after the process (Larson, 2013).These findings

47DISSERTATION
could be compared depending upon its application a number of relevant research findings that
indicated to the fact that effective training and educational sessions can be helpful in
improving clinical outcome for the patients.
Further, to understand the effectiveness of educational and training session in
spreading awareness and increasing literacy, it was seen that del-PinoJones et al. (2019), also
conducted such study in their research process and eventually, their attitude towards the role
of ANPs in the care process was conducted to understand the effectiveness of the training
process.The researchers conducted a mix methodological study in this aspect and then
conducted the survey, the primary aim of which was to analyse the understanding of
physicians about the roles and responsibilities of ANPs and other nursing professionals
among other professionals and in the process, included both open and closed ended questions
for the evaluation of the perception of the physicians towards the role of Nurse practitioners.
In this aspect, total 25 participants that working in the healthcare facility as physicians with
more than 6.2 years of practice experience were included in the survey process. From the
conduction of the survey, it was seen that positive responses by Physicians in relation to the
role of NPs in providing care to the patients, improve patient efficacy and elevate the level of
patient satisfaction (PinoJones et al. 2019). Further, from the conduction of the survey, it was
also indicated that physicians preferred to work with ANPs with multiple years of experience
and stated that it helped in improving patient outcome and hence, it was observed that the
healthcare physicians were neglecting the ANPs that have joined the healthcare process were
not provided with effective training and education so that they can fulfill the expectations of
the experiences physicians.
Other research findings could be used to validate the findings of this paper as the
research process conducted by Kutzleb et al.(2015), the ANP professionals and their care
process were analyzed in the healthcare facilities and minimal understanding of their

48DISSERTATION
responsibilities were obtained. The researchers used the evidence based a specific framework
for the analysis of the process and after conducting the study, they used the framework within
the New Jersey Medical Center which is famous primarily concerned for treating patients
with chronic illness. In the conducted study, all the physicians and nurses were involved so
that their knowledge and understanding of each other’s; responsibilities could be effectively
analyzed and then the data obtained could be analyzed. Hence, form the conducted study, it
was effectively analyzed that nurses and physicians were not clear about their different type
of roles within the healthcare facility. Besides this it was also found that, application of
different legislations in the process of expansion and for the scope for ANPs was found to be
controversial with no clear understanding among the healthcare professionals.
Chapter 6
Conclusion
While concluding the research process it could be mentioned that it is important to
analyze the role of ANPs in healthcare facilities of KSA. In Saudi Arabia, healthcare facilities
are facing tremendous problem in management and conduction of the process. The research
process, effectively mentioned that majority of the healthcare facilities are suffering from
political and strategic complication and hence, the structure of the healthcare process. In this
research process as well, the roles and responsibilities of the ANPs were analyzed with a pre-
survey and then after the educational intervention researchers used the post surveys to
understand the process. The research methods, quantitative study included methods such as
surveys so that among the 50 participants included in the process, all the questionnaires could
be collected and then their responses could be used as the data collected and analysis process.
In this aspect, all the participants were asked to provide their consent so that with ethical
considerations, the research process could be conducted. Therefore, upon conclusion of the

49DISSERTATION
research it could be mentioned that all the literature review critically helped to analyze the
several critical and important research papers through the application of that identification of
the role and responsibilities of the Advanced Nurse Practitioners ANPs in working in the
effective care facilities for better quality and improved patient outcome. The review helped in
evaluation of the perception of the healthcare physicians complied with the regards to role of
Advanced Nurse Practitioners within the healthcare facilities in KSA. Further, it was also
assessed that majority of the Physician’s perceive about the Advanced Nurse Practitioners as
their assistants as they were not aware of their roles and responsibilities and they were also
confused about their roles.. However, in this research process, the concept about Advanced
Nurse Practitioners is yet to be assimilated into the healthcare system of Saudi Arabia which
should be done at the earliest in order to cater to the healthcare needs of the growing
population at a time when there is an acute shortage of physicians.

50DISSERTATION
References
Alboliteeh, M., Magarey, J. and Wiechula, R., 2017. The profile of Saudi nursing workforce:
A cross-sectional study. Nursing research and practice, 2017.
Aldossary, A. M. 2013. The role legitimacy of nurses in Saudi Arabia. Journal of Health
Specialties, 1(1), 28.
AlYami, M. S., & Watson, R. 2014. An overview of nursing in Saudi Arabia. Journal of
Health Specialties, 2(1), 10.
ANA 2019. ANA Enterprise | American Nurses Association. [online] ANA. Available at:
https://www.nursingworld.org/ [Accessed 25 Mar. 2019].
Anderson, H., 2017. Professional identity and the advanced nurse practitioner in primary
care: A qualitative study (Doctoral dissertation, University of York).
Begley, C., Elliott, N., Lalor, J., Coyne, I., Higgins, A. and Comiskey, C.M., 2013.
Differences between clinical specialist and advanced practitioner clinical practice, leadership,
and research roles, responsibilities, and perceived outcomes (the SCAPE study). Journal of
Advanced Nursing, 69(6), pp.1323-1337.
Berger, A. A. (2018). Media and communication research methods: An introduction to
qualitative and quantitative approaches. Sage Publications.
Birley, G., and Moreland, N. (2014). A practical guide to academic research. Routledge.
Cepaluni, G., Mariano, K.L.P. and Mariano, M.P., 2019. Preserving Domestic Autonomy:
Weak Migration Laws and the Mercosur Strategy of Limited Integration. In Latin American
Geopolitics (pp. 83-107). Palgrave Macmillan, Cham.

51DISSERTATION
Choy, L. T. (2014). The strengths and weaknesses of research methodology: Comparison and
complimentary between qualitative and quantitative approaches. IOSR Journal of Humanities
and Social Science, 19(4), 99-104.
Content.hcpro.com 2019. [online] Content.hcpro.com. Available at:
http://content.hcpro.com/pdf/content/296954.pdf [Accessed 27 Feb. 2019].
Dalton, M. A. 2013. Perceptions of the advanced nurse practitioner role in a hospital
setting. British Journal of Nursing, 22(1), 48-53.
Dalton, M.A., 2013. Perceptions of the advanced nurse practitioner role in a hospital
setting. British Journal of Nursing, 22(1), pp.48-53.
delPino-Jones, A., Wolfe, B., Wimmer, K., Bowden, K., Rosenthal, L., Nogar, C., ... and
Cumbler, E. 2019. Physician Perceptions of Advanced Practice Providers on Hospitalist
Teams. The Journal for Nurse Practitioners, 15(2), e37-e40.
Donelan, K., DesRoches, C. M., Dittus, R. S. andBuerhaus, P. 2013. Perspectives of
physicians and nurse practitioners on primary care practice. New England Journal of
Medicine, 368(20), 1898-1906.
Donelan, K., DesRoches, C.M., Dittus, R.S. and Buerhaus, P., 2013. Perspectives of
physicians and nurse practitioners on primary care practice. New England Journal of
Medicine, 368(20), pp.1898-1906.
Elliott, N., Begley, C., Sheaf, G. and Higgins, A., 2016. Barriers and enablers to advanced
practitioners’ ability to enact their leadership role: A scoping review. International Journal
of Nursing Studies, 60, pp.24-45.

52DISSERTATION
Fassinger, R., and Morrow, S. L. (2013). Toward best practices in quantitative, qualitative,
and mixed-method research: A social justice perspective. Journal for Social Action in
Counseling& Psychology, 5(2), 69-83.
Ferraris, V.A., 2017. Evidence and resident physician duty hours: Should scientific
experiments be more suspect than universal implementation of an untested practice?. The
Journal of thoracic and cardiovascular surgery, 153(3), pp.632-635.
Field, B., Booth, A., Ilott, I. and Gerrish, K., 2014. Using the Knowledge to Action
Framework in practice: a citation analysis and systematic review. Implementation
Science, 9(1), p.172.
George, T., 2016. Role of the advanced practice nurse in palliative care. International journal
of palliative nursing, 22(3), pp.137-140.
Hain, D. and Fleck, L., 2014. Barriers to nurse practitioner practice that impact healthcare
redesign. OJIN: The Online Journal of Issues in Nursing, 19(2).
Halliday, S., Hunter, D.J. and McMillan, L., 2018. Ward staff perceptions of the role of the
advanced nurse practitioner in a ‘hospital at day’setting. British Journal of Nursing, 27(2),
pp.92-97.
Harris, M.F., Advocat, J., Crabtree, B.F., Levesque, J.F., Miller, W.L., Gunn, J.M., Hogg,
W., Scott, C.M., Chase, S.M., Halma, L. and Russell, G.M., 2016. Interprofessional
teamwork innovations for primary health care practices and practitioners: evidence from a
comparison of reform in three countries. Journal of multidisciplinary healthcare, 9, p.35.
Hartas, D. (Ed.). (2015). Educational research and inquiry: Qualitative and quantitative
approaches. Bloomsbury Publishing.

53DISSERTATION
Hendry, C and Walker, A. 2004. Priority setting in clinical nursing practice: literature
review. Journal of advanced nursing, 47(4), 427-436.
Hibbert, D., Aboshaiqah, A. E., Sienko, K. A., Forestell, D., Harb, A. W., Yousuf, S. A., ...
and Leary, A. 2017. Advancing nursing practice: The emergence of the role of advanced
practice nurse in Saudi Arabia. Annals of Saudi medicine, 37(1), 72.
Hibbert, D., Aboshaiqah, A.E., Sienko, K.A., Forestell, D., Harb, A.W., Yousuf, S.A.,
Kelley, P.W., Brennan, P.F., Serrant, L. and Leary, A., 2017. Advancing nursing practice:
The emergence of the role of advanced practice nurse in Saudi Arabia. Annals of Saudi
medicine, 37(1), p.72.
Hibbert, D., Al-Sanea, N.A. and Balens, J.A., 2012. Perspectives on specialist nursing in
Saudi Arabia: a national model for success. Annals of Saudi medicine, 32(1), pp.78-85.
Hirschi, T., andSelvin, H. C. (2017). Delinquency research: An appraisal of analytic
methods. Routledge.
Iglehart, J.K., 2013. Expanding the role of advanced nurse practitioners—risks and rewards.
Kemp, A.E., 2016. Mass-gathering Events: the role of advanced nurse practitioners in
reducing referrals to local health care agencies. Prehospital and disaster medicine, 31(1),
pp.58-63.
Kerr, L.M., 2016. Advanced nurse practitioners'(emergency) perceptions of their role,
positionality and professional identity(Doctoral dissertation, Sheffield Hallam University).
King, R., Tod, A. and Sanders, T., 2017. Regulation of advanced nurse practitioners:
understanding the current processes in the UK. Nurs Stand, 32(14), pp.43-50.
Kleinpell, R.M. ed., 2013. Outcome assessment in advanced practice nursing. Springer
Publishing Company.

54DISSERTATION
Kutzleb, J., Rigolosi, R., Fruhschien, A., Reilly, M., Shaftic, A. M., Duran, D. and Flynn, D.
2015. Nurse practitioner care model: meeting the health care challenges with a collaborative
team. Nursing Economics, 33(6), 297-305.
Lamadah, S. M., & Sayed, H. Y. 2014. Challenges facing nursing profession in Saudi
Arabia. Journal of Biology, Agriculture and Healthcare, 4(7), 20-25.
Lampard, R., and Pole, C. (2015). Practical social investigation: Qualitative and quantitative
methods in social research. Routledge.
Larson, E. (2013). Monitoring hand hygiene: Meaningless, harmful, or helpful?. American
journal of infection control, 41(5), S42-S45
Leung, L. (2015). Validity, reliability, and generalizability in qualitative research. Journal of
family medicine and primary care, 4(3), 324.
Lowe, G., Plummer, V. and Boyd, L., 2013. Nurse practitioner roles in Australian healthcare
settings. Nursing Management, 20(2).
Lucas, G., Gallagher, A., Zasada, M., Austin, Z., Jago, R., Banks, S. and van der Gaag, A.,
2019. Understanding complaints about paramedics: a qualitative exploration in a UK
context. Australasian Journal of Paramedicine, 16.
McDonnell, A., Goodwin, E., Kennedy, F., Hawley, K., Gerrish, K. and Smith, C., 2015. An
evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute
hospital setting. Journal of advanced nursing, 71(4), pp.789-799.
Mosa, A.S.M., Yoo, I. and Sheets, L., 2012. A systematic review of healthcare applications
for smartphones. BMC medical informatics and decision making, 12(1), p.67.
Neuman, W. L., and Robson, K. (2014). Basics of social research. Toronto: Pearson Canada.

55DISSERTATION
Neuman, W. L., and Robson, K. (2014). Basics of social research. Toronto: Pearson Canada.
Nhsggc.org.uk 2019. NHSGGC : Advanced Nurse Practitioners. [online] Nhsggc.org.uk.
Available at: https://www.nhsggc.org.uk/about-us/professional-support-sites/nurses-
midwives/advanced-nurse-practitioners/# [Accessed 27 Feb. 2019].
Parahoo, K., 2014. Nursing research: principles, process and issues. Macmillan International
Higher Education.
Pedersen, C. and Tariman, J.D., 2018. Beliefs and Attitudes of American Nurses on Physician
Assisted Suicide: An Integrative.
Poghosyan, L., Boyd, D. and Knutson, A.R., 2014. Nurse practitioner role, independent
practice, and teamwork in primary care. The Journal for Nurse Practitioners, 10(7), pp.472-
479.
Punch, K. F. (2013). Introduction to social research: Quantitative and qualitative
approaches. sage.
Ramira, M. L., Peraza-Smith, G. B., McLeod, R. and Clark, M. J. 2018. CHALLENGES,
BARRIERS, AND SATISFIERS OF FOREIGN EDUCATED PHYSICIANS WITH THE
FAMILY NURSE PRACTITIONER ROLE IN THE UNITED STATES. Journal of Cultural
Diversity, 25(1).
Sanders, G.D., Neumann, P.J., Basu, A., Brock, D.W., Feeny, D., Krahn, M., Kuntz, K.M.,
Meltzer, D.O., Owens, D.K., Prosser, L.A. and Salomon, J.A., 2016. Recommendations for
conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel
on cost-effectiveness in health and medicine. Jama, 316(10), pp.1093-1103.

56DISSERTATION
Spooner, A.J., Aitken, L.M. and Chaboyer, W., 2018. Implementation of an Evidence‐Based
Practice Nursing Handover Tool in Intensive Care Using the Knowledge‐to‐Action
Framework. Worldviews on Evidence
‐Based Nursing, 15(2), pp.88-96.
Tsafnat, G., Glasziou, P., Choong, M.K., Dunn, A., Galgani, F. and Coiera, E., 2014.
Systematic review automation technologies. Systematic reviews, 3(1), p.74.
Verma, S. and Acharya, S.S., 2018. Social identity and perceptions about health care service
provisioning by and for the Dalits in India. Social Identities, 24(3), pp.327-338.
Yee, T., Boukus, E., Cross, D. and Samuel, D., 2013. Primary care workforce shortages:
Nurse practitioner scope-of-practice laws and payment policies. National Institute for Health
Care Reform Research Brief, 13, pp.1-7.
Elsous, A., Sari, A.A., Radwan, M., Mohsen, S. and ZAYDEH, H.A., 2017. Psychometric
Soundness of an Arabic Version of the Jefferson Scale of Attitude toward Physician and
Nurse Collaboration (JSAPNC): A Preliminary Study. Iranian journal of public health, 46(5),
p.650.

57DISSERTATION
Appendix
Awareness about the role of ANPs in healthcare system
1. Do you think an ANP should be viewed as the collaborator and colleague with
doctors rather than his or her assistant?
2. Do you think ANPs are qualified to respond to the psychological aspects of
patient’s needs?
3. During their education, do you think medical and ANPs should be involved in
teamwork in order to understand their respective roles?
4. Do you think ANPs should be involved in the policy development and decision
making regarding their working conditions?
5. Do you think ANPs are accountable for their patients care process?
6. Are you aware of the overlapping areas that lies between the responsibilities of
doctors and ANPs?
7. Do you agree with the fact that ANPs expertise in patient education and
psychological counselling?
8. Do you agree with the fact that doctors should be provided with all the dominant
authority in healthcare matters?
9. Do you support the fact that doctors and ANPs should equally contribute to the
decisions regarding the discharge of patients from the acute care service?
Job role-responsibility knowledge
10. Do you think the primary role of ANP is to carry out the physicians order?

58DISSERTATION
11. Do you agree that one of the primary role of ANP is to involve in making policy
decisions about the hospital support services upon which their work depends?
12. Do you think it is the responsibility of the ANPs to monitor the effect of medical
treatment for the patients?
13. Do you think ANPs should clarify the doctor’s order when they feel it might have
the potential of detrimental effect on the patients?
14. Do you think it is the responsibility of the doctors to develop collaborative
relationship with ANPs?
15. Do you think the ANP education should be inclusive of strategies for inter-
professional relationship between ANPs and doctors?
Demographics
1. Gender
2. Nationality
3. Degree
4. Employment status
5. Training occurred
6. Deportment of work
7. Designation