Advanced Nurse Practitioner Role in a Primary Care Setting: A Quality Improvement Project Acknowledgments

Introducing the Advanced Nurse Practitioner Role to a Primary Care Setting in
Kingdom of Saudi Arabia: A Quality Improvement Project
Acknowledgments
I would like to express my kind regards to my supervisor Dr. Siobhan Rothwel who played
an important role in assisting me in this project. She was supportive in her comments and
assisting me the requirements of this project. My gratitude is based on the role that Dr.
Catherine Corrigan introduced me to the Advanced Nursing Practice program which has
since inspire me. I deeply appreciate her courage through over the last 2 years from teaching
classes, revising papers, writing algorithms, and training how to use software. She has created
for me the best environment to develop my master skills. I would also like to thank Dr. Mary
Brigid Martint for her enormous kindness, comments, and her brilliant ideas. I owe her
special thanks for providing me with enabling me to get benefit from her expertise in the
research module.
For all support during the master period, I’d like to express my gratitude for Dublin City and
Prince Norah Universities and the Ministry of Health in Saudi Arabia.

1.0 Introduction
The introduction of the Advanced Nurse Practitioner (ANP) to primary healthcare
settings leads to elevated patient safety, enhanced patient care, and maintain patient medical
care continuity (Kooienga & Carryer, 2015). Previous data reports show that the role of
ANPs is approximately 90% of the primary care services that patients receive which are also
done by other professionals like doctors (Bauer, 2010). Further, it has been reported that
ANPs have higher scores in patient satisfaction, health improvement, illness prevention and
patient acceptance (Newhouse et al., 2011; Grumbach & Grundy, 2010). The patient
expectations on the ANP are based on the need to be accountable as reported in the increased
satisfaction rates among the patients that they serve (Swan et al., 2015; Oliver, 2017). This
comes in handy as the population keeps on increasing and the number of patients that require
care also increases.
The role of ANPs in the current healthcare environment is based on factors like
developing life expectancy and population growth, health-related problems such as diabetes,
and hypertension or bad habits like smoking (Kralewski et al., 2015). The roles of these
professionals have also been extended to other healthcare areas like acute care and
emergency settings meaning that the roles that they play in the primary care are advanced and
include different activities that fall within their clinical jurisdiction (Hibbert, Al-Sanea, and
Balens 2012)
Studies by different scholars have reported the increasing role of these professionals
in clinical settings and how their presence has changed the clinical experience of most
patients. A study by Kralewski et al. (2015) assessed the relationship between the ANPs and
the patient cost level and the care quality in eighty five primary care settings concluded that
ANPs played the leading role in reducing the healthcare costs and leading increased

healthcare quality.. In another study, Swan et al. (2015) study showed that the ANPs provided
better services since they provided safe and worthy care which led to improved patient
outcomes. Martinez-Gonzalez et al. (2014) study focussed on the exchange of physicians by
ANPs is common in care settings with a low number of physicians beneath a need for high
quality care and how this led to a better clinical environment. Furthermore, McDonnell et al.
(2014) indicated that if ANPs accomplish tasks done by junior doctors in a primary care
setting, positive consequences from healthcare workers, patients, the organization will be
obtained.
Barrat and Thomas (2018) indicated that there is a demand for inclusion ANPs in
terms of healthcare services to reduce shortages and meet the high demands. Lastly, Torrens
et al. (2019) identified the restrictions on the role of ANPs in primary care settings. The study
reported that there are potential barriers that are faced when employing ANPs in primary
healthcare due to the nature of the clinical settings that exist. This means that there is a
problem of autonomy, supervision, role division and even integration into the clinical
environment which is based on the problem of fitting the ANPs within the existing clinical
roles where there are other professionals.
1.1 Background Information
KSA health care system is managed and guided by governmental agencies. The
ministry of health manages the healthcare sector in KSA. There are many medical, and
hospital services are operated by the semi-public organization (Al-jedai, et al., 2016). The
healthcare quality services are provided by also the private sectors which supervise the
general plans. KSA has developed its healthcare bases that are supposed to update the
healthcare services that are provided to its citizens in the primary healthcare setting (Hibbert,
Al-Sanea, and Balens, 2012). However, there are many unsolved challenges that can affect
the quality of care that patients receive. To counter this problem, Al-ASmri et al. (2019)

sought to identify the KSA healthcare challenges being faced. From the study the major
challenges were: the high services demand, leadership issues, increasing of chronic diseases
and increased costs
The healthcare system in KSA has not used ANPs to reduce the shortages being
encounters and meets its healthcare needs (Aboshaiqah, 2015).Thus, the MOH needs to
define the different roles of nurses clearly since the number of hospitals and patients in the
country is high, compared to a small number of physicians, clinicians, and specialized nurse
practitioners (Oliver, 2017). Consequently, the nursing shortage and lack of postgraduate
specialist nursing education are significant factors that contribute to the weak implementation
of ANP (Hibbert, Al-Sanea and Balens 2012). Aboshaiqah (2013) indicates that the
importance of ANP in primary healthcare settings in KSA is to enhance positive patient
outcomes.
1.2 Purpose of the QI project
The purpose of this QI project is to introduce an ANP to a primary health care setting
in plan to evaluate the impact of their role in the chosen primary healthcare setting. The Saudi
healthcare system faces the challenge of inadequate primary care preparation with the general
practitioners that it serves. As the country ageing population increases health challenged are
also increasing thus calling for the need to have a better primary care system that can meet
these changing needs. This means that the only solution to this problem is to advance the
nursing role so that they can have the responsibility of prescribing and independence in
making clinical decisions (Hibbert, Al-Sanea and Balens, 2012). Moreover, ANP do not just
deal with acute and chronic disease but also use clinical reasoning and manage uncertainty.
This means that ANPs can examine, treat, support the clinical mentor, prescribe appropriate
medication under supervision to the patients making several decisions on the interpretation of

the test results, and on the diagnosis (Hibbert et al. 2017). They are also supposed to
determine the specialised needs of patient and referring them to appropriate professionals.
1.3 Objectives and Aim
Aim:
To evaluate the benefits of the ANPs in KSA so that patient safety and care can be enhanced.
Objectives:
To measure the impact of the ANP introduction to a primary care setting.
1.3 Project question
Are there any benefits to patient satisfaction and patient waiting times by introducing an
Advanced Practice Nurse to a primary care setting in KSA?
2.0 Literature review
The research strategies for the literature reviews include three online medical
databases consisting of PubMed, Cinahl, Google scholar, quantitative, and qualitative studies
that examined advanced nursing practice and its influence on the primary care setting. The
search for literature will be based on the use of key words for finding the appropriate studies
that meet the requirements of the study.
Research has shown that there is an existing gap on the importance and role of ANPs
in primary healthcare setting in KSA due to limited research that has been carried out on this
topic. In one study, Hibbert, Al-Sanea, and Balens (2012) investigated the emerging role of
ANPs in KSA and reported that although they have been existing for the last three decades,
there has been little formal legislation that defines their role. This means that the ANPs have
existed without a clear definition of their roles and the relationship that they have with other
professionals. Saudi nurses have also been defined as lacking educational advancement
opportunities and development which can lead to better clinical outcomes. This is the reason
why Hibbert, Al-Sanea, and Balens (2012) called on the need to develop a standardised
education system in the country that will empower the nurses with appropriate skills while at

the same time developing regulations that define the roles that ANPs can play in clinical
settings. This means that by improving the nursing college education in Saudi Arabia, the
country can have a better nursing experience for its population.
The limited research on the role of ANPs has created difficulties in identifying the
challenges that exist in the field and the best way to improve the ANP practices in healthcare.
This creates a heathcare research gap in Saudi Arabia due to the limited information that
exists on the topic. Despite that, similar studies in other countries have highlighted the
challenges that ANPs face in dealing with healthcare problems. Carnwell and Daly (2003)
reported that despite the fact that there is an increasing call on the use of ANPs in clinical
settings, there are management and support problem that the professionals experience due to
the nature of the primary care setting that they operate in. Ljungbeck and Sjögren Forss
(2017) study added that Swedish healthcare professional opinion on ANPs showed that the
speciality experience of these professionals is limited since they are not adequately utilised
due to lack of regulations. The fact that nurse leaders and managers are not fully aware of this
new role makes it difficult for them to integrate it within the clinical settings. Jenkins,
Docherty, and Cain (2018) recommended that this challenge can be addressed through the
development of practice areas through support, improving patient experience and promoting
change within the clinical environment so that ANPs can be allowed to practice adequately.
Furthermore, results by Bergman et al. (2013) show that the limited support of the
ANPs by management is a major factor that contributes to high attrition rates and poor
retention of ANPs who prefer alternative healthcare roles. Anderson, Adamson, and Birks
(2018) study reported the challenge of unlimited preparation that most stakehlders who are
supposed to support the ANPs have. The study by Anderson, Adamson, and Birks (2018)
investigated how to practice websites present GPs, PNs, and ANPs to patients and the
implication of creating awareness about available consulting options. Results from 79 sites